Ovacome Summer 2014

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feature The big taboo Sex may be the last thing on your mind when recovering from an ovarian cancer diagnosis. But there is plenty help available to get your mind and body in the right place after treatment, says Dr Helen Fairhurst from the Winton Psychosexual Medicine Clinic. For many, returning to a normal sex life after treatment for ovarian cancer can be difficult. But it is even more of a problem if the subject remains taboo for patients, partners and the medical profession. A study in the British Journal of Cancer in 2003 * found that while a majority of healthcare professionals thought most women with ovarian cancer would experience difficulties, only one in four doctors and one in five nurses brought the subject up with patients. Things may have moved on since the 2003 study and some cancer centres – such as Dorset, where I work offer exceptional support to women through their gynaecological nurses. However, clinicians – and patients themselves – often need to do more. Dr Helen Fairhurst For instance, there is a network of pyschosexual clinics on hand throughout the UK, run by members of The Institute of Psychosexual Medicine. Women can access these clinics by self-referral or referral by their GP or other health professionals. And women themselves need to feel empowered to ask questions. Your focus may be on getting over the cancer. But don’t be afraid to bring up the subject of sexuality and how it may be affected by the type of treatment you are having as soon as you feel ready to discuss it. The sooner the better. We know quality of life and general wellbeing can be greatly enhanced if problems with sexuality are addressed early on. Sexual problems are not always just down to physical reasons. Emotional factors, not always experienced at a conscious level, interfere with sexual pleasure. The underlying causes of a problem may be physical or psychological in varying proportions, but are rarely limited to one or the other. There are several ways cancer and its treatments can undermine a person’s sexuality. The impact of surgery, chemotherapy and radiotherapy will be direct and physical. But there may be other obstacles when it comes to intimacy, such as feeling disfigured, too tired to bother, changes in sensory perception and difficulty reaching orgasm. Also women can feel that their body, which has been prodded and probed by the health professionals, is no longer really part of them. But remember, however, that the ‘core’ of your being inside you is maintained, regardless of the treatment you have had. Lack of libido Low sexual desire or libido is a common problem. Many different emotional and physical factors can affect sexual desire and may be present in women living with cancer. Tiredness, stress, relationship problems, menopause symptoms, worries about children, elderly relatives, finances and work, or difficulties accepting the changes in body image that come after surgery are just some examples. And of course, in some cases sex may be a low priority after facing a cancer diagnosis and treatment. Coping with illness symptoms and the effects of treatment can be challenging enough. Women may feel too unwell to summon up the energy for the exertions of sex, but still long for physical closeness. Others find it difficult to enjoy sex without thinking of their cancer. At the same time, partners may have difficulty relating to the anxieties and fears that come with a cancer diagnosis. They might not understand why their partner feels less sexy, especially once treatment is complete, and they can see an outward return to normality. This can lead to communication misfirings and a downward spiral becomes established, just at the time when some love and support is vital. If a woman is harbouring anger and resentment towards her partner, it can be difficult to get in the right frame of mind to enjoy sex. Solutions will vary from person to person, but discussion with partners, friends and health professionals is often beneficial. Patients often ask about using hormones to improve their libido. While it is true that both oestrogen and testosterone are needed for good sexual function, and are reduced by the removal of both ovaries, many other factors can influence sexual desire. This means that hormone replacement may not be the solution. Also, there is uncertainty about whether taking these hormones to deal with a sudden surgical menopause could increase cancer recurrence risk. A recent study showed that women given Hormone Replacement Therapy (HRT) after a surgically induced menopause following treatment for epithelial ovarian cancer ** had improved longevity as well as a good control of 10 Phone Ovacome’s nurse led support line on 0845 371 0554 it together
feature symptoms such as hot flushes. However, it is still difficult to be confident that HRT is not a risk factor for recurrence. Change in sensation Altered sexual pleasure is another common problem found in women who have had surgery for gynaecological cancer. For some women, orgasms have always been generated by the muscle contraction of their uterus at the time of climax. Following hysterectomy, they are no longer able to feel this sensation and may find it difficult to orgasm through clitoral stimulation instead. They may even be scared to try clitoral stimulation fearing it might harm the healing process or possibly even lead to a recurrence of their cancer. While logic tells them that this is not correct, they find it difficult to get rid of this fear. Physical examination by a doctor trained in psychosexual medicine, although not always welcomed by women after treatment, can then be useful helping correct misunderstandings about effects of surgery, improve body image and sexual confidence and to face feelings of loss in a caring environment. Painful sex Painful sex, or dyspareunia can also start after a surgical menopause. The lower level of oestrogen caused by this can lead to the vagina becoming dry, thin and losing its former elasticity. Local creams and pessaries containing oestrogen hormones can help. Examples include Vagifem pessaries (which contain oestrogen hormones), Sylk natural lubricants and Replens moisturisers. But, as with libido, this might not be the complete solution and looking at emotional factors can be very important too. Vaginismus, the involuntary spasm of the muscles at the entrance of the vagina often due to subconscious unacknowledged emotions, is another painful complaint. One woman I have met with this problem coped very well during her hospital admission for surgical treatment, but the true impact of her cancer diagnosis came later when she started to experience anxiety about her health and also anger. Her previously active and fulfilling sex life had become virtually non-existent and painful. Her self-confidence suffered: she felt ugly and unattractive. Her husband seemed to take the brunt of her anger not least because he was apparently unable to empathise with her anxiety about cancer recurrence. He just didn’t understand that she needed compliments, to be understood, to be listened to. Physical examination revealed dryness of the vagina wall, as well as some vaginismus: both likely to be contributing to the painful sex. She was not at all keen to use hormone replacement, even in the form of locally applied oestrogens, despite reassurance from her cancer specialist that it would not increase her likelihood of cancer recurrence. She used a vibrator to help open up her vaginal tissue – this was her choice as she hated the idea suggested by her surgeon to use graded vaginal dilators instead. Most importantly, we were able to make the link between her vaginismus and her emotional difficulties, resulting in her angry wretched vagina barring entry to her ‘annoying’ husband. She also gained some valuable support from friends, including holding a virtual funeral for her womb and also from other women at the local cancer support group. • Dr Helen Fairhurst gave a talk on sexuality after treatment for gynaecological cancer at Ovacome’s recent Members’ Day. The two studies cited in this piece are: Lack of communication between healthcare professionals and women with ovarian cancer about sexual issues * British Journal of Cancer 2003, Stead, Brown, Fallowfield and Selby and ** Eeles RA et al, Adjuvant Hormone Therapy Improves Survival in Epithelial Ovarian Cancer: Results of the AHT randomised trial, submitted to the British Medical Journal June 2014. Helpful resources Ovacome has some useful fact sheets in this area - ‘Ovarian cancer and sexuality’ and ‘Treatment-induced menopause’ - www.ovacome.org.uk http://www.macmillan.org.uk/Cancerinformation/ Livingwithandaftercancer/Relationshipscommunication/ Sexuality/Sexuality.aspx Institute of Pyschosexual Medicine for a list of therapist locations - www.ipm.org.uk College of Sexual and Relationship Therapists - www.cosrt.org.uk The Menopause Exchange - www.menopause-exchange.co.uk Dana-Farber Cancer Institute in Boston: Dr Sharon Bober’s Sexual Health Program and videos - www.dana-farber.org/Health-Library/How-cancertreatment-affects-sexuality-in-women.aspx. This piece has been reviewed by Dr Richard Osborne, a consultant medical oncologist at the Dorset Cancer Centre in Poole. it together Phone Ovacome’s nurse led support line on 0845 371 0554 11
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Ovacome Summer 2014

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