Cervical Cancer and Sexual Health

Cervical cancer develops as a result of abnormal cells that begin to appear in the cervical tissue over time. Cervical cancer can cause health problems that include sexual health. Women with cervical cancer may experience loss of sexual interest (26%- 85%), diminished lubrication (27%-35%), dyspareunia (26%-55%), dissatisfaction with sexual life (30%-37%), narrow/ short/ dry vagina (32%-50%), reduced intercourse in 45%, and orgasmic dysfunction in 20% of women treated. The main side effects of treatment are vaginal dryness and pain. Some women feel stigmatized because the human papilloma virus (HPV) is classified as a type of STI and triggers many cases of cervical cancer. HPV is a very common, sexually transmitted virus, but for most women, the immune system clears the infection. Most types of HPV do not lead to cancer; however, in a minority of women, the infection lingers and creates malignant changes.  

Cervical Cancer Treatments 

Conization is a small surgery that removes a cone of tissue in the center of the cervix. It is used for severe dysplasia (pre-cancer changes in cells on the cervix) or for very early-stage cervical cancer. A Loop electrosurgical excisional procedure (LEEP) is another option that uses a small instrument to remove tissue at risk to progress to cancer. Although these procedures can be emotionally traumatic, they do not damage a woman’s ability to enjoy sex once she is healed. She also usually remains able to get pregnant and give birth. Some women benefit from brief sexual counseling to feel comfortable with sex again. 

Radical hysterectomy is the standard surgery for women who have early-stage cervical cancer that has invaded the cervix but has not spread beyond it. This operation removes not only the uterus, along with the ligaments that held it in place, but also the upper third of the vagina. The vagina is closed at the top so that it is shorter than before. Radical hysterectomy can now be done through a laparoscope, using only small incisions so that healing time is less. After radical hysterectomy, women who do not become menopausal rarely have pain with intercourse or vaginal dryness.   

Cervical cancer rarely spreads to the ovaries. If a woman is in her 20s to 40s, one or both ovaries are usually left in place if possible, as to avoid early menopause. The doctor will discuss the benefits and risks of keeping vs removing the ovaries. Many young women choose to keep one or both ovaries, as early menopause can have an impact on not only sexual health but bone health as well.   

Radiation therapy or chemoradiation are the treatments used when tumors are somewhat larger but have not spread to places away from the cervix. Radiation from an external machine is usually included, along with a period of intense, very focused radiation from rods placed into the uterus and upper vagina. Adding chemotherapy has increased the percentage of women who survive in the long-term, but complications are also somewhat more common with the combined treatment. 

Radiation therapy for cervical cancer may have more sexual side effects than surgery. The higher the dose to the vaginal lining and walls, the greater the risk of complications. During radiation therapy, the vaginal lining gets very irritated and may eventually close. There are things that may help, for example using a vaginal dilator every few days or using a water-based lubricant and a gentle, slow approach to penetration to help minimize pain.  

During healing after radiation, a process of scarring occurs called fibrosis. Fibrosis may cause the vaginal lining to produce less lubricating fluid, it may be helpful to minimize pain to use lubricants.  

 A few women may experience complications: 

  • Some get ulcerations--deep sores in the upper vagina that hurt and take a long time to heal. 

  • In very severe cases, a rectovaginal fistula develops. It is a new opening between the vagina and rectum. Stool from the rectum can leak out of the vagina, which is very upsetting. Infection can also occur. 

  • Some women also get vaginal "stenosis," a narrowing of the canal, usually in the mid- to upper part of the vagina. A severe stenosis blocks a woman from having intercourse because the penis cannot fit beyond the narrow point. Vaginal stenosis can be treated, either with surgery (although after radiation, healing can be a problem) or vaginal dilation.  

When a cervical tumor is quite large but has not spread to a distant area of the body, or if cervical cancer comes back in the local area, despite radical surgery or chemoradiation, a major surgery called total pelvic exenteration is sometimes done. The goal is to remove any tissue that harbors cancer cells, along with an edge of healthy tissue all around. The surgeon removes the vagina, the uterus and ovaries, the bladder, the urethra, the rectum, and anus.  

A woman may have the vagina rebuilt as part of total pelvic exenteration. Many different techniques have been used, including skin grafts, pieces of intestine, or "flaps" made of an area of skin and its underlying muscle. A vagina built from muscle flaps does not produce its own lubrication; as a result, a water-based or silicone-based lubricant can be used for intercourse. Flaps usually have less sensation than the surrounding skin, although they are often connected to their original nerve and blood supply. Some flaps come from the muscles of the inner thighs while other flaps come from the belly muscles or the buttocks.  

Most women who have total pelvic exenteration keep their clitoris and vulva. During lovemaking, pleasurable feelings from the breasts, clitoris, inner and outer lips, and other erotic zones may compensate for the loss of feeling inside the vagina. Not all women return to a successful sex life after total pelvic exeneration.  

Sexual Considerations 

There are various ways to enhance comfort during sexual activities if vaginal dryness is a concern. For example, utilizing lubricants or adjusting sexual positions. If additional guidance or suggestions are needed, consider talking with your doctor.  

You may still achieve an orgasm without the presence of a cervix. The nerves around the cervix are not the ones that carry sensation. The most sensitive part of the vagina is nearest its entrance, and even when sex involves vaginal penetration, the clitoris gets a lot of stimulation. The clitoris does not lose any sensitivity after radical hysterectomy.  

Women who are in menopause after any type of treatment for cervical cancer may benefit from vaginal estrogen if they are under age 50, and from use of vaginal moisturizers and lubricants that do not contain hormones.  

Loss of vaginal size, especially in women having radiotherapy as part of their treatment, may be prevented or treated by using special vaginal dilators regularly to stretch out the vagina, or by having sexual intercourse several times a week. Keeping the vagina open is not only helpful if a woman is sexually active, but also makes follow-up pelvic exams easier and less uncomfortable.