Sexual problems – female sex organs

Cancer and its treatments can affect your sexual health. You may have vaginal dryness or shortening, painful sex or low sex drive. But many sexual problems related to cancer can be treated or managed. First, you need to be able to talk about them.

You're not alone if you find it very hard to talk about sex. Don't let feeling awkward or embarrassed get in the way of getting the help you need. Sexual health is just as important as other areas of health. Doctors and nurses are there to help, not to judge. And everything you tell them is confidential. It's worth trying to find someone on your healthcare team you can talk to about sex, or ask to see a new healthcare professional. Try to think of a sexual problem as being like any other side effect – you need to be open and honest with your healthcare team in order to get the best treatment for you.

Find out about the female sex organs and reproductive system.

These are some of the sexual problems that can develop after cancer treatment:

Vaginal dryness happens when the vagina doesn't make enough moisture or lubrication. Sexual penetration can be difficult or painful when the vagina is dry. Vaginal dryness is one symptom of menopause, and cancer treatments like surgery, chemotherapy and radiation therapy can make you go into menopause (called treatment-induced menopause).

Vaginal stenosis is when the vagina becomes narrower and shorter. It can be caused by hormone therapy, radiation therapy to the pelvic area or some types of surgeries of the vagina. It can also be caused by graft-versus-host disease (GVHD) after a stem cell transplant. Having a shorter and narrower vagina can make penetration painful.

Painful sex can make you less interested in sex or afraid to have sex. If you are worried that having sex will be painful, you may find it harder to become aroused. This may lower the amount of natural lubrication your body makes, which can lead to more pain and tension.

Side effects of treatment can change how you feel and affect your sexual desire.

Treatments for cancer of the sex organs or nearby organs, such as uterine, ovarian, cervical, bladder, vaginal, vulvar, colon or rectal cancer, can cause sexual problems.

The following surgeries can cause sexual problems:

A hysterectomy is surgery that can be used to treat uterine, ovarian, cervical or vaginal cancer. There are different types of hysterectomy. A hysterectomy can cause vaginal stenosis and make the genital area numb. If the ovaries are removed as part of the surgery, it can also put you in menopause and cause vaginal dryness.

A radical cystectomy is surgery for bladder cancer. It removes the bladder along with the uterus, ovaries, fallopian tubes, cervix, front wall of the vagina and the urethra. You will have a urostomy so that urine can pass out of the body. Vaginal reconstruction may be done to rebuild the vagina you will have vaginal stenosis.

An abdominoperineal resection is surgery used to treat colon cancer. It can sometimes remove the uterus, ovaries and back wall of the vagina. Vaginal reconstruction may be done to rebuild the vagina but it will be shorter than it was. If the ovaries are removed, it can cause early menopause and vaginal dryness.

A vulvectomy is surgery for vulvar cancer. A vulvectomy removes part or all of the vulva. It may also remove the clitoris. Removing part or all of the vulva can cause discomfort because the padding around the vagina is gone. The vulva can look different after surgery depending on how much tissue was removed. Being concerned about this and what your partner might think can affect your interest in sex and feelings about sex. Reconstructive surgery may be done to rebuild the outer and inner lips of the vulva but there will still be a loss of feeling.

A pelvic exenteration is surgery done for advanced cancer in the pelvis. It removes the uterus, cervix, ovaries, fallopian tubes and vagina. Sometimes the bladder, urethra and rectum are also removed. Vaginal reconstruction is done but the vagina will be shorter than it was. Recovery from a pelvic exenteration can take 6 months or longer.

Surgery for breast cancer that removes part or all of a breast can also cause sexual problems. The most common sexual side effect is feeling less attractive. The breasts and nipples are sources of sexual pleasure and surgery can affect that.

Radiation therapy to the pelvis can cause sexual problems. It can cause treatment-induced menopause with hot flashes and vaginal dryness. Radiation therapy to the vagina can cause tenderness and scarring to the walls of the vagina, which can lead to vaginal stenosis.

Chemotherapy and hormone therapy can cause treatment-induced menopause along with vaginal dryness and a lower sex drive. Side effects of treatment, such as fatigue and pain, can also affect your sex drive.

Emotional factors, such as the following, can also affect your sexual health and lower your sex drive:

• anxiety, depression and stress
• changes in body image, confidence or self-esteem
• fear of pain
• worrying about sexual performance
• unhappiness and embarrassment because of physical changes
• worry about how partners will react

Whether it is safe to have sex during treatment depends on your treatment plan. Ask your doctor if there are times when you should avoid having sex and what you should do to protect yourself and your partner when you do. For example, if you had surgery to the pelvic area, you may have to wait for your body to completely heal before you try having sex.

Your healthcare team may recommend using a barrier method (condoms or a diaphragm) for a few days after chemotherapy to prevent exposing your partner to chemotherapy drugs that can get into vaginal fluids.

Some cancer treatments may cause birth defects to a developing fetus so you should use birth control to avoid pregnancy during treatment. Talk to your healthcare team about which birth control method is best for you and how long you should use it for.

Your doctor may do a physical exam and pelvic exam to help find the cause of your sexual problems. Your doctor will also ask you questions about your sexual history, the type of sex you have and how it fits into your life, whether or not you have a partner and personal questions about your daily life and  feelings.

Once the type and cause of the sexual problem is known, your healthcare team can suggest ways to manage it. Talking openly and honestly with your sexual partner will be important, both as a first step and as you continue to find ways to feel sexual pleasure together. Information and counselling can help. Some psychologists or social workers specialize in sex therapy. Your healthcare team can also suggest relaxation exercises and techniques to reduce anxiety.

The following may help you manage vaginal dryness, vaginal shortness and painful sex.

Deep pelvic thrusts from a partner may be painful if you have vaginal stenosis. Talk to your partner about your discomfort and what positions are painful. Try exploring other positions that may be more comfortable. Changing position may provide more control over the depth of penetration.

Using moisturizers regularly can help keep the vaginal tissues moist and relieve vaginal dryness. Moisturizers cover the tissues in the vagina with a thin, mucus-like coating. Moisturizers should be used every other night for the first 4 to 6 weeks and then can be reduced to every 3 to 4 days. You may have some discharge at first when using the moisturizers, but this usually decreases over time.

Drugstores carry different brands of moisturizers. Your healthcare team may be able to recommend one. You may need to try several to find out which works best for you.

Lubricants are used during sex to make it more comfortable. They may have a water, silicone or oil base. You will still need to use a lubricant even if you are using a moisturizer.

Your healthcare team may be able to recommend a lubricant. Don't use ones with perfume or colouring because they can irritate tissue in the vagina. Don't use oil-based lubricants with latex condoms. Oil-based lubricants can make latex condoms break and may increase the chances of bladder and vaginal infections. You may need to try several types to find out which works best for you.

Your healthcare team may suggest different medicines depending on what is causing the sexual problem.

Low-dose vaginal estrogen may be used in flexible ring, cream or tablet form to deliver estrogen to the vagina to restore vaginal health if moisturizers or lubricants aren't working.

Intravaginal dehydroepiandrosterone (DHEA) may be used to treat vaginal dryness or pain.

Vaginal lidocaine can be put on the vaginal opening before sex to lessen pain and increase pleasure.

Hormone replacement therapy (HRT) may be used to treat hot flashes if you have a type of cancer that isn't affected by hormones.

Vaginal dilators are plastic or rubber tube-like devices used to stretch vaginal tissues and prevent the vagina from shrinking. When the dilator is in place, it feels much like a large tampon. They can be used after surgery or radiation therapy to the pelvis to avoid or minimize the effects of vaginal stenosis.

If you have surgery to rebuild or reconstruct the vagina using skin grafts, you may need to wear a special type of dilator all day or night for a while.

If you have vaginal stenosis after radiation therapy ends, it is very important to stretch the vagina with a vaginal dilator and by having sex a few times a week for 6 to 12 months. Using the dilator may not be necessary over the long term, but you will need to continue using it if you aren't having sex regularly. Using the dilator over your lifetime will keep the vaginal walls stretched and open, which helps with pelvic exams.

Talk to your doctor or healthcare team about vaginal dilators and how they can help you. They can tell you where to get a dilator, what size to get and how to use it.

Relaxation techniques, warm baths, massage or gentle touching can help decrease pain. They can also help you relax.

Pelvic floor exercises stretch and strengthen the pelvic floor muscles and return their tone to normal. A physiotherapist or other healthcare professional can teach you how to do them. A physiotherapist may also suggest internal massage of scar tissue and pelvic floor muscles to relieve pain.

Sex may not have been a priority for you or your partner during treatment. When you feel you are ready to start to try having sex, think about what sparked romance for you before treatment and try the same thing. Try music, a romantic meal or a night out. Relax and take your time. Talk about how you feel and simply enjoy being together.

Other effects of cancer such as body changes, pain, fatigue, depression or trouble sleeping can lower your sex drive. Some people worry that they are no longer attractive to others. Try to focus on things that you think are most attractive about yourself. Have sex partially clothed instead of naked if it makes you feel more comfortable. Being physically active, maintaining a healthy weight and eating well can help you feel better about yourself and it can also help with fatigue and other side effects.

Talk to your partner about how you feel, what feels good and what doesn't, and if you are tired or uncomfortable. Even if you can't have sex you can still enjoy holding hands, kissing, cuddling and other ways of being close with your partner.

Surgery for cancer may make a certain position painful. Try different positions to find out what works for you and your partner.

Talk to your healthcare team about coping with changes in your body image and sexual health. They may be able to suggest ways to help you manage side effects such as fatigue, hair loss, pain, difficulty sleeping or depression that also affect your sex drive. You may find it helpful to talk to others in a support group or online discussion board.

Our booklet Sex, Intimacy and Cancer has more information to help you and sexual partners understand and cope with the ways that cancer and its treatments can affect sex and sexuality.