Vaginal Atrophy & Intimacy After Cancer Treatment

Vaginal dryness and pain with sex are among the most common effects of cancer treatment. They are also among the least discussed. You do not have to accept this quietly. Specific, well-established things help.

Most of it comes down to two things: estrogen, and direct damage to tissue.

Chemotherapy can lower estrogen levels. The National Cancer Institute notes it "can cause primary ovarian insufficiency. This means the ovaries aren't producing hormones and releasing eggs. Symptoms may include hot flashes, irregular or no periods, and vaginal dryness, which can make sexual intercourse difficult or painful." Chemotherapy can also affect vaginal tissue directly. That may cause sores.

Hormone therapy may cause low estrogen levels. That leads to hot flashes, irregular or no periods, and vaginal dryness.

Radiation therapy to the pelvis can cause low estrogen, and so vaginal dryness. It can also cause vaginal stenosis. NCI describes this as a "less elastic, narrow, shorter vagina." Radiation can cause vaginal atrophy too, meaning "weak vaginal muscles and thin vaginal wall." These changes cause vaginal itching, burning, and inflammation. They also cause pain and discomfort during sex. The American Cancer Society is blunt about the risk. Scarring from radiation can make vaginal sex and internal exams "painful or even impossible" if it is not addressed.

Lubricants

Use these during sex. The American Cancer Society advises a water-based or silicone gel "that has no perfumes, coloring, spermicide, herbal remedies, or flavors." Apply it generously. Put it on the vaginal opening and the area around it, not just inside.

Avoid oil-based products such as petroleum jelly. They can cause yeast infections, and they damage latex condoms. Avoid nonoxynol-9 (N-9) too. It can irritate tissue and make pain worse.

Vaginal Moisturizers

These are different from lubricants. You use them on a regular schedule, not just around sex. They restore moisture to the tissue. The American Cancer Society notes that many women with cancer who have vaginal dryness use vaginal moisturizers several times per week. Putting one on at bedtime allows better absorption. Moisturizers do not replace lubricant during sexual activity. You may well use both.

Vaginal Estrogen

NCI lists several options here. Vaginal gels or creams stop a dry, itchy, or burning feeling. So do vaginal lubricants or moisturizers. NCI also lists "vaginal estrogen cream that may be appropriate for some types of cancer." That last phrase matters. Whether it is appropriate depends on your cancer. The American Cancer Society notes vaginal estrogen comes as a gel, cream, suppository, ring, or tablet. It says studies indicate minimal absorption into the bloodstream. But it says to raise this with your care team, above all with a hormone-sensitive cancer. Make this decision with your oncologist. Do not settle it from a website.

The National Institute on Aging notes two non-hormone prescription options approved by the FDA. They are ospemifene and prasterone. Both are for moderate to severe painful sex caused by menopausal vaginal changes.

Dilators

Pelvic radiation or graft-versus-host disease may have affected your vagina. If so, NCI recommends a dilator "to help prevent or reverse scarring." The American Cancer Society describes using one several times a week to prevent scarring and narrowing. It says "the dilator feels much like putting in a large tampon for a few minutes." Dilators come in a range of widths. You move up to a larger size as flexibility improves. Use them alongside Kegel exercises. That helps you learn to relax the pelvic floor rather than tense against the dilator.

These sources give a frequency: "several times per week." They give no exact minutes per session, and no number of weeks. Ask your radiation oncology or gynecology team for the schedule they want you on.

Pelvic Floor Work

NCI lists exercises for the pelvic muscles. They lower pain, improve bladder retention, and improve bowel function. They also increase blood flow to the area, which can improve sexual health. Pelvic floor physical therapy teaches you to relax vaginal muscles. That reduces pain and helps treat narrowing. Ask your cancer care team or gynecologist for a referral.

Positions and Pacing

Choose positions that let you control how deep penetration goes. Spend more time on foreplay first. Small changes, real reduction in pain.

NCI states that most women can be sexually active during treatment. Confirm this with your doctor. There may be times when you are at increased risk of infection or bleeding, and are advised to abstain from intercourse. Condoms may be advised as well. Some types of chemotherapy may remain in vaginal secretions, and condoms prevent your partner's exposure. And if you are of childbearing age, contraceptives may be advised during treatment and for a period afterward.

NCI suggests asking these. What sexual problems are common among women receiving this treatment? When might these changes occur? How long might they last, and will any be permanent? How can they be prevented, treated, or managed? What specialists would you suggest I talk with?

• Call 911 or go to an emergency department if vaginal bleeding is very heavy and does not slow, or comes with feeling faint, a racing heart, breathlessness, or severe pelvic pain. MedlinePlus says very heavy bleeding needs attention straight away, and it matters even more if treatment has lowered your platelets.
• Call your care team the same day if you bleed from the vagina and are not expecting a period, or you bleed at all after menopause. MedlinePlus says any unexplained bleeding between periods, and any bleeding after menopause, needs a provider's attention. Bleeding that starts after using a dilator counts.
• Call your care team the same day if bleeding comes with pelvic pain, unusual tiredness, or feeling dizzy.
• Call your care team the same day if treatment has left your blood counts low and you notice bleeding, or new pain and discharge that could be an infection. NCI notes there are stretches of treatment when infection or bleeding risk is raised and you may be told to hold off on intercourse.
• Call your care team within a day or two if dryness, soreness, burning, itching, or pain during sex carries on even when you use a water-based lubricant. That is MedlinePlus's cue to be seen, and it is the point where prescription options get discussed.

• MedlinePlus (NIH): Vaginal dryness. https://medlineplus.gov/ency/article/000892.htm
• MedlinePlus (NIH): Vaginal bleeding between periods. https://medlineplus.gov/ency/article/003156.htm
• National Cancer Institute: Sexual Health Issues in Women and Cancer Treatment. https://www.cancer.gov/about-cancer/treatment/side-effects/sexuality-women
• National Institute on Aging (NIH): Sex and Menopause: Treatment for Symptoms. https://www.nia.nih.gov/health/menopause/sex-and-menopause-treatment-symptoms
• American Cancer Society: Managing Sexual Side Effects as a Woman with Cancer. https://www.cancer.org/cancer/managing-cancer/side-effects/sexual-side-effects/women-managing.html