Talking about sex is difficult at best – and particularly when things are not going well. Most of us will be reluctant to talk to our partner, let alone a doctor. Add breast cancer to the mix – and that reticence is only magnified. One in eight women will develop the disease during their lifetime. And most will have enjoyed an active sex life.
But breast cancer surgery can have a crushing effect on body image and self-esteem, while drugs to treat tumors can cause menopause, decrease libido and make sex terribly uncomfortable. Nevertheless, intimacy is rarely discussed during medical consultations. Maybe women are too afraid or too embarrassed to mention it.
Maybe the doctors are also, or maybe they're just concentrating on survival statistics, not quality of life. You see, this is a situation that I have personal experience, from both sides of the consulting room table.
Dr. Liz O & # 39; Riordan, 44, was treated for breast cancer twice and wrote about her experience bringing her additional knowledge of her work as an NHS consulting surgeon specializing in the disease.
The Doctor. O & # 39; Riordan said she was 40 when she received her diagnosis, stock photography
I am 44 years old and a consultant for breast surgery at East Suffolk and the North Essex NHS Foundation Trust. The basis of my job is to treat women with breast cancer. I discuss diagnosis, prognosis, treatment plans and possible outcomes.
But in the past I rarely, if ever, discussed sex, always assuming a general practitioner or breast-care nurse was having this conversation.
And then, at age 40, I received the devastating news that I had breast cancer. I had cysts before, so when I noticed a new lump in my left breast, I was not so worried, but I had checked anyway. A few weeks later, a mammogram, ultrasound, and subsequent biopsy confirmed that I had a large tumor.
I knew what was coming – chemotherapy followed by mastectomy and radiation therapy. My tumor was sensitive to estrogen, so I also needed the hormone-blocking remedy, tamoxifen, which triggered an instant menopause.
At the time, I was in denial, struggling to accept the truth about what was going on, no matter sharing with my loved ones.
The Doctor. Riordan said that when he married her husband, Dermot, never thought of getting sick when he made the sick and health vows.
I later realized my emotions in words: I started writing about my online experience and found a new community that shares stories and advice about cancer with honesty, caring, and sometimes humor. In 2016, I wrote a post titled: "Let's talk about sex …"
To be honest, I found it incredibly hard to put into words as it is so close to home.
I was married to my husband Dermot, 54, who is a fellow surgeon only a few years ago when I was diagnosed. Like most couples, we swear to love each other "in sickness and in health." But when you say those words, you never think you'll get sick.
Suddenly, my husband had a wife with a numb, often painful false breast, and a Brillo hair absorbent, which, thanks to a chemically induced menopause, threw the bed covers over the night, dripping with sweat.
Dr. O & # 39; Riordan suffered premature and immediate menopause after she had to take tamoxifen as part of her treatment for breast cancer
At one point, I even told him to leave me for a woman with two breasts and a healthy libido.
What Liz's husband, Dermot, has to say …
Dermot says, "Inevitably, there are periods in any relationship when you do not have sex – it's a fact of life.
"But cancer throws everything out of order.
"It's not that you do not want to have sex." And it was not a question for me whether I still thought Liz was attractive or whether I still loved her.
'But when your partner is going through hell, it will not happen. When you do not do this for a while, it can be strange and unnatural and not very spontaneous.
"It's just a fact of life that your sex life will never be what it was.
'And you can feel alone, but you just have to do it.
"If sex is not spoken, not having sex becomes the new norm.
"So unless you talk about it, you'll never get your sex life back."
Dermot told me to stop being so stupid that he loved me and was not going anywhere. And he's been really amazing in dealing with whatever treatment he gave us.
But the guilt persisted, for I knew that a relationship with little intimacy is not good. Sex can be the glue that keeps couples together, but cancer can separate them.
After breast cancer, you need to approach a physical relationship differently because your libido will never be the same.
Last May, my cancer returned to the scar tissue where my left breast was. After an operation to remove it and more radiotherapy, I needed to take a different type of hormone-blocking drug, since tamoxifen did not work.
For the new drug to work properly, I had to stop my own production of the female sex hormone estrogen produced by the ovaries, which is why in September I removed mine. I wrote in this blog post about sex: "I'm slowly learning to accept the new self."
And I still am.
Today, I ask all my patients about their sex life. If you've ever had breast cancer, you may not feel bothered about sex and that's okay. But if you want things back on track, I can help – using my own experiences as a doctor and patient.
So, where do you start? Well, here is everything I would like to know – a guide that every woman, or man, with breast cancer and her partner should read …
The Doctor. Photographed on the day of her marriage to her husband and fellow surgeon Dermot, 54, she said it is important for couples to talk about their sex lives when undergoing cancer treatment.
Accept your body feels and works differently
Surgeons can now do amazing things. We can remove lumps, leave hidden scars and reshape the breast. If you need a mastectomy, we can reconstruct your breast using an implant (which is what I had) or your own tissue. But something I did not enjoy until after my operation was that a rebuilt breast is totally numb. Mine had no feeling, so it was no longer an erogenous zone for me.
I did not like looking in the mirror, so what should my husband do with it?
When my cancer returned, I had my implant removed and being flat was even harder to adjust. Instead of a left breast, I have several scars and skin damage from radiation therapy.
It's hard to feel sexy when I'm naked in front of my husband. He tells me it still looks hot, but it took him a long time to believe in it.
But I finally realized that although breast cancer has stolen my hair, my chest and my fertility, I'm still the woman he fell in love with.
What you seem naked is only a small part of your fascination.
Night sweats mean separate duvets
If your breast cancer is sensitive to estrogen, you will receive medication to lower your body levels. These drugs, like chemotherapy, cause menopause.
It is much worse when you are young and it happens at night. Heat waves and night sweats are common. Waking up, soaking wet – I thought of getting wet the first time it happened. My husband and I now have separate duvets and I do not disturb my dad anymore when I throw the covers. But you lose the intimacy of sharing a bed.
This menopause can also cause dryness and vaginal irritation and you may completely lose your sexual desire.
Estrogen is a natural lubricant and without it sex can be uncomfortable, painful or impossible.
Start talking … when the time is right
The most important thing I learned is to be open and honest with your partner. Find a neutral time somewhere private and tell them your fears – you are worried if it will be painful, if they will not find you sexy or if your sexual desire has simply disappeared.
Give them time to tell you what their concerns are as well.
They may be scared to hurt you, or they do not know if they should touch your scars or avoid them altogether.
Tell your medical team what's going on.
It can be scary and embarrassing to talk about sex, or lack thereof, with your nurse, GP or consultant. But there's plenty we can do to help. There are also menopausal specialists who specialize in helping women with these symptoms and side effects.
Dr Louise Newson has a brilliant website, menopausedoctor.co.uk, as well as Dr. Hannah Short, drhannahshort.co.uk.
Do not be afraid to seek advice
I experienced all feelings of guilt after my diagnosis. In my opinion, it was my fault if sex disappeared from the agenda.
I was angry that I had lost my sexual desire and resented the fact that I had cancer when my friends did not have it.
These are the feelings that can trigger anxiety and depression even years later.
Most cancer centers have access to a counselor specially trained by Macmillan Cancer Support.
I found this service priceless, especially talking to someone anonymous who did not think I was crazy and had answers to many of my problems.
My counselor helped me figure out how to talk about sex in a way that would neither offend nor disturb Dermot. This has had a huge impact on both of us.
Do research and do it too
I wrote the Complete Guide to Breast Cancer, with another doctor and breast cancer patient, Trish Greenhalgh, to share everything we learned.
But I also recommend that women read Jane And Me's My Menopausal Vagina. Ask your partner to read it also so he understands what you are going through.
The Breast Cancer Care charity has excellent online information on how to get back to sex. They also have an application called BECCA, with helpful advice from patients and specialists.
I also follow two great sex experts on Twitter, @jodivineuk and @SamTalksSex, who are breaking the sex taboos and offer great advice.
I mention more on my site at liz.oriordan.co.uk.
Rediscover the joy of hugs and dating nights
It can be very difficult to get into the mood after cancer treatment. So go back to the basics – try a first date again and spend some time cuddling on the couch as teenagers. Take off the pressure; can help you two reconnect.
Dermot and I have fallen into the habit of not making time for ourselves. So we started a weekly movie night. Just the two of us; no cell phones or distractions.
We learn to have fun together again outside the room, remembering why we fell in love.
If you do too, you'll be more inclined to take you to the next step. Just spend that time trying to make each other feel good.
Practice really makes perfect …
Hormone treatment consumes your sex drive, so it may take a lot more time to get excited and although technically you may still have an orgasm, it's important to explore what works for you right now – without your partner's pressure, and then together.
Training your pelvic floor muscles (try stopping your urine in the middle of the flow) can make orgasm easier and more powerful. A simple online survey will show what you should do, or you can ask your doctor.
I advise all patients … take a bag of tricks
For many, life after breast cancer does not mean more spontaneous sex, especially if you have vaginal dryness. The lubricant is your savior and I recommend the "YES" range, which is organic without the addition of chemicals. An added bonus is that your doctor can prescribe them, so you do not have to pay – cancer patients receive free prescriptions.
Without sexual desire, it can take forever to get into the mood. A small vibrator can really help. And dilators can be a godsend as they can help stretch and relax the vaginal muscles.
Look for a set that gradually gets bigger in size. I recommend the Inspire Dilator kit, which is made of soft silicone. You can buy them online and they will be shipped in a discreet packaging.
Still struggling? Medications can help
If you still struggle with dryness despite the lubricants, your doctor may prescribe a topical estrogen cream or a vaginal pill such as Vagifem. This has been a complete watershed for me.
And since the amount of estrogen the body absorbs from these drugs is minimal, they are totally safe, even if the cancer type is sensitive to hormones.
There has even been a test to show that they do not increase the risk of recurrence.
Finally, your partner may struggle to maintain an erection, especially if he is afraid of hurting him. If this is the case, your doctor may prescribe a pill like Viagra to help you.
Breast cancer survivors deserve a pleasant and rewarding sex life. Talk to your partner. Talk to your doctor. Explore sex toy sites. It's trial and error, but you can reclaim your sex life and have fun trying.
- The Complete Guide to Breast Cancer: How to feel empowered and take control, by Professor Trisha Greenhalgh and Dr. Liz O 'Riordan, is published by Vermilion at £ 14.99.