Sealed Section: sex after breast cancer

Sexuality and a healthy sex life is a human right. It’s a fundamental part of adult wellbeing, can be healing and restorative, and is an important means of self-expression. You shouldn’t have to miss out on the benefits of intimacy just because you’re going through a life-threatening illness.

Sex therapist Edit Horvath, endocrinologist Dr Stella Milsom and breast cancer survivor Rose Wharepapa answered your most pressing questions about sex and intimacy after breast cancer in a recent webinar. You can watch the full webinar here.

Q. I’m 45 and single, broke up with my fella just after diagnosis. I struggle to trust any man now. Any advice on learning to trust again?

E: Start with yourself, start trusting yourself and use those strategies Rose was talking about. Make yourself beautiful, for yourself. Be nice to yourself, be healthy. Look to make friends and after that slowly open yourself up to the possibility of meeting someone.

Q. I’ve finished my treatment for breast cancer but I’m feeling flat. Any advice?

S: There’s an excellent article from Jean Hailes that discusses decision-driven intercourse as opposed to desire. Provided that it’s enjoyable, sometimes it’s a matter of deciding you should go ahead and do it rather than waiting for the rush that you might have experienced when you were younger, or the relationship was newer.

E: I have a couple who come to me who talk about the fact that if they plan to have a date night, so they know the set-up is going to be there for an intimate and loving time, they get really into it even if the desire wasn’t there before they began planning. I think if the timing is right and the decision is made then the feeling will come with that.

R: It’s also about feeling confident about sexuality and yourself. Embrace the things that make you feel pretty: dressing up, make up, treating yourself to a manicure, working out in the gym – whatever rocks your boat, then you feel more womanly and sexy. It’s a real psychological thing and it starts when you wake up in the morning. If your partner is nice and chats to you then you’ll go to work and think aww and by the end of the day you’re still loving him, so sex is bound to happen. On the other hand, if he wakes up grump and then all of a sudden rolls over in the middle of the night and says “let’s go for it”, it’s just not the same. It’s all about building that intimacy on a daily basis.

E: Some people feel that planning intimate moments is a bit artificial but think about when you began your relationship – you would have been thinking about what you were going to wear, what you were going to say etc. for the whole week before date night on Friday. The whole build up creates anticipation – it’s all part of the excitement.

Q. When you’ve got a new partner, at what point do you say “I only have one boob”?

E: I think when you know that the relationship is worth it, when you decide the person is worthy of your honesty. Think about it as a friendship – when would you tell a new friend this? It’s important to feel safe so it’s probably not the best idea to talk about it in the pub or if you’ve had a few drinks – that won’t land well and you probably won’t say it the way you want to. Start talking about the fact you’ve had a life-threatening illness and go from there. Take your time with it – it might not be one conversation, it could be several.

Q. Have you seen much difference in your practice between pre-cancer treatment orgasm and post-treatment?

E: It really depends on the age and health of the people, the relationship itself and what sort of advice is given. There are some women who have poor or no orgasms prior to cancer treatment, but afterwards they have better or more orgasms because their partner is a lot more patient and a lot more careful with them. The skillset and patience of the lover can be very important – and this is true at any age and any stage of a relationship.

S: Sexual function is just a spectrum and it’s important to allow advice on improving sexual function to be shaped by a person’s unique sexual history. Sexuality varies hugely among women: some really don’t have much sexual desire at all and never have, while others are easily, and frequently aroused. What I do see, from an endocrinologist perspective, is that if women have never been very sexually active beings, they don’t get better when they become post-menopausal (for whatever reason). Women, however, who’ve have a good sex life and have become post-menopausal sometime do quite bitterly describe a reduction in sexual functioning. Again, there are differences in oestrogen levels but I think it’s far more multi-factorial. Of course we’ll go through hormones and the medical side but almost invariably we’ll have assistance from our psychology colleagues. I often tell my patients that the psychologist may well fix more sexual dysfunction than I’ll do as an endocrinologist. And remember, I’m seeing pre-menopausal women who have quite regular periods and excellent hormones, and they’re still experiencing quite marked sexual dysfunction. It’s a very complex area.

Q. Are bio-identical* hormones definitely a no-no if your cancer is hormone positive?

S: That’s a very topical issue. The quick answer is yes, they should be avoided. If what you mean is “natural” forms of oestrogen, there are many approved forms that can be used, depending on an individual’s medications and risk profile. We know the safety data, we know the risk benefit profile, and the side-effects so you’d have to ask yourself why someone would go down an alternative pathway that has been developed as a marketing tool. Bio-identical oestrogen is unstudied and it’s strong – unless it’s an approved variety you can’t even be certain that one preparation is the same as the next. For accurate statements about these hormones and the pros and cons, take a look at Australian Menopause Society or the International Menopause Society.

Q. It’s been 5 years since my treatment finished and I still suffer from vaginal dryness and itchiness. I’d like to not have to use lubricant every time… You mentioned vitamin E earlier, are there any foods that are good or bad for this?

S: Unfortunately there’s no data that shows food supplements to be effective although oral or vaginal vitamin E is said to be helpful so might be well worth a try. If you’re five years out and not on an aromatase inhibitor and you’ve explored the moisturiser and lubricant options, a discussion about low dose vaginal oestrogen with your oncologist could be worthwhile. Remember vaginal oestrogen is ultra-low dose and essentially isn’t absorbed into the circulation so we’re not talking about systemic hormones which we’d prefer to avoid.

Q. What is the best lubricant?

Stella: In New Zealand, my gynaecology colleagues tend to use Astroglide or Sylk but if you go online, to the Australian Menopause Societyor Jean Hailesfrom Melbourne, you can access an extended range. If you’re talking about a moisturiser, our oncology nurses are very enthusiastic about Replens. Moisturiser can be very helpful if used on a regular basis, as opposed to a lubricant just for sexual experiences, but it probably doesn’t compare with the effect of actually replacing a little bit of oestrogen because it’s this absence that’s affecting the vaginal mucosa, secretions and elasticity.

Q. Does masturbation improve vaginal dryness?

S: That’s a really good question. I’m not aware that it’s been specifically studied but I can’t see why masturbation particularly if you, to be blunt, penetrate the vagina and cause it to stretch, would be useful.

E: And if good lubricant is used, it helps when there’s no intercourse or way to enhance the vaginal muscle – we do need to acknowledge the fact that if you don’t use it… you lose it!

Q. I’m too tired to feel sexy. Do melatonin supplements help with fatigue and libido?

S: The whole sleep issue is very interesting, there’s no doubt that poor sleep is part of the set of symptoms for postmenopausal women and, yes, oestrogen deficiency can give night sweats etc. but there’s far more to it than that. In terms of management, first line is cognitive behavioural therapy. A useful programme that many of my patients engage in is called Shut-I, it’s sleep CPD administered by the University of Viriginia, it’s a completely internet-based programme. Melatonin certainly has a role in sleep and I don’t believe there’s any safety issues with breast cancer patients using it. The big question is how long to use it for. Relying on sleeping tablets is fine for emergencies, but they don’t give you a lot of sleep and they’re not good for setting up a good sleep architecture – it’s a short term fix. A better strategy is introducing good habits – getting up at the same time, practising neurolinguistics programming and reducing alcohol intake.

R: Healthy diet and regular exercise – I know that if I’ve had a workout (even a walk), I’ve got some fresh air, I’m eating healthily. When I don’t it keeps me awake, sugar levels go up and down. So a balanced diet and exercise are really helpful.

S: Just don’t do all your exercise at night and raise your core bod temperature. Deepak Chopra advice would be to get plenty of exercise, have sun exposure morning and afternoon, keep regular sleep hours, no naps or sleeping in, lots of green leafy veg and your lightest meal at end of the day.

Q. What can you use for hormone cream if you’re HER2+?

S: You’d want to have a discussion with your oncologist but as I mentioned oestrogen cream is local (almost no system absorption) so unless you’re on letrozole, or letrozole-like drugs, most oncologists would probably be in agreement.

*Bio-identical hormones that are identical in molecular structure to the hormones women make in their bodies. They’re not found in this form in nature but are made from a plant chemical extracted from yams and soy. (source)