Pelvic radiotherapy for women

Radiotherapy uses radiation to kill cancer cells. You might have radiotherapy to the pelvis to treat cancers such as:

• cervical cancer

• vulval cancer

• vaginal cancer

• anal cancer

The side effects vary from person to person. They might affect how you are feeling sexually.

Early menopause

Pelvic radiotherapy can cause an early menopause by stopping your ovaries from working.

The symptoms of a menopause due to cancer treatment are the same as those of a natural menopause, but they can be more intense if it comes on suddenly. You might have:

• hot flushes and sweating

• vaginal dryness

• low mood or depression

• loss of confidence and self esteem

• tiredness

• thinning bones

• loss of interest in sex

If you haven’t already been through the menopause, this means your periods stop and you won’t be able to become pregnant. This is called infertility.

The risk of infertility depends on:

• the dose of radiation to your ovaries
• your age (the risk is higher the older you are)
• if you have chemotherapy with the radiotherapy

Finding out that treatment for your cancer may leave you infertile can be extremely distressing. Especially if you had hoped to get pregnant in the future. Your doctor and nurse will support you and talk about possible options.

It is sometimes possible to move the ovaries out of the treatment area before radiotherapy begins. This is called ovarian transposition. It is usually done by keyhole (laparoscopic) surgery. Ovarian transposition may prevent an early menopause.

You can see a fertility specialist before you start cancer treatment. They can talk to you about the possibility of freezing your eggs, embryos or ovarian tissue.

External and internal radiotherapy

For some types of cancer, such as cervical cancer, radiotherapy can be external or internal. 

External radiotherapy targets radiation at the cancer from a radiotherapy machine outside of the body. Internal radiotherapy, also called brachytherapy, gives radiation from inside the body. For cervical cancer, a radioactive source goes inside the vagina. This gives a high dose of radiotherapy both to the cervix and the vagina.

Both external and internal radiation can cause:

• vaginal dryness
• fibrosis  
• narrowing of the vagina

The skin inside the vagina can also become thin, delicate and easily torn. This can lead to pain, discomfort or bleeding, and may make intercourse painful. Rarely, ulcers (sores) can form inside the vagina when the skin tears. These can take a few weeks, or even months, to heal.

You may not feel like having sex while you are having a course of pelvic radiotherapy. The treatment can make you feel very tired. It can also give you cystitis  and diarrhoea . You may also find that you feel too sore to have sex comfortably.

For many people it is best to avoid intercourse altogether during this time. But you can still enjoy a sexual relationship. There are many other ways of satisfying each other. It is important to talk to each other about what you want.

It is important to avoid pregnancy during radiotherapy, as it might harm the baby. Talk to your specialist about a suitable type of reliable contraception before starting treatment. 

Narrowing of your vagina

Pelvic radiotherapy can make the tissues in the vagina less stretchy. This is called fibrosis. Fibrosis can narrow the vagina, making it uncomfortable and difficult to have sex.

Vaginal dilators after treatment might help to prevent this. Ask your healthcare team about dilators if they haven't been mentioned to you.

Vaginal dilators

Dilators are cone shaped plastic objects that you put into your vagina to help stretch it.

You can can use vaginal dilators from 2 to 8 weeks after treatment to help prevent narrowing of the vagina. Ask your doctor or nurse when you should start using them. The dilators come in sets of different sizes. You begin with one of a comfortable size. Then you use larger ones until your vagina is stretched enough for you to have sex comfortably. Some people involve their partner with this.

How to use them

There are international guidelines for using vaginal dilators and these are described below. Ask your medical team for individual advice.

You usually start with the smallest size and go up to whatever size is comfortable for you. 

For the first 6 months 

Use dilators with a water soluble lubricating gel at least twice a week and up to twice a day, for 3 to 10 minutes each time.

Between 6 and 12 months

Use dilators once a week.

After 12 months

Use your dilators occasionally as long as you are not having any difficulty.

Alternatives to vaginal dilators

Sexual intercourse also helps to keep the vagina open. It is a good alternative to using dilators.

You might prefer to use your fingers or a vibrator to help stretch your vagina. Sometimes water soluble lubricants do not give enough lubrication for comfortable intercourse. So you may want to try a silicone based lubricant instead, which gives more lubrication. They are usually fine to use after any vaginal irritation caused by radiotherapy has settled down.

Chemoradiotherapy for cancer in the pelvic area

Sometimes chemotherapy is combined with radiotherapy (chemoradiotherapy) for cancers in the pelvic area. Having the two treatments together can make the vaginal area very fragile and sensitive.

Always use reliable contraception if you're having chemotherapy treatment. You should avoid becoming pregnant, as the treatment drugs could harm the baby. Women who have or have had breast cancer are usually advised not to take the pill. This is because the hormones it contains may affect the cancer.

It is not known for sure whether cancer drugs, such as chemotherapy, can be passed on through semen or secretions from the vagina. Because of this some doctors advise people to use a barrier method, if you have sex during their treatment. This applies to vaginal, anal or oral sex. Barrier methods include condoms, femidoms or dental dams.

Generally, doctors advise a barrier method only for the time a person is actually having the treatment. And for about a week after treatment.

Advice like this can be worrying, but this does not mean that you have to avoid being intimate with your partner. You can still have close contact and continue to enjoy sex.

Tiredness

You might feel tired during your radiotherapy treatment. This could be because: 

• of having cancer

• your body is using energy to repair damage to healthy cells from the radiation

• you're in pain

• you're having to travel quite a way for your radiotherapy appointments

• you're feeling anxious and stressed - this might affect the quality of your sleep at night

Radiotherapy side effects tend to get worse as you progress through your treatment. So you might not feel tired at the beginning of your course but might do towards the end and for a few weeks afterwards.

Try not to be too hard on yourself if you don’t feel like having sex when you are tired. You can express your sexuality in different ways if you have a partner or are single.

Help and support

These changes and the emotions it can bring can be difficult to cope with. It might help to talk to a partner, relative or friend. Let your nurse, specialist or GP know how you are feeling. They can let you know what help and support is available in your treatment centre or in your area. 

Some people choose to talk things through with a counsellor or therapist. Or you could contact some of the organisations that offer support and information about relationships and sexuality.

Cancer Research UK nurses