Patients undergoing cancer therapy are faced with many difficult side effects and changes in their bodies. For women, a frequent but unexpected side effect of cancer therapy is painful intercourse. Painful intercourse or dyspareunia may result from physical changes in the vagina following radiation and/or surgery or a depletion of the female hormone, estrogen, which can cause vaginal dryness. Female patients receiving certain chemotherapy agents may be at risk for premature menopause due to the effect of medication(s).  Women with cancers of the cervix, uterus, ovaries, or vagina/vulva may undergo radical surgery or radiation, which leads to scarring and narrowing of the vagina. During treatment, most women and physicians are concerned with their battle against cancer, and there is rarely a discussion to explain the long term effects on the patient and their partner’s sexual lives. In this MUSC Women’s Health Blog, we will discuss the effects of breast and gynecologic cancer therapies on women’s sexual function. 

Breast cancer
Breast cancer therapy may involve medications, such as tamoxifen and raloxifene, which intentionally decrease the amount of estrogen in a woman’s body.  The reason for this is that certain breast cancers are sensitive to and grow in the presence of estrogen. As a result of this estrogen depletion, the vagina’s natural lubrication is lessened and muscles of the pelvic floor are weakened.  As a result, the vagina becomes constricted, making intercourse difficult and painful.  Another complication of pelvic floor and tissue weakening is urinary incontinence, which has a significant negative impact on a woman’s social and sexual function.  As one 42 year old breast cancer survivor described it, “If I had known that I was not going to be able to have sex after fighting for my life, I certainly would’ve enjoyed and had more sex while I could”. 

Gynecologic cancer
Gynecologic cancer therapy often involves surgery. Gynecologic cancers include those of the uterus, cervix, ovaries, and vagina/vulva. Some of these surgeries can be quite radical, removing all or most of the female organs and occasionally lymph nodes which drain the pelvis. These surgeries can lead to pelvic pain and swelling.  If a woman has surgery on the vagina or the vulva, she may experience scarring and a change in the appearance of her genital area. Radiation can lead to similar scarring and thinning of the vagina and vulva, which can be painful and disfiguring. 

Strengthening the pelvic floor
Please refer to Dr. Lazenby’s previous blog on pelvic floor strengthening. Click on this link to see more about the topic and learn some helpful exercises.  

The good news
The good news is there are treatments available to correct and prevent dyspareunia and pelvic organ prolapse after cancer therapy. Diligent strengthening of the pelvic floor muscles with physical therapy during the early stages of treatment may help the tissues remain healthy and supple.  Sometimes, strengthening of the muscles may need to be augmented with neuromuscular stimulation. Massaging the vaginal tissues and vulva can also improve blood flow and tissue suppleness to decrease dryness.  In the cases of vaginal shortening and constriction, progressive dilation can restore vaginal length and allow pain-free intercourse.  The overall goal of these therapies is to return bulk and strength to the pelvic floor muscles. In general, 12 weeks of pelvic floor exercises are recommended to build muscle mass, although beneficial effects may be recognized within 6 weeks.

Specially trained physical therapists can provide pelvic floor rehabilitation and strengthening exercises to patients during and after cancer treatment. The therapists evaluate the muscle and tissue integrity and develop an individualized plan of care for each individual. Individualized therapy may include deep tissue mobilization, stretching, scar and lymphedema management in order to improve tissue function.  In regards to dyspareunia, these physical therapists can instruct patients in exercise regimens for improving pelvic muscle strength, use of progressive dilators for vaginal constriction, and specific sexual positioning to avoid pain. 

Surviving a battle with breast or gynecologic cancer does not have to mean the end to sexual pleasure and function. Cancer patients with concerns about premature menopause, dyspareunia, genital scarring, and urinary incontinence should discuss this with their care providers and consider meeting with a pelvic floor physical therapist.

by:  Rebecca Stimac, PT and Gweneth Lazenby, MD

Sexuality is a core part of being human. And yet, it is one of the most challenging topics for us to discuss with our health care providers, partners, and friends. For women, the perimenopause and postmenopause years represent a time of unique challenges for maintaining our sexual health. This interactive session will feature a panel of health providers who will focus on the social, cultural, medical and psychological influences on women's sexual health during this phase of life. We hope you will join us for what promises to be a stimulating conversation.

Panelists:
Angela Dempsey, MD, MPH
Gweneth Lazenby, MD
Linda Austin, MD
Sue Ellen Hawkins

Moderator:
Darlene Shaw, MD

Join us Wednesday, Jan, 13 at 6 pm on the MUSC Campus at the Basic Science Auditorium
Event and parking are free (parking available at Ashley-Rutledge garage) 

To register, please call 792-5817 or visit www.musc.edu/women

Co-sponsor:  Center for Women
Additional Sponsors: Skirt! Magazine and Wachovia Bank
Food provided by Whole Foods

The Lowdown on STD’s: Chlamydia
Chlamydia is the third most common sexually transmitted infection (STI) in the United States.  It is the most common bacteria causing an STI.  According to a 2007 Center for Disease Control report, South Carolina ranks 3rd out of the 50 states in chlamydial infections.  Those at most risk of infection are single, minority women between ages 15-21 with new or multiple sexual partners.  However, Chlamydia affects women and men of all backgrounds. 

Like all sexually transmitted infections, Chlamydia enters a woman’s body during intercourse.  Chlamydia trachomatis is different from most bacteria in that it must live inside cells, making it difficult to grow in a culture. In this way, it is more similar to a virus.  Chlamydia prefers to live inside the cells of the cervix (the opening of the uterus) and the cells that line the bladder. 

Symptoms
Most women infected with Chlamydia are asymptomatic. Cervical infection may present with pain or bleeding during intercourse or a change in vaginal discharge.  Symptoms of chlamydial infection of the bladder and urethra can mimic a urinary tract infection.  Similar to women, men do not usually have symptoms.  If symptomatic, they may present with a discharge from the penis or pain during urination or ejaculation.

Diagnosis
Prenatal diagnosis and treatment of Chlamydia is extremely important. Women with untreated Chlamydia can develop postpartum fever and uterine infection.  Forty percent of babies born to mothers with untreated Chlamydia will develop eye infections.  Worldwide, Chlamydia conjunctivitis is a leading cause of preventable blindness.

The majority of cases are diagnosed during routine gynecologic exams and pregnancy screening.  At the time, physicians may note a discharge from the cervix.  Because Chlamydia does not grow in routine culture, standard diagnostic tests use nucleic acid amplification to detect the proteins that make up the bacteria.

Treatment
The CDC recommends immediate treatment of Chlamydia and encourages expedited treatment of known partners.  The most commonly prescribed antibiotics are macrolides, tetracyclines, and fluoroquinolones.  Because Chlamydia often accompanies a gonorrheal infection, patients diagnosed with gonorrhea are often treated for both.  For those in a relationship, both partners should complete treatment and wait approximately 1-2 weeks after their last dose to have sex to avoid re-infection.  Couples can also use condoms to prevent re-infection.  Condoms are the only reliable method for prevention of Chlamydia transmission.

Effects of Untreated Chlamydia
Due to the absence of symptoms, many women are unaware of current or past chlamydial infection.  Untreated Chlamydia can have devastating effects on the reproductive organs.  Although it initially infects the cervix, Chlamydia can migrate upward into the uterus and fallopian tubes. Upper genital tract infection can lead to infertility, pelvic inflammatory disease, and chronic pelvic pain. 

Women concerned they have been infected with Chlamydia or another sexually transmitted disease can be tested at their physician’s office, the state health department or a non-profit clinic such as Planned Parenthood of America.  MUSC Women’s Health offers a specialty clinic for STI testing and treatment of women and their partners.

by:  Gweneth Lazenby, M.D.

Now that I’m pregnant, can I still have sex?
This is a common question from our obstetric patients.  For most women, the answer is “yes!”  However, there are exceptions.  Many patients feel uncomfortable discussing sex or sexuality with their physicians.  The purpose of this installment is to dispel any myths and reiterate any truths concerning sex during pregnancy. 

During intercourse and orgasm, pregnant women may experience mild cramping.  This is normal and is not associated with miscarriage.  Some women experience vaginal spotting after intercourse.  Spotting is usually due to the softening and increased blood flow to the cervix and does not lead to miscarriage.  Any heavy bleeding or leakage of fluid more than semen should be reported to your physician.  It is natural to begin having breast discharge later in pregnancy.  Some women may have milky breast secretions during orgasm later in pregnancy.

Talk about it
Women’s emotional and physical bodies undergo incredible change during pregnancy.  In regards to sex, women may notice increased vaginal lubrication, engorgement or swelling of the genitals, and a change in the character of orgasm.  Some women experience more intense and more frequent orgasms during pregnancy. Despite these positive effects, women may be less interested in sex at times.

During the first trimester, women have increased fatigue and may be battling morning sickness, both of which can decrease desire.  By the second trimester, women are feeling better, but their bodies have begun to change with a noticeably growing belly.  Towards the end of pregnancy, women experience increased pelvic pressure and general discomfort.  Given all the physical and emotional factors that affect a woman’s desire to have sex, it is important for partners to communicate their changing expectations for sex during pregnancy.

Mama Sutra
For the times when it feels right, couples will certainly encounter the need to change positions to accommodate for the baby on board.  The missionary position or woman lying on her back is difficult by the second trimester due to blood flow requirements of the growing uterus.  The following positions are recognized as more conducive to comfortable intercourse while pregnant: woman on hands and knees, couple spooning, partner lying or sitting with woman on top, and partner behind with woman side lying with knees drawn to chest.  If the woman experiences vaginal dryness during pregnancy, water-based lubricants are best.  In regards to alternative forms of intimacy, manual or oral stimulation of the clitoris and vagina are safe in most pregnancies.  Sexual accessories such as vibrators and dildos can be safely used during pregnancy.  Patient’s advised to avoid vaginal or anal sex should also avoid insertion of these devices.   

Slow down Mama
Although sex is safe in the majority of pregnancies, there are conditions in which your physician may advise abstinence.  In the first trimester, these may include women experiencing bleeding or threatened miscarriage, a history of cervical incompetence, or immediately following a surgical procedure such as a colposcopy or cerclage.  Some physicians may instruct patients with a history of preterm labor, threatened preterm labor, or a dilated cervix to avoid vaginal intercourse.  All women with ruptured amniotic membranes or a placenta previa (placenta covering or near the cervix) should abstain from any penetrative intercourse. 

Sex induced contractions
At the end of pregnancy, many women are anxious to deliver and inquire into “natural” methods for inducing contractions.  Many cultures believe that sex and orgasm can induce labor.  I have reviewed the research available for term pregnancy and induction.  At this time, there is little to no evidence to suggest that vaginal sex with a male partner can lead to labor or decrease length of pregnancy.  Orgasm and nipple stimulation have been shown to cause contractions, but do not necessarily lead to labor.  For those healthy women who wish to try anyway, we say “go for it.”  
  
by:  Gweneth Lazenby, M.D.

Request an appointment with a MUSC provider.