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Recovery from a devastating disease like breast cancer is a long and challenging road that frequently involves making peace with lots of change—different bodily sensations, altered abilities, different goals and perspectives. Rather than a return to “business as usual,” recovery is often a process of accommodation.

All that adaptation and accommodation applies to sex as well. Sometimes, the goal is not so much to regain the “before” experience as to redefine, along with your partner, what sex means “after” cancer. To start from now with patience and hope, because whatever your starting point, you will improve. That’s the resounding message from other survivors who have faced the same journey: “Don’t give up,” and “You are not alone.”

As you reconstruct the contours of your life, of which sex is a critical part, here’s a toolkit that might help you get started and might also help sex to be more comfortable.

First, some ideas to consider as you begin to reclaim your sexuality:

Self-image is a huge hurdle for most women who’ve had breast cancer, even after reconstruction surgery. Everything feels different, and sometimes there’s no feeling at all. According to a 2011 study of 1,000 survivors of breast cancer, co-author Mary Panjari, of Australia’s Monash University, found that women with body-image issues (and who doesn’t have issues with body image?) were much more likely to report sexual function problems.

Perhaps it’s comforting to know that, while you struggle with the psychological and physical scars of your illness, for most partners, the way you look isn’t a problem. “In our study, we asked women if they thought their partner felt differently about their appearance and the majority said, ‘No different.’ But the women felt differently about themselves,” says Panjari. Again, you’re not alone, and there are steps you can take:

  • Consider finding a support group for cancer survivors, and not just for advice on sex. Some women like them; others don’t, but at least give it a try.
  • Consider couples therapy. As a couple, you need to figure out a path forward, sexually speaking. He may worry about hurting you or pressuring you. You may be consumed by how you look or experiencing loss of desire and sensitivity, vaginal dryness, numbness. And your medications may exacerbate your condition. Finding a sex therapist who can walk you through these changes could be your best gift to yourself and your relationship.
  • Exercise when you feel ready. A regular workout will help you tone muscles, lose weight, and feel stronger and more capable. It gets more blood to your brain and your bottom, and it releases endorphins, the feel-good neurotransmitters in your brain. Simply feeling confident and capable can help stimulate your sex drive.
  • Masturbate. This primes the pump. You can get lubrication going and see what feels good where. “Masturbation is a normal form of sexual activity and release,” says Dr. Marisa Weiss, founder of Breastcancer.org. “I tell my patients it’s a form of exercise and conditioning for the vagina—which has suffered considerable change and lack of use during breast cancer treatment.”
  • Remember: Breasts are only one part of a whole-body experience. Don’t focus on the tree when you have an entire forest to explore.

Now for that toolkit. These are items every postmenopausal woman should have on hand—they’re just more important for breast cancer survivors.

  • Vaginal moisturizer. This is for regular, daily use, not just for sex. It conditions the vagina and keeps the tissue healthy and moist
  • Lubricant. Use this lavishly in your vagina for extra lubrication during sex.
  • Pillows. Lots of pillows for soft support where you need it. If a position feels ouchy, try cushioning the area with a pillow.
  • Erotic movies and other scene-setting paraphernalia—candles, incense, music.
  • Sexy attire. If you need to start out—or stay—clothed for a while, get sexy lingerie that covers the strategic parts.
  • Read the information about vaginal comfort and genital sensation on my website: middlesexmd.com and the very helpful blog posts about sex after cancer by our own medical advisor, Mary Jo Rapini.

 

 

In the last post, I ran up the flag for oral sex—mostly as a way of keeping our repertoire broad and deep as we and our partners face age-related issues with sexual sensitivity and/or function. After all, there are many ways to skin this particular cat.

But, as with any kind of sex, a little technique and creativity can put some spice into what too often devolves into a boring routine. All the tricks in the world, however, can’t take the place of communication and some interest and even excitement about the task at, um, hand.

Some level of communication is fundamental to sexual play and exploration. You can encourage: “I love it when you do that.” You can ask: “Does this feel good?” “What would you like better?” And you can pay attention to non-verbal cues: breathing, muscle tension, sounds, movement.

I’d also like to emphasize that, while it’s good to push your boundaries, if any part of sexual exploration feels really uncomfortable or off-putting, you don’t have to go there. We all have lines, and it’s important for both partners both to draw them and to respect them. But don’t just draw lines, continue to look for ways to keep the intimacy alive.

I’ve had women tell me that fellatio (oral sex on men) gave them a sense of empowerment, because they were controlling the action. By the same token, it gives the guy a break—he’s not in charge, plus he still has a good view of the action, which can be its own kind of turn-on.

With loving attention and communication on the front burner, here are some ways to change up your oral sex technique.

  • Take it slow. Don’t go for broke right away—let momentum build. Start with sensitive areas at the periphery—belly, inner thighs, buttocks. Use light touch, blow, kiss, lick. Take your time.
  • Move in. When you get to the genitals, keep the action soft and slow at first. Cup his testicles in your hand or mouth. Slide your tongue up the shaft of his penis. The frenulum is a particularly sensitive spot on the underside of the penis where the shaft meets the head. Tease a little before you commit.
  • Take a break. If your jaw gets tired, use your hands or your tongue to keep the action going.
  • Cool off. For a surprising change of pace, take a drink of ice water. The change of temperature is startling.
  • Heat and spice. Don’t keep doing the same old thing while you’re in warm-up mode. Use different sensations, change the speed and the rhythm. Build up to a firm, steady rhythm. Even if he isn’t totally erect, he can still orgasm and ejaculate.
  • Avoid the gag. You don’t have to deep-throat. Use your hand on his shaft and only take the head of his penis in your mouth. Then, you can suck or use your tongue creatively while stroking the rest with your hand.
  • Swallow—or not. You’ve probably already settled this, but if you don’t want to swallow his ejaculate, you can tell him to warn you just before he comes.
  • Hold him gently afterward.

Of course, the need for skill and technique apply equally to cunnilingus (oral sex on female genitalia). If your partner could use some coaching, slip him the highly rated “essential guidebook to oral sex,” She Comes First: The Thinking Man’s Guide to Pleasuring a Woman by Ian Kerner.

Women whose men have taken it to heart (and to bed) give it rave reviews.

Kerner also has a female guide to men’s sexuality, which includes pointers on oral sex: Passionista: The Empowered Woman’s Guide to Pleasuring a Man.

Now that you have your required bedtime reading, maybe you want to give each other an occasional pop quiz.

I may be going out on a limb here, but I’d like to make a case for oral sex. It gives us another avenue to intimacy and pleasure, and as such, is an important component of a lusty love life. It’s a skill that couples should try to develop. Or at least keep an open mind toward.

Here’s why.

First, most women (70 percent. Did you get that number?) don’t climax with vaginal penetration alone. In my practice, postmenopausal women commonly tell me that the only way they can orgasm is through clitoral stimulation or oral sex.

For all women, no matter the age, the most dependable orgasm is clitoral—which, as we’ve said before, is a powerful organ with twice as many nerve endings as the penis.

Sure, the clitoris (and the penis) can be stimulated in many creative ways, but the mouth and tongue are darned effective.

Second, I know I sound like a broken record, but we lose sensitivity and the ability to lubricate vaginally as we age. And our partner’s ability to maintain an erection will eventually wane as well, despite the little blue pill. As the old penis-in-vagina sex becomes less dependable, it’s helpful to have other tricks up our sleeve.

Oral sex is one way to keep sexual pleasure alive as a couple. No less venerable an institution than the AARP says so in this article. It makes sense to give ourselves alternatives and room for compensation, so that when one capability diminishes, another can fill in the gap.

Now, I’m not for a minute suggesting that you haven’t tried oral sex. Sex coach Kathleen Baldwin, says that “It’s somewhat rare in my experience to find a woman over 40 who doesn’t enjoy oral sex.” She thinks that mature women are less influenced by cultural norms and are more familiar with how their bodies function, including their lady parts.

For many women, however, the “yuck” factor presents an impediment. Some women consider their genitalia “gross.” They worry about cleanliness or odor. They worry that it will take them too long to climax.

Funny thing is, most men really like oral sex—both giving and receiving it. I ran across an article by a man on the topic, who writes:

It’s an amazing feeling to satisfy a woman, and cunnilingus is the most foolproof way to do it.

It also minimizes our own performance phobia. Women can’t see what we’re doing, our tongues will never need Viagra and we’ve all got a similarly sized piece of equipment. But most of all, [cunnilingus] is a five-sense experience that places us up close and personal in a way that no other act can. …most vaginas smell and taste pleasantly mild…

The pleasure you can give your partner (and ultimately yourself) may be worth getting over any squeamishness. And you can always address the cleanliness issue by showering (or a bath!) before sex.

Oral sex, whether cunnilingus (oral sex to a woman’s genitalia) or fellatio (oral sex to a man’s genitalia) works best with some technique, and like any other skill, practice makes perfect. The most direct path to improvement is communication. You have to let your partner know what feels good. (More on technique in the next post.)

One final consideration: if you aren’t sure about your partner’s status with regard to sexually transmitted disease (STDs): you can still transmit them with oral sex. Chances of infection are lower, but Chlamydia, gonorrhea, herpes, human papyllomavirus (HPV), even HIV can still be “caught” through oral sex. For example, one woman I know caught genital herpes from a cold sore on her husband’s mouth!

So, if you’re with a new partner and you aren’t completely knowledgeable about his or her sexual history, you need to use protection—a dental dam (piece of latex placed over the vulva) condom, or femidom (female condom).

Kind of takes away the sexy, but it sure beats the alternative.

Oral sex is just another way of expressing intimacy and sharing pleasure. And it’s a particularly nice option if more traditional forms of lovemaking become problematic. Well, heck. It’s a nice option any time.

Most topical or localized estrogen creams are prescribed to be used twice a week, which is the level at which they typically provide the most benefit with the fewest unintended consequences. If the usual application isn’t helping you regain comfort, a conversation with your health care provider could be in order.

Localized estrogen is most effective for vaginal atrophy; if you have other “systemic” symptoms of menopause, like hot flashes or night sweats, systemic estrogen may be worth considering. Systemic estrogen also improves vaginal health, but because it enters the system (as opposed to “localized” estrogen), there are more overall health considerations for its use.

If we had a conversation about how you measure “more effective,” I might suggest other, nonhormonal options that could be helpful to you. Moisturizers can improve tissue health, lubricants increase comfort and pleasure, warming products and vibrators enhance sensation, and massage oils encourage intimacy, for example. I encourage women to experiment with all of them!

You know that silly song about the thigh bone being connected to the hip bone—and so on?

Well, the kernel of truth in the ditty is that, when it comes to health and our bodies, things are indeed beautifully and intricately connected.

You can’t do healthy things for your thigh bone—or your heart or your sex life—and not have it affect other corporal systems as well. So, while we might focus on breast health in honor of Breast Cancer Awareness Month, rest assured that healthy, cancer-free breasts involve habits and choices that are good for the rest of your body as well.

There’s a lot to celebrate when it comes to breast cancer, like steadily decreasing rates since the year 2000. But we still have a long way to go. About 12 percent—1 in 8 women in the US—will develop invasive breast cancer sometime in her life. Our most significant risk factors are 1. being a woman and 2. being older.

Women over 55 account for two-thirds of invasive breast cancers diagnosed each year. This is because, over time, we tend to accrue genetic mutations, and with age we’re less adept at repairing them.

Those are the facts. But we don’t have to helplessly wait for the shoe to drop. We can make lifestyle adjustments that will lower our risk of getting this cancer and improve our overall quality of life, including our sex life. (And don’t forget that a healthy sex life is also good for our health.)

Because it’s all connected, right?

So here are lifestyle changes that you can make specifically targeted toward breast health:

Maintain a healthy weight. Being overweight or obese—those with a body mass index (BMI) over 25—increases one’s risk of developing breast cancer, especially in postmenopausal women. This could be because estrogen is stored in fatty tissue, and women who have more fat are also exposed to higher levels of estrogen, which has been undeniably linked to breast cancer. But other issues related to obesity may also be involved, such as insulin and glucose levels. Some estimates suggest that 17 percent of breast cancers in North America could be avoided simply by maintaining a healthy body weight. Check out this page for a solid, common-sense approach to weight loss.

Eat healthy food. Not only will a healthy diet help maintain a healthy weight, but it’s a critical component to avoiding cancer. Some foods contain properties that help repair the wear and tear to our bodies in the normal course of life. These “super foods” contain antioxidants that help protect our bodies from cancers.

The link between food and cancer isn’t always straightforward or well-understood, and dietary fads change with the season. Basically, though, the approach to healthy eating remains the same: eat a variety of foods with an emphasis on fruits, vegetables, and whole grains. Avoid processed foods. Avoid fats and sugars. Above all, avoid super-sugary beverages, which are directly linked not only with obesity but also with some forms of cancer.

Finally, eat fresh and eat at home. (You can’t control what goes into your food at a restaurant.) Eat organic foods to avoid exposure to synthetic chemicals.

While the voices touting various diets and food fads are myriad, confusing and contradictory, here are some basic food facts from breastcancer.org. The USDA also has a website with tons of food and diet information here.

Exercise. Weight, diet, and exercise. This is the trifecta of good health. Some well-regarded sources say that 30-40 percent of cancers could be avoided simply with these healthy lifestyle choices. That’s staggering. And when you add in quality of life factors that come with the trifecta, well, it’s overwhelmingly worth the difficulty of losing weight, eating well, and exercising regularly, wouldn’t you say?

Regular, moderate exercise can lower your risk of breast cancer. Not to mention all the other good things you get with exercise, such as better mood, cardiovascular and joint health, greater stamina and flexibility, better sleep, better bones, and more regular bowel movements. What are we waiting for?

Even women who have already been diagnosed with breast cancer may improve survival rates or prevent recurrence with moderate exercise, like walking only 4-5 hours per week, according to the American Cancer Institute.

Don’t have time? As the trainers in my exercise video say, “Make time.” It doesn’t matter what your physical ability is right now—just start slow and keep on going.

Don’t drink. Sorry to be a killjoy, but the more you drink, the greater your risk. A woman who has three alcoholic drinks per week is 15 percent more likely to get breast cancer than a woman who doesn’t drink at all. If you’re on hormone replacement therapy or if you’ve already been diagnosed with breast cancer, you should be one of those non-drinking women.

What about that healthy glass of red wine? Sorry, it all counts. The benefit of red wine doesn’t outweigh the risk. If you’ve never had breast cancer, just don’t drink every day, but if you have risk factors, switch to non-alcoholic options.

Don’t smoke. This almost goes without saying. Yes, the major risk is lung cancer, but actively smoking as well as exposure to second-hand smoke increases the risk of breast cancer in premenopausal smokers. Plus, women who smoke have greater difficulty recovering from breast cancer treatment.

Avoid chemical exposure. This is like trying to dodge raindrops, given the chemical soup we live in every day. And most of the chemicals in our environment and in the things we use have never been tested for toxicity or carcinogenic properties. Some types of chemicals are known to be hormone-disrupting, which alter the way our natural hormones function. Research is ongoing about the way these substances work and their link to possible cancers, but the connection isn’t well understood.

In the meantime, how do we negotiate the reality of the world we inhabit without neurotic overreaction but also without putting our heads in the sand? Of greatest concern with regard to breast cancer are those chemical with hormone-disrupting properties, including those in pesticides, growth hormone residues in meat and dairy products, and certain plastics.

In general, some precautionary practices would be to

  • Buy organic food. Here’s a list of the “dirty dozen”—the foods that have the highest levels of pesticide residue.
  • Plant a garden. Put up your own food.
  • Use fewer and simpler cleaning and personal care products. Look for certified “green” cleaning products (with GREENGUARD or EcoLogo insignias, for example) or make your own.
  • Don’t use pesticides on your lawn or garden.
  • Use BPA-free plastics or glass or stainless steel jars and bottles. Avoid #3 (PVC), #6 (polystyrene) and #7 (polycarbonate) plastics, which are linked to breast cancer.

You may not be able to tackle everything on this admittedly intimidating list, but it’s better to make a few changes than not to do anything at all. And the foundation you lay now will become even more important in maintaining health and functionality as you age.

This summer, in a blog post on the absence of pharmaceutical options for my treatment of women with hypoactive sexual desire disorder (HSDD), I said “I’m not in the room for the FDA discussions.” Thankfully, that’s about to change.

I’ve written here a number of times (as early as 2010 and as late as earlier this year) about the progress with the pursuit of “pink Viagra” and its frustrating setbacks. My message has consistently been that women’s sexuality is complicated, and no pill is going to fix everything for everyone.

But because of that very complication, as a physician, I value having options available. For one woman, simply thinking about intention and follow-through is enough to change the equation. For another, a combination of moisturizer, lubricant, and a powerful-enough vibrator is restorative. A third may require localized estrogen to rejuvenate tissues and restore comfort. You get the idea.

What that means is that the more options I have, the more likely I am to be able to work with a woman to maintain or restore the level of physical intimacy and sexual activity she wants. And I’m increasingly aware that while there are 26 drugs approved by the FDA for men’s erectile dysfunction, there is nothing that’s been approved for women facing comparable issues.

It’s not for want of trying. From the outside, it looks as though the bar is set higher for drugs for women than drugs for men. The side effects noted for drugs recently considered seemed more mild than that list we can all recite from hearing Viagra commercials since 1998. It doesn’t matter whether this is an intentional bias; what matters is that the FDA assure that it’s even-handed and supportive of women and their sexual health moving forward.

And that’s where the change comes in. Later this month, I’ll be traveling to Washington, DC, to attend a public hearing and then a workshop of women’s health experts, both intended to establish the reality of women’s experience (43 percent of us suffer from some sexual dysfunction!) and how the FDA can productively respond.

You can lend your voice to the proceedings. There’s a consortium of us who are concerned with women’s sexual health. We’re gathering signatures to a petition so that it’s clear to the FDA when we meet that this is a real problem, suffered by real women who seek a range of solutions. Add your voice at EvenTheScore.org or sign the #WomenDeserve petition at Change.org. Follow the discussion at the WomenDeserve Facebook community.

And I’ll keep you posted on the progress your voice has supported!

You’ve noted that your clitoris appears to be smaller, which is a normal part of aging. With the absence of estrogen, it’s estimated that a woman loses 80 percent of her genital volume—unless there is some intervention. The two most effective ways to minimize this diminishment are to remain sexually active (that “use it or lose it” thing I’ve talked about before) and to use localized estrogen. Both help to maintain the integrity of the genital tissues.

Our intent is not to “prevent” menopause, because it’s a normal part of our lives. With my patients, my aim is to mitigate enough of the symptoms of menopause to be able to maintain the sexual intimacy that’s an important part of life for many of us.

More often than you’d think, a patient who thought she was “done with sex” comes to me for help when she enters a new relationship. It’s possible to reverse some of the atrophy that happens naturally with inactivity, but it’s more difficult than maintaining sexual health along the way. If a woman is certain that she has no interest in being sexually active, there’s no negative health effect of the genital atrophy—beyond the loss of the positive health benefits of sex.

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