We are writing a series of article covering the topic “Cancer and Sexuality”.  In part 1 of this series we covered about the question what is sexuality and how cancer affects it.  In part 2 we covered what type of cancer treatments exist and how they bring changes in woman and man’s sexuality. In this series we cover various remedies available for such changes.Because sexual changes can have many causes—especially for patients with cancer—your doctor should evaluate you physically, psychologically, and emotionally. For example, you may need to have lab work for thyroid functioning or hormone levels. Test results, combined with your descriptions of how you feel physically and emotionally, will help your doctor determine the cause of your sexual changes.

An important part of recovering is to try resuming sex when you feel ready. Do not rush yourself to “get better” as fast as you can, but try to avoid long periods without any sexual touching. Resolving sexual changes can be a slow process, but you need to start somewhere, even just with cuddling on the couch or “making out” as you may have done when you were a teenager.

Despite your cancer or cancer treatment, you should be able to feel sexually satisfied. It may require remedies from your doctor, time, patience, and an openness to try new experiences, but eventually you will enjoy sexual activity with your partner that feels right for you. Your personal comfort level with any medical or psychological treatments you try will play a big part in their success.

This section includes more information on:

• Remedies for Women
• Remedies for Men
• Suggestions for Patients With Ostomies
• Alternatives to Sexual Intercourse
• Self-Pleasure
• Conversation Starters With Your Doctor

Remedies for Women

Remedies for sexual changes in women range from over-the-counter options to those that require a doctor’s prescription. If you feel embarrassed or uncomfortable about asking for items at a drugstore, you may be able to purchase some of them over the Internet with delivery to your home.

If you have surgery that changes the way your body looks, ask your doctor whether counseling or cosmetic or reconstructive surgery are options, perhaps even later, after you have healed from your cancer treatment.

If you have pelvic radiation, then your doctor may prescribe vaginal dilators to help keep the vagina from scarring or shrinking during cancer treatment. Dilators are cylinder-shaped and may be made out of hard plastic or softer silicone. They come in sizes from small ones similar to a finger or tampon to large ones often larger than the average erect penis. Women who are anxious or have pain should begin with a small dilator and work up to trying larger ones. The whole process should be as painless as possible. Dilators should be well lubricated, and dilation should always be gentle. Never force the dilator into your vagina. If you have trouble inserting the dilator, learning to control the muscles around the vaginal entrance may be helpful. Many self-help books or pamphlets for women describe Kegel exercises, a technique of learning to identify the muscles to tense and relax them at will. After pelvic radiation, the scarring process can go on for years, so using dilators or having intercourse may be a lifelong commitment. (Many doctors recommend that patients either have sexual intercourse or use dilators three times a week, but more research is needed to show how often is really necessary.)

To help with vaginal dryness, use over-the-counter, water-based or silicone-based lubricants. Look for unscented versions that are thin and watery, like the vagina’s normal moisture. Avoid oil-based lotions like petroleum jelly or baby oil because these products may increase your risk of vaginal infections. Keep the lubricant by your side during sex since you may need to reapply it. Make sure both you and your partner spread some over your genital areas. Women who have chronic vaginal dryness may also want to use an over-the-counter vaginal moisturizer. These gels come in a tampon-type applicator for use three times a week before bedtime, and may take up to two months to reach their full effect. You and your partner can use the lubricant as you caress each other, helping to apply it to each other.

Most women who have had cancer, especially those age 50 or above, are told to avoid taking estrogen because it may increase the risk of breast cancer. However, if lubricants and moisturizers are not enough to make sex comfortable, you may want to consider a low-dose vaginal estrogen. Two forms of vaginal estrogen are helpful in restoring vaginal stretch and lubrication, with only minor amounts escaping into the bloodstream. The Estring, like the ring of a diaphragm without the rubber cup, stays in the vagina for three months at a time and slowly releases a form of estrogen. Some women prefer Vagifem, a suppository that melts inside the vagina. Although many doctors will prescribe these types of estrogen, some believe that there is no such thing as safe estrogen, especially for breast cancer survivors.

Nonhormonal vaginal creams or clitoral suction devices, which often are advertised on TV and the Internet, claim to enhance sex. However, it’s a good idea to discuss these types of remedies and their effectiveness with your doctor or nurse before making any purchases. Many of the lotions that are supposed to increase excitement claim that research shows they work. Often the “research” is not published in a scientific journal and is only based on small groups of women.

When you are ready to have sexual intercourse, show your partner how to touch you in ways that are arousing and make you feel good. Find positions that give you control over movement and minimize deep penetration, such as by being on top or with you both lying on your sides.

Remedies for Men

Remedies for sexual changes in men range from over-the-counter options to those requiring a doctor’s prescription. If you feel embarrassed or uncomfortable about asking for items at a drugstore, you may be able to purchase some of them over the Internet with delivery to your home.

Recovery of erections after cancer surgery in the pelvic area is typically gradual, taking one to two years. During this time, some doctors believe that using medical therapies that promote erections, whether by pill or injection into the penis, may ultimately help healing be more complete. Alprostadil is a medicine injected into the side of the penis to create an erection. Typically the dose is determined by some trial and error, beginning with an injection in a doctor’s office. When getting ready for sexual intercourse, you must give yourself the injection about 10 minutes before you want to have an erection. Men often use pen injectors to make the process easier. Since some men have aching in the penis after injection, a urologist may prescribe a mixture of medicines for injection using a lower dose or including a local anesthetic to numb the tissue inside the penis. With any injection, side effects may include bruising at the injection site or, over time, developing some scar tissue in the penis. Alprostadil also can be given as a suppository that is put into the urinary opening of the penis, but this method is much less effective.

Sildenafil (Viagra), vardenafil (Levitra), and tadalafil (Cialis) are pills taken by mouth before sexual activity. These pills belong to a class of medicines called phosphodiesterase-5 inhibitors. They do not produce an erection by themselves but make it easier to get one during sexual stimulation. They tend to work best for men who can get a lot of penile swelling, but not a completely firm erection. However, some urologists prescribe these pills to be taken daily or at least several times a week to encourage recovery of erections. Many men cannot use these pills successfully to have intercourse after pelvic cancer surgery or radiation therapy since their erection problems are more severe. Men with heart disease need to discuss with their doctor whether it is safe to use these medicines. They can cause low blood pressure in men who need nitroglycerin for chest pain.

A vacuum erection device (or vacuum constriction device) is a plastic tube that fits over the penis and by suction, helps the penis become erect. To keep blood trapped in the penis, the man slips a band from the base of the cylinder onto his penis before removing the pump. The erection tends to be cool to the touch and the skin somewhat blue in color, since the blood comes from the veins rather than the arteries. More expensive versions require a prescription and come with access to a “help line” to troubleshoot how best to use the pump.

If you have surgery that will change how your body looks, ask your doctor if implants or reconstructive surgery are an option. Men who have a testicle removed can have a silicone implant put into the scrotal sac. One treatment for erection problems is the penile implant. Bendable rods or a pump system is surgically implanted into the penis to help with erections. From the outside, the pump is less obvious. When inflated, the pump can create a very firm, thick erection but often with a minor loss of length. Men often try other treatments before deciding on a penile implant.

A few men who have intensive chemotherapy or a bone marrow or stem cell transplant end up with damage to the testicles that results in abnormally low levels of the hormone testosterone in the bloodstream. Survivors of testicular cancer may have low hormone levels because the remaining testicle is somewhat abnormal. Replacement testosterone can be given as a skin patch or a skin gel. A referral to an endocrinologist is necessary, and you cannot use this treatment if your testosterone levels are already normal or if you have had prostate cancer.

A variety of special latex bands or rings are available to help you maintain an erection with the alprostadil injection or the vacuum erection device. Some men try to use a band by itself. Never use a band around the penis unless it is made with a special safety handle or snap fastener so that it can be easily removed. Never leave a band on for more than 30 minutes.

When you are ready to have sexual intercourse, show your partner how to touch you in ways that are arousing and make you feel good.

Men usually find as they get older that their erection may lose firmness during lovemaking, but with stimulation, can become full again. This is normal, although cancer treatment may make the problem worse. If you are worried about being ready for vaginal penetration, you or your partner can caress your penis to restore a firm erection when you need it.

Some vitamins and herbs, which often are advertised on TV and the Internet, claim to fix erection problems. However, it’s a good idea to discuss these types of remedies and their effectiveness with your doctor or nurse before making any purchases. In fact, most of these products are useless and may interact with prescription medicines, causing the medicines to be less effective.

Suggestions for Patients With Ostomies

Men or women who have had an ostomy (the surgical creation of an artificial opening for elimination of body waste) may feel self-conscious and uncomfortable with sexual activity. United Ostomy Associates of America Inc. provides guidebooks and fact sheets about having sex with an ostomy.

Here are suggestions that many survivors find helpful:

• Be careful about the amount and types of food you eat (or about drinking fluids if you have a urinary ostomy). It may be difficult for sexual activity to be spontaneous. Instead, make a “date” with your partner at a time when you don’t expect to have a lot of ostomy activity. If you are able to irrigate your colostomy, it may be easier to schedule sex during a quiet period and to wear just a cap over the ostomy itself.
• Change your ostomy pouch, even if it is less than one-third full.
• Make sure your ostomy bag is empty and flat. You can tape it down or roll it up to keep it out of the way.
• If you feel discomfort, change positions. If you feel uncomfortable or self-conscious and want to cover up the pouch, consider wearing a camisole, shirt, or other sexy top or bottom. Women may choose to wear crotchless panties.
• Manufacturers make products that may help ease your concerns. Consider purchasing deodorant for the ostomy pouch, a pouch with a filter for odor or a colorful cover, or a pouch made for exercise that hangs sideways. On the internet you can find pouch covers or lingerie designed to help women feel feminine and attractive despite having an ostomy.

Alternatives to Sexual Intercourse

If traditional sexual intercourse feels painful or makes you uncomfortable, think about other ways to seek sexual pleasure and intimacy with your partner. By practicing sexual activities that are different from what you would normally do, you may be able to have an enjoyable experience without feeling pain or becoming tired. Sharing pleasure or reaching an orgasm from mutual caressing can relieve sexual frustration and help you feel like a lover again.

People sometimes feel uncomfortable with certain types of sexual activity; for example, having orgasms through hand caressing, oral sex, anal sex, or using a vibrator. Feelings of unease may come from cultural views, religious beliefs, or messages from your childhood.

Only you can decide what kinds of sexual touch are comfortable. Be sure to talk to your doctor, nurse, social worker, therapist, or chaplain if you feel unsure or conflicted. They are available to listen to your concerns and give you advice. From a medical or psychological point of view, most types of sexual activity are healthy and normal, as long as you do not hurt yourself or impose sex on someone who does not agree. However, some cultures and religions do set limits on what kinds of sex are “OK.”

Here are suggestions that many survivors find helpful:

• Give yourself a lot of time to get “in the mood.” Eat a romantic dinner by candlelight. Listen to sensuous music. Hold hands, caress each other, and allow time for foreplay so that you are as sexually aroused as possible.
• Enhance your sexual experience through techniques to help you relax, playing out fantasies, taking a shower or bath together, lighting scented candles, listening to arousing music, and talking about the fun you have had together in the past.
• When you are both fully aroused, try experimenting with each other in new ways. Give each other foot rubs and sensuous back rubs with scented oils. Use gentle touches, kissing, and fondling to stimulate your partner.
• Use your hands to stimulate yourself or your partner, or use your mouth to stimulate your partner.

Self-Pleasure

Whether single or in a relationship, caressing your own body and even bringing yourself to orgasm is one way to make yourself feel more comfortable with sex after cancer treatment. After a diagnosis of cancer, some patients feel as if their bodies have betrayed them. Pleasuring yourself can help you feel good about your body again, feel like a sexual person, and help you have good physical feelings instead of painful ones. Women who bring themselves to orgasm have an easier time having orgasms with a partner, so it also may be a way to enhance sex with a partner.

Masturbating is also a good way to find out whether your sexual sensitivity or sensations have changed after cancer treatment. For example, men can find out if they are able to have erections, and both men and women can find out if they are able to have orgasms. You can explore your sexual responsiveness and level of arousal without any pressure or expectation from someone else. If you are in a relationship, once you understand more of your own sexual readiness, invite your partner to participate.

Conversation Starters With Your Doctor

Many people avoid talking to healthcare professionals about sexual changes because they feel embarrassed, ashamed, or afraid. Some people feel guilty about “bothering” the doctor, or they worry about “being a good patient.” However, all patients have a right to information that affects their quality of life, which includes sexuality. It’s normal to feel uncomfortable or awkward, but your doctors, nurses, and social workers are a professional team and have training and experience talking about these issues. If you do encounter a doctor or other healthcare provider who dismisses your concerns and questions about sex, seek a second opinion.

Listed below are suggestions for beginning a conversation:

• How do you expect that my cancer treatment will affect my sexuality?
• Is it safe for me to have sex? (It is usually safe to have sex during cancer treatment unless your doctor tells you not to. Sex can be a problem if you have bleeding in the genital area from cancer, if you have recently had surgery or radiation implants, or if your immune system is very weakened. Talk with your doctor to see whether it is safe for you to participate in sexual activities.)
• Should I be using contraception to avoid pregnancy during my cancer treatment?
• Are my sexual changes short term, or do you think they are permanent?
• I don’t think about sex or feel interested in sexual activity. Why do you think I feel this way?
• I think about sex and would like to participate in sexual activity, but I don’t feel that my body is responding the way it did before my cancer or cancer treatment. Why do you think this is happening?
• I feel tired all the time, and it’s negatively affecting my sex life. Is there anything I can do to feel better?
• I’ve noticed changes with my erections since I started this new medicine. What do you think is causing this?
• What are some possible remedies that may help me enjoy sex again?
• How can I find more information about remedies for sexual changes? How do I go about trying one of them?
• My friend told me about a (treatment, herb, supplement, food, etc.) that may help my sexuality. Is it OK to try this?
• I feel embarrassed about starting sexual activity because my body is different. Is it an option for me to have cosmetic or reconstructive surgery? Can you refer me to a counselor?
• I feel nervous (or my partner feels nervous) about starting sexual activity. Could you please reassure me that it’s OK? Are you sure that sexual activity won’t negatively affect my cancer or cancer treatment?
• My partner told me that (he or she) is worried about catching my cancer or getting sick from my treatment. Could you please reassure us about this?