Ten top tips: sex after cervical cancer

More people than ever are surviving cervical cancer, and for longer. Yet, to live well it is vital that we address the often long-lasting effects a cancer diagnosis and treatment can bring. In our research into the long term consequences of cervical cancer treatment, we found that 67% of women experienced changes to their sex life as a result of their treatment, whether that was surgical, or involved chemotherapy or radiotherapy.¹

The impact on sex and intimacy can be physical or mental, with the two often intertwined. The physical impacts of treatment can result in sex being more painful or uncomfortable (dyspareunia), while the treatment often leads to those viewing their genitals as medicalised, making it harder to connect with them sexually. This does not just impede the ability to have sex or gain pleasure from sex and intimacy, but we know via our support services that the effects on relationships, self-esteem and mental health can be profound.

Thankfully, there are many interventions that can help. Nurses play a pivotal part in ensuring that women who have had cancer treatment can still enjoy sex and intimacy, and can reconnect with themselves. The following tips cover some physical solutions, as well as psychological support you can offer.

1. Identify the cause

If someone is experiencing pain during sex or intimacy, it’s important to ascertain the cause. For example, surgery and radiotherapy or brachytherapy can cause vaginal stenosis (shortening and narrowing), changes to physical sensations in genitals, or vaginal tissues becoming less supple and more fragile or thin. The approach to care must be individualised, depending on the treatment which has taken place.

2. Lubricant and creams

Reduced vaginal lubrication is a common cause of discomfort during sex. This can be due to difficulty in getting aroused or damage to cells in the vagina. Prescribing a lubricant is really important, as they are beneficial not just for penetrative sex but also during foreplay and masturbation. Water-based and silicone lubricants are safe to use with condoms and dental dams, unlike oil-based lubricants. You may also prescribe oestrogen creams or pessaries to treat vaginal dryness.

3. Dilators

Dilators can prevent vaginal stenosis, and you can prescribe a set which begins with a small dilator and builds up gradually. However, dilation therapy can also be practised with fingers, vibrators or other similar shaped devices – many patients are more comfortable with something they are more familiar with. You can work with them to understand for how long and how frequently they should be used.

Not everybody gets on with dilation therapy, and for some it may be a reminder of treatment or the cancer they would rather move on from. Education may help to encourage their usage, and reminding of their importance in preventing vaginal changes, in order to maintain good bladder and bowel function. It may also help women to know that dilators are not only a ‘cancer thing’, they are often used as treatment for vaginismus, after childbirth or endometriosis surgery too.

Other tips on using dilators:

Take care of the vaginal skin. Moisturiser or vaginal oestrogen on a regular basis helps prevent bleeding and discomfort.
Find a comfortable position – the patient will know which position feels best, and there’s no right or wrong
Use lubricant. Before starting, it can help to warm the dilator in a glass of warm water and warm the lubricant up using your hands.
Increase the size slowly. This is best done by using the smallest until it inserts with ease, then using the next size up at the end of a session.

4. Pelvic floor exercises

The fear of pain can cause vaginismus (involuntary pelvic floor spasms). Relaxing the pelvic floor muscles can help to relieve tension and pain from the entrance of the vagina. Pelvic floor exercises for this purpose are different to exercises which are used to improve bladder control, as the latter focus on squeezing muscles rather than relaxing them. Pelvic physiotherapists or sex therapists can advise on techniques. Pelvic floor exercises can often be used alongside dilation therapy, as well as breathing exercises or other relaxation techniques.

5. Change position

Certain positions for penetrative sex may be more painful than others. Positions which let a woman control the movement, depth or speed of penetration may help, such as being on top. Alternatively, shallow or no penetration may be preferable. Encourage your patient to talk to their partner and experiment with different, more comfortable positions. A loving, supportive partner will try something different, rather than continuing with something painful, so encourage open and honest conversations.

6. Menopause

If treatment has brought on the early menopause, the symptoms it brings, like hot flushes and vaginal dryness, can contribute further to sex becoming uncomfortable, painful or simply very different to before. Equally, low mood, changes to appearance and decreased sex drive may mean that sex and intimacy are less frequently a priority. While vaginal moisturisers and lubricant can be recommended, vaginal oestrogen with or without hormone replacement therapy (HRT), can improve the vaginal tissue’s health. Equally, HRT may ease the symptoms of menopause in the longer term, so discuss this option with your patient.

7. Try things alone

Recovery from cervical cancer often involves getting to know your body all over again. Your patient may be finding that discussions around sex and intimacy are very difficult to have with a partner, especially if they have been through cervical cancer treatment recently. You can encourage your patient to explore what works for them by themselves, in their own time, where they can focus solely on their own pleasure. For example, clitoral function is unlikely to have been affected by treatment, so this may be somewhere to focus, which can be done by themselves, or with a vibrator or sex toy.

8. Find a new normal

The first thing most want to do after treatment is ’get back to normal’ yet for the majority, it’s not that simple. You can encourage patients not to compare themselves to how they looked or felt before, and start to think about finding the new ‘normal’. It might be useful to encourage patients to think of other times in life this has been possible, such as after another major life event. This does not mean ‘put up with what you’ve been dealt and just accept the difficult side effects of treatment, but find a way to manage them instead.

9. Speak to others

For women affected by cervical cancer, dealing with difficult side effects on top of a cancer diagnosis can be incredibly isolating. Many will never have met another women going through the same things. Encourage patients to visit the Jo’s Cervical Cancer Trust community where we have specific sections for dealing with changes to relationships and sex and intimacy. From sharing tips to lending support, they will know they are anything but alone and not the only one facing this.

10. Signposting

Aside from Jo’s Cervical Cancer Trust, there are some brilliant organisations you can point your patient towards.

The British Association for Counselling and Psychotherapy has a directory of therapists specialising in different areas such as cancer, sex and relationships
The Sexual Advice Association is a charity offering information leaflets on sexual difficulties, including intimacy and sexuality for cancer patients. It also has an app, where you can access confidential, expert advice on questions you may otherwise feel uncomfortable about asking.
Maggie’s offers support groups and counselling services for cancer patients.

Other references:

[1] https://www.jostrust.org.uk/about-us/our-research-and-policy-work/our-research/long-term-consequences-cervical-cancer