Life after mastectomy: sex, self-image, and coping strategies

Having a mastectomy and reconstruction surgery as part of breast cancer treatment is a deeply personal decision. People with breast cancer often have to do a lot of research to get up to speed on their treatment options, side effects, pain management, and prognosis.

As surgery techniques have improved, there are also more reconstruction options to consider. All are designed to help recreate the look and feel of breasts. Those decisions can affect your quality of life after surgery, as well as your feelings and beliefs about yourself.

How your body moves in the world, the way clothes fit, and how to plan an exercise routine after surgery are all part of the equation. So is sex. Body image and sexual function are affected by breast cancer surgery.

Some people may also abruptly experience symptoms of menopause (the absence of menstrual cycles for 12 months in a row) due to certain surgeries and therapies. These can affect sexual wellness, emotionally and physically. Symptoms of menopause can include:

• Mood changes
• Difficulty sleeping
• Hot flashes
• Pain during sex or changes in sexual arousal

With that in mind, here are tips for making decisions related to body image after mastectomy, along with ways to cope with the side effects of additional treatments.

Acknowledging your feelings can help

“When a woman sees herself naked in front of a mirror with a surgical scar, it can change how she views herself,” says Julian Berrocal, MD, a breast surgeon at Women’s Health and Healing of the Palm Beaches in Florida. “Surgeons work hard to make incisions so that the scar is as hidden as possible, so that she’s not always reminded of cancer.”

But with mastectomy, such subtlety isn’t always possible. As a result, some people may have trouble accepting their appearance, even if other people provide reassurance that they love them just as they are. After mastectomy, some people may doubt their attractiveness and sex appeal, affecting their desire for intimacy.

It’s natural to experience feelings of grief, anger, and sadness. It can help to acknowledge and allow yourself to experience these feelings. Moving toward acceptance may help you focus on things that bring you happiness.

Breast reconstruction considerations

Although everyone has a different experience, breast reconstruction can help some people regain confidence in the way they look. It may come with other benefits, too, such as improvements in self-esteem, mental health, and sense of sexuality. The procedure is typically performed by a cancer surgeon with a specialty in breast cancer.

Dr. Berrocal says that before breast cancer surgery, he typically discusses breast reconstruction options with patients. "'Going flat' [leaving one side of the chest flat] is one option some patients choose,” says Berrocal, “and there should be no stigma in that.”

There are few instances, Berrocal adds, when reconstruction can’t be done at the same time as the surgery for breast cancer. In those cases, someone could opt for reconstruction after they have finished other cancer treatments.

Tattoos are an option

Some people who get reconstruction after mastectomy choose tattooing. Tattoo artists can draw a nipple and areola (the colored skin around the nipple) over breasts or flat chests, says Berrocal. Or they can create artistic images, such as flowers or butterflies. Tattoos can help people feel more empowered and comfortable with their new appearance.

Other treatment issues

Another aspect of breast cancer treatment that can affect a woman’s sex life is whether they need additional treatments, such as chemotherapy (drugs that kill cancer cells or slow their growth) and radiation (high dose X-rays that shrink and destroy cancer cells), says Berrocal. These can lead to fatigue, nausea, and other symptoms that can decrease sexual desire.

“Some types of chemotherapy can put women in menopause prematurely,” he says. “This can lead to hot flashes and vaginal dryness.” People who are treated with “anti-estrogen” medications like tamoxifen (which must be taken for 5 to 10 years) and anastrozole may also experience hot flashes and loss of sex drive, pain during sex, headaches, and depression. Anti-estrogen medications decrease levels of the female sex hormone estrogen.

"Vaginal lubricants can help with dryness,” says Berrocal. Since one function of estrogen is to create lubrication, applying an estrogen cream to the vagina can be helpful. Berrocal says that even though absorption of estrogen throughout the body is low when it’s applied as a vaginal cream, some oncologists treating patients with tumors that are sensitive to estrogen recommend avoiding even a small dose applied to the area. This is because estrogen can promote the development of tumors in some breast cancers. The American College of Obstetricians and Gynecologists, meanwhile, supports the use of vaginal estrogen in breast cancer survivors. Your healthcare provider (HCP) can help advise on whether such treatments may be right for you.

Open communication can help

A return to a pre-breast cancer sex life may take about a year or two, says Berrocal, depending on treatment. Meanwhile, there are many ways to maintain emotional intimacy, even if you don’t feel ready for sex:

• Open and honest communication is key. Your partner may be uncertain about how to show affection and there may be fear of causing you pain. So, it’s important to let them know what you’re thinking and how you’re feeling.
• Cuddling, hugging, and other signs of affection can be comforting and create an opportunity for these conversations until you feel ready to resume your sex life.
• Some people have fears about what the future holds for their sex life. If you find yourselves stuck or unable to talk about sexual issues, it may help to see a counselor or join a support group to work through your concerns.

Looking ahead

“Surgeons are trained to talk about treatment and explain surgical options,” says Berrocal. But, he adds, someone shouldn’t hesitate to bring up problems and concerns about vaginal dryness, pain around the scars, or any other issues that could interfere with their sex life.

“Our focus is quality of life, and helping patients return to what it was before their cancer diagnosis,” he says. Open communication can make it possible to enjoy sex again after a mastectomy. For further questions about recovery from mastectomy and how your insurance may help cover some of the costs, speak with your healthcare provider.