*NOTE: This content is intended for adults who have experienced cancer and may not be appropriate for children.
Sexual problems are one of the most common, lingering side effects of cancer treatment. As many as 60% of women find that sexual caressing or intercourse becomes painful after cancer diagnosis and treatment. Normally, the vagina undergoes changes during sexual excitement that make intercourse comfortable, such as increasing in size and becoming lubricated. The natural process of menopause reduces vaginal lubrication and size, but changes are gradual in that case. Some cancer treatments lead to severe vaginal dryness and shrinkage, as well as making the area at or around the vaginal entrance more tender and easily irritated.
What cancer treatments are most likely to cause dryness and pain with sexual caressing or intercourse?
- Treatments that cause sudden menopause in women who were still premenopausal at cancer diagnosis—including removing both ovaries as part of cancer surgery or severe damage to the ovaries from radiation to the pelvic area or chemotherapy
- Direct radiation to the vaginal area, which can cause damage to the vaginal lining and walls
- Aromatase inhibitors, a type of hormone therapy often used as part of breast cancer treatment, makes vaginal dryness and shrinkage more severe, even in women who were already in menopause
- Stem cell or bone marrow transplants from a donor can cause severe scarring from graft vs. host syndrome when the immune system attacks the vulva and vagina
What can you do if sex has become painful?
It is important to seek help, because this problem can often be greatly improved. The Prisma Health Cancer Institute’s Center for Integrative Oncology and Survivorship (CIOS) has a new program, the Sexual Health Evaluation (SHE) visit, that includes both dialogue with a trained nurse practitioner to help understand the problem and a physical examination when needed to diagnose any changes of the vulva and vagina.
A first step is often to use an over-the-counter vaginal moisturizer, usually a gel that a woman puts into the vagina using a small applicator several days a week to keep the vaginal lining moist. Moisturizers might include Hyalo-GYN™ or Replens™. There are many on the market, and the staff at CIOS can help you understand the differences between them and where to buy them.
Even with the regular use of a vaginal moisturizer, most women should add either a water-based or silicone-based vaginal lubricant for comfort during sex. Many excellent lubricants are on the market, but it is important to make them part of your routine. Keep a lube by the bedside and have both partners apply it during caressing. Even the best lubricants will dry out, so stop and use some more if needed! The staff at CIOS can assist in which one might be good to try and even where to buy them. Some are not beneficial to use during sexual activities and there are even some it is best to avoid altogether.
If the combination of moisturizer and lubricant are not enough to prevent sex from being painful, many women get relief from a low dose of estrogen hormone in the vagina in the form of a cream, tablet or vaginal ring. Women are often afraid to use any estrogen because they worry it will increase their risk of having breast cancer as a new or return diagnosis. Oncologists are very cautious about vaginal estrogen in women with a history of hormone-sensitive breast cancer, but studies suggest low-dose vaginal estrogen is probably safe. Women who have had other types of cancer may overestimate the dangers of vaginal estrogen, but should always consult their oncology team prior to use.
Women also may benefit from stretching the vagina with a set of special silicone tubes called vaginal dilators, especially in combination with muscle exercises (Kegels) that help a woman control muscle tension around the vaginal entrance that may be contributing to pain. Some physical therapists also have special training in pelvic rehabilitation to treat pain or incontinence with sex. The staff at CIOS can help identify patients who might benefit from this type of referral. Some patients also might need an update on how to do Kegel exercises since there are newer instructions on how to do these properly.
The most important point is that help is available. Sexual pleasure is an important aspect of quality of life. Painful sex is not only a loss for a woman cancer survivor, but also can damage intimacy and affection in her relationship with her partner. For more information about the SHE visit, email the CIOS program at firstname.lastname@example.org or call Stephanie Hoopes, RN, at (864) 455-5219. To view more resources, visit Will2love.com.
This blog post was co-written by Gina Franco, MSN, ANP-C, director of Integrative Oncology & Survivorship at the Prisma Health Cancer Institute, and Leslie R. Schover, PhD, clinical psychologist and founder of Will2Love.