Ways of Dealing With Sexual Problems

Ways of Dealing With Sexual Problems

What to expect

When you first think of restarting sexual activity, you may be afraid it will be painful, or that you will never reach orgasm again. Your first sessions of lovemaking may not be what you expected. But just as you learned to enjoy sex when you started having sex, you can relearn how to feel pleasure after cancer treatment. Often people realize that their sex life was less than ideal before cancer and make changes in their sexual practices. Use this opportunity to look at your sex life in a new way.

The areas of your genitals most sensitive to touch may be a little different, or perhaps touch that felt exciting before cancer treatment is now painful. You might find your favorite position for intercourse has changed. If your vagina or vulva has been affected by surgery, you will need time to get used to the new feelings you have during intercourse.

Vaginal dryness

Cancer treatments often reduce the amount of moisture that your vagina produces when you are excited. You may need extra lubrication to make intercourse comfortable. If you use a vaginal lubricant, choose a water-based gel that has no perfumes, coloring, spermicide, or flavors added, as these chemicals can irritate your delicate genital tissues. Lubricants can usually be found near the birth control or feminine hygiene products in drug stores or grocery stores. Common brands include K-Y Jelly and Astroglide®. Be aware that some of the newer lubricant products include herbal extracts (such as aloe or lavender), which may cause irritation or allergic reactions in a few people. Also, warming gels can cause burning in some people. Be sure to read the labels and talk with a nurse, doctor, or pharmacist if you have questions.

Replens® and K-Y Liquibeads® are vaginal moisturizers that you can use 2 or 3 times a week to help keep your vagina moist and at a more normal acid balance (pH). The effects of these products last longer than those of lubricants, and you can buy them without a prescription. Lubrin® and Astroglide Silken Secret® are other moisturizers that are marketed as longer lasting than typical lubricants. Vitamin E gel caps can also be used as a vaginal moisturizer. Use a clean needle to make a small hole in the gel cap and either place the entire capsule within the vagina or squeeze some of the gel onto your fingers and insert them into the vagina. Vitamin E may stain undergarments.

Some women do well with local vaginal hormones to help vaginal dryness. These hormones are applied to and absorbed into the genital area, rather than taken by mouth. They come in gel, cream, ring, and tablet forms. Most are put into the vagina, although some creams can be applied to the vulva. Local vaginal hormones must be prescribed by a doctor.

Petroleum jelly (Vaseline®), skin lotions, and other oil-based lubricants are not good choices for vaginal lubrication. In some women, they may raise the risk of an itchy yeast infection. If latex condoms are used, they can also be damaged by petroleum products and lotions. Also, watch out for condoms or gels that contain nonoxynol-9 (N-9). N-9 is a birth control agent that kills sperm, but it can irritate the vagina, especially if the tissues are already dry or fragile.

Before intercourse, put some lubricant around and inside the entrance of your vagina. Then spread some of it on your partner's penis, fingers, or other insert. This helps get the lubricant inside your vagina. Many couples treat this as a part of foreplay. If intercourse lasts more than a few minutes, you may need to stop briefly and smooth on some extra lubricant. Even if you use vaginal moisturizers every few days, you can still use gel lubricant before and during sex if needed.

Premature menopause

If you have gone through premature (early) menopause because of cancer treatment, you may be bothered by frequent hot flashes, especially at night. Some women also feel grumpy and less interested in sex, though these symptoms may be linked more to stress and poor sleep than to a shortage of hormones. Pre-menopausal women who have had surgery to remove their ovaries are more likely to report problems with low sexual desire. If you think this has happened to you, talk with your doctor about whether you may be helped by small doses of androgens. (See the section "How the female body works sexually" for more on androgens.)

Replacement female hormones in a pill or patch can help with vaginal dryness and hot flashes (see "Vaginal dryness," discussed previously). But because estrogens can promote cancers of the breast, uterus, and ovaries and cause other health problems, doctors are less likely to prescribe them than they once were. Women who have vaginal dryness can now use tiny doses of estrogen in gels, creams, rings, or tablets by putting them right into their vagina. The gel, cream, ring, or tablet slowly releases small amounts of hormones to the vagina and nearby tissues, so that very little enters the bloodstream.

If you have questions or concerns about hormone replacement therapy, talk with your doctor or health care provider about its risks and benefits as they apply to you. If you and your doctor decide that hormone therapy is the best treatment for you, it is usually best to use it at the lowest dose that works for you and for the shortest possible time. It is important that any woman taking hormone therapy be checked each year by her doctor for any signs of cancer.

If your doctor does not advise hormones for you, hot flashes can also be treated in other ways, such as by taking medicines that control the nervous system's reaction to a lack of estrogen. Some drugs that are commonly used this way are the anti-depressants called serotonin reuptake inhibitors, such as venlafaxine (Effexor fluoxetine (Prozac , paroxetine (Paxil), and others. Many women with milder hot flashes may do well with exercise and relaxation techniques alone. There are many ways to treat hot flashes--both with medicines and with minor changes in your environment. Ask your doctor or nurse about ways to help reduce your hot flashes.

Coping with the loss of a body part

Women who lose a part of their body to cancer, especially if it is a breast or an area of the sexual organs, sometimes miss the pleasure they felt from having that area stroked during sex. If you are in this situation, ask your partner to stroke your whole body. You may find new places to replace the pleasure you used to feel. Women often are embarrassed to look at or touch their own private parts. Becoming more familiar with your genitals can be important in restoring your sexual pleasure after cancer treatment.

You can feel more comfortable about your genitals by taking some time to look at them and touch them. Have you ever looked at your own genitals in the mirror? Many women have not, or at least have never located the different parts. Take a few minutes to study your own body. Take a hand mirror and hold it so that you can see your genitals. Find the different parts: outer lips, inner lips, clitoris, urethra (urinary) opening, entrance to the vagina, and anus. Take a finger and lightly touch each part, touching the anus last to avoid spreading germs to the urethra. Which areas are most sensitive to touch?



If you feel embarrassed or find your genitals ugly, try looking at them again in a day or so. Are your negative feelings as strong? Some artists have compared the shape of a woman's genitals to a flower or a seashell. Can you see your genitals as having their own beauty? Has your cancer treatment changed the look of your outer genitals in any way? If so, make it a goal to get used to the changes and explore them with touch to see if any areas are still sore or tender.

Reaching orgasm after cancer treatment

Almost all women who could reach orgasm before cancer treatment can do so after treatment. Most will have orgasms just as easily before. But for some it may take practice. Many books or videos for women contain detailed steps on how to reach orgasm.

"I'm having trouble reaching orgasm. What can I do?"

If you enjoy being touched but still have trouble reaching orgasm, you may need to try something new to push yourself toward more excitement. Here are a few ideas that might help a woman reach orgasm.

Have a sexual fantasy during lovemaking. A fantasy can be a memory of a past experience or a daydream about something you have never tried. A strongly sexual thought can distract you from negative thoughts and fears about performing.
Use a hand-held vibrator to give extra stimulation during your lovemaking. Hold it yourself or ask your partner to caress your genitals with it. You can steer your partner to the areas that respond best and away from those that are tender or uncomfortable.
Change the position of your legs during sexual activity. Some women reach orgasm more easily with legs open and thigh muscles tense. Others prefer to press their thighs together.
Tighten and relax your vaginal muscles in rhythm during intercourse or while your clitoris is being stroked. Or, tighten and relax the muscles in time with your breathing. This helps you focus on what you're feeling. Contract your vaginal muscles and pull them inward as you inhale, and let them relax loosely as you exhale. Pretend you are breathing through your vagina.
Ask your partner to gently touch your breasts and genital area. Experiment with your partner to find the type of touch that most excites you.
If a sexual problem has not cleared up after you have worked on it for many weeks or months, try some of the ideas in the section, "Professional help." If your partner does not want to go with you to counseling, the health care specialist you see may be able to help you involve your partner.

Preventing pain during sex

Pain during intercourse is one of the most common sexual problems for women. This can be pain in a non-sexual area of the body or pain in the genitals. Even if your pain is in a non-genital part of the body, it can keep you from feeling pleasure during sex. This type of pain might be soreness in one arm after a radical mastectomy or tingling and numbness in your hands and feet after some types of chemotherapy. Pain may even make it hard for you to use intercourse positions that worked well in the past.

Non-genital pain

If you are having pain not related to your genital area, these suggestions may help lessen it during sexual activity.

Plan sexual activity for the time of day when you feel the least pain. If you are using pain medicine, take it an hour before planned sexual activity so it will be in full effect during sex. Try to find doses of medicine that offer pain relief without drowsiness.
Find a position for touching or intercourse that puts as little pressure as possible on the sore areas of your body. If it helps, support the sore area and limit its movement with pillows. If a certain motion is painful, choose a position that doesn't require it or ask your partner to take over the hip movements during intercourse. You can guide your partner on what you would like.
Focus on your feelings of pleasure and excitement. With this focus, sometimes the pain fades into the background.
Genital pain

Another side effect of some cancer treatments is genital pain. Sexual activity may cause pain in the vagina itself or in the delicate tissues around it. Some women's vaginas are shorter and narrower after surgery or radiation. If you don't produce enough natural moisture to make your vagina slippery, intercourse can be dry and painful. It can leave a burning feeling or soreness. The risk of repeated urinary tract infections or irritation also goes up.

If you have genital pain during sexual activity:

Always let your doctor know about the pain. A number of common problems can cause pain on the vulva or deep in the vagina. Medical treatments can often help. Genital pain is sometimes a sign of cancer. Do not let embarrassment get in the way of seeking medical care.
Make sure you feel very aroused before you start intercourse. Your vagina expands to its fullest length and width only when you are highly excited. Also, the walls of your vagina then produce lubricating fluid. As women go through menopause, whether because of aging or because of cancer treatment, it may take a longer time and more touching to get fully aroused.
Spread a large amount of water-based lubricating gel around and in your vagina before having intercourse. You can also use lubrication suppositories (pellets) that melt during foreplay. Vaginal moisturizers should be used regularly, whether or not you have intercourse.
Let your partner know if any types of touching cause pain. Show your partner ways to caress you or positions that aren't painful. Usually, light touching around the clitoris and the entrance to the vagina won't hurt, especially if the area is well lubricated.
For intercourse, try a position that lets you control the movement. Then if deep penetration hurts, you can make the thrusts less deep. You can also control the speed.
One position that often works well is for you to kneel over your partner with your legs on either side of his body. Either sit up or lean forward and support yourself with your arms. An advantage of this position is that your partner can easily caress your breasts or clitoris. This may add more pleasure to intercourse.

Another good position is for partners to lie on their sides, either with your partner behind you, like spoons, or face to face.

Using Kegel exercises to learn to relax the vaginal muscles

Once a woman has felt pain during intercourse, she often becomes tense in sexual situations. Without knowing it, she may tighten the muscles just inside the entrance of the vagina. This makes intercourse even more painful. Sometimes she clenches her muscles so tightly that her partner cannot even enter her vagina.

You can become aware of your vaginal muscles and learn to relax them during intercourse. Exercises that teach control of the vaginal muscles are called Kegels, named for the gynecologist, Dr. Arnold Kegel, who came up with them. Practicing Kegels can help you decrease pain during intercourse.

The first step is to find your vaginal muscles. The muscles around the entrance to the vagina are the same ones that you use to stop the flow of urine. The next time you urinate, try stopping the flow for a few seconds. Notice how you do this. When you relax your muscles, the urine flows again. You can make the same motion when you are not urinating. You don't need to tighten your stomach muscles, leg muscles, or hold your breath. Just tighten the muscles in the genital area. To check whether you have found the muscles, try slipping a finger about 2 inches into your vagina. When you contract your vaginal muscles, you should be able to feel at least a slight twitch of the vaginal walls around your finger.

Once you have located the muscle, practice gaining control over it. The basic Kegel exercise is to tighten your vaginal muscle while you count to 3, and then release the tension. Repeat this movement 10 times, once or twice a day. People around you can't tell that you are doing Kegels, so you can practice wherever you wish -- while reading, watching TV, or working at your computer.

Kegels can add to a couple's pleasure during sex. If a woman tightens and relaxes her vaginal muscles during sexual activity, she may focus more on the feelings that are building. Her partner can feel the movement of her vagina. This movement may add to their excitement.

The most important benefit of Kegel exercises is to help you relax your vagina during entry and intercourse. Begin by making sure your vagina is wet when you and your partner are both aroused. Take a few seconds to tighten your vaginal muscles. Then let them relax as much as possible before your partner enters. Agree ahead of time that if you feel any pain, your partner will stop until you stretch your vaginal muscles again.

If intercourse is painful and difficult, you or your partner can stretch your vagina with a finger before you try penetration. Lubricate a finger and slowly slip it inside your vagina. Use the Kegel movements to tighten and release your vaginal muscles as you slowly move it deeper in. When one finger is no longer painful, try using 2 fingers, and then 3, before you try your partner's penis. Remember to use plenty of gel, and go slowly.

If you try most of these ideas but are still having genital pain, you may need some help from a gynecologist or sex therapist. Some women need to stretch their vaginas after cancer treatment by using a series of vaginal dilators in different sizes.

Using a vaginal dilator

A vaginal dilator is a tube, most often made of plastic or rubber, used to enlarge, or stretch out (dilate), the vagina. Dilators also help women learn to relax the vaginal muscles. Dilators come in many forms.

Vaginal dilators are often used after radiation to the pelvis, cervix, or vagina. Using the dilator several times a week (3 times is recommended) keeps your vagina from getting tight when scar tissue develops after radiation treatment. An alternative to using a vaginal dilator is to have intercourse a few times a week.

Since scarring in the pelvis after radiation can develop over many years, you should follow this schedule for the rest of your life. After surgery that rebuilds the vagina with skin grafts, you may need to keep a special type of dilator in your vagina all day or night for a while.

Your doctor may suggest a certain way to use the dilator. The points below describe a typical way to use a vaginal dilator:

Lubricate the dilator with a water-based gel.
Lie down on your bed at a time when you know you will have at least 15 minutes of privacy. Gently and slowly slip the dilator into your vagina. If your vagina feels tight, hold the dilator still while you contract and relax your vaginal muscles.
When your vagina feels looser, push the dilator farther in. You may need to repeat the squeezing and relaxing a few times before the dilator is fully inserted. Some women also find it helpful to bear down, pushing their vaginal muscles outward as if having a bowel movement.
When the dilator is in as far as possible, leave it in your vagina for about 15 minutes. You can pass the time by reading, watching TV, listening to music, or even talking on the phone. If the dilator slips out, gently push it more deeply into your vagina.
When you remove it, wash it with a mild soap and water. Be sure to rinse all the soap off so no film is left to irritate your vagina the next time you use it.
A woman is often given one dilator in the size needed to fit her vagina. But if she is trying to overcome pain or needs to stretch out a vagina that is too small, she may use a series of dilators. She can start with one about the size of a finger and slowly go to larger models until she feels her vagina is large enough to allow penetration.

Try to find a private, uninterrupted time to do your dilator exercises. Many women find it easier to do these exercises early in the day. Often, with work and family obligations, evening exercises may be difficult.

Dilators work best when used early after radiation or surgery to prevent vaginal shrinkage. Don't wait until you have an overly tight vagina. The dilator will not work nearly as well. If you go for many months without a sexual relationship, it is very important to use your dilator to keep your vagina in shape.

If you feel hesitant about using a dilator, you may need some practice getting more relaxed. The exercises on looking at and touching your genitals, described earlier in this section, may help you. Use a mirror to locate your vaginal opening the first time you insert the dilator.

Some women wonder if using a vaginal dilator is the same as masturbating. The answer is no. The section "Keeping your sex life going" may help you clarify your feelings about self-stimulation. Even if you do not feel comfortable masturbating, you can use a vaginal dilator without creating strong sexual sensations, just as you use a tampon.

A dilator is not the same thing as a dildo or a vibrator. A dildo is an object shaped like a penis. Its purpose is to stimulate a woman's vagina in masturbation. Although you can move your dilator inside your vagina to give yourself sexual pleasure, it is not a dildo. Sexual pleasure is not its purpose.

A vibrator is a small appliance that may also be shaped like a penis. Other types look more like a handle that comes with attachments. A vibrator provides strong stimulation when touched to the genital area. It is designed to add pleasure and variety to your sex life. If you have a vibrator that fits comfortably inside your vagina, you can use it instead of a vaginal dilator to stretch your vagina.

If you feel comfortable with self-stimulation, you may sometimes choose to combine sexual pleasure with stretching your vagina. No matter how you decide to use your dilator, the key is to use it as often as prescribed. You should feel relaxed about making dilation a lifelong habit.