Last week a brief media splash highlighted a study from my friend Sharon Bober, PhD and her colleagues at Dana Farber Cancer Center on the lack of availability of sexual health aids for patients at major cancer centers (Abstract). Noting that products such as vaginal moisturizers and lubricants or vacuum erection devices for men could help with post-cancer sexual problems, the team chose 25 major cancer centers (NCI and NCCN designated) and called their specialty boutiques and shops, which typically sell wigs, cosmetics helpful during chemotherapy, and other products to help with cancer-related side effects. Callers posed as cancer patients or family members looking for help with products for a men’s or women’s sexual problem. Only one center offered a variety of options. Of the 23 that responded to calls (sometimes with multiple tries and attempts to find the most appropriate outlet), 87% had no sexual aids for men on site and 72% had none for women. Furthermore, one of the co-authors, Dr. Chris Recklitis, noted in an interview (Brief Video) that the staff reached at most centers were highly uncomfortable discussing sexuality, which could certainly discourage patients from further questions.
I understand the researchers’ premise. Although lubricants, vibrators, and men’s penile rings or pumps are available all over the internet from specialty stores such as Smitten Kitten, Babeland, Good Vibrations, or Pure Romance, and also from large retailers like Amazon and Walmart, many cancer patients who are older or have more conservative values may be reluctant to search for them. Even if they find outlets, the sheer variety of products is bewildering. Chances are, they will not make an optimal choice of vaginal lubricant, penile erection device, or vibrator. Some of the products with the most evidence-base are not widely distributed and may only be available from their own website. It would be nice to have an in-house “sexual health boutique” to guide patients and make the purchase easy. I am not sure what the Dana Farber team is envisioning, but I do have thoughts on how to structure such a resource.
Cancer centers are inherently conservative environments with a wide range of patients in terms of nationality, subculture, education, and attitudes. To have a sexual boutique corner of the gift shop or even the shop that provides scarves, wigs, ostomy covers, etc. would unfortunately be likely to offend some patients, leading to complaints and controversy. Also, the staff and sometimes volunteers who interact with patients in those environments may not take well to training on how to discuss sexual problems, especially in such a public environment.
Will2Love is currently partnering with the very progressive and patient-centered Center for Integrative Oncology Survivorship program at Greenville Health System in South Carolina. They have put together “gift bags” for women who have a sexual health visit, including samples of lubricants and a small vibrator to help women get started. However, the sexual health aids are presented in the context of a visit to assess the woman’s concerns, provide brief sexual counseling, and ensure that referrals for medical and mental health specialty care are made. To me, this is the ideal way to make sexual health aids available to patients—as part of sexual counseling services. Will2Love’s system for oncology practices includes training frontline clinicians, such as advance practice nurses, physician assistants, or social workers, to do an initial, thorough assessment and counseling visit. They could certainly have samples of sexual health aids that would be helpful, or even be able to have patients purchase them from the hospital pharmacy with a written “prescription” that could be discreetly presented at the counter. Sadly, I am only aware of 14 cancer hospitals that formally offer sexual counseling services.
Too many pharma commercials and internet stories of miracle cures have given cancer patients the idea that a magic pill, new type of vibrator, laser treatment, or herbal lotion is all that is needed to restore a good sex life. Unfortunately, sexual rehabilitation after cancer is typically much more complex. Women need to experiment with combinations of nonhormonal vaginal moisturizers and lubricants to find out how to avoid pain from genital dryness and vaginal shrinkage. Often, use of vaginal dilators of graduated sizes or low-dose vaginal estrogen is required for better outcomes. For men, penile rings by themselves are rarely effective. Penile erection devices, combining a vacuum pump to draw blood flow into the penis and a ring to maintain the erection come in many versions—prescription and nonprescription, with and without safety valves, and manual or battery-powered. Using them correctly takes practice and often some coaching. But even more than the complexities of devices, achieving sexual pleasure may require new communication skills between partners and a revising one’s view of sex from a “performance model” that always ends in some kind of penetrative sex to an opportunity to share pleasure and intimacy with a wider variety of touch and caressing. Buying a pink, penis-shaped vibrator is not going to get you there. Sex therapists have devised a variety of individual and couple exercises to guide this process. Will2Love’s online programs for men and women present them in self-help format, but some couples will benefit more from working with a trained therapist.
That said, if I were going to provide sexual health products for frontline sexual counselors to distribute in cancer settings, here are some products I would consider:
What Kinds of Vibrators?
During and after treatment for cancer, getting regular blood flow to the genital area may minimize shrinkage of soft tissue in the penis helping to maintain or recover erections. The oxygen in the fresh blood helps maintain the health of small blood vessels involved in erection. Although less research is available, the same principles may help reduce vaginal shrinkage and help to maintain the ability of women’s genital tissue to stretch and produce lubrication during sexual arousal. Using a vibrator on the sensitive sexual areas of the body will typically increase local blood flow, sometimes without even an awareness of mental sexual arousal. So using a vibrator is one option to promote genital health after cancer. You can easily buy vibrators that will give pleasure for under 20 dollars. For many women, the “bullet” or handle with attachment type of vibrator, used on and around the clitoris is much more effective than a penis-shaped vibrator placed in the vagina. For men, a whole host of vibrator shapes are available, including rings that surround the base of the penis or sleeves that are supposed to feel like a vagina or anus. If you want a vibrator that is sleek, waterproof, and offers many different patterns, speeds, and intensities of vibration, you can easily find a deluxe one for between $100 and $200.
However, there are two vibrators that may offer an advantage in recovering from cancer, although I would caution that there is not yet proof that they are more effective than less expensive models.
The Viberect®, a tong-shaped device with vibrating pads to place on either side of the head of the penis is said to “help restore critical nerve reflexes required for erections, improve blood flow towards and within the penis…” and to “help strengthen muscles around the penis that act as physiological ‘penis rings.’” This explanation of the erection mechanism is quite inaccurate, so take the claims with several spoons of salt. One randomized trial followed 68 men who had good erections before nerve-sparing radical surgery for prostate cancer. About half used a special vibrator (not the Viberect®) once daily for a week before the operation and again for a 6-week period afterwards. The others did nothing special. Erections a year later were slightly better for the treated group, but the difference was not statistically significant (i.e. the vibrator use did not improve sex at a level better than chance).
Women are instructed to wear Fiera®, a hands-free vibrating and suction device that fits over the clitoris by themselves, to get aroused for couple sex. A hands-free vibrator like the Fiera® could make it simpler for women to stimulate genital blood flow several times a week after cancer surgery or radiation therapy, or during treatment with aromatase inhibitors. A small study showed that using the Fiera® did increase blood flow—but it is not yet clear whether the suction ring creates more local blood flow than just vibration. Dr. Leah Millheiser, the gynecologist who helped design Fiera®, is interested in using it in clinical trials with cancer survivors.
What Kinds of Genital Moisturizers and Lubricants?
Genital dryness and loss of vaginal size is the most common problem for women after cancer treatment. Some women experience a premature, sudden menopause after chemotherapy, pelvic radiation, or pelvic surgery. Others were already in menopause but have much worse problems, especially women given aromatase inhibitors as hormone therapy for breast cancer. Genital graft vs. host syndrome after a stem cell transplant from a donor is another cause of dryness and scar tissue formation. Many women do not realize that vaginal moisturizers are a different kind of product from lubricants. Moisturizers do not contain hormones, but are gels put in the vagina with an applicator or as a suppository. Like a moisturizer for your face, they help the vaginal lining stay moist all the time, so they are meant to be used regularly, not just before having sex. Although most moisturizer packaging suggests using them 1-3 times weekly, cancer survivors may need more frequent use. The moisturizer I have found most effective for cancer patients is Hyalo Gyn®, which can be purchased online from its own website.
Genital lubricants are meant to be used during sexual activity. Even women who use a vaginal moisturizer regularly should try adding a lubricant for sex, either water-based or silicone-based. The lubricant should be used liberally on both partners and kept handy in case more is needed during lovemaking. Silicone-based lubricants are more expensive but stay slippery longer. Some may stain clothing or sheets and cannot be used on silicone sex toys. Water-based lubricants can sometimes be drying if they do not conform to good standards of a quality called osmolality. Some also contain ingredients that as glycerine or parabens that some women may wish to avoid. Look for lubricants that have FDA 510k clearance from safety testing. It is difficult to find out information on water-based lubricants’ ingredients, but some that appear to meet criteria include Sylk®, Sliquid H20®, Sutil Luxe®, and Pjur Nude®. I do not recommend coconut oil, although some oncologists swear by it, because of the potential increased risk of vaginal bacterial infections.
Vaginal dilators can be extremely helpful when women have pain with penetrative sex. Dilators come in a wide variety of diameters and lengths, from the size of a finger or tampon, to that of an erect penis. Women can learn to insert a dilator in private, using a lot of lubrication, while tensing and relaxing the muscles surrounding the vaginal entrance. As they gain in muscle control and ability to have a larger dilator in the vagina without pain, confidence on returning to partner sex can increase. Dilators also may help to physically stretch the vagina and prevent shrinkage during recovery from pelvic surgery or radiation therapy. My favorite dilators are made by Soulsource and can be purchased in a full range of sizes without a prescription. The ones women use most often are made of soft, washable silicone and come in nonthreatening pastel colors. A special, more rigid type is available for women who have more scarring, for example from graft vs. host syndrome. Another option is a new, inflatable dilator that can be increased in girth as needed, the Milli. It includes a vibrating function but is also far more expensive than a set of Soulsource dilators.
Preventing Pain from Deep Vaginal Penetration
Some women have trouble with pain deep in the vagina during penetrative sex because of pelvic scar tissue or tender areas. I often suggest a woman put lubricant on her hand and use a position that allows her to circle the bottom of her partner’s penis to prevent deep penetration, but still give him sensation. A hand’s-free method may be to use the ComeClose protection ring, which fits around the base of the penis and is sold on one website in England. I have not had the chance to talk to women who have tried it.
Tracking Return of Male Fertility
Although we have not been addressing fertility directly, a growing number of start-ups have been focusing on helping women track menstrual cycles either to assist or avoid conception. Return of female fertility after cancer is so complex that I am unsure how useful these products would be. Another company, Trak® has a home test for sperm counts paired with an educational phone app. Men who want to become fathers after cancer treatment that has impaired their fertility could use the Trak® system to get a general idea of whether their sperm count is likely to be enough for conception, or whether it is time to see an infertility specialist. Also a good reminder that men wanting to avoid a pregnancy should not assume they are infertile!
And Just for Counselors
One of the most helpful tools I have found in educating cancer patients about their treatment and its effects on sexual function or fertility is a lifelike, three-dimensional genital model. For women, one that shows the vulva in detail on the front and the reproductive organs on the back is best. For men, a similar one including the penis and pelvic organs works very well. My favorite models are expensive, but are a great source of discussion and desensitization. They are created by a real artist, Jim Jackson.
Availability of therapeutic sexual aids for cancer survivors: A survey of major cancer centers. Sharon Bober, Alexis L Michaud, Christopher J. Recklitis; Dana-Farber Cancer Institute, Boston, MA. Abstract 134, 2018 Cancer Survivorship Symposium.
This educational material is intended for informational purposes only and is not intended to replace, or substitute for, professional advice, counseling, diagnosis, or treatment. Always seek the advice of a qualified health provider with any questions you may have regarding a condition. Never disregard professional advice or delay in seeking treatment because of something you have read in this educational material.
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