Survivorship - May 11, 2017
Sex and Intimacy for Breast Cancer Survivors: During Treatment and Beyond
Almost all women who have received treatment for breast cancer have a list of questions that they find difficult to ask during a clinical visit with their oncologist. “Women want to talk about aspects of sex and intimacy,” says Maryann Forrett, CNP, RN, of the Breast Clinic at the Mayo Clinic in Phoenix, Arizona.
Cancer treatment can create vaginal dryness, making intercourse painful. Surgeries can deprive women of sensation in their nipples and breasts.
“Sex is a big issue, and there is a lot to discuss about the physical changes created by treatment. Equally important are questions about recreating intimacy. Now that the focus on treatments and side effects is over, many women find it is difficult to feel sensual with their partners again,” said Ms. Forrett.
Nurses are the primary contacts for most women posttreatment. Ms. Forrett finds that her patients are eager to talk about the sex and intimacy once she introduces the topics. “I raise the questions that they are thinking about, but don’t know what to ask,” said Ms. Forrett.
Consequences of Treatment
Perhaps surprisingly, Ms. Forrett usually begins by talking about the physical consequences of treatment: painful intercourse, a lack of sensation in nipples and breasts, and often a poor self-image associated with surgical scars and reconstruction.
“I usually start by asking if they are experiencing vaginal dryness during intercourse. I explain why many of the medications cause dryness, what a dry vagina looks like, and why water-based lubricants tend to stop working over time.”
Ms. Forrett has noticed that women as well as men are eager to discuss sexual problems once they realize she is comfortable listening to their concerns, and answering with concrete advice and help.
“They’re so relieved to finally talk about a way forward,” she said.
After everyone is comfortable talking about anatomy and physiology, Ms. Forrett tries to lead the conversation into the realm of intimacy. “Intimacy happens outside of the bedroom,” explains Ms. Forrett. Many couples find that emotional connection can be elusive after months of cancer treatment, including surgery.
Mind and Body Connection
“Libido for women is so often centered in a mind–body connection, and needs to be nurtured and communicated. Women want to be touched and kissed in many different places, to help us feel loved. Often I give couples homework to help them rediscover how to start dreaming again about what life is going to look like; what is fun for them,” she says.
“Every woman is different, and her situation is unique, but certain aspects of treatment and its effects are the same for everyone,” says Ms. Forrett. Here are some of the questions that Ms. Forrett tries to raise with her patients, and her answers.
Q&A: Sexuality After Cancer
Q: What causes the vaginal dryness, and how can I make intercourse less painful?
Answer: An estrongenated vagina before treatment is thick, moist skin over muscle. The cervix is located in the upper half of the vagina, and some of the lubrication comes from there. The lower third of the vagina has more nerve endings than a male penis. When we remove estrogen from the body through aromatase inhibitor therapy or surgery, the vagina becomes dry, and the tissue thins. The vaginal tissue becomes dry and red, and without use, it shortens or atrophies.
Without lubrication, normal intercourse generates friction that causes pain. This causes sexual avoidance. The thinner the vaginal walls, the less effective water-based lubricants become over time. In addition, many lubricants are not made for internal insertions, which is what is needed in this case. I recommend oil-based lubricants; for example, vitamin E suppositories work very well. Many patients also use coconut oil as a lubricant.
Q: Is it possible that my vagina has shrunk? Insertion feels like a painful stretch.
Answer: Yes. If a couple has not had intercourse for 1 year or more, the vagina, like any other muscle, may have atrophied. Vaginal dilators come as a set of dilators that range from small to large and gradually stretch the vagina to its original width and length.
Low doses of vaginal estrogen help to rejuvenate an atrophied vagina. This is a decision that is made between the patient and the provider. Often, all that is needed is encouragement and reassurance that the dilators will work with time and consistency.
Q: I am embarrassed when I am naked with my partner. My breast looks fine, but I can’t feel anything. My nipples are missing; I have scars. I don’t feel attractive or captivated by my partner’s touch anymore. What can I do?
Answer: I always ask if she has given her partner a chance to see her reconstruction. Sometimes, all you need is reassurance from your partner or provider that you look great and no longer have cancer. Many women don’t realize they can get 3D, nipple tattoos, which look real and don’t fade.
If breast stimulation is not effective, I encourage couples to experiment with sensate focus. Touching their bodies in nonsexual ways to connect the mind with the body.
I remind women again that intimacy happens outside of the bedroom, and that reconnecting is probably not going to happen in front of a TV. I’ve seen it happen many times: when a couple actively tries to refocus their relationship and rediscover intimacy, their appreciation for each other rekindles like magic.