Research tells us that even though quality of life for most breast cancer survivors returns to normal about a year following treatment, concerns with relationship intimacy and sexual function often continue for much longer*. As part of Fiera’s new “Ask The Expert” series and as Breast Cancer Awareness Month comes to a close, Nuelle’s Chief Scientific Officer Dr. Leah Millheiser interviews renown expert in female sexual health and cancer survivorship Dr. Michael Krychman about the impact of diagnosis and treatment on sexuality.
Dr. Millheiser: What are all of the factors influencing sexual function after a diagnosis of breast cancer?
Dr. Krychman: Sexual function before the cancer diagnosis is often considered a predictor of post-cancer sexual functioning. Couples that have good communication skills and enjoy a healthy sexual and intimate life often can cope and reestablish good sexual functioning after the cancer experience.
That said, cancer can invade and erode a well-established relationship. The treatments of cancer, be it surgical removal of one or both breasts, radiation therapy, chemotherapy or the addition of long-duration medications, can impact even the best of relationships. Both the medical and psychological impact of treatment can damage a sexually successful relationship. Good communication between a woman, her partner and her cancer care team can help restore sexual vitality after the cancer experience.
Dr. Millheiser: Does menopausal status at the time of a breast cancer diagnosis influence how much sexual function will be affected during and after treatment?
Dr. Krychman: It is estimated that approximately 25% of breast cancers are diagnosed before the age of 45, in the pre-menopausal period. With better diagnostic techniques and increased surveillance it is estimated that the number of younger women with a breast cancer diagnosis will rise.
The most concerning issues are the impact of surgically induced menopause (removal of the ovaries) and/or chemically induced menopause on the vaginal epithelium. It is felt that younger women who abruptly enter menopause and have seen their hormones plummet are severely affected by the drop in circulating estrogen levels. They frequently experience troublesome vaginal and vulvar dryness and, as a result, painful intercourse. Often younger women will complain of sudden changes in sexual desire, which is distressful. In addition to changes in desire, women will often report delayed time to orgasm and decreased orgasmic intensity (strength of orgasmic response).
Dr. Millheiser: What are some of the ways in which a couple can maintain intimacy following a diagnosis of breast cancer, especially during and after initial treatment?
Dr. Krychman: There are several techniques to enhance and preserve the sexual and intimate lives of cancer patients and their partners during the diagnosis and treatment of cancer. Communication is always an important aspect of any intimate relationship. As a result, emotional closeness and discussing concerns and changes that are taking place in the relationship is vital. Keeping issues bottled up inside in silence can be problematic and lead to disconnection between partners.
Fatigue, pain, and side effects from medications or chemotherapy may prevent intercourse but closeness with hugging, caressing and shared intimacy is still important. Listening to your body and resting when you need rest, sleeping when tired and seeing your health care professional are extremely important if you are experiencing side effects. Sometimes, planning sexual activity when fatigue, pain and side effects are at a minimum is the best solution. Keeping sex spicy and exciting with novelty is also important, even in the face of disease.
Dr. Millheiser: How do you counsel your younger patients who may be in their 20s-40s at the time of their diagnosis about easing back into the dating scene post-treatment?
Dr. Krychman: Reemerging into the dating scene as a single breast cancer survivor can be a scary experience. The concern about disclosure and discussing the issues surrounding breast cancer can be concerning for a woman. Many women are instructed to go slow, trust their bodies and emotions and enter into relationships as they would with cautious optimism. There is no general rule when or what to disclose. Some women feel more comfortable at the outset of the relationship, whereas others prefer to establish an emotional bond before the cancer discussion. Advising women to trust their emotions and their feelings is helpful. If a woman is concerned about what exactly to say, she should role-play with a trusted friend in order to get comfortable with the conversation.
Dr. Millheiser: Many women are placed on a medication, called an aromatase inhibitor, to prevent breast cancer recurrence for up to 10 years following their diagnosis. One of the main side effects of this medication is vaginal dryness and discomfort during sexual activity. What are some of the non-hormonal options available to address this issue?
Dr. Krychman: Aromatase inhibitors can cause severe vaginal and vulvar dryness. As a result, the vagina can become very irritated, itchy or even painful. Non-hormonal vaginal moisturizers may provide some relief as they naturally help revitalize the vaginal lining. It is also important to use a personal lubricant for sexual activity. Lubricants may be water, oil or silicone-based and it’s important to read the labels to avoid potential irritants. Colors, flavors, warming agents and bactericides/spermicides may exacerbate the vaginal dryness and increase the pain. For vulvar irritation, vitamin E or A+D ointment may be beneficial. It’s important to read labels carefully and choose high quality products to help nurture your vaginal and vulvar regions.
Seeking professional help from a specialist like a sexual medicine expert or someone from your oncological health care team may also be advisable. It may not only be vaginal dryness! It’s important to keep in touch with the latest research. There are always new and emerging data and treatments on the pipeline that may help revitalize the vaginal area.
*Rowland J et al. Addressing intimacy and partner communication after breast cancer: a randomized controlled group intervention. Breast Cancer Res Treat 2009;118:99-111
Michael L. Krychman, MD, is the Executive Director of the Southern California Center for Sexual Health and Survivorship Medicine located in Newport Beach California. He is the former Co Director of The Sexual Medicine and Rehabilitation Program at Memorial Sloan-Kettering Cancer. He also is a clinical sexologist and has completed his Masters in Public Health and Human Sexuality. Dr Krychman has a degree in Erotology, Sexual Education and Forensic Sexology. Dr Krychman is also an AASECT certified sexual counselor. He is an Associate Clinical Professor at the University of California Irvine, Division of Gynecological Oncology and the Medical Director of Ann’s Clinic, a high-risk program for Breast and Ovarian Cancer Survivors.