Side effects of pelvic radiotherapy in women
This information is for women who are having, or are about to have, radiotherapy to the pelvic area (lower part of the abdomen). Radiotherapy to the pelvis can cause side effects. This information is about the possible side effects and how they can be controlled if they occur.
The pelvis is the area of the body between the hips, in the lower part of the tummy (abdomen). It contains the parts of a woman’s body that help her to reproduce (the reproductive system).
This includes the:
The pelvis also contains the bladder and lymph nodes (glands), which help to drain fluid.
The pelvic area also includes part of the digestive system:
the large bowel (colon, rectum and anus)
part of the small bowel.
Side effects of pelvic radiotherapy
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Radiotherapy destroys cancer cells in the treated area, but it can also have an effect on some of the surrounding normal tissue.
Radiotherapy affects people in different ways, so it’s difficult to predict exactly how you will react to it. The side effects you have will depend on different factors. These include the type of cancer you have, the dose of radiotherapy given, whether it’s external or internal radiotherapy, and whether you have other treatments as well, such as chemotherapy.
For example, radiotherapy to treat cancer of the rectum or anus is not likely to cause as much bladder irritation as radiotherapy to treat cancer of the bladder, cervix or womb. Women who have internal radiotherapy on its own will not have as many side effects as women having a course of external radiotherapy. If you’re having chemotherapy at the same time as radiotherapy (called chemoradiation), some side effects may be more severe.
Your cancer specialist, specialist nurse or radiographer will explain the most likely side effects in your situation. Let them know about any concerns or questions that you have. They’ll be able to explain how side effects can be treated and give advice on how to cope with them.
Most side effects are temporary and start a week or two into the treatment. They may continue to get worse for a couple of weeks after treatment, before they begin to get better. Side effects usually improve gradually over the next few weeks or more.
Occasionally, some side effects don’t completely go away, or side effects develop months or years later as a result of the radiotherapy. These are called long-term or late effects.
Side effects during treatment
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During treatment, you may have some of the side effects explained here. It’s important to tell your radiographer, cancer specialist or specialist nurse if you do. They can give you advice on how to manage them and tell you about the treatments that can help.
Radiotherapy often makes you feel tired, especially towards the end of the course of treatment. The tiredness continues after the treatment has finished and may last for a few months. You’ll find that your energy levels will gradually improve. However, it can take a while to recover, so don’t be too hard on yourself.
There are some things you can do to help manage tiredness:
Pace yourself so you don’t overdo it and take regular rests.
If you’re able to, plan some physical activity into your day, such as going for a short walk. This will help to build up your energy levels.
Ask family and friends to help out, perhaps with things like household tasks and taking care of the children.
Make sure you get enough sleep.
We have more information about coping with tiredness (fatigue), keeping physically active during treatment and getting a good night’s sleep.
Effects on the skin
Sometimes, radiotherapy can cause a skin reaction in the area being treated. The skin may redden or get darker, and become dry, flaky and itchy. Towards the end of treatment, the skin sometimes becomes moist and sore, and there may be breaks in the skin, especially around the back passage and groin.
Your radiographer or nurse will check your skin regularly. Tell them if your skin is sore or you notice any other changes. They will assess your skin and may prescribe a cream or dressings to help. They can also prescribe painkillers, if needed.
Your radiographer or specialist nurse will tell you how to look after the skin in the treated area. They will usually give you the following advice:
Keep the skin in the area clean, washing it gently with lukewarm water and unperfumed soap, then carefully patting it dry with a clean, soft towel.
Avoid using talcum powder, shower gel or any scented products on the treated area, as these can irritate the skin.
Check with the radiographer or nurse before you put anything on the skin in the treated area.
When taking a shower, use a very gentle stream of lukewarm water. If you take a bath, don’t soak in the water for long.
Use a simple, unperfumed moisturiser on the skin such as aqueous cream.
Wear cotton or silk pants that are loose-fitting (like shorts) and won’t rub against the skin. Avoid wearing tights or tight-fitting trousers.
Don’t shave, wax or use hair removal creams until a few weeks after radiotherapy is over and any skin reaction has healed.
Avoid smoking, as this can make skin reactions worse.
Skin reactions may be at their worst up to two weeks after radiotherapy finishes, before beginning to improve. If you’re sore or are having any problems with your skin during this time, contact the radiotherapy department for advice.
You’ll need to protect the skin in the treatment area from the sun for the first year after radiotherapy. After this, the skin will remain sensitive to strong sunlight, so if it is ever exposed, you should always wear suncream with a high sun protection factor (SPF) of at least 30.
Pelvic radiotherapy may make your pubic hair (hair around your genital area) fall out. It should start to grow back again within a few weeks after radiotherapy finishes, but it maybe thinner. Occasionally, hair loss can be permanent.
Bladder side effects
Pelvic radiotherapy can cause irritation and inflammation of the lining of the bladder. You may find that you have some of the following symptoms:
a need to pass urine often (frequency)
a need to pass urine during the night (nocturia)
a burning sensation when you pass urine (similar to cystitis)
a feeling that you can’t wait when you find you need to empty your bladder (urgency)
blood in your urine (haematuria)
leaking small amounts of urine (incontinence).
Your doctor can prescribe painkillers or anti-inflammatory drugs to ease these symptoms. A sample of your urine may be tested to make sure there’s no infection present. If you have an infection, your doctor will prescribe a course of antibiotics for you. There are also things you can do to help with these symptoms.
What you can do
Drink at least 2-3 litres of fluid a day - urine that’s concentrated irritates the bladder and makes symptoms worse, so drinking more reduces this.
Avoid smoking, which can make the symptoms of bladder irritation worse.
Avoid drinks that can irritate the bladder. These include drinks containing caffeine (tea, coffee, cocoa and cola), alcohol, fizzy drinks, acidic drinks (fresh orange and grapefruit juice) and drinks with artificial sweeteners (‘diet’ or ‘light’ drinks).
Let your nurse or radiographer know if you leak urine (incontinence).
If symptoms get worse, you have a high temperature, or you feel you can’t pass urine, contact the hospital straight away.
If you have incontinence, your nurse will take a urine sample to check for signs of infection. This is a common and easily treatable cause of incontinence. They may also arrange for you to have pads if needed and give you advice on looking after your skin. If the problem doesn’t settle within a few weeks, they can refer you to a continence specialist for advice and treatment.
Just Can’t Wait toilet card
If you need to go to the toilet more often, or feel that you can’t wait when you do want to go, you can get a card to show to staff in shops, pubs and other places. The card allows you to use their toilets without them asking awkward questions. You can get a card from the Bladder and Bowel Foundation.
Bowel side effects
Pelvic radiotherapy can cause some of the following side effects:
loose stools, diarrhoea or sometimes constipation
a need to open your bowels urgently
cramping pains in your tummy (abdomen) or back passage
passing a lot of wind.
Some other, less common side effects are:
feeling as if you need to go to the toilet although your
bowel is empty (tenesmus)
passing mucus or blood when you empty your bowels
slight soiling on your underwear or some leakage (incontinence), although this is rare.
Tell your cancer specialist, specialist nurse or radiographer about any bowel side effects you have.
Diarrhoea is the most common side effect and usually starts during or after the second week of radiotherapy. If you have diarrhoea, your specialist will prescribe anti-diarrhoea tablets such as Imodium® to reduce it.
Some people are advised to make changes to their diet during radiotherapy. This may involve eating a more bland diet and cutting down on fibre. Your specialist nurse or radiographer will tell you if this is appropriate for you. You’ll always be advised to drink plenty of fluids.
If you have tummy cramps, let your cancer specialist or nurse know. They can prescribe anti-spasmodic or muscle relaxant drugs to help with this. If you’re constipated, your doctor will usually prescribe a laxative and you’ll be given advice on diet.
Let your nurse or radiographer know if you have any soiling or leakage. They will give you advice on coping with this and looking after the skin in the area.
Bowel side effects usually start to improve about two weeks after radiotherapy has finished. Sometimes, it may take a few months for the bowel to settle down.
What you can do
Drink at least 2-3 litres of fluid a day (to replace fluid lost through diarrhoea) and avoid drinks containing caffeine and alcohol.
Follow any dietary advice given by the hospital.
Take your anti-diarrhoea tablets or other medicines as prescribed by the hospital.
If side effects don’t get better, let the hospital know.
Avoid smoking, which stimulates the bowel and can make diarrhoea worse.
Effects on the vagina
During radiotherapy, you may have a skin reaction in the treated area.
Radiotherapy to the pelvis can make the vagina narrower, less stretchy and drier. This may make having sex uncomfortable. It may also be more difficult for you to have internal examinations.
Narrowing of the vagina
Your specialist nurse may recommend that you use vaginal dilators to try to prevent the vagina from narrowing. Dilators are tampon-shaped, plastic tubes of different sizes that you use with a lubricant.
You may be advised to start using the dilator during radiotherapy or afterwards. Using a dilator regularly may make it easier for you to have sex after treatment and for your doctors to examine you internally.
Your specialist nurse or radiographer will advise you on how helpful a dilator may be in your situation and explain how to use them.
Having regular penetrative sex may also help prevent vaginal narrowing, but you may still be advised to use a dilator.
This can make having sex uncomfortable, but there are lots of vaginal lubricants and creams that can help. You can buy them from chemists and some supermarkets. Hormone creams can also be used to help with dryness and vaginal narrowing. These are available on prescription from your doctor.
Moisturising creams and lubricants
There are creams you can use regularly to help with dryness, and lubricants you can use during sex to make it more comfortable and pleasurable.
Replens MD® is a cream that’s available from most chemists. You apply it 2-3 times a week and it works for up to three days. Hyalofemme® is a newer cream that you can apply every day. These creams can be prescribed by your doctor.
Water-based lubricants including Senselle®, Astroglide®, Sylk®, Vielle® or Durex® lube can be bought at chemists or some supermarkets. Organic lubricant products such as Yes® or V Gel® are available to buy online.
Oestrogen creams or pessaries
These contain very small amounts of oestrogen and can be used as a cream or as a tablet that’s inserted into the vagina (pessary). They help with dryness and may prevent the vaginal wall from becoming thin.
If you have a cancer that’s dependent on hormones to grow, always check with your cancer specialist whether oestrogen creams or pessaries are suitable for you.
Effects on your sex life
You may be advised to wait a few weeks until after radiotherapy before having sex. This is to allow any inflammation and side effects to settle. Ask your doctor or nurse for advice on this, as it can vary.
You may find that you don’t feel like having sex for a while. This may be because of ongoing side effects, anxiety, or how you feel about yourself sexually. You, and your partner if you have one, may need a period of time to adjust.
It’s not unusual to feel nervous about having sex for the first time after pelvic radiotherapy, but it’s perfectly safe for both you and your partner. Taking your time, making sure you’re relaxed and using vaginal lubricants or creams will help to make it feel more comfortable. If you have sexual difficulties that don’t improve, it’s important to let your cancer specialist and specialist nurse know.
It can be difficult to talk about your sex life and any problems you’re having, but doctors and specialist nurses are used to dealing with intimate problems. They can often give you advice and support if things aren’t going well. Your hospital doctor or GP can refer you to a counsellor or sex therapist.
There’s more information about coping with the impact cancer and its treatment can have in our section on sexuality and cancer.
Some hospitals may advise that you can still have penetrative sex during radiotherapy. Although pelvic radiotherapy will bring on the menopause, your periods may not stop completely until after treatment is over. If you’re having sex during treatment, it’s very important to use effective contraception to prevent pregnancy until your periods stop completely. This is because radiation may cause damage to a baby that is conceived during or shortly after radiotherapy.
If you have problems with your bowels, such as loose stools or diarrhoea, you should use a barrier form of contraception instead of the contraceptive pill. This is because diarrhoea can affect the way that the contraceptive pill is absorbed.
You should always talk to your specialist nurse or doctor before you stop using contraception.
Pelvic radiotherapy stops the ovaries producing oestrogen and progesterone and brings on the menopause. Early menopause as a result of radiotherapy may cause more noticeable symptoms than a natural menopause. Symptoms can include:
hot flushes and sweats
passing urine more often
lower sex drive
aches and pains
mood swings and poor concentration.
The menopause also means your ovaries are no longer producing eggs, so you will not be able to get pregnant.
Hormone replacement therapy (HRT)
You may be able to have HRT to replace the hormones your ovaries are no longer producing. This can improve some menopausal symptoms, although it can’t prevent infertility.
Early menopause at a young age can increase the risk of bone thinning (osteoporosis) and heart problems later in life, so HRT can also help protect against these.
If you have a cancer that’s not dependent on hormones to grow, there’s usually no reason why you can’t have HRT. Womb cancer is a hormone-dependent cancer, so HRT is usually not advised in this situation. You can ask your cancer specialist or nurse if HRT is suitable for you.
Managing menopausal symptoms
If HRT is not advised, or you don’t want to have it, there are other ways to manage menopausal symptoms. You can ask your doctor or specialist nurse for advice. Low doses of antidepressant drugs or a drug called clonidine (Catapres®, Dixarit®) can reduce hot flushes and sweats.
Some women find that using slow, controlled breathing techniques, yoga or acupuncture helps with flushes. You can use different vaginal lubricants or creams to help reduce discomfort from vaginal dryness, which can be caused by the menopause. Making lifestyle changes may help reduce some of your symptoms and improve your general health.
The Daisy Network is a support organisation for women who’ve had an early menopause. It can provide you with more information. Ask your specialist nurse for advice if you’re finding menopausal symptoms difficult to manage.
Diane talks about her experiences of an early menopause after she had treatment for breast cancer.
Pelvic radiotherapy stops the ovaries producing eggs and affects the lining of the womb. As a result, you won’t be able to get pregnant. Infertility can be very distressing and hard to come to terms with, especially if you had planned to have children or add to your family.
Getting the right support can help you to cope. If you have a partner, it may be a good idea to include them in this too. Your doctor or nurse can usually arrange for you to talk to a professional fertility counsellor or therapist. Our cancer support specialists can also give you further help and advice.
Talking to other women in a similar position may be helpful. Some of the organisations on our database provide this, as well as counselling.
Before having radiotherapy, some women may want to see a fertility specialist to discuss the possibility of storing eggs or embryos (fertilised eggs). This is if they are considering trying to have a child through surrogacy (when another woman carries a baby for you) in the future. Your cancer specialist can refer you to a fertility specialist to discuss this.
After pelvic radiotherapy
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Most of the side effects of radiotherapy should gradually disappear once the treatment has finished. But it may take some time to recover. Looking after yourself by getting enough rest and gradually increasing your physical activity will help with your recovery.
Your cancer specialist or nurse may give you specific advice to help with your recovery. For example, you may be given information on when you can expect to go back to work, and on how to gradually build up your activities. Women are usually given advice about using vaginal dilators.
Some women who had a gynaecological cancer may be taught to do regular exercises to strengthen their pelvic floor muscles. If you smoke, it’s advisable to stop.
After treatment, you’ll be seen at the hospital every few months for regular check-ups. Let your cancer specialist or nurse know if the side effects don’t improve, or if you develop new symptoms, even if it’s between appointments.
Share your experience
When treatment finishes, many people find it helps to share their thoughts, feelings and advice with others. This can be especially helpful for other women who may be about to start their treatment. Just hearing about how you’ve coped can be very helpful to someone in a similar situation. We can help you share your story.
Well-being and recovery
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After radiotherapy, you may want to think about ways you can help your recovery. In this chapter, we’ve included some ideas for improving your overall health. Some of these suggestions may help to reduce any ongoing side effects, the risk of developing certain late effects, other health problems and some cancers. These are things you may always have done or are already doing for yourself.
If you smoke, get help to stop
Smoking increases side effects during radiotherapy, so the best time to stop is before you start treatment. But it’s never too late to benefit from giving up smoking.
Smoking makes ongoing side effects worse, increases the risk of developing late effects and makes any late effects more severe. For example, smoking increases bladder symptoms and makes problems with diarrhoea worse. It can also increase the risk of bone thinning (osteoporosis).
Giving up smoking is one of the healthiest decisions you can make. It can be hard to stop when you’re already feeling stressed, but there’s a lot of support available. If you want help and advice on how to stop, you can talk to your cancer specialist, specialist nurse or GP. You can also contact Smokefree.
Eating healthily will help you feel better and give you more energy. In general, a healthy diet includes five portions of fresh fruit and vegetables every day and not too much red or processed meat.
However, after pelvic radiotherapy, some people may not be able to cope with as much fruit and fibre in their diet. If changes in your bowel habit are affecting what you can eat, let your cancer specialist or nurse know. They can refer you to a dietitian for advice.
Keep to a healthy weight
Being overweight is a risk factor for some cancers and other health conditions such as heart problems and diabetes. It also puts pressure on your pelvic floor muscles and your joints. You may find our section on weight management after cancer treatment helpful.
Look after your pelvic floor muscles
Pelvic floor muscles support the organs in the pelvis and are important for bladder and bowel control. Radiotherapy to the pelvis can weaken these muscles. They are also naturally weakened by childbirth, the menopause and getting older.
Some women are advised to do regular pelvic floor exercises after radiotherapy for a gynaecological cancer. It’s important to do pelvic floor exercises correctly, so you’ll usually be referred to a physiotherapist or nurse specialist who will teach you how to do them. The Bladder and Bowel Foundation has leaflets explaining how to do pelvic floor exercises.
Keep physically active
Keeping active will help build up your energy levels. It will also help you to keep to a healthy weight, strengthen your bones and protect your heart. Regular physical activity reduces stress and can help you sleep better.
Walking is a good way of staying physically active. You don’t need any special equipment and you can gradually build up how much you do. There are lots of other types of physical activity you can try too. There’s more information in our section about physical activity and cancer treatment.
Stick to sensible drinking guidelines
Current guidelines recommend women should drink no more than 14 units of alcohol a week and have some alcohol-free days every week. Alcohol can make any ongoing bladder and bowel side effects worse.
Reduce the risk of lymphoedema
If the lymph nodes in the pelvis (see the diagram above) are affected by radiotherapy, swelling of the leg or legs (lymphoedema) may develop. The risk of lymphoedema depends on the type of cancer you had and the treatment you received. Your cancer specialist or nurse can tell you if you’re at increased risk. If you are, it’s important to protect the skin on your legs and feet.
Doing the following things will help:
Keep the skin clean and use moisturisers to keep it supple.
Clean grazes or cuts straight away and see your GP if the area gets red, hot or swollen.
Use an electric razor if you want to shave your legs.
Wear well-fitting shoes and use nail clippers instead of scissors to cut toenails.
Cover up or use a high factor suncream (SPF 30 or above) on sunny days.
Keep to a healthy weight.
Keep physically active and avoid standing for too long in the same position.
If you notice any swelling in your foot or leg, always get it checked by your cancer specialist or nurse. Your cancer specialist or nurse will be able to tell you more about lymphoedema.
Late effects of pelvic radiotherapy
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Late effects are side effects that don’t go away within six months (long-term), or new side effects that develop months or years later as a delayed response to treatment.
Many women who have pelvic radiotherapy don’t have late effects or, if they do, they are mild and don’t interfere with their daily lives. Newer ways of giving radiotherapy are designed to reduce the chance of developing late effects as much as possible.
The risk of getting late effects depends on different factors, including the type of cancer you had, the dose of radiotherapy and any other cancer treatments you’ve had. Your cancer specialist or nurse can tell you more about your risk.
If late effects do develop, they can often be treated effectively or managed to make them easier to deal with. Some late effects improve over time and may eventually go away on their own. The most common late effects after pelvic radiotherapy are changes to the bowel and bladder.
All these effects are discussed in more detail in our information about the long-term effects of pelvic radiotherapy.
It’s common to feel a range of emotions during and after cancer treatment, and it’s not unusual to have a low mood at first. But as you recover and get back to your everyday life, these feelings usually get easier to deal with. Talking to family and friends often helps. If things don’t improve or you feel anxious or depressed, let your doctor or nurse know so that they can arrange for more support for you.
Some people find meeting others in a similar situation helpful. There may be a local support group near you. Our cancer support specialists can tell you about what’s available in your area.
Or you may like to join our online community, where you can get and give advice and support based on your experiences.
With thanks to: Dr Susan Davidson, Consultant Clinical Oncologist; Heather Dias, Macmillan Radiotherapy Specialist; Lynn Holmes, Clinical Nurse Specialist Gynae-oncology; Gillian Knowles, Nurse Consultant; Dr Jane Orton, Consultant Clinical Oncologist; Dr Amen Sibtain, Consultant Clinical Oncologist; Dr Mary Wells, Senior Lecturer in Cancer Nursing; members of the Pelvic Radiation Disease Association; and the people affected by cancer who reviewed this edition.
Faithfull S, Wells M. Supportive Care in Radiotherapy. Churchill Livingstone. 2003.
Halperin E, et al. Principles and Practice of Radiation Oncology. 5th edition. Lippincott Williams and Wilkins. 2008.
Harris R, et al. Radiotherapy Skin Care: A Survey of Practice in the UK. Radiography. 2012. 18 (1): 21–27.
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