Many women with breast cancer develop painful intercourse. To develop a second reproductive tract issue while undergoing therapy for breast cancer is just adding insult to injury. There are a couple of common diagnosis that can contribute to painful intercourse (also called dyspareunia) for women with breast cancer, and definitely some treatment options.
The first step is doctors need to enquire about sex life. While the surgery, radiation, chemo, and estrogen modulating drugs are all life saving therapies, treating a disease can’t just be about surviving it also has to be about living. And sex, for most people, is an essential part of living.
I tell my patients (well, I tell everyone really) that sex is a vital communication tool. Not only does it feel good, but it strengthens a relationship. I suspect many doctors (and perhaps even some patients), even after therapy is completed, think that sex seems like a small thing after coming through surgery, radiation, and chemo. However, I disagree. A woman (and her partner) should not be subject to an absent sex life in addition to coping with cancer. While many may find the stress of therapy has been enough for now, in my experience many are thrilled to be asked about their sex life and even more thrilled to hear about treatment options if there are problems.
The two most common causes of painful sex for women with breast cancer are vaginal dryness and pelvic floor muscle spasm. Let’s tackle them one at a time.
Vaginal dryness. Sex is friction and the vagina is built to withstand a fair bit of it. The vagina has two main friction fighting features. First of all, there are multiple cell layers in the vaginal wall. Several layers will get rubbed off during intercourse, but many more healthy layers remain to protect the more delicate, deeper tissues. The second protection is lubrication, which lessens the effect of friction on the cells of the vagina. Without estrogen, the layers of cells in the vaginal wall cannot be maintained, and so the vagina wall becomes thinner and more fragile. The lack of estrogen also affects the ability of the vagina to lubricate. The net effect is that penetration can literally rub the vaginal walls raw.
Women who are estrogen receptor positive (more than half of the women with breast cancer) end up with therapies designed to dramatically lower their estrogen levels such as surgical removal of the ovaries, or medication specifically designed to block the effects of estrogen on tissues, like aromatase inhibitors. Even for women who are not estrogen receptor positive and don’t receive estrogen reducing/blocking therapies this vaginal thinning and lack of lubrication can occur. For many it is simply age related (the average age of diagnosis of breast cancer is 61, so well into menopause) made worse by the effects of chemotherapy on the cells. After menopause, the estrogen-deficient tissues simply have trouble recovering from chemo. Vaginal atrophy (the technical term for these menopausal related changes) is easily diagnosed by a combination of history (many women describe extreme rawness or a sandpaper like sensation during intercourse, often with some bleeding after attempts at penetration) and physical exam (red spots on the vaginal walls and over all appearance of the tissues). Looking at the cells under the microscope will confirm the diagnosis if there is any doubt.
The other cause of painful sex is muscle spasm. The muscles of the pelvis (also called the pelvic floor) wrap around the vagina, bladder, and rectum. When these muscles spasm, it causes pain with intercourse in addition to making a functionally smaller vaginal opening, which is also increases pain. This isn’t due to breast cancer or the therapy per se, but can be precipitated by chronic stress. Muscle spasm on the pelvic floor is diagnosed by palpating the muscles internally through the vagina.
Okay, so what are the treatment options?
Muscle spasm is treated with specialized pelvic floor physical therapy. Some women may also need to use graduated dilators (progressively larger phallic shaped objects) as part of the therapy.
Treating the effects of low estrogen may or may not be possible. For a woman who is not estrogen receptor positive, using vaginal estrogen is just fine. It was not estrogen in the Women’s Health Initiative that was associated with the breast cancer risk, but rather the progesterone. Using an estrogen ring (Estring) probably gives the lowest blood stream levels (the blood hormone levels for estrogen remain virtually unchanged with this product, in the lower post-menopausal range, and so little or none gets in to the blood stream). Within 2 months, the vaginal estrogen will have reversed the menopausal changes in the vagina. It is also important for women to use a lubricant that is likely to be less irritation, typically a silicone based product (you are looking for glycerin and paraben free). Some women prefer using a natural oil as a lubricant, such as coconut oil or olive oil.
For women with an estrogen receptor positive tumor, the idea of an estrogen ring is more tricky. While the blood levels are negligible so theoretically there should be no effect on the cancer, there are no studies looking at women who have used an Estring and the effect on recurrence. I did a PubMed search today (10/04/11) and there were no clinical trials, just an opinion article from 2001 suggesting the ring should be safe because of the pharmacokinetics and the very little, if any, estrogen that enters the blood stream. Certainly not an evidenced-based recommendation for or against using the Estring. Whether or not a woman with an estrogen receptor positive breast cancer chooses an Estring to treat her painful intercourse will be an individual decision. Some may feel the risk is negligible and others may feel that without definitive data, “negligible risk” based on opinion is just not enough of a safety endorsement. Other options are using the right lubricant (an oil typically works best if there is no estrogen) and to consider the option of anal sex.