Dr. Angela Wicker-Ramos PT, DPT, CLT-LANA
Oncology Physical Therapist and Certified Lymphedema Therapist
Breast cancer treatment for many people may include an oral medication that blocks hormone production. Hormones occur naturally in the body and control the growth and activity of cells. Estrogen and progesterone can help certain types of breast cancer to grow. Hormone therapy works by reducing or blocking the amount of estrogen and/or progesterone in the body. Some examples of these medications include Anastrozole (Arimidex), Letrozole (Femara), Exemestane (Aromasin), Tamoxifen (Novaldex), and Goserelin (Zoladex). Anti-Estrogen medications can cause bone loss, joint and muscle pain, weight gain, fatigue, muscle atrophy/weakness, decreased libido, and pelvic health issues. Regular exercise can help improve bone density, achieve weight loss, improved energy, increase strength and muscle mass, improve sex drive, and assist in pelvic floor strength and decreased issues with incontinence.
Your pelvic floor is a group of muscles that create a “hammock” from your pubic bone to your tailbone. They are involved in:
• Bladder and Bowel Control
• Sexual Function
• Abdominal Organ Support
• Core Strength
Breast cancer treatment can cause weakness, thinning, and dryness in the pelvic floor region that may cause pain, tightness, weakness, and/or leakage issue. Fatigue and decreased activity along with changes in hormone levels can cause atrophy (muscle loss) in the pelvic floor muscles. This may lead to urinary or fecal leakage in some individuals. If you are experiencing leakage please mention it to your medical team as pelvic floor rehab can cure or significantly improve incontinence issues.
Some foods and drinks can aggravate the bladder and increase leakage or the feeling or urgency with urination. These include:
• Carbonated beverages
• Spicy foods
• Sugar and artificial sweeteners
Other lifestyle changes that may help leakage and urgency include:
• Maintaining a healthy weight
• Having regular bowel movements
• Urinating every 2 to 4 hours
• Exercising for 20- 30 minutes at least 3-4 days per week
Dehydration, waiting too long before going to the bathroom and being sedentary can increase incontinence and urgency issues. Healthy bladder habits are urinating every 2-4 hours during the day and 0-1 times per night.
The muscles of the pelvic floor are strengthened with Kegels and other exercises to condition the core, hips, and lower back. ***If you are experiencing pain in the pelvic region to not perform Kegels until assessed by a medical doctor and a pelvic floor therapist*** In some cases Kegels can do harm if the muscles in the pelvic floor region are too tight or are spastic. These conditions may cause pelvic pain; however, if you are dealing with incontinence without pelvic pain Kegels may be helpful.
In order to perform a Kegel you want to tighten the muscles you would use to hold back urine and hold back gas. If you perform these while sitting you should feel the muscles in the vaginal and rectal region tighten (or lift up towards your head.) If you isolate these muscles correctly (without bringing in other muscles) a person observing you would not see any movement and will not know you are doing Kegels.
It is important to work on both the power and the endurance of the pelvic floor muscles. A basic recommendation for pelvic floor strengthening is:
• 3 sets of 10 quick contractions (1 second contract, 1 second relax)
• 10 repetitions of long holds (10 second hold without holding your breath.)
This should be performed 2x/day. These exercises are easiest lying down, harder seated, and most challenging in the standing position. Along with Kegels it is important to strengthen your hips, abdominal region, and lower back to create strength and stability to the entire pelvic region. A pelvic floor specialized physical therapist can help develop an individualized prescriptive exercise program.
Pelvic pain can be caused by multiple factors (many of which are seen in those who have dealt with cancer treatment) including hormone changes, pelvic and abdominal, surgery, emotional stress, and postural changes. If you are experiencing pelvic pain there are treatments that may help including lubrication, moisturizers, topical medications, and pelvic floor rehab. Please let your medical oncologist and gynecologist know if you are experiencing pelvic pain because there are treatments available and you do not have to suffer in silence.
Pelvic floor rehab for pelvic pain may include treatments such as trigger point and myofascial release, relaxation techniques and conscious control of pelvic floor musculature, dilator program and education on vulvar care, lubrication, and sexual positioning.
Understanding the difference in types of lubrication may be helpful when dealing with vaginal dryness and discomfort.
Oil Based Lubricants
(Examples: baby oil, mineral oil, vegetable oil, coconut oil and hand creams)
• Oil based lubricants are recommended ONLY for masturbation, as the oil can leave a coating that increases the risk of bacterial infections.
• Oil-based lubricants should never be used with condoms. Oil-based lubricants will disintegrate the latex.
Silicone Based Lubricants
(Examples: Wet Platinum, Eros, and ID Millennium)
• These lubes last longer than water-based lubricants and may be used safely with condoms and other latex products.
• Silicone-based lubricants can also be used for sex in and around water.
• Silicone-based lube can be more difficult to rinse off, and some women note vaginal irritation if they don’t wash away silicone products directly after intercourse.
• These lubes should not be used with silicone-based sex toys, because they will bond with the toys and cause discomfort.
Water Based Lubricants
(Examples of brands containing glycerin include KY Jelly, Sylk, Astroglide, Probe, and Aqualube. Slippery Stuff is a glycerin free lube.)
• These are the safest lubricants for use during both intercourse and masturbation.
• They do not cause latex to deteriorate and should not irritate the skin.
• Additionally, water-based lubricants rinse off easily in plain water.
• Water-based lubricants come in two general types, with and without glycerin. (Glycerin is a slightly sweet tasting substance.)
• Women who often have vaginal yeast infections may wish to avoid glycerin lubes, as the sugar can encourage yeast growth
• Replens is a topical moisturizer that is hormone free. You use it as you would a body moisturizer to reduce dryness on a daily basis.
• VMagic is a vaginal skin cream that helps reduce tenderness, dryness, and irritation in the vulvar/vagina region. It is also hormone free.
The impact of cancer treatment on bladder and sexual function is often ignored and can be challenging to discuss with your healthcare team. It is an important component of survivorship/thriving and should not be ignored. Please know that there are interventions and treatments available to help. Let’s start this conversation and keep it going because you are not alone and do not have to just settle with this “new norm”. Incontinence, urgency, and pelvic/genital pain can be addressed and your pelvic health is important for your quality of life.
Angela Wicker-Ramos PT, DPT, CLT- LANA is the owner, certified lymphedema therapist and oncology physical therapist at Cancer Rehab and Integrative Medicine. From 2018 – 2019 she was Director of Health and Wellness at Texas Oncology. She has lymphedema certifications from both the Academy of Lymphatic Studies (ACOLS) and the Lymphology Association of North America (LANA). Angela participated in the Survivorship Training and Rehabilitation (STAR) program from 2012–2015 and is Oncology Rehab Certified through the Physiological Oncology Rehabilitation Institute (PORi). She also has advanced training through the APTA on Women’s Health and Pelvic Floor Dysfunction. She has developed the oncology rehab and lymphedema programs at multiple clinics/hospitals in New Mexico and Texas prior to opening a private practice oncology specialty clinic in 2015. Angela participates in community and national presentations/educational events including the Breast Cancer Resource Center, Cancer Support Community of Central Texas, and Livestrong. She is on the steering committee for the Austin Cancer Support Coalition.
Angela has also been interviewed regarding oncology rehabilitation and lymphedema for The Stupid Cancer Show, The Dr. Carol Show, Pelvic Zen Blog Radio, Beyond the Boobie Trap, and Seton Healthline, and the Onco PT. She has participated in multiple educational classes at Austin Community College and Texas State University. Angela contributes to the Multidisciplinary Cancer Conferences hosted by the Cancer Care Collaborative and Tumor Boards at St. David’s and Seton Hospital. She is a member of the National Lymphedema Network (NLN) and the National Association for Professional Women.