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!”
In addition to noting the differences in what people say about their sex lives, I’ll draw your attention to the communication and relationship differences between these transplant survivors.

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?
Amielle: E: or T:

17. Dilators Available on Internet

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

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

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