(Sex) Life after radiotherapy treatment for cervical cancer

Dr Mariza Tunmer, a radiation oncologist, tells us more about how radiation may cause side effects that can affect sexual health. Then Hester van Aswegen, a physiotherapist, advises what can be done to overcome these side effects.

THE RADIATION ONCOLOGIST

Radiotherapy is an important treatment modality used to treat many, if not most, patients with cervical cancer. When aiming to cure a patient diagnosed with cervical cancer, the treatment course will usually entail daily treatments, Monday – Friday, over six to seven weeks.

Where possible, a low weekly dose of chemotherapy should be combined with radiotherapy as this improves cure rates. Most of the radiotherapy treatments will be delivered from the outside (External Beam Radiotherapy (EBRT)), like an X-ray. Towards the end of the external treatments, a few internal treatments (usually three to five) also need to be given (brachytherapy).   

Radiotherapy and the combination of chemotherapy and radiation may result in significant side effects and it’s important to know what to expect when having this treatment. Early or acute side effects of radiotherapy occur while on treatment or within three months from starting. Late or chronic side effects may start after this and persist. A useful way to think of it is that the body ‘remembers’ the radiation.

Early effects

Early on during treatment, the mucous membranes of the genitourinary tract may become inflamed. This may cause symptoms such as discomfort, pain and burning. Early skin effects which occur while on treatment include redness (erythema), dryness and itchiness (pruritus). 

As you progress through treatment, the skin and mucous membranes in the treated area may start to peel. This may be a dry peel (dry desquamation) or progress to a weepy, wet peel (moist desquamation). Your doctor will explain how to care for the skin during chemoradiotherapy to reduce the severity of this reaction. It’s important to avoid chemicals, sun exposure and anything else which may aggravate the local reaction.  

Late effects

Although the early reaction described above usually heals within a few weeks of treatment, late effects may occur over time, as the skin, mucous membranes and other soft tissues in the treated area may become harder and stiff. This is known as fibrosis.

Many patients experience narrowing of the vagina and with time this may seem to get worse. The tissues in the area may lose elasticity and this may make having sex uncomfortable or even painful. Another problem many patients experience is vaginal dryness. 

Many of these problems aren’t only as a direct result of radiotherapy on the soft tissues of the pelvic area, but also because the ovaries no longer secrete hormones the way they did before.

Light at the end of the tunnel

Fortunately, all is not lost and with education and supportive measures many patients who are treated for cervical cancer can return to having a satisfying sex life.

This usually involves different measures, such as starting hormone replacement therapy, regular use of lubrication and vaginal dilation, either with a dilator or by starting to have regular penetrative sex once the early inflammatory side effects have settled.

Fortunately, there are professionals trained to assist patients with these kinds of measures. Hester is one of them and she will tell us more about this.

Depression and anxiety

Finally, being diagnosed with cervical cancer, or any gynaecological cancer, is a traumatic event in any woman’s life. Many patients may experience anxiety or even depression. Apart from the cancer symptoms which are often embarrassing, uncomfortable, and scary, if a patient needs to undergo an intensive course of treatment, it may take its toll on both the patient as well as her loved ones. Don’t be afraid to reach out for help and support. 

Many patients with cervical cancer can be cured, so it’s important to know what to expect during treatment and to learn how to cope with the changes that the body undergoes afterwards.  

THE PHYSIOTHERAPIST

When you’ve survived cancer, it certainly is a victory, but it comes with its challenges due to the adverse side effects. Many of the sexual health issues experienced by cervical cancer survivors can be addressed in clinical practice. 

A multi-modal treatment paradigm is usually necessary to effectively treat these complaints in this special patient population and physiotherapy forms an essential part of the team.

As mentioned, radiation causes changes in the muscles, fascia, tendons, ligaments, and skin in the pelvic region. This tightness leads to decreased mobility as well as weakness of the structures within the pelvis, abdomen, inner thighs, hips, and buttock muscles. 

The scar tissue, increased muscle tone and myofascial trigger points can not only contribute towards pain with sexual intercourse, but also cause urinary and bowel dysfunction (e.g. difficulty emptying the bladder, urinary and bowel frequency and urgency, and constipation), cancer-related fatigue, and lymphoedema.

Sexual complaints include changes in sexual desire, arousal, and orgasmic intensity and latency. Many women suffer from debilitating vaginal dryness and painful intercourse.

Pelvic health

A physiotherapist who is trained in pelvic health can assist to improve the quality of life and help manage the symptoms in an optimal manner.

The treatment includes:

• Advice on bowel problems like managing anal fissures and constipation (skin protection, down-training overactive pelvic floor muscles, achieving good stool consistency, proper defecatory techniques (see image below).
• Improving bladder and bowel control by pelvic floor rehabilitation and urge inhibition techniques that will restore normal muscle function.
• Dealing with dyspareunia (painful intercourse) by giving advice on dilator selection, choosing an appropriate lubricant and teaching muscle relaxation.

The pelvic floor muscles play an essential role in control of bladder, bowel and sexual function, and initially therapy will help you to identify the muscles and understand how to start with pelvic floor rehabilitation to improve mobility and strength, and regain control over time.

Manual physical therapy, for example, trigger point therapy, stretching and myofascial release. This helps to stretch, mobilise and desensitise the scar tissue and restore normal function.

Relaxation and breathing techniques are essential to enable you to deal with anxiety and stress but also assist in relaxation when doing dilator or manual therapy

Using dilators can help to stretch the vaginal tissues and muscles. This will make vaginal examination more comfortable and make it easier for you to start or continue sexual intimacy. Dilator use may lessen the effect of vaginal scarring and maximise the vagina’s flexibility to reduce pain.

Dilators come in different sizes and are used together with a lubricant. The dilator is gently inserted into the vagina while you lie or stand in a comfortable position. It’s recommended to leave the dilator in for a period (depending on your comfort) and when able, to start moving it around to help stretch the muscles. The physiotherapist will teach you how to do this correctly. 

Vaginal lubricants

Radiotherapy also causes vaginal dryness and using lubricants and moisturisers could assist with dilator use and intercourse.

Vaginal lubricants work by reducing the friction associated with thin, dry genital tissue. They come in liquid or gel form and are applied to the vagina and vulva (and, if desired, to a partner’s penis) right before intercourse (sex). Lubricants aren’t absorbed into the skin, are immediate-acting, and provide temporary relief from vaginal dryness.

A wide variety of lubricants are commercially available, either as water-based, silicone-based, or oil-based products. Water-based lubricants have the advantage of being non-staining. 

Oil-based lubricants (such as petroleum jelly and baby oil) should be avoided, as they can cause vaginal irritation. It’s advisable to avoid lubricants that contain perfumes or colourings.

Vaginal moisturisers are less sticky than lubricants and are absorbed into the skin and cling to the vaginal lining in a way that mimics natural secretions. It’s applied regularly, not just before sex, and their effects are more long-term, lasting up to three or four days.

For both moisturisers and lubricants, you may need to experiment with several products to find the one that’s best for you and always consult your doctor if there is any irritation or side effects

Other sexual-related problems e.g. with sexual interest, arousal, and orgasm, can be managed with medication or cognitive behavioural therapy or counselling.

Managing fatigue and other side effects

Physiotherapists should also advise patients on an optimal exercise programme to manage fatigue, to increase strength and mobility, to reduce pain and help prevent osteoporosis. 

Bone density often decreases because many gynaecological cancer patients go through abrupt menopause when their ovaries are removed. Physiotherapy helps patients to maintain strong bones, mobility, balance, and everyday function all the while being mindful of cancer-related fatigue.

References:

1. Effects of radiation therapy on the structure and function of the pelvic floor muscles of patients with cancer in the pelvic area: a systematic review.’ J Cancer Surviv. 2016 Apr;10(2):351-62. doi: 10.1007/s11764-015-0481-8. Epub 2015 Aug 28. Bernard, S. et al
2. ‘Effect of a pelvic floor muscle training program on gynecologic cancer survivors with pelvic floor dysfunction: a randomized controlled trial.’ Gynecol Oncol. 2012 Jun;125(3):705-11. doi: 10.1016/j.ygyno.2012.03.045. Epub 2012 Apr 1. Yang EJ, et al
3. Maintaining sexual health throughout gynaecologic cancer survivorship: A comprehensive review and clinical guide. Huffman LB¹, Hartenbach EM¹, Carter J², Rash JK¹, Kushner DM; Gynecol Oncol. 2016 Feb;140(2):359-68. doi: 10.1016/j.ygyno.2015.11.010. Epub 2015 Nov 7.
4. https://www.targetingcancer.com.au/wp-content/uploads/2015/10/Recovering-after-Pelvic-Radiation-Therapy-a-guide-for-women.pdf
5. https://pelvicpainrehab.com/female-pelvic-pain/2983/life-after-cancer-the-role-of-pelvic-physical-therapy/
6. KM0035-PELVIC RADIOTHERAPY LEAFLET.indd
8. KM0035-PELVIC RADIOTHERAPY LEAFLET.indd

MEET OUR EXPERT – Dr Maríza Tunmer

Dr Maríza Tunmer is a specialist radiation oncologist working in private practice at Wits University Donald Gordon Medical Centre in Gauteng. She also works as a sessional consultant at Charlotte Maxeke Johannesburg Academic Hospital. 

MEET OUR EXPERT – Hester van Aswegen

Hester van Aswegen is a physiotherapist with a special interest in pelvic floor dysfunction. She is passionate about providing the best service possible to patients with pelvic floor dysfunction and also educating the public and medical professionals about physiotherapy services available for these conditions.