Question: My current treatment may put me into menopause. How do I know if I am going through it? How will it impact my sex life (should I ever have one again)?

Answer: Menopause (or peri-menopause, the changes that occur as hormone production from the ovaries slows down or is shut down by chemotherapy, surgical removal of the ovaries, or radiation exposure) announces itself quite loudly! Common signs are hot flashes (and disturbed sleep) and dryness of the vulva and/or vagina. This means that any sexual touch or vaginal penetration hurts. There is no mistaking that! As a result, sexual desire may completely disappear (who wants to have sex if it hurts?), and relationship strain may occur. Your health care providers should be providing you with information about potential side effects and, importantly, what you can do to help yourself deal with them or a referral to a sexual medicine expert or sex therapist who can help.

Question: Because I was 22 and worked a low-paying job at the time, and freezing eggs was not covered by my insurance, I was unable to preserve my fertility due to a lack of money. I have been hesitant to date anyone because I am unsure of my ability to have children, and I would like to be upfront with anyone I date so they can be fully informed before becoming overly attached. Is it realistic to think this way? Would a doctor be able to order tests to check my fertility without me actively trying to conceive? Is it weird to want these types of test results prior to getting into a serious relationship? My mom is usually with me at my appointments, so I have been unable to comfortably discuss this with my oncologist.

Answer: Your question is a reasonable one (and not at all weird!), and I understand your concern and need for accurate information. Yes, there are tests that can suggest your fertility status but remember that any results will be a ‘snapshot’ of your hormonal status at the time of the test(s) so may not be relevant in the future. You can also ask the nurse who works with your oncologist to make an excuse for you to speak to the oncologist alone. But…and I don’t know what your relationship is with your Mom….she may have the same questions about your fertility as you do! I am the mother of 2 young adults, and I hope they can talk to me about this kind of stuff. But everyone is different, of course. I would hope that your Mom is a source of support to you as you have gone through your cancer and would be a support to you with any fertility-related concerns.

Question: Curious … If I am taking Temodar (oral chemo for brain cancer), can I still receive oral sex from my partner? 

Answer: Oral chemotherapy medications can be present in bodily fluids, including vaginal fluids, for the entire duration of treatment and for at least 48 to 72 hours after the last dose. While the risk of harm from limited exposure is considered low, it is important to take precautions to protect partners from potential exposure to these medications. Using condoms or, in your case, a dental dam, will provide protection for your partner. The reality is that there is hardly any research into oral chemotherapy and body fluids.  The advice above is what is for IV chemotherapy. What information have you received from your oncology providers? They should be advising you, and their assumption that you are not sexually active is not an excuse!

Question: Struggling with menopausal symptoms after cancer and feel lost 

Answer: Chemical menopause is generally WAY worse than a natural menopause (usually somewhere around 52 years of age). There are things that can help with the symptoms:

• Hot flashes – respond well to some antidepressants, and those can also help with anxiety. Wearing cotton clothes and layers, cotton or bamboo bedsheets, exercise, and avoiding alcohol and spicy food mah help too.

• Low libido – this is a challenging one, often tied to altered body image, pain, and emotional issues. RESPONSIVE desire (feeling desire once you are aroused) may be the norm for you now. ‘Come as You are’ by Emily Nagoski is a good book to read about this. Also, anything by Dr. Lori Brotto.

Question: During surgical menopause, when I can’t use hormone therapy or creams, how can I keep my vagina from atrophying? How can I continue to have penetrative sex without pain if vaginal moisturizers alone aren’t working?

Answer: If your cancer is not hormone-dependent, there is no reason why you cannot use hormone replacement therapy. Even for women with hormone-dependent breast cancer, there is good evidence that local estrogen is safe. Vaginal moisturizers are for daily comfort and not for penetration. For any kind of sexual touch and penetration, you need to use a silicone-based lubricant and reapply it during sexual activity if it starts to dry up. It is also important for you and your partner to ensure that you are aroused (don’t rush!) before penetration.

Question: I’m a year and a half post-chemo, and finally got a diagnosis of vulvar atrophy and hormone issues from chemo. It just seems to be so uncommon, especially for my age, that I couldn’t get an explanation for my symptoms. I worried now that I’ll never get to have a normal sex life. Hormonal replacement seems to have many side effects and complications with my other conditions. Are there things that can be done to help? There’s just so little information out there for my age, and nobody seems to understand. 

Answer: The usual advice for a dry vulva and/or vagina is to use moisturizers for daily comfort and lubricants for sexual touch and penetration. But these are ‘band-aid’ solutions. The only thing that will really help is estrogen, either systemic or local. I don’t know what your other conditions are, so I cannot speak to that. It is really awful that no one in your oncology team has provided you with guidance or referred you to a GYN who can help. It sometimes takes a while to find hormonal treatment that works for the individual, but there are many options available! Keep advocating for yourself! 

Question: My question is that my penis shrunk from the steroids they gave me for chemo as a pre med and I wanted to know if there’s a way to make go back to its normal size and my doctor told me that if I have kids in the future that they have high chances of developing the same type of cancer as mine so I am not going to have kids I am going to adopt but I want to get checked but what can I do to get my penis back to its normal size can I try pump or penis enlargement pills I feel very shy in that area thank you for answering Mt questions  and thank you so much for your service 

Answer: Penis size is important to many/most men, even though for women, it tends not to be that important! You can certainly try a penis pump. Using one without the constriction band and with gentle suction every day or every other day may help to increase the size, but there are no guarantees. Also, if you are overweight, the fat pad at the front of your pelvic bone often makes the penis look shorter. Losing weight (if you need to) can increase the length of the penis. Penis enlargement pills are not a good idea, full stop. You should talk to your primary care provider about checking your testosterone levels to see if a testosterone supplement (prescription only, not off the shelf!) may be of some use.

Question: Dear Dr. Anne Katz, I am 42 years old and going through my second bout of cancer. The first occurrence was four years ago. Each time I’ve had brain surgery (cancer was in my dura mater) and radiation. (It sounds very dramatic, but my prognosis is actually very good–it’s not an aggressive cancer, and my doctors at MD Anderson consider it treatable.) The first bout coincided with the end of a five-year relationship. I’ve been with a new partner, who has been absolutely wonderful in many ways. He helps me with everything. He’s adoring and kind. I met him when I needed so much help. But we’ve never had much of a connection sexually. A little bit at first, but since my cancer came back, sex has stopped altogether. It’s been about eight months. We’ve fought about it, I think I brought it up the wrong way, and maybe it’s poisoned things. He has problems with impotency and seems completely uninterested in sex. (He is 15 years older than me.)  I also have lost all interest, maybe this is normal when you are going through cancer? I feel so confused about our relationship. There are so many societal messages that a good relationship must include a healthy sex life. I’ve never experienced any problems with sex in a relationship until now, but I also had never gone through cancer before. I feel safe and, in many ways, happy with him. But I’m going to be 43 soon, and the question nags at me — should I end our relationship because we don’t have a sex life? I feel like I’m sitting on a fence and time is running out. I love him, but should I give up on that dimension of my life? How important is sex really? Am I settling? Thank you for reading. 

Answer: We place so much emphasis on sex – sex sells everything from candy to cars! – and there are many couples who are happy and have a good relationship without sex. Some degree of erectile dysfunction is common in men your partner’s age, and his lack of interest in sex may have nothing to do with you, but rather is in reaction to his erectile problems. It is also possible that if the two of you lack sexual chemistry, that is all it is (that may seem like a lot), but that is not uncommon either. Your cancer, however, complicates matters; did you stay in the relationship despite the lack of sexual chemistry because you were not sure that you would find another partner? It is also completely normal to not want to have sex at all stages of the cancer experience, and in my practice, I mostly see couples or individuals who become interested again only after they have gone through treatment and (the long) recovery period and are well into the survivorship phase. 

Are you settling? Maybe… but if you weigh the pros and cons of this relationship, that might be okay for both of you.

Question: I have absolutely no desire to have sex. What can I do to fix it?

Answer: You have been through a LOT and have the scars to prove it! The lack of desire may be related to your altered body image (justified), the side effects of the chemo and radiation that have resulted in pain with sexual touch or penetration. And then there is the colostomy…..  We know that for some women, a total hysterectomy alters the occurrence or sensations of orgasms, and of course, you likely have a LOT of internal scarring from the removal of lymph nodes and pelvic floor muscle. 

But you know all this…

What can you do to fix it? Firstly, spontaneous desire (as we see in movies and on TV) usually only happens at the start of a relationship, and if you are waiting for desire to kick in (when you are in an established relationship), it may not. Why? Because in established relationships, women are more likely to experience RESPONSIVE desire. Responsive desire happens when you become aroused by a partner’s touch (even non sexual touch), or their words or actions (nuzzling your neck, for example). So if you wait around for spontaneous desire, you may be waiting for a long time….

Mindfulness-based meditation and a mindfulness practice are evidence-based interventions that have been shown to increase desire. Please read the book by Dr. Lori Brotto (Better Sex Through Mindfulness) – she explains this beautifully, and her suggestions will help!