It astounds me how often this conversation is NOT happening between women and their doctors.

Oftentimes, I’ll see a patient for the first time, with a history of breast cancer and all of the hormonal shut down that accompanies breast cancer treatment AND the simultaneous march into perimenopause and menopause. (Perimenopause being the added bonus of feeling like you are in menopause, but you get to retain the beauty of bleeding like a stuck pig every month…just terrific.)

The impact of both menopause and breast cancer hormone treatment is the progressive thinning and dryness of vulva and vaginal tissue. It causes painful sex, increased urinary or vaginal infection and incontinence or urinary urgency. But what is truly surprising is the lack of a true discussion about this very important aspect of life.

Yes, women are thankful to survive breast cancer.

Yes, they are grateful for being alive and overcoming cancer.

Yes, they are suffering silently in large numbers due to the lack of sex drive, painful sex and many other issues related to vaginal dryness or “atrophy” to use the medical terminology.

My sense from a lot of survivors is that they may have raised the issue in the past with their oncologists or gynecologists. They were told it was a common problem because of menopause or because of the medications used to treat breast cancer, and that there weren’t a lot of allowable options, since most treatment involves the use of estrogen hormones.

That’s what I call the “Have a Nice Day!” conversation. “Next!” “Case closed!” “We’re done here!”
Because libido, painful sex, dryness, breast cancer, and menopause — are generally considered to be not so easy to fix.

If you have time right now, I refer you to a few articles I’ve written before about vaginal dryness and painful intercourse.

Reading these posts will give you the background about sexual issues impacting women of all ages and hormonal states. The content however is definitely relevant to someone diagnosed with breast cancer. There are definitely added layers of intricacy to the story. I find that it’s not just ONE thing that may be problematic. There are often layers that need to be identified, examined and addressed.
» Libido cannot be addressed until the act of sexual intimacy is NO LONGER PAINFUL!!!

Here is my approach to someone who reports vaginal burning, pain with intercourse and the like:

• What’s the story?
• What’s the timeline of events? When exactly did things start to change?
• What about your sexual history?
• Were things totally great and then *POOF* — the situation just spiraled into the abyss of “I hate sex and this whole topic is depressing?”
• Were there issues even before things got to the stage of really awful?
• What surgery and medical treatment did you receive and how did this impact your sexual health?

• What is going on?
• Tell me about your symptoms?
• Where does it hurt?
• Sex aside, what does it feel like “down there” on a regular basis?
• How does it feel during sex?
• What other vaginal or bladder or intestinal issues are at play?
• What medications are you taking?
• What treatments have you tried before?

Let’s see what’s happening…the Physical Exam!! Let’s meet the cast members!

There are many operating “characters” here…

The Labia

The Labia — The vulva which includes inner and outer labia will be played by Whoopie Goldberg, Olympia Dukakis and whichever Kardashian is least popular. It’s like the chorus. No one really notices them, until the music starts playing and SOMEBODY – who shall remain nameless – sings off key. A very marginalized piece of the puzzle. There are a ton of sensitivity receptors in this area and if the pearly gates are rusted shut, no one will be seeing the rest of the musical. This outer area is often totally bypassed in the rush to get to the vagina. The labia must be attended to. It will NOT be IGNORED (for any fans of “Fatal Attraction.”) Many times, the dryness and thinning of this area will create tearing, fissures and an overall not fun time. This area is not so easily repaired for women with a history of breast cancer because topical estrogen and hormonal creams are ill advised.

The Clitoris

The Clitoris — This role is considered to be the “star of the show” and will obviously be played by Liza Minnelli. For the Millennial crowd, Hannah Montana fits the part…you know the one…she married a Hemsworth. Miley Cyrus!!! Yes, I knew the name would come to me!! So this tiny area is the one many a “love” partner finds illusive, the Loch Ness monster, so to speak. This is where there is a lot of drama, screaming, heavy breathing (mostly faked) and the big finale….aka the female orgasm. Not as flashy as the male counterpart. Usually not as messy, since we all know who’s responsible for clean-up. But at any rate, this is ALSO greatly affected by the hormonal shifts of menopause, perimenopause, medications and cancer therapy. The area becomes less easily stimulated, may shrink in size and is generally less responsive. It may be in desperate need of resuscitative measures.

The Vagina

The Vagina — This is where the heavy lifting is done. Meant to survive and withstand the passage of items 12 times its own size, the role of Vagina will of course be played by either Bill Bixbie from the original Incredible Hulk TV show or Mark Ruffalo, the current version of the Incredible Hulk in the Avengers series. Frankly, he’s a bit of a panty liner in my opinion to befit the strength, resilience and durability of a vagina, but, metaphorically speaking, he will do. Many relegate the vagina to a less important role with regard to sexual pleasure. Let us not forget that the G spot lives there. But the G spot is of zero value if the rest of the vagina is not happy. By not happy I mean, not lubricated, not elastic, not well vascularized (in other words, not getting the blood flow it desperately needs). Or for the “Shelter In Place” fans out there: in need of a root touch up for the grays, doing way too much day-drinking and taking too much Xanax to sleep.

The Cervix and Uterus

The Cervix and Uterus — Although this pair is generally relegated to womb detail and the trimmings that accompany that party, they do deserve mention as they may play a role in the female orgasm. These female parts will be played by Meghan Markle and Kate Middleton because for purposes of this discussion, these two are mainly figureheads and no one is exactly sure what they are actually doing when they aren’t giving birth to royal offspring. Having said that, as Meghan Markle just demonstrated, they can certainly stir the pot, and if these two are not happy for some reason, they may lead to lousy sex.

So there you have it. The cast of characters. Can’t wait for the movie to come out!!!

Now the point of all this is to say, that issues related to painful sex or less enjoyable sex or urinary incontinence or frequent bladder and vaginal infections can involve any or all of these areas. Oftentimes it isn’t just ONE problem. However you need to approach this systematically and start fixing issues one at a time in order of prime importance. It’s like an onion with a lot of layers to “unpack.” (Oh! you had to say it. —Ed.)

HERE’S WHAT I EVALUATE INITIALLY:

THE VULVA AND VAGINAL TISSUE

Most of the time the thinning, dryness and elasticity creates pain, fissuring, bleeding, a burning sensation and the like. This is critical to start addressing. If you can’t address it by restoring the estrogen that is lacking for obvious reasons in a patient with breast cancer, the best option far and away is using a vaginal laser or radio frequency treatment. This is probably the most effective treatment in my experience. I use the Femilift and Votiva, Forma V. There are some nuanced differences between these two modalities depending on what it is I want to accomplish with a patient, but both are amazing for vaginal dryness and painful sex, significantly improve incontinence and can restore the normal pH balance needed to prevent vaginal urinary tract infections.

THE VAGINAL MUSCLES

Levator Spasm or Vaginismus may be at play as well. These conditions involve an involuntary gripping of the vaginal muscles particularly at the opening that create significant pain when touched. Suffice it to say, that this oftentimes will accompany pain with intercourse, but may not be obvious at first until the vaginal tissue is restored to normal factory settings. Your doctor can evaluate you for this condition and then will refer you to a specialized pelvic floor physical therapist for treatment. Check out this article entitled: Beyond the Kegel: the who, why, and how of pelvic floor PT.

THE NERVOUS SYSTEM

Vestibulodynia — a fancy term for “my vagina is killing me!” This occurs when the nerves at the opening of the vagina are way too sensitive to touch and pressure and instead interpret these sensations as burning, stabbing, sharpness and stinging pain. This condition is often associated with estrogen deficiency issues, however, that is not the only cause. Many times we don’t know why this happens, but if diagnosed there are many different ways to approach this. Some may include anesthetic agents topically or compounded creams with several ingredients designed to retrain the nerve pathways. Some women may need pelvic floor therapy with specialists trained in addressing this condition. Some women may be taking medications that are responsible for upregulating the nerve pain pathways. But regardless of the cause, it is an important factor often misdiagnosed in women.

THE BLOOD FLOW

Hypovascularity — also known as reduced blood flow. Blood carries oxygen. Blood makes areas more full and engorged. These are critical factors in giving you a more (or any) pleasurable sensation, lubrication and are very important for helping create the right conditions for better orgasms. Or in some cases “any” orgasms. One important player here is Nitric Oxide. As Dr. Nathan Bryan PhD quipped:

“This compound is responsible for regulating blood flow to the sex organs. For women to have an orgasm, there must be an increase in vaginal and labial pressure. This pressure is controlled by an increase in blood flow to the clitoris. Without nitric oxide, there cannot be an increase in blood flow to the clitoris and consequently no increase in pressure and no orgasm. Therefore, restoring Nitric Oxide production can improve blood flow to the pelvic region and sex organs and improve lubrication, desire and orgasms.”

Some ways to support better total body Nitric Oxide production include:

• Physical Exercise: Moderate physical exercise stimulates the production of nitric oxide
• Eating Tons of Leafy Greens: Eat more green leafy “choc-full-of nitrate” enriched vegetables
• Stop Using Antiseptic Mouthwash: You need certain types of bacteria in your mouth to allow the production of Nitric Oxide
• Take Care Of Your Teeth and Maintain Your Stomach Acid: This is needed to support the conversion and eventual absorption of nitric oxide from foods rich in Nitric oxide

I have other tricks up my sleeve for this but first we need to assess if this is actually your issue. Check out Pneuma Nitric Oxide Skin Serum and Neo 40 Pro. These can enhance your own Nitric oxide production and are hormone free. The skin serum is meant to aid in wound healing AND to help defeat wrinkles. However, it can also be used “down there” nightly to improve blood flow AND can be used 15 minutes prior to intercourse to try to up the ante in the orgasm department.

Thusly…the post has come to an end. The point is, don’t live with the status quo. Be persistent about your sexual health needs. And if you aren’t getting answers from your doctors, find someone who may have more experience, time and interest in the nether regions!!!

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For more information about my wellness programs and my practice, check out my website drsadaty.com. Hey Look! You are already here…

Ready for the legal disclaimer? Information offered here is for educational purposes only and does not constitute medical advice. As with any health recommendations, please contact your doctor to be sure any changes you wish to consider are safe for you!