Reclaiming Your Sexuality After Gynecologic Cancer

00:00:00:00 – 00:00:37:23
Unknown
Hello, everyone. Welcome to today’s webinar. Reclaiming Your Sexuality After Gynecologic Cancer. I’m Maggie Alexander, the senior director of Gynecologic Cancer Patients Support and Education at Share. Before today’s presentation begins, I’d like to tell you a little bit about Share. We’re a national nonprofit that supports, educates and empowers anyone diagnosed with breast or gynecologic cancer, and whose outreach to the general public about signs and symptoms.

00:00:38:00 – 00:00:59:09
Unknown
Because no one should have to face breast, ovarian, uterine, cervical or metastatic breast cancer alone. For more information about upcoming webinars, support groups, podcasts, and our help line, please visit our website at Share Cancer Support dot org.

00:00:59:09 – 00:01:20:12
Unknown
And now I’d like to introduce today’s speakers who will. We’re so excited to have with us, and I’ll hand it over to Nora and Nicole to introduce themselves. Hi there. I’m Nora Lersch. I’m a nurse practitioner and I’m based in Portland, Oregon.

00:01:20:13 – 00:01:44:06
Unknown
Now, I have been a nurse practitioner for about 30 years. The first half of my practice was in family practice and gynecology. Last half has been in gynecological oncology and breast cancer. I also run a sexual health clinic for cancer patients. I started the first sexual health clinic at UPMC a few years ago and then decided to move, moved out to Portland and Providence.

00:01:44:08 – 00:02:06:01
Unknown
Fran’s Cancer Institute was gracious enough to help me start the first one for Providence Cancer Institute, and I am trained as a sexual counselor. I’m certified through Asec, which is the American Society of Sexual Educators, Counselors and Therapists.

00:02:06:03 – 00:02:29:23
Unknown
I have to really focus on I’m trying to say what a sex stands for, too. I saw your face because it was like, So anyway, hi everybody. I’m Nicole Dreibelbis. I’m a women’s health nurse practitioner, also working currently in gynecologic oncology. My entire career has been in guidance for the last almost nine years, and just over a year ago I was able to open our regions.

00:02:30:00 – 00:03:00:04
Unknown
I’m in central Pennsylvania First Oncology Sexual Health Clinic, which we currently take care of vulva owning patients only. So I can share my PowerPoint here. Oops.

00:03:00:06 – 00:03:31:18
Unknown
There you go. Okay. So after today’s presentation, attendees should be able to list two types of intimacy at least Explain the difference between sex versus intimacy versus sexuality. Less two ways Cancer and cancer treatment can impact sexuality and intimacy. Understand ways to improve intimacy in your relationship and understand ways to improve pelvic pain. So I think the best place to start is talking about what intimacy actually is.

00:03:31:20 – 00:03:56:16
Unknown
So I did what most of our patients do if they need to know something and we’re not around. As I put intimacy in Google and I selected for images and these are all the images that came up, obviously many more than that, but these were the first couple. So you can see every single picture has two human beings in it of different genders, races and whatnot.

00:03:56:16 – 00:04:19:11
Unknown
But essentially it looks like the theme here when you’re looking at it as closeness, being in each other’s personal space, depending on the scenario, it looks like some of them are having a great time. Some of them are just snuggling. So intimacy can mean a lot of things to a lot of people. So then I looked at Webster’s Dictionary and said, okay, what is this?

00:04:19:11 – 00:04:48:07
Unknown
So it’s a state of being intimate or familiarity, something of a personal or private nature. So some synonyms are belonging, familiarity, chumminess, which kind of made me giggle, closeness, nearness. And there are obviously different ways we can talk about intimacy. So you can have the intimacy of old friends, the intimacy of a relationship which can be more romantic, just an intimate setting with a couple people.

00:04:48:07 – 00:05:15:13
Unknown
It doesn’t necessarily always have to be sexual, although that’s a lot of what we end up in implying when we’re talking about intimacy. So there are several types of intimacy depending on where you work or not where you work site where you look. There are there can be anywhere illicit from three types of intimacy to seven. So I kind of broke it down into these for emotional cognitive experience and physical.

00:05:15:15 – 00:05:47:22
Unknown
And so when we talk about sexual intimacy, which is part of what we’ll talk about today, that falls under physical, but it does also or can also fall under emotional and experiential as well. So there are some key factors needed for intimacy. Trust is a big one. You know, you’re much more likely to feel like you can get close with someone, whether that’s physically or as far as emotionally telling them your deepest, darkest secrets if you can trust them.

00:05:47:22 – 00:06:19:06
Unknown
And so trust is a really important foundation for an intimate relationship, regardless of whether or not it’s romantic. Being able to, you know, always rely on somebody to be there for you without judgment and to kind of keep your confidence is really important. Acceptance is really huge as well. Right. You need somebody who’s going to accept your falls, accept you for who you are and be honest with you, make you feel safe.

00:06:19:08 – 00:06:43:03
Unknown
Compassion is huge as well. You know, a lot of partners will never understand what it’s like to go through a cancer journey if they haven’t been through one. And so having them be able to support you and, you know, keep you safe, do the things that you need while you’re undergoing cancer treatment is really important as well. Affection can be something it doesn’t always have to be kissing or hugging.

00:06:43:05 – 00:07:03:08
Unknown
It could be something as simple as, Hey, I was at the store today and I saw your favorite candy bar, so I bought it for you. You could do that for coworkers or friends as well. Not just romantic relationships, but affection is important to show people really how much you appreciate them. Communication is in capital letters for a reason.

00:07:03:14 – 00:07:24:08
Unknown
Communication is really key and I won’t go too much into it because I know Nora. We’ll talk about it a little later. But especially when we’re talking about sexual relationships, nobody talks to us about how to discuss sex and so when you’re having good sex, it doesn’t matter if you don’t know how to talk about it because it’s going well.

00:07:24:10 – 00:07:47:12
Unknown
But once things start to change and maybe, you know, somebody starts developing pain or something is not going well, we often just kind of stop talking about it at all or don’t talk about it often enough. So again, Nora will hit on that a little bit more in a little while, but communication is huge. Oops. I know. I thought this was cute.

00:07:47:13 – 00:08:06:03
Unknown
You know, let’s not complicate our relationship by trying to communicate with each other. What’s probably the man saying that not to be biased, but my husband would probably be the one to say that between the two of us. So there are benefits to intimacy. It can absolutely increase your sexual desire. And that makes sense if you think about it.

00:08:06:03 – 00:08:28:08
Unknown
The more you can trust somebody, the more somebody is compassionate towards you, the more somebody is showing you affection in any kind of way, whether it’s unloading the dishwasher for you because they know it’s your least favorite chore or, you know, like I said, buying your favorite candy bar or kissing you. Right. Those things can add to increasing your sexual desire.

00:08:28:10 – 00:08:57:10
Unknown
You can also greater relationship satisfaction when you increase your intimacy with someone. And that makes sense as well, right? If you are becoming closer with someone, you’re building that trust, You’re building that acceptance and compassion, and you really kind of can grow the relationship in that way. There are health benefits, it improves your immune function, it lowers your blood pressure and also lowers your risk of heart disease and can improve your mental health.

00:08:57:10 – 00:09:25:04
Unknown
It is you know, intimacy is a nice stress reliever. And again, it doesn’t have to be physical intimacy. It can just be feeling like you can open up to somebody and telling them whatever you feel like you need to say without judgment. So I think it’s important to discuss what the difference is between sex and intimacy and sexuality, because there are slight differences and sometimes we use those words interchangeably when they’re not really meant to be.

00:09:25:06 – 00:09:53:03
Unknown
So sex does not require intimacy. Sometimes there happens to be intimacy as well, but it is truly just a physical act. So that can occur without intimacy. Intimacy is the actual feeling of closeness. And again, that can be emotional or physical and sexuality is who you are as a sexual being, how you see and express yourself. And so there there are slight differences with each one of these, but it’ll help to define them now as we move forward to keep talking.

00:09:53:05 – 00:10:17:11
Unknown
So one of the things that I wanted to mention was the sexual response cycle. The sexual response cycle has been through a couple of different variations. This is the signs. And what I would say with this one is it’s nice because it’s a circle. So it it definitely acknowledges the fact that our journeys in life in general are not linear.

00:10:17:13 – 00:10:59:15
Unknown
We don’t just go straight across and there’s always different things that can impact our spontaneous desire, our response of desire. And this really does a good job at showing that. So I do have a little video, so it’s not some sharing there, but ouch. Okay. Okay, let’s start this over and play this right to anger everywhere. Remind of after a little note that we all know an up and down than but until recently we didn’t realize that anything happening on the inside.

00:10:59:17 – 00:11:28:02
Unknown
In earlier times we looked to religious figures for relationships and it took a while for people to come around to the idea of sex and sexual nature. We weren’t studying scientifically or ideas that needed to be studied to respond to sexual life. We can talk about the different theories on how we respond to sexually, what let’s with the body sexual response is, as we know today, what is a sexual response?

00:11:28:02 – 00:11:49:13
Unknown
I want to put it simply, the sexual response cycle is how we respond mentally and physically sexual stimuli. When we’re talking about sexual response, we’re talking about how our brains respond to sexual stimuli and how that creates changes in our bodies to prepare for sex. This is how researchers know there’s a pattern for how most human beings respond.

00:11:49:15 – 00:12:11:01
Unknown
And we can create a model for there are multiple model or visual representations of our bodies responses to sex. Each of these models talk about the sexual function in a different way. And because human beings are unique, we might find that not all of them fit you. Which one do you think would be best? So we’re not actually going to talk about that.

00:12:11:01 – 00:12:38:14
Unknown
I’m going to scoot forward a little bit. The video, because there are so many different parts of it and we’ll watch the rest of it here. But on 2000, each version of the sexual response brings something unique to sexual research as a whole. Rosemary Bond model was no different. She thought of different factors being in a long term relationship or how the gender can impact our response and then other models and women.

00:12:38:16 – 00:13:05:18
Unknown
But we didn’t know that included how they turned on and back off. She recognized that testosterone was a key player in natural response, making it a biological function. But that wasn’t always the case for women. She looked at different cultural disorders typically experienced, such as hyperactive sexual desire disorder, and considered how women sexual response could often be more mental or psychological and biological.

00:13:05:20 – 00:13:29:17
Unknown
The model is a bit more complex. Who’s is? Unlike the other models, We start at a place of sexual neutrality not being sexual, but we might be open to it. If we find the right stimuli, then that stimuli it becomes about the psychological and biological response. We might start experiencing desire long ago and we can go back and forth between the two.

00:13:29:19 – 00:13:53:10
Unknown
Now, unlike the other model of how long we discuss physical or orgasm. But it suggests that the goal of sex might be emotional intimacy and physical satisfaction, which might not be strictly orgasm. Without intimacy and connection. It might mean that if I did not want to continue having sex with this person, that bond is would help a long term relationship.

00:13:53:12 – 00:14:12:03
Unknown
And it means you might not start sex each time at sexual neutrality. Then that’s the gist of this model. And they’re not focused on the sexual model, but it does get a lot of points that go straight. My models don’t represent sex with everyone in some way or another. It’s how we got here. And I might even be wondering.

00:14:12:07 – 00:14:36:04
Unknown
This is including to identify if that’s what happens. Yeah, I can even find inclusivity matters in an article about sexuality. Medical news today said some who identify as asexual will experience arousal. Someone will masturbate while having no interest in having sex with another person. There’s a lot more research to be done and a whole lot more we can learn.

00:14:36:06 – 00:15:10:08
Unknown
Hopefully this is giving you a little more insight as to how research currently thinks about sexual response. No matter what models you relate to, the most sexual interest usually starts in the main, or the binding usually follows. So it makes me so mad that being a classroom toxic are longer and take wants to give them even. Sorry. I thought Nora on and said it makes me so mad.

00:15:10:08 – 00:15:42:12
Unknown
And I was like, What makes you so mad? And then I realized it was a commercial, so I apologize for that. So then what we need to talk about is how cancer impacts sexuality and intimacy, because it does. Otherwise we wouldn’t have to have webinars like this to help spread information about, you know, how to improve things. So cancer can absolutely cause a decreased libido, whether that is because of extra stress, which certainly cancer can cause, or if there are physical symptoms from a cancer that are maybe causing pain.

00:15:42:12 – 00:15:57:10
Unknown
You know, I’ve had patients come in and say I’ve had ten years of painful sex and I have no libido. Well, of course you don’t. You don’t you don’t want to have sex. If it’s going to be painful, you’re doing it because you want to connect with your partner and you want to make them feel good and make them happy.

00:15:57:12 – 00:16:31:04
Unknown
But of course, you don’t want to do it because it doesn’t feel good for you right now or it is hurting you. Same with decreased ability to orgasm. A lot of our patients who have surgeries to their clitoris or radiation to that area or even chemotherapy can attack small nerves or it can decrease the ability to orgasm. Menopause alone causes enough of an impact on sexuality and intimacy, let alone if you’re in menopause and then also getting a cancer diagnosis or your cancer treatment causes you to be in menopause.

00:16:31:04 – 00:16:57:23
Unknown
And it’s kind of like a double whammy then. And so menopause can cause vaginal dryness, urinary frequency, urinary leakage, hot flashes, mood changes. There are so many parts of that that can absolutely impact your sexuality in your intimacy, changes in self and sense of self and body image. Having cancer treatment can change a lot about your body, how it looks.

00:16:58:00 – 00:17:22:12
Unknown
We all know that the media does not do a great job at making women feel comfortable in general. That was what their bodies look like and then add some scarring or surgical changes. And a lot of patients, especially breast cancer patients that I’ve been seeing, maybe don’t realize how much their breasts contribute to their sexual satisfaction until they no longer have feeling or have decreased feeling.

00:17:22:14 – 00:17:54:20
Unknown
Possibility of decreased blood flow to the genitals. Post radiation. There is a shield for penises when they when penis owners receive radiation. However, there’s not anything similar for the clitoris at the moment. Persistent fatigue and pain. Those things absolutely impact how you feel on a day to day basis, but also whether you feel up to having intercourse or getting in a position where maybe your joints hurt or your hips hurt or your vagina hurts, there’s so many different things that can impact.

00:17:54:20 – 00:18:19:06
Unknown
And this is just a short list. So how do you discuss this with your provider? It is important, right? A lot of what I will say is when I was a provider early in my career, I did not routinely ask about sex. And I will say I did not because I didn’t know what to say. If a patient had issues, yes, I knew I could recommend some lubricants.

00:18:19:08 – 00:18:38:10
Unknown
But once I really realized this was something my patients needed, that’s when I started looking for more information. And now, you know, years later, here I am. But don’t be afraid to ask questions because there’s a chance that your provider may have information that they just didn’t know you needed, so they didn’t share. There are a multitude of providers you can talk to.

00:18:38:10 – 00:18:58:07
Unknown
You can talk to your oncologist, you can talk to a guy psychologist, you can talk to your PCP. There may even be a sexual health counselor or or therapist in your area. That would be helpful. But overall, don’t be afraid to ask questions. So that’s the best way to advocate for yourself if you’re not being asked the questions in the first place.

00:18:58:09 – 00:19:16:06
Unknown
So if you feel shy or uncomfortable, just know there are no rules as to why you are asking the question. You don’t have to explain yourself. Sometimes when I when I’m nervous or I’m getting ready to ask a question where I’m nervous about the answer, I will just continue to talk and I will overexplain why I’m asking the question.

00:19:16:08 – 00:19:35:08
Unknown
It’s not necessary. You really can just go in there and say, I’ve been experiencing vaginal dryness. Do you have any tips? You also don’t have to have a medical issue. You don’t have to bring up the conversation about sex. It doesn’t need to hurt in order for you to bring up that conversation. And you can ask how to increase your pleasure.

00:19:35:08 – 00:19:57:15
Unknown
Right? Just because you’re not having pain doesn’t mean you don’t deserve to improve of your sexual intimacy If that’s what you’re looking for. And you can focus on emotions, you can talk about how sex makes you feel, that can be helpful with a counselor as well as the other groups I listed. And there’s no rules for how you ask.

00:19:57:17 – 00:20:17:02
Unknown
So you can just start by saying I’m having problems with dryness or pain with sex. I’m not having a sex as often as I’d like. My vaginal dryness is really affecting my sex life. I want to have an orgasm or I’ve never had an orgasm. What can I do? How can every gain sexual pleasure? I have a low sex drive.

00:20:17:02 – 00:20:36:08
Unknown
What can I do? So even just bringing up a symptom or bringing up a feeling can start the ball rolling. And if you get met with you know that they aren’t the person to ask. Maybe they have suggestions on who to get you to. I think I’m going to turn it over to Nora. Are you going to share your story?

00:20:36:11 – 00:21:34:13
Unknown
I think should by video? And then can you just stop sharing for a sec? I thought I did. you did? Okay. In your screen. Okay. Can you say that? Perfect. Great. So as Nicole was discussing, communication with intimacy is really key, especially if you have had trouble in the past with not connecting with your partner. Many patients that I talked to say they didn’t have no desire.

00:21:34:15 – 00:21:58:07
Unknown
They loved their partner. They want to be close with them, but they have no desire to have sex and they’re not really sure how to get that desire. PACK Well, part of that is starting a conversation about it. So making the time to discuss with your partner that you’re having some issues is really important. As Nicole said, we’re not taught how to discuss sex and when things are going well, really don’t talk about it.

00:21:58:07 – 00:22:22:13
Unknown
It’s just, you know, running along. But when you’re having an issue, taking that time, getting your partner in a at a time when you’re not thinking about something else, where you’re not trying to make dinner or having childcare issues or right around when you’ve had sex, because that can feel like you’re saying, well, there was a problem. So here, let me discuss this now.

00:22:22:13 – 00:22:53:00
Unknown
So talking when you’re saying on a walk or maybe driving can be an easier way to broach the subject and when you do talk about it, use feeling words, use feeling statements so that there isn’t judgment to that your partner and they don’t have to feel that you’re blaming them or that it’s coming from them. You can say, you know, I feel this way about how close we are and I really miss this type of closeness, and I’d like to get back to that type of place.

00:22:53:02 – 00:23:13:15
Unknown
And then the other thing is to do reflective listening is if your partner says, you know, well, I hear blah, blah, blah, blah, blah, blah, blah, and you say to them, What I hear you saying is this really verify and validate their feelings, too, because your partners are also struggling with not having the intimacy in the relationship. You may have had pre-cancer.

00:23:13:15 – 00:23:40:14
Unknown
And so getting to a place where both of you can feel like you’re being heard is really important. And one of the keys to bringing back libido, it’s Nicole talked about our brain is our biggest sex organ. And so when we have gone through a trauma like cancer and if we’re having pain, many of those things just really tamp down the hormones that tell us to have a arousal.

00:23:40:16 – 00:24:07:10
Unknown
And one way to get that, those hormones to start to increase and go to the right places in our brain is by masturbation or self stimulation. And as the same is true for intimacy and sex, masturbation has many health benefits, including feeling good and helps you reduce stress and improve sleep, helps you improve desire and helps you improve self esteem about it.

00:24:07:12 – 00:24:25:06
Unknown
And I always tell patients, you know, if you don’t know what feels good to you, how do you expect your partner to know what feels good? So if you can explore your body, even if it’s not bringing yourself to climax, but feel what feels good to you, what doesn’t feel good? What angles of touch are better or worse?

00:24:25:08 – 00:24:46:05
Unknown
How quickly to touch the clitoris, how slow to touch it. Those things can all help for you to discuss with your partner that this feels good or that feels good. So masturbation, while it’s really a hard subject for a lot of patients and there’s a lot of guilt around, it is really a very healthy thing that you can do for yourself.

00:24:46:07 – 00:25:07:20
Unknown
And then the other thing as Nicole talked about, is we need to treat pain. If you have had pain when you have sex, your libido is going to go because it’s saying, please don’t touch me, please protect me. I don’t want to have pain. So there are many things that we can do to treat that pain. And generally for most patients, we can get them to a point where they’re not having discomfort.

00:25:07:22 – 00:25:32:12
Unknown
So lubricants and moisturizers are really important lubricants. Nicole taught me this. Lubricants are for love. Moisturizers are for maintenance. Our lubricants that we have include water based silicone and oil based. For most people, I recommend silicone based lubricants, and the one I recommend the most is Uber Lube, because it’s approved by the World Health Organization water based lubricants.

00:25:32:12 – 00:25:50:01
Unknown
What I hear a lot of times from patients is that it felt okay in the beginning, but then it seemed to fade away. And that’s because water based, when you have friction, gets absorbed and it goes away, when you use a silicone or an oil based lubricant, it’s it tends to hang around and you won’t have that wear off.

00:25:50:01 – 00:26:17:14
Unknown
Of fact, some people prefer oil based because they feel it’s a little more natural there. So you can use olive oil, you can use coconut oil. But others feel that that may increase the risk for infection. And the studies really aren’t clear on that. So with silicone based products, often you can get the amount of lubricant that you need without it fading away.

00:26:17:16 – 00:26:47:09
Unknown
I do tell people to avoid the ones that are warming or have stimulating type of properties. Those tend to really irritate the back to the vaginal tissue. And then moisturizers are really important. All women that go through menopause, I think, should pump vaginal moisturizers or vaginal estrogen, depending on your situation, because our vaginas, after we go through menopause or cancer treatment are basically like our mouths without saliva.

00:26:47:11 – 00:27:13:16
Unknown
And so that tissue that is supposed to be thick and supple and move a lot is unable to do that. Once it’s lacking. Estrogen and moisturizers help to bring the moisture to the surface and help to repair the tissue, not to the level of estrogen, but can be quite helpful for patients. There’s been many studies that have shown that it can be as helpful, especially if you add hyaluronic acid to that.

00:27:13:22 – 00:27:34:19
Unknown
That is what we’d see in face creams and is in Halo gel and also is in we don’t have good clean love on hair, but good for love. That’s another moisturizer, that’s really good. And they have a bio nourish which has hyaluronic acid. And I tell patients that you can use this every day, even though the the chewables say two or three times a week.

00:27:34:21 – 00:27:54:04
Unknown
I feel like getting I have trouble remembering if something’s two or three times a week, but if something’s daily, I tend to remember it a little bit better. And I tell patients, just put it in your on your vagina, right? When you’re doing your moisturizer for the rest of your body, you put a little bit on your finger and then you just insert that into your vagina and move it around.

00:27:54:06 – 00:28:16:08
Unknown
And that act of inserting it into your vagina with your finger does a couple of things, helps you feel a little bit more comfortable about touching yourself and understanding where everything is in the vulva. And it also helps to improve the blood flow to the vagina so that you’re increasing healing properties to the vagina and stimulation and that’s very good for it.

00:28:16:10 – 00:28:50:05
Unknown
I always say to women that our sex drive and our vagina unfortunately are a little bit of a use it or lose it proposition. The less we have sex, the less we want sex, the less our vagina is used, the less it wants to be used. That’s not to say you should have sex when you’re having pain, but anything that can help to stimulate increased blood flow to the vagina will help with vaginal dryness and so that’s where if it’s comfortable inserting your finger and putting the moisturizer in can be very helpful.

00:28:50:07 – 00:29:14:22
Unknown
It I’m sorry, we have double slides. This is just another slide of lubricants and moisturizers. And then this is just a little discussion about a little slide on the use of hormone therapy for gynecological cancers. When there’s talking about hormone therapy here, they are talking about oral hormone therapy or oral replacement, but it also applies to vaginal estrogen replacement.

00:29:14:24 – 00:29:40:24
Unknown
And so in uterine cancer, in early stage endometrial cancer, we feel that generally vaginal estrogen is safe to use and is not absorbed systemically. When you use vaginal estrogen and when you get the hand out for vaginal estrogen, it’s going to have all of the risks and benefits of oral medication. They’ve never adapted it to the vaginal indications.

00:29:40:24 – 00:30:02:17
Unknown
The FDA, although we’re lobbying them hard right now to try to get that to change. But if you are using vaginal, we consider that that the estrogen is not systemically absorbed. And why that is, is that when we don’t have estrogen in our vagina, as I said, the tissue gets kind of thin and it’s not able to resist things as much.

00:30:02:19 – 00:30:41:03
Unknown
And so when you put the estrogen into the vagina, it gets absorbed systemically a little bit for the first 8 to 12 weeks. And they’ve done studies on this. They’ve watched women’s estradiol levels, estrogen levels. And then as you use that daily for about 2 to 3 weeks, you can then go down to every 2 to 3 times a week because the tissue, instead of being thin and tearing easily and uncomfortable, gets thicker and gets more moisture and gets more flexible and doesn’t absorb the estrogen anymore.

00:30:41:03 – 00:31:05:07
Unknown
And so our estrogen levels then go down to postmenopausal levels again. And so that’s why we feel it’s safe in endometrial cancer, which can’t be driven by estrogen. That’s why we feel it’s safe in ovarian cancer. You top and it’s safe in cervical cancer. And a lot of our cervical cancer patients have had treatment at a younger age and really are struggling with vaginal dryness.

00:31:05:07 – 00:31:28:21
Unknown
They’ve had radiation. They might have been put into menopause early. And so vaginal estrogen is going to be really important in those patients. And then you’d have to have the discussion about advanced stage, endometrial cancer, uterine sarcoma and low grade serous, and enter Metroid ovarian cancer with your class. If you’re a clinician to see if they feel that it would be appropriate.

00:31:28:23 – 00:31:49:19
Unknown
And then there’s another product that you may see called DHEA. And I’m going to try and say the name dehydration at the end and drugs through, which is a mouthful. This is FDA approved for the treatment of what we call GSM, which is genital urinary syndrome of menopause. And that’s basically the vaginal dryness that happens to the tissue when we don’t have estrogen.

00:31:49:21 – 00:32:12:11
Unknown
And it has been shown to really help with pelvic pain and pain with sex. It hits two receptors. It hits estrogen receptors and androgen receptors, which is testosterone. And they have not found that it has any elevation of hormones. So we think that theoretically it should be safe in cancer patients, but we just are lacking the studies in it.

00:32:12:13 – 00:32:48:20
Unknown
I think that to use this medication, you have to have a very nuanced discussion with your provider and somebody that’s adept at prescribing it, has experience with it, and can go over what the literature says. And then another treatment that you might have if you see somebody like Nicole or I or a physical therapist is dilator therapy, and this can be really helpful if you’ve been having pain, because what is important is that once we treat the vaginal dryness and get the tissue feeling better, sometimes the opening to the vagina is still a little tight.

00:32:48:20 – 00:33:13:12
Unknown
And that’s because, again, the elasticity of the tissue has gotten lost and things have gotten tighter around the opening or sometimes the pelvic structures are tightened in the vagina and the vagina is a little shortened. So Basil Dilator, our soft, they come in multiple sizes and you can start with the smallest size and you gradually work your way up.

00:33:13:13 – 00:33:41:23
Unknown
You need to work with a practitioner. That’s a depth that and understanding how to use and then explain it to you. But what this does is allow the body to understand that something can be the vagina and it not hurt. And that has to be a key association because again, since our brain is the biggest sex organ, if our brain associates vaginal penetration intercourse with pain, then it’s going to be a hard no.

00:33:42:00 – 00:34:02:13
Unknown
So our body has to get used to saying, wait, that’s inside me. And that doesn’t hurt. And you can start with the smallest dilator and gradually work your way up. And I always say to work up to whatever your partner’s size is or what you feel comfortable with. And the other thing that can be really helpful for pain is physical therapy.

00:34:02:15 – 00:34:24:14
Unknown
And these physical therapists are trained to do pelvic floor therapy. It’s done in a private setting. So you’re not out in the regular rooms where all the people are doing their neck in their back therapy. But just like when you string your neck and you don’t want to use it, the same can be true of the muscles that support our pelvis.

00:34:24:16 – 00:35:01:09
Unknown
They can become tight and spasm even. And so, of course, when we try to have anything in the vagina that hurts and and it can get worse over time because the more pain we have, the more it’s cyclic. Our body tightens down, says, No, I don’t want anything in there. And the pain gets worse. So physical therapy works to do breathing exercises, strengthening and stretching exercises, and sometimes manual therapy where they actually feel on the inside of the vagina and work, just like we do to work out a knot in our neck or in our back.

00:35:01:09 – 00:35:31:21
Unknown
They’re working out a knot or a spasm that might be in our pelvic floor. Really, really important part of the way we get people back to feeling better and not having discomfort. Some other recommendations that that we usually say are just overall health because our brain is our biggest sex organ. Getting good sleep and not feeling fatigued is a key to restoring your libido when you’re tired all the time.

00:35:31:21 – 00:35:56:03
Unknown
Of course, you don’t want to have intimacy with your partner. That’s like the last thing that’s on your mind. And so getting good sleep, important for all aspects of our health, including our sexual health, as well as exercise. People that exercise have better libido than people that don’t. That’s been proven in studies. And so while exercise is good for our overall health, it’s also good for our sexual health, and it helps us to feel better about ourselves.

00:35:56:03 – 00:36:24:04
Unknown
When you feel better about yourselves, you’re more likely to want to be intimate with somebody and feel more comfortable with that. I’m going to skip over mindfulness and sensate focus for the next couple of they’ll be on the next couple of slides. I want to talk just a second about pre medicating. So if you have developed chronic pain maybe from other illnesses that you have or from your cancer treatments, pre medicating with your pain medication is really important.

00:36:24:06 – 00:36:56:17
Unknown
And that’s where setting aside time and we’re going to talk about this with sensate focused setting aside time with for intimacy and scheduling that is important that you take your medication beforehand so that you can be fully present and not have pain during that time. Vibrators can be a really important tool to bring in to increase fun. It also is really helpful if you do have decreased sensation after your cancer treatment, especially the chemotherapies we have can cause nerve damage.

00:36:56:22 – 00:37:23:02
Unknown
And while it affects the nerves in the fingers and toes, it also affects the nerves in the genital area and. So vibrators can be really helpful in restoring improving the ability to climax. Our clitoris is our most and our other most sensitive aspect of our vagina nerves, but it has over 10,000 nerves. And it’s important that that is stimulated during intercourse.

00:37:23:02 – 00:37:54:00
Unknown
For most women to be able to climax. And vibrators can help with that. And then lastly, you can use 4% lighter cane externally on the vagina or the vulva to help. And you do that maybe 15 or 20 minutes before you’re going to have intercourse. And that can help more vaginal penetration and that can help with discomfort. Mindfulness is another thing that helps with overall health, and anything that helps with overall health can help with sexual health.

00:37:54:02 – 00:38:25:12
Unknown
This is intentionally focusing your thoughts so that you can influence desire and arousal. And that can be something as simple as structure breathing during the day. I tell a lot of women to do square breathing, which is where you breathe in for 4 seconds, breathe out for 4 seconds, and you’re picturing a square as you do this. Breathe in for 4 seconds, breathe out for 4 seconds, and you do that several times in a row to just center yourself and kind of focus your mind.

00:38:25:14 – 00:38:50:13
Unknown
You can do meditation if you like meditation, or you can get apps like poem app, this one that will walk you through a meditative hour, mindfulness programs, and they can be as short as 3 to 5 minutes. But that’s been found. If you do that on a regular basis, can actually increase your libido or your sex drive as well.

00:38:50:15 – 00:39:17:11
Unknown
And then lastly, there’s something called sensate focus, and this was developed by Masters and Johnson, and it helps couples discover intimacy and connectedness without the pressure of sexual performance. And it includes touch, massage and exploring different sections of the body. This can be prescribed by a very, very scheduled, but I find that a lot of patients find that that’s too clinical.

00:39:17:11 – 00:39:59:10
Unknown
And so I usually do a sort of an adapted version of sensate focus with my patients, especially if I’m treating somebody for discomfort, vaginal discomfort. I work on getting the marginal discomfort better and answer their work as I’m working on that. You are at home working on intimacy with your partner, so you have that important conversation about, you know, you want to try to regain intimacy in your relationship and what ways can you do that and an important part is making time for intimacy, scheduling time throughout the day that you can focus on just each other.

00:39:59:12 – 00:40:18:04
Unknown
And I usually tell people two times a month, if that feels too much, you can do it one time a month and it feels like it’s not enough every week. But you schedule many other things in your life that are pleasurable. You schedule going out to dinner, you schedule going to the movies, going to a concert. It’s no different that we need to schedule time for intimacy and pleasure.

00:40:18:06 – 00:40:43:15
Unknown
And so taking the time to be intimate with each other and when you start, I tell people, just do kissing and touching with your clothes on, touching your neck, your hands, your arms, your legs, feeling what feels good, and getting used to having somebody touch you again and feeling that trust again, that it’s okay, that it’s not hurting and you don’t have any goal to go to intercourse or climax.

00:40:43:17 – 00:41:06:19
Unknown
It’s just about the kissing and touching. So remember back to the beginning of your relationships when you used to kiss and touch all the time. This is the time where you take a month or two and you just focus on kissing and touching and then you gradually progress that you might go to where you kiss and touch with your clothes off, but your underwear on and you’re not touching any of your intimate parts.

00:41:06:19 – 00:41:28:20
Unknown
You are just touching again, skin, arms and legs. And you do that for a month or two and then you progress to where you might hide your clothes off and you are starting to touch intimate parts of your body. But there is no expectations that it needs to lead to climax. And then after a month or two and you can do this at whatever speed feels, good.

00:41:28:20 – 00:41:59:01
Unknown
If a couple of weeks is good or a couple of months, then you progress to touching genitals and coming to climax. And that can touching with hands or oral stimulation. And then you go on to if that’s your goal of vaginal penetration. And so you do a stepwise approach to it and you need to do a lot of conversations during this as to what letting your partner know how you feel about it, where you think you are progressing.

00:41:59:03 – 00:42:17:17
Unknown
Some people progress quickly on this topic, some a couple weeks, others it’s three or four months where they stay in one one area of intimacy and maybe that’s where you stay and that’s okay that you want to just get to that place where you’re intimate with your partner, where you’re talking more, touching a little bit more, kissing a little bit more.

00:42:17:19 – 00:42:42:17
Unknown
And you’re not your goal is not to get too vaginal penetration, but if that’s your goal, you take it step by step. I hope that makes sense. So some of the key takeaways on this is I hope we pointed out that communication is key. You need to talk with your partner about what you’re going through and about ways that you would like to start to tackle some of the things that have been going on.

00:42:42:19 – 00:43:04:12
Unknown
You need to try to restore intimacy, and I think that’s really the goal for most people is that they feel like they’ve lost that sense of intimacy with their partner and they want to bring that back. And so that’s crucial. And then treat pain and be patient with yourself. You’ve been through a huge trauma when you’ve had cancer and your body is and your mind is healing from that.

00:43:04:14 – 00:43:40:18
Unknown
And so when you’re ready, treat the pain. Try to get the vagina and the vulva to feeling good and then be patient with how you get back to intimacy and restoring libido in your relationship. And these are references and I’m going to stop sharing my screen. Great. Thank you so much, Nicole and Nora, for that great presentation. And so now let’s begin the Q&A.

00:43:40:20 – 00:44:09:11
Unknown
There were a lot of pre submitted questions and you can still submit questions in the Q&A section at the bottom of your screen. We will try to get through as many questions as we can in the remaining time. All right. So you talked about moisturizers and lubricants, and we got this question about when and how often to use them.

00:44:09:13 – 00:44:38:01
Unknown
I can tell you are so lubricants you should use really any time you’re having stimulation of the genitals or vaginal penetration, because it really is protective. Some people, if they are using vaginal estrogen or regular moisturizers, can get can get to a point where they don’t need lubricant. But that’s the exception, not the rule. And moisturizers really should be.

00:44:38:01 – 00:44:58:05
Unknown
I feel they should be used on a daily basis, but at a minimum 2 to 3 times a week, because like I said, your your vagina without estrogen is like your mouth without saliva. And we must moisturize our face every day. A lot of people put moisturizer on their body every day. Your vagina is no different. It really should moisturize that on a daily basis.

00:44:58:07 – 00:45:23:20
Unknown
Great. Thank you. And then this person brought up a really important point and point about, you know, these patients who have a lot of poking and prodding and peering at, you know, their those parts of their bodies, their vagina and everything. And so it’s really hard to separate that. And sexuality. I don’t know if either of you have any kind of guidance around that.

00:45:23:22 – 00:45:51:12
Unknown
Yeah, I actually I take the short answer to that, but I can absolutely expand on that. So I hear that a lot. I’m sure Nora does too. We medicalized the pelvis so much, especially if you’ve had a gynecologic cancer and you know it’s necessary because there’s a cancer there, we need to treat it. And then if you end up with radiation or any kind of vaginal shortening or scar tissue stenosis, we may need to do dilator therapy.

00:45:51:12 – 00:46:13:22
Unknown
And oftentimes, you know, that that is really the point to where people are like, okay, I don’t want to put anything in there. I don’t even want to put this big dilator in there. And I have to. So I just I want to be left alone. I don’t want to think about it anymore. Sometimes masturbation is a good way to reconnect with your body in that regard because you are in control.

00:46:13:22 – 00:46:42:17
Unknown
And it can it just you you can, you know, kind of explore what makes you feel good now that things have changed if you are given a dilator, those giant white ones that are really hard. I always kind of joke with patients that you could probably keep it under your pillow and kill an intruder with it if they came in, if it’s the hard ones and not the soft ones, you know, maybe switching it up, maybe getting something that’s more comfortable, even getting a vibrator is completely reasonable.

00:46:42:17 – 00:47:22:05
Unknown
And so sometimes trying to take what we give you and switch it to, you know, everyday life things as outside of the medical world. And that’s tough to do. It takes time. I don’t know if more has got more to add to that. I think that was a great answer. Great. Thank you for that. And then worse, there’s been some questions submitted about sort of the the other person in the relationship and what if that person has their own issues with sexuality or someone even put in the chat about, you know, their partner might not get turned on by them anymore.

00:47:22:05 – 00:47:45:00
Unknown
So how how can people navigate that, that aspect of it? I think when I talked about kind of the progressive intimacy, I think that that is really important having that conversation with your partner, because once you sit down and talk with them, they’re struggling with it as much as you are and they’re going to be relieved that they’re that you’re bringing this up and you’re having the conversation.

00:47:45:02 – 00:48:19:02
Unknown
And it may not be one conversation, it may be multiple. But then you get to a point where you’re saying, okay, let’s focus on trying this first. Let’s try the kissing, maybe a little touching. Let’s see how that feels and let’s just sit with that for a bit of time and see where it goes from there. And then as you progress through that, if you’re still having issues, sometimes you can see a sexual therapist and Nicole and I are counselors and we do provide some of that when you see us in the clinic.

00:48:19:04 – 00:48:49:12
Unknown
But there are some couples that we’ve had that really they’ve had problems pre-cancer or they tried these techniques and we’re just not really getting to the root of the problem. Then sexual therapy can be a really important aspect. You can go to the Asec website and they have sexual trained sexual therapists that are listed in all 50 states that you can schedule to see and see them for counseling.

00:48:49:14 – 00:49:13:03
Unknown
Right? But that’s a really great resource. And then this isn’t just asking if there’s a particular vibe or a vibrator that either of you would recommend. I’m going to take this one. So I’m not I’m not brand loyal. But what I will say is, if you go on Amazon, people are very generous with their reviews of sex abuse on Amazon.

00:49:13:03 – 00:49:36:15
Unknown
And so what I tell my patients, as if you go on there and you’re looking the way you know it’s a good one is generally if it has four stars or more and if it has at least a thousand reviews because I think one of the really popular ones has 37,000 reviews, it’s got to be fully tested. So I trust the Amazon group to let go if it’s not going to work well, and generally they’re pretty inexpensive.

00:49:36:15 – 00:50:02:02
Unknown
I mean, I’ve seen them as little as eight or $9, and those don’t tend to have high stars, but there are some that are 20 or $30, so pretty still kind of affordable. I think the biggest thing is to know what type you’re looking for because there are different types of vibrators. So one, the one that I end up recommending the most to my patients is a wand vibrator where it has a long handle and then the whole head of it vibrates.

00:50:02:04 – 00:50:22:11
Unknown
And that’s because you can you don’t have to have it directly on the clitoris for it to really work. It just has to be in the neighborhood and everything vibrates. And so it helps with positions, it helps with decreased sensation related to radiation changes or menopause. And so it just kind of ends up being a pretty foolproof one to get.

00:50:22:11 – 00:50:49:24
Unknown
So if you look on Amazon for a wand vibrator and then just look for one that’s highly rated and rated by a lot of different people, you’ll get a good one, I promise. A good, great tip. Go with the one with with really good reviews to and so this person is asking so they had cervical radiation and they were told to use a dilator, but they weren’t comfortable doing it at the time.

00:50:50:01 – 00:51:20:05
Unknown
Is it too late to do it down the line if there is now lots of scar tissue there, or is that something they could still utilize? They may not be able to get all of the length of the vagina back, but they can maximize the length that they have now by starting to use the dilator and they can get the soft ones like we showed in the video or in the slides, and you can work with those.

00:51:20:07 – 00:51:55:19
Unknown
And it’s also you can have your partner use an O-ring which is a little ring, not a little ring to minimize any anybody’s size that you put on on the penis. And so that helps to prevent. Thank you from doing having deeper penetration with your partner is still getting the same sense of stimulation. So that’s one way you have a workaround if your vagina is foreshortened because some of the women that have had surgery for cervical cancer, we’ve had to actually take the top of the vagina away.

00:51:55:19 – 00:52:32:17
Unknown
So the vagina is just naturally shorter now. And some women have it shortened either because they have had radiation or because they’ve been through menopause. And it’s been a time since anything has been inside the vagina and it’s actually just shortened it on its own. And so all those reasons you could have a shorter vagina and using a ring with your partner if they have a penis and using a dilator that maximizes the size that you would still have helped select licensing system.

00:52:32:19 – 00:52:59:04
Unknown
Right. And then we just got a question about whether estrogen products are prescription only. Yes. And so how would a patient go about getting what they talk to their gynecologic oncologist? Yeah, I would have the conversation first with your G went oncologists. They might be comfortable prescribing that for you. If they’re not, they can at least tell you if they think that it is okay to use with your type of cancer.

00:52:59:06 – 00:53:26:10
Unknown
And then you can go to a practitioner like Nicole or I or your gynecologist and see and talk to them about prescribing it. And then this person is asking whether vibrators that warm up are a good idea. I didn’t even know that existed, but I don’t know, I, I would tread lightly. So not not to share too much.

00:53:26:10 – 00:53:58:01
Unknown
I’ve never used one of those. Didn’t even know they existed. I realize it. It sounds a lot interesting, but I. I don’t know that it’s necessarily needed, so I don’t know. Nor have you heard of those. Yeah, I don’t know. I would say if you’re going to use use with caution because I don’t know what kind of controls there are as far as what if you, you know, like a heating pad, if you can click if you want it, level one, two, three, four or five level hot.

00:53:58:03 – 00:54:24:23
Unknown
But I would just use those cautiously if you have one. Right. And then this person is asking about like the time line after abdominal hysterectomy. Their doctor told them they had to wait for their vaginal cup to heal. I just yeah, eight weeks is usually the but that is very we don’t have good studies to know how long.

00:54:24:23 – 00:54:54:13
Unknown
It’s just like after childbirth they say, you can start having intercourse after eight weeks. Well, not everybody’s vaginas ready at eight weeks. So definitely having the pelvic exam and asking your practitioner, how do you feel like things have healed? You feel like I’m ready to have intercourse. Do you think I should wait a few more weeks, maybe come back and have another check with your practitioner If you’re not ready and have them look again and see can can be very helpful.

00:54:54:15 – 00:55:19:00
Unknown
Actually tell our patients 12 weeks, because that’s assuming that they probably won’t all listen and not have sex for 12 weeks. You tell them 12 and they do ten. We’re happy with that. But yeah, I’d say 12 weeks and it’s especially with an abdominal test. If you have that big belly incision too, you know, you have to kind of work around how that’s feeling for you as well.

00:55:19:02 – 00:55:46:12
Unknown
Right. And I just want to this is just I want to I don’t know if everyone saw this, but I just want to mention this person is saying how great that their pelvic floor therapist was for their recovery. And so I just wanted to highlight that for anyone who maybe want to look into getting one of those. And then another question about vibrators, whether to use it externally or internally as well.

00:55:46:14 – 00:56:06:23
Unknown
I think whatever feels good to you and that’s where you explore and have fun with it. Some people do both, and there are vibrators that you can insert manually and then it will also touch the clitoris. There’s ones that you just put on the clitoris. There’s ones that you just put in the vagina, but they vibrate so you can use them on the outside and explore.

00:56:06:23 – 00:56:32:22
Unknown
And generally when you go if you go to one of the shops in your area, they’re usually very knowledgeable about this and it’s not your sex shops from years ago. It’s they are trained professionals that have lots of education about this ours and Portland has a library section, every type of vibrator that you could imagine, ones that I never knew existed.

00:56:32:24 – 00:57:00:00
Unknown
And they can be really a great resource for you. Right? And then this person is talking about how that you know, they can’t have intercourse and it still very painful and I guess their doctors are hesitant to give them anything. But they what, they don’t want to not do something about this. So I’m wondering if either of you have any advice for them about what to, you know, sort of how to go about addressing that?

00:57:00:02 – 00:57:28:18
Unknown
Yeah, I think the first step, if you’re not already, is using a vaginal moisturizer. They’re over-the-counter, they’re not home or hormonal. So they absolutely will not impact your cancer or increase your risk of recurrence or progression. And so I would like Nora, I was saying get one with hyaluronic acid. Try that. Even though the box says one or two or three times a week, whatever that says, I have some patients who use it daily.

00:57:28:20 – 00:57:47:03
Unknown
Oftentimes what I’ll tell patients when they’re starting a moisturizer is to use it every night for a week and then they can decide, you know, if that feels comfortable, they can continue every night. Sometimes I get the opposite complaint after a week where they say, okay, well, now I’m too wet. Like now I just feel like I just charge all the time.

00:57:47:05 – 00:58:24:16
Unknown
I almost missed being dry. So then they kind of have to taper down to what’s comfortable for them, but especially if been struggling for a long time. I will tell them to use it every night for at least a week or two just to kind of help soothe and build up the tissue that’s already angry. Right. And then we do get a question about whether there are any complementary or holistic health modalities that either of you have seen benefit patients, sex lives.

00:58:24:18 – 00:58:55:23
Unknown
I mean, I think if you’re having pain, acne, you know, some people use acupuncture. And so treating any of the symptoms like hot flushes, pain fatigue and using complementary modalities for that I think is really good because that’s going to increase your sex, drive your libido and help you to be more intimate with your partner. So I think wellness is really important and if diet plays a role in it as well.

00:58:55:23 – 00:59:22:23
Unknown
So they’ve done studies more recently where they’ve looked at genital blood flow and arousal in women prior to changing their diet and then after they’ve been on a plant based diet or stayed on a omnivore diet and the plant based participants had increased blood flow, increase increased arousal after just eight weeks. So diet really does make a difference as well.

00:59:23:00 – 00:59:54:01
Unknown
Right. Thank you for that. So it looks like we’re out of time, so we will be able to get to any more questions. But thank you so much, Nora and Nicole, for your great presentation and for all of your thoughtful and thorough answers to these questions. And thank you, everyone who attended today and submitted these great questions. We really hope that this will help to provide some tips and tools that you can utilize.

00:59:54:03 – 01:00:19:10
Unknown
We’ll have the recording of this program available on our website in 1 to 2 weeks. Also, please make sure to check Cher’s website for upcoming educational programs, podcast episodes and support groups. And don’t forget to follow us on social media. Well. We also ask that you please take a moment to complete the survey at the end of the webinar.

01:00:19:15 – 01:00:44:16
Unknown
The survey will pop up in the browser when the webinar ends, and the link will also be in the follow up email. All surveys are anonymous and we really use that feedback to improve our programing. So please take that. And so this that concludes today’s webinar. Thank you again, Nora and Nicole, and I hope that everyone has a great rest of your day.

01:00:44:18 – 01:00:49:13
Unknown
Thanks so much, everyone. Thank you.