Can women enjoy sex without pain after cancer?

Gina Franco, ANP

Integrative Oncology, Lifestyle Medicine

Sexual problems are one of the most common, lingering side effects of cancer treatment. As many as 60% of women find that sexual contact or intercourse becomes painful after cancer diagnosis and treatment. Women may also experience decreased desire and difficulty with orgasm. Gina Franco, MSN, ANP-C, explained why this happens and offered some solutions for those looking to enjoy sex without pain after cancer.

Why do women experience sexual pain during and after cancer 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.

Cancer treatments that are more likely to cause sexual pain include the following:

• 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.
• Surgery that shortens the vagina or alters the external opening of the vagina.

What can you do if sex has become painful?

It is important to seek help because this problem can often be greatly improved. Below are some options to help reduce pain and improve your ability to enjoy sex without pain after cancer.

Vaginal moisturizer. 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™.

Vaginal lubricant. 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.

Low-dose topical hormones in the vagina. 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 or DHEA/testosterone hormone in the vagina in the form of a cream, tablet or vaginal ring. Women are often afraid to use any hormones 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 and low dose DHEA/testosterone even safer. Women who have had other types of cancer may overestimate the dangers of vaginal hormones but should always consult their oncology team prior to use.

Vaginal dilators. Women 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.

Pelvic floor therapy.  Painful intercourse may be due to tightness in pelvic floor muscles or narrowing of the vaginal canal, A pelvic physical therapist helps address issues related to the pelvic organs and pelvic floor, or core muscles.

Can anything be done about decreased sexual desire?

Cancer treatments may lead to a low libido or a low desire for sex and intimacy. Anxiety, stress, fatigue and altered body image can also compound decreased desire for sex. A thorough review with a trained professional to discuss any medications that could be decreasing desire, as well as looking at newer medication options for increasing sexual desire in women, is recommended.

“The most important point is that help is available,” Franco said. “Sex without pain after cancer is definitely possible! 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. We also have newer drugs and treatment options that have offered us more options to try for women.”