Under the Sheets

Although usually an afterthought following a breast cancer diagnosis, intimacy and sexuality issues associated with cancer and its treatment are common among patients and survivors, say experts.

Unfortunately, these issues are often not discussed between patient and doctor, either during the treatment decision phase or afterward. Sally Kydd, PsyD, licensed clinical psychologist and breast cancer survivor, says it would be ideal if health care professionals who interact with newly diagnosed women raised the issue of how cancer treatment can affect a woman’s sexuality. “Since, now days, most women survive breast cancer, rather than die of it, I believe it’s time to focus on quality of life issues, like sexuality, at the beginning of treatment.”

And similar to fertility and long-term effects, sexuality is slowly being recognized as an important issue in both the medical and survivorship communities. 

“The fertility issue got addressed a lot more once it came to people’s attention, but sexuality, which affects a much larger group of cancer survivors, still remains kind of a stepchild,” says psychologist Leslie R. Schover, PhD, author of Sexuality and Fertility After Cancer. However, there has been a greater awareness of the issue over the past few years, and improvements in helping patients and survivors—and their partners—overcome these problems.

Finding the Cause

There are many different reasons why survivors may have a decrease in libido, ranging from emotional issues to the physical, and often a mixture of both. Finding the cause is the first step in determining how to overcome each problem.

Emotional issues may stem from body image changes, such as being self-conscious about scarring, lack of breasts, or weight gain. Talking with a counselor or a support group may help you to overcome any body image issues you may have. Regular exercise and improving your diet may also help with weight loss, energy, and your overall mood.

Physical issues, such as vaginal dryness or loss of feeling in the breasts, may also create havoc in the bedroom. Knowledge of certain side effects before treatment begins can help survivors prepare for them and may even be a determining factor in deciding on treatment. Kydd, who co-authored Intimacy After Cancer: A Woman’s Guide, says she was fortunate to have a surgeon who told her that a double mastectomy would mean she would not experience sexual pleasure from her reconstructed breasts.

“He gave me the opportunity to evaluate different treatments prior to having surgery,” she says. “It didn’t change my mind, but I was grateful for the opportunity to make an informed decision about treatment.” 

If breast touching was once erotic, the loss of feeling in the nipple and surrounding tissue may negatively affect intimacy between partners. If breast touching no longer arouses you, due to either loss of sensitivity, being self-conscience about scarring, or it reminds you about the cancer, you may need to talk about what else your partner can do to arouse you. It may be that you and your partner may need to find other erogenous zones, such as the neck, feet, hands, and inner thighs, or other methods of arousal.  

A decreased libido may also be the result of hormonal changes. Surgery to remove the ovaries and some types of cancer treatments can push women into premature menopause, which, in addition to hot flashes and weight gain, can also lower your sex drive and cause vaginal dryness which can make sex uncomfortable and even painful.

Lubricants such as Astroglide and K-Y Brand Jelly before sexual intercourse may help, and estrogen-free products such as Replens (polycarbophil) applied a couple of times a week can also increase moisture over time. Some experts also believe that low doses of estrogen applied topically to the vaginal area or an intrauterine device that delivers continuous low doses of estrogen may be safe to improve vaginal dryness and atrophy, but these are still controversial in patients with estrogen-positive breast cancer.

Other medications, namely some anti-depressants and anti-anxiety drugs, can also be the problem, as they may decrease libido. If this is the case, it may be that a switch in medication is all you need. If you believe your medication to be the cause, talk to your doctor about other alternatives. 

Talking It Out

The emotional complexity of cancer becomes even more complicated when sexuality is involved, and even couples with strong connections can get lost in the challenges of trying to talk about feelings that arise relating to sexual issues.

CURE editor-at-large and survivor Kathy LaTour, interviewed around 100 women for her book The Breast Cancer Companion, finding that for some, intimacy become more complicated because it seemed to bring up other emotions at the same time. For her, it was trying to be open to emotions, including fear, that might surface during intimacy, confusing both her and her husband when she tried to explain it. Only when she joined a support group and was able to talk about her emotions did she begin to understand what was happening and move beyond it.

Kydd says issues with sexuality can often be worked out with discussion, but don’t expect overnight changes. “It took time and a whole bunch of perseverance, and lots of communication for me to deal with the grief and loss and trauma of what I experienced, and for the relationship to emerge stronger and more fulfilled than before I was diagnosed with cancer,” says Kydd about her own breast cancer experience.

Start slow and make time for sex, suggests Schover. You may need to change your routine and allow more time to become aroused. “Most couples get into a routine,” she says. “Maybe now you need to (make) a time for sex when you’re not fatigued.”

Talking with a professional can help you learn how to overcome these barriers. Approaching the issue with your doctor, nurse, or a social worker may be a good start. They may also be able to refer you to a therapist who can help with couples communications, as well as dealing with the physical and emotional issues related to sex and intimacy.

It’s important to find a therapist who has training as a mental health professional with a specialty in treating sexual or relationship problems, such as a social worker, psychiatrist, or psychologist.

You can find a therapist that specializes in sexual issues, marriage counseling, and emotional issues through organizations such as the American Association of Sexuality Educators, Counselors, and Therapists (www.aasect.org); the American Psychological Association (www.apa.org); the National Association of Social Workers (www.helpstartshere.org); or a state association for licensed marriage and family therapists. 

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