Sexual Health and Intimacy

In survivorship, women experience both the physical and psychosocial complications of breast cancer treatment, which can have a significant negative impact on body image and sexual function. Abrupt hormone changes due to chemotherapy or hormonal therapy, surgery, or radiation may have caused sexual health problems. This includes partial or complete loss of one or both breasts, premature menopause due to cancer treatment, physical challenges of alopecia, and lymphedema. These changes alter a woman’s relationship with herself and can negatively impact a woman’s perception of her physical appearance and sexuality.

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• What is sex?

  • The act of having sexual intercourse. This can also include other ways you express intimacy.

• What is sexuality?

  • The way you express yourself as a sexual being.

• What is intimacy?

  • How connected you are with another person – can be physical, emotional, or mental.

 

You are not alone!

 

General prevalence of  sexual health related concerns:

• Up to 66% of women with cancer report sexual dysfunction

• Rates of sexual dysfunction are as high as 90% among gynecologic cancer survivors

• 75–90% of breast cancer survivors (BCS) experience sexual dysfunction

• 77% of female lung cancer survivors report sexual health symptoms

• 75% of colorectal cancer survivors report sexual health symptoms

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You may feel embarrassed or ashamed to ask about sexual health issues after surviving cancer. However, sexual health concerns are just like any other side effects from cancer deserve attention. You should feel empowered to bring up these issues to your primary care providers. If a doctor or clinician does not seem comfortable or experienced with these concerns, there are professionals who can help. Ask for a referral to urologist or gynaecologist, other professionals who treat sexual difficulties. 

 

Sexual dysfunction during and after cancer treatment is extremely common. Therefore, the treatment of sexual dysfunction in cancer care is complex and requires coordination between care teams. Many women are embarrassed or ashamed to ask about sexual health issues after surviving cancer.

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Physical symptoms to report:​

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• Little or no interest in sex

• Reduced vaginal lubrication (dry vagina)

• Decrease genital sensation (feeling touch)

• Reaching orgasm

• Pain during sex

• Or any other concerns

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Psychological and/or emotional symptoms to report:​

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• Body image concerns

• Anxiety

• Depression 

• Poor self-esteem​

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Risk factors:

• Individuals who received radiation, chemotherapy, and endocrine therapy

• Individuals who underwent mastectomy

• Higher baseline body mass index (BMI)

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Why does sexual dysfunction happen:

• Physical impacts of treatment: Treatments like chemotherapy or radiotherapy can disrupt sex hormones, causing symptoms such as vaginal dryness. Hormonal therapies may also inhibit hormones essential for sexual function 

• Surgical effects of treatment: Procedures such as mastectomy or lumpectomy might impact a woman's body image and lead to sexual dysfunction. Additionally, the risk of nerve damage from these surgeries can result in decreased sensation  

• Psychological impacts of treatment: The emotional stress from treatment and uncertainties about the future can decrease sexual desire and function. The trauma experienced during treatment can also affect self-image and physical functioning, making a woman feel less desirable and self-conscious, particularly during sexual activities.

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Here are some questions you might ask your providers:

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• How can sexual side effects be relieved or managed, if they do occur?

• Can sexual side effects occur after treatment ends?

• Is it safe for me to have sex during cancer treatment?  Would you recommend that I talk with a counsellor or sex therapist?

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Intimacy is very closely connected to your feelings about your relationship as well as your feelings about yourself. Therefore, finding a counsellor who has experience working with people with cancer and talking through some of these issues can help both you and your partner. 

 

Good communication involves talking openly and honestly about your thoughts, feelings, and fears with someone who listens and supports you. By establishing open and ongoing communication with your spouse or partner, you both can better adapt to the change cancer has caused in your lives as well as in your relationship.

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Treatment options:​

For vaginal dryness and painful sex:

• Personal lubricants, vulvovaginal moisturizers, low-dose vaginal estrogen

  • Topical vaginal therapies are the first-line of treatment. 

  • Moisturizers can be applied 3-5 times a week.​​​

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For vaginal stenosis and vaginismus

• Vaginal dilators, advised to start using them early on,  2-4 weeks after pelvic radiation (more information below)

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For vaginal stenosis, pelvic pain, bowel or bladder issues:

• Pelvic floor physical therapy

  • ​A pelvic floor physical therapist can help with decreasing the pain and promoting vaginal muscle relaxation  

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For decreased libido/arousal

• Counseling and/or therapy

  • Psychosocial and/or psychosexual counselling can help with the stress, anxiety, discomfort associated with sexual dysfunction. 

  • Mental health counselling, sex therapy, and/or couple-based interventions can also help with improving intimacy, body image concerns, and sexual functioning.​​

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For difficulties achieving an orgasm:

• Foreplay, non-penetrative option, and vibrators can help with the loss of sexual function

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For low sexual desire:

• Androgens, bupropion, flibanserin, and bremelanotide can help with low sexual desire, however evidence supporting them is limited

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Other strategies you can consider: ​

• Seeking out a counselor: Feeling connected to your relationship and yourself is closely tied to intimacy. That’s why seeking out a counselor who has experience helping individuals with cancer can be beneficial for both you and your partner. They can assist in addressing these issues and provide support.

• Identifying next steps: Talking with your healthcare provider can assist you in navigating and tackling this challenge. Consider including your partner in these conversations as well.

• Lifestyle changes: Focus on reducing stress and improving overall health through changes in diet, exercise, and relationships

• Counseling or therapy: Discussing feelings and concerns with a professional can help change perspectives and mindset, increase body appreciation, and boost self-esteem

• Self-management: Ways you can manage your symptoms include:

  • Self-education/awareness

  • Physical exercise

  • Self-confidence-building exercises

  • Journaling/stress management

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How to use vaginal dilators:

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1. Choose the best time for you when you are alone and comfortable

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2. Get your dilator out, use the smallest dilator first

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3. Wash your hands thoroughly with soap and water

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4. Wash the dilator with warm water and unscented soap

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5. Start applying water soluble or water-based lubricant on your dilator and if needed, on the opening on your vagina *Do not use Vaseline or any oil-based lubricant*

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6. Begin to lie on you back with your knees bent and spread about shoulder-width apart

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7. Start opening your labia with one hand

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8. Inhale deeply, then slowly exhale through your nose or mouth. As you do this, gently insert the dilator into your vagina using your other hand. The deep breathing helps relax your vaginal muscles, making it easier to insert the dilator.

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9. Once the dilator is in place, hold it there for a few seconds. If you don’t feel too much discomfort, take another deep breath and, while exhaling, gently push the dilator further in until it feels as far as it can comfortably go.

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10. If you don’t feel any pain, keep the dilator in place until you’ve reached its maximum comfortable depth. If you experience pain, gently remove the dilator and try again the next day.

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11. If there is no pain, gently maintain some pressure on the dilator to ensure it reaches the deepest part of your vagina.

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12. Once the dilator is fully inserted, try to gently move it in small side-to-side and up-and-down motions. This helps stretch and expand the vaginal walls. When you're done, carefully remove the dilator. It's normal to experience a small amount of spotting or bleeding after use.

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13. Clean the dilator with warm water and an unscented soap to remove any remaining lubricant. Rinse it thoroughly and allow it to air dry. Store the dilator in a clean, dry place.

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14. Finally, wash your hands again.

 

 

Every person’s needs are unique, so it’s important to reflect on these topics so that you can better understand how breast cancer has affected your sexual health. Consider asking yourself:

• How do you think that cancer has affected my sexual activity? 

• Are there any differences in my sexuality before and after treatment?

• What are your goals for sexual health and intimacy?

• Have you shared any of these concerns with your partner?

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​All of the physical changes that your body is going through can impact how you see yourself and feel about sex. But it’s important to remember that you are not alone. Many other survivors go through this too. In fact, a recent analysis found that 70% of breast cancer survivors with partners reported sex difficulties post-treatment

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