How breast cancer affected my body and sex life Darlaine HoneyThursday 21 Jun 2018 7:00 am Share this article via facebookShare this article via twitterShare this article via google
Having breast cancer shattered my self-esteem I was diagnosed with breast cancer in October 2016 after a routine screening appointment. When they told me, I felt strangely calm. I just wanted the cancer gone and to get on with my life.
Breast cancer diagnosis stops the vast majority of women from wanting sex My partner of four and a half years, Bernie*, came with me on the day of my diagnosis. He said to the nurse, ‘don’t worry, I’ll look after her’. In the beginning, I was so caught up in the whirlwind of appointments and surgeries that it was hard to take anything in.
Then I noticed after the first of my five operations that Bernie stopped giving me any sexual attention. At first, I thought it was because he was scared to hurt me, but it just continued. In fact, I don’t think we ever had sex again.
By January 2017, I was finding it increasingly hard to manage emotionally. I was working full time, commuting for four hours a day and going to endless hospital appointments – it was overwhelming.
I gradually felt the need to be on my own for a bit, so I temporarily moved out of our home into a bedsit. But we still spent some evenings and all the weekends together and we spoke constantly – we were still very much a couple.
So it was awful to find out he was on a dating site the very same day I had my final operation, a double mastectomy. After the surgery, he was outwardly very supportive – he helped me with my dressings and generally took care of me, so the discovery was a real shock and has caused me intense pain.
It was a huge double whammy – having breast cancer and losing my breasts was bad enough, but to be rejected by my ex was incredibly traumatic. I’m fine with my new breasts, but I’m worried about how a sexual partner will react to them
This turn of events has shattered my confidence – in my body and in myself as a female. It’s a year on and I feel really anxious about the possibility of starting another relationship.
Not only am I worried about being knocked back again because I don’t look the same, but I’m really nervous about negotiating sex with someone new as my body has changed so much.
For example, hormone therapy – which I’ll be on for at least another seven years – comes with a whole host of side effects, including painful joints, vaginal dryness, and mood swings.
If and when I have sex again, I run the risk of getting stuck in an awkward position, or falling asleep in the middle of a date. And although I do have an amazing friend who has been trying to help me get back to sex, I still don’t feel confident or comfortable and have to be covered up.
I can’t imagine what it will be like with someone new. If I start dating again, when would I tell them about my breast cancer?
Would they also reject me?
I imagine my ‘foobs’ (my name for my reconstructed breasts) may look a little strange with no nipples, but actually I’m fine with them as I’m grateful to have the cancer removed. I’m starting to feel stronger and more able to move forward with life – I’m just not there with sex yet.
I know I have a long way to go, but I will get there.
Women who opt for breast reconstruction after a mastectomy have a strikingly high rate of complications, according to a new report. One in three develop a postoperative complication over the next two years, and one in five requires more surgery. In 5 percent of cases, reconstruction fails.
Those who used their own body tissue to rebuild a breast had significantly higher rates of complications than those who used artificial implants, the study found.
The women who used tissue transplanted from the belly area also had weaker abdominal muscles that made simple activities like getting out of bed difficult. But they were more satisfied with their breasts at the end of the process and enjoyed a greater degree of sexual well-being than women with implants.
“They key takeaway from this research is that these are complicated decisions,” said Dr. Edwin Wilkins, a professor and researcher at Michigan Medicine and an author on both of the studies, published on Wednesday in JAMA Surgery. “These operations are not without risk.”
Dr. Andrea L. Pusic, chief of plastic surgery and reconstructive surgery at Brigham and Women’s Hospital in Boston, also an author on both of the studies, said the findings are not meant to be prescriptive. “These papers aren’t saying women should have one operation or another,” she said. “They’re about filling in the blanks that aren’t always explained to women, so they know the pros and the cons and can make good decisions.”
Dr. Pusic said the complication rate after reconstruction is probably “higher than what we’ve been telling people” but emphasized that “choosing reconstruction largely restores satisfaction with your breasts and psychosocial functioning. But it’s not uncommon to have bumps in the road.”
The studies were based on data from the Mastectomy Reconstruction Outcomes Consortium, which Dr. Wilkins and Dr. Pusic lead. It followed some 2,300 women who had breast reconstruction surgery between Feb. 1, 2012 and July 31, 2015 at 11 medical centers in the United States and Canada. More than half of the women had artificial implants inserted. About a third had reconstructions using their own tissue, a procedure known as autologous reconstruction.
The patients were followed for two or more years after the surgery. During this time, researchers tracked all medical complications and evaluated quality of life using a questionnaire called the BREAST-Q, which looked at satisfaction with the breasts as well as psychosocial, physical and sexual well-being.
The researchers defined complications broadly, including even minor problems like a wound that took extra time to heal and required an antibiotic ointment. Still, the authors and other plastic surgeons said the results were eye-opening.
“I was surprised the difference was so stark between the autologous reconstruction and the implant, and that the autologous tissue flap complication rate was so high,” said Dr. David H. Song, chairman of the department of plastic surgery at Georgetown University School of Medicine, who was not involved in the research but was a co-author of a commentary on the studies.
But Dr. Song said the research, which followed women for only a few years, did not take into account that many women with implants might need to undergo additional surgery down the line because implants may need to be replaced after 10 years or so.
Some advocates for breast cancer survivors and women who have undergone breast reconstruction were not surprised by the figures. “I have heard lots of horror stories,” said Geri Barish, principal officer of 1 in 9, a breast cancer group on Long Island.
Alise Nacson, a 41-year-old researcher in Washington, said she underwent an eight-hour procedure last year that used tissue, including fat, skin and blood vessels, from her belly to create new breasts after a double mastectomy. But the surgery on her left side failed when the transplanted tissue, called a “‘flap,” was rejected, leaving her with only one reconstructed breast. Now she is facing another operation.
“I lost a flap, which is one of the worst outcomes,” Ms. Nacson said. On the other hand, she said, “I love the breast that I have, and I adore having a flesh breast.”
Donna Lo Nigro, a 43-year-old mother of two from Wading River, N.Y., had a double mastectomy followed immediately by reconstruction with implants in 2015. Within months, she developed a painful infection and abscess in one breast, and eventually had to have both implants replaced. Then a replacement operation failed, and she had to have the second set of implants removed.
In April of 2016, she decided to try using her own tissue for breast reconstruction and had a nearly 12-hour-long procedure, which was successful. “It’s fabulous, and I’ve had no complications,” Ms. Lo Nigro said.
The research identified several factors that increase the risk of developing a complication, including being older, being overweight, smoking, undergoing a bilateral reconstruction procedure, undergoing radiation therapy during or after reconstruction or having had chemotherapy.
Although patients are often encouraged to have reconstruction immediately after mastectomy, patients who delayed reconstruction were found to be significantly less likely to develop complications than those undergoing immediate reconstruction.
While the new information is helpful, some doctors were skeptical that it would make decisions much easier for cancer patients.
“Patients trying to make a decision about surgery have just been told they have cancer,” said Dr. Deanna J. Attai, a breast surgeon and assistant clinical professor at David Geffen School of Medicine at the University of California, Los Angeles. “That alone is enough to shake even the strongest of clear thinkers.”
When a patient with an eye condition walks into an ophthalmologist’s office, the fact that she has been treated for breast cancer may not raise warning flags for the clinician. But there’s accumulating evidence that ocular conditions such as dry eye, retinopathy, and cataracts may be at least partly due to some breast cancer medications.
Only a small percentage of breast cancer patients experience clinically evident ocular side effects from their medications. Nevertheless, because these drugs are so widely used, the related eye conditions may affect many women. The breast cancer medication most commonly identified with ocular side effects is tamoxifen. However, chemotherapy agents, such as 5-fluorouracil (5-FU), can also have ocular side effects. And more researchers are becoming concerned that the drugs known as aromatase inhibitors, which now are often prescribed as adjuvant endocrine therapy, may also have adverse effects on the eye, including small retinal hemorrhages, increased incidence of floaters, and dry eye.
“Tamoxifen has long been known to cause eye problems, including dryness, irritation, cataracts, and deposits in the retina, in the area of the macula, that result in macular edema,” said K. V. Chalam, MD, PhD, MBA, professor and chair of ophthalmology at the University of Florida College of Medicine in Jacksonville. Most of the ocular side effects are dose related, he said. “Certainly, the side effects we see with tamoxifen are much less profound than they used to be because of the lower doses now used.” Years ago, many breast cancer patients were prescribed doses of 150 mg or more, he noted. “In such cases, the ocular side effects from tamoxifen could be profound. That’s not the case anymore with the usual dose of 20 mg or less.”
Widespread effects. Tamoxifen is a selective estrogen receptor modulator (SERM) and acts against breast cancer by occupying estrogen receptors. It’s the only SERM approved for every stage of breast cancer. Because estrogen affects a wide variety of physiological functions and estrogen receptors are present in the eye, the changes in estrogenic activity brought about by tamoxifen have the potential to affect visual processing, as well as the lacrimal and meibomian glands that protect the surface of the eye, according to Alvin Eisner, PhD. Research shows that tamoxifen increases the risk of posterior subcapsular cataracts by as much as fourfold, which is significant because these types of cataracts can substantially impair visual function, said Dr. Eisner, a researcher most recently at the Northwest Sarcoma Foundation who specializes in ophthalmology, vision science, and cancer treatment.
Cataract. Researchers at the University of Southern California analyzed the self-reported incidence of eye disease among 1,297 female breast cancer patients taking tamoxifen who were enrolled in a population-based case-control study. They found that women who used tamoxifen for four to five years had a relative risk (RR) of 1.4 for all types of cataracts; those who were on the drug for more than six years had an RR of 1.7. They concluded that five or more years of tamoxifen increases cataract risk and that “healthy women considering tamoxifen use to reduce the risk of breast cancer should be advised of the possibility of cataract development.”1
Yet some ophthalmologists say that the question of whether tamoxifen increases risk of cataracts is still unresolved. “It’s fairly rare to find that a cataract is due to a medication, and I think that the jury is still out on whether tamoxifen may cause cataracts in some patients,” said Rick Fraunfelder, MD, MBA, professor of ophthalmology at Oregon Health & Science University and the Casey Eye Institute. Dr. Fraunfelder is also director of the National Registry of Drug-Induced Ocular Side Effects.
Retinopathy. However, use of tamoxifen, particularly at higher doses and for longer periods of time, may lead to retinopathy, Dr. Fraunfelder said. “Patients on tamoxifen can get striking white to yellow refractile bodies around the macula. These effects tend to occur at least one year after therapy begins and are cumulative.”
But, according to Dr. Eisner, tamoxifen retinopathy is overemphasized. A review article he coauthored states that “the initial findings of tamoxifen retinopathy at an auspicious time in the evolution of BC [breast cancer] treatment have led to an overemphasis on this condition in the sense that vision symptoms (e.g., photopsia) due to other intraocular conditions may be too readily misattributed to tamoxifen retinopathy and/or downplayed.”2 Estimates of the prevalence of retinopathy among breast cancer survivors on standard doses of tamoxifen have varied widely among published studies, with rates ranging from 0 to 6 percent, Dr. Eisner said.
Pointers for following patients on tamoxifen. Dr. Fraunfelder recommends that breast cancer patients have a baseline eye exam within the first year of treatment with tamoxifen, including an examination of the macula and testing of central and color vision. Dr. Chalam recommends that most breast cancer patients on tamoxifen be followed every four to six months, and those with symptoms should be seen by an ophthalmologist as often as every three months. Any sign of symptomatic ocular conditions should prompt a discussion with the patient as well as her oncologist.
According to Dr. Chalam, the ocular risks increase with long-term use of tamoxifen because the effects of the drug on the eye are cumulative over time. “The side effects usually occur at least one year after therapy begins,” Dr. Fraunfelder said. However, one condition that may occur relatively earlier is subclinical swelling within the optic nerve head, Dr. Eisner said. In addition, he noted that early, subtle cases of cystoid tamoxifen retinopathy may sometimes be detectable with optical coherence tomography (OCT).
The presence of asymptomatic refractile bodies is not a sufficient reason to discontinue tamoxifen, but if a patient starts to lose color vision or central vision while on the drug, the ophthalmologist should confer with the patient’s oncologist about stopping or switching treatments. Retinal hemorrhages and cystoid macular edema—which can result from tamoxifen use—may also indicate that a patient should stop taking tamoxifen or be switched to an alternative drug, Dr. Fraunfelder said.
The good news about the ocular side effects of tamoxifen is that if the drug is discontinued or the dosage reduced, ocular toxicities such as macular edema or retinal deposits are often reversible, Dr. Chalam said.
However, if the patient is on a high dose of tamoxifen and exhibits chronic maculopathy, there is a very real risk of losing vision permanently, Dr. Fraunfelder said. “It’s very rare for a patient to go completely blind, but many lines of visual acuity can be lost,” he said. “If you start getting vision loss after taking tamoxifen, it can be progressive and may continue even if you stop the drug.”
Alternatives to tamoxifen. Oncologists have the option of prescribing raloxifene (Evista) as an alternative to tamoxifen for breast cancer prophylaxis, and it may have a more favorable side effect profile. Although the National Surgical Adjuvant Breast and Bowel Project Study (STAR) found that there were fewer cases of breast cancer among tamoxifen users, women on raloxifene had fewer cases of uterine cancer, as well as of cataracts (RR = 0.79) and cataract surgeries (RR = 0.82).3
“Oncologists now have more choices, and patients experiencing ocular effects from tamoxifen can often be switched to raloxifene, although the use of raloxifene would be off label,” said Dr. Chalam.
Chemotherapy drugs can also cause ocular side effects. According to Dr. Eisner, 5-FU can sometimes result in epiphora, while methotrexate can lead to conjunctivitis and other inflammation of the ocular surface.2
Because chemotherapies are toxic to rapidly dividing cells (such as those in a tumor), they can also be harmful to other cells that divide and renew on a regular basis, including those in the corneal epithelium. As a result, these agents can cause dry eye, which can usually be treated with lubricating drops, according to Dr. Chalam. Docetaxel, a taxane drug, can also lead to epiphora, as a result of stenosis of the tear drainage apparatus, said Dr. Eisner.
Conjunctivitis may occur when chemotherapy drugs leak into the tear film. “The chemicals irritate the eye, but the condition is temporary and goes away once the patient is done with chemotherapy,” Dr. Fraunfelder said, adding that there is no long-term damage. Topical nonsteroidal anti-inflammatory eyedrops can be used along with artificial tears if a patient has eye pain, he said.
In recent years, aromatase inhibitors (AIs) such as anastrozole (Arimidex), letrozole (Femara), and exemestane (Aromasin) have been increasingly prescribed to postmenopausal breast cancer patients as adjuvant endocrine therapy, sometimes after two to three years of tamoxifen treatment. The short-term ocular side effects of AIs often seem to be mild, at least according to the limited cross-sectional studies that have looked at this question, Dr. Eisner said, although “There is theoretical potential for AI-induced estrogen depletion to increase the long-term risk of serious eye disease.”
Although AIs work by inhibiting estrogen synthesis rather than by occupying estrogen receptors as tamoxifen does, some of the AI side effects are similar to those of tamoxifen, according to Dr. Eisner. The estrogen suppression that occurs with AIs might be regarded as causing an accelerated female aging that resembles an exaggerated menopause.
A study by Dr. Eisner and colleagues suggests that anastrozole can cause small retinal hemorrhages in some patients.4 He said that his research indicates that breast cancer patients who take anastrozole are more likely to have retinal hemorrhages than tamoxifen users. These hemorrhages may be the result of excessive traction on the retina, caused by estrogen depletion.5Related effects, such as posterior vitreous detachments, may occur during the natural menopausal transition, he said. Dr. Eisner noted that it’s possible to assess the tractional effects of AIs through the use of OCT. Other possible effects of AIs include photopsia and increased incidence of floaters, as well as dry eye.
Dr. Eisner pointed to the need for more studies of the effects of AIs, particularly longitudinal studies to better document and help clarify their ocular effects.
“As many as 40 percent of women completely abandon their use of AIs before the prescribed time because they can’t tolerate the side effects. Although the ocular side effects may be less important or less compelling than well-known side effects such as arthralgia or hot flashes, they nevertheless may provide the straw that breaks the camel’s back for breast cancer patients on these drugs,” said Dr. Eisner.
1 Paganini-Hill A, Clark LJ. Breast Cancer Res Treat. 2000;60(2):167-172.
2 Eisner A, Luoh SW. Curr Eye Res. 2011;36(10):867-885.
3 Vogel VG et al. JAMA. 2006;295(23):2727-2741.
4 Eisner A et al. Optom Vis Sci. 2008;85(5):301-308.
5 Eisner A et al. Breast Cancer Res Treat. 2009;117(1):9-16.
Drs. Chalam and Eisner report no related financial interests. Dr. Fraunfelder is a consultant to Teva.
Tamoxifen is a hormone therapy drug taken by many premenopausal women after completing their initial treatments for estrogen receptor positive breast cancer. To treat the side effects of tamoxifen (such as hot flashes) and to help with depression, doctors often prescribe antidepressants. Yet many antidepressants can interfere, or completely cancel out, the benefits of tamoxifen.
What should everyone taking tamoxifen know?
Tamoxifen Uses with Breast Cancer
Once a woman is finished with the primary treatment of breast cancer, with therapies such as surgery, chemotherapy, and radiation therapy, she may need to take tamoxifen. For women who have estrogen receptor positive tumors, hormone therapy can reduce the risk of the cancer coming back (recurrence) by around 50 percent.
The choice of medication depends on menopausal status. If a woman is premenopausal, tamoxifen is usually the drug of choice. (For those who are postmenopausal, or who are premenopausal but have received ovarian suppression therapy, an aromatase inhibitor is usually used instead).
Breast cancer cells that are estrogen receptor positive are fueled by estrogen. Estrogen present in the body (made by the ovaries) binds to these cancer cells to cause growth. Tamoxifen works by binding to these receptors so that estrogen can't, essentially starving the cancer cells of their food.
The side effects of tamoxifen include menopausal-type symptoms such as hot flashes, low libido, and vaginal dryness. For women who have not yet reached menopause, the hot flashes can be very annoying, but we've learned in recent years that some antidepressant medications can reduce these hot flashes.
Unfortunately, some of these antidepressants can also reduce the effectiveness of tamoxifen.
Breast Cancer and Depression
Not surprisingly, many women who have been treated for breast cancer develop depression. The combination of a life-threatening diagnosis, the side effects of treatment, and the changes to body image that go with treatment all set the stage for a large emotional impact. Unfortunately, after many women with breast cancer were treated (almost routinely in some places) with antidepressants, it was discovered that several antidepressants can reduce the effect of tamoxifen. How does this occur?
Tamoxifen and Drug Interactions
Tamoxifen and drug interactions are common, and this includes many medications in addition to antidepressants. Since many of these are commonly used drugs, including over-the-counter drugs such as Benadryl, it's important to talk to your doctor and pharmacist about any medication, over-the-counter preparation, or dietary supplement you are considering, while you are on the drug. Since many people take tamoxifen for 5 to 10 years, this is even more important. Keep in mind that not all physicians are familiar with these interactions (and we are learning more all the time).
What this means is that if you should go to urgent care, for example, with an infection, talk to your oncologist or pharmacist before taking any medications that have been prescribed.
Tamoxifen is metabolized in the body to endoxifen. Endoxifen is 30 to 100 times stronger than tamoxifen, and is responsible for most of the clinical effects. Tamoxifen is broken down to endoxifen by the cytochrome P450 enzyme CYP2D6 (plus others that are less important). Any drugs that reduce the activity of CYP2D6 (and there are many) can reduce this break down process and hence, the amount of endoxifen that is produced.
Tamoxifen and Antidepressants: Interactions
We are still learning more about specific antidepressants and their effect on tamoxifen levels in the body, but thus far we've noted that different antidepressants can effect tamoxifen in different ways. Some antidepressants (such as Prozac and Paxil) almost completely negate the effect of tamoxifen. In this case, it would be like not taking tamoxifen at all (and not having the benefit of a reduction in recurrence risk).
With other antidepressants there is a moderate interaction, and with others, only a slight interaction. In contrast, one dietary supplement may actually increase the effect of tamoxifen (and also the side effects), although other studies have shown the opposite..
Below is a table that summarizes what we believe is true about several antidepressants today. This is an area of active research, and it's likely we will be learning more in the near future. If you are considering an antidepressant medication, have a careful discussion with your doctor, but also periodically ask if anything has changed.
Antidepressants And How They Interact With Tamoxifen
Interaction with Tamoxifen
Prevents antiestrogen benefit
Medium interference with antiestrogen benefit
Note: Studies confirm that Zoloft interferes with Tamoxifen.
Saint John's Wort (hypericum)
Modest inhibition of antiestrogen benefit
Note: Pristiq and Remeron have not been well-studied for interaction with Tamoxifen.
Black Cohosh (Actaea)
May inhibit or enhance the antiestrogen benefit depending on the study.
Note: There are just a few studies for interaction with Tamoxifen, and most have been done "in vitro" (in the lab and not in humans).
Knowing about the potential interactions between tamoxifen and antidepressants is crucial if you are considering any of these drugs. Some antidepressants strongly negate the effects of tamoxifen, and it's thought that this interaction is the reason behind the increased death rate of women with breast cancer who took Paxil. Currently, the safest option both for hot flashes and depression appears to be Effexor, but again it's important to note that this is an active area or research, and we may learn more in the near future. Since black cohosh has a reputation of helping with hot flashes related to breast cancer treatment, but may also interact with tamoxifen, it's important to talk to your oncologist about any medication, over-the-counter preparation, or dietary supplement you are considering.