How women can manage sexual health after pelvic radiation

Radiation therapy to the pelvis can be used to treat gastrointestinal cancers, such as anal cancer and rectal cancer.

Because the anal canal and rectum are so close to a woman’s sexual organs, side effects from pelvic radiation can affect women’s sexual health. Here, I’ll answer common questions about sexual side effects from pelvic radiation for anal and rectal cancer patients, and how women can manage their sexual health after treatment.

How does pelvic radiation affect a woman’s sexual organs?

Radiation can damage the tissues and organs of the pelvis. Direct radiation damage to the vagina and other structures, such as the clitoris, can impact a woman’s sexual health after treatment. For pre-menopausal women, radiation damage to the ovaries can also cause hormonal changes that further contribute to sexual health problems. 

What are common vaginal side effects from pelvic radiation?

During and shortly after pelvic radiation, women may experience the following acute vaginal side effects:

• discharge
• pain
• irritation
• bleeding

Months or years after pelvic radiation, women may experience permanent vaginal damage, which can lead to dryness, shrinkage, pain or bleeding. In rare cases, a fistula, or abnormal connection, between the bowel and the vagina can occur.

Because vaginal sex can be difficult or painful during radiation, many patients will choose to refrain. When we treat patients with anal cancer and rectal cancer, we don’t instruct patients to avoid sex during radiation treatment. But that may be different for gynecologic cancers.

What are common hormonal side effects from pelvic radiation?

During or after pelvic radiation, premenopausal women usually experience changes to their menstrual cycle. Ovarian damage from radiation often causes premature menopause, which can lead to infertility and sterilization, but it can also contribute to vaginal dryness and pain during intercourse.

Radiation can cause premature menopause, which can cause hot flashes, mood swings and vaginal dryness. Premature menopause can also lead to infertility.

If you are going to be treated with pelvic radiation, it’s important to talk to your doctor about fertility preservation if you may want to have kids in the future. If you’re an MD Anderson patient, you can ask to be referred to us before you begin radiation so you can figure out what your options are.

How do you help patients manage these side effects?

We approach side effects management in two different ways: prevention and treatment.

For prevention, we take steps to protect the vagina from unintentional radiation during treatment.

We often place a vaginal dilator into the vaginal canal during radiation sessions. When treating anal and rectal cancers, the back wall of the vagina is very close to the tumor. However, when we insert a vaginal dilator, which is a cylinder-shaped device that pushes the front wall of the vagina away from the back wall, we’re able to protect the vagina. This reduces the overall volume of the vagina that is damaged by radiation and can potentially improve a patient’s sex life down the road.

After pelvic radiation is done, we advise patients to continue to use a vaginal dilator and/or have penetrative vaginal intercourse at least three times per week to reduce the risk of vaginal stenosis, which is the shortening and narrowing of the vaginal canal.

We have several treatment options for women who develop sexual dysfunction after pelvic radiation. These include pelvic floor physical therapy and estrogen supplementation.

Pelvic floor physical therapy can be a game-changer for women experiencing painful intercourse after pelvic radiation. An experienced pelvic floor physical therapist can offer a lot of interventions and strategies to help patients with their pelvic floor muscles and improve their sexual health.

I also refer patients to my gynecology colleagues. They discuss things like vaginal moisturizers, vaginal estrogen or estrogen replacement therapy, which can help maintain the vaginal lining and help with vaginal lubrication and painful sex.

When should patients talk to their doctor about pelvic radiation affecting their sexual health?

It’s never too early to bring up concerns about your sexual health with your doctor.

After they’re diagnosed with cancer, patients are often focused on their chances of survival. So it’s understandable that their future sex life may not be at the front of their mind. That’s why I try to bring it up early and often. Proactive, preventive measures to maintain sexual health work a lot better than trying to fix things once sexual problems start.

What else should women know about pelvic radiation and their sexual health?

Sexual health is a complex issue that cannot be described by vaginal and hormonal measurements alone. Emotional, psychological and relationship issues also play a big role in holistic sexual health after cancer. Sex therapy can be a helpful intervention to work through individual barriers to a satisfying sex life.

Even if the anatomy has changed, there are ways to change how you think about sex to still enjoy this part of your life.

I’m learning more about sex aids, or things couples can use to help them have a satisfying experience. For example, there is a silicone cylinder-type device a man can wear on his penis during intercourse that controls the depth of penetration. This can be particularly helpful for women with vaginal stenosis.

At every follow-up appointment, I ask patients if there are any barriers to their sex life. If there are, we look for solutions.

If your sex life changes after pelvic radiation, there are still ways to be intimate and enjoy that part of your life. I want patients to know that although this is a common problem after pelvic radiation, there are things we can do before and after treatment to improve your sexual health. Don’t be shy about talking with your cancer care team about this if it is an important aspect of your life!

Emma Holliday, M.D., is a gastrointestinal radiation oncologist.

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