The following article features in Issue One of the ST BREAST magazine.
It’s a topic many breast cancer patients feel self-conscious discussing with their doctors, but Dr Belinda Kiely believes sex during and after breast cancer treatment is “a big deal”.
The Sydney-based oncologist specialises in breast cancer and says sex and relationships are almost “inevitably” impacted by a breast cancer diagnosis and the subsequent side effects of treatment.
“Many women I am looking after are having a lot of problems with relationships, intimacy, and sex,” she admits, “but many are afraid or embarrassed to talk about it”.
“A breast cancer diagnosis and all the treatments that follow this can bring both emotional and physical side effects, impacting a woman’s body image, sexual function and wellbeing.”
Dr Kiely said one of the effective ways to treat breast cancer is with hormone therapies that reduce the oestrogen levels in the body but unfortunately, reducing oestrogen has many side effects, including problems with sexual function. The most common sexual problems are a loss of libido, vaginal dryness and pain during intercourse.
“Young women can really struggle as breast cancer treatments often result in a premature menopause,” she says. “Young women can be put into menopause quite suddenly so the menopausal symptoms can be more severe.
“I am treating a 35-year-old woman at the moment and we have put her into menopause with hormone blocking treatment. Almost overnight she developed hot flushes, sweats, reduced libido and vaginal dryness. These things can happen really quickly at an age when she should not be dealing with them.”
For women who are already post-menopausal when diagnosed with breast cancer, hormone therapies can further reduce oestrogen levels.
“This can be like a ‘double menopause’ and the side effects are often greater.
“It is a big problem and can result in women stopping their hormone therapy because of the impact it has on their quality of life. This is concerning because they are
stopping the treatments that are reducing their risk of breast cancer returning.”
Dr Kiely says the important thing for women to remember is that they are not alone and “there are many things we can do” to try and manage the symptoms during and post-breast cancer treatment.
A major side effect of hormoneblocking therapies is vaginal dryness.
“For a number of women this dryness can be so painful, that they can’t handle any sort of penetration at all,” Dr Kiely says. “Even a pap smear is impossible. For vaginal dryness the main treatments are moisturisers and lubricants.
“Vaginal moisturisers should be used on a regular basis independent of sexual activity.
“Lubricants can also reduce discomfort during penetrative sexual activity. There are waterbased, oil-based and silicone-based lubricants available so women may need to try out a few different ones or speak to someone who specialises in this to determine which lubricant is best for them.”
Dr Kiely says those women still experiencing difficulty might want to try vaginal dilators to help stretch the vaginal tissues.
“Women can start with a very small dilator and then gradually increase the size. A pelvic floor physiotherapist can provide guidance. Vibrators can also be helpful.”
If vaginal symptoms do not improve, a low dose vaginal oestrogen can be considered. These are available as tablets, creams and pessaries that are inserted directly into the vagina. These work best if inserted daily for two weeks, to allow the vaginal wall to heal and then decrease to twice weekly to maintain the benefit.
“There is a bit of controversy about whether vaginal oestrogens are safe to use in breast cancer,” Dr Kiely says. “There has never been a study looking at whether women who use vaginal oestrogens have a higher risk of their breast cancer returning but some small studies have measured oestrogen levels in the blood in women using low dose vaginal oestrogens and these have not shown a significant rise in oestrogen levels.
“I do think we need to explain the risks and benefits to women to help them decide if they want to use a vaginal oestrogen. I am comfortable with women using a low dose vaginal oestrogen in small amounts, especially if it helps them stay on the hormone treatment for their breast cancer.”
Dr Kiely admits that some relationships won’t and don’t endure a breast cancer diagnosis and treatment.
“Most partners are great and are very supportive, but they struggle too and are often unsure what best to do and say. Others, sadly don’t want to stick around, but sometimes this happens because things weren’t that great to begin with. Some women believe their partners would be better off finding someone more attractive and whole. Interestingly, when you actually speak to their partners, this thought has never entered their minds.
“Often it’s about how a woman feels about her body. I had a woman recently who was in tears because she could not even look at herself in the mirror after her mastectomy. She is really struggling with being flat-chested and does not feel like a woman anymore.
“A cancer diagnosis changes so many things for people but put simply, it takes away selfconfidence. Unfortunately, it takes time for that confidence to be regained.
“People often forget to be kind to themselves and give themselves a break. Open communication with their partner is a great first step.”
Dr Kiely says loss of libido or interest in sex can be very difficult to treat and is usually caused by many factors including low oestrogen, fatigue, pain from surgery, fear of cancer recurrence and poor body image.
“It is particularly a problem when a woman’s partner wants more sex. Sometimes partners also experience loss of libido because they are worried about the cancer.
“I want women to know that all of this is very normal. Communication is really important. A loss of libido is a normal reaction to the treatments you have had, the changes to your body, and the stress of having cancer.
“I have had patients who have had breast cancer treatment and who have gone on to continue fulfilling sex lives, but it does take time and effort. And some of them have seen psychologists or counsellors to help them. It probably takes longer to be aroused and they have to concentrate on other things, like kissing, going on dates, nice lingerie, massage, touch, and foreplay – these thing all become more important.
“We tend to think sex is just penetrative, penis in vagina sex, but there are a lot more ways of being intimate.”
Dr Kiely says communication is vital and women should talk not only to their partners, but feel comfortable asking for help from members of their treating team.
Doctors, nurses, psychologists, counsellors and social workers can all help with problems related to sex and relationships.
“Unfortunately, bringing up the topic of sex with their doctor can be difficult for women. I try and normalise it by explaining the common problems experienced by other women with breast cancer and then ask if they are experiencing similar problems. I don’t always have a solution, but I try and help by suggesting useful resources or arranging a referral to someone I think can help.
“Women need to know it may not be like this forever. For most, it does turn around, but it will be different. For some women, their sex life may never be the same as it was but with good support and advice and a lot of patience and even a sense of humour, this can be turned around and it can still be fulfilling.”
Dr Belinda Kiely