Vaginal changes, sexual well-being and cancer

Side effects of cancer treatment can affect your sex life. Some side effects may happen if cancer treatment directly affects your pelvic area or hormone levels.

You may find our information about the body and sex helpful.

Not everyone will have the side effects we mention here. You may have side effects or questions that are not mentioned in this information. It is also important to remember that your sexual well-being and relationships can be affected by more than just physical changes.

We have more information about:

• cancer and relationships
• emotional effects of cancer
• side effects that cause erection problems and other changes
• side effects that affect other parts of the body.

Your cancer team can answer any questions you have about your treatment. They will explain what to expect. It is important to talk to your cancer team if these issues are affecting your sex life. This may be your:

• cancer doctor
• specialist nurse
• therapeutic radiographer, if you are having radiotherapy.

You can also talk to your GP or practice nurse.

Some treatments and ways of managing problems can work better when started early.

Some cancer treatments can directly affect the vagina. These treatments include surgery and radiotherapy to the pelvis. Other cancer treatments may cause menopausal symptoms, which include vaginal changes.

Ask your cancer team, GP or sexual health service for advice if you have pain during vaginal sex. This may include using fingers, hands, vaginal dilators or sex toys inside the vagina. A doctor, nurse or another member of your cancer team can examine you and give you advice.

There can be many reasons for this type of pain. For example, it may be caused by vaginal dryness.

If you have a partner, explain how you are feeling about vaginal sex. It may help to experiment with positions. There are other ways to give and receive pleasure.
It may help to:

• learn relaxation techniques to use before sex
• use exercises during penetration to relax the pelvic floor muscles – a physiotherapist can give you information about these
• use a lubricant if your vagina feels dry
• take control of the depth and speed of penetration – being on top or on your side may help
• only start vaginal sex when you or your partner are already close to orgasm.

When you are aroused, the vagina usually produces some natural fluid. Without this, vaginal sex may feel uncomfortable or painful. Vaginal dryness can happen because you are tired, stressed or less interested in sex. It may also happen if your treatment has caused menopausal symptoms.

Hormonal therapy drugs often cause vaginal dryness. For example, aromatase inhibitors used for breast cancer can cause dryness. Tamoxifen can cause thicker vaginal discharge.

You could use the following products to help with vaginal dryness and make sex more comfortable:

• Lubricants – a gel or liquid you apply before or during sex to make the vagina wetter. We have more information about lubrication.
• Vaginal moisturisers – a cream you apply regularly to draw moisture into the vaginal walls. There are different types of moisturisers. These include Replens, YES VM (vaginal moisturiser) and Hyalofemme. Ask your cancer team about which types may be best for you and how often you should use them.
• Vaginal oestrogen – a cream, small pellet (pessary) or ring that releases the hormone oestrogen into the vagina if you have had the menopause. This is not suitable for everyone or after some types of cancer. Your cancer team can tell you whether this is right for you.

Your GP or cancer team can prescribe these products. You can also buy lubricants and moisturisers from a shop, pharmacy or online.
Some products, such as oil-based lubricants, will damage latex condoms or caps (diaphragms) and make them less effective. Always check the instructions. If you are not sure, ask your GP, cancer team or pharmacist for advice.

If you have had the menopause, hormone replacement therapy (HRT) can help with vaginal dryness. Your cancer team or GP can explain whether HRT is suitable for you. This depends on the type of cancer you have had.

The vagina may become narrower and less stretchy after pelvic surgery or pelvic radiotherapy. The vagina walls may become dry and thin. They can also stick together. This can make vaginal sex uncomfortable.

Your cancer team may give you vaginal dilators to help prevent narrowing. Dilators come in different shapes and sizes. They are often made of plastic or silicone. You use these regularly inside the vagina with a lubricant to gently ease the walls of the vagina apart. This gradually stretches the vagina. You can gradually increase the size of the dilator once it feels more comfortable.

Dilators are often used, but there is no strong evidence about how effective they are. Rarely, they may cause damage to the vagina, especially if they are not used correctly. Your cancer team will explain how to use them safely. They may be able to arrange support and advice from a sex therapist for you.

You may also be able to help stop the vagina narrowing by regularly:

• having vaginal sex
• using a dildo or vibrator inside the vagina
• using lubricant and fingers inside the vagina.

Surgery to remove the womb and cervix may shorten the vagina slightly. Radiotherapy can also cause the vagina to shorten.

After you have healed, this will not usually affect whether you can receive vaginal sex. The vagina is naturally stretchy and expands when you are aroused. You may not notice any difference in how sex feels.

If you find vaginal sex uncomfortable, trying different positions can help. You may want to take control of the depth of penetration. If your partner wears a silicone penis ring (also called a constriction band) to increase pleasure or help with an erection, this may help you both judge the depth.

After pelvic radiotherapy, the walls of the vagina can become fragile. They may bleed easily – for example, after vaginal sex or using vaginal dilators. Always tell your cancer team or GP if this happens. They will check why you are bleeding and give you advice.

You can help protect the vagina by:

• using a lubricant during vaginal sex
• managing vaginal dryness with vaginal moisturisers
• preventing vaginal narrowing
• trying different sexual positions.

Sometimes bleeding may continue long term after treatment. If bleeding does not improve, your doctor may suggest treatments. These include using a chemical called silver nitrate on bleeding areas to seal them off. They also include taking tablets called tranexamic acid to help reduce bleeding.

Thrush is a common infection that can affect the vagina. You are more likely to develop thrush:

• during pelvic radiotherapy
• during chemotherapy
• if the vagina is dry.

Symptoms of thrush include a creamy-white discharge and itching. Your cancer team, GP or sexual health service can give you tablets, cream or pessaries to treat the infection. Or you can buy them from a pharmacy or supermarket.

If you have not had thrush before, you should ask a healthcare professional for advice about treatment. Always ask for advice if:

• you are not sure whether it is thrush
• symptoms do not improve
• it keeps coming back.

If you have had sexual contact with a partner, including oral sex, they may also need treatment.

Using vaginal moisturiser regularly can help reduce the risk of developing vaginal infections. Having a dry vagina can also increase the risk of getting urinary tract infections (UTIs).

Some types of surgery can affect the clitoris. The head of the clitoris may be removed as part of surgery for vulval cancer. Or during surgery for bladder cancer, the end of the urethra near the clitoris may be removed. This can affect the blood supply to the clitoris and make it less sensitive during sex. Radiotherapy to the pelvis can also make the clitoris less sensitive. You may worry you will be unable to orgasm after these types of treatments.

Touching the clitoris can be an important way of reaching orgasm. If things feel different, you may need to experiment to find what feels good now. Using sex toys can also help you to explore different sensations.

The clitoris reaches down both sides of the vulva and back into the pelvis. Even if the head of the clitoris has changed, you may find these other areas are sensitive and lead to orgasm. Or you may want to try other types of sexual touching. There are lots of ways to give and receive sexual pleasure. A sex therapist can give you advice and support.

Some cancer treatments affect the way the ovaries or pituitary gland work. This may cause menopausal symptoms.

Sometimes menopausal symptoms get better after cancer treatment ends. But some treatments cause a permanent menopause at a younger age than normal. This is called early menopause or premature ovarian insufficiency (POI). Your cancer doctor or specialist nurse can explain whether this is likely with your treatment.

We have more information about coping with menopausal symptoms. There are also other organisations that offer information and support about this, including Menopause and Cancer and the Daisy Network.

 Sometimes after a donor stem cell transplant, the donor’s cells attack the body’s own cells. This is called graft versus host disease (GvHD). It can happen soon after transplant or months or years later. GvHD can be an ongoing problem.

The symptoms of GvHD depend on the area of the body affected.

GvHD can affect the vagina and cause dryness, irritation and bleeding. This can change how you feel about your body and sex. It can also make having vaginal sex less comfortable.

Tell your cancer team if you have vaginal changes after your treatment. You may need steroids and other drugs to treat GvHD. Your doctor may also suggest using vaginal lubricants, moisturisers or hormone replacement therapy to improve vaginal changes.

Changes to the anus or rectum may affect your sex life if you are receiving anal sex. This includes using fingers, a hand or sex toys inside the back passage.

Changes can be caused by some types of:

• pelvic radiotherapy
• surgery to the lower bowel.

If you want to receive anal sex, your cancer team may advise you to wait for a time after treatment. Your body needs time to recover and heal. It is important to ask your cancer team for advice. They can explain how long you should wait and whether it is safe for you to receive anal sex. Some types of treatment can also cause pain when having anal sex. Your doctor, nurse or sex therapist can give you advice on how to manage this.

When you feel ready to try, start slowly and gently. Use lubricant to help protect the anus and rectum. Take your time and build up slowly to full penetration.

Long-term changes and anal sex

Sometimes changes are longer term and can mean anal sex is no longer possible or safe. A sex therapist may be able to help you cope and find different ways to enjoy sex. Your risk of having long-term changes depends on your treatment.

Radiotherapy to the rectum may make it:

• narrower
• less stretchy
• more fragile.

It can also affect how well the bowel tissue heals. Your cancer team may suggest you avoid receiving anal sex to prevent damaging the rectum. Damage can become a serious problem if the tissues cannot repair. Some people may also have bowel problems such as leaking stool or needing to poo quickly.

Surgery may cause long-term changes:

If the anal opening was surgically closed as part of your operation, you will not be able to receive anal sex.

If the rectum was surgically closed further inside your body, you may still be able to receive anal sex. But you will need to wait until all wounds have healed.
If receiving anal sex is part of your usual sexual activity, these changes can have a big impact on your sex life and relationships. It is important to get the right information from your cancer team about your treatment and how it may affect you. You may find our information on talking about sex with your healthcare team helpful.

Anal and rectal changes can also affect how it feels to receive vaginal sex. This is because the rectum and vagina are close to each other in the body. You may find vaginal sex is uncomfortable in some positions. You may need to try different positions to find which ones are best for you.