How Sex After Cancer is Possible

Dr. Kristin Rojas is a Society of Surgical Oncology fellowship-trained breast surgical oncologist and gynecologic surgeon with a passion for comprehensive wellness in women's cancer care. We discuss how you can feel more empowered about getting back your sexual health, or preparing for some of the things you may be dealing with. before, during and after your cancer treatments.

Georgie Kovacs: Tell us about yourself.


Dr. Kristin Rojas: I wear two hats. I'm a board certified gynecologist, and a fellowship trained breast surgeon. I knew I wanted to have a career in women's health, and I did my residency at Brown University where they had a unique program for the GYN residents to be involved in the care of breast cancer patients. I subsequently did a fellowship in breast surgical oncology or breast cancer surgery.


Because I started out as a gynecologist, I realized how incredibly common the questions around sexual health and cancer were. When looking at the literature, more than 80% of women, specifically breast cancer patients report sexual side effects from treatment. This is why I started this program called MUSIC stands for Menopause Urogenital Sexual Health and Intimacy Clinic. It is for women with a history of any type of cancer or experiencing sexual dysfunction It's an under-discussed topic and so my goal is to make it normal conversation.

Georgie Kovacs: What impact does cancer have on one’s sexual health?

Dr. Kristin Rojas 05:17

Outside of the psychosocial impact of the cancer diagnosis, which is a huge hit to a woman and her caregivers or her partner, her family, there actually are these biological consequences of cancer treatment that really almost mirror the effects of a normal menopause. As a society, I think we don't do a great job preparing women without cancer for menopause. It's not something we all talk about until it's your problem, and then you quietly ask your friend if they're experiencing the same symptoms. Imagine what it is like for women with cancer!


Chemotherapy basically shuts down your ovaries and thus induces menopause. However, your body is used to having normal fluctuations in estrogen, and when you drop those levels of estrogen, it affects not only your brain, but also your heart, your bones, vulva, and, vagina.


The resulting symptoms are hot flashes because it's like a drug withdrawal from estrogen, which does a lot of good things in your body. Then secondary effects that usually fall shortly after, are vaginal dryness, which usually manifests as painful sex. Oftentimes, with this big psychological hit of a diagnosis, women are putting their intimate lives on the back burner while they focus on getting through treatment. They may go back to try to have sex after all those acute issues are resolved. However, many patients report that, when resuming sex, it felt like knives, and they aren’t prepared. Bleeding after sex can be traumatizing.


Sexual health (physical and psychosocial) can be impacted by chemotherapy and pelvic radiation. The latter can make the vagina shorter or narrower making penetrative intercourse impossible.


There are interventions that we have during treatment to help prevent those sequela. Oftentimes, we're just trying to throw so much information to patients and get them through this multi-step process, that we don't always do a great job addressing those issues.

Men who receive their treatment for prostate cancer are told on their first visit, this is going to impact your sexual function, and women aren't always told that.

Georgie Kovacs: Is there a difference in the support men versus women receive for their sexual health once diagnosed with cancer?


It's interesting, because men, there's been studies looking at this men who receive their treatment for prostate cancer are told on their first visit, this is going to impact your sexual function. And women aren't always told that. When you Google sexual problems or sexual dysfunction, it is mostly about erectile dysfunction. That’s where we can do a lot better.

Georgie Kovacs: How does a woman navigate the healthcare system to ensure her sexual health is part of the conversation before, during, and after cancer treatments?

Dr. Kristin Rojas

The first visit is about taking a history, understanding what type of cancer the patient has, their most bothersome symptoms, and what's really impacting their life. Because of my GYN background, I can do a GYN exam and get more details about why they're experiencing pain or what may be the clue to figure out how to fix their problem.


Even in places that don't have someone like me, you can still start to address the symptoms even without a very detailed pelvic exam. I tell patients to keep their regular gynecologist and think of this as a super sub-specialized visit and I often coordinate with their gynecologist, see them a couple of times and then can send them back.


Georgie Kovacs: What are the most common symptoms a cancer patient would have related to her sexual health?


Dr. Kristin Rojas

The most common symptoms in the program are painful sex, which is the first manifestation of vaginal dryness that patients usually feel, and then low desire. Those are like the biggest biggest concerns.


Vaginal dryness is not too complicated. I have three steps in the program, anda lot of it is education. Estrogen goes really low in the tissues of the vulva and the vagina, where the vulva is the outside and the vagina is the muscular tube. The vagina becomes delicate, less stretchy, thinner, and they're much more likely to be irritated by chemicals, artificial fragrances and things that we don't even think about like the detergent that we wash our underwear with or sitting in a bubble bath for a long time. All those things can start this cycle of inflammation that just makes sex painful or dryness worse or this feeling of burning and irritation all the time.


The first step is to eliminate irritants and be really cautious about what touches the area. This includes reading labels and avoiding things with preservatives and artificial fragrances. And


The second step is to start a moisturization regimen. Just like we use under eye cream and put on moisturizer every night, start thinking about moisturizing the vulva and the vagina at least three times a week.


Lastly, it is important to focus on the pelvic floor. I recommend patients see a pelvic health physical therapist. They help patients focus on relaxing the pelvic floor muscles, because by the time they get to me, they've gotten all kinds of crazy advice.


Georgie Kovacs: Do you have specific recommendations for safe moisturizers or lubricants cancer patients can use to improve their pain with sex?


Dr. Kristin Rojas

In the past there was one brand name, and we would tell everyone to use the over the counter one at the grocery store. However, we actually have way better products now that have really high tech formulations that don't even necessarily have hormones. This is important because women with hormone-sensitive cancer, such as breast cancer patients with a history of estrogen receptor positive breast cancer, should avoid estrogen products although sometimes we do need to use them. Other cancer types like cervical, colorectal, lung or colon can all use hormone medications.


I separate moisturizers from lubricants. Think of moisturizers for maintenance, and then lubricants for sexual activity.


The moisturizers I tell patients to look for have hyaluronic acid, the same molecule that's in eye cream, and pulls moisture from the environment and holds it on the skin. There's vaginal moisturizers with hyaluronic acid form of suppositories or gels. Starting that three times a week can make a huge difference. I recommend the Bonafide suppositories called Revaree, Good Clean Love’s Bionourish, and HYALO GYN.


For lubricants, you want to find one that doesn't have any gimmicks such as fragrances, flavors or warming sensations. Focus on a silicone-based lubricant such as Uberlube. It's a silicone based lubricant that has no preservatives, is super slippery, and doesn't irritate.


A lot of like over the counter grocery store lubricants can really irritate patients because they have a lot of chemicals in them. I empower patients to be the ones that pick the lubricant because a lot of times that's put on the partner and the partner just shows up with whatever's at the grocery store.


Georgie Kovacs: Are there other products you recommend?


Dr. Kristin Rojas

Another option is a dilator which is helpful for training them to relax the muscles and help stretch out the tissues of the vagina to make sex less painful.


One last thing I'd like to mention is a device called the Ohnut. It was invented by a woman who had really bad endometriosis. Those patients often have times of pain with deep penetration with sexual activity. It acts like a bumper via stackable silicone rings that you place on the penis to limit the depth of penetration.


Georgie Kovacs: Tell us more about the pelvic floor PT and why it is so important.


Dr. Kristin Rojas

Pelvic floor physical therapists focus on the pelvic floor and understand how to heal. So much on social media is about kegels, that that is not what these patients need because the pelvis is like a basket of these muscles woven together. When you start feeling pain with sex, you start having spasms in these muscles, unconsciously. It starts this negative feedback loop. We need to train these patients to be able to relax those muscles. But it's hard if sex has been painful for a while. Women will have this anticipatory anxiety where they're nervous and tense, and it's hard to really get them to relax those muscles.

Georgie Kovacs: When estrogen levels drop, clearly, from the sexual health perspective, you've talked about the moisturizer and lubricant, but what about the other impacts of the hormone changes?

Dr. Kristin Rojas

I see a lot of young women who've undergone very intense chemotherapy for leukemia, lymphoma, and then have had bone marrow transplants, which we call stem cell transplants, and they have menopause in their 20s and 30s. Having no estrogen from that early almost certainly leads to osteoporosis, and potentially an increased risk of having a heart attack, maybe even dementia. So it’s not just even sexual function, it's like your entire body is impacted. The first sign of that is hot flashes because that's like your body's barometer for where you're at with regards to estrogen.


I am a strong advocate for giving them those systemic hormones back using an estrogen or estradiol patch. I always give patients the estradiol patch and change the dose based on how frequent their hot flashes are. They start to feel so much better.


There are people out there who are really big advocates for bioidentical hormones but estradiol is the same molecule. Bioidentical as a concept became really popular because, for a long time, we were giving women Premarin which was conjugated equine estrogens which are all these estrogens that aren't even natural to us. Our bodies don't really respond very well, understandably, to another species’ hormones.


If women still have their uterus, though, we do need to give them some progesterone back because estrogen by itself can increase the risk of abnormal cells going in the uterus. There's different ways we can do that. Sometimes by pills, sometimes it's through a progesterone IUD.

Georgie Kovacs: If you have an estrogen-sensitive cancer, you can't get an estrogen patch. In that case, then what happens?


Dr. Kristin Rojas

If you have a history of estrogen-sensitive breast cancer or endometrial cancer, which is the lining of the uterus, we have to be really careful about what formulation we give you, because some things have estrogen properties and can act as a stimulant to grow.


There's a big difference between systemic hormones, which is via a pill by mouth or patch, and those that work locally.


Vaginal estrogen works locally, so even for women with a history of estrogen receptor positive breast cancer, I do often prescribe low dose vaginal estrogen, especially if their symptoms of dryness are really severe. There's no evidence showing that there's increased risk of recurrence for those patients, but it's just a long conversation. We're probably just only understanding the tip of the iceberg for that.


For women with estrogen receptor positive breast cancer, oftentimes, we're blocking estrogen with different medications. And it's important to take those because they're really critical for decreasing the risk of recurrence. And so in that case, we typically don't often give estrogen back by any form because we're trying to block the estrogen. So it's really complicated. And that's oftentimes why oncologists that I work with have a lot to counsel patients on and it's a very complicated topic.

Georgie Kovacs: Let’s talk sexual desire. I'm sure there's a psychological component, but then there's also the hormonal component.

Dr. Kristin Rojas:

Patients who don't have estrogen receptor positive breast cancer, endometrial cancer, giving back those hormones really helps with desire. Desire really is an androgen-led process. Testosterone is an androgen; DHEA is an androgen which is a precursor to testosterone. Systemic testosterone for women without a history of cancer is not at this time FDA approved. There's a lot of off-label ways to prescribe it.


The other conservative measures for libido are exercise, which increases your natural testosterone and patients are exhausted after cancer treatment. I also talk to patients about sleep hygiene - the bed should be for sleeping or sex.


The two pharmaceutical options available to women that nobody knows about (yet there's six forms of Viagra on the market) and neither one is hormonal - flibanserin which is a once a day pill and the brand name is Addyi. It is important to know that combining this pill and alcohol can cause low blood pressure and some other side effects. I would say probably anecdotally about half of my patients respond to this medication about two months in.


The second option, which I actually have not prescribed in my practice yet, is called bremelanotide, Vyleesi. It came out, I believe in 2019. It’s an injection that you give yourself before sex. My cancer patients are subjected to a lot of injections, and they are not enthusiastic about this.

Georgie Kovacs: What do you want women to know most?


Dr. Kristin Rojas:

If you're a patient, and you're experiencing these issues, even if you don't have cancer, and you're experiencing these issues, bring them up to your doctor. They may get really flustered, and not really have an answer for you but if five patients that day in the clinic ask them the same que