Sexual health is an important part of an individual’s wellbeing. Both the surgery and medications used to treat low-grade serous cancer (LGSC) can have an impact on a person’s sexual health.
The purpose of this guide is to give people affected by low-grade serous carcinoma and any partners an overview of common sexual side-effects associated with LGSC and the tools available to manage them without the use of hormone replacement therapy (HRT).
HRT is commonly used to manage sexual side-effects in other types of ovarian cancer but because LGSC is hormone sensitive it is generally not recommended as there is a risk it could encourage cancer growth. This can make LGSC sexual side effects more complex to treat but as outlined in this guide there are still many safe, hormone-free options available to people.
This article was written in conjunction with Dr Kristen Rojas @kristinrojasmd – a breast cancer surgeon, board certified gynaecologist and director of the MUSIC Sexual Health After Cancer Program at University of Miami who is passionate about improving sexual health in people affected by cancer.
Sexual Health Concerns During and After Treatment
Chemotherapy, pelvic radiation, or estrogen-suppressing medications for cancer treatment may lead to gynaecologic concerns. These issues most commonly manifest as vaginal dryness, painful sex, and low desire. When the issues of vaginal dryness and painful sex are not addressed, these symptoms may persist or be exacerbated by a condition known as pelvic floor muscle dysfunction.
Sexual health concerns should be discussed with one’s oncologist, gynaecologist, psychologist or counsellor, and primary care team. They are usually addressed by a gynaecologist, pelvic health physical therapist, sex counsellor, or a primary health care team.
Vaginal Dryness and Painful Sex
Vaginal dryness and irritation are often manifested as painful sex or recurrent infections. Dr. Kristin Rojas, a breast cancer surgeon and board-certified gynaecologist, Director of the MUSIC Sexual Health After Cancer Program at University of Miami, recommends the below three steps to address these common issues with treatment.
- Eliminate irritants:
Most gynaecological symptoms associated with cancer treatment are exacerbated when the delicate skin of the vulva and vagina come in contact with long-name chemicals and artificial fragrances. The reflex for most patients when they start to experience symptoms may be to use vagina-specific “washes” or “wipes,” and allergic reactions in this area manifest as increased pain, burning, and irritation. These products, even with gentle-sounding names, can wreak havoc on the delicate balance of good (lactobacilli) and bad (odour-causing) bacteria of the vulva and vagina. This area should be cleansed with water only, and soaps of any kind (including bubble bath) should be avoided.
Vaginal moisturizers (different from lubricants) improve dryness, irritation, and increase the elasticity (stretchiness) to decrease pain with sex. These should be applied to the vulva and vagina at least three times per week. Avoid products with preservatives and artificial fragrances. Examples of moisturizers include: organic single-ingredient coconut oil, Vitamin E suppositories (e.g., Key-E), and commercial products that include hyaluronic acid or lactic products (for example Hyalo Gyn, Revaree [Bonafide], Bionourish [Good Clean Love]).*
Lubricants should be as slippery as possible, and silicone-based lubricants without preservatives or gimmicks, such as flavors or warming capabilities, are superior to water-based lubricants, which are sticky, need to be reapplied, and may cause further drying.*
*If you depend on condoms for infection or pregnancy protection, check the labels to ensure your chosen moisturizer or lubricant is condom-compatible since some silicon and oil-containing products may degrade latex.
Urinary Tract Infections (UTI) and Prevention
If prone to recurrent bladder infections, a single dose (1 tablet) of a gentle antibiotic (e.g. Macrobid/nitrofurantoin) after sex and/or daily Methenamine Hippurate (Hiptrex) can help prevent UTIs (discuss with your doctor).
Caution is advised with vaginal lasers such as the Mona Lisa. These lasers work by causing tiny burns in the vagina, and they were never FDA approved for this use. There are reports of patients experiencing burning, scarring, and chronic pain, and Dr Roja’s recommends that these devices should be avoided in women who have undergone treatment with cancer.
Use of Hormones
Please discuss any hormonal use with your doctor. In general, systemic hormonal replacement therapy (for example, pills and patches) is not recommended in estrogen-sensitive cancers like LGSOC.
The safety of vaginal estrogen in LGSOC is unknown. Studies in other types of cancer have not shown an increased risk of recurrence. But unlike breast cancer, LGSOC occurs close to the site of application. There is a theoretical risk that local absorption through the vaginal wall could encourage cancer growth.
Similarly, vaginal androgens such as testosterone or DHEA have not been tested in patients with LGSOC. While the suppository prasterone (DHEA) is FDA-approved for painful sex under the name Intrarosa, LGSOC may also contain androgen receptors and until further information is available about prasterone’s safety in this population, it should be avoided.
Pelvic Health (Also Known as Pelvic Floor, Gynaecological) Physiotherapy
A pelvic health physiotherapist is a physical physiotherapist with additional specialist training in the muscles and function of the pelvic floor. Both weak and tight pelvic floor muscles can affect enjoyment of sex. Often the muscles can be both weak and tight.
Depending on the underlying cause, pelvic health physiotherapists may provide instructions for tools like dilators, pelvic wands, Ohnut protector rings; teach techniques including stretches and breathing techniques, exercises, and position recommendations; and perform manual therapy including external and internal muscle massage. While pelvic floor tightening exercises such as Kegels are promoted by some, these exercises can actually worsen painful sex in many cancer survivors and should be avoided unless specifically advised by a professional.
Adjustments to the pelvic floor, including pelvic health physiotherapy, may also help with other issues that may impact sexual enjoyment including urinary or faecal incontinence, constipation or frequent urination, night-time urination affecting sleep, lower back/abdominal/hip pain, balance issues/fear of falling, and cancer-related fatigue through joyful movement.
If vaginismus (vaginal muscle tightness/spasms) is significant, vaginal botulinum toxin (Botox) administered by a gynecologist may be helpful to temporarily relax the vaginal muscles to assist with pelvic physiotherapy treatment and pelvic pain.
Tips for Low Desire
Low desire as a result of cancer treatment is a complex problem. Oftentimes, treating the dryness, pain, and pelvic floor muscle dysfunction associated with cancer treatment can undo the negative feedback loop associating pain and anxiety with sexual activity, improving desire.
Some medications may adversely impact libido; these include certain antidepressants. Patients should discuss with their medical provider whether they are eligible to switch from an SSRI to another type of antidepressant, such as buproprion, that does not have sexual side effects.
Other tips for improving desire include physical exercise, which improves body image and natural libido-boosters, masturbation and avoiding screens in bed. For those who are partnered, addressing communication and relationship issues can be helpful.
There are two prescribed pharmacologic options for low desire, although there are no safety data available for cancer survivors. Flibanserin is a once-a-day pill proven to increase the number of sexual events per month. However, flibanserin should not be taken with heavy drinking, and some medication combinations may increase the side effects of tamoxifen. Bremelanotide is a newer treatment which is an injection given in the abdomen prior to sexual activity. It should not be used in patients with heart disease.
There are very little data on the effectiveness of non-prescription supplements improving desire. Ristela (Bonafide) is a plant-based, hormone-free supplement that increases blood flow to the vulvovaginal area, and has been shown to be effective in placebo-controlled trials.
In addition to many physiological changes, psychological issues including fear, depression, anxiety, self-esteem, and loss of identity can also impact sexual enjoyment. Sex will be different. Do not try to replicate your previous sex life. Start from the beginning and acknowledge the challenges.
For more information relevant to sex and cancer:
- Follow cancer surgeon Dr Kristen Rojas’s sexual health account @music_sexaftercancer on instagram
- Visit the Australia Pelvic Pain Foundation (and download their Easy Stretches to Relax the Pelvis handout)
- Watch expert pelvic floor physiotherapist Dr Jilly Bond’s talks on Pelvic Pain and DIY pelvic therapy including using a pelvic wand (we strongly recommend consulting a pelvic physio in person before attempting any DIY therapy).
- Watch Ovarian Cancer Australia webinar Love in the time of cancer which includes Alisi’s experience as someone living with low-grade serous ovarian cancer
- Follow pelvic floor Physiotherapist Dr Sara Reardon @the.vagina.whisperer on instagram (infertility trigger warning – account also discusses pregnancy)
- Ask 200 Questions with Sex with Cancer website
- Watch OCRA’s Sexual Intimacy After Cancer with Oncology Counsellor Dr Sage Bolt (2020) or Oncology Social Worker Jennifer Bires (2021)
- Watch Ovarian Cancer Canada’s Webinar the 411 on Sexual Changes After Cancer with Sexuality Counsellor and Clinical Nurse Specialist Anne Katz
The information in this article is for general reference and should not be used as a replacement for personalised medical advice. People should consult with their cancer specialist before attempting any treatments discussed in this article.
13 February 2023