MiddlesexMD

I Will Observe Cervical Health Awareness Month

Resolution #2

The stars have aligned for our January resolutions series. Not only is January designated as Cervical Health Awareness Month, but I’d say that the cervix counts as an “often neglected body part” related to our sexual health or well-being, which was the criterion for this January resolutions series.

The good news about the cervix is that there really isn’t anything you have to do to improve its function—no exercise, no diet, no special creams or lotions. Basically, it’s four centimeters of tough muscle between the vagina and the uterus. It keeps a baby in safely tucked inside the uterus and then dilates when it’s time for the baby to be born. That dilation is what labor is all about, as though you could ever forget. It really has no sexual function, contrary to previous belief.

The deal with the cervix—and why we have this special month devoted to it—is that you can almost ignore it if it’s healthy, but if it acts up, as with cervical cancer, then you have a problem, Houston.

And that’s why you can’t completely ignore it. So let’s give the lowly cervix a little blog luv.

Times have changed with the sexual revolution and advent of cheap, easy, and effective birth control. There’s a whole lot more sex happening with more partners, for one thing. And with that has come a lot more sexually transmitted diseases. We talked about that at length, beginning here, but as it relates to the cervix, here’s the rub.

The precursor for cervical cancer is what we call SIL (squamous intraepithelial) change (or dysplasia in physicians’ lingo). That change is nearly always caused by human papillomavirus (HPV; there are rare occasions where cervical cancer isn’t HPV related), and HPV is pretty much ubiquitous among sexually active people (80 percent). Plus, it’s a virus, so once you have it, there’s no cure. Usually that’s no problem. In 70 to 90 percent of cases, a healthy immune system clears it up within two years—kind of like the common cold.

But as we know, viruses are wily, shape-shifting critters. There are about 100 strains of HPV, only a few of which are considered high risk for cervical cancer. About 12,000 women get cervical cancer every year in the US, and one-third of them die. This isn’t a huge number, but the tragic thing about cervical cancer is no one should die from it because cervical cancer is extremely easy to detect and treat. In women older than 65 with cervical cancer, 42 percent had never been screened.

Screening guidelines and testing procedures have changed in recent years, however, so it’s no wonder if you’re confused about what to do and how often to do it. There is now a test for HPV, which is recommended for any woman over 30. There is also the tried-and-true Pap test that tests the cervix for precancerous cellular change, or dysplasia. This test is recommended to start at age 21.

A woman with a history of negative results and no other complications only needs a Pap test every three years. Combined with a negative HPV test, the wait can be five years.

Obviously, if your cervix was removed during a hysterectomy (and you DO know whether or not it was removed, don’t you?), and if you don’t have a history of cancer or dysplasia, you are done with Pap tests forever. Even if your cervix is intact, until recently the guidelines advised that women over 65 with no history of positive Pap results no longer need screenings.

All that may be changing.

In a 2013 study of women between 35 and 60 found that some women who had been monogamous or celibate for decades began testing positive for HPV. The results suggested that these women had been carrying latent and undetectable levels of the HPV virus from sexual encounters in their youth that had spontaneously reactivated during menopause. This is akin to a childhood case of chicken pox returning later in life as shingles.

“As long as you are controlling these infections, your immediate risk of [cancer] is going to be low,” molecular biologist Dr. Patti Gravitt explains in this article from Johns Hopkins. “But if menopause, or just getting old, increases HPV reactivation, then we need to look at what this means for screening these older women who came of age during the sexual revolution and are much more likely to reach menopause with latent HPV than the postmenopausal women we have screened in the past.”

In the face of this surprising finding, the North America Menopause Society now recommends that “all women who have had multiple partners should not stray too far from their Pap smear or HPV test at menopause until we know more about the increased risk of HPV flare up at menopause.” 

Even women who have had their cervix removed should be aware that rarely HPV also causes vaginal and vulvar cancers. So more than ever it pays to be aware of your cervical health—and your HPV status. Being postmenopausal doesn’t give us a pass anymore.

 

 

Lifestyle Choices for Breast Health

You know that silly song about the thigh bone being connected to the hip bone—and so on?

Well, the kernel of truth in the ditty is that, when it comes to health and our bodies, things are indeed beautifully and intricately connected.

You can’t do healthy things for your thigh bone—or your heart or your sex life—and not have it affect other corporal systems as well. So, while we might focus on breast health in honor of Breast Cancer Awareness Month, rest assured that healthy, cancer-free breasts involve habits and choices that are good for the rest of your body as well.

There’s a lot to celebrate when it comes to breast cancer, like steadily decreasing rates since the year 2000. But we still have a long way to go. About 12 percent—1 in 8 women in the US—will develop invasive breast cancer sometime in her life. Our most significant risk factors are 1. being a woman and 2. being older.

Women over 55 account for two-thirds of invasive breast cancers diagnosed each year. This is because, over time, we tend to accrue genetic mutations, and with age we’re less adept at repairing them.

Those are the facts. But we don’t have to helplessly wait for the shoe to drop. We can make lifestyle adjustments that will lower our risk of getting this cancer and improve our overall quality of life, including our sex life. (And don’t forget that a healthy sex life is also good for our health.)

Because it’s all connected, right?

So here are lifestyle changes that you can make specifically targeted toward breast health:

Maintain a healthy weight. Being overweight or obese—those with a body mass index (BMI) over 25—increases one’s risk of developing breast cancer, especially in postmenopausal women. This could be because estrogen is stored in fatty tissue, and women who have more fat are also exposed to higher levels of estrogen, which has been undeniably linked to breast cancer. But other issues related to obesity may also be involved, such as insulin and glucose levels. Some estimates suggest that 17 percent of breast cancers in North America could be avoided simply by maintaining a healthy body weight. Check out this page for a solid, common-sense approach to weight loss.

Eat healthy food. Not only will a healthy diet help maintain a healthy weight, but it’s a critical component to avoiding cancer. Some foods contain properties that help repair the wear and tear to our bodies in the normal course of life. These “super foods” contain antioxidants that help protect our bodies from cancers.

The link between food and cancer isn’t always straightforward or well-understood, and dietary fads change with the season. Basically, though, the approach to healthy eating remains the same: eat a variety of foods with an emphasis on fruits, vegetables, and whole grains. Avoid processed foods. Avoid fats and sugars. Above all, avoid super-sugary beverages, which are directly linked not only with obesity but also with some forms of cancer.

Finally, eat fresh and eat at home. (You can’t control what goes into your food at a restaurant.) Eat organic foods to avoid exposure to synthetic chemicals.

While the voices touting various diets and food fads are myriad, confusing and contradictory, here are some basic food facts from breastcancer.org. The USDA also has a website with tons of food and diet information here.

Exercise. Weight, diet, and exercise. This is the trifecta of good health. Some well-regarded sources say that 30-40 percent of cancers could be avoided simply with these healthy lifestyle choices. That’s staggering. And when you add in quality of life factors that come with the trifecta, well, it’s overwhelmingly worth the difficulty of losing weight, eating well, and exercising regularly, wouldn’t you say?

Regular, moderate exercise can lower your risk of breast cancer. Not to mention all the other good things you get with exercise, such as better mood, cardiovascular and joint health, greater stamina and flexibility, better sleep, better bones, and more regular bowel movements. What are we waiting for?

Even women who have already been diagnosed with breast cancer may improve survival rates or prevent recurrence with moderate exercise, like walking only 4-5 hours per week, according to the American Cancer Institute.

Don’t have time? As the trainers in my exercise video say, “Make time.” It doesn’t matter what your physical ability is right now—just start slow and keep on going.

Don’t drink. Sorry to be a killjoy, but the more you drink, the greater your risk. A woman who has three alcoholic drinks per week is 15 percent more likely to get breast cancer than a woman who doesn’t drink at all. If you’re on hormone replacement therapy or if you’ve already been diagnosed with breast cancer, you should be one of those non-drinking women.

What about that healthy glass of red wine? Sorry, it all counts. The benefit of red wine doesn’t outweigh the risk. If you’ve never had breast cancer, just don’t drink every day, but if you have risk factors, switch to non-alcoholic options.

Don’t smoke. This almost goes without saying. Yes, the major risk is lung cancer, but actively smoking as well as exposure to second-hand smoke increases the risk of breast cancer in premenopausal smokers. Plus, women who smoke have greater difficulty recovering from breast cancer treatment.

Avoid chemical exposure. This is like trying to dodge raindrops, given the chemical soup we live in every day. And most of the chemicals in our environment and in the things we use have never been tested for toxicity or carcinogenic properties. Some types of chemicals are known to be hormone-disrupting, which alter the way our natural hormones function. Research is ongoing about the way these substances work and their link to possible cancers, but the connection isn’t well understood.

In the meantime, how do we negotiate the reality of the world we inhabit without neurotic overreaction but also without putting our heads in the sand? Of greatest concern with regard to breast cancer are those chemical with hormone-disrupting properties, including those in pesticides, growth hormone residues in meat and dairy products, and certain plastics.

In general, some precautionary practices would be to

• Buy organic food. Here’s a list of the “dirty dozen”—the foods that have the highest levels of pesticide residue.
• Plant a garden. Put up your own food.
• Use fewer and simpler cleaning and personal care products. Look for certified “green” cleaning products (with GREENGUARD or EcoLogo insignias, for example) or make your own.
• Don’t use pesticides on your lawn or garden.
• Use BPA-free plastics or glass or stainless steel jars and bottles. Avoid #3 (PVC), #6 (polystyrene) and #7 (polycarbonate) plastics, which are linked to breast cancer.

You may not be able to tackle everything on this admittedly intimidating list, but it’s better to make a few changes than not to do anything at all. And the foundation you lay now will become even more important in maintaining health and functionality as you age.

Q: What is my "vaginal cuff"?

As you suspected, the "vaginal cuff" is the healed incision at the top of the vagina after the surgical removal of the cervix and other pelvic organs.

The vagina is just as functional as it was before surgery, but the depth is unpredictable. The tissue is somewhat elastic and stretchy–comparable to the inside of your cheek when you poke your tongue against it. If there seems to be less depth than you (and your partner) need, using dilators can gently and gradually stretch the tissue to a new capacity.

An intravaginal vibrator (like the Liv2) may be helpful to you as you determine what your needs and your new reality are. Sincere congratulations on achieving remission from the cancer for which you were treated, and best wishes as you rediscover your sexual self!

Q: What's the connection between HRT and cancer of the endometrium?

A definition first: The endometrium is the mucous membrane that lines the uterus. For women who have had hysterectomies, the endometrium is not an issue in planning hormone therapy (HT).

For others, the endometrium is a "target tissue" (like many others) for estrogen and progesterone. During our reproductive years, those hormones signaled the lining of the uterus to thicken (proliferative endometrium influenced by estrogen) and then to shed (secretory endometrium influenced by progesterone), over and over in our menstrual cycle.

Endometrial cancer is a well-recognized consequence of "unopposed estrogen," a continual message to proliferate and thicken without the proper "opposing" influence of progesterone. Nearly all endometrial cancers will be "estrogen influenced."

When we plan HT for a woman in menopause with a uterus, we must balance estrogen and progesterone. (And, in fact, for a woman in reproductive years who doesn't ovulate, which typically triggers progesterone, we'll compensate with progesterone therapy.)

As with most cancers, there are factors we can't always explain. Obesity, however, is the most common risk factor; in fact, obese women are at higher risk than their friends on HT including both estrogen and progesterone. Fat (adipose) tissue produces estrone, an estrogen that is very weak but does influence the endometrium. Sometimes we biopsy obese women and find "precancer" of the endometrium; part of our treatment is progesterone in an effort to reduce their cancer risk.

Just one more reason, I'm afraid, to make healthy habits a priority—and to work with your health care provider for HT that takes your health history and priorities into account.

A Breakthrough in Breast Cancer Research

Breast cancer doesn’t really have much in common with sex. But I know it's hard to be very interested in sex when you have cancer or are recovering from cancer treatments or are working to feel good about your body again after having had cancer.

However, anyone interested in staying vibrant and healthy (not to mention sexy) should be interested in the breakthrough research on breast cancer just announced in the journal Nature.

Turns out, genetic mutations caused by cancer and the unique genetic “fingerprint” they leave may be the new frontier for cancer treatment and could suggest treatments targeted to specific genetic mutations.

This research, which is the scientific equivalent of putting a man on the moon, is an outcome of the Cancer Genome Atlas, a federally funded study to map genetic changes caused by common cancers. Breast cancer is the third (after colon and lung cancer) to come under intense analysis, with several hundred researchers tracking the genetic changes caused by unmetastized tumors from 825 women.

As a result, four new subtypes of breast cancer based on 30 to 50 genetic mutation have been identified, which suggest new approaches to treatment and also explains why some one-size-fits-all treatments may not work.

“When treating breast cancer, we offer specific therapies that have been tested on large populations of cancer patients,” said Dr. Stephanie Bernik, chief of surgical oncology at Lenox Hill Hospital in New York City in an article for HealthDay News. “…This research helps move us to the point where we will look at a tumor's genetic makeup and tailor a specific treatment that will attack the tumor cells based on the tumor's genetic fingerprint.”

This research may alter cancer treatments by

• Basing treatment on the genetic signature of the cancer rather than its location in the body. For example, one of the less common but most deadly breast cancers is genetically very different from other breast cancers but very similar to ovarian cancer, suggesting that treatment for this breast cancer could also be similar to that for ovarian cancer.
• Avoiding unnecessary, ineffective, and potentially harmful treatment. For example, one of the most common cancers, whose growth is fueled by estrogen, was routinely treated by an estrogen-blocking drug. The genetic study identified two different types of this common cancer, which suggests more targeted treatments. So, besides receiving appropriate treatment, cancer patients may also be able to avoid potentially harmful treatment. “Targeted therapies allow for more effective treatment of tumors, while minimizing the treatment of tumors with less effective therapies and their subsequent side effects,” said Dr.Bernik.
• Suggesting new avenues for research. When these subtle genetic differences are identified, new research and treatments can begin. For example, some women with the same HER2-enriched gene respond to treatment by the drug Herceptin, and other women don’t. Now, ongoing clinical trials will try to identify the differences in the genetic makeup of the HER2 tumor that may explain the different responses to treatment.

While this research may be seismic for oncologists, it will be years before the laborious process of testing and approvals are complete and we begin to see the results on the ground and in our doctors’ offices.

Still, this affirms the need for informed, individual health decisions, weighing all factors, instead of applying one-size-fits-all thinking. And, taking the long view, this is great news for our daughters and granddaughters.

After Cancer: Take Care of Your Vagina

Whether you were already menopausal or were abruptly deposited into menopause after treatment for your cancer, you’re probably familiar with what happens to your vagina when you lose estrogen.

You may experience the burning, itching pain of thin, dry vaginal walls and fragile skin on your genitals. You don’t lubricate like you used to, so sex can be difficult or painful. Or, if you’re experiencing the muscle spasms of vaginismus, sex may be impossible. Less estrogen is a good thing for some cancer treatments, but it’s darned tough on the vagina and, by extension, on your sex life as well.

So, while vaginal health is important for all women during menopause, it’s critical for those undergoing cancer treatment. Your vagina and pelvic floor need a lot of TLC right now to stay comfortable and responsive. Fortunately, compared to the other things going on in your life, taking care of your bottom is usually straightforward and inexpensive. Besides, keeping your vagina in good shape might eliminate one problem area and allow you to stay in touch with your sexual self, too.

Consider this four-part approach to caring for your vagina and pelvic floor.

First, use vaginal moisturizers and lubricants.

Moisturizers are your first line of defense. These are non-hormonal, over-the-counter products that are intended to keep your vagina hydrated and to restore a more natural pH balance. They should be used two or three times a week, just as you’d moisturize any other part of your body. Lubrigyn, PrevaLeaf Oasis, and Emerita are examples of moisturizers.

Using moisturizers is important whether or not you’re having intercourse. It should just be part of a regular health maintenance regimen.

Use lubricants liberally before intercourse, on sex toys such as vibrators, and any time you touch the delicate tissue on your genitalia. Also apply lubricant to your partner’s penis.

At this point, keep your lubricants plain and simple—no scents or flavors; avoid warming lubes. Don’t use any product with glycerin, which can create an environment conducive to yeast infections, and don’t use petroleum-based lubricants.

Second, keep your pelvic floor toned. “The pelvic floor is really important in keeping your internal organs in place, preventing incontinence, and enhancing sexual pleasure,” says Maureen Ryan, nurse practitioner and sex therapist.

Plus, knowing how to relax your pelvic floor muscles is helpful if you’re experiencing the involuntarily spasms of vaginismus.

Kegel exercises, in which you flex and relax the muscles around your vagina, will tone the pelvic floor. Or, you can purchase exercise tools to tone your pelvic floor muscles. This is a great way to make sure you’re exercising the right muscles.

Third, use dilators if your vaginal capacity is compromised. Dilators are cylinders that come in sets with various sizes. They’re meant to gradually increase the size and capacity of the vaginal opening, which can be important, especially after some cancer surgeries and treatments that constrict the vaginal opening or create scars and adhesions.

To some extent, dilators are helpful just to reassure you that you can tolerate something in your vagina again.

Start with the smallest size dilator, lubricate it, and gently insert it as far in as you can tolerate. Try doing kegel exercises, tensing and relaxing your pelvic floor muscles. Can you feel your muscles close around the dilator? Keep it in for maybe ten minutes and repeat this exercise several times a week. Move on to the next largest size when you can tolerate it.

Fourth, use a vibrator (lubricated, of course). Self-stimulation increases blood flow to your genitals and helps reacquaint you with the feelings and sensations of your body. The more stimulation you can bring to the area, the healthier it will be.

The point is to keep the vulvo-vaginal area moist and flexible, to increase blood flow, to stay responsive, to maintain capacity, so that when you and your honey are ready to start your engines, you’ll both enjoy a smooth ride.

Staying Close after Cancer

“Women often shut down emotionally from their partners [after a cancer diagnosis] for a number of reasons,” says Maureen Ryan, sex therapist and nurse practitioner. “Maybe they’re scared; maybe they’re afraid of what’s to come. So they shut down and build a wall against intimacy.”

It makes sense. Survival has suddenly become a priority. You’re faced with complex decisions, a long and difficult treatment with a big question mark at the end. You may already be stretched emotionally and physically with a career and children at home, and maybe other obligations as well. The demands of a relationship seem overwhelming.

Sex? Fuggedaboudit.

While you probably won’t be interested in sex for a while after treatment, staying connected—maintaining the bonds of intimacy—with your partner is critical. “Studies show that if you had a rewarding sex life pre-cancer, that’s the best indicator about your quality of life post-cancer,” Maureen says.

And if you didn’t, maybe this illness will be the catalyst that allows you to focus on what’s important as a couple. In a speech, sex therapist Emily Harrell points to a Canadian study of breast cancer survivors that found “almost half the couples felt the cancer brought them closer.”

Here are suggestions from doctors and therapists for keeping the flame alive through the tough times:

Talk. This is such a tired bromide, but without communication, what do you have left? Set aside time to talk when you usually feel good and are without interruptions—no cell phone, visitors, or television. You each need to share your thoughts, fears, and anxieties. You need to talk about decisions. You need to explain what you need. If either partner shuts down, the other will feel rejected and isolated. This is a fragile time. You need all the support you can get.

Talk about sex—how you feel about it, what feels good, and what you can’t tolerate right now. “It’s important to tell your partner that even if you don’t want [sex] right now, that you’d like to regain your desire again,” Emily says. “You’re hoping to one day feel the desire to be intimate again.”

And don’t forget to talk about the good stuff. “I think the biggest thing is not letting the cancer consume the relationship,” Emily says. “This can… happen to a lot of couples. Try to spend some time not focusing on the cancer.”

Touch. “We need touch from the moment we’re born until the moment we die,” Maureen says. Touch releases oxytocin—the cuddle drug—and that makes you feel better, like a big belly laugh. Touch heals and reinforces connection.

As Mary Jo Rapini mentioned, it’s important not to make assumptions about your partner’s motives for touching you. He’s probably not after sex, just the feeling of intimacy that can drain away without sex.

If touch is painful, Maureen suggests creating a body map. Draw a simple outline of a body, like a gingerbread figure, and mark the spots where you like to be touched. You can even prioritize what feels good, better, best. Also mark with a red X where you don’t want to be touched. This is a graphic, non-verbal aid for your partner.

Finally, sensate focus is a program developed by Masters and Johnson that incorporates gradually increasing levels of touch, from very light, non-sexual touching and increasing over time to include sexual touch. This can be a gentle way to introduce sexuality slowly and at a pace you can tolerate.

Move the goal posts. As we’ve said many times on MiddlesexMD, sex is much broader than the old penis-in-vagina experience. Explore new avenues of sexual satisfaction, from kissing and cuddling to erotic massage. Take it slow. Do what feels good. Take performance anxiety off the table.

Your body may feel and respond differently now, and sex may be different. But this doesn’t always entail less or loss. According to many couples, the sex can be better. In fact, a new study by the Duke Research Institute found that while cancer changes sexual intimacy and function, often for a long time after treatment, this didn’t correlate with a lessening of sexual satisfaction.

“Sex is about connection,” Emily says. “It’s about love; it’s about intimacy, and that can look a lot of different ways. I find that most rewarding skills that couples learn is not having goal-oriented sex, but really just exploring each other without judgment and experiencing each other and the emotions that they really feel for each other.”

Sex and Cancer: The Body

Here is the second part of our talk with Mary Jo Rapini, a therapist who specializes in intimacy counseling (the first part focused on the mind). She often receives referrals from oncologists who have treated women and men for cancers that, post-treatment, require a re-thinking, re-learning, re-framing of their intimate life. Says Mary Jo:

When a couple is referred to me, it’s usually because the cancer part of their life is now under control. That is, they have their diagnosis, understand staging, and have been receiving treatments, with some evidence that treatments are working. Until that point, survival is the critical concern for most couples.

This time of diagnosis and sheer survival can actually bring couples closer — they realize that what they used to argue about is petty. On the other hand, really bad relationships will many times get worse. Women who are sick might ask themselves what they're doing, what happened in their relationship. When that’s the case, my first step is figuring out the emotional environment. Where is this couple now, at this moment in time?

When we do come around to talking about intimacy in the relationship, my first concern is with pain. Painful sex is a really common problem for survivors. Low energy is another problem. People receiving treatments or recovering from extensive treatments have very low stores of energy.

Women recovering from surgery and radiation for any kind of cancer, including breast or uterine cancers, may be adjusting to new losses and scars that affect body image, sensation, mobility, or all three.

And while thinking about restoring sexuality may be pretty far from her mind, the truth is that reengaging with a lover has been shown to really help with recovery. Sex is very healthy—for our bodies and our minds—and a loving intimacy is certainly one of the best things we have to live for.

Get help. Your intimate life may have been perfect your whole lives, your relationship sound, your commitment to one another unshakable, but still a good counselor can give you things to think about, assignments and exercises that can help you to re-engage after harrowing course of treatment. Consider it a gift to yourselves, a reward for surviving.

Planning is everything. Spontaneous sex was great when you were teenagers, but now things are different. Intimacy is best now when it is anticipated and planned. Choose a day of the week when nothing much else is going on. Choose a time in that day when you are likely to have less pain. Be sure you have an hour of pain medication in your body before engaging in cuddling and caressing.

Set a new goal. Sexuality is often so goal-oriented we forget that sex is good for more than just orgasm. When orgasm is difficult to reach—for either of you—why not take it off the table and enjoy the benefits of sexual intimacy without it? Massaging erogenous zones is extremely pleasurable—provided there is no pain—whether we achieve orgasm or not. It still circulates blood, increases healthy hormone production, and helps couples bond to one another. Set a new goal: bonding and intimacy. Use that vibrator to make one another purr, and let purring be enough for a while.

Become a prop master. Pillows, pillows, pillows. If you spend any time in a hospital, you will notice that nurses really know how to use pillows to prop people into comfort in bed. Well, we can use them too, to prop us into comfortable positions for intimate caressing and lovemaking. We may not have needed them before surgeries or treatment, but may really need them now, when a slight change in position or angle may make a huge difference in comfort and painless lovemaking.

Patient exploration is the key. Most of us don’t know how our bodies will respond to treatment. Our mileage varies. So patiently exploring how treatment may have changed our sense of touch and taste and smell, in addition to pain and pleasure—this takes time. Be a scientist about it. Experiment, experiment, with all the patience of a field biologist!

Use a light touch. When we get chemo, our skin can become very sensitive. Chemo changes the epidermis of the skin. Our sense of touch shifts. That’s where things like feathers, mitts, and lotions become so important as tools for exploration, because your body is different on chemo. Figuring out those changes is the work ahead for both of you.

Some of the chemos are so toxic any intercourse would be too rough on fragile tissues. That’s a good time to think about a different form of expression, beyond intercourse. Find new ways to connect.

Wetness now, more than ever. Most women can’t handle intercourse during treatment. Chemotherapy can be very drying, and our skin, our vaginal tissues, are just too fragile. But if you are going to try intercourse during treatment, lubrication is extremely important. Try a lube that has a trace of silicone. I especially like Yes for this purpose. A little bit of silicone can give that lube sticking power. Too much is hard for a dry vagina to clear on its own.

Slow down. Pretend you are new lovers, virgins, even. Go very slowly. Be prepared to relearn everything about to make love to each other. Kissing can change. Taste can change. Relax, take interest, explore, report, and learn.

Sex and Cancer: The Mind

“Not everything that is faced can be changed, but nothing can be changed until it is faced.” –James Baldwin

We've been hearing from many women who are receiving treatments for various forms of cancer: What about us, they ask. Post-menopause is one thing, but what about post-cancer treatment? Or mid-treatment? How do we maintain intimacy when we are going through chemo or radiation or when surgery has changed our bodies and the way we feel about them?

We sat down to discuss these very difficult questions with our pal and counselor, Mary Jo Rapini. Her practice gathers couples referred before, during, and after cancer treatment to talk about sexuality and intimacy and how to maintain physical expressions of love when we are sick. This is a big subject, with many possible angles, so we will break it down into two pieces: the mind and the body.

Here's part of what Mary Jo told us:

I see lots of women with breast, ovarian, and uterine cancer in my practice. I ask to see her first, before meeting with the couple together. Women have a strong protective instinct; they will put up walls when they get sick, in part to protect themselves, but also to protect their loved ones, to avoid burdening them. I will coach her to share this crisis. That protective sense turns out to be too distancing. Whatever she is going through, whatever she decides for her course of treatment, the people who love her are in it with her. Their world is changing too, and it’s important to respect that and bring them along on the journey, consult with them. It's important to have a team in this fight.

When a couple comes to me mid-treatment or post-treatment, they walk through the door with the goal to restore their sex life. The first thing I do is to slow them down, to hit the reset button. I give them a list of things to think about that goes like this:

1. Focus on the positive.
2. Take intercourse off the table until you have the energy for it, but don’t stop thinking about sex. Don’t stifle your own sexual thoughts out of guilt. Tell your partner, I still really desire you and wish I could make love to you.
3. Remember sex is more than intercourse.
4. Discuss your fears of the cancer.
5. Consider buying your partner something sexy or feminine that will help her feel like a woman.
6. Be a good listener and let her set the pace.

My focus for couples at this important time is to feel pleasure and relaxion first, before working on feeling excited. Excitement is exhausting, and exhaustion can lead to failure and frustration. I ask them to just flat out remove the goals of intercourse and orgasm from the picture. I promise we will get to these, eventually, but for now, let’s not worry about it.

I had an aneurysm that nearly cost me my life. For me, orgasms changed a lot. For one thing, they made my head ache. With a clip on arteries in my brain, and my blood flow trying to figure out a new path—orgasm took a lot out of me. Sex didn’t give me the energetic feeling I used to have. Instead, orgasms robbed me of energy for the rest of the day. A lot of my cancer patients tell me that intimacy tires them, so planning is important.

A recovering cancer patient has to plan how she will spend the little energy she has on home and health and relationships. This is a very important adjustment, especially if a couple has always enjoyed a spontaneous sex life in the past.

I prescribe a lot of hand-holding and hugging. We know the importance of hugging now, how it builds and maintains bonds for us. Most men will tell me that when their partner is sick, this is what they miss more than anything. The worst thing people can do when they can’t have sex is to withhold all touch. When a couple only touches as a pre-cursor to sex, touch can be loaded with expectations, and we need to break through that. We need to experience touch as a pleasure in itself.

During treatment, during chemo and radiation, just take intercourse off the table, but replace it with lots and lots of touch. Hand holding, back scratching, feather-brushing, rubbing hair, petting. Have fun touching, kissing, necking, without the worry of failure. Just revel in closeness.

Once you’ve gotten this connection really going, add water. Because water is relaxing. Shower together. Or take a bubble bath (but stay away from very strong scents). Light candles, bring in soft music. Focus on enjoying each other. Wash each other. Especially, wash each other’s feet. When something feels especially good, say so.

When you are in treatment for cancer, self exploration is really important. Experiment with self touch, especially where you have had surgery. Touching helps you deal with grief of loss and letting go. If you have lost a breast, you need to feel that void and be able to grieve it. Whether to include your partner in this exploration is entirely your choice, but it can very helpful for both you and your partner to join in this exploration and support you in your grief.

With any kind of an illness, the ill person asks, “Who am I now?” A serious illness changes the self, sometimes just a bit, but often profoundly. And if one self in a couple changes, then it follows that the couple’s sense of couplehood changes. Talk together about the changes you experience and notice.

A healthy partner often feels guilty about wanting sex; he knows a sick partner doesn’t have energy for sex. The healthy partner is a caretaker and not a lover right now. Talking about that is very helpful and important. Getting a counselor to talk with both or either of you during this time of adjustment can be the best investment you’ve ever made.

If you are sick, don’t underestimate your lover. We are all pretty good at putting our sexual needs on the shelf, as long as we feel loved. The most helpful way to show your love is through touch. Touching can make talking more available. Some things you hate to tell your partner. But if you are touching them while you talk, there are moments when the communication is so authentic, you will find you can say anything. And that is the sound of real intimacy.

“Each of Us Will Recover at Her Own Pace”

Without doubt, breast cancer is a game-changer, altering every area of life and relationships. At first, amid the flurry of medical decisions, surgery, chemo, and recovery, you don’t have the time or energy to think about sex. But then… how do you make your way when all the furniture is rearranged? When your body, your emotions, your self-image and feeling of security, and your relationship with your partner are so permanently changed?

For a while, sex is understandably the last thing on your mind. Your chest is a surgical site; chemotherapy and radiation may make you nauseous, bloated, and incredibly fatigued; it may induce menopause if you haven’t already made that passage. Cancer survivors frequently experience depression as well. It’s important to know that if you don’t feel like sex for a period of time, you don’t have to go there. Focus on getting well first, say the experts, without completely shutting the door to intimacy. You can still love and support each other in small ways—holding hands, taking a walk, reading in bed together—to keep the coals alive during this period of stress and anxiety.

Your partner is under a lot of pressure, too, and is probably struggling to find purchase on the slippery slope of this crisis, uncertain about how to support you, and how or when to approach the sticky wicket of sex. Your partner may be waiting for you to make the first move, or be afraid of hurting you.

It might be helpful for both of you (or just your partner) to talk with your doctor or a counselor. Forthright, open communication about sex (or any other issue) can make the difference between feeling your way in the dark alone or shining a light on a difficult path. The most challenging situations can be overcome with honest dialog and the willingness to seek help and information.

Over time, as you begin to heal, you face the inevitable hurdle: resuming your sexual life. How will your partner respond to the way you look; for that matter, how do you feel about your changed body? Your incision site may still be tender or you may be undergoing reconstructive surgery. Chemotherapy may have brought on menopausal symptoms. Maybe you’re not sure you feel like having sex at all, and you certainly don’t feel very sexy.

First, take it slow. You (and your partner) have been through a prolonged, life-threatening crisis. In addition, you’ve lost an important erogenous zone. Unless your doctors have been able to spare your nipples and their nerve endings, you probably can’t feel anything in an area that used to be erotic and arousing.

You and your partner need to become acquainted with your new body. You may have lost your breast(s), but other parts—neck, shoulders, ears—may become more sensitive. Your first foray into sex could be an exercise in gradually raising your awareness of sensation rather than worrying about intercourse.

Try simply touching each other. Leave the genitals out for now. Talk about what feels good. Or—don’t talk at all, just be together, touching each other. Slowly, in this session or the next, add genital exploration and move on to intercourse when it feels comfortable. Sex will be different—and not necessarily for the worse.

Experts say that you don’t have to “love your scars.” If you’re uncomfortable letting your partner see you naked, wear sexy lingerie. On the other hand, your partner may be able to reassure you that you are as loved as you ever were, and that’s incredibly affirming.

Second, assemble your tool kit. This should include lubricants to make penetration easier and sex more pleasurable. Maybe experiment with toys; try massage oils. Experiment with positions that are comfortable. Lying on the affected side may be painful, for example. You may prefer being on top or on your knees with your partner behind you. Since so much is different anyway, why not shake up the routine? Be sure to discuss any problems or questions about sex with your doctor. A solution may be easier than you think.

In a blog about sex after having had both breasts prophylactically removed, one young woman likens the experience of resuming sex with her husband to a second adolescence—shy, awkward, fumbling, uncertain. “But like adolescence, this is a phase I will grow out of. I will become more comfortable with my body and my husband will too.… But all of this is uncharted territory, and I'm trying to do what feels right to me. Each of us will recover our sexuality at her own pace, and this is the (frank) truth about mine.”