Sexual Side Effects of Breast Cancer Treatment
At the 2019 San Antonio Breast Cancer Symposium, Dr. Kelly Shanahan was one of the moderators of a panel sponsored by Breastcancer.org and Sermonix Pharmaceuticals on the sexual side effects that breast cancer treatment can cause. As a dual citizen of this discussion — she’s both a metastatic patient who has experienced some of these side effects and an OB/GYN who used to treat people for these side effects — she’s uniquely qualified to help us all understand the topic and offer solutions.
Listen to the podcast to here Dr. Shanahan explain:
her personal journey with breast cancer
why anti-estrogen medicines and chemotherapy can cause vaginal dryness, vaginal atrophy, and pain during intercourse
some of the causes of loss of libido
solutions to some of the most common sexual side effects, including vaginal dryness and thinning, pain, lack of desire, and hot flashes
Dr. Kelly Shanahan is a metastatic patient advocate and METAvivor board member. She had to give up her OB/GYN practice because of side effects from metastatic breast cancer treatment.
— Last updated on February 11, 2022, 9:44 PM
Jamie DePolo: Hello! As always, thanks for listening. Our guest today is Dr. Kelly Shanahan, a metastatic patient advocate and METAvivor board member. Dr. Shanahan had to give up her OBGYN practice because of side effects from metastatic breast cancer treatment. At the 2019 San Antonio breast cancer symposium, Dr. Shanahan was one of the moderators of a panel on the sexual side effects that breast cancer treatment can cause.
As a dual citizen of this discussion — she’s both a metastatic patient who has experienced some of these side effects and an OBGYN who used to treat people for these side effects — she’s uniquely qualified to help us all understand the topic and offer solutions.
Kelly, welcome to the podcast.
Kelly Shanahan: Thank you very much for having me, Jamie, and I love that, “dual citizen,” although I wish my dual citizenship were something like, I don’t know, American and Irish or something like that.
Jamie DePolo: I know, it’s not a dual citizenship that most… that nobody would want that, unfortunately. But it does make you very uniquely qualified to have this discussion, so I’m really happy to talk to you today. So before we start on the side effects, if you’re comfortable, just to give people who may not know you some background, would you mind telling us about your personal journey with breast cancer and where you are today?
Kelly Shanahan: I was, back in 2008, a very busy OBGYN in solo private practice. I have a daughter, she was 9 at the time, and I just put my practice and my family first, and I don’t even think I was on the list. So my office manager scheduled me for a mammogram — and it had been 2 years since my prior mammogram — and I went in. And ironically, a friend of mine who was also a patient of mine had had a mammogram the day prior, and it was obviously cancer, and this facility had taken really great care of her.
So I asked to see the radiologist who had taken great care of my friend the day before, and she said, “Well, you know, while you’re here let’s look at your mammogram,” and called up the images. And she said one bad word, and I said a different bad word because I had a very obvious breast cancer. It turns out I had stage IIB estrogen-receptor-positive breast cancer in my right breast. I live in a small town, I practice in a small town that is a ski resort, so we have orthopedic surgeons coming out the wazoo, but we didn’t have a comprehensive breast cancer team. We had general surgeons that I loved and respected, but no plastic surgeon that was here full time.
So I went to San Francisco, had a bilateral mastectomy with immediate reconstruction, and I remember giving my husband my Dictaphone that I used in my office to make notes and asking him to just record what the surgeon said about my lymph node. And I had one positive lymph node, which bought me typical 4 months of IV chemo, Adriamycin plus Cytoxan followed by Taxotere, and I went on my merry way.
I had hormone-receptor-positive cancer and was placed on an aromatase inhibitor that caused severe, severe arthritis symptoms in my hands that made it really, really hard for me to do surgery. So I thought, “I had a mastectomy, I had chemo, I’m fine,” and I did not complete a full 5 years.
We fast forward 5 years, and I totally forgot about breast cancer, it was something to be put in the past medical history section of forms, and I was going on with my life. I’m now in my 50s, and I was walking up the stairs at my office one day, and I sneezed as I was taking a step and had immediate horrific back pain. And I thought I pulled a muscle. I mean, it’s the logical thing. Didn’t get better, I started seeing massage therapists and my chiropractor. It continued to worsen and I thought, “Oh, man, I herniated a disc.” And yeah, we’ve got orthopedic surgeons coming out of the wazoo, but I don’t have time to deal with this, and I continued to ignore it.
Ironically, I was subleasing my office one day a week to an oncologist. My town believes in orthopedics, doesn’t so much believe in oncology, and we have no oncologists now, we didn’t have any full-time oncologists then. This guy saw me limping, and he said, “You’ve had breast cancer and you should probably have scans.” But I was busy, still in solo private practice, now a not-quite 15-year-old daughter who was in theatre, and I was driving to rehearsals and going on field trips and doing all sorts of mom stuff plus doctor stuff, and it was a couple of months later before I had an opportunity to have scans. It so happened that it was my birthday, and I decided about 2 months in advance to cancel the four or five patients that were already on the schedule and I’d go get a scan done. It would prove that I had a herniated disc, and I’d go get a mani/pedi and I’d go shopping and we’d go out to dinner.
Well, none of that happened, because I had scans, and my back pain was because I had metastatic breast cancer, I’d actually broken a vertebra, I had metastases in every bone visualized. I had lesions in my left leg that if I had tripped and fallen my leg would have broken. So 6 days after I was diagnosed, I was in the operating room having a rod put in my left femur. Ten days after that I started IV chemo, and I have been living with metastatic breast cancer now since November of 2013.
I developed permanent neuropathy from IV chemo that I had, and I had to stop practicing medicine. Certainly don’t want somebody with numb fingers catching your baby or handling a scalpel. I also became concerned that because of my numb fingers that I might miss a breast lump, I might miss an ovarian cyst because I couldn’t feel things as well, so one of the collateral damages of my disease was losing my career.
Jamie DePolo: Thank you very much for being so open about that, I appreciate it. To give people a little bit of a roadmap of our discussion, I’d like to talk about the treatments and side effects first, and then kind of go into maybe some options for easing them, some of the solutions.
So, whether the hormone-receptor-positive is metastatic or earlier stage, we hear from a lot of women that the anti-estrogen medicines — the tamoxifen, the aromatase inhibitors — are really wreaking havoc on their sex lives. And if this isn’t too nosy, did you have that kind of side effect when you were on an aromatase inhibitor, and I guess as a physician, could you explain why this happens?
Kelly Shanahan: Sure. To answer your first question, you know, my life is pretty much an open book. They absolutely wreaked havoc on my sex life, both in terms of desire and in terms of the physical manifestations. Estrogen is a super important hormone, and to just talk about estrogen in relationship to our reproductive organs and sex life, estrogen is key to vaginal moisture. Without estrogen, whether it’s natural menopause or whether it’s an artificial menopause from having ovaries removed for various reasons, or going on medications that block estrogen, when estrogen levels are low the tissues in the vagina thin, there’s less natural lubrication. Thinner tissues mean they’re also drier, they’re not as elastic.
If you think about it, vaginas have to expand to have a bowling ball come through there in the process of birth. And a lot of that elasticity is lost, and so even though with sexual intercourse the penis clearly is not as large as a bowling ball, the vagina still needs to accommodate it. So that elasticity is lost, the tissues are thin, they are dry, they tear more easily, you’re much more likely to get an infection, it’s just plain out uncomfortable. Frankly, it’s just plain painful.
You know, with natural menopause, I used to liken it when I would talk to my patients about menopause, it was like, no, menopause is not like turning off a light, where all of a sudden everything’s cool and then you flip a switch and you’re menopausal and things are horrible. It’s more like a dimmer switch, where things happen gradually. That’s not true for women that are premenopausal before a breast cancer diagnosis, and whether through surgery or through chemotherapy that kills the ovaries or through medications that deplete estrogen, it is that flipping a light switch. And it really wreaks havoc with the sex lives and with our self image.
It’s not for the weak of heart. To be a woman facing breast cancer requires a lot of fortitude.
Jamie DePolo: Okay. And I’m curious, because a lot of — as you mentioned, the vaginal atrophy, the dryness, the pain during sex — a lot of it is attributed to the anti-estrogen medicines, but we also hear from women who were diagnosed with hormone-receptor-negative breast cancer that they’re having some of the same things. Obviously they’re not on tamoxifen or an aromatase inhibitor. Does chemotherapy then contribute to all of this as well?
Kelly Shanahan: It certainly can. So for women with triple-negative breast cancer or early-stage women with hormone-receptor-positive breast cancer who initially have to go on the traditional Adriamycin plus Cytoxan plus a taxane, these cytotoxic chemotherapies attack rapidly dividing cells. And if you think about it, when we’re premenopausal, every month our ovaries are dividing and making an egg that’s then released. So cytotoxic chemotherapy can shut down our ovaries. And sometimes it’s temporary, where women that are receiving chemotherapy will stop having their periods for a while, and then they finish their course of chemotherapy and lo and behold a few months later the periods return.
But in that time when the ovaries are shut down because of the chemotherapy, menopausal symptoms can happen. And it can happen with 17-year-olds being treated for leukemia or 35-year-olds being treated for breast cancer and everybody above and below those ages. So this is not a problem for only women with hormone-receptor-positive breast cancer.
One of the differences, especially for younger women, early-stage women who are not estrogen-receptor-positive who go on chemo and they have their ovaries shut down, is that number one, their ovaries may start working again and so these side effects can go away, and number two, there is no medical reason that those women can’t use estrogen-containing products if their breast cancers are estrogen-receptor-negative.
For women with estrogen-receptor-positive disease, especially early-stage women who may be on estrogen-blocking drugs like tamoxifen or an aromatase inhibitor for 5 to 7 to 10 years and they’re going to have to deal with that for that timeframe, and for those of us that are metastatic, we’re going to have to deal with it for the rest of our lives. So anyone diagnosed with breast cancer may have sexual side effects. And not just direct effects of hormone-blocking drugs or side effects of chemotherapy, but I also think just having cancer and having cancer that affects organs of the body that are so tied to our sexuality is a factor in and of itself, especially with some of the libido issues.
Jamie DePolo: Yeah, I wanted to get into that next because loss of desire, loss of libido is another big complaint tied to breast cancer diagnosis and treatment. And I’m curious, from your standpoint, how much of that relates to self image, body image, you don’t like what you see or what you see is different in the mirror, and then does that translate into desire with a partner, because maybe a woman sees herself as not desirable or attractive?
Kelly Shanahan: I think that’s part of it, that self-image piece is part of it. We’re talking about libido, and libido is so multifactorial. It’s not just — and I’m sorry for any men that might be listening to this, but if you guys get enough blood flow to your penis, you’re pretty much good. But we women are way more complex than that, and a big factor of libido is our self image, the way we think our partners view us as being attractive. And in western society, so much of what is considered attractive in a woman has to do with having breasts, and whether we’ve had a lumpectomy or a mastectomy, reconstruction, no reconstruction, flat, whatever, our view of ourselves and what we perceive as our partner’s view of ourselves has changed, and that can affect our sex drive or libido.
Also, no matter what the treatments are, it doesn’t matter whether you’re on a hormone-blocking medication or you’re on cytotoxic chemo or you’re on some type of other targeted therapy like for HER2-positive disease, you may not have anything that directly affects your vagina — vaginal dryness, atrophy, those kind of symptoms — but if nothing else, I don’t think there’s a single cancer treatment out there that doesn’t cause fatigue. And many of us have families, we are working, we are trying to do it all, and we’re tired. We may feel some resentment for our partners because we’re going through cancer treatments and we’re still working, we’re still taking care of the household and you know, why can’t you close the kitchen cabinet doors?
So all of those things play into our desire to have sex, and that’s why I think it’s very important to communicate. I mean, I remember when I was diagnosed early stage, and I had a bilateral mastectomy with immediate reconstruction so I had expanders in. And when the drains were out and it was slightly less grotesque than had been with the drains in and my husband wanted to have sex again, for me it was like, “Why do you want to have sex with me, I’m like a thing now.” And he expressed to me that it didn’t matter. It didn’t matter whether I had breasts, whether I had implants, whatever, I was still me and we were still a couple and that it didn’t matter what I looked like. It was a little harder for me to accept it.
And the other thing is that for many of us, our breasts are a huge part of arousal. And most doctors do not tell you this, but if you have a mastectomy, putting aside some very, very, very new techniques that weren’t available when I had a bilateral mastectomy 12 years ago, you lose all sensation. I chose to have something called a total skin-sparing mastectomy, which I likened to kind of scooping out the inside of a bagel and leaving the bagel crust. So I still have my original nipples, I still have all the skin, but they scooped out all of the underlying breast tissue, which also means they scooped out all the nerves. So I may look perfectly “normal,” but there is zero sensation at the nipples.
So for people that found stimulation of the nipples to be very arousing, that’s gone. You may or may not have that with a lumpectomy, and there are newer surgical techniques now where the surgeon tries very hard to spare the nerves that go to the nipple so it may not be as big of a problem moving forward, but not all surgeons can do that technique.
So that’s something else to think about, and it took a while to accept that that was very different and it was going to be different, and I just had to move on from that.
Jamie DePolo: Okay. It’s really a multi-pronged issue. We’ve got a lot of things that are playing into this, and then you spoke about the importance of communication. You know, talking, whether it’s to your doctor about your concerns, to your partner.
I kind of want to focus on the doctor part, because while this is changing, a lot of oncologists are male, a lot of breast cancer patients are female. And I have read — I don’t want to make assumptions about everyone, but I have read — that in the past some doctors felt that, “Well, you’re alive, you should be happy for that and deal with the side effects.”
That mindset is changing, but I still think a lot of women are reluctant to bring up this topic. And even if they do want to bring it up, maybe they’re unsure which doctor should they talk to? Do I talk to my oncologist, do I talk to my GP, do I talk to my OBGYN? Could you give us some insights on that?
Kelly Shanahan: Absolutely, and I experienced this personally, and I don’t think I experienced this because I’m an OBGYN or a physician in general. When I was early stage I saw a male oncologist. Never once did that male oncologist ask me a single, solitary thing about side effects other than nausea, vomiting, things like that. Never, ever asked about whether it was affecting my sex drive, sex life in any way, shape, or form, even when I was on an aromatase inhibitor. When I was diagnosed metastatic, I initially saw a male oncologist who, again never, ever, ever mentioned this, and when I brought it up. said, “Well, you’re an OBGYN.” I have heard from friends who have brought this up mainly, but not exclusively, with male oncologists, sometimes with female oncologists, young and old, the same, “Well, go talk to your OBGYN.”
As an OBGYN, I can tell you that when I was diagnosing people with breast cancer and taking care of their GYN needs after their treatment or during their treatment for breast cancer, they would always ask me, “Well, oh my God, I have horrible vaginal dryness, what can I do?” And as an OBGYN I would say, “Well, here are some things but we need to talk to your oncologist,” and sometimes I would be able to have a productive conversation with an oncologist and sometimes I just had to wing it because the oncologist wasn’t interested.
I think things are improving. When I switched from the initial oncologist I saw with my metastatic diagnosis for various reasons, I saw a female oncologist. The first thing that she said to me when she walked in the exam room was, “You are now on an aromatase inhibitor, and hopefully you will respond to it and you will be on it for years. It can have some pretty significant sexual side effects. Are you experiencing any of this? I know you’re an OBGYN, but are you experiencing anything? Because I can offer you some suggestions and solutions.”
And that was the first time that anyone had ever mentioned it. I’m now seeing one of her partners just because it’s more convenient, and he’s the same way. He asks about these things and again, kind of like, “I know you’re an OBGYN but you know, do you have any of these issues, can I help you address them even if it means I refer you to one of your OBGYN colleagues?”
I really applaud doctors that are open with their patients, because a long life is meaningless unless it’s all for the good life. And for so many people, a healthy sex life is truly part of living, and I really feel for the younger people who have been diagnosed with cancer that have had to deal with this, that are in the dating world or newly married or younger.
I’m, for many reasons, grateful that I wasn’t diagnosed with metastatic cancer until I was in my 50s. My husband and I just celebrated our 25th wedding anniversary, so things are a little easier for us than someone who may be in a new relationship or a relationship that is still relatively young, where sex is even more important than it may be as we get older. Not to say when I was practicing that I didn’t have some 80-year-olds who had pretty active sex lives. I was like, “Dang, you’re my hero.”
Jamie DePolo: Yes. Yes, I think we all aspire to that, so that’s good. And that’s really good to hear. Now, before we move on to solutions — I was trying to figure out where to fit this concept into the conversation — but the partner clearly can play a huge role in this as well by being understanding, accommodating. Could you talk a little bit about that?
Kelly Shanahan: I think having a partner that will bring up the subject, like, “Hey, honey, I noticed that you kind of grimace when we try to have intercourse, how can I make this better? Would you like to try X, Y, or Z?” Intercourse does not have to be vaginal penetration. Intercourse can be oral. For some people just cuddling. Sometimes having a really great conversation is better than the best sex, so I think it’s really important for partners to talk to one another.
I think for us as women, we’re so conditioned to please everybody else that I think we do that with our partners. Sometimes have that conversation to say, “You know, this traditional version of intercourse that we have had all these years is no longer working for me, let’s try this. Can we just sit on the couch and watch a movie and hold hands,” I think can be very important, and also giving our partners permission to talk about it.
It doesn’t seem fair or right that we often have to be our own best advocate. And whether that’s bringing up the subject with our partners or bringing up the subject with our doctors if our doctors do not bring it up, we need to be empowered to speak up and with a partner to have a conversation about what works for both. There are some couples who may have been having sex 3 days a week, which is just not working for the hormonally depleted woman, but maybe once a week will work. And you know, maybe sometimes we need to give our partners permission, not to step out on us with another person but to, I don’t know, watch porn or just talk dirty to each other. Whatever works for you, but you’ve got to communicate and be honest with one another.
There is many a marriage that has died due to incompatibility with sex life that’s been exacerbated with this whole breast cancer thing, and so many of those potentially could be saved by open and honest communication.
Jamie DePolo: Excellent. So now this is probably what most people are listening to this podcast for is solutions. And I know I’m not going to expect you to have a solution for all, but perhaps some suggestions that people could try, obviously depending on their diagnosis, because anyone diagnosed with hormone-receptor-positive disease is a little bit more limited in some of the products they can use that way. But what would you suggest for vaginal dryness?
Kelly Shanahan: First of all, start simple. Just as we moisturize the skin on the rest of our body — especially for those that live in a dry climate like I did, get out of the shower you put on moisturizer — we can moisturize our vaginas. There are products that are available that are not lubricants to be used with vaginal penetrative intercourse, but that are vaginal moisturizers that are to be used on a regular basis. There are some big brand names like Replens, there are some more natural products. The important thing is that these are usually not oil-based lubricants, not petroleum jelly-based. I’m kind of like, don’t put things in your vagina that you put in your car.
So using a vaginal moisturizer on a regular basis, maybe 3 days a week, can help keep those tissues moisturized. And then with the active intercourse itself, additionally you use a vaginal lubricant. And again, there’s big brand names like K-Y and Replens and my personal favorite, because I love this name and I always think of the Jetsons having sex, is Astroglide. You use that with the act of intercourse, and it’s slippery. There’s nothing natural like that that’s going to actually thicken and beef up the vaginal tissues, although regular intercourse does help with that. So those are some more natural things.
The idea that if you’ve been diagnosed with estrogen-receptor-positive breast cancer, you 100% absolutely cannot ever use an estrogen product in your life is false, and the American Society of Clinical Oncology actually has a statement out that women with estrogen-receptor-positive breast cancer can use vaginal estrogen products. This is different than an estrogen pill that you consume, that you swallow, or an estrogen patch that goes through your whole body to help with things like hot flashes. These are either creams or little tiny tablets or rings that go into the vagina to provide estrogen locally in the vagina.
This statement came out a few years ago, and 20 years ago when I was practicing OBGYN and I’d have a patient with estrogen-receptor-positive breast cancer complaining of these symptoms, I would say to her, “Listen, we certainly can’t give you estrogen throughout your body, but what I can do is I can draw a level of a certain type of estrogen called estradiol to kind of see what it is. Then I can give you an estradiol-containing vaginal product.” And I usually recommended a cream, because you could use more cream, you could use less cream, whereas the tablets are so tiny you can’t cut them. And 20 years ago, I don’t think there were any vaginal estrogen rings on the market. And I said, “We’re going to do this, and then I’m going to check your estrogen level once a month for 3 months. It might go up a little bit at first, but then it should come down. And as long as it’s not elevated, we’re probably relatively safe in doing this.”
Well, it turns out that that’s true, but now most people don’t even check baseline or estradiol levels following treatment. So it is likely safe for a woman with an estrogen-receptor-positive breast cancer to use vaginal estrogen, and again, there’s various forms of it. A lot of oncologists like the rings. When I stopped practicing several years ago I was still predominantly prescribing the creams because again, you could use a little bit, if you needed a little bit more that was okay, you could customize it a little bit.
But if you see an oncologist who said, “Oh, no, you can’t do this,” then just refer them to ASCO, like, “You might want to look up ASCO’s guidelines on this, because they do have guidelines.”
Loss of libido is a little harder. There are prescription medications designed for women to improve libido. I’ve never been impressed with them, I pretty much never prescribe them. There’s not much evidence, but there is a hormonal compound called DHEA, dehydroepiandrosterone, I think, that can also be used as a vaginal lubricant, but may improve libido a little bit.
Again, not a lot of studies on this. I know a couple of institutions have started some work, I don’t know if there’s anything published on it. Last time I looked I didn’t find any papers, but it’s been a little while, probably a year since I’ve looked. But it’s another thing you can ask your doctor about. Again, libido’s between your ears, and I think the biggest fix for decreased libido is open, honest communication with a willing partner.
And then, hot flashes. Tamoxifen, aromatase inhibitors, besides all the joint pain that can come with the aromatase inhibitors, which can make certain positions less comfortable — again communication, try different things. And the vaginal dryness that can accompany, especially the aromatase inhibitors... the old hot flashes. You can be in the middle of an intimate moment, and all of a sudden it’s like, “Whoo, baby, somebody just turned on the heat and not in a good way,” and you’re sweating and your face is red and that’s really, really challenging. There are non-hormonal things. Vaginal estrogen is not going to help with hot flashes, and certainly if you’re hormone-receptor-positive you do not want to be taking systemic estrogen. But if you’re triple-negative, if you don’t have the hormone receptors and you’re miserable with hot flashes because you’re naturally menopausal, talk to your doctor about the possibility of using a little bit of estrogen.
And there are a lot of non-hormonal methods. Some of the antidepressants are very effective at treating hot flashes. And then simple things, like I remember I had a friend of mine who was a couple years older than me, and I remember her calling me up one day and saying, “I’m having hot flashes when I drink wine. And don’t tell me not to drink wine.” And I went, “Well, you figured it out.” Alcohol causes a spike in estrogen and then a drop, plus the sugars in alcohol, a lot of people get hot flashes with sugar. I said, “So you figured it out, so here’s my suggestion. Don’t be about it and call me up at 8 o’clock on a Saturday night because you’ve already figured out the problem!” So my suggestion is, don’t drink alcohol Sunday night through Friday night or through Thursday night when you have to go to work the next day, but if you want to have it on a weekend where it doesn’t matter quite as much if you have hot flashes that disturb your sleep, have at it.
So if you notice that things like alcohol or a dessert will cause you to have hot flashes, well, think about minimizing that. I’m super lucky that when I was diagnosed early stage, it turns out that I was going through menopause and I had no idea, because I never had a hot flash. And the only time I have hot flashes now, despite being on an aromatase inhibitor for the past 5 years continuously, is if I drink wine and have dessert. So I will usually make the choice to do one or the other. I usually choose the wine, but if my husband and I go out to dinner and we’re going to some fancy place and we’re having some nice wine and I have a dessert, I know that I’d better make sure the windows are open or maybe I have to turn on the ceiling fan in our bedroom.
So things like that are just simple things that can help with those types of symptoms.
Jamie DePolo: Okay. I have one question for you, too, before we wrap up. From what you said before about the brain is the biggest sex organ, it would seem to me that if somebody is able to find a good solution for vaginal dryness or for pain during intercourse, then that can then help with loss of libido. Because it seems like if it’s just painful and you get all stressed about it, then that’s not going to help desire at all.
Kelly Shanahan: Absolutely. Because it’s another thing that I used to tell my patients is, if it hurts to have sex, you’re not going to want to have sex because you’re not stupid. So if we do address the vaginal dryness and the pain during penetrative intercourse, then yes, that often can help libido because we’re not tensing up and dreading the act of intercourse.
Jamie DePolo: Okay, and what about pelvic floor exercises. I imagine they probably wouldn’t do much for dryness, but what about the thinning, is there any evidence that they help at all?
Kelly Shanahan: That’s a great question, Jamie, and no, they’re not going to help the vaginal tissues thicken up. But part of pelvic floor exercises is not only just contracting or doing those Kegels to help keep us from peeing our pants as we get older when we laugh and stuff, it’s often conscious relaxation. So women who do regular Kegel exercises often can relax the musculature and therefore make sex less uncomfortable. So on multiple levels doing Kegel exercises and pelvic floor exercises is a great idea, and I’m really glad you brought that up.
Jamie DePolo: Okay. Okay, thank you. So to wrap up, just kind of give everybody a summary, if you had to pick three or four things that people should know about the sexual side effects of breast cancer treatment, what would you say?
Kelly Shanahan: Number one is just because you have breast cancer does not mean you cannot use vaginal estrogen. Talk to your oncologist. Number two, talk to your oncologist if your oncologist does not bring up the potential sexual side effects of your treatments. Ask for solutions. Ask for referral to an OBGYN, to a nurse practitioner, to a sex therapist if a lot of it is the libido and communication issues with your partner. And number three, open communication with your partner is very, very important. And as a fourth, I’ll throw in the use of regular vaginal moisturizers. Just like you moisturize your face, moisturize your vagina.
Jamie DePolo: All right, Kelly, thank you so much, I really appreciate your insight.
Kelly Shanahan: Thank you, Jamie. It’s always good to talk with you.