Patients undergoing cancer therapy are faced with many difficult side effects and changes in their bodies. For women, a frequent but unexpected side effect of cancer therapy is painful intercourse. Painful intercourse or dyspareunia may result from physical changes in the vagina following radiation and/or surgery or a depletion of the female hormone, estrogen, which can cause vaginal dryness. Female patients receiving certain chemotherapy agents may be at risk for premature menopause due to the effect of medication(s). Women with cancers of the cervix, uterus, ovaries, or vagina/vulva may undergo radical surgery or radiation, which leads to scarring and narrowing of the vagina. During treatment, most women and physicians are concerned with their battle against cancer, and there is rarely a discussion to explain the long term effects on the patient and their partner’s sexual lives. In this MUSC Women’s Health Blog, we will discuss the effects of breast and gynecologic cancer therapies on women’s sexual function.
Breast cancer
Breast cancer therapy may involve medications, such as tamoxifen and raloxifene, which intentionally decrease the amount of estrogen in a woman’s body. The reason for this is that certain breast cancers are sensitive to and grow in the presence of estrogen. As a result of this estrogen depletion, the vagina’s natural lubrication is lessened and muscles of the pelvic floor are weakened. As a result, the vagina becomes constricted, making intercourse difficult and painful. Another complication of pelvic floor and tissue weakening is urinary incontinence, which has a significant negative impact on a woman’s social and sexual function. As one 42 year old breast cancer survivor described it, “If I had known that I was not going to be able to have sex after fighting for my life, I certainly would’ve enjoyed and had more sex while I could”.
Gynecologic cancer
Gynecologic cancer therapy often involves surgery. Gynecologic cancers include those of the uterus, cervix, ovaries, and vagina/vulva. Some of these surgeries can be quite radical, removing all or most of the female organs and occasionally lymph nodes which drain the pelvis. These surgeries can lead to pelvic pain and swelling. If a woman has surgery on the vagina or the vulva, she may experience scarring and a change in the appearance of her genital area. Radiation can lead to similar scarring and thinning of the vagina and vulva, which can be painful and disfiguring.
Strengthening the pelvic floor
Please refer to Dr. Lazenby’s previous blog on pelvic floor strengthening. Click on this link to see more about the topic and learn some helpful exercises.
The good news
The good news is there are treatments available to correct and prevent dyspareunia and pelvic organ prolapse after cancer therapy. Diligent strengthening of the pelvic floor muscles with physical therapy during the early stages of treatment may help the tissues remain healthy and supple. Sometimes, strengthening of the muscles may need to be augmented with neuromuscular stimulation. Massaging the vaginal tissues and vulva can also improve blood flow and tissue suppleness to decrease dryness. In the cases of vaginal shortening and constriction, progressive dilation can restore vaginal length and allow pain-free intercourse. The overall goal of these therapies is to return bulk and strength to the pelvic floor muscles. In general, 12 weeks of pelvic floor exercises are recommended to build muscle mass, although beneficial effects may be recognized within 6 weeks.
Specially trained physical therapists can provide pelvic floor rehabilitation and strengthening exercises to patients during and after cancer treatment. The therapists evaluate the muscle and tissue integrity and develop an individualized plan of care for each individual. Individualized therapy may include deep tissue mobilization, stretching, scar and lymphedema management in order to improve tissue function. In regards to dyspareunia, these physical therapists can instruct patients in exercise regimens for improving pelvic muscle strength, use of progressive dilators for vaginal constriction, and specific sexual positioning to avoid pain.
Surviving a battle with breast or gynecologic cancer does not have to mean the end to sexual pleasure and function. Cancer patients with concerns about premature menopause, dyspareunia, genital scarring, and urinary incontinence should discuss this with their care providers and consider meeting with a pelvic floor physical therapist.
by: Rebecca Stimac, PT and Gweneth Lazenby, MD