May 2004: Sleep or Sex? You Can Have Both!

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Fatigue or low libido affecting sex?

Question from Towi-from-Norway: I have a high grade of cancer-related fatigue, and one of my biggest problems is to find a normal balance between rest and activity. Sex is one of the "activities" I struggle with. After a sex act, it feels like I need a week holiday. Is it the fatigue or only lower libido?

Answer —Su Kenderdine, M.D.: I would suspect that it's a combination of both. Certainly, when you have a lot of fatigue, if you limit the physical activity of the sex act by stimulating your husband with your hand for a long time before he's close to climax, then it takes less physical energy for you and him to come to pleasure. But it is a tremendously demanding and draining thing emotionally because you're sharing your energy—your soul energy, your sex energy—with another human being, and this is a time that you naturally need to conserve energy for yourself.

So I would work with some sexual toys, some ways to limit the physicalness of sex. It may be that you need to be the receiver of tenderness, caresses, massage, but not expend physically the intense drain of bringing yourself and someone else to climax.

Where to start rebuilding esteem, libido?

Question from Rachel: I can't stand my body any more. I'm overweight. I'm dry as a bone. I have no desire. I have no energy. Where do I start?

Answers —Su Kenderdine, M.D.: I think we all feel that at various times. We don't have to feel good about our bodies to engage in some sexual activity if we're with a partner who feels very cut off if there's not. Also, some sexual activity can make us feel better about our body just as it is.

Lots of lubricants make a difference. Negligees make a difference. Satin sheets, low lights, being in a bathtub together where you don't see each other so much, being outside in the dark where it adds some different element that takes you away from focusing on how negative you feel about your body.

I think we do have to pleasure our bodies to begin to like them again, pleasuring them through something simple like stretching and baths and massage. Sometimes, dieting and exercise feel like another drain on you or like a punishment.

Marisa Weiss, M.D., president and founder: Don't assume that your negative feelings about your body are shared by your partner. Usually they're in your own head and your partner is just waiting for a signal or a clue that says you're interested in physical contact or any kind of sexual intimacy.

Su Kenderdine, M.D.: I think we get confused that sex is all about beauty, and I believe it's really not. When we're very young, I think, beauty is a key piece in arousal. But I don't think society's subjective look is a key piece in touching.

Marisa Weiss, M.D., president and founder: Your vagina responds to your mind and your feelings about yourself, so if you feel like "damaged goods," too heavy, or in any way undesirable, your vagina will stay relatively dry and unreceptive. You'd be surprised how a little change in how you see yourself can result in more wetness, more elasticity in your vagina through your own body's sexual response. That connects how you feel with your whole sexual response "team."

Su Kenderdine, M.D.: I think that more emphasis on sexual stimulation to ears, to eyelids, to the back of the neck, to the armpits, to the belly and the bellybutton, to the inner thigh, and to the buttocks and to the feet can begin to add to our arousal and our connectedness—our sex being connected to all of our body, if you will. The poor vagina feels like it's taking the whole load, and it may not have to. You bring in a lot of other ways to begin to feel good about the sex and intimacy.

Marisa Weiss, M.D., president and founder: Some women find that they can get stimulated and more in the mood with erotic literature or with videotapes or even some of the sex toys. I recommend looking at goodvibes.com and the store Toys in Babeland (www.babeland.com).

Guidance for continuing lack of libido?

Question from Website Question: My loss of libido during and especially following BC treatment has been extremely difficult for my partner and it's jeopardizing our relationship. I was 39 years old and pre-menopausal at diagnosis. I had eight rounds of chemotherapy and have been on tamoxifen ever since. I still menstruate. It has been four years, but my lack of libido continues. Can you give any guidance?

Answers —Su Kenderdine, M.D.: It may be that even though you're still menstruating, you are really in a perimenopause where the ovaries aren't putting out as much estrogen as in the past, and, surely, even if they are, the tamoxifen is working against that. Some women find that adding a testosterone patch can make a difference, but it's never been studied in women with breast cancer, so you can't be sure that it's safe.

What can make a difference is working with your partner about a lot more, and prolonged, foreplay. That may involve baths and massage and reading poetry or erotic things together, or deciding to be together physically in a way that doesn't mean that you're going to have sex. That may allow you to be close and intimate, and some of the arousal then comes back.

Marisa Weiss, M.D., president and founder: Clearly, it sounds like your sexual life has changed. You may need to discover how your body will now respond, or turn off, to stimulation. Things that helped in the past may no longer do the trick.

You may need to bring in some tips and toys to help re-ignite your sexual response. For example, it may be that the in-and-out of intercourse with the associated friction is too much stimulation of a tender vagina and vulva and clitoris. Instead, it may be that the stimulation of a vibrator directly to the lower vagina, the lips outside as well as the clitoris, might provide significant stimulation without as much friction and discomfort to the area.

There are all kinds of gadgets that you might experiment with. There is a "dolphin" that can be used to stimulate the outside area. You may choose a vibrator that goes into the vagina and also has a little "rabbit" that is attached and stimulates the outside at the same time the inside is being stimulated. There are so many choices. Some of the gadgets can be used yourself as well as with your partner. Sharing toys as an adult can be a lot of fun.

Su Kenderdine, M.D.: Sometimes our partners can't express anger at our disease and their frustration with the disease except via sex. Only through anger about sex are they allowed to express anger around the cancer. It may be that you use this as an opportunity to draw out your partner's anger because it may not be about just sex but about the cancer. Just as you had to work through your anger about having cancer, your partner may have to go through the same process.

Sometimes doing this in a therapeutic session with a therapist is the best way to go because anger is very scary. A partner feels like they're a bad person if they have any anger around an issue of cancer in their loved one—that they're the worst of the worst. So it probably needs to be handled real carefully and real lovingly.

Advice for lack of sleep, pain during sex?

Question from Susan: I am experiencing sleep and sexual problems. I wake during the night as much as seven to ten times. Often, I feel tired the next day. I awake because of hot flashes and being thirsty. When having sexual relations with my husband, due to the dryness, I experience a lot of pain. What can I do for both of these conditions?

Answers —Su Kenderdine, M.D.: You will, eventually, not awaken when you have a hot flash, so at this point, concentrating on allowing yourself to go back to sleep quickly is the key. Because even with that many awakenings, if it's only for 2-3 minutes, you should be able to get enough positive sleep to not be tired.

Marisa Weiss, M.D., president and founder: If you're struggling with hot flashes because you're in menopause early or your hormonal therapy is just bringing them on, ask your doctor to help you and your body get used to the new climate that you're experiencing.

There are medications like Effexor or Paxil that can be used in low doses to help reduce hot flashes. Perhaps over time, as your body adjusts to the situation, you may be able to be comfortable without these medications, but many of my patients get significant relief and usually stay on them, sometimes for extended periods of time.

Su Kenderdine, M.D.: You do need a vaginal lubricant. Put it into the vagina before sex, on the outer lips, both the small and larger outer lips, and also on the penis.

The depth of penetration may need to be controlled as well, so you may want to shift to a different position—if you're on top, you may be able to more carefully control how deep and vigorous the thrusting is. If your partner is behind you entering from the rear, he can't go as deeply into the vagina because of the thighs and buttocks tissue, so that can spare the vagina some of the wear- and-tear of reaching climax.

A wonderful method is both of you lying on your sides, holding his penis between your thighs and using a great deal of muscle pressure and tension. Also, masturbating your partner with your hand until he's very close to climax and only entering then puts less wear-and-tear on the tender vagina. It's a new dance that you have to work out, so that it's comfortable, and it can have funny and fun parts to it—all the creative positions you experiment with as part of this.

Marisa Weiss, M.D., president and founder: That's such great advice, Su. Also, when you're using sex toys, be sure to use lubrication with the toys as well. It's also important to wash them off after usage, using the same soap that you would use to wash off your genital area.

Will touching of breasts stimulate cancer cells?

Question from Helen: I, age 56, have had estrogen dominance in my perimenopause, lots of heavy vaginal bleeding, now diagnosed with LCIS (lobular carcinoma in situ, an overgrowth of cells generally considered a pre-cancerous condition). My fear is that touching breasts and circulating hormones from sex will stimulate pre-cancer cells/cancer cells.

Answers —Su Kenderdine, M.D.: You can be assured that touching your breast will not increase the circulation of estrogen in your body. Nor is there any data that touching the breasts starts or moves cancer cells.

Marisa Weiss, M.D., president and founder: There are a lot of myths about touching and illness. Make sure to air your concerns so that you're not stuck worrying about something that is not based in reality. It's important to tell your partner that touching did not bring on the cancer and that touching through and beyond treatment is safe.

Also, if you don't want some parts of your body touched because of discomfort or because it brings on fear in you, then guide your partner to other parts of the body that you're more ready for. During radiation treatment, it's important to let your partner know that you are not radioactive. He or she will not "catch" any radiation from you. When your tissues are tender because of treatment, that's probably not the best time for vigorous touch. Light touch can be extremely sensual throughout your body.

Su Kenderdine, M.D.: Being sexually aroused yourself doesn't change your hormone levels, and coming to sexual climax by whatever means doesn't cause your hormones to elevate. It certainly causes the glands in the vagina to create wetness, but that's not increasing hormones or hormone levels.

Causes of UTIs during chemo?

Question from Website Question: I have had numerous UTIs (urinary tract infections) while undergoing chemo (Taxol/Gemzar) for metastatic cancer. The usual treatment is antibiotics after a urine culture. Does intercourse or oral sex contribute to these infections or is it because my immune system has been compromised?

Answers —Su Kenderdine, M.D.: UTI means urinary tract infections, and, yes, sex can bring on a urinary tract infection even when we're not taking chemotherapy. The urethra is very close to the vagina and the pressure can push bacteria up that short little space into the bladder.

If the tissues in that area are dry and thin because of hormone levels being down (and they usually are when we're taking chemo), extra lubrication can make a big difference in preventing this. Having sex while your bladder is full and then immediately jumping up and peeing can help a lot.

Marisa Weiss, M.D., president and founder: Peeing before and after. The best way to help prevent developing a urinary tract infection because of intercourse is to drink a lot of water leading up to the time in the evening that you would have intercourse, peeing just before, and as soon as the sexual stimulation is done, get up and pee again. This can make a really big difference.

Su Kenderdine, M.D.: Keeping your urine acid through drinking cranberry juice can also make a big difference. The chemo may add to how easily the infection gets really bad, but it's probably mechanical stuff causing the infection, not primarily the chemo causing the infection.

Marisa Weiss, M.D., president and founder: You may consider asking your doctor about taking one dose of an antibiotic, like Macrobid, just after intercourse, if intercourse was particularly drawn out or rough for the vagina and if you have a tendency towards developing urinary tract infections.

Sex only with condom during chemo?

Question from Website Question: I was told if one is getting chemo that sex is not permitted unless a condom is worn. Is this true?

Answers —Marisa Weiss, M.D., president and founder: After you have chemotherapy, your body gets rid of the chemotherapy in various ways. Depending upon the chemotherapy, it may leave your body through the urine, partly through your bowels and through other secretions. So, just after you have chemo, some of the chemotherapy drugs can be measurable in your vaginal secretions. This could possibly irritate the penis.

Some doctors recommend that in the first day or two after chemotherapy (that's if you're in the mood and you want sex at that time), you use a condom just to prevent contact between the penis and your vaginal secretions that may have a low level of chemotherapy in them. One of the things that Su and I want you to think about is what's going on in your own mind. We're not recommending that you assume a sexual life if you're not ready.

One of the key things that will help reclaim your sex life is when you feel you're ready emotionally or physically to try to bring this back into your life. Neither one of us is encouraging you to become sexually active if you don't feel well and you don't feel up to it. For example, if you're experiencing nausea or pain from chemotherapy (some of the chemotherapies cause mouth sores as well as vaginal sores), then it's unlikely that you're going to be interested in sex.

If you feel that way, let your partner know that you're feeling poorly, that you're not interested in sex that night, and that it has nothing to do with how much you're normally attracted to him or her. Often communicating this can make your partner feel wanted, not rejected, even if you're not sexually active at that time.

Su Kenderdine, M.D.: When a woman has a baby, the last thing she's interested in for the first weeks to months is sex, but she feels absolutely no guilt about that because her hormones are so fixed on the baby. All of society says it's absolutely right for her to be totally fixed on the baby and couples survive that (though men grouse about it).

But, as a comparable situation, it may be a time that sex as an act that you give to someone else or do for someone else is not going to be in your repertoire while you need energy for yourself. When sex feels like it's giving to you also and lifting you up as well, that's the time to add it to your life.

When do sleep, good sex come back?

Question from Website Question: Is there an average time after treatment for breast cancer that women regain adequate sleep and resume satisfying sex before we need to consult various doctors? How much time is "enough time"?

Answers —Marisa Weiss, M.D., president and founder: If you are unsure about when and how your body is going to recover, talk to your healthcare team right away. Even if significant improvement would naturally be around the corner, you want to know what you can do to help make it happen sooner rather than later.

You will find that many other women are experiencing the same concerns you have. During the time that you're trying to rediscover a sexual life that is satisfying to you and a regular everyday life that brings you joy and meaning, tap into a support group to learn from others who are experiencing some of the same issues.

Su Kenderdine, M.D.: Sometimes, while we're going through the fatigue of treatment, if we give ourselves permission to rest and recuperate in ways that we haven't given ourselves before, it can make a big difference. Nap when you get home from work or midday if you're at home, give over certain chores, don't cook dinner for that period of time, or don't do the laundry or the shopping. Sometimes being terrifically creative in how we give ourselves rest and recuperation can make a huge difference.

Do Lupron and Arimidex affect sensation?

Question from Website Question: I am on Lupron and Arimidex. I seem to have lost significant sensation in my vagina/clitoris. Is this possible? Will normal sensations come back? I've only been on it for a few months. I am using the Estring and Astroglide, which is helping, but it's not the same as the real thing.

Answers —Marisa Weiss, M.D., president and founder: Lupron is a hormone that shuts down the ovaries and limits their production of estrogen as well as testosterone and progesterone, all hormones that participate in sexual response. Arimidex reduces the amount of estrogen that your body makes in fat and muscle tissue, so the bottom line is that this combination of medicines is drastically reducing the hormones in your body. Su, I'd love to hear what you have to say about this.

Su Kenderdine, M.D.: I think we can see decreased sensitivity in the tissues from no estrogen, essentially. The Estring is wonderful for the inside of the vagina, but the estrogen from that does not reach the clitoris and does not reach the inner small lips of the vulva. I personally think I'd talk to your doctor about using a tiny bit of Estrace cream on the clitoris, the same medicine as in the Estring, but applying it to the clitoris and the inner lips so their sensitivity is preserved as well.

Marisa Weiss, M.D., president and founder: As we discussed in a question above, your body is definitely in a different state of being. Its ability to get aroused and stay excited and hopefully have a chance of reaching a climax is going to be different. Check out some of the solutions we suggested that may provide a new way of stimulating your body, like erotica, massage, and sex toys.

Su Kenderdine, M.D.: This is a time that secondary erotic zones can make a difference. The ear, the eyelids, the nape of the neck—and, never forget, the Chinese felt that foot massage and pressure were a key for sexual arousal and climax.

How to increase energy, endurance?

Question from Susan: I am seven months out of treatment. I received four treatments of chemotherapy and six-and-a-half weeks of radiation. While I am doing somewhat better with fatigue, I am still not back to a more normal energy level. I am exercising three to five times weekly and take some vitamins. Is there anything more I can do to increase my energy and endurance?

Answers —Su Kenderdine, M.D.: I'd say be a little gentler on yourself. I think that you are probably pushing a little hard. I would keep it to three times a week max and I would see that energy comes from rest as well as from physical exertion. Seven months is not a long time for a lot of us after treatment. I think the one gift I've had from breast cancer is I never made myself go back to the same level of pushing as before, so maybe be a little gentler.

Marisa Weiss, M.D., president and founder: There are a lot of ways to get moving again in gentle ways. Yoga classes can be really wonderful at building up concentration, flexibility, tone, balance, as well as strength. Tae Kwon Do is also a dance-like form of exercise that has a meditative quality to it.

Walking alone or with a friend can also be very pleasant. Pick a nice place to walk. Stop along the way and rest if necessary. During the time that you're not feeling like yourself, be careful. Safety can be a key issue. When you're not feeling strong and in balance, you may be likely to fall when you try to build up your activity level. So don't move too fast, no sudden changes in direction, wear good shoes with a good grip on the road, don't run up or down the stairs, don't store things on the side of the stairs that you could fall over. Make sure your rugs have a smooth transition on the floor so you don't trip and fall.

Risk of dependency on Phenergan?

Question from Website Question: I have not slept through the night since I was diagnosed with breast cancer 18 months ago. The best remedy I have tried is Phenergan (a codeine-based cough medication) which improves my sleep, but I still wake up at least three times per night. I am concerned that my body will get used to the Phenergan.

Answers —Su Kenderdine, M.D.: You're right; your body will get used to that. It isn't the best method to use. Certainly, there is a wide variety of sleeping pills, but I would think that after 18 months, you probably need to start thinking about weaning off any medication and working with the waking up. If it's just because of hot flashes, attack those more directly with medication.

But I suspect that it's a bit emotional at this point and that worry is a factor. You may want to work on meditative techniques to relax yourself and fall back to sleep quickly and naturally. The simplest is to visualize the most beautiful place you've ever been, and in your mind's eye be there—see the colors, smells, the flowers or the ocean or wherever it is, feel the air on your body. Have a visual activity that's very pleasing and relaxing that keeps your mind from thinking and worrying and helps you fall back to sleep more rapidly.

Marisa Weiss, M.D., president and founder: It's not uncommon for people to have anxiety about waking up, anxiety about staying up, and also anxiety about when you're going to fall back to sleep. This anxiety is all about worrying about how tired it might make you the next day. Also, in the middle of the night, when you're alone, you might find yourself alone with your fears about breast cancer and recurrence.

Nighttime is the worst time for fears. Fears always get inflated and out-of-control during the night. You could make a deal with yourself and say during the night, "I know that this fear of breast cancer is going to be with me for a long time. I'm open to thinking about it during the day but not during the night." This can actually make a significant difference.

You might also find that if nighttime is the time when you experience a lot of the fears about breast cancer as well as breast cancer treatment, plus fears about side effects of treatment, these fears can become associated with your bed and your bedroom. Over time, if this keeps up, your bed and your bedroom feel unsafe and a place where anxiety is triggered. In this situation, you might be able to break up this pattern by starting to sleep in a different room, moving the bed around, repainting your room or changing it in a symbolic way. Little changes can make a positive difference if this is something that you're struggling with.

Su Kenderdine, M.D.: You need to recognize that the fears are exaggerated at night, but they may be coming at night because you're trying to protect people you love during the day and not speak your fears during the day. I urge you to let people know and let yourself know and think about it during the day for a set period of time, because it doesn't go away for you. But, after a while, we feel like we should pretend for everybody else that we're normal again and that just buries it, and it only has the night to have its review.

Marisa Weiss, M.D., president and founder: These fears can be like a nightmare. If this is happening in your life, seek out some help to change the nightmare back to some night dreams.

Advice on reaching orgasm?

Question from Tootsie222: I have trouble having an orgasm. What should we do?

Answers —Su Kenderdine, M.D.: Your arousal time may well be different now, and it may take much more to bring you to full arousal. The tissues may not respond quite as easily and quickly as they once did, so you may have to be brought to climax in new ways, be that a tongue, sex toy, hand, or a lot more fantasy. You have to experiment with it all.

I do think, though, that all of us who go through breast cancer at some point go through a time when we are so focused on ourselves and what we're going through that we can't be distracted enough by anything to let go with an orgasm. If you're in that kind of an intense period, you may have to be satisfied with just sexual pleasuring but not reaching an orgasm for a while. To reach orgasm, we have to step out of ourselves so completely, let all the barriers down and let all our concerns go in that instant. You may not be able to do that right now.

Marisa Weiss, M.D., president and founder: But you still can have some fun.

Su Kenderdine, M.D.: Definitely!

Will ovary removal affect sex life?

Question from Annesenchack: I am considering having my ovaries removed now that my breast cancer treatment is over. I am only 32 and have only been married for 4 years. I am concerned at the effect having my ovaries removed will have on our sex life. Can you provide some help?

Answers —Su Kenderdine, M.D.: You're right; it would not be friendly to your sex life. I'm not sure that the research shows that removing the ovaries adds so much positive benefit to be worth what it does. Medication really can go a long way in reducing the negative of the ovary function without surgery.

Marisa Weiss, M.D., president and founder: I agree. But if your doctors are recommending removal of the ovaries because of a breast cancer gene in your family, in order to reduce your risk of ovarian cancer and breast cancer as well, then using medications to reduce ovarian function won't accomplish the intended benefit of prophylactic ovary removal. If your doctor's intention is to reduce the estrogen in your body as far down as it can go, this can be done with medication rather than surgery or radiation to the ovaries.

Either way, if your ovaries are removed or if they're shut down by medication, your young body will experience a whole new environment with much less of the hormones that it's used to experiencing. Your body can adapt significantly to this and adjust itself and help bring back parts of what felt like normal to you. But it still will be different.

Su Kenderdine, M.D.: Remember, a lot of women well into their menopause in their 70s continue to enjoy sex, want sex, and reach climax. So you can have a good sex life. Is it different and probably less intense than a 22-year-old? Yes. But your sex life comes from your head, not your ovaries, ultimately.

Suggestions for getting back to dating?

Question from Serena: What about those of us who don't have a partner now? I'm so anxious about getting back to dating, much less sex, since breast cancer and surgery. Any suggestions?

Answers —Marisa Weiss, M.D., president and founder: The most important thing is to try to meet people who you can create a relationship with, while doing something you enjoy. You might find at this time in your life that it may be best to establish a friendship with a potential partner that could lead to an intimate relationship.

You don't have to reveal everything about yourself to someone whom you've just met. You share things about yourself with somebody that you have a connection to and that you are forming a relationship with. Once a friendship or a relationship is in place, it will feel much more comfortable to talk about good things as well as difficult things.

When the time comes for you to share that you had breast cancer and that you have scars and other changes in your body, do it before you hit the bedroom. I can tell you that revealing this information for the first time when you're in bed does not work well.

Su Kenderdine, M.D.: But don't neglect pleasuring yourself and your sensual being while you're alone. That can be getting massages, getting facials, having a pedicure, getting yourself sexy underwear that makes you feel good, nice lotions, nice perfumes. Crawling into a pretty bed did it for me when I was alone. Experiment gently with yourself with sexual arousal and climax so you begin to know how those things work for you now. Don't neglect yourself sensually during this time because you're alone.

Marisa Weiss, M.D., president and founder: When you do take care of yourself in a sexual way that Su has described, it will change the way you see yourself and how other people will experience you. Anybody in your life, including a potential partner, is going to pick up your "vibes." The clues, your actions, things you say, the way you walk, all of those things tell your potential partner a lot about you.

You can intentionally create clues, put out some vibes to give your partner a sense of what you're interested in and ready for. If you share about your breast cancer experience, if you let them know that you've come to a place where you're OK with it, that you're moving beyond it, and that you're comfortable sharing your body, then your partner will pick up what you say almost like an instruction.

How to tell prospective partner about surgery?

Question from Website Question: I am having a mastectomy and reconstruction next week and want some suggestions on telling a prospective partner.

Answer —Marisa Weiss, M.D., president and founder: All of us on Breastcancer.org this evening wish you the very best for your surgery and reconstruction next week. Lillie Shockney, a Breastcancer.org professional advisory board member and a three-time breast cancer survivor and a breast cancer nurse at Johns Hopkins, suggests that women think of the mastectomy as a "transformation" taking you from where you are now dealing with a cancer to another place that is much healthier and safer.

As you move through your reconstruction, you can find information and pictures at Breastcancer.org that can help you set goals and expectations for you and your team. Be sure to let your plastic surgeon know what your expectations are. That way this doctor can do a better job of meeting them.

Renewal of intimacy in lesbian relationship?

Question from Website Question: What advice do you have for a lesbian couple where one has just finished chemo and radiation (43 years old) and the other one has also gone through a different kind of stress (caretaker) and we have a three-year-old? Our sex life and intimacy has gone to the lowest level in our relationship. We don't sleep well or enough and this is also taking its toll.

Answers —Su Kenderdine, M.D.: First, you guys just need to hold each other and caress each other and be gentle with each other and with your three-year-old. Your first priority for all of you is naps and daydreaming together and peaceful times. I would urge you to think caressing, not sex, and let it be that, and if it's a couple of months, that's fine. Sleep and caress, caress and sleep.

I think the less demands you put on one another and the gentler you are with your frailties, the better. It can be a time when you draw closer together rather than get pulled apart. Human frailty is one of the most beautiful things about us, and our truest love shows when we're frail and weak and in need, not when we're strong and perfect and winning the marathon.

Marisa Weiss, M.D., president and founder: Communication between you is also critical. Here, gentleness and compassion for each other are also critical.

Arousal medications in the works for women?

Question from Website Question: Any word on a women's Viagra? Really, is there anything ER/PR+ women can take? Is anyone looking into it? My oncologist just shakes his head; meanwhile my sex life is about dead.

Answers —Su Kenderdine, M.D.: Viagra has not proved effective for women. It failed as an arousal drug for women, and I don't know of any medication on the market now.

Marisa Weiss, M.D., president and founder: If you're a woman, it's difficult to watch the Super Bowl and see how many erectile dysfunction drugs are on the market for men, yet the pharmaceutical companies have not found at least one effective medication for women. For sure, we want primetime Super Bowl action also. There are two sex specialists, Berman and Berman who practice at UCLA, who are seriously studying several preparations that help increase blood flow to the clitoris and vagina and, in turn, increase sexual arousal.

We definitely need more attention in this area. You know that the clitoris is similar to the penis in its embryologic origin. This means that the penis and the clitoris come from the same type of tissue. When you are sexually aroused, your clitoris becomes erect just like the penis does. So I think it's hopeful that a medication one day that helps with erections for men may also help with arousal and erections for women.

Su Kenderdine, M.D.: In the 60s, we felt that marijuana would increase one's sensual awareness and allow sensation to be much more powerful, and we felt that would lead to sex more readily. These were not controlled experiments, but it's certain that some places and cultures feel that has value. It may not really increase libido, but makes touch much more intense, and sexuality is heightened and can help to bring on arousal.

Marisa Weiss, M.D., president and founder: Marijuana is not legal in the U.S. But researchers are looking at ways to use the chemicals in marijuana for medical treatment, which may become legal if they're proven to be effective.

Minorities and sexuality, post-cancer?

Question from Website Question: I am a public health professional specializing in minority health. Are there data or research on how the issue of sexuality after breast cancer specifically affects non-white women? What has been your experience in helping non-white women navigate this situation?

Answers —Marisa Weiss, M.D., president and founder: Sexuality can vary tremendously from one culture to another. One culture may be very open with nudity, sexual practices, experimentation, and talking openly about all these things, like in Scandinavia. Other cultures, such as in the African American culture, have historically had barriers against oral sex. These barriers have changed over the years, but there may be some residual resistance against experimenting in that way.

There's only one of each one of you, no matter what culture, part of the world, age group, menopausal status, or disease stage that you come from. Sometimes, it's important to pull up a chair and have a conversation with yourself and find out what you feel comfortable with, or your clients feel comfortable with, as they rediscover their intimate life. What would they like to see happen? Do they want a partner? If they have a partner, what do they hope to share with this partner? I find when I lead a conversation that way that it's relatively easy to figure out the interest and wants of the unique person in front of me. This helps guide the conversation that follows.

Su Kenderdine, M.D.: I have no scientific basis except through individual patients and fictional literature, but, boy, I think it's a lot harder for African American women. I think they're traditionally treated as sex objects and objectified, and they are culturally more easily made to feel second-hand goods when they're less than perfect. It's a tougher struggle and they also, on the whole, are more uncomfortable talking about sex. It's a touchy issue that needs one-on-one help.

Marisa Weiss, M.D., president and founder: There are other cultures, like the Japanese culture, that have centuries-old traditions of eroticism. This may result in more play and more enactment of fantasy, but it may not have an impact on the cultural acceptance of talking openly about it. Every culture has its own good things as well as not so great things. As each of us moves forward in our lives, we can pick the best parts of the different cultures around the world that feel comfortable and exciting, and that might be one way that you can start to imagine and think about what you want your sex life to become over time.

Su Kenderdine, M.D.: Thank you all for being here. I pray that we helped a little and I'm honored that you came and talked with us. I just want to say that, as a breast cancer survivor myself, there's good that comes out of this, not just bad. Keep up the struggle. God bless!