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Q1: I was diagnosed with breast cancer aged 36, 4 yrs ago. Had a double mastectomy and reconstruction. Had chemo and radiotherapy. Am still taking tamoxifen.

The problems I face and feel are that I am hideous, what if I am in an accident and someone takes my top off, how can my husband find me attractive, especially when he has seen me bald and sick and single breasted for a time? I hate that when he bends to kiss my reconstructed breasts I feel nothing. I feel the surgery and medication have aged me. People would disagree and say that I look younger than ever.I am menopausal but still having irregular periods, hormone spikes where I get very hot, achey and spotty. The months without hair and breastless psychologically nearly did for me. I know of the efficacy of leaving reconstructive surgery until post radiation treatment but mentally it was nearly too much. I am slim, size 10 and tall. I strive to look good and yet feel always insecure and always desperately inadequate when I see my friends. Why do they have what I do not? Why do they know nothing of this fear and these premature aches and pains and stiffness and maybe most of them never will.

That my children were exposed to my sickness and my mortality I feel unfair. They have coped very well and have done me proud although I am not sure I could say the same about myself. I have tried to protect them from the worst of my illness and my feelings and largely, they like most other people see that I am well and fit and fine. Which I am. I wish I could have had my body until I was older. That I had not had this at that point in my life. I have had counseling and it has done me no good. I hear about other people with breast cancer and they are all older, I am so jealous.

I don’t have a question really I just want people to know how awful this is. Name and address withheld.

A1: I am so very sorry to read about your troubles at such a young age and of the lasting psychological trauma that they have caused. They have probably exacerbated an underlying feeling of insecurity and inadequacy. I notice that you keep these feelings hidden when you see your friends, a very understandable and probably wise decision but everybody needs to talk to someone beyond their own household. Counselling is inevitably regarded as the first port of call, and is sometimes very successful, but there are inevitably other cases where it is not the treatment of choice. Obviously a friendly and understanding approach by the doctor is essential but when the trouble is that someone's difficulties have induced quite severe depression more targeted treatment is necessary. In your case the reasons for your despair is so obvious that you haven't realised that your troubles have obliterated your insight. Feelings of self revulsion, ugliness and unworthiness are common symptoms of the type of depression that can be relatively easily treated successfully in 82 per cent of patients.

It may well be that your friend and husband are right and that you do look very good and younger than ever but that your mood is so depressed that you won't believe this until the depression has been lifted. The role of the treatment of depression following cancer surgery is often overlooked and I should have another talk with your own doctor and ask whether he, or she, could make arrangements to see a psychiatrist with an interest in oncology.

Although it is little consolation to you your reaction to the surgery and chemotherapy is not unusual although it is not perhaps surprisingly the most common one. A great deal of work was done on the psychological effect of having masectomy about twenty or thirty years ago when masectomies were more common and even more disfiguring. It was found that the majority of women were so relieved to be rid of their cancer that they tolerated the disfigurement without suffering devastating psychological malaise. The more interesting feature of the study that is relevant to your case was the very little difference that a masectomy made to the way the majority of husbands or partners viewed the difference the surgery had made to their wife's sexual attractiveness. The people who conducted the survey had assumed that surgery would have had far more effect on men than in fact it did. The women involved were much more likely to be upset by their appearance than were those with whom they lived who claimed to have felt no difference to the way they saw their wife.

Breasts have a prominent role in the sex life of humans that is not proportional to their reproductive importance. Of all animals this characteristic is only found in humans. In other animals the breasts are neither sexually exciting to potential mates, nor erogenous zones to the female who has them. In humans breasts have come to represent femininity and female allure and the advertising world has enhanced this by constantly broadcasting idealised images of them. So called perfect breasts are now pictured everywhere, and unintentionally have thereby made life much harder and less secure for women who have masectomies. Fortunately breast re-constructions are now done much earlier. Most men are still so very much more interested in the appeal of the face, the smile, the eyes and the general presentation of the woman so that once her wound has healed she seems to them to be as new. Some men who have a tendency to partialism - the over-developed sense of being attracted by one part of the female body - are almost equally divided between those who like bottoms (as all mammals other than humans do) or breasts.

I quite agree about the terrible psychological trauma hair loss produces, but it does re-grow as Kylie Minogue has demonstrated. Wigs are very much better than they were but obviously this is not quite the same as natural hair and husbands and children are bound to see a woman who lives with them without her wig from time to time. Likewise the side effects of some chemotherapy (no longer all chemotherapy) can be off-putting. This is not only because chemotherapy makes the patient feel lousy but because it produces nausea, vomiting and infected mouths their distress is obvious to the family. Fortunately treatment for the side effects of chemotherapy has also improved and the MacMillan service are experts at making recommendations about this. You will be glad that this aspect of your treatment is over.

You won't be able to rejoice in your recovery until you find someone who is able to prescribe appropriate treatment to lift your present despairing mood. I hope that you do receive this as you deserve to enjoy yourself after all you have been through. Talk to your doctor.