Looking after your sexual wellbeing after cancer

If you have been through cancer treatment, you may have experienced a common issue faced by many women with cancer – changes to your sexual life.

Problems with sexual wellbeing can be a common and distressing side effect for women with any type of cancer, with between 30 to 80 per cent experiencing issues. Oxford Women’s Health Gynaecologist Dr Olivia Smart says sexual wellbeing is a critical part of cancer survivorship and living well, so it is important to talk to your doctor if you have concerns.

“Cancer is an awful disease and between its symptoms and the effects of treatment, things like sexual desire, arousal and orgasms can be affected. For some women, they may start experiencing pain during sex, decreased sensation, or find they have low or no interest in sex. These symptoms can be really distressing, but it’s important to know that there is help available.”

Sexuality is heavily influenced by biological, psychological and sociocultural factors. So when you combine invasive treatments like surgery, with the emotional distress of a cancer diagnosis, and perhaps a deep-rooted belief that a sick person shouldn’t be worried about their sex life, it can be easy to find your sexual wellbeing has taken a knock. “There are lots of things your doctor can recommend to address problems you might be having,” Dr Smart says.

“For women experiencing vaginal dryness, oestrogen treatments are generally very safe and effective even for women who have had breast cancer. Likewise, dilators are important for maintaining or improving vaginal capacity especially if you’ve had radiotherapy treatment in your pelvic area.”

“If the dilators that your treating team gave you are a bit off-putting, there are softer silicone options available that might be more suitable for you.”
 

Dr Olivia Smart

There are also non-medical things that could be explored to improve symptoms. Types of lubricants used, fabrics worn, moisturisers, and even tight gym clothes can impact vulval and vaginal health. Counselling might be a good option to discuss the things you’re thinking or feeling that are affecting you. Your doctor can talk to you about all of these options.

The hardest part for women is often broaching the topic with their doctor.

“Lots of people feel embarrassed or ashamed talking about these things with their GP, but please know that your doctor is there to help and will have had other patients come to them for the very same or similar issues. Your sexual wellbeing is just as important as any other aspect of your health.”

If you’d like more information or support, talk to your doctor or check out these online resources:

·       The Cancer Society’s booklet, Sex and cancer: A guide to managing the impact of cancer on your sex life, https://www.cancer.org.nz/cancer/living-with-cancer/sex-and-cancer/

·       Talk Peach – Gynaecological Cancer Foundation of New Zealand, https://www.talkpeach.org.nz

·       Sex Therapy New Zealand, https://stnzltd.co.nz

Taking control of IBS symptoms through nutrition

Nutrition is a key part of managing the discomfort and distress of irritable bowel syndrome (IBS). The condition can greatly impact a person’s quality of life, causing abdominal pain, bloating, diarrhoea, constipation and/or a change in bowel habits, but with specialised management, these symptoms can be significantly improved.

Oxford Women’s Health Dietitian Sara Widdowson regularly supports women who come to the clinic for guidance on what they can do to reduce their IBS symptoms. “IBS mainly affects women. It’s more prevalent for those under the age of 35, but can also develop in women reaching menopause or who have a family history of the condition,” she says.

IBS is a gastrointestinal disorder that affects the large intestine. There are lots of factors that can contribute to its development including a change in gut bacteria, hypersensitivity to certain foods, stress and anxiety, and intestinal diseases caused by micro-organisms such as viruses, bacteria and parasites. “One of the first things your doctor will usually do to determine if you have IBS is ask you to start a special diet to identify foods that are triggering your symptoms. This will typically involve a low FODMAP diet.”

FODMAP is an acronym for six different types of carbohydrates that are commonly associated with digestive problems: Fermentable, Oligosaccharides, Disaccharides, Monosaccharides and Polyols.

The diet is very successful for around 80 per cent of people, with many noticing a significant improvement or even complete relief from their IBS symptoms. During the first phase of the diet, a person avoids high FODMAP foods for around three-to-four weeks (which should see a reduction in symptoms), before methodically reintroducing one type of FODMAP a week to identify which ones are irritating your large intestine. 

“Your doctor will help you understand which foods are in each group. There are also really great low FODMAP websites, cookbooks and
 

Sara Widdowson

apps available with delicious, easy recipes to try,” Sara says.

Once the problem foods are identified, the aim of the game is to personalise your day-to-day diet for long-term success. Often, many of the diet changes you might need can be achieved with simple food swaps, such as opting for lactose free milk in your coffee and gluten free bread at breakfast, swapping a sandwich for a pulse chicken pasta salad at lunch, and having roast vegetables with your chicken or steak instead of asparagus and leek for dinner.

Other nutritional changes that can improve IBS symptoms include:

·       Eating enough of the right fibre. Soluble fibre from things like oats and psyllium husk are great at keeping you regular while bulking up stools to reduce diarrhoea.

·       Keeping caffeine intake to less than 200mg a day.

·       Avoiding sweeteners like sorbitol, mannitol and xylitol that are common in pre-workout products, protein powders and chewing gum. These sweeteners cannot be digested by the small or large intestine.

·       Having probiotics. Particular types of probiotic have been shown to support better gut health for people with IBS.

“If you suspect you might have IBS or you notice persistent gut problems that aren’t going away like diarrhoea, constipation or pain, make sure you talk to your doctor,” Sara says.
 

Supporting chronic pain with lifestyle medicine

Living with chronic pain often goes hand-in-hand with feelings of stress and anxiety with some people also experiencing headaches, panic attacks, and breathing issues. To help people manage these challenges, Oxford Women’s Health’s physiotherapist and mindfulness facilitator, Jo Hopkinson-Haigh, teaches people useful science-based tools to enhance their wellbeing.

She draws on her background as a physiotherapist, qualified yoga instructor, a BradCliff Breathing Method certified practitioner, and her work in acceptance and commitment therapy. “Stress and anxiety are huge for people living with chronic pain,” Jo says. “They may also feel fearful, ignored, completely stuck in their own thoughts and have back and neck pain because they feel as though they are carrying the weight of the world on their shoulders.”

Long-term stress has a huge effect on every organ system in our body as increased cortisol is released into the body. “While stress can be normal, it’s not normal to be constantly stressed, and it should only ever be short lived,” Jo says. When supporting people with chronic pain – pain lasting longer than three months – Jo says the body-mind connection can be an important path to treatment. Here are some of Jo’s key takeaways that will help downregulate the nervous system, and provide hope and understanding to enable patients to manage chronic pain:

The nervous system
When our sympathetic nervous system is in the red zone, we are operating in a state of fight or flight. Being in this heightened emotional state affects our heart rate, digestion, sleep, cortisol, and tension. We should really be in the green zone (a downregulated parasympathetic nervous system) so the body can rest, repair, and digest in a state of calm.

"When I discuss this with patients, they often realise they’ve been living in the red zone since high school,” Jo says. “Most chronic pain patients have not felt what calm feels like in their bodies for a very long time. While we need both zones for survival, the body can’t heal in a state of fight and flight.”

Breathing
The number one way of calming the nervous system is by learning to breathe diaphragmatically, Jo says. “When I first see patients, their breath rates are up to 18-22 breaths per minute, they’re breathing through their mouth, and they’re using their upper chest or upper neck muscles to breathe,” she says. “This means they’re only using the upper part of the lungs to get their gas exchange, hence why they’re having to breathe at a faster rate.” 

Jo focuses on calming the nervous system by working to reduce the respiratory rate. With some diaphragmatic breathing practise, people should be breathing at between six and 10 breaths per minute.
“Once they learn what baseline calm feels like, they often have tears in 
 

 Jo Hopkinson-Haigh

their eyes because they haven’t allowed their nervous system to feel calm for so long,” she says. “Every patient who comes to see me leaves the clinic with a respiratory rate that is lower than when they came into the clinic.”

Sleeping
Once diaphragmatic breathing is mastered, Jo focuses on the importance of rest. “Sleep is essential for survival,” she says. “It is where we repair, restore, and regenerate ourselves, so it must be prioritised.” She encourages people to get eight hours of sleep to heal the body; get outside into the morning sunlight to allow for the conversion of serotonin to melatonin; and improve sleep hygiene habits. This includes turning off phones and laptops before bed as the blue light inhibits the release of melatonin, the hormone that helps to manage the sleep cycle.

Exercise snacking
As Jo says, our bodies are made to move. In fact, exercise is essential to build muscle and healthy mitochondria. This is why Jo encourages people living with chronic pain to ‘snack’ on exercise by moving throughout the day. This could be venturing to the letter box, parking in the farthest car park, walking around the block when waiting to pick up the kids, taking the stairs, and incorporating simple yoga movements into your day. Jo also works with patients on acceptance and commitment therapy to help people who feel stuck in their thoughts and feelings.

Emotional wellbeing
All emotions have a physical response in our body and influence pain, Jo says, pointing out that we can’t be stressed and breathing well at the same time. For this reason, she focuses on breathing techniques that support the nervous system. “I like to teach people their pain is transient, temporary, and reversible,” she says. “Often people feel they have tried everything, so it’s nice to be able to say to them, ‘you are currently just stuck, and I will teach you to be unstuck’. Lifestyle and state of wellbeing have a huge influence on pain, and we have a body-mind connection we need to tap into.” 
Jo says we also need to remember to be our own biggest cheerleaders and talk to ourselves with care and kindness.

“If we’re talking to ourselves in a calm way, we start to bring ourselves into that parasympathetic nervous system and that calming side of our nervous system. We need to be able to say to ourselves: “What I’m feeling at the moment is hard, but it is transient”.
 

Oxford Women’s Health awarded certification

Oxford Women’s Health was recently re-awarded national certification in Rooms/Office-Based Surgery and Procedures by the DAA Group. General Manager Catherine France says the team is proud to have also been especially commended for several clinic initiatives and the high level of the clinic’s practice. “We’ve chosen to undergo certification as we believe that undergoing an external audit is the most rigorous way to confirm our 

ongoing commitment to providing high quality services for patients. We take the systems and procedures we have in place to enable our services seriously, so it is wonderful to see our efforts reflected in our very positive certification feedback.”
 

What to expect with Menopause Hormone Therapy

So, you’ve been prescribed Menopause Hormone Therapy (MHT), but what happens next? While your clinician will have provided you with an explanation of menopause and how MHT can help relieve symptoms, we understand you’ll still have lots of questions about how everything will go for you. To help, Oxford Women’s Health clinicians have put together an information sheet answering common queries that you can access HERE. Here's a breakdown of what you can expect when you start MHT.

Symptoms won’t improve overnight
People generally start to notice changes within a few weeks, but this varies depending on your symptoms, your type of prescription, and other health conditions. For others, it may take several months to notice significant improvements.

MHT should not cause weight gain
However, menopause does cause changes to weight and body shape that don’t always respond to MHT. Speak to your clinician if you experience weight gain due to bloating or fluid retention as the dose may need to be adjusted.

Some bleeding may occur
About 30 per cent of women will notice some bleeding after starting hormone therapy. If it occurs more than six months after starting, is heavy or persistent, then further checks will be needed and may include a scan of the uterus or sampling of the uterus lining.

Skin reaction? There are other options to try
You will need to stop using patches if you experience a reaction as the absorption of estrogen will be poor through inflamed skin. You can switch to tablet or gel estrogen, or try a different brand of patch.

See your doctor if you feel anxious
Estrogen and progesterone usually help to reduce anxiety, so we would not expect patients to experience increased anxiety after starting MHT. 
 

If this happens to you, speak with your doctor to work out if the hormone therapy is having an unexpected side effect or there is another cause for the anxiety.

Symptoms may return
Menopause is a process that takes many years. Over time, estrogen levels slowly decrease, so it is not uncommon for women to need a change in dose to make up for the progressive fall in estrogen. Sometimes if the brand of medication is changed, doses need to be adjusted due to alterations in the way the body processes the new medication.

The right dose is unique to you
Your clinician will assess you to determine what is right for you. In a nutshell, the right dose of estrogen is the one that largely settles your symptoms and doesn’t cause side effects. You may hear other people mention they are on different doses, but this will be because everyone is different in terms of how they absorb and process the hormone therapy, and everyone is at different stages of their menopause journey.

How does cyclical progesterone work?
Cyclical progesterone is used early in menopause to help regulate periods. If taken for 10 to 14 days as prescribed and then stopped, it will lead to a withdrawal bleed. The drop in progesterone levels in the blood, signals to the uterus to shed its lining. This is similar to the bleed we experience when taking the contraceptive pill.

Help, I still have questions!
Please make a follow-up appointment with your menopause clinician if you have further questions. If your concern is urgent, please see your own GP as we cannot provide an urgent service.