Female sexuality and cancer

What is sexuality? 
Sexuality is one of our basic needs because humans need to feel affection and intimacy. Sexuality does not only relate to sex itself and purely physical processes. Sexuality encompasses personal ideas, feelings, desires and imagination. It is part of a person's identity. Sexuality is more or less significant depending on a person's stage in life or lifestyle (e.g. being in a partnership or unmarried, having a family). Sexuality may be a source of sensuality and pleasure, but it can also trigger feelings of disappointment. It is complex.

The most important points in a nutshell 
Sexuality means more than just sexual intercourse. Sexuality is an individual matter; it means something different to each person and changes over the course of their life. The female reproductive organs include the vulva (external genitalia), vagina, uterus, fallopian tubes and ovaries (internal reproductive organs) as well as the female breast. Sexual arousal can be influenced actively. The pelvic floor is also known as the pleasure muscle.  Speak to your gynaecologist if you have any questions about your menstrual cycle. When going through the menopause, do not take any medication that you have not discussed with your gynaecologist.

The female reproductive organs 
What constitutes the external genitalia? 
They include the vulva and clitoris, clitoral erectile tissue, labia minora and majora, urethral and vaginal openings.

The most common problems 
Lack of desire 
"I have colon cancer and am receiving chemotherapy. Being diagnosed with cancer is very stressful for me. I don't feel like having sex at the moment, but I do like it when my boyfriend gives me a massage. How do I tell him without hurting his feelings?"
Cancer and/or the symptoms associated with it can affect sexual desire. Perhaps you are no longer responding to the usual erotic stimuli. You may perceive these stimuli as strange or inappropriate. Or you don't feel like having sexual intercourse with your partner. This kind of response is understandable. Many sufferers tend to lose the connection to their body while undergoing treatment. They are grateful that they are being treated for their cancer. Despite this, women affected feel that they are at the mercy of many medical procedures.  
You have to undress in front of strangers over and over in order to undergo various types of therapy or medical examinations; you are often either completely naked or only lightly clothed. This infringes your privacy. It may make you no longer want to be touched by your partner. This dislike of physical contact is often temporary.  
Give it time.

Frequently asked questions about cancer, treatment and pregnancy 
The questions below are examples of some of the things you might be concerned about while undergoing cancer treatment. Speak to your doctor if you have any further questions.

Is cancer infectious? 
No, cancer is not infectious. Cancer cells are not transmitted by touching, kissing or having sex. Not even if you perform oral or anal sex with your partner. Cancer will not be passed on to your child if you are pregnant. Consult your doctor if cancer runs in your family. It may be a genetic mutation that is passed on from generation to generation. Geneticists can detect these genetic mutations by means of a blood test. Geneticists are biologists who study the heredity of diseases.

Protect yourself 
However, unprotected sexual intercourse with different partners increases the risk of contracting the following viral infections:  

• Hepatitis (type B or C) 
• Herpes 
•  Human Papillomavirus (HPV) 
• HIV 

Some of these viruses increase the risk of getting cancer. Being infected with hepatitis (type B or C) viruses increases the risk of developing liver cancer. Some human papillomaviruses for instance can cause cervical cancer (cervical carcinoma).

Will I be radioactive while undergoing radiotherapy? 
Neither external radiotherapy (percutaneous radiotherapy) nor internal radiotherapy (brachytherapy) will make your radioactive. However, you should use a reliable form of contraception and avoid getting pregnant for six months after completing treatment.  
Ask your doctor if you have any further questions about radiotherapy.

What should I do while I am undergoing chemotherapy? 
While you are undergoing chemotherapy, traces of the medication will also be present in your vulva and vaginal secretions as well as in semen. This may irritate your partner's mucous membranes. Use a condom for at least the first two days after receiving chemotherapy. 

When should I abstain from sexual intercourse? 

• Following abdominal surgery until the incision has healed completely. 
• Do not have sexual intercourse if it causes pain.  
• Following radiotherapy in the genital area. Wait until the affected mucous membrane has healed completely.  
• In the case of cervical or bladder cancer, vaginal bleeding or bleeding during urination may occur. Sexual intercourse may exacerbate this. Avoid sexual intercourse if you are bleeding. 
• The platelet count (thrombocytes) can decrease during chemotherapy. This increases your risk of bleeding. Ask your doctor if you should abstain from sexual intercourse. You will have regular blood tests while you are undergoing chemotherapy.  

However, you do not need to forego physical contact, massages and gentle caresses during this time.

Can I still have an orgasm even when having treatment? 
Patients who have previously had an orgasm usually also experience it after their treatment. A new beginning is often not easy. Many women have to rediscover their different bodies. Some women need new methods to become sexually aroused and to orgasm. Allow yourself the time to do so.
  
Can I have anal intercourse? 
Bleeding, injuries or inflammation occur more frequently with anal intercourse. This risk can increase while you are suffering from cancer. Chemotherapy can reduce your blood platelet count (thrombocytes) or white blood cell count (leucocytes). Bleeding can occur more easily if your blood platelet level is low. If your white blood cell count is low, your immune system is weakened. This means you have an increased risk of bleeding, injury or infection. Avoid anal sex where possible. Or use condoms and lubricant. Consult your doctor if you are unsure about certain sexual practices.

Is my partnership at risk because I have to abstain from sexual intercourse?  
Your recovery is the main priority. The majority of couples have so much more in common than sexual fulfilment during intercourse. Don't feel under pressure. Discuss your fears with your partner. However, if your fears persist, it may also be helpful to talk to a psycho-oncologist or sex therapist. Your regional Swiss Cancer League or the cancer helpline can provide you with contacts and addresses.

Dating with cancer? 
Women affected by cancer say that they became more aware of their needs during their illness. They discover new interests, start doing sports. It is not uncommon for those affected to become more self-confident and know better what they desire and do not desire from a relationship.  
Nevertheless, uncertainty about how the new partner might react to the disease remains. Discuss your fears or insecurities. You should discuss physical changes (e.g. breast removal, prosthesis, stoma) before you become closer physically. Sometimes a "new" partner has to process this information first and needs time to do so. What feels like a "rejection" usually has to do with one's own fears and insecurities. Give him/her enough time. The more you are comfortable with yourself, what you are going through and the changes in your body, the easier it will be for your new partner.

Questions if you wish to have children  
The main priority for anyone diagnosed with cancer at a young age is getting better. However, cancer treatments can damage your ovaries. That is why it is important that you discuss your desire to have children with the treatment team before you undergo cancer treatment.

What questions do you need to ask your doctor? 

• Can I have children although I am being treated for cancer? 
• What steps can I take if I would like to have children in the future? 
• What are my chances of having children using frozen eggs? 
• Will fertility treatment affect my cancer treatment? 
• Who covers the cost of fertility treatment? 

What can you do? 
Freezing your eggs 
The procedure for this treatment is as follows:  

• Before your cancer treatment, you will receive fertility treatment at a specialised centre (fertility clinic).  
• You inject yourself with medication for a few days to encourage the follicles in your ovaries to produce more eggs (stimulation) 
• These are retrieved by the doctor for reproduction.  
• These eggs are usually frozen in an unfertilised state.   
• This procedure is known as oocyte cryopreservation. 

After cancer treatment 
In order to conceive using these frozen eggs, you will need to undergo artificial insemination (IVF or ICSI). Your eggs are fertilised in a test tube using your partner's sperm. The reproductive specialist will re-implant these fertilised eggs during a transfer.  
In the "Wissen gegen Krebs” (knowledge in the fight against cancer) podcast series, a young woman talks about freezing her eggs.

Freezing ovarian tissue 
The gynaecologist will remove all or part of an ovary. The ovary that has been removed is then frozen. The ovary will be replaced after your cancer treatment. If the ovary starts to produce eggs again up to the point of ovulation, you may conceive naturally, which means without the need for a medical procedure.

Medication 
The oncologist will prescribe medication to shut down your ovaries. This means that no eggs will mature in the ovary and you will not ovulate. This medication acts to protect the ovaries from damage caused by cancer treatment. Trial results for this treatment are inconclusive. Speak to your doctor about whether you could have this treatment in addition to freezing your eggs.

Ovarian transposition 
Radiation treatment in the pelvic area can damage the ovaries, which is why they are sometimes moved upwards and to the side to protect them from damage. However, doctors only perform this procedure in very rare cases. Your doctor can explain the exact reasons as to whether this procedure is advisable in your case.
 
What does your health insurance cover? 
In Switzerland, basic health insurance covers the freezing of eggs (cryopreservation) for up to five years. You must be under 40 years old. You will have to cover all other fertility treatments yourself (IVF).

When is a pregnancy no longer possible? 
You can no longer get pregnant if you have had a hysterectomy. If your gynaecologist has had to remove your ovaries, you can only get pregnant through egg donation.  To date, this has only been permitted abroad. Consult your doctor.

Questions regarding pregnancy and cancer 
Does cancer treatment cause birth defects in the unborn child? 
The risk of an unborn child developing a birth defect is not any higher following cancer treatment. However, the level of knowledge among experts in the field alone is not enough to rule out a residual risk.

Contraception during treatment 
You should avoid becoming pregnant while undergoing treatment for cancer. Chemotherapy and radiotherapy also affect the quality of your eggs. This can cause birth defects in the unborn child. For this reason, use a reliable method of contraception during and for a time after treatment.  
You should postpone getting pregnant until after your treatment has ended. Questions about family planning? Discuss them with your doctor.

Cancer and pregnancy 
There has been great progress made in the treatment of pregnant women with cancer. Some women only start cancer treatment after they have given birth. However, some patients may need immediate treatment. Many women affected are able to carry their child to term despite needing treatment. 
The treatment that doctors advise an affected pregnant woman to undergo depends on each individual case:  

• Which week of pregnancy is the patient diagnosed with cancer? 
• How far advanced is the cancer? 
• How aggressive is it? 

The treatment team carefully weighs up the risks for both mother and child. 
Surgery, radiotherapy and chemotherapy may be harmful to the unborn child (foetus), but this is not necessarily the case. Birth defects in the unborn child are very rare and mainly occur in women who are in their first trimester.  
Not all hospitals are equipped to treat pregnant women diagnosed with cancer. Ask about your treatment team's experience and get a second opinion where necessary.   
Click here to read Fabienne Bartholdi's story, who was diagnosed with cancer during her pregnancy.

Relationships and sexuality 
"Since I've been diagnosed with cancer, we've only had sex very occasionally. It’s stressing me out. I am putting myself under pressure because I think I should initiate sex with my partner again. I also think I owe this to him after such a long period of illness and therapy. At the same time, I would first like to process everything I have been through during my cancer treatment. I need time for myself to do that. Can our relationship survive this?"

Relationship 
There is much more to the bond between a couple than sexual intercourse itself. There are lots of ways to show your partner that you love them, to feel connected and close to them. For example, trust, common interests, respect, tenderness, a similar attitude to life, humour and many other things help to create a bond.

How does a couple's relationship change when one of them has cancer? 
Cancer changes a couple's relationship. Perhaps responsibilities need to be reassigned. If they have children, they must be looked after and given lots of support. In most cases, there is a "new" day-to-day routine. This can be difficult because the whole family has to adjust.  
Many patients are physically weakened by cancer treatment and need more support with household chores, childcare or even personal hygiene. It changes the roles in a relationship. Your partner may feel helpless and wonder how they are supposed to cope with all of this on top of everything else. Problems in the couple's relationship that have not been discussed may put additional strain on the relationship.  
Women rarely feel the desire to have sexual intercourse while undergoing treatment. But they still wish to feel close and connected to their partner. Some patients also wish to talk, spend relaxing evenings as a couple or go for a walk together. Many women tend to process the cancer on their own. They need time alone in order to do so.

What can you or your partner do? 
Take your time 
There is no right or wrong way to decide how often you have sexual intercourse with your partner. You may want to explore this on your own first, especially if your body or feelings have changed. Talk to your partner about what feels right for you at this point. Don't let your partner or other people put you under pressure.

Include friends and family 
Have the courage to ask for help. You will not be able to carry on with your everyday life as usual. Especially if you have children, you will need to ask friends and family for help. If your friends and family are not close enough to help you, ask your cantonal or regional branch of the Swiss Cancer League about support services. Having someone help you with day-to-day matters will also take the pressure off your partnership. Your partner will then feel less like they have to organise and do everything on their own.

Your partner needs time, too 
A cancer diagnosis is a huge mental strain for patients’ partners as well. They are afraid of losing their loved one. Your partner is often insecure and needs time to process their feelings. Added this are new daily responsibilities that have to be dealt with. Perhaps your partner doesn't want to hurt you and is therefore nervous about touching you. This may feel like a rejection. Talk to your partner about their withdrawal. If you are feeling insecure, you can also show him what kind of touch you find pleasant. Together, think about how you could show each other affection apart from sex (e.g. small gifts, flowers, compliments). The following questions about yourself and your partner may help you to understand your own needs. They may be helpful as a way of addressing the topic.

Questions you can ask yourself  
What were things like before you fell ill? 

• What was your sex life like before you fell ill? Describe it. 
• Was I satisfied with our sex life? 
• What did I like about it? 
• What did I not like about it? 
• How often did we have sexual intercourse? 
• Could we also enjoy an erotic experience without having sex? 
• How important was our sex life before I became ill? 
• Did we talk about our sex life in the past? 

What is it like today? 

• Am I satisfied with our sex life? 
• Do I trust my partner? Am I afraid of him rejecting me? 
• What is it that scares me? 
• What makes me feel good? What causes me pain? 
• What do I find attractive about myself? 
• How do I feel about the changes happening to my body? 
• What do I like doing? What do I need for a fulfilling sex life? 
• Which kind of touch or fantasies arouse me sexually? Have they changed as a result of my illness? 
• What puts a damper on my sexual arousal? 

Further questions regarding "Partnership" 
Are you open to new things? 

• Would I like to see changes to our sex life? 
• What does that mean for my partner? 
• Am I prepared to try something "new"? 

How do we feel about each other? 
What connects us? Shared interests, tenderness, a friendly relationship, financial issues? 

• How is my partner doing? 
• What would he/she like me to do for him/her? 
• Is there a noticeable distance between us?  
• Has our behaviour towards each other changed since the illness? 
• Do we have a shared language when it comes to sex? 
• What are our needs in terms of sex? Similar? Different? How do we address it?