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SEXUALITY AND CANCER
( By JASCAP )

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Solutions to sexual problems

Some solutions to sexual problems caused by cancer and its treatment

In this section there are some suggestions of what may help with some of the sexual problems that you may experience as a result of cancer or its treatment.

A mismatch in desire
Pain during intercourse
Vaginal problems
Lowered sex drive in women
Loss of erection after surgery
Support with body changes

A mismatch in desire
It is important to let your partner know if you do not feel interested in sex. It can be helpful to explain how you feel, so that they do not feel rejected. You can also suggest what you are happy to offer as an alternative – such as, 'I don’t want to have sex but would love to give you a cuddle’.

If your partner is feeling frustrated it may be helpful for them to reduce the frustration through masturbation, either with you or alone.

If you have fatigue (continual tiredness that is not relieved by rest) and don’t have much energy, it might help to make love differently. Less energetic positioning, where your weight is well supported, can reduce strain. You may prefer quicker sexual contact rather than longer sessions. These are things you can talk about together.

If the tension is building between you, you may find it helpful to get support from a counsellor who specialises in offering help in these circumstances.

Pain during intercourse

Pain during intercourse can occur after pelvic surgery or radiation to the area. It may also occur if medicines reduce the production of natural lubrication.

Pain can reduce sexual feelings and reduce desire. Often, an experience of pain can lead to a fear of pain, which can in turn lead to tension. This tension can then distract the person from achieving arousal, prevent lubrication and cause further pain.

There are many reasons for pain. It is important to let your partner know what is painful so that you can explore other positions or ways of making love. Often, the cause can be treated simply. If you have pain, it is important to tell your doctor, who can examine you to find out why and suggest solutions.

If you have pain or are worried about pain, it may helpful if you:

take control over the depth and speed of penetration
try to ensure your partner, and/or you, are close to orgasm before penetration
make love after pain medicines have been taken
use pillows and cushions to help you feel more comfortable and supported
make love side by side, to reduce body weight on a sore scar area.

Our booklet on controlling cancer pain might help.

Vaginal problems
Cancer treatments, such as chemotherapy, hormonal therapy, or radiotherapy to the pelvic area, may cause changes to the vagina that can lead to dryness, narrowing, ulcers and infection. These changes may lead to pain during intercourse.

Vaginal dryness
This can be helped by a number of creams and gels that can be put directly into the vagina.

Replens® is a non-hormonal cream available from most chemists. It is applied 2–3 times per week and works for about three days at a time. The cream binds to the vaginal wall and the water held within it reduces dryness and boosts the blood flow in the vagina.

Ovestin®, Ortho-gynest®, and Premarin® are available on prescription from your doctor. They contain very small amounts of oestrogen and can be used as a cream or a pessary. The effect in the vagina is short lasting. The amount of oestrogen in this product is considered to be so small that it does not cause any hormonal influences elsewhere in the body.

Vagifem®, also on prescription, is a gel which contains a small amount of oestrogen. It can be used twice a week. A small research study has shown that Vagifem can increase the amount of oestrogen circulating in the body. Because of this risk, Vagifem may not be recommended for women who are taking aromatase inhibitors, such as anastrozole (Arimidex®), exemestane (Aromasin®), or letrozole (Femara®). Your specialist or breast care nurse can give you further advice and information about this.

Water based lubricants such as KY Jelly, Senselle®, Astroglide® and SYLK® which can be bought at a chemist, can help to increase moisture levels, making sex easier. Some women prefer to use glycerine as it is cheap and not embarrassing to buy due to its many uses.

Vaginal narrowing
This may happen after radiotherapy to the pelvis and sometimes after surgery. After your treatment you will usually be advised to use vaginal dilators. These are plastic tubes of varying sizes which you can be inserted by yourself or as part of joint sexual touch. The dilators prevent the two side-walls of the vagina sticking together, and are used with lubricants. They are available from your doctor or specialist nurse at the hospital. An alternative way to prevent vaginal narrowing is to have regular intercourse or to use a vibrator.

Vaginal ulceration
Radiotherapy can also cause sore areas (vaginal ulcers) which may bleed slightly. These can take weeks, or sometimes months, to heal. If you have any unusual bleeding after intercourse, you should to tell your doctor and ask for an examination.

Vaginal infection
Some women find that they are prone to getting vaginal thrush infections while having radiotherapy or chemotherapy. This is because there are changes in the acidity in the vaginal area, which allow the normal organisms in the vagina to overgrow. You may have thrush if you notice a creamy-white discharge, or an itchiness in the vaginal area which gets worse if you scratch. This is easily treated. The medicines can be bought from your chemist. If you have had sexual contact, your partner may also need to have treatment.

Penetrative sex is perfectly safe during radiotherapy or chemotherapy if you are not affected by any of these vaginal side effects. You should use effective contraception if there is any risk that you could become pregnant, and your doctor can advise you on the best method for your situation.

Lowered sex drive in women
Sildenafil (Viagra®) and similar drugs can be used to raise women’s sex drive. They may also increase vaginal lubrication leading to reduced pain during sex, more arousal and increased ability to achieve orgasm.

Loss of erection after surgery
Many men have erection difficulties after cancer surgery or radiotherapy to the pelvic area, but the treatment may not be the only factor. Studies have found that men commonly find they have sexual problems after operations that have nothing at all to do with their genital area. Your cancer operation, therefore, may not be the cause of all your sexual difficulties. There may be psychological factors involved, which you are not consciously aware of.

Some men find that they can have full erections with time. Even if they cannot, a half-erect penis can still be effective for making love. The positioning for this may be better with the partner on top guiding the penis inside.

If you have had an operation that has damaged the nerves that control erection, this need not be the end of your sexual life. You do not need to have a hard penis to give your partner pleasure. You may find it helpful to increase your range of sexual activity to include oral sex, mutual touching, increased masturbation, or use of a dildo or vibrator to increase your pleasure and that of your partner.

Medicines, pumps, implants and injections
If you have problems getting or maintaining an erection there are many options to help you. Remember that these will give you a hard penis, but will not necessarily increase your feelings of arousal.

Tablets of sildenafil (Viagra®) help to produce an erection by increasing and restricting the blood supply in the penis. They are usually taken an hour before lovemaking, and then, following direct sexual stimulation, an erection will occur. These tablets should be prescribed by your GP.

However, they may not be recommended for you if you have heart problems and/or are taking certain drugs, such as nitrates. They can cause side effects for some people which include heartburn, headaches, dizziness and visual changes. A possible side effect is that occasionally the erection lasts for more than a couple of hours and there is a danger of damage to the tissues of the penis.

Vardenafil (Levitra®) tablets are similar to Viagra. They normally work within 25–60 minutes. The most common side effects are headaches and flushing of the face.

Tadalafil (Cialis®) tablets can be used. They can be taken up to 36 hours before lovemaking. Your doctor may be able to prescribe them on the NHS. Tadalafil works by increasing the effects of one of the chemicals produced in the body during sexual arousal. It should not be taken by people who are taking certain heart medicines.

Injection of a drug such as alprostadil (Caverject®, Viridal®) or papaverine directly into the penis, using a small needle, causes an erection. The drug restricts blood-flow and traps blood in the penis, causing an instant erection. Some experimentation is often needed at first to get the dose right.

One of the possible side effects is that if too much of the drug is given, the erection stays for too long and there is a danger of damaging the tissues. Some men who use these injections say that the head of the penis is not as hard as the shaft. The injections are prescribed by your GP. Usually this method is recommended to be only used once a week, which may not be enough for some men or their partners.

Pellets of alprostadil (MUSE®) can be inserted into the penis. The pellet melts into the surrounding area and, after some rubbing to distribute it into the nearby tissues, produces an erection. Some men find that the pellet is initially uncomfortable.

Vacuum pumps (sometimes called vacuum constriction devices) can also be used to produce an erection. The pump is a simple device with a hollow tube that you put your penis into. Pumps are either operated by hand or battery, and draw blood into the penis by creating a vacuum in the tube. Once the penis is full of blood, a rubber ring is placed around the base to keep the erection. The vacuum is released and the pump removed. The erection can be maintained for about 30 minutes. Once you have finished making love the ring is taken off and the blood flows normally again.

The advantage of vacuum pumps is that they don't involve inserting anything into the penis, but it does take a couple of weeks or so to get used to using one. It is particularly helpful for people who are not able to take other medicines. Your penis may feel slightly colder than usual to your partner because the blood is not moving around. The other important thing is to wear the ring for only half an hour at a time.

The pump can be used as many times as you want, providing you allow a half hour between each use so that the blood can flow properly. The pumps are available on the NHS.

Penile implants are sometimes used after all other methods have been tried. There are two main types that have to be inserted during an operation. The first type uses semi-rigid rods that keep the penis fairly rigid all the time, but allow it to be bent down when an erection isn’t needed. The second type involves a hydraulic device that, when activated, causes an erection. Your doctor can discuss penile implants with you.

If you think any of these options might be useful to you, your doctor can give more information.

Support with body changes
Body image is the mental picture we have of our own appearance. This image is drawn from what our body actually looks like, and also from how we think we look. Throughout life, our body image is constantly changing. Our body image can be altered whether or not a cancer or its treatment causes change to our appearance.

Changes in body image can cause feelings of distress that go far beyond the physical effects of a cancer and its treatment. When there has been a change in body image which is sudden and dramatic, you may feel abnormal. You may also have feelings of shame, embarrassment, inferiority and anger. When the change is a visible one, these feelings can be reinforced by the reactions of other people.

Hiding changes
If the change can be hidden under clothes, for example, a colostomy or mastectomy, it is common to react by trying to pass as normal. You might hide the change, avoid looking at it, and conceal it from others. This avoidance can lead to you feeling increasingly anxious about the thought of someone finding out.

Having a stoma, or having a breast removed, is likely to cause a significant change in the way you feel about your body. If this is true for you then you could try making love in underwear or partly-dressed rather than completely naked. Changing the lighting level during sex can also help to build your confidence about how your body looks. It may help to lie on your side for lovemaking to prevent pressure on scars or stomas. Facing away from your partner, not towards, may also help.

Talking about your feelings around body image
The most important thing is to tell someone your fears, rather than hiding them and letting them grow into something bigger. The more able you are to face the things you have been avoiding, the better. However, it might be very important to have spent some time thinking through your worst fears, and planning a way of managing this to help build your confidence.

If you are the partner of someone who has changes in their real or perceived body image, it may also take you time to adjust to and accept the changes. You may need to talk through your own fears.

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