Medical menopause had hit, almost instantaneously. I’d been warned I would enter menopause due to treatment, and as a GP knew the symptoms to expect, but I hadn’t expected it to hit so suddenly and violently.
Hot flushes and drenching sweats hit me day and night, joint pains made it hard to walk in the mornings, I had extreme word-finding difficulty due to brain fog – all of which was augmented by the toxic side effects of chemotherapy.
The effects of cancer treatment
Many women will enter menopause during cancer treatment either due to medication, surgery or pelvic radiotherapy. For some this is permanent. In women treated with chemotherapy for breast cancer, up to 40% under the age of 40 and 70-90% over the age of 40 will enter permanent menopause.
Cancer treatment can have a profound effect on sexuality, both physically and psychologically. Changes in body image, a loss of confidence, physical changes and pain from surgery, radiation burns, treatment induced menopause and for some, life-long drugs which block or alter hormones. An abrupt drop in oestrogen and testosterone may lead to symptoms of vaginal dryness, itching and vulval discomfort, pain on penetration, bleeding after sex, urinary urgency, increased risk of infection and incontinence as well as loss of libido.
Sex and intimacy
With over 186,000 new cases of cancer per year in women in the UK and 75% of women aged 16 to 74 being sexually active, sex and cancer is an important topic. Yet, sex and intimacy may feel like a taboo subject when faced with a life altering diagnosis. Women can feel that their sexual wellbeing isn’t a valid concern, that it’s inappropriate or selfish to consider it when compared to the bigger issue of survival.
‘Normal’ life continues during treatment and beyond, as do relationships and intimacy which can be expressed in many ways. Sexual intimacy leads to the release of brain chemicals which promote feelings of closeness, pleasure and bonding and can reinforce a sense of togetherness and resilience.
Sex and intimacy are not luxuries, they are important parts of wellbeing and closeness. Talking about sex during and after cancer treatment should be as normal as talking about hair loss, and financial support. Research shows that women are often reluctant to raise their concerns around sex and intimacy due to embarrassment, shame and not feeling that it is a valid concern.
Clinicians may seem too busy or unapproachable and gender or age differences between a clinician and patient can be a barrier. Some clinicians may not feel comfortable or sufficiently knowledgeable to discuss sex with a patient.
Midway through my own treatment, I asked the oncologist if I could use vaginal oestrogen to make sex more comfortable. His expression tightened with unmistakable disapproval, as if my question had strayed beyond the boundaries of what was acceptable in a clinical conversation. There was an awkward silence, then the response: “Well, this is something to be considered after you finish treatment.”
I felt ashamed and embarrassed, as if I was some kind of deviant for considering my sexual wellbeing when my focus should be on survival. Later, on reflection, I wondered if I would have had the same response from a female clinician. If I, a medical professional with the language to communicate what I needed, had felt this way, how much harder was it for other patients to ask for help?
Questions about sex during cancer treatment
These questions are inevitable and important. They include:
- Should I initiate sexual intimacy when my partner is having treatment?
- Will my partner still want to have sex with me when my hair falls out?
- Am I still at risk of pregnancy?
- Is oral sex safe during chemotherapy
Initiating sexual intimacy when you or your partner are having treatment can bring a fear of rejection, worry about causing discomfort as well as concern over if it’s appropriate to do so. As with many aspects of relationships, communication is key – discussing and exploring how each person feels about initiating intimacy. What are your/their concerns, how can you signal to each other when you want to initiate intimacy and how do you communicate if you don’t want to? Try not to make assumptions, there’s usually no medical reason to stop having sex during treatment and if there is, your healthcare team should make that clear. You can’t pass cancer on to your partner during sex.
Talking about how you feel about your changing body image can be helpful. Hair can often feel like an important part of someone’s identity, and when it falls out it is often not just head hair, but all body hair. You might feel more comfortable wearing a soft hat or wrap, you might want to have a different lighting level – tell your partner what feels comfortable for you.
Contraception
It is important to ensure you use contraception during treatment, and if you are considering pregnancy during treatment you must talk to your healthcare team. If you are using oral contraception, check with them if there is any risk that any cancer medications might make the contraception less effective. In some cancer types, you might be advised to stop any hormonal contraception. There isn’t enough evidence to say whether chemotherapy drugs enter semen or vaginal secretions. This means we don’t know if it is safe or not, and so you may be advised to use a barrier like condoms, femidoms or dental dams if you are having vaginal, anal or oral sex. Check with your healthcare team how long you need to use barrier methods during treatment, it may only be for a week after each infusion.
These are important and valid questions, and there is information and support out there. You may have a support nurse in your healthcare team that you can talk to or an onsite patient support centre. If you don’t feel comfortable doing so, then there are online resources and helplines at the end of this article.
Vulval or vaginal symptoms
For women with vulval or vaginal symptoms, vaginal moisturisers and lubricants are recommended. Some lubricants contain parabens which act a little bit like oestrogen, and it has been suggested that women treated for hormone sensitive cancers should avoid them. There is, however, no solid research showing whether these products are either harmful or safe in this situation. Products which are paraben free are available.
Women who have completed their treatment and are unable to have oestrogen-based treatments may be able to have a drug called Ospemifene for vulval and vaginal symptoms although this would need to be discussed with the oncology team and/or a gynaecologist specialising in cancer and menopause.
Other medications
Whilst many women who have had cancer can take HRT, there are specific cancers and cancer subtypes where HRT is not recommended due to the possibility of it causing a recurrence. For those who cannot take HRT, vaginal oestrogen may be an option. Your oncology team can advise you or your GP whether this is safe.
There are non-hormonal drugs which may help with hot flushes although their efficacy is variable and may be outweighed by side effects. They may interact with ongoing medications for cancer, so it is important to make your health care team aware of any other medications you are taking as hospital prescribed medication is not always noted on your medication screen in your GP record. Supplements such as soy and red clover have oestrogen like properties and should be avoided in women with breast cancer.Vitamin E, black cohosh and magnetic devices are not recommended.
Reclaiming your sexuality
Cancer treatment impacts not only health, it impacts intimacy, confidence and sex, yet these issues are rarely spoken about openly. Too often women feel embarrassed or dismissed when they try to raise sexual concerns with their healthcare team which can add shame to an already overwhelming experience.
Support is out there, from specialist nurses to information from trusted charities like Cancer Research UK and Macmillan. The more we break the silence and normalise these conversations, the more women will feel empowered to ask questions, seek help and reclaim this vital part of their lives.
