How Breast Cancer Affects Sexual Health with Dr. Shelby Terstriep

Here today to talk about the ways that breast cancer can affect sexual health and what to do about it is Dr. Shelby Terstriep.

About Dr. Terstriep

Dr. Terstriep is quadruple boarded in internal medicine, hematology, oncology and palliative medicine and is a clinical associate professor at the University of North Dakota. Dr. Terstriep graduated from the University of Missouri-Kansas City School of Medicine and completed her internal medicine residency and medical oncology and hematology Fellowship at Mayo Clinic in Rochester, MN. She spent her research time in the Mayo Clinic Center for Innovation (formerly SPARC lab) learning techniques in developing patient-focused healthcare delivery models. She is passionate about enhancing the quality of life for cancer survivors throughout the spectrum of their cancer journey, clinical research and innovation in care delivery.

Transcript

Adam (00:03):

Support for the Real Pink podcast comes from Lilly Oncology. People living with metastatic breast cancer or MBC deserve more Lily oncology aims to bring more awareness of MBC through more education or research and more dedicated solutions to support the women and men living with NBC and the communities that surround them. Learn more at the more for NBC Facebook page from Susan G Komen. This is real pink, a podcast exploring real stories, struggles, and triumphs related to breast cancer. We’re taking the conversation from the doctor’s office to your living room today. We’re going to be talking about how breast cancer affects sexual health. We’re joined today by Dr. Shelby Terstriep. Dr. Terstriep, thanks for joining us. Hi, thanks for having me. I’m looking forward to chatting with you about this. I know this is an important topic, but to start off, can you just tell us a little bit about yourself and how you became so passionate in working in the breast cancer space?

Shelby (01:04):

Yes. I mean, I’m a medical oncologist and I really became passionate about breast cancer during my oncology training. First of all, I love women’s health. And as I, as a woman, I feel like I identify with, you know, the new unique challenges that we face in training. I realized that treatment was just such a small part of somebody’s life that it became really, how do I move forward after a breast cancer diagnosis? And I really loved learning about ways to reduce the side effects, you know, the psychology tools to really help with the emotional impact and then learning about healthy lifestyle changes and how to motivate people through, you know, life coaching technique.

Adam (01:43):

Hmm. Oh, that’s great. And that’s so important and I’m glad that you’re doing this really important work. So I know today we’re going to talk about sexual health and one of the most common side effects of cancer treatment is fatigue, which I can imagine makes sex the last priority for many women. Do you have any advice for our listeners about how to improve fatigue and get back energy for intimacy?

Shelby (02:05):

Yeah. Fatigue is definitely one of the most common and distressing really side effects from cancer treatment. And of course, if you have significant fatigue, sex can become pretty low on your priority list. What I see often is that people blame the cancer and the treatment indefinitely, and then consequently feel like there’s no hope for improvement. So what I’d like to do with my patients is that we really make sure to look at all the underlying reasons for fatigue and really maximizing those things and not just blaming it on it indefinitely for the cancer treatment. So things like, you know, are the blood counts low. And are there any things that we can do about it? You know, is the hemoglobin low? Is there iron deficiency, B12 deficiency contributing? I always check the thyroid because many treatments can affect the thyroid and women are more at risk for thyroid problems in general, with some of the treatments that we do use some of the, that can affect the vital organs.

Shelby (03:01):

So making sure the heart is functioning well and the lungs, and then medications is a big one. What medications are people on? So often things get added to the medication list and we never really remove anything. And so looking at pain medications, add to histamines, antidepressants supplements, drug, drug interactions, nor are there anything that could be contributing to that fatigue then really assessing people’s nutrition. Are they eating healthy? Is there things that we can tweak in their diet? Are they just eating carbs or are they not incorporating any fruits and vegetables? Are they getting enough protein? Is there anything that we need to really supplement? And then, you know, mood I’m assessing somebody’s mood, you know, depression, fatigue is one of the biggest side side effects of depression. And then anxiety, you know, is, are you anxious? Is that impacting your sleep? You know, often women will say, or, you know, women and men will say, I wake up at 3:00 AM and then I just cannot get back to sleep.

Shelby (04:02):

And I’m just start thinking about things while really kind of combating that. Then if that’s the issue and then assessing sleep, are you waking up all the time? Are you drinking too much caffeine? Are you getting restful sleep? Do you have hot flashes that are waking you up? Are you going to the bathroom too often? You’ll really let’s improve those symptoms so that you get a better sleep. And then if you’re snoring, I definitely investigate for sleep apnea because we know that there is a higher incidence of sleep apnea with cancer patients and when treated it, you know, people can feel so much better, sleep apnea is undiagnosed. It can lead to a whole host of other medical problems. So I think that’s really important. So besides looking for, and correcting some of those underlying things, some of the tips to manage the fatigue is really getting moving.

Shelby (04:50):

There are so many studies that show that exercise and moving your body even just natural movements will help increase our improve energy. Right? Yeah. And medications can be helpful sometimes. So if somebody has severe fatigue, we can use stimulants things like Ritalin, light therapy can be helpful. We talked earlier that I’m from North Dakota and some of the dead of winter can really be, you know, hard on people’s energy. And so, you know, ordering that light box off of Amazon is, can be extremely helpful. And then, you know, when it comes to sex, really figuring out what times of day do you have more energy? Is it morning? Well, it’s okay to have sex in the morning. Or are there times, you know, your treatment cycle that you feel more energetic, really kind of analyzing that, you know, what time of day do you feel the best?

Adam (05:41):

Hmm. Yeah. So I think what I’m hearing you say is, number one, don’t just assume it’s only the cancer that’s causing the fatigue, but look at everything holistically and see if there’s ways you can improve your energy in some of those areas to help offset where the drain is happening in the, in the treatment area. And then also, I think I’m hearing you say also, you know, plan ahead, schedule time, like think, think ahead on that. Cause that can also help to find better opportunities along the way, right?

Shelby (06:08):

Yeah, exactly. I mean, you know, people will say it off and that, you know, schedule in those dates and it is true. I mean, we really have to make time for ourselves and our partners and if we don’t, you know, it’ll be just on the lower end of our priority list.

Adam (06:23):

Yeah. Yeah. And I know that’s difficult to think about when you’re going through a cancer treatment, but it is certainly important. And so, so the next question, you know, I know cancer treatment can lead to pain during sex. Can you share some of the most common causes for this pain and any tips you have for how to manage it?

Shelby (06:39):

Yeah. I mean, controlling pain is with sexual activity is so important because it can kind of lead to a vicious cycle. You know, thinking about when you’re in pain, you win some clench and tense up and then you run away and avoid it. And so when we avoid something because it hurts, we are, or we’re scared our natural psychological response is to make the pain and fear even bigger in our brain. Then the, then the pain becomes even more intense when exposed to it again. So it really needs to look at what’s causing the pain and really trying to break that cycle of pain. And that can become, that can be hard. But we don’t want to get into that pain avoidance, increased pain and more avoidance. And by far and away, the most common cause of chronic pain with sexual activity is vaginal dryness from lack of estrogen.

Shelby (07:32):

And dryness can be inside the vagina, but it can also be on the outside in the vulvar area and the, by the urethra. So one, you know, tip or if you have it right on the outside is we can use some light Aquin ointment and put it right there. And that just kinda numbs it up and really gets rid of that pain. And, you know, that’s a prescription, but a lot of people who have ports, porta caths have amla cream and that’s basically the same thing. So you can actually use your Emma cream that you use for your port and see if that can help decrease the pain there. The other thing is you know, really to control the vaginal dryness. And I think, you know, we’ll be talking about that too. But that’s a critical component of this dilators can be used to gradually train yourself to relax your pelvic muscles and to not clench up during penetration. And then if these techniques aren’t working really looking at physical therapy for the pelvis or pelvic rehabilitation, and that can really desensitize you for, from that pain experience. I think it’s important to think about, you know, anybody who has had sexual trauma or if you’ve had ongoing pain for a long time, maybe definitely helpful to get psychotherapy sex therapy or a combination of the two as well. Yeah.

Adam (08:57):

And so so one thing you mentioned is that vaginal dryness is the most common sexual concern in general can, and it can be magnified by cancer treatment. So just walk us through a little bit more about that. Like why, why is that the case? And do you have any additional advice

Shelby (09:11):

Yeah. For breast cancer? Bandol dryness definitely is the most common thing. We, you know, we, we often put people into menopause through chemotherapy or surgically removing their ovaries or through the medications we use like Tamoxifen or aromatase inhibitors. It all increases like I call it is a hyper menopause. So it’s menopause on steroids and that can lead to itching, burning, frequent urinary tract infections and then pain with sexual activity. And so I, you know, the first place to start is vaginal moisturizers. You would use those three times a week, but you can go up to daily and those you can get over the counter, you know, things like Replens is, you know, just available at target Walmart, any of the other stores. And that’s really to just give you baseline moisture. That’s not help use for lubrication during intercourse or vaginal penetration during intercourse or any type of vaginal penetration.

Shelby (10:11):

We definitely would recommend a lubricant. And that really helps to decrease the friction. And, you know, there’s three types of lubricants silicone based oil and water based and all have their own unique properties and reasons why people would use one over the other. So, you know, I think it’s definitely those things. And then after that, going on, you know, that’s that working, looking at vaginal estrogen and that can come in creams, tablets rings, and those are prescriptions and definitely with a history of breast cancer, you’ll want to discuss that with your oncologist. You know, there’s never been any studies that have shown increased risk of breaths, breast cancer recurring, but these studies have been small. So everybody feels like they may be an inconclusive, but at some point, you know, it, it may be needed. And, you know, using the minimum of vaginal estrogen as possible or using a, another hormone called [inaudible] could be helpful, or if you’re on breast cancer treatment, sometimes I’ll try switching from one hormone blocker to another.

Shelby (11:20):

So say if you’re on a Roman TACE inhibitor, that’s often more drying and then switching to a Tomo, then going back to Tamoxifen can be helpful. And then I think making sure that I address other things like pain, like we talked about earlier or vagina Smiths, which is like the involuntary clenching of the pelvic muscles, kind of looking at, you know, treating those things too. And then another, you know, newer thing is a vaginal laser therapy and we are waiting on final data for this approach, but preliminary are looking very promising. And so we’re excited about this and what it does is it delivers a small dose of energy to the vagina or the vaginal tissue, which stimulates new cell formation, which hopefully can improve the lubrication. So that would be nice because then we could avoid using estrogen therapy in those who have severe symptoms. That’s fascinating. Yeah. It’s exciting. I think you know, I think in the next one to two years, we’ll have information on that.

Adam (12:24):

That’s great. So I know that communication about sexual with concerns is not an easy thing for a lot of people. What advice do you have for our listeners about how to communicate sexual concerns with their healthcare team and with their partners?

Shelby (12:37):

Yeah, it’s very challenging to talk about with anyone. I mean, I think that, you know, it’s often considered a taboo topic, especially depending on how you grew up. I mean, in the Midwest, we’re very stoic and we don’t talk about things anyway, and then sexual concerns are even, you know, more difficult. But I, you know what I think about it, you know, really we need to start thinking of it like any health concern or any quality of life concern is impacted by cancer and it’s treatment. And we should, you should be able to talk to your medical team about that. You know, and unfortunately some doctors, nurse practitioners, physician assistants, nurses, they may not feel comfortable discussing it because most often they didn’t get education about it or they don’t feel like it’s their specialty, or they’re just generally uncomfortable talking about sex. And we hope that that’s changing and that doctors are starting to pay more attention to this, but you may experience some funny looks or feel dismissed when asking questions.

Shelby (13:38):

And that may be hard for you to want to open up even more at your doctor’s visits. So I think my tips for this is really before your visit, you know, just like any other symptom, nausea or joint aches or pains or anything that you would have, what do you do beforehand? You write it down, think about the symptom you’re having. How long has this symptom been going on? What have you already tried and what is making it worse and better write all those things down because even I, as a physician go into my doctor and my mind goes blank. And so I think it’s just so critical to have those in writing, because then it’ll stimulate you to ask those questions or be able to answer those questions. And then, you know, once you have once you’re in the visit, when the nurse comes in the room and asks you what you want to talk about today, make sure that you tell her or him, you know, often, you know, you’ll think in your head, I want to just reserve that and just tell the least amount of people. So I’m just going to tell the doctor when he comes in or she goes in and don’t do that, you know, tell them all your problems, including the sexual health problems that you want to discuss, because then it’s on that doctor’s radar and they can make the agenda in their mind of your visit. And it will be including that symptom.

Adam (14:59):

And it also occurs to me too, that if you make the list of questions ahead of time, if you’re someone that has trouble communicating about sexual concerns, but if you had the list ahead of time having that list in your hand, you can just read that question. It just makes it that much easier to ask the question. It’s not that you’re not comfortable somewhere for your eyes to go while you’re asking the question,

Shelby (15:18):

Right? Yeah. And it takes the emotion out of it, right? Yeah. Because all you need to do is just get the words that’s right. That’s right. You know, and then don’t ask that, don’t expect that your oncologist will ask you about sexual concerns because often they may not think of that as something that’s normally in their agenda of what they want to talk about. And another thing is, is don’t wait until the end, when the visit is wrapping up, just, you know, like, Oh, by the way, you know, we, by the way, I have this concern because it’s a, it’s a real concern. And it, it takes time to discuss that concern. So setting it, setting the stage for it right upfront, these are the things I want to talk about, you know, this is my list, you know, not just to the nurse, but also to the doctor. Yeah.

Adam (16:02):

Yeah. And that makes, that makes a lot of sense. It means it’s an important part of our lives and we need to be willing to talk to it as an important part of our lives. So that’s why we’re talking about it.

Shelby (16:12):

Yeah, exactly. And I think the more that we make it normal to talk about, the more doctors will feel like, Hey, I’m, I’m getting asked this question a lot. So I need to have an answers. I need to have answers. I need to do more research and learning about this. And I think that’s what we’re trying to do by this podcast and by other, you know, other educational endeavors that you know, that we’re trying to get the word out on. Yes, this is real for our patients and we need to be better about addressing this

Adam (16:43):

That’s right. That’s fantastic advice. I really appreciate it. Well, Dr. Terstriep, thank you so much for joining us here on the show. Thank you for your advice and your candor. We really appreciate it. And we learned a lot.

Shelby (16:54):

Thanks. Thanks for having me.

Adam (16:58):

Thanks for listening to Real Pink, a weekly podcast by Susan G Komen for more episodes, visit Realpink.komen.org for more on breast cancer, visit komen.org. Make sure to check out @SusanGKomen on social media. I’m your host, Adam, you can find me on Twitter at AGA Walker or on my blog, Adam J walker.com. Thanks to Lilly Oncology for supporting the Real Pink podcast. Join Lilly Oncology and raising more awareness, education, more research, and more dedicated solutions for metastatic breast cancer. Together. We can do more for MBC. Join the conversation at the more for MBC Facebook page.

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Intro and outro music is City Sunshine by Kevin MacLeod. Ad music is Trusted Advertising by David Renda licensed from Fesliyan Studios Inc.