Sexual side effects

It’s normal to lose interest in sex at times after diagnosis and during treatment. Breast cancer treatments or the cancer itself can cause fatigue, discomfort, pain, and other side effects that impact your sexual desire and activity. These side effects can happen during treatment, or months or years afterward.

It's important to know that you are not alone. LBBC is here for you with support and guidance to help you manage side effects and stay connected to your sexual self.

Below, we'll talk about common breast cancer treatment side effects that can impact your sexual life. We'll also provide links to detailed information on maintaining your sexual health, getting comfortable with your body image, communicating with a partner, and more.

Sexual side effects of different treatments

Many breast cancer treatments can cause side effects that can interfere with sexual life. But not everyone experiences every side effect, and there are many ways to manage them if they happen. In this section, we’ll talk about the common treatments that can cause these side effects.

Surgery

Different breast cancer surgeries can result in sexual side effects:

• Mastectomy and lumpectomy are cancer-removing surgeries that remove all or part of the breast.
• Breast reconstruction rebuilds the breast after cancerous tissue is removed.
• Lymph node surgery (sentinel node biopsy or axillary node dissection) removes tiny immune system organs called lymph nodes so that doctors can check for cancer spread.
• Ovary removal is recommended for some women, especially if they have an inherited BRCA mutation that greatly increases the risk of breast and ovarian cancers.

The physical effects of these surgeries can change your body image, or the way you feel about your body. They can also change how your body feels to you and your partner. And sometimes, these changes can bring a loss of interest in sex. Here are some of the surgery side effects that can impact sexuality:

• Pain: As you recover from breast surgery, there can be burning and constricting sensations or sudden, sharp pain as your body heals. For some people, there can be chronic, ongoing post-surgery pain.
• Loss or change of sensation in the breast: Breast surgery cuts nerves and can change or eliminate feeling sensation in and around the breast, and on the breast skin. Some mastectomy surgeries require removal of the nipple. All of these may concern you if you enjoy breast play or have orgasms when your breasts, nipples, or areolae (the area around the nipple) are touched.
• Lymphedema: Some people who've had underarm lymph nodes removed later develop temporary or permanent swelling in the arm. Lymphedema can also happen in other parts of the body where surgery took place, such as the breast or abdomen. This can be painful, and it can affect the way you feel about your body.
• Axillary web syndrome, also known as cording: This is another potential side effect of underarm lymph node removal. The term "cording" comes from the rope-like structures under the skin of the inner arm that develop near the site of scarring and may extend down the inner arm to inside the elbow. The cords tend to be painful and tight, making it difficult to lift your arm higher than the shoulder or fully extend the elbow.
• Menopausal symptoms: For women who choose to have their ovaries surgically removed before natural menopause, the immediate result is medical menopause, which quickly brings on hot flashes, night sweats, vaginal and vulvar dryness, mood changes, fatigue, and changes in sex drive.

Radiation therapy

Radiation therapy directs high-energy x-rays at specific areas to kill cancer cells. Breast radiation does not directly decrease sexual arousal or response, but it can cause side effects that may impact your sexual life, including:

• Breast discomfort, due to tenderness and swelling
• Fatigue
• Range of motion problems in areas around the breast because of scarring or lymphedema
• Skin changes, such as redness, changes in sensitivity, and thickening of the breast tissue or skin

If you enjoy breast play or have orgasms from touching your breasts, nipples, or areolae, skin changes may be of special concern.

Chemotherapy

Chemotherapy travels through the bloodstream to kill cancer cells that are growing or dividing quickly. Although very effective at killing cancer cells, chemotherapy also affects all quickly dividing cells — even healthy ones. These include the cells of the ovaries, which produce estrogen. Estrogen helps to maintain the vaginal moisture that makes sex comfortable.

Sometimes chemotherapy irritates the tissues of the vulva (the area outside the vagina) and the vagina itself, making it dry and inflamed. Irritation can spark flare-ups of genital herpes or genital warts if you had them in the past. Other side effects from chemotherapy may include:

• Low libido or sexual desire
• Difficulty getting aroused or reaching orgasm
• Lack of energy for sexual activity because of nausea, vomiting, or fatigue
• Pain during penetration when the penis, a sex toy, or a finger is inserted into the vagina
• Pain when the vulva is touched
• Menopausal symptoms, such as hot flashes and irregular or no menstrual periods
• Light spotting after penetration due to thinning of the vaginal lining

Targeted therapy

Targeted therapies are medicines that target changes in specific proteins or markers on or within cancer cells that help the cells to grow. Instead of killing all fast-growing cells, these medicines target just the cancer cells.

These medicines often have fewer side effects than chemotherapy, but they are usually given with chemotherapy. If you receive both treatments, you could have the same common side effects as you would with chemotherapy alone, such as hair loss, nausea, fatigue, vaginal dryness, and loss of sexual desire.

Hormonal therapy

Hormonal therapy blocks or lowers the hormones that hormone receptor-positive breast cancer needs to grow. Hormonal therapy includes treatments such as:

• Tamoxifen, approved for pre- and postmenopausal women
• Aromatase inhibitors, approved for postmenopausal women

Hormonal therapy can increase menopausal symptoms and impact your sexual health. Side effects include:

• Hot flashes
• Night sweats
• Insomnia
• Irritability
• Joint pain
• Reduced sex drive
• Vaginal and vulvar dryness
• Vaginal atrophy (thinning of the vaginal walls)
• Pain during sex
• Irregular periods if you are premenopausal
• Bone loss

Oophorectomy and ovarian suppression medicines

If you test positive for an inherited BRCA1 or BRCA2 mutation, the risk of developing breast cancer and ovarian cancer is significantly higher than for women who do not carry these mutations. One risk-reducing strategy is surgery to remove the ovaries, a procedure called oophorectomy. If you are premenopausal, ovary removal will put you in immediate menopause.

For some pre- or perimenopausal women, ovarian suppression may be recommended. Ovarian suppression uses medicines such as leuprolide (Lupron) and goserelin (Zoladex) to stop the ovaries from making estrogen. These medicines cause symptoms that last as long as you're receiving the medicine, and for a short time afterward.

Both oophorectomy and ovarian suppression can result in menopausal symptoms such as hot flashes, vaginal and vulvar dryness, lowered sex drive, and painful sex. Especially with oophorectomy, symptoms can be more intense than they would be if you went through natural menopause.

Antidepressants

Some antidepressants, called selective serotonin reuptake inhibitors (SSRIs), can lessen sexual desire and affect your ability to reach orgasm. SSRIs are sometimes prescribed to help with hot flashes.

Depression is common during and after treatment for breast cancer, and depression can lead to a loss of interest in sex. If antidepressants are part of your treatment and you believe they are adding to your sexual concerns, talk with your doctor about possibly switching to another antidepressant or stopping altogether.

Anti-nausea medicines

Antiemetics, medicines used to control or stop nausea during chemotherapy or other treatments, have side effects that may interfere with sexual desire. These include drowsiness, diarrhea, constipation, headache, and fatigue.

Your sex life is not over

We know that the above list of side effects can feel overwhelming to read. It's important to know that not everyone will experience all the side effects mentioned above. And no matter what kind of treatment you have, breast cancer does not mean an end to your sex life. There is lots of help available that can restore sexual enjoyment and intimacy.

If you feel like you do want to try sexual activity, start slowly. See what different kinds of nonsexual touch feel like to you. If you have a partner, touch such as holding hands, stroking an arm, or hugging can nurture intimacy and help you feel connected. Whether you are partnered or single, there are ways to take care of yourself and maintain a sexual life.

If sex feels painful, there are many things you can do, including stretching pelvic muscles with dilators, using vaginal lubricants and moisturizers, and trying new positions. Learn more about managing pain during sex.

Finding help for sexual side effects

As you plan treatment, talk with your care team about potential sexual side effects and any steps you can take to manage them. Many healthcare professionals are sensitive to this issue and want to help you. Even if they don’t have all the answers, your care team can direct you to other professionals who can help.

We know that it can sometimes feel uncomfortable to bring up sexual side effects with your oncologist or oncology nurse. But don't be afraid to ask for advice or for a referral to a sexual health specialist. Here are some tips to start the conversation:

• When you make your next oncologist appointment, mention that you would like a few extra minutes to ask questions.
• Before your appointment, write down the symptoms you've been having, as well as any questions you have.
• Be as specific as you can. For example, say, “I have pain during sexual penetration. What can I do to get relief?”
• Rehearse what you want to say before your appointment. It can help to say the words out loud to a partner or friend, or in front of a mirror.

If your care team is unsure how to help, or if they seem uncomfortable discussing your sexual concerns, ask for a referral to a specialist in sexual health, cancer survivorship medicine, or both. These professionals give specialized care to people who are living with the sexual side effects of cancer treatment.

To learn more about how to manage sexual side effects, visit our section on sex and intimacy.

Sexual side effects and metastatic breast cancer treatment

Metastatic breast cancer (MBC) treatment can cause sexual side effects the same way that early-stage breast cancer treatment can. Side effects can vary based on the type of treatment you have. If you’re having difficulty with sexual side effects, you are not alone. Talk with your nurse or doctor about what you’re experiencing. There are many ways to address sexual side effects, and your care team can make recommendations.

If the cancer is hormone receptor-positive, treatment may start with hormonal therapy, with or without targeted therapy. These medications work to lower or block estrogen. Other treatments that may be recommended for MBC can also impact estrogen and the ovaries. These include oophorectomy, ovarian suppressing medicines, and chemotherapy. All of these treatments can cause sexual side effects.

Hormonal therapy

Hormonal therapies used to treat MBC include:

• Aromatase inhibitors, approved for postmenopausal women
• Fulvestrant (Faslodex), approved for postmenopausal women
• Elacestrant (Orserdu), approved for postmenopausal women
• Tamoxifen, approved for pre- and postmenopausal women
• Toremifene citrate (Fareston), approved for postmenopausal women

Oophorectomy and ovarian suppression medicines

If you have tested positive for a BRCA gene mutation that raises your risk of ovarian cancer, ovary removal (oophorectomy) may be recommended for you. If you are premenopausal, this surgery causes immediate menopause (medical menopause) and sexual side effects.

If you are premenopausal and your care team has recommended taking ovarian suppressing medicines to further lower estrogen in your body, you will likely experience menopausal side effects that can interfere with sexual life.

Chemotherapy

Chemotherapy is another treatment that impacts the ovaries and causes sexual side effects. Chemotherapy can sometimes irritate the tissues outside the vagina (the vulva) and the vagina itself.

Still, in MBC treatment, chemo is often given in single doses, not combinations. If you're being treated with one chemotherapy medicine and not taking any other medicines that impact estrogen, sexual side effects may not be as intense as they might be if you were being treated with a chemo combo.

Specific side effects that can impact sexual life

The treatments mentioned above can cause these sexual side effects:

• Hot flashes
• Night sweats
• Insomnia
• Irritability
• Joint and bone pain
• Loss of libido
• Vaginal and vulvar dryness
• Vaginal atrophy (thinning of the vaginal walls)
• Pain during sex
• Irregular periods if you are premenopausal
• Bone loss

Not everyone experiences every side effect. But if you're being treated for MBC, just being on multiple treatments and experiencing many different emotions can have a big impact on sexuality. An MBC diagnosis can be exhausting, and if you have bone metastasis or bone loss, it can make some sexual positions uncomfortable. Hot flashes and night sweats don't feel sexy, and if you have pain during sex, or if penetration is not possible, it can be upsetting. It's not always easy to find the energy or desire to be sexual. And that's okay. Whether or not you engage in sex is 100% up to you. And if you do decide you want to be sexual, there are many, many options to ease side effects and support enjoyable sex.

It's important to communicate with your care team about sexual side effects so that they can provide guidance and recommend treatments that can help. You can also ask for a referral to see a healthcare professional or counselor who specializes in sexual health and cancer treatment.

To learn more about how to manage sexual side effects, visit our page on navigating intimacy and sexuality with MBC, as well as our sex and intimacy section.