Sex after Cancer: Navigating a Return to Intimacy

Noa Benjamini was not about to let the fallout from her uterine cancer hold her back.

Helping hands

Elena Ratner, MD, (left) and Mary Jane Minkin, MD, help cancer survivors regain sexual intimacy.

Credit: Robert A. Lisak

Facts about sex after cancer
  • As many as 90% of female cancer survivors in the U.S. may have sex and intimacy issues.
  • Male cancer survivors grapple with issues such as erectile dysfunction.
  • Yale Medicine's Sexuality, Intimacy and Menopause Clinic (SIMS) treats both the physical and psychological fallout of cancer.

One day several years ago, Noa Benjamini, then 45, was watching her teenage son play football and thinking about the treatments for uterine cancer that lay ahead. Two weeks later she had a minimally invasive hysterectomy and landed a job as a contract manager at Yale, taking breaks to walk a few blocks for radiation treatments.

“I’m that type of person,” says Benjamini. “I just move on.”

What she did not anticipate was cancer’s fallout—symptoms nobody seemed to talk about. Benjamini found herself scouring the Internet for help with dry skin and dry hair, weight gain and hot flashes, pain and bleeding during intercourse. Some symptoms were the result of sudden menopause. Others were side effects of radiation.

Frank talk about sex

“I was asking, ‘What do I do about this? What about that? I needed answers,’” Benjamini says. “All those changes that are supposed to happen gradually at menopause were happening to me quickly. I thought I’d shrivel up.”

Her oncologist referred her to Yale Medicine’s Sexuality, Intimacy and Menopause Program at Smilow Cancer Hospital at Yale New Haven, where she credits doctors for helping her recover fully from cancer. “They listened,” Benjamini says. “They made me realize how young I still am.”

Today, Benjamini is still a patient at the SIMS clinic, one of a handful of medical centers in the U.S. dedicated to the sexual health of cancer survivors—even though an estimated 85 percent to 90 percent of the 6 million female cancer survivors in the country have intimacy issues. Many women find that the treatments that saved their lives wreak havoc with their sex lives.

“Many cancer specialists are of the belief that patients sort of adapt. You’re a survivor: You should be happy,” says Mary Jane Minkin, MD, a menopause specialist who co-founded the clinic with colleague Elena Ratner, MD, an oncologist.

To learn more about the program, click here.

Changing the culture

“What we are trying to do for these patients is to create a change in culture,” Dr. Ratner says. “We want to make sex part of normal conversation. When a cancer survivor visits a doctor, the question should be part of the normal social history—‘Do you smoke? Do you drink? Are you happy with your sex life?’”

Providers in the clinic talk openly and frankly about sex with patients and sometimes their partners, even discussing sexual positions and ways survivors can feel attractive again. “We talk about vaginas every day. We look at sexuality as a normal part of survivorship and a vital part of living,” Dr. Minkin says. “People come in and are astounded.”

A full recovery

Mary Jane Minkin, MD, (left) and Elena Ratner, MD, talk with a patient.

Along with wigs for chemo patients, the Cingari Boutique at Smilow Cancer Hospital stocks vibrators, vaginal moisturizers and lubrication creams as well as vaginal dilators in various sizes for women who may have a narrowing of the sex organs after treatments.

After one of her initial visits to the clinic, Benjamini left with a “toolbox” of treatments including Divigel, an estrogen gel to treat vaginal dryness, and black cohosh, an herb used to treat hot flashes. She was later prescribed antibiotics for vaginal bleeding.

Other patients have benefited from Osphena, the only Food and Drug Administration-approved, prescription-only, non-estrogen oral pill for painful sex resulting from menopause. As for estrogen, while many women in the United States question its safety, Dr. Minkin says their fears are not supported by the research.

“There are definitely women who shouldn’t be taking estrogen, but there are women, including some cancer survivors, who can take it to very good effect,” she says.

While female survivors were the original focus of the clinic, Dr. Minkin and Dr. Ratner recently partnered with Yale Medicine urologist colleagues to provide similar services for male cancer survivors. 

Others need continued support. A cervical cancer survivor told Dr. Ratner during their initial conversation that she had not had intercourse in eight years. “I thought that this is how things are after this kind of surgery,” the doctor recalls the patient telling her.

Treating the body

For men, sexual dysfunction is usually an anatomical issue, with erectile dysfunction (inability to achieve and maintain an erection) at the top of the list.

For women, it is exceedingly more complex. Survivors face multiple physical challenges, like loss of feeling in a breast after reconstruction or painful vaginal narrowing after radiation to the pelvis. Young women who have had hysterectomies, chemotherapy or radiation are especially concerned about early menopause and loss of libido. Many female survivors report pain during sex, less energy for sex, difficulty reaching climax, loss of desire or negativity during sex.

Benjamini recalls her struggle: “Number one was the pain during intercourse, and achieving orgasm is completely different—the length of it and the strength of it.”

Viagra, taken primarily by men to increase blood flow to the penis, has helped some women, including Benjamini, to achieve improved lubrication, sensation and orgasm.

Emotional healing

While Yale’s Sexuality, Intimacy and Menopause Clinic is one of only a handful of such facilities nationwide, it is unique in that it treats both physical and psychological problems. Every patient spends time with a counselor. “Emotional healing is part of feeling whole again. It brings enjoyment and depth to relationships,” says Dwain Fehon, PsyD, who manages the counseling aspect of the clinic.

Some patients return for continuing short-term cognitive behavioral therapy with a counselor, often bringing along a spouse or partner.

In some cases, healing has limits. Men who are impotent after prostate surgery or women who lose erogenous sensation in a breast after reconstruction must learn new ways of defining sexuality and maybe explore other areas of the body.

“Cancer can have a significant impact on sense of self,” Fehon says. “The challenge is to continue to find ways to feel a sense of purpose, of meaning and enjoyment. Therapy is frequently centered on just those things—how to maintain resilience and sense of purpose—and that’s the case with life in general.”

Building on the research

Because sexual intimacy in cancer survivors is a relatively new field, Yale Medicine doctors continually strive to learn more. “We are trying to provide some objective data that is very much lacking in this field,” Dr. Ratner says.

One thing research has shown is that if a patient enjoyed sex before cancer, he or she will have a better chance of enjoying it afterward. “I use the piano joke,” says Dr. Minkin. “‘After the accident, can I play the piano again?’ The answer is: ‘Well, did you play the piano before?’”

Benjamini, now living in Boston, continues to drive to New Haven to visit the clinic every three months. “I like to check in and see if there are any new treatments on the market.” She has an unwavering belief in the results, and in the healing power of intimacy. She has met many women who have decided that sex is over after cancer.  She always tells them they are wrong.

“They talk about their aches and pains, how their knees hurt, how tired they are. Not me,” she says. “You have to keep asking questions and bring up every little thing that’s not working. Women would be surprised at how well they can heal if they have the right support.”