Sexuality and Metastatic Breast Cancer
Sex can be life-affirming, fun, a stress-reliever, and a way to express love. Certainly, a metastatic breast cancer diagnosis does not change the fact that you’re still a sexual being. Many women diagnosed with metastatic breast cancer say that sex — which can include penetrative or nonpenetrative activity — is an important part of their lives and of their relationships with their spouses or partners. But it’s not always easy to balance your sexual needs with the physical and emotional challenges of a metastatic breast cancer diagnosis.
Sometimes pain because of metastases or side effects from treatment can take the enjoyment out of having sex. Rather than sex feeling pleasurable, it may start to feel more like something you’d rather avoid.
Still, some women diagnosed with metastatic breast cancer have said that they sometimes put up with painful sex anyway, even when they have no sex drive, because they’re concerned about their partners being satisfied. And it may feel like something you want to do, despite any discomfort, if your partner has been very supportive of you through diagnosis and treatment.
"Some women tell me that a big part of why they have sex is because their partner has been so supportive, and they want to be able to give their partners pleasure,” says Lynn Wang, MD, sexual medicine specialist at Main Line Health System in Wynnewood, Pa. It can be tough if the sexual side effects of treatment and feelings about the future are interfering with physical intimacy.
If you’re dealing with physical problems that are affecting your sex life, it’s a good idea to keep these things in mind:
You have a right to not feel like having sex. It's completely normal to not want to have sex. It happens to all women, often as a result of treatments for metastatic breast cancer. If sex hurts or if you are too tired, you are not obligated to have sex.
There are many other fulfilling ways besides sex to express intimacy. An important part of staying connected is basic touch: hugging, holding hands, or gentle back rubs.
Communicating with your doctor about sexuality
It makes sense to talk to your medical team about any physical problems you may be having so you can find ways of making sex more physically comfortable and pleasurable.
It’s important to know that, according to some research, healthcare providers have not always been ready to talk about sex with patients who are diagnosed with metastatic breast cancer. They might avoid discussing sex because it’s not their area of expertise or because the subject makes them feel uncomfortable. It’s certainly true that healthcare providers tend to be more focused on treating metastatic breast cancer than addressing sexual concerns.
But cancer treatment teams are being trained more and more on how to discuss and address sexual health issues. When it comes to talking about ways to make sex more comfortable, you may need to take the initiative. Here are some ways to start the conversation with your healthcare provider:
Make sure your medical team understands that sex and intimacy is important to you. This way, they can prioritize addressing your needs.
Be as specific as you can about your problems so your medical team is able to explore possible solutions. For example, “Since this course of chemo started, intercourse has been painful.”
Ask if your hospital or clinic has resources or referrals on sex and metastatic breast cancer. Some facilities can link patients to a host of helpful information and experts. You can also check resources such as the American Cancer Society’s Sex and the Woman With
Cancer. The American Association of Sexuality Educators, Counselors and Therapists also offers a tool that can locate professionals in your area.
Take it a step further. “Healthcare providers commonly may ask if you are experiencing vaginal dryness or if sex hurts,” explains Sara McClelland, PhD, associate professor and researcher, University of Michigan. “These questions assume that sex is only happening via intercourse. Don’t stop there. Use it as an opportunity to discuss any other sexual matters that are coming up.”
Sexuality and bone pain
Bone pain as a result of metastases can sometimes contribute to discomfort with certain sexual positions. Experimenting with new approaches can help. Here are some ideas:
Tell your partner if you’re in pain. If sex causes you any sort of pain, tell your partner about it. Don’t suffer in silence.
Try things other than intercourse. Sex can involve more than just intercourse
and penetration. Sometimes, a heartfelt cuddle session can be satisfying. If you’re both up for a change, try oral sex, massage, or mutual masturbation. Besides alleviating discomfort caused by pressure or friction, expressing yourself sexually in various ways can also be fun.
Change positions. If the missionary position causes bone pain in your spine, for example, see if getting on top is more comfortable.
Use a pillow or wedge. Placing a pillow underneath a tender area may help alleviate pressure or friction. The Liberator Wedge is one example of a product that can reduce this type of pain with sexual positions.
Sexuality and surgery scars
When it comes to sex, everyone feels differently about scars from metastatic breast cancer surgery. Some women feel proud of their surgery scars and see them as symbols of strength. Other women may feel uncomfortable about their scars and may prefer their partner neither touch them nor look at them. Think about what feels good to you:
Be vocal about what you like and do not like. Let your partner know if you do not want your scars touched. It’s important to be clear and not to assume your partner can guess how and why you feel the way you do. For example, “I appreciate that you’re touching my scar, but I do not like how it feels. Can you stroke my back instead?”
If you’re feeling self-conscious, wear something that makes you feel more comfortable. For example, a satin camisole or short nightgown can remove the distraction of your scars and help you focus on the moment, on your pleasure, and on your partner’s pleasure.
Some women choose to wear their prosthesis with a bra during sex. If you’ve had a mastectomy without reconstruction, you may decide to wear a prosthesis some of the time, including during sex. Look for specialty shops such as Nordstrom that fit mastectomy bras with prosthetics.
Makeup. If you feel self-conscious about your scars but do not want to cover them with clothing, try some heavy concealer and see if you feel better when you apply it. The decision to use makeup or not is a personal choice. For some women, putting a little makeup over scars helps them focus on the moment.
Sexuality and treatment side effects
Treatments for metastatic breast cancer, including surgery, chemotherapy, and hormone therapy, cause changes to your body that can affect your sex life:
Hormonal therapy can cause menopausal symptoms such as vaginal dryness and hot flashes.
Chemotherapy and other treatments can cause fatigue and, for some women, trigger sudden-onset menopause.
Even though side effects like these are common, only one in three women diagnosed with metastatic breast cancer receives information from their healthcare provider about how treatments may affect their sex lives. It’s worth asking your doctor how treatments may affect your body, your level of sexual desire, and your energy levels.
An erogenous zone is a body part or area of the body that is highly sensitive. When an erogenous zone is stimulated, it can lead to a sexual response. Common erogenous zones, in both women and men, are the genitals, lips, neck, nipples, and buttocks.
Treatment for metastatic breast cancer may affect some of your erogenous zones:
surgeons may have had to remove one or both of your nipples because cancer was found in close proximity to them
body parts that were once very sensitive, such as the breasts, may become numb because of surgery
But the good news is that the skin on most of your body can trigger sexual arousal when a partner touches it. Erogenous zones can be different from person to person. Some people, for example, might find the back of the neck a sensual erogenous zone, while others might consider it tickle territory.
It can help to slow down and pay attention to your erogenous zones. Learn which ones work best for you or if there are new ones you weren’t previously aware of. Do you prefer, for example, a kiss on the neck or to have your buttocks or thighs gently massaged? How do different kinds of touch on different parts of your body make you feel physically and emotionally? Erogenous zones are highly individual, so there’s no single answer.
Vaginal dryness happens when estrogen levels drop, causing the walls of the vagina to become thinner, less flexible, and to produce less lubrication. It can be caused by natural menopause, as well as several treatments for metastatic breast cancer. Chemotherapy, for example, can bring on menopausal symptoms, including vaginal dryness. Hormonal therapy can cause the vagina to produce less lubrication. In some women, risk-reducing hysterectomy including the removal of the ovaries can also cause menopause, leading to vaginal dryness.
Vaginal dryness can make sex uncomfortable or even downright painful. Here are some suggestions that can help:
Try a vaginal lubricant. If your body is not producing enough moisture on its own, using a vaginal lubricant may help make intercourse or penetration more comfortable. Apply and reapply it as needed in and around your vagina to relieve friction and ease dryness and pain. Most lubricants are water-, silicone-, or oil-based and are found over the counter and at many online stores (a good alternative for people who feel self-conscious about purchasing lubricant at a physical store). They can be washed off with soap and warm water. A study found that women diagnosed with breast cancer preferred silicone over water-based lubricants and that total sexual discomfort was lower with silicone-based lubricants than with water-based lubricants.
Lubricants to avoid. The simpler the ingredients list, the better. If you can pronounce it and know what it is, the ingredient is likely okay to use. Stay away from lubricants that are perfumed, petroleum-based (like Vaseline), or oil-based (these may increase the risk of vaginal infection, tend to have an unpleasant odor, and can damage latex condoms). Since little is known about their safety, also avoid lubricants that give sensations of warmth or tingling. It’s also a good idea to avoid parabens. They can penetrate the skin and act like a very weak estrogen in the body. In addition, stay away from lubricants with propylene glycol, a form of alcohol that could be irritating, and glycerin, which can promote yeast infections.
Reputable brands include Good Clean Love and Slippery Stuff Paraben Free, which are water-based; Uberlube, which is silicone-based; and Sliquid, which comes in both water-based and silicone-based formulations. Read the labels (or research what’s in them) and try to avoid lots of chemical ingredients. Several women in our Community at Breastcancer.org also recommend “Scream Cream,” a vasodilator (it relaxes the blood vessels, allowing more blood flow to the clitoris). Your pharmacist must create this cream by hand, and you need a prescription from your physician.
Natural oils such as mineral oil and coconut oil also work, but it’s important to know that they can break down the material in condoms.
Use products intended for vaginal use. Hand creams and body lotions are not good choices since they can contain irritating ingredients.
Ask your healthcare provider about prescription lubricants.
Foreplay can also help. Foreplay is important to help you get to a state of arousal. A slow, methodical foreplay session can sometimes make a difference in helping you to become more excited and naturally lubricated.
Change your position. Certain positions may feel better than others. Experiment with different positions and see what feels most comfortable for you.
Vaginal tightness can be caused by vaginal atrophy, vaginal scarring, pelvic floor muscle spasms (vaginismus), or a combination.
Vaginal atrophy is a thinning and dryness of the vaginal tissues that happens when estrogen levels drop during and after menopause. But certain metastatic breast cancer treatments that lower estrogen levels, such as hormonal therapy, can also cause vaginal atrophy. Vaginal dryness can cause pain or burning at the vaginal opening and pain on penetration. But the vagina may also feel like it is tight.
There are several ways to help deal with vaginal tightness and lessen penetrative pain or discomfort, whether with pelvic exams, vibrators, or intercourse. Here are some ideas:
Bearing down. This is the opposite of a Kegel exercise — pushing gently as though you are having a bowel movement or coughing.
Daily massage of your vaginal opening with oil. Lynn Wang, MD, sexual health specialist at Lankenau Hospital in Wynnewood, Pa., says, “Different oils have different properties, but unfortunately, these aren’t well studied for vulvovaginal atrophy. Nevertheless, commonly recommended oils are vitamin E, mineral oil, and coconut oil. I tend to recommend organic sunflower oil, for its skin healing properties.” You can incorporate vaginal massage into your daily routine by putting two to three drops of oil onto the pad of your thumb. Then, insert your thumb about 1 to 2 centimeters into your vagina, focusing on the outer, bottom half of the vagina and gently massaging the oil into your skin for 10 to 15 seconds. This technique targets the most problematic area for most women with vulvovaginal atrophy. One important note: Oils should not be used with latex condoms, as they can lead to condoms breaking.
Vaginal dilators are graded-sized vaginal inserts, usually made of plastic or silicone, that help lengthen and widen the vagina and its opening. They can also help stretch any vaginal scar tissue that may contribute to pain and discomfort during vaginal intercourse. (Scarring may be caused by pelvic surgery, radiation, or trauma and injury).
Vibrators: Many women use vibrators regularly. Using vibrators can increase pleasure whether alone or with a partner. Using a lubricated vibrator also may help maintain vaginal health and prevent or reverse vaginal narrowing.
Physical therapy to help treat pelvic floor spasms: Pelvic floor physical therapists have specialized training in the treatment of pelvic floor spasms and other issues that may contribute to pelvic floor dysfunction, including chronic pelvic pain or incontinence. In this technique, a physical therapist helps relax and stretch vaginal muscles through gentle exercises and massage. The physical therapist can also teach you exercises to do at home to help strengthen your pelvic floor. Visit the American Physical Therapy Association’s section on Women’s Health to find a physical therapist in your area.
Laser treatments: You may have heard of vaginal laser treatments to help treat vaginal atrophy. The manufacturers of these energy-based devices say the procedure helps blood flow return to the vagina, promoting healthy tissue growth.
However, on July 30, 2018, the U.S. Food and Drug Administration (FDA) issued a warning about energy-based devices used to treat vaginal conditions and symptoms related to menopause, urinary incontinence, or sexual function. Currently, no vaginal laser device or procedure is cleared or approved by the FDA to treat any of these vaginal issues. The FDA is concerned that the safety and effectiveness of the devices hasn’t been proven in scientific studies and that using the devices could lead to serious side effects, including vaginal scarring and burns. Much more research and long-term follow-up is needed to further understand how safe and beneficial this technology really is.
Sexual desire, also called libido or sex drive, is your appetite for sex. Just as some treatments for metastatic breast cancer may cause you to lose your appetite for food, some treatments also can lower your desire for sex. It’s important to understand how and what you are feeling so you can share your feelings with your partner. Consider joining a support group, either in person or online. If you’d rather speak with a sexual health professional, you can find one by using the referral directory at the American Association of Sexuality Educators, Counselors and Therapists.
Learn more about loss of libido.
Several treatments for metastatic breast cancer can cause fatigue, which can affect your sex life and your intimate relationships:
Surgery can disrupt your body’s normal rhythm, causing fatigue that lasts longer than you may expect. General anesthesia and after-surgery discomfort, pain medication, and restricted activity can also cause fatigue.
Chemotherapy may reduce the number of red blood cells (the cells that deliver oxygen from your lungs to your cells), immune cells, and platelets (clotting cells) produced by bone marrow. Chemotherapy medicines also can damage some cells or limit their ability to function. Low blood cell counts can contribute to fatigue. If you have a low red blood cell count, for example, a condition called anemia, you probably have less energy. If your immune cell count is low, your body has to work harder to fight off infections. Infections and fever can lead to fatigue. Chemotherapy also may cause early menopause for some women. This changes the balance of hormones in your body and can lead to fatigue.
Radiation can often lead to fatigue. When you’re getting radiation, you may be feeling weak from earlier surgery or chemotherapy. Radiation therapy to a large area of bone can lower your red blood cell and immune cell counts, which can contribute to fatigue. Plus, the daily demands and schedule changes that come with radiation therapy be tiring.
Hormonal therapy reduces the amount of estrogen in your body, as if you were going through menopause. This can make you feel tired and weak. Many pre-menopausal women have menopausal side effects while taking hormonal therapy, such as hot flashes, which can disrupt sleep and lead to fatigue.
If you are feeling fatigued, here are some ways you can regain some energy:
Exercise. Although it may sound counterintuitive to exercise when you are tired, exercise, with your physician’s guidance, helps reduce fatigue both during and after treatment for a cancer diagnosis.
Seek out a therapist. A study showed that psychological interventions, including cognitive behavioral therapy (CBT), can help lessen cancer-related fatigue both during and after treatment. These approaches can help you identify, understand, and then change any negative thoughts you’re having, which in turn may free up some of your energy. To find a certified psychologist or therapist in your area, visit the American Psychological Association website.
Take power naps. A short nap can refresh and revive you. Just be sure not to nap too often or too close to bedtime so it does not affect your overnight sleep quality.
Revamp your diet. The food you consume can affect your energy level. Eating cleanly and consuming ingredients you know and can pronounce is important for everyone. Assess your diet and make changes with your physician’s guidance, and read up on nutrition tips and resources.
Choose foods that provide sustained energy. Complex carbohydrates such as whole grains, legumes, and vegetables release energy slowly. Simple carbohydrates, on the other hand, such as sugar, white flours, and fruit juices, can cause your energy to quickly spike and then drop.
Choose snacks that give you the biggest nutritional boost. A candy bar and a green smoothie, for example, can have roughly the same number of calories. But the green smoothie, besides being creamy and sweet, can keep you feeling full longer because it contains the fiber of vegetables and fruits. The smoothie also provides you with important vitamins and minerals. The candy bar, on the other hand, is mostly empty calories — you are getting little nutrition for the calories you are consuming.
Stay hydrated. Dehydration can make fatigue worse. Be sure to drink plenty of water or herbal teas throughout the day.
Try complementary practices. Complementary techniques, including yoga, meditation, acupuncture, acupressure, and massage, have numerous health benefits, including reducing fatigue and stress and promoting relaxation.
Some treatments for metastatic breast cancer can cause weight changes. Everyone’s weight can fluctuate a few pounds up or down throughout their lives. But weight changes of 5% to 10% of your body weight can affect your self-image and, as a result, your intimate relationships. If you have gained or lost enough weight to the point where it is affecting your self-esteem, your sexual desire, or your energy level, talk to your medical team about a nutrition and exercise plan so you can get to and maintain a healthy weight that makes you feel comfortable.
Learn more about weight changes, including breast cancer treatments that are associated with weight gain or loss.
A hot flash is a sudden, intense, hot feeling on your face and upper body that can be accompanied by a rapid heartbeat, sweating, nausea, dizziness, anxiety, headache, weakness, or a feeling of suffocation, followed by chills. When your body’s estrogen levels drop or estrogen receptors are blocked, your body’s thermostat can get confused, resulting in hot flashes.
Although we commonly associate hot flashes with menopause, several treatments for metastatic breast cancer can cause hot flashes as well:
ovarian shutdown or removal
If you’re experiencing hot flashes and they feel severe, talk to your medical team. For example, if you’re taking hormonal therapy, they may be able to adjust your prescription.
Read more about hot flashes.
When living with a metastatic breast cancer diagnosis, emotional challenges can have an effect on your desire for sex and intimacy. While sex toys and lubricants may help ease some of the physical challenges, dealing with emotional challenges requires more time and self-reflection. But the rewards can be well worth the work.
It’s normal for women who are living with a diagnosis of metastatic breast cancer to feel anxious and fearful about the future. Feeling a sense of powerlessness and a lack of control is also normal. But dwelling on these feelings or “getting stuck” can get in the way of living in the present and interfere with your desire for sex.
Here are some steps you can take:
Acknowledge how you’re feeling. Name the feeling. Sit with it for a while. Let it go when you are ready.
Understand that where you are now is not necessarily where you will be in the future. Feelings are temporary. Although you may feel anxious at this moment, in a day or a week, you may have a completely different perspective.
Avoid catastrophic thinking. You may not feel sexual at a certain moment, but that does not mean you won’t feel sexual again.
Try yoga. With its focus on breathing and staying “in the present,” yoga has been shown to help reduce depression, anxiety, and fatigue.
Depression is linked to high levels of sexual difficulties for many people, including those who are diagnosed with metastatic breast cancer. If you are feeling depressed, it’s important to let loved ones know and to consider seeking the help of a therapist or counselor.
If you need medication to help manage depression, it’s important to know that — like some treatments for metastatic breast cancer — many depression medications may affect your desire for sex. It’s important that you speak with your medical team so that you are getting the treatment you need for depression and see how you can address any issues with loss of libido in a safe way.
Learn more about strategies to manage depression.
Women who are diagnosed with metastatic breast cancer are all too familiar with loss — losing hair, breasts, libido, and sometimes, self-esteem. Grieving the loss of the body you once had can sometimes affect your ability to enjoy sex and intimacy.
Here are some ways to manage feelings of grief:
Acknowledge any losses you are feeling. Think about what you lost and how this makes you feel. Feel the emotions and let them exist without judging them.
Grieve your previous body. The five stages of grief are denial, anger, bargaining, depression, and acceptance (the stages often overlap). Do whatever you need to help yourself process each of these stages. You might consider writing in a journal about your feelings, making some art reflecting your previous body and your new body, or talking with a therapist.
Stay open to new experiences and new ways of thinking. With any kind of loss comes a deeper understanding — of yourself, of others, and of what is truly important to you. After a loss, some people reprioritize their lives in meaningful ways they never would have previously considered.
Keep your perspective. Sex is but one bodily function, and it is temporary. What is your body is doing well? Can you feel gratitude for these functions?
Understand that grief is temporary. Grief does not last forever. There will be a time when it starts to ease. If you are feeling stuck in grief, seek the support of a counselor or therapist to help you move through it.
Sexual Health, Intimacy, and Metastatic Disease: Reclaiming Your Sexual SelfFeb. 15, 2017
While many people believe the word “intimacy” means sexual intercourse, sex is only one aspect of intimacy. Affection, honesty, closeness, and a sense of safety are also part of intimacy.
Living with a metastatic breast cancer diagnosis can create new physical challenges and bring up feelings that can interfere with intimacy. Redefining your expectations about sexual desire and clearly communicating your needs can take some of the pressure off.
“Intimacy is having a deep connection with someone or something, having gratitude for it, and deciding we want to put energy into it,” explains psychotherapist Kelly Grosklags, LICSW, BCD, FAAGC. “It may have nothing to do with sex. Most intimate connections are like the infinity sign — with energy going back and forth between the two people.”
Sometimes, the bond that sex typically strengthens can also be reinforced in other ways —
by spending time together, having an honest conversation, or by nonsexual touching and caressing.
Be sure to talk about intimacy with your partner, even if it may seem a bit awkward at first. Here are some tips to help you figure out what intimacy means to you:
Think about the most meaningful connections in your life. What makes them meaningful?
What do you need? Ask yourself what you need right now, not what you needed when you were 20 years old or what you needed before a metastatic breast cancer diagnosis. Do you need, for example, a hug? A tender kiss? A caress? A belly-busting joke? Encouraging words? Quiet time listening to music together? A vacation getaway to a sunny spot?
Find out what your partner needs, too. Listen and try to hear what your partner is saying without judging. Then assess what you are able to give to your partner right now — for example, a sensual massage, a playful tickle, a cuddle, or a heartfelt compliment.
Body image and sexuality
Healthcare providers usually tell women with a metastatic breast cancer diagnosis about the common side effects and experiences of medications and procedures. Altered body confidence and diminished self-esteem are not usually on this list. But it can be a soft side effect of metastatic breast cancer treatment.
Most women expect temporary effects from metastatic breast cancer treatment, such as hair loss, weight loss, and possible loss of libido. But permanent changes — such as scarring, breast reconstruction, or having no breasts — can affect the way some women see themselves, which can also affect the desire for sex.
How can you change the way you feel about your body? In some ways, improving your body image is like strengthening your muscles at the gym. Strength won’t come overnight, but as you gradually try new routines, flexing your self-esteem muscle can get easier and become a new way to take care of yourself. Positive body image is also not just linked to better quality of life but also to a better ability to function emotionally.
Here are some tips to start changing the way you think about your body:
Redefine beauty. The media and society’s pressures can skew the way we think about beauty. Challenge yourself to redefine your beliefs about beauty. Ideals can be different for everyone. What qualities do you find beautiful? Strength, assertiveness, generosity? Are you comfortable with the idea that beauty begins inside, not out?
Do a media fast. Every day, we are bombarded with media images of glamourous celebrities who require a full-time staff to keep up their appearance and air-brushed models who represent an ideal that is simply not attainable. Just as eating junk food doesn’t improve your health, a steady diet of these images doesn’t help improve your body image. If you watch a lot of TV or read fashion magazines, taking a break for a week or two puts the focus back on you and your own definition of beauty.
Acknowledge how you are feeling. Are you feeling frustrated with your body or experiencing a sense of loss? Just sit with any unpleasant feelings and acknowledge them for a while, without judging them and without pressuring yourself to feel differently. A feeling is just a feeling, and feelings can change.
Talk about it. Share your feelings with your close friends or partner, in an online forum, or with a healthcare provider. They may offer fresh perspectives, solutions, and resources.
Say something kind to yourself every day. Many of us criticize ourselves when we see ourselves in a mirror. If you catch yourself in the act, try giving yourself a compliment instead.
Accept compliments. Do you brush off positive things people say about you? When someone praises you, do you believe them? Sometimes it’s uncomfortable to accept a compliment and you feel like people are talking about someone else, not you. Experiment with feeling open to the good things people say about you.
Accentuate the positive. Woman often have a certain body part they don’t particularly like, such as thighs, stomachs, breasts — or lack of breasts — and ignore the rest. What is your favorite body part? Do you have a ballerina’s long neck, strong shoulders, or stunning eyes? Compliment yourself and play up your favorite body part.
Control what you can. Tending to your appearance is not vain; it’s an important part of self-care. Instead of concentrating on things that are out of your control, control what you can. Choose clothes that are visually appealing to you and comfortable. If it makes you feel more confident, put on some makeup or pamper yourself with a professional manicure or pedicure.
— Last updated on February 10, 2022, 3:55 AM