Orgasms After Cancer (Part 1): Understanding the “O” in “OMG!”
Disclaimer: This information is not a substitute for medical care. Always inform your healthcare team of any concerning symptoms you are experiencing, and consult with your provider before starting new treatments, therapies, or health routines.
As if all the other side effects from cancer treatment aren’t bad enough, survivors can also experience frustrating changes in their sex lives, including newly altered (or absent!) orgasms. Why does this happen, and what can be done?
These two important questions call for a two-part answer! That’s because before we can talk about some ideas for strengthening or rediscovering your orgasm game, I think it’s helpful to understand a little bit more about orgasms in general. After all, it seems that this component of sexual response is rather shrouded in mystery and pretty misunderstood — especially for all the ladies out there.
If you have a vulva, or you are the sexual partner of someone who has a vulva, learning about the what, why, and how of orgasms (Part I) can de-mystify their existence and shed some light on how to take charge of more pleasurable sexual experiences (Part II).
So, let’s get started with some of the basics, shall we?
What are Orgasms?
An orgasm is a physiological reflex that can occur with sexual stimulation, and it is typically perceived as intensely pleasurable. The reflex consists of involuntary rhythmic muscle contractions of the uterus and pelvic floor (the muscles around the vagina, anus, and urethra) (7), along with the release of a cocktail of feel-good chemicals in the brain (2,12). The subjective sensation associated with an orgasm experience is often described as a peak of built-up tension radiating throughout the genitals and/or the body. There can be a continuum of intensity, with some orgasms feeling mind-blowing and others feeling like gentler, more subtle ripples or waves of pleasure.
How Do Orgasms Happen?
When activated, sensory nerves located in the genitals send messages to the brain for interpretation, and autonomic nerves tell the body to respond with physiological changes like increased blood flow (7). If the brain says “Yes! That’s sexually exciting, and we’ve got some time to dedicate to this party!”, the arousal response is reinforced and amplified. Signs of physiological arousal can include flushed skin; increased heart rate, blood pressure, and breathing; vaginal lubrication; and a heightened sensitivity to touch. With the right amount and type of sustained stimulation, the threshold that triggers the orgasm reflex is reached, and orgasm occurs (2).
Why Do Orgasms Sometimes… Not Happen?
Even though an orgasm is technically a reflex (kind of like a sneeze), it can take some finesse and skill to trigger it. For women and vulva-owners especially, there appears to be a sort of learning curve to this phenomenon (7). This is evidenced by the fact that more frequent orgasms are associated with age and experience (7,11); and that the capacity to orgasm seems to develop as women learn and practice what techniques work for them (2,7).
Plus, the key word here is threshold — the orgasm reflex is triggered when a threshold of stimulation and arousal is reached. Anything that gets in the way of building the arousal needed to get to that threshold can get in the way of an orgasm. What it takes to reach this point is different for everyone, and it can even change for the same person depending on the situation or context (4). What works on one day or with one partner (or by yourself!) may not work in a different circumstance. The one thing that most orgasms do have in common, however, is the clitoris. For the majority of women, orgasms don’t happen without at least some amount of clitoral stimulation.
What’s so Special about the Clitoris?
If you feel a little clueless about where the clitoris is or what it does, join the club! Unfortunately, this sexual organ is often inaccurately portrayed in human anatomy and completely ignored in sex ed. Even medical professionals have been misinformed, since the clitoral structure was frequently left out of anatomy textbooks for years (7). Talk about erasing female sexuality!
However, when it comes to orgasms, the clitoris is most certainly the MVP. If it were up to me, every clitoris would come with an owner’s manual that detailed the operation and maintenance of this unique organ, whose only purpose is to provide sexual pleasure.
Anatomical descriptions often refer to the clitoris as a button- or pea-sized external genital structure located just above the urethral opening (where pee leaves the body). This is actually called the glans, and it’s the part of the clitoris that you can see from the outside. The glans is made of erectile tissue and packed with nerve endings that make it highly sensitive to touch, and it’s covered by a protective skin called the clitoral hood, or prepuce.
But the glans is only the tip of the iceberg, so to speak, because most of the clitoral structure is actually hidden internally. The glans is attached to the internal body (or shaft) of the clitoris, which extends back 2-4 centimeters before curving down and splitting into two lengths of erectile tissue called crura. Together, the glans, body and two crura are attached at the root of the clitoris. This whole structure looks a lot like a wishbone, and can measure 10 cm (about 4 inches) or more (7,12)! Two additional structures of erectile tissue extend down from the root of the clitoris separately from the crura to form the vestibular (or clitoral) bulbs.
For a 3D visual, check out the YouTube video from Slate listed at the end of the article (8), or Google it!
Because the clitoris is composed of erectile tissue similar to a penis, this tissue becomes similarly engorged (filled with blood) in response to sexual stimulation, enlarging in size and becoming more sensitive to touch (7). And although orgasms can be initiated in different ways, including stimulation of non-genital erogenous zones like the breasts and nipples, through fantasy alone (what can I say? The brain is a powerful sex organ!), and during sleep (4), the most common route to orgasm for women is via stimulation of the clitoris (7,12).
Even for women who report achieving orgasm during penis-partnered sex, the clitoris is the likely star. This contradicts the claim that there is an anatomically separate and distinguishable structure made of erogenous tissue located inside the vagina that is responsible for these “vaginal orgasms.” Despite the cultural ubiquity of this so-called G-spot, its existence has yet to be proven by science (7,10,12). Check out the section on the G-spot controversy for a rundown on the current evidence (or lack thereof).
How Does Cancer Affect the Orgasm Response?
Cancer can affect a number of components important to orgasm. For example, altered sensations and response to touch can impact the type and duration of stimulation needed to orgasm. Orgasms may feel less intense or less satisfying, or you may be able to reach a plateau of tension but never really have that pleasurable release. These changes can be disappointing and frustrating. What’s going on? The culprit of alterations in orgasm experiences for survivors may be related to physical, mental and emotional, or interpersonal factors. Often, it’s a combination of these.
Several treatment-related physiological changes can impact orgasms. This includes damage to the blood vessels and nerves that supply the genitals and pelvic floor muscles. This might occur with pelvic surgery or radiation (2,4,5), and it can alter sensation and blood flow. For many women, breast and nipple stimulation contributes to sexual arousal and the orgasm response, and this can be lost after surgery for breast cancer. Chemotherapy may also damage blood vessels and nerves, and genital neuropathies can develop (6).
Surgical menopause (9) and low estrogen levels (5) have been associated with orgasm problems. Estrogen loss may affect the pelvic floor muscles, and can impact vaginal tissues. Genital tissues may be less likely to respond with engorgement, and there may be less natural lubrication. Sometimes women find that while more stimulation is needed, this can be difficult to achieve when tissue changes make touch painful or uncomfortable.
Some medications can interfere with sexual arousal and orgasm, too. For example, this can occur when taking SSRIs and SNRIs (5), which are commonly prescribed for depression and (in smaller doses) to help with hot flashes related to decreased levels of estrogen.
Mental and emotional stressors unrelated to sex can be very effective inhibitors of sexual arousal and orgasm. Our brains are excellent at prioritizing what to pay attention to and what to ignore, and anything perceived as threatening (like anxieties, fears, or worries) will get moved to the top of the list, while anything less important (like sexual arousal signals) will often get filtered out, dampened down, or ignored.
In partnered relationships, cancer may also change how couples relate to one another. Communication about sexual changes can be difficult, and it might feel easier to ignore sexual problems rather than to try and talk about them. Couples often benefit from help initiating these discussions.
So, What Can Be Done?
The good news is that there are a number of techniques that can address these issues, and that’s what Part II is for! Next time, we’ll look at some strategies that survivors can explore that may help revive that loving feeling again (or maybe for the first time). But also, we’re going to put orgasms in their place by positioning them within the overall context of sexual satisfaction, and by unpacking the differences between pleasure and performance. Curious? Stay tuned!
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The G-Spot Controversy
The term “Gräfenberg Spot” (later shortened to “G-spot”) was coined by the authors of a medical case study published in the 1980’s, in which they described a woman who could experience an orgasm in response to stimulation of the anterior (front) wall of her vagina. This term was a nod to the earlier work of German gynecologist Ernst Gräfenberg, who had earlier identified and described a similar area that seemed particularly sensitive to sexual stimulation in some of his research subjects (12).
However, these observations hardly proved the concept, and the G-spot hasn’t held up under subsequent scientific scrutiny. Researchers have not been able to objectively prove the existence of such a structure from an anatomical, neurovascular, or histological standpoint (7,10,12); nor has there been any convincing evidence of a difference between “vaginal orgasms” and “clitoral orgasms.”
What the evidence does bear out, however, is that the internal components of the clitoris are in close proximity with the vaginal canal and the urethra, and can actually be stimulated through the anterior vaginal wall located at an area suspiciously close to the supposed G-spot (7,10). Additionally, the reported feeling of thickness or swelling in that area of the vagina during the arousal phase of sexual response is likely related to the engorgement of the clitoral tissue pressing against the vaginal wall (7). This helps explain why many women DO subjectively report an especially sexually sensitive area at this location.
Further, the reason why some women orgasm with penis-partnered sex while others don’t may be as simple as the anatomical variance between women (4). Where the clitoral structures are in relation to the external vaginal opening and internal vaginal canal may be a little different for each person, leading to differences in stimulation during sex. So, different women have different experiences because, well, their bodies are all built a little differently!
In conclusion, the idea that stimulating a specific area of the vaginal wall can produce pleasurable sensations or even orgasms for some women is not really under dispute. This has been subjectively reported by women, and there is measurable evidence that vaginal stimulation produces physiological arousal responses. It just doesn’t appear to be related to some unique tissue or special anatomical structure — the most likely scenario is that the clitoris is simply getting titillated from a different direction. Who knew!?
Bibliography and References
1. American Cancer Society (2022). Managing female sexual problems related to cancer. https://www.cancer.org/treatment/treatments-and-side-effects/physical-side-effects/fertility-and-sexual-side-effects/sexuality-for-women-with-cancer/problems.html
2. A Woman’s Touch. (2020). Orgasms for people with vulvas and vaginas. https://sexualityresources.com/wp-content/uploads/Orgasm20-1.pdf
3. Bradford, A. (2020). Treatment of female orgasmic disorder. UpToDate. https://www.uptodate.com/contents/treatment-of-female-orgasmic-disorder
4. Bradford, A. (2021). Female orgasmic disorder: Epidemiology, pathogenesis, clinical manifestations, course, assessment, and diagnosis. UpToDate. https://www.uptodate.com/contents/female-orgasmic-disorderepidemiology-pathogenesis-clinical-manifestations-courseassessment-and-diagnosis
5. Bober, S. L., & Krapf, J. (2021). Overview of sexual dysfunction in female cancer survivors. UpToDate. https://www.uptodate.com/contents/overview-of-sexualdysfunction-in-female-cancer-survivors
6. Hughes, M. K. (2009). Sexuality and cancer: the final frontier for nurses. Oncology Nursing Forum 36: 241-246.
7. Mazloomdoost, D., & Pauls, R. N. (2015). A comprehensive review of the clitoris and its role in female sexual function. Sexual medicine reviews, 3(4), 245–263. https://doi.org/10.1002/smrj.61
8. Slate. (2016, October 3). What the clitoris really looks like. https://www.youtube.com/watch?v=Zo7sy3g-_Qw
9. Shifren, J. L. (2022). Overview of sexual dysfunction in females: Epidemiology, risk factors, and evaluation. UpToDate. https://www.uptodate.com/contents/overviewof-sexual-dysfunction-in-females-epidemiology-riskfactors-and-evaluation
10. Vieira-Baptista, P., Lima-Silva, J., Preti, M., Xavier, J., Vendeira, P., & Stockdale, C. K. (2021). G-spot: Fact or fiction? A systematic review. Sexual medicine, 9(5), 100435. https://doi.org/10.1016/j.esxm.2021.100435
11. Wincze, J. P., & Weisberg, R. B. (2015). Sexual dysfunction: A guide for assessment and treatment (3rd ed.). The Guilford Press.
12. Yeung, J., & Pauls, R. N. (2016). Anatomy of the vulva and female sexual response. Obstetrics and gynecology clinics of North America, 43(1), 27–44. https://doi.org/10.1016/j.ogc.2015.10.011