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According to the Cancer Council Australia 150,000 Australians will be diagnosed with cancer this year. Thanks to improvements in diagnostics, earlier detection and advances in treatment - more and more people are kicking cancers to the curb. However, the side effects of some cancer treatments can cause physical changes that impact a survivors' quality of life.
In this interview, we spoke with Heather Jeffcoat [DPT], owner of Femina PT and author of Sex Without Pain: A Self-Treatment Guide To The Sex Life You Deserve. We discuss how cancer treatments can impact sexual health and what you can do about it.
Surgical treatments, radiation therapy, chemotherapy, targeted therapy and hormone therapy can result in ovarian damage, anatomic alterations, neurologic, myofascial and pelvic organ injury - all of which will impact sexual function. Data from Lindau et al (2015) shows that women want help for their sexual dysfunction, however rarely bring it up to their providers.
It is well known that gynecologic, urologic and colorectal cancers that receive radiation will have a direct negative impact on pelvic floor muscle function. Radiation-induced vaginal stenosis has a direct effect on sexual function, as it leads to tightening and shortening of the vagina secondary to the formation of fibrosis. And result in difficult or painful intercourse (dyspareunia) and post-coital bleeding.
I also see a forgotten population of women with breast cancer that have indirect side effects of sexual dysfunction, especially painful intercourse due to estrogen-blocking hormone therapies.
My patients are often told “Yay! You don’t have cancer”, but they are given little to no guidance on the loss of sexual function that follows. Aromatase inhibitors are especially associated with a high risk for vaginal dryness and sexual side effects.
Sexual pain, or the anticipation of sexual pain, often preempts desire - affecting arousal and ability to orgasm. This can lead to feelings of stigma, sadness, anxiety, depression and/or inadequacy and changes their sexual role in their relationship(s). Through this they may suffer a loss of their sexual self. Media’s portrayal of “normal” sex and sexuality can further worsen the emotional and physical side effects women are experiencing.
The hormonal side effects that occur in estrogen-dominant cancers are lifelong. When female genitalia does not have estrogen, it results in vaginal dryness, vaginal burning, genital itching and urinary symptoms of urinary burning, urgency and frequency.
When the pelvic region is radiated, stenosis occurs. Early intervention is important to minimise the extent of stenosis that occurs - and the longer it is left to its own devices, the more difficult it will be to reverse the changes. Stenosis continues to occur long after radiation is complete, up to 2 years or more.
Emotional side effects can also be lifelong.
An interdisciplinary team is necessary to manage the complete biopsychosocial picture.
At a minimum, there should be well-coordinated care with their gynecologist, physiotherapist and sex therapist or psychotherapist. Depending on other pain concerns, incorporating acupuncture or massage are great adjunct services that can help with their overall wellbeing.
Ideally, we are starting to see women within 4 weeks of their radiation therapy (when cleared by their physician) to minimise the long-term effects of stenosis with pelvic cancers.
I approach my patients like a specialised orthopaedic patient. Each patient intake consists of a detailed history, not just of their cancer, but especially how their cancer is affecting their daily activities and sexual function.
They can expect a typical physio exam in three parts. The first part assesses posture, muscle imbalances and movement impairments on a larger scale. The second part consists of an assessment of vulvovaginal structures and tissue health. Contraction ability, the ability to rest after contraction and overall strength of the pelvic floor muscles is also assessed. We also assess the coordination of bearing down and check for pelvic organ prolapse. Nerve testing is also done, and we are especially looking for injury from surgery or radiation therapy that may be causing neuropathic genital pain, such as radiotherapy-induced entrapment of the pudendal nerve). As time allows, we also complete a lymphatic and scar tissue assessment.
We use intravaginal and intrarectal manual therapy techniques to address pelvic floor muscle overactivity and combat stenosis. We are also really big on teaching our patients how to replicate in-office techniques with dilators.
The home program is one of the single most important things we can teach our patients, both how to use dilators and progress through a kit towards sexual function.
Scar tissue techniques are also employed. Teaching them to be self-efficacious with such an intimate problem is incredibly empowering.
We hope that this information has helped you learn more about how cancer treatments can impact sexual health, and if you are suffering from these symptoms - given you the confidence to talk to your health provider about your options.
If you want to learn more from Heather, go and check out FeminaPT.com and if you want to book in to see her she has three locations in the Greater Los Angeles area. Her book Sex Without Pain: A Self-Treatment Guide To The Sex Life You Deserve is available for immediate PDF download at sexwithoutpainbook.com. The hard copy is available on Amazon and distributed by Pelvic Relief in the UK.
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