SEXUALITY and INTIMACY for Women after Cancer

1. SEXUALITY and INTIMACY for Women after Cancer Karen Syrjala PhD Co-Director, Survivorship Program Director, Biobehavioral Sciences a member of the

2. Topics: • How does cancer affect sexuality for women? • What can you do about it?

3. What female survivors say: “Zip, zilch, nada, gone.” “Since my treatment I have had no desire and have not been able to reach an orgasm. My partner does not know about my lack of interest, it would hurt him.” “I really would like to have the feeling of love again or orgasm. You wonder what you are doing wrong.” “Same partner, much less sex. Both of us are content, but miss being frequently and spontaneously sexually intimate. Dry vagina and yeast infections are a drag.” “My body had changed so much I felt very unattractive and not sexy at all. I thought that he would find me repulsive…” “We have a healthy sex life. My partner is patient with me!”

4. Fears of survivors & partners • Hurting partner or demanding too much • Rejection fear: • ‘He/she can’t find me attractive when I look like this.’ • ‘He/she won’t be responsive if I ask so why ask?’ • Suppressing own needs / over-focus on the other person • Talking will make it worse

5. Other Barriers and Beliefs • When it’s time, I’ll / he’ll / she’ll feel like it • Being alive is enough • She / he doesn’t want to talk about it • Nothing can be done so it’s cruel to bring it up • If it’s a problem, she’ll bring it up • It will take care of itself with time

6. Sexual Function Quality & Quantity Women recover in sexual frequency rates by 2 years, but do not fully recover in quality. Women remain below rates for without cancer in frequency and quality. 40-60 % of women are not sexually active at each time point Syrjala et al. Blood, 2007

7. After Treatment: Who has more problems? • Poorer sexual function before treatment • Being female • Older age • Poorer physical function 1 year after treatment • Lower relationship satisfaction before treatment • Not returning to sexual activity by 1 year • Becoming postmenopausal from treatment and no hormone therapy by 1 year • Depressed or anxious

8. Types of sexual difficulties • Sexual Interest not decreased after cancer • Sexual Desire • Fewer thoughts or fantasies • Less responsive to partner’s touch/initiation • Sexual Arousal • Difficulty with lubrication or erection • Change in physical sensations

9. Types of sexual difficulties • Orgasm • Longer time to climax • Unable to climax • Less intense climax • Pain • Decreased lubrication • Vaginal tissue atrophy • Infection or • Nerve increased sensitivity to touch • Vaginismus – muscle spasms • Vulvodynia – neuropathic sharp intense pain

10. Types of sexual difficulties • Body Image • Surgical scars, loss of breast or other body parts • Changes in body, muscle tone, skin • Weight gain or loss or shift • Receptiveness to Sexuality • Mood changes: irritability, depression, worry • ‘Protecting partner’ reduces intimacy

11. Issues Differ by Age / Situation • Young • Lack of information • Relationship changes: not in a stable relationship or with a single partner • Menopause symptoms may be more abrupt, severe • Don’t have sexual patterns to know clearly what changed • Single / No partner • Dating and explaining • Need safe ways to try things out • If want to be sexual later, need action now • Mature • “Maybe it’s just aging” • Increased sensitivity of skin, other changes in responses require adaptation of partner and person

12. Causes: Chemotherapy • Damage to ovaries depends on age, type of drugs, and dose of drugs • Women who stop menstrual periods and then restart them are still at risk for early menopause

13. Causes: Premature Ovarian Failure • Permanent ovarian failure is not uncommon • Ovaries no longer make estrogen • Vagina loses blood flow / ability to stretch • Vulvar skin and vaginal lining become thin and fragile • Vagina does not deepen as much with sexual excitement • Pain with sexual touch or penetration, burning, spotting of blood after intercourse, • Frequent urinary track or vaginal yeast infections • Leaking urine

14. Treating Pain Problems

15. Causes of Painful Sex • Vaginal dryness & tightness from menopause • Radiation damage to vaginal tissue • Pain after surgery to genital or pelvic area (adhesions and scarring)

16. Specific Techniques for Sexual Pain… • Learn to control pelvic muscles: tense & relax • Use coital positions that minimize deep penetration and give the woman control • Consider a set of graduated vaginal dilators • Could vaginal expansion and blood flow from sexual arousal work as well as mechanical stretching?

17. Dilators Available on Internet www.soulsourceenterprises.com www.vaginismus.com

18. Learn About Lubricants • Use nonhormonal lubricants optimally; Replens and water-based types • Lubricate all surfaces as part of foreplay • Keep water-based lubricant handy in case more is needed

19. Water-based: Astroglide Liquid Silk GV Slip Inside Hydra-smooth Sensua Organic Probe Silicone-based: Wet Platinum Eros Types of Lubricants

20. Vaginal Moisturizers • Replens takes up to 2 months to have full effect • Early vaginal discharge but does have double-blind studies published • Feminease, claims to be all-natural • Moist Again has applicator

21. Lube Resources • www.evesgarden.com • www.drugstore.com

22. Local Estrogen Treatment • If lubricants don’t help, consider vaginal estrogen • Estring and Vagifem local vaginal hormones with very little systemic escape • Oncologists and gynecologists may disagree about safety of oral or transdermal (skin patch) hormones

23. Treating Desire Problems

24. Causes of Low Desire after Cancer • Loss of desire is the most complex and difficult sexual problem to treat • Stress of illness • Depression • Chronic fatigue • Relationship issues exacerbated by illness • Body image changes • Painful sex • Lack of estrogen • Multiple medications

25. Is the EROS® Better Than a Vibrator? $400 $40

26. Is Testosterone the Answer?

27. Maybe for Those With Truly Low Hormones • Fad for replacement testosterone • No good evidence it works in women over time • Safety issues in cancer survivors • Increases risk of breast cancer • Taking DHEA from health food store or bioidentical hormones just as risky • No correlation with woman’s own testosterone • Or with sexual desire or satisfaction in naturally postmenopausal women

28. Pills to Enhance Sexual Desire • No aphrodisiac yet, but drugs being tested • Be careful of claims for: • Pink Viagra • Dream Cream • Avlimil • L-arginine, etc.

29. Major Issues • Return to sex as soon as possible, but gradually. • Estrogen therapy is not a magic bullet, but if an option, it’s likely to help (at least with transition). • Especially if premenopausal before treatment. • If an option, start of estrogen right after completing treatment. • Valuable for improving long term sexual function. • Unclear how long is useful and safe • Lower dose hormones: • Vaginal creams • E-ring (vaginal ring)

30. Techniques to Enhance Desire • Identify activities that increase sexual desire: • Intimate talks, cuddling, romance • Physical sports or dance • Use erotic stories, videos, fantasies • Talk to your partner about what has changed in your responses, how to please you • Get counseling for relationship conflict or depression • Change meds that could be interfering • Treat any sexual pain or vaginal dryness

31. COMMUNICATION… • SET ASIDE TIME: Talk and listen! • Listen, try to remain open to the discussion. Keep the words non-blaming and ‘I’ focused. • Chances are both partners are interested in improved intimacy and sexuality. • Sensitive subject takes sensitivity, timing, neutral setting. (Not when tired or in bed trying sex.) • Agree on a time, decide if prefer a neutral professional to assist.

32. GO BACK TO ‘DATING’ • Start with a plan for intimate time, not sex • Avoid the performance focus on sex • Remember the fun of “petting” • Try sex in the shower or tub • Get in the mood with dancing • Practice all by yourself • Try a “mini-vacation” • Candles, low lights, music, start with intimacy, not sex

33. Reaching Orgasm More Easily • Goal is to promote arousal • Do not make orgasm a goal that creates performance anxiety • Use fantasy and erotica • Try self-stimulation techniques • Consider a vibrator

34. Conclusions • Nearly all of us feel vulnerable about our sexuality. • But sex is an important part of living fully. • Sexual problems are ‘normal’ after treatment. • Use it! Help it happen.Don’t wait until you feel like it – you may not at first. • Plan time for intimacy. • Communicate with your partner!

35. Seek Help for Sexual Problems • You need to bring up the topic with your doctor • Doctors may have their own barriers to addressing sexual problems. Find one who can help you. • Insurance may not cover all of the costs • Both partners need to understand the range of treatments available and agree on one

36. SOLUTIONS IN FINDING HELP • Written materials: • ACS Sexuality and Cancer Booklets • Sexuality and Fertility after Cancer, Leslie Schover, 1997 • See an endocrinologist • See a sexuality specialist - GYN • Talk to sexual counselor with your partner