Sex After Cancer

As a women’s health physical therapist, I see many women devastated by painful sex after cancer treatment. Please know that there is hope, there is help—in most cases, there is even a cure.

When you have cancer, sex is probably the last thing on your mind. You’re in survival mode, focused more on living than on loving.

But after your treatment ends, you may discover that it’s destroyed more than your cancer. One common—yet little-discussed—effect of treatment is painful intercourse (what doctors call dyspareunia). Like too many survivors, you may avoid sex or suffer silently, unsure where to turn.

Rest assured: there is hope. You deserve to enjoy sexuality and intimacy, and physical therapy can help you replace pain with pleasure.

How cancer takes a toll on sex

Cancer treatment. Chemotherapy, radiation, hormone-blocking therapy, and the removal of both ovaries: these treatments can trigger hormonal changes and menopause. As estrogen levels decline, the vagina starts to change. It can become thinner, drier, and less elastic; the muscles may tighten and weaken; and the vaginal opening, interior, lips (labia), and clitoris can get smaller. All can lead to dyspareunia. The pain can range from mild itching to excruciating burning, and it may affect the area around the vaginal opening (vestibule), the inside of the vagina, or the pelvis.

Sexual abstinence. If you skip the gym for a while, you start to get out of shape. The same holds true for the vagina: if you don’t have sex because you feel sick or because intercourse hurts, your vaginal muscles start to lose tone. They become tighter, less elastic, and weaker, which can cause or worsen intercourse pain. As the saying goes, “Use it or lose it.”

Painful orgasm. In some women, tight or weak vaginal muscles lead to painful orgasm, sometimes called dysorgasmia.

Vaginismus. Other women get trapped in a cycle of painful intercourse, fear of penetration, and protective vaginal tightening, which perpetuates their pain. This involuntary vaginal clenching is called vaginismus.

* Keep in mind that even if you have cancer, painful intercourse may be caused by something else. The culprit may be a gynecological condition such as endometriosis, pelvic inflammatory disease, vestibulodynia, or vulvodynia; or a vaginal skin condition, infection, cyst, or lesion. Or the cause may be a urological condition such as interstitial cystitis or a urinary tract infection. Even musculoskeletal conditions—back, hip, or leg problems or arthritis, for example—can make intercourse hurt. The correct diagnosis is crucial, so please consult with your gynecologist or urogynecologist.

How pelvic floor physical therapy can help

Today there’s a new specialty at the intersection of physical therapy, gynecology, and urology. Called pelvic floor physical therapy, it’s a first-line treatment for pelvic floor muscle dysfunction and painful intercourse. Specially trained physical therapists employ these gentle, proven techniques, tailoring treatment to the patient’s individual needs.

Manual therapy. Healing begins with hands-on therapies such as stretching, myofascial release, and trigger-point release—all inside the vagina. These gentle massage-like techniques relax tight tissues and muscles, melt away tender points and trigger points (sore knots that refer pain elsewhere), and reduce pain sensitivity. Your physical therapist uses the same techniques to loosen any tightness in your abdomen, back, hips, and thighs, because restrictions in these areas can contribute to pelvic and vaginal pain.

Pelvic floor biofeedback. Safe and painless, this feedback guides your vaginal exercise program. You insert a tiny probe into your vagina or rectum, then view your pelvic muscle activity via a graph on a biofeedback monitor. (If you can’t insert the probe, your physical therapist places sensors on the skin between your vagina and rectum.) You begin with pelvic drops—vaginal release exercises that teach your pelvic muscles to relax. Then you progress to vaginal muscle toning exercises. This guided exercise program relaxes spasms, promotes blood flow, increases elasticity, and decreases pain sensitivity. Home practice is vital to your recovery. (Note: Biofeedback is not advised for pregnant women.)

Therapeutic exercise. Your therapist may also teach you core-stabilization exercises. These include postural, stretching, and strengthening exercises for your abdomen, back, hips, and legs. All can help relieve pelvic pain.

Dilators. When you feel comfortable, your physical therapist may show you how to insert fingers, followed by gradually larger dilators, to gently stretch and desensitize your vagina. Home practice maintains and continues your progress.

In addition to physical therapy, you may benefit from vaginal lubricants and moisturizers, topical numbing cream, dietary changes, supplements, and gentle vaginal care. Sex therapy and psychological counseling can help you cope emotionally with sexual pain, communicate with your partner, rediscover your sexuality, and rekindle your sex life.

For more information, visit:

American Association of Sexuality Educators, Counselors and Therapists

American Physical Therapy Association Section on Women’s Health

International Pelvic Pain Society

The International Society for the Study of Vulvovaginal Disease

National Vulvodynia Association

The North American Menopause Society

The V Book: A Doctor’s Guide to Complete Vulvovaginal Health, by Elizabeth G. Stewart, M.D.

The Vulvar Pain Foundation

Raquel Perlis