Love and Libido after a Total Mastectomy

Women have a strong sense of self and body that helps them visualize themselves at all times. A small physical defect will hardly ever pass unnoticed and unacknowledged by the dear women. In a mirror image, they will perceive “what the other sees” in her, especially the other women. Then it should come as no surprise that the utterly traumatic surgical event of a Total Mastectomy for Breast Cancer often has a devastating physical and psychological tally on their minds and moods.  In order to experience libido or “the desire for sexual company”, women have to feel at ease from the physical and emotional standpoints, which is hardly the case in post-surgical patients. This is one of the least discussed issues in our medical practices, compounded by the fact that it is almost never addressed in medical schools’ curriculums, even in the supposedly “enlightened” countries. Physicians and other health care personnel are left with the extremely bad option of learning sur-le-champ, often quasi-alone.

After forty years of medical practice, we have collected a few nuggets of wisdom for these patients, even though we never practiced Gynecology and we have always avoided doing any Gyn exams ever since we were in medical school. However, talking to patients and friends after undergoing that procedure, we found these challenging issues:

1. Toxicity of associated medication.
2. The unwise hurry to have a Prosthesis.
3. The lack of an honest discussion between partners
4. The absence of a proper bereavement process

A – Toxicity of associated medication

In 1998 the Food and Drug Administration (FDA) approved the use of Tamoxifen for the use in both men and women that were diagnosed with hormone-receptor-positive early-stage Breast Cancer to avoid the recurrence of the disease after surgery; similarly it is being used for patients with advanced-stage of the disease and had metastases of a hormone-receptor-positive neoplasia. The pharmacological activity is dependent on its conversion to its active metabolite, endoxifen, by the enzyme CYP2D6, which acts as an estrogen modulator to competitively inhibit the binding of endogenous estrogens. It is available in a pill form (Nolvadex) or  a liquid from, easier to swallow (Soltamox) Almost ten percent of Breast Cancer patients have a slow-functioning CYP2D6, which can hamper the effectiveness of the drug and several medications, most notably the selective serotonin re-uptake inhibitors (SSRIs) like the anti-depressants, can block its activity. This drug has serious side effects like blood clots, Stroke and Endometrial Cancer but also less prominent ones like vaginal bleeding, dryness of vagina and loss of libido that affect the quality of life.

B – The unwise hurry to have a Prosthesis

Many surgeons precipitously offer the possibility of having a prosthesis installed right after the resection, in a kind of “two-for-one” deal to supposedly expedite the healing process of women. Unfortunately, most women would surely miss “the part that was taken away” and consider that prosthesis as an alien object that does not have the necessary seal of approval by her hormonal and psychological self. If there was an honest discussion with her family and sexual partner about the traumatic aftermath of the procedure, why rush through the protocols and insert the prosthesis?

C – The lack of an honest discussion between partners

There is not a hint of sexual enticement or libidinal drive in a woman that feels nausea and pain after the surgical act, compounded by the psychological stigma of “being uglier’ than before. Patients have to take charge of the physical and emotional distress to slowly research and find the pharmacological, hormonal, psychological and sociological interventions to ease her burden. One of the most damaging approaches consist of “sticking the head in the ground’ like an ostrich to avoid facing the dark undertones of this radical procedure. Nothing will be the same after it. Patients, partners and family members must honestly deal with the reality and find ways to heal. Women should make clear to their partners that they cannot recover the same kind of sex life. There will be times of physical discomfort, depressive states, untoward side effects and frustration. The patient, partner and family should carefully consult the caring professionals to find the proper pharmacological solutions and psychological help to overcome the trauma post-mastectomy.

D – The absence of a proper bereavement process

When we lose a loved one, we must sadly go through one the worst human processes: bereavement. After the initial shock and denial stages, we progressively start accepting that most tragic fact. Only after we methodically go through each and every stage, will we be able to overcome grief. Similarly, a woman, that was aesthetically and psychologically attached to her own body before,  must go through the same stages until she can find a way (or ways) to cope with the stark reality. In those circumstances, the sustained support of her partner and family play a pivotal role.

After a Total Mastectomy, a savvy woman will learn the new parameters of her new physical and psychological coordinates and, eventually, she will recover her lost desire for sex and company. She will need the continued assistance, tolerance and patience of all those who love her dearly. Piercing through her dense fog of dire despair, we should be a beacon of hope and encouragement so she can resume her life journey in earnest.

What do you think? Please tell us.

Don’t leave me alone.