THE SILENCE ON SEX and cancer is deafening. Although sex is a natural and important part of life, patients, survivors and partners don’t always feel supported in this area of treatment aftermath.
Recently, the American Society of Clinical Oncology (ASCO) and the National Comprehensive Cancer Network (NCCN) issued updated guidelines on the subject. For women’s cancers, ASCO recommends that all oncology professionals offer psychosocial and/or psychosexual counseling, in addition to treatment for genital symptoms. The NCCN advises screening for physiological factors, such as menopause or illness; disease-induced changes; medication- induced side effects; and psychological factors. For nearly 40 years, Leslie Schover, Ph.D., a clinical psychologist and the founder of Will2Love, has helped patients overcome cancer-related concerns about sex and fertility.
In an interview with CURE, she provided answers to the questions that many are too embarrassed to discuss.
What are the most common sexual concerns among women who have been treated for gynecologic cancers?
Schover: The most troublesome is vaginal dryness, pain with caressing on the vulva and pain with penetration of the vagina, which often goes along with reduced vaginal size. They are concerned about anything that can cause premature menopause or — even for women who are already menopausal — worsen the symptoms. Loss of stretchiness of the vaginal area, loss of blood vessels and a more tender vulva can cause a lot of problems because of pain.
The second most common concern that women face is loss of desire for sex. But the first thing I ask when I hear that is “Are you having pain?” If sex hurts, you won’t look forward to it.
Some women are concerned about incontinence, either urinary or fecal, which can be embarrassing. It’s a really under-recognized problem.
How can women overcome these sexual challenges?
It’s important for women to be assertive and talk with their oncologist. If they don’t get a good response, they should talk with their gynecologist. It’s a real dilemma for women, because a lot of times community gynecologists don’t know a lot about cancer-related sexual problems.
A woman may regard her gynecologist as kind of the sex expert, but a lot are not knowledgeable about these problems. Sometimes it helps to look for a gynecologist who specializes in menopause.
One thing women can do right away, especially if they are experiencing pain, is try over-the-counter vaginal moisturizers and lubricants that don’t contain hormones.
Some of these products require daily use to be effective. I recommend that women use a combination of a vaginal moisturizer at bedtime three times a week, or up to daily if needed, and then add in a good water- or silicone-based sexual lubricant when they have sexual activity. They should spread it liberally on themselves and their partner. Even the best lubricants dry out after a few minutes, so instead of doing this secretly in the bathroom, make it part of lovemaking and foreplay.
A vaginal dilator, which stretches the vagina, is another option, although it’s best to consult a gynecologist to make sure it’s safe.
When is it safe to have sex again following a cancer diagnosis?
For most women, it’s OK at any time. There are a few exceptions, however. If a woman has a tumor, like a cervical cancer, with a lot of bleeding, then her oncologist may tell her to avoid sexual penetration until enough treatment has been given to reduce the extreme bleeding. Another problem: when the immune system is suppressed, such as during chemotherapy. Again, the oncologist may suggest not having sexual activity — or even avoiding other close contact with people — to lower the risk of infection. These are both usually temporary issues. A few chemotherapies also can cause temporary vaginal irritation. A person wouldn’t want to aggravate that by trying to have sex when she is hurting.
How can partners get involved, and how can single women who are dating handle this?
When a woman is in a close relationship, the more she and her partner talk, the better off they’ll be. It’s best to discuss it before being in the bedroom, because that’s when both people are most vulnerable. Find a private time and say, ‘There is some stuff I’d really like to talk about.’ If it’s difficult to talk with one another, that may be a great reason to see a counselor, who can offer a safe space.
For women who are single, dating is a challenge in general. After cancer, people always ask: ‘When should I tell a new partner about my cancer? Should I tell a partner about my cancer history?’ I think one common mistake people make is blurting it out immediately. Get to know the person and get a sense of their friendliness before bringing up the illness or any limitations on your sex life.
The other extreme mistake is to try to hide it, and then have someone find out and feel really insulted or betrayed. The one reassuring thing that I try to always say is that if someone rejects you because you have had cancer, you wouldn’t really want to have that person in your life.
How can women regain their sexiness when they may feel less attractive?
It’s a learning process and requires practice. I often suggest that women practice looking at themselves in the mirror. They should start out completely dressed and wearing their usual makeup, then identify three things that they like about the way they look. When they can do that, they should do the same wearing just a bathrobe and no makeup. Finally, they should look at themselves in the nude and still make those positive affirmations.
There are plenty of myths about sex and cancer. Which ones would you like to bust?
One of the big ones is that cancer is contagious through sex. People get confused partly because there are a few types that are related to the human papillomavirus, which is sexually transmitted. But it’s the virus that is transmitted, not the cancer.
Then there is the myth that having sex will make cancer worsen or return. Sometimes women, especially those who are less educated, worry that caressing breasts leads to breast cancer, and there are no relationships there.