Cancer Treatment-Induced Pelvic Pain

I use the phrase “game changer” a little too often. I apologize to everyone that knows me that gets irritated with it. It’s like when I read the The Bachelorette tell-all’s and couldn’t understand why “shit show” was the only word they could use to describe their experience. I say “game changer” so much that surely now the game is back to its original form – it cannot possibly change any further.

The latest game changer is Dr. Deborah Coady’s article titled “Sexual Health in Women Affected by Cancer”.  This piece came out just this month.  I want to frame this article because I both love Dr. Coady and her work.  Now, she co-wrote it, but I can hear her voice in the writing.  Some of it reads with a bit more sass than I’m used to seeing in medical literature – but I like that.  Here are the highlights:

The new, correct term to describe a woman that has had cancer is no longer “cancer survivor”, but instead “woman affected by cancer”. Women live after cancer comes into the picture. Cancer affects women. Women can be given the tools to take hold of how cancer affects them. These tools can come in the form of societal support, medical support and spiritual support. This is a type of “people first” language that describes individuals living in their experience instead of defining individuals by their diagnosis alone. Because I love to teach, I need to be mindful of this. It’s literally easier for me to say “cancer survivor” or “cancer patient” than to use a few extra small words. But, that is my responsibility now. My facial muscles can handle the extra movement.   My mouth will not fall off from exhaustion. I’m sure of it.

The article states that women should be treated prophylactically. What does this mean? This means that if a woman is given a medication that is known to cause a symptom, then that symptom should be treated before it starts.

It’s like how when my local Austin urologists are going to perform a prostatectomy on a guy, they send the man into see me first to prepare him to have minimal urinary incontinence and erectile dysfunction symptoms.  Then the surgery is performed.  Then the guy comes back to me for more treatment.  Because we know the cancer treatment for prostate cancer can induce incontinence we therefore assume the patient will have incontinence so we treat the incontinence before it even starts.  We best prepare this patient for optimal outcomes.

It’s like how some women who get a real urinary tract infection are given both an antibiotic and a prescription to treat a yeast infection should it follow the original infection. Antibiotics are known to cause a change in vulvovaginal flora which can cause a yeast infection.

But…treating women affected by cancer is also not like these examples because sometimes a woman doesn’t get a yeast infection after her antibiotics and she doesn’t need to take the yeast infection treatment. In women affected by cancer, many, many, many treatments will with 100% certainty cause pelvic pain symptoms. And now here are some of the details:

Radiation and surgery treatment can cause neuropathy and/or neuromas. When radiation is directed at organs that are close to pelvic nerves (or any other nerve), guess what, those nerves can get radiated too. This can cause neuropathy to the pelvic nerves sending pain along the course of that nerve. Anywhere that nerve goes, pain can go. According to Coady’s article, this can even cause nerve compression. <— I did not know this.

Drugs such as Tamoxifen and aromatase inhibitors reduce the body’s estrogen production. This is estrogen suppression. This is truly, the great suppression.  When this happens…read my muscular lips: no new estrogen. And just like Reagan wanted to keep people affected by AIDS from entering the United States, Tamoxifen and aromatase inhibitors keep estrogen from flowing freely through your united states. (Did that analogy work? Eh. It stays.)

This means that parts of your body that are highly dependent on sex hormones such as the vulvovaginal tissue and most especially the opening of the vagina (which is the vestibule (which is also technically vulvar tissue (which is what I teach in my course (which Dr. Coady so kindly does a Q&A in)))) are not getting adequate supply and therefore will atrophy. This means that the clitoris will get small. The hood of the clitoris will start to attach to the clitoris. The labia minora (the little hairless lips) will shrink and start to get absorbed by the labia majora. The opening of the vagina will get smaller. The tissue that makes up the opening of the vagina – the vestibule – will become painful and irritated. The opening of the vagina might start to tear. The vagina itself will become dry and frail.  Just for kicks now, it might start to burn with urination or it might feel like a constant need to pee or a constant sense of having a urinary tract infection.

Now close your eyes (while you continue to read). Imagine a resort. Not just any resort, but a fruitful resort allowing wet, wild fun and life funded by sex hormones.   Lots of sex hormones. Sex hormones coming out the wazoo. Sex hormones constantly flocking to this resort because it is the hottest place since that New York City club advertising three-breasted women and hot dogs.

But then everything changes. Now the economy is in a really bad way and what little sex hormones are left are being used for survival, pure survival. Sex hormones can’t be wasted on fun. Sex hormones can’t be wasted on getting wet. We are rationing here. Desperate times call for desperate measures.   That once rich, lavish, scandalous resort is now bankrupt. It’s doors closed. And when someone drives by to check on it two years later…well…well…just imagine a wasteland. The resort is unidentifiable. The frame of the buildings are gone. Whatever framing is left is covered in cobwebs. The architecture is completely destroyed and the sun has melted all of the lawn chairs. Tumbleweeds roll by. This place is abandoned and honestly, scary.

That’s what the great suppression is capable of.

We leave the resort abandoned and alone.

But.

It’s. Gonna. Be. Okay.

This place has a happy ending.

According to Dr. Coady’s article “Sexual Health in Women Affected by Cancer”, the symptoms of Tamoxifen (and for now aromatase inhibitors) can be treated before they even begin. Once a patient is placed on these drugs, they can try to maintain their vulvovaginal health by using topical estrogen. I have never, ever heard this before. Have you? Surely not. Surely you had to re-read that again.

This here is the game changer. The game is changed. It’s not the same game anymore. Now it’s a different game. Game. Changer. (shit show) Game. Changer.

Remember that topical estrogen is applied to the vulva and vagina – depending on where you want it to go. The article states that there is little to no absorption of estrogen in the blood stream when small dosages of estrogen are applied at the vulva (the external genitalia including the clitoris and the labia majora and minora) and the vestibule (technically this is vulva but it can feel like it’s internal).

This is where things get good. This is how that abandoned resort gets all its sex hormones back. Slowly the grass starts growing again. The framing goes back up. The foundation is redone. The cobwebs are blown away. Somehow the lawn chairs sit up.  The doors open again and slowly but surely fun times are had by all. It takes time, but this resort is back.

The atrophic changes that take place at the vulvovaginal tissue are reversible in 90% of individuals. That is what this article says. This article isn’t really about medicine, it’s a story of how a once beautiful resort suffered in the great suppression, but then it got its groove back.  That’s really what this article is saying.  It’s saying that all vulvas can fight the great suppression.  All vulvas can make it to the other side.  Make vulvas great again!  Yes vulvas can!   Vulvas are stronger together!  Vulvas have a dream!  Ask not what your vulva can do for you, but what you can do for your vulva!  How is that for some magic rub?

 

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