By Clare Fox

Clare Fox, a Breast Care Specialist Nurse, based in Kendal, addresses the painful realities attendant upon the experience of breast cancer: the fear of how this affects sexuality.

The diagnosis of breast cancer is a devastating experience for a woman, for not only does she face a potentially life-threatening illness, but also the possibility of mutilating surgery. Her first priority will be to go ahead with treatment as soon as possible and this treatment may include surgery, chemotherapy, radiotherapy and endocrine therapy. Coping with treatment is very stressful in itself but added to that a woman has to come to terms with a change in her body image. This can have a profound effect on the way she feels about herself and can also affect the way she feels about close relationships. It therefore follows that during this time a woman will need the support and reassurance from those she loves: her husband or partner, family and friends. Most women will adapt to the changes encountered in their bodies due to treatments for their breast cancer and will continue to have fulfilling lives and relationships. However, it comes as no surprise to discover that 20 to 30 per cent of women can experience some psychological and sexual problems following breast surgery and treatment for breast cancer. It is useful, therefore, to look at ways that may help her to deal with these changes and rebuild her life after a diagnosis of breast cancer.

Body Image

Whenever we open a newspaper or magazine or switch on the television we are often confronted by the image of a perfect female form. This can be difficult for a healthy woman if she does not match up to the ideal but consider how hard this can be for the woman who has just received a life-shattering diagnosis of breast cancer. The breast is a symbol of many things. It is a symbol of womanliness, sexual attractiveness and motherhood. Loss or disfigurement of a body part that is so significantly related to feminine identity can therefore produce a profound negative effect on a woman's body image. Not only has she to cope with the psychological impact of the diagnosis, but also with the knowledge that a major symbol of her femininity and sexuality is going to be tampered with. Breasts can play an important role in a couple's physical relationship. Some women have breasts that are very sensitive to tactile stimulation and treatments such as surgery or radiotherapy can diminish or remove this sensitivity - thus treatments for breast cancer can affect a woman's sexuality and influence her interest and pleasure in sex. By exploring the following treatments areas of concern can be highlighted and possible solutions explored.

Surgery

Surgical treatment can consist of either removal of the lump and some surrounding breast tissue or removal of the whole breast as well as removal of the lymph glands under the arm. Whichever surgery is performed the woman is left with a scar as a reminder of a loss of her wholeness. Furthermore, however minimal the change to her breast as a result of surgery, it is a change that has to be reintegrated into her whole body reality. Being 'different' may cause a loss of self-worth and confidence. There is some evidence to suggest that early breast reconstruction following mastectomy may possible reduce the psychological impact in relation to body image problems and sexual functioning. Women facing mastectomy should, therefore, be given information and access to breast reconstruction. It is often assumed wrongly, however, that if a woman has breast conservation surgery she ought to feel grateful that she still has her breast and therefore shouldn't experience problems with her sexuality and body image. If this is the attitude that is conveyed to the woman she may then experience guilt about any negative feelings and thoughts she is experiencing with regard to these issues. This potential conflict can in turn interfere with her adaptation and process of recovery. Women need to be encouraged to express their feelings and be reassured that these feelings are normal.

It has been suggested that an important part of the process in accepting the change in body image is to prepare and help a woman to look at her scar. This can be achieved by talking about the effects of surgery and looking at photographs or drawings of what to expect as a result of surgery. It is important that the woman decides when she wishes to look and is allowed time and support to do so. This can occur in hospital or at home and some women may choose to have their partners present but some may not. Most women find that their partners are much less concerned by their scars than they imagine and once the subject has been discussed openly they can feel more at ease with their changed body image. Fears of rejection after breast surgery is a frequent and real concern for many women. A woman being treated for breast cancer may feel that she is no longer sexually attractive even though her partner is trying to tell her otherwise. She may fear rejection from her partner and so may withdraw from a close and physical relationship. He may interpret this withdrawal as a sign that she no longer wishes a physical relationship and so very easily a situation of misunderstanding can occur. A woman within an established relationship may need encouragement to resume her previous behaviour and levels of modesty and, may also wish to explore ways of reducing the confrontation of her partner with her changed image. Some suggestions may be made to help her. She may wish to wear night-clothes that allow a prosthesis to be worn, e.g. a sleep bra and, if breast stimulation is part of her normal foreplay she may wish to wear a breast-feeding bra that allows the breast to be exposed while retaining the prosthesis in place. Other strategies she may adopt could include undressing before her partner does, sexual intercourse in the dark and the use of alternative positions that will reduce contact with the breast or affected side. Certain methods can also be explored to reduce pain and discomfort following surgery such as relaxation techniques, analgesia or a warm bath before intercourse. The inventive use of pillows to protect the scar and to support the affected arm may also prove useful.

Radiotherapy

Some women undergoing radiotherapy as part of their treatment may experience skin reactions which can vary from slight redness to very sore broken areas. Close physical contact with the affected areas at this time can be achieved by adopting alternative positions for love-making. Radiotherapy can also cause tiredness and a general lethargy and desire for sexual intercourse may therefore be reduced. Perhaps noting the time in the day when energy levels are highest could be helpful to couples in identifying the best times for sexual activity both during and following treatment.

Chemotherapy

Chemotherapy treatment can also result in feelings of exhaustion and a reduction in libido and this can be a source of extra strain for the couple. Drugs used in chemotherapy can produce fatigue, nausea, vomiting, depression, malaise, depression, hair loss, and abnormal absence of menstruation. Pre-menopausal women should be aware that their menstrual cycle may be affected and it can take a variable length of time to return to normal, therefore birth control methods should be taken to prevent a pregnancy during treatment and for at least 12 months afterwards, or according to their doctor's advice. Some women find it disconcerting to experience menopausal symptoms during chemotherapy and reduced vaginal secretions may make sexual intercourse painful. This can be helped by the use of water soluble lubricants and, extended foreplay may also help to increase the natural production of secretions. Chemotherapy can last several months which can place a further strain on a couple particularly as decreased libido and irritability can in some cases persist after the end of treatment. It is important for couples to have sufficient information and access to health professionals who are willing to talk and provide support at this vulnerable time.

Endocrine Therapy

Many women take the drug Tamoxifen for five years as part of their treatment for breast cancer and this can also cause problems with an altered body image and sexuality. Weight gain, vaginal dryness, reduced libido, hot flushes and sleep disturbances may all occur and reduce a woman's sexual interest or excitement. It is important to offer women sensitive and supportive listening and to allow them to voice and express their concerns.

Lymohoedema

Lymphoedema, a heavy swollen arm, can occur in a significant proportion of women after breast surgery. This can happen weeks, months and even years after treatment. This can cause much distress and be perceived as a disfigurement or as a visible reminder of the cancer. This condition can be controlled and often reduced by special massage techniques and arm sleeves and women need to be aware that help and advice can be obtained.

Breast Prothesis

Restoring a woman's breast contour after her surgery is a very important part of helping her in her endeavours to adjust to the diagnosis and her altered body image. An external breast prosthesis remains the most common method of restoring breast contours after partial or complete mastectomy although the number of women having breast reconstruction is increasing. Women should be aware that they can have a breast reconstruction at any time following surgery and some women may wait for two or three years or even longer. An external breast prosthesis is a false breast form that can be placed inside a bra with the aim of producing an equal and balanced appearance when dressed. The provision of a closely matching prosthesis is an essential part of helping a woman adapt to the loss of her breast and she should have access to a sensitive and skilled fitting service. This should also provide information on swimwear and bras. Feeling confident again in her appearance may assist in coming to terms with her altered body image and help to re-establish her self-esteem.

Partners' Concern

It is important to emphasise that partners of women can and do experience as much distress and difficulty following a diagnosis of breast cancer as their women. Men often say they experience intense feelings of helplessness and fear and do not know how best to support their wives and respond to their needs. They have a need to communicate their fears and concerns and it is important that health professionals are aware of this and provide opportunities for them to discuss these issues. Research has demonstrated that men perceive significantly less support from health-care professionals and more limited opportunities to obtain support. They need the reassurance that they are reacting in a helpful manner, or alternatively guidance if they are unsure. Furthermore, men can also experience sexual difficulties after their partner's treatments. Some of the common problems are fear at the possible loss of the partner due to her cancer; fears for his own health and feelings of being deprived or even anger at his own loss of sexual fulfilment. Often the opportunity to express these feelings can be beneficial and, as well as access to health professionals, men should be given information on national help lines such as the partner volunteer service run by Breast Cancer Care.

Conclusion

Each woman is unique and will react to her breast cancer in her own way. What may be a problem to one woman will not have the same effect on another. But every woman needs time to recover both physically and emotionally, during and after treatment. And every woman needs the support and understanding of her partner, family, friends and health professionals, so that she can deal with the effects on her sexuality caused by breast cancer treatments to help her to adjust to the changes she will experience.