Pelvic radiotherapy can affect your sexuality and sex life. This section discusses the possible changes that may happen. You may also have effects from other treatments, such as surgery, chemotherapy or hormonal therapy. It may be helpful to read information about how these other treatments can affect your sex life. If you have had a combination of treatments, you may be more likely to have effects on your sex life than if you only had pelvic radiotherapy.

Our separate section on sexuality discusses ways of dealing with the physical and emotional changes that cancer treatments can cause.

You may find it helpful to talk to your partner about the changes you have noticed in how your body responds sexually. You can talk to sexual therapists or counsellors in detail about the effects these changes or difficulties are having on you and your partner. They can be contacted through:

• your treatment team (doctor or specialist nurse)
• your GP
• directly through the websites and sources of help listed: for example, the British Association of Sexual and Relationship Therapists (BASRT).

During and after cancer treatment, many women find that their interest in sex reduces, or may disappear completely. There are many reasons for this, including:

• the emotional impact of adapting to the changes that a cancer diagnosis brings
• the treatments
• any side effects, such as nausea, diarrhoea or tiredness.

Sexual interest may also be lowered after treatments which stop the ovaries producing hormones. This causes an early menopause. Taking hormone replacement therapy (HRT containing oestrogen and progesterone) can increase your sex drive. Some doctors may recommend a small dose of testosterone to replace the amount normally produced by the ovaries. Your doctor can tell you whether or not HRT (with or without testosterone) may be helpful for you. Some women with breast or womb cancer are advised not to have HRT. This is because there is a risk that the hormones may stimulate the growth of these cancers.

You and your partner may find it helpful to talk with each other about the changes you have noticed. It is good to look into ways of overcoming them as a couple. You may want to have general, relationship or sexual counselling. Counselling can help increase interest in sex and help you to come to terms with changes.

Radiotherapy to the pelvic area can cause inflammation of the walls of the vagina. When the inflammation reduces, scar tissue can form, which can make the vagina narrower and shorter. The vaginal walls may be dry and thin, and can stick together. Less vaginal lubricant may be produced, which can make you more likely to get vaginal infections such as thrush. The vaginal changes can be very uncomfortable and can make the vagina sore, especially during intercourse. It can make penetrative sex or a medical vaginal examination more difficult and possibly painful.

To help keep the vagina supple and to prevent scar tissue from forming you will be advised to use vaginal dilators. It is usual to start using them from 2–8 weeks after the radiotherapy treatment has ended. You will be given a range of dilators to use, starting with a small one and working up to larger sizes. Regular sexual intercourse can also help to keep the vagina healthy, although this may initially be uncomfortable. You can also use a vibrator or your fingers to gently stretch the vagina to keep it supple and make sexual intercourse and vaginal examinations more comfortable.

Vaginal dilators are tampon-shaped plastic devices with a rounded end. There are a number of different types available. They also come in varying sizes. Instructions for using dilators may differ slightly from hospital to hospital, but the principles are the same.

The dilator is inserted gently into the vagina. A water-based lubricant such as KY Jelly can be used if needed. You can lie down or may prefer to stand, with one leg bent up and supported on a chair or the toilet. You may also prefer to use the dilator during a bath.

Once you have inserted the dilator, you can slowly and steadily withdraw and insert it repeatedly over 3–5 minutes. Or, you can rotate it gently, while pushing deeper into the vagina, using a circular motion. The movement will help to break down any fixed scar tissue (adhesions). When you have finished, remove the dilator and wash it with warm soapy water.

Your doctor or specialist nurse will tell you how to use the dilators and how often to use them. You will need to carry on using the dilator once a week for as long as you can. It is not yet known how long it is best to use the dilator for, but most specialists advise from 6 –12 months. Some women may need to carry on using them for life. If you are having sexual intercourse at least twice a week you don’t need to carry on using the dilators.

Other things to remember when using the vaginal dilator:

• If insertion is difficult, do not force the dilator – try a smaller size.
• If insertion is tighter than usual, you may need to use the dilator more often.
• A small amount of bleeding or 'spotting' after using the dilator is quite normal.
• If you notice a lot of bleeding or pain, contact your nurse or doctor.

Radiotherapy and an early menopause can reduce the production of natural lubrication in the vagina. Hormone replacement therapy (HRT) can help to keep the vagina healthy. If you are not able to take HRT you may still be able to use vaginal oestrogen creams that are put inside the vagina. Oestrogen creams are sometimes given to help prevent the vaginal wall from becoming too thin. Your body absorbs some of the oestrogen but not enough to have a harmful effect. Your doctor, radiographer or specialist nurse can discuss this with you.

You can also use non-hormonal lubricants, such as Replens®, KY Jelly, Aquagel, Sylk®, and Vielle®. They are available from your chemist. Some women find that benzydamine douches can help to relieve dryness and irritation. The douches can be prescribed by your doctor or specialist nurse.

You may find that a few months after the radiotherapy, when the early side effects have reduced, you have a slight stinging or burning in your vagina when your partner ejaculates. You can use extra lubricant gels to help reduce this feeling. If the usual lubricants do not work, you can try silicone-based lubricants which can coat the vagina more effectively. Silicon-based lubricants are available from sex product shops or websites such as www.sh-womenstore.co.uk or www.beecourse.com

Some women find that the silicone-based lubricants really help, but for other women they may cause stinging or itching. It is important to take note of any effects that the lubricants cause and stop using any that cause irritation. Let your doctor or specialist nurse know if you are having problems.

The skin and the blood vessels just below the surface lining of the vagina can become fragile and easily damaged. This is known as telangectasia. It can cause pain, soreness or bleeding, especially after sex. Rarely, sore areas in the vagina can take a long time to heal and this is known as vaginal ulceration. If this happens it is best to avoid intercourse during this time. You can still enjoy a sexual relationship. It is important to talk to your partner about what you both want.

Some women notice that after cancer treatment their orgasm can feel different. Some women find that the sensation may feel less intense than before. It may also take longer to reach orgasm. This is thought to be due to changes in the blood flow and nerves in the pelvic and genital area (especially after pelvic surgery or radiotherapy). Many women say that the changes may be due to feeling different about the way their body works and feels sexually.

If you have any changes that make you feel worried or upset it can help to speak to someone such as a sexual counsellor. You can explore whether there are things that can improve the situation.