Updated October 2021.
Sex and cancer. You don’t often hear those words in the same sentence. Kristin Rojas, M.D., wants to change that.
“I have a special interest in the less talked about aspects of survivorship, like sexual health and intimacy. Thirty years ago, breast cancer wasn’t even talked about. The conversation around survivorship has changed. It’s no longer, ‘Will you live?’ but ‘How will you live?’” Dr. Rojas says. Dr. Rojas is a board-certified, fellowship-trained breast cancer and gynecologic surgeon with Sylvester Comprehensive Cancer Center.
Her point is well taken. Depending on the stage and type of cancer, five-year breast cancer survivor rates are increasing. “Women diagnosed in the early stage have an almost 100% chance of being alive in five years. Targeted treatments have emerged in the last five years that are total game changers for women with more advanced disease. The prognosis continues to improve,” Dr. Rojas says.
When cures have consequences
Though women are living longer, life-saving treatments take a toll on their sexual health. Chemotherapy may temporarily stop estrogen production and hormone-blocking medications lower the amount of estrogen in the body. Because younger women are often diagnosed with more aggressive breast cancers, their treatments can initiate what’s known as a medical or surgical menopause. Over time, premature menopause may introduce a host of sexual health problems:
- Vaginal dryness, irritation, and atrophy
- Hot flashes
- Painful sex
- Pelvic floor dysfunction, including incontinence, constipation, pain during sex, reproductive health problems
- Low libido
- Difficulty reaching climax
Now that treatment guidelines recommend anti-estrogen therapy in breast cancer patients for 10 instead of five years, Dr. Rojas says younger patients have a higher risk of female sexual dysfunction (FSD). In fact, 80% of breast cancer survivors experience FSD. Women and men diagnosed with other cancers also experience sexual health issues.
At the beginning of her career, Dr. Rojas encountered so many women with FSD that she created a program to address issues for women of all ages and sexual preferences. She has now launched a similar program at Sylvester. Typically, the first hour-long visit would include a gynecologic exam and in-depth discussion. Subsequent visits can be virtual, if the patient prefers.
With people living longer, healthier lives, older breast cancer patients now opt for treatment more than their mothers might have. “If there’s one thing I’ve learned in my work, it’s not to assume anything about intimacy preferences, regardless of age or sexual orientation. And you don’t need to be partnered or sexually active to experience sexual dysfunction. The same symptoms can lead to painful urination and bladder infections which can land older women in the ICU,” says Dr. Rojas.
What’s the biggest obstacle to solving FSD? Silence.
“When I started working with women with breast cancer, only a few brought up concerns about sexual health issues. Learning about those women clued me into the problem. When I started asking, I learned that almost every woman experiences some sexual side effects with treatment. As providers, we want to help, but the issues are complicated and there are not a lot of options for women, compared to men’s sexual dysfunction. Also, patients and their oncologists are concerned about potential interactions with medications or the risk of recurrence,” Dr. Rojas says.
Oncologists deliver so much information during a patient interaction, there’s not always enough time to discuss more sensitive subjects. That is why the program Dr. Rojas introduced at Sylvester focuses on sexual health and will draw on her gynecology experience. “I’m comfortable communicating with women at vulnerable times in their lives.” Female sexual dysfunction is also beginning to gain more recognition from the pharmaceutical and personal product industries.
A quest for solutions led Dr. Rojas to explore ways to help breast cancer survivors cope with the most common intimacy and sexual health concerns. She starts with conservative treatments, treating dryness and pain first, followed by pelvic floor issues, then libido. “Dryness and loss of elasticity, or stretchiness, cause pain with penetration during intercourse. Once women associate pain with sex, I believe it contributes to a negative feedback loop that can cause pelvic floor muscle spasms and dysfunction. Most women don’t innately want to participate in a painful act that may also be associated with guilt, diagnosis, and changes in body image. While treating low libido is complex and involves assessing relationship status if partnered, as well as metabolic/endocrine issues, and side effects from medications, breaking the negative cycle of sex equals pain and anxiety is a good place to start.”
Here are her recommendations:
Problems: Vaginal dryness, atrophy, painful sex
- Organic, single ingredient coconut oil. Use the oil as part of your daily regimen after showering to lock in moisture. Liquefy the oil by rubbing it in your fingers, then apply to the vulva, which is the outside of the vagina and includes the labia majora and labia minora.
- Avoid irritants. Estrogen-deprived skin is delicate and may become allergic to harsh ingredients. Avoid dyes, fragrances, parabens, and other chemicals found in laundry detergent, body wash, bubble baths, and other products. Skip douches or feminine washes altogether, as some contain chemicals known to cause cancer. They also upset the delicate balance of good and bad bacteria within the vagina.
- Vaginal moisturizers with hyaluronic acid. This ingredient occurs naturally in the body and is often found in facial moisturizers. Hyaluronic acid pulls moisture from the environment, helping skin stay moist. Ask your doctor for hormone-free product recommendations.
- Lubricate before sex. Silicone-based products are less sticky and last longer. Opt for products with simple ingredients.
- Vaginal dilators and physical therapy. If atrophy is severe, dilators can stimulate and gently stretch the vaginal tissues. Pelvic floor physical therapy may also help.
- Hormone therapy. If other methods are unsuccessful, Dr. Rojas may prescribe low-dose vaginal estrogen suppositories to improve the health of the vaginal tissues and alleviate pain. A newer hormonal option that does not include estrogen is vaginal DHEA or prasterone, which is a testosterone precursor that can act similarly to vaginal estrogen and is FDA-approved for painful sex. While no studies show that vaginal estrogen increases the risk or progression of cancer risk, speak to your oncologist before using any hormonal product.
Problem: Pelvic floor dysfunction
- Physical therapy. Specially-trained female physical therapists work one-on-one with women to relax the pelvic floor muscles and restore function.
Problem: Low libido
- Exercise. Working out improves your mental and physical health, body image, and energy level.
- Sleep hygiene. Fatigue and sleep deprivation can sabotage a healthy love life. Maintain a regular sleep schedule, use your bed only for sex and sleeping, and shut down the screens a couple hours before bed.
- Drink less. The old adage that alcohol increases desire but interferes with performance holds true.
- CBD products. CBD is marketed for every conceivable health problem, yet is not regulated by the Food and Drug Administration. At this point, there’s no scientific evidence showing that CBD improves libido.
- Be mindful. It takes time to get into the mood, especially if you’re dealing with stressful health issues. Practice slow, deep breaths to calm your body and mind.
- Evaluate your medications. Anti-depressants like Zoloft lower libido, while others like Wellbutrin work similarly without sexual side effects. Ask your doctor if you should switch medications.
- Pharmaceutical options for women. Flibanserin (Addyi) and Bremelanotide (Vyleesi) drugs help some patients struggling with low libido. Flibanserin works in the brain and is a non-hormonal drug. Caveat: Tamoxifen can interfere with Flibanserin and cause dizziness. If that happens, Dr. Rojas suggests taking Flibanserin every other day. Bremelanotide requires an injection to the stomach or thigh 45 minutes before sex – not the most convenient or conducive path to better lovemaking.
Be your own advocate
“Some patients feel guilty bringing up sexual health concerns; they think they should be grateful just to be alive, but the more women speak up, the more doctors and pharmaceutical companies will respond,” Dr. Rojas says. She looks forward to continue to work with Sylvester’s multidisciplinary team to build programs that support women in all aspects of their cancer care. “It takes a team of experts, and this program is just one aspect of that team.”
If you have questions, ask your gynecologist if they know someone who specializes in sexual health issues. Remember, advocating for yourself not only helps you, it helps others. As Dr. Rojas says, “No woman should have to suffer in silence.”
Nancy Moreland is a regular contributor to UMiami Health News. She has written for several major health care systems and the Centers for Disease Control and Prevention. Her writing also appears in the Chicago Tribune and U.S. News & World Report.