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Female cancer and Sexuality – Part 2: Intervention regarding female sexual health

Many women experience a variety of sexual dysfunctions after cancer and its treatments. Knowing how to give first sexual counselling to the patient is one of the 5 A’s Model points, specifically, “assistance” is required. The brief checklist seen in part 1 addresses the main problems and concerns by directly asking “Do you experience any of the following?”. Here is brief counselling advice for each.

1. Decreased sensation

When a woman endorses this symptom, the first question must be “what kind of sensation are you referencing?”. Loss of sensation can include both genital sensations experienced during sexual activity as well as other types of diminished sensation caused by surgery, chemotherapy-related neuropathy, or possible lower extremity lymphedema. Provide first pieces of information about the possible causes of decreased sensation. Strategies that help to facilitate arousal by drawing blood flow and promoting circulation in the pelvic area may be helpful. Examples include pelvic floor exercises, self-stimulation, vibrators, and vacuum devices. The vacuum device is applied over the clitoral area to pull blood flow to the pelvis, thereby promoting engorgement, it has proven beneficial for cancer patients who have undergone radiation therapy, with possible rehabilitative effects on the tissues. The use of a vibrator and/or self-stimulation may be as effective because these options similarly promote oxygenated blood flow to the pelvic floor through sexual arousal. Educational resources on pelvic floor exercises or a referral to a sexual health expert to discuss these strategies are recommended. Another source of loss of sensation is the nipples: after mastectomy, breast sensation may be profoundly altered, if not absent entirely. Women and partners may need to adjust to complicated feelings of loss and learn to create new sexual routines.

2. Decreased lubrication

Vaginal dryness is one of the most common and distressing problems for female cancer survivors. Provide information about how the treatments may cause oestrogen deprivation and decrease genital blood flow, resulting in loss of vaginal lubrication and consequently loss of genital tissue elasticity. Vaginal dryness is often accompanied by burning, itching, or chafing. Provide education about moisturisers and lubricants (such as water-based or silicone-based lubricants) as well as how the maintenance of sexual activity can be useful in managing vaginal dryness and dyspareunia. Provide information about vaginal health strategies. In addition, there can be a discussion on hormonal therapies, such as local vaginal oestrogen (cream, ring, or tablet form) which is a particularly effective but controversial treatment for vaginal dryness. Detailed risk-benefit discussions must occur between the patient and the professional.

3. Difficulty reaching orgasm

Often women either experience difficulty in reaching orgasm or go through detrimental changes in arousal after undergoing treatment. These might be related to menopausal symptoms, yet they are often not discussed with clinicians. Vaginal dryness, a decrease in sensations and psychological concerns are all elements that may interfere with reaching the climax. Women may find it helpful to use sexual aids such as vibrators and lubricants, and must be informed about potential interactions, like that silicone-based lubricants can compromise the material integrity of silicone vibrators. In addition, women who have had their clitoris or other sensitive areas of the vulva removed will have difficulties. Removal of the uterus, cervix and ovaries can also change how a woman experiences orgasm. Tips can be given to such patients to improve the quality of intercourses like : a) stroking, caressing and massaging, or guiding the partner’s hands or fingers to areas that arouse and excite the patient; b) using erotic books, magazines or films; c) Consider using an electric vibrator, which may give you extra stimulation; d) exploring reaching orgasm without penetration, trying oral sex, masturbation or all- over touching; e) doing experiences that make the patient relax and reconnect with the partner. Further assistance might be needed to address other psychological areas of distress.

4. Pain during sexuality

One of the most common reasons female cancer survivors experience pain with sexual activity is that cancer treatments often result in vaginal atrophy, which refers to a compromised lack of vaginal moisture, blood flow, and tissue elasticity. One approach is to have women employ a systematic regimen of using vaginal dilators, a set of tapered devices that vary in size and facilitate mechanical stretch of vaginal tissue. Sex may also be painful for women who experience vaginal narrowing from pelvic radiation or foreshortening from surgical intervention. For these women, consistent dilator programs may also be helpful. Alternative sexual positioning and liberal use of pillows may also ease pain and discomfort. For women who experience severe foreshortening of the vaginal canal as a result of surgery or radiation, pain during penetrative intercourse may be due to ‘collision dyspareunia’. An option available is the Come Close Ring, a cushioned ring placed at the base of the penis that limits the depth of penetration during sex and prevents painful collision. Applying numbing agents such as lidocaine to the vulvar and vestibular tissues before insertion also improves comfort and creates less distress with intercourse. Addressing pain during sexual activity is important, because if not addressed, female cancer survivors may begin to anticipate painful intercourse and thereby develop secondary vaginismus. Further counselling for relaxation techniques on the pelvic floor can be useful

5. Vulvar or vaginal pain not sex-related

Generally, to address vulvar burning, itching, or chafing accompanying vaginal atrophy or as a result of radiation, women should be taught to moisturise the vulva and vagina. Ideally, women should be referred to a GYN specialist who has experience working with cancer survivors. Some women may have other pre-existing issues of pain, such as vulvar vestibulitis, which require a more comprehensive evaluation with a sexual pain specialist.

6. Low desire

This is probably one of the most complicated topics because it involves a series of interrelated physical, hormonal, emotional, and relationship factors. If a woman is experiencing sexual intercourse that is uncomfortable or painful, it is not surprising that there is a loss of desire as the initial presenting problem. It is important to identify the eventual associated physical factors above mentioned. Medical comorbidities can also negatively affect libido, as can various medications. Partner and relationship factors should be acknowledged, although they are often not considered in clinical inquiry. Both couple and individual counselling can be helpful.

Bibliography :

- Bober, S. L., Reese, J. B., Barbera, L., Bradford, A., Carpenter, K. M., Goldfarb, S., & Carter, J. (2016). How to ask and what to do: a guide for clinical inquiry and intervention regarding female sexual health after cancer. Current opinion in supportive and palliative care, 10(1), 44–54. https://doi.org/10.1097/SPC.0000000000000186

- Overcoming sexual challenges with cancer. (n.d.). Cancer Council Victoria. Retrieved September 2, 2022, from https://www.cancervic.org.au/living-with-cancer/sexuality-and- intimacy/overcoming-specific-challenges#orgasm

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