Sexual Function in Gynecologic Cancer Survivors

Alison Amsterdam; Michael Krychman

Disclosures

Expert Rev of Obstet Gynecol. 2008;3(3):331-337. 

In This Article

Etiology

Cancer therapy impacts sexual functioning in gynecologic cancer survivors due to the location of the disease and the modalities used in therapy. Specific surgical dissections and radiotherapy portals that are unique to this class of malignancies can interrupt genital pelvic neural pathways, lead to early menopausal symptoms, create negative self-schema or concept and increase the level of sexual morbidity experienced by this patient population.[3,4]

Operative procedures used to manage gynecologic neoplasms change anatomical detail(s) and have the potential to compromise the neurovascular integrity to genital pelvic organs that are vital to the sexual response cycle. Studies have shown that the incidence of sexual complaints after gynecologic cancer treatments can range from 40 to 100%.[5] Extensive pelvic resections can cause women to experience changes in the perception of their female identity and bodies that can lead to difficulty with self-esteem.[6] Confounding factors include hormonal disruption, reproductive failure, sexual morbidity and bowel and bladder changes that can promote emotional and relationship alterations.[4,7,8] Significant loss in sexual capacity commonly occurs after pelvic exenteration leading to complaints of lowered libido, decreased sexual interest and dissatisfaction with sexual activity.[9,10] Other procedures that affect the vaginal vault may cause narrowing or vaginal stenosis, decreased or absent lubrication and significant discomfort because of fibrosis and scarring resulting in decreased mobility and difficulty with sexual positioning.[11]

Discussions regarding sexuality prior to surgical procedures are paramount. By undertaking these challenges upfront, healthcare providers have the potential to facilitate adequate preparation to assist patients' psychosexual adjustment.[11] Some female patients are not educated about their sexual anatomy so therefore teaching them about normal physiological sexual arousal and response can help improve functioning. During the gynecological examination, patients should be encouraged to examine their genitals with the aid of hand-held mirrors while the physician identifies important structures such as the clitoris. Explaining sexuality in clear and easy to understand language can often help demystify some of the longstanding misconceptions concerning sexual function. Pamphlets, books, videos, websites and other visual aids serve as a future reference.

Many physical changes from radiotherapy can lead to difficulty with body image in addition to the physiologic side effects from the treatment. For example, some women experience skin thickening, contractures and changes in texture and color in the pelvic region. Vaginal fibrosis and shortening of the vaginal vault can be caused by intravaginal treatments. This can result in a decreased capacity for penetrative intercourse and decreased sensitivity to the clitoris and surrounding genitalia. General physical symptoms, such as fatigue, diarrhea, nausea, vomiting and frequent voiding,[12] as well as pubic and cephalic hair loss, may also contribute to a woman's lack of interest in pursuing sexual intimacy. In addition, patients and/or their partners often have unfounded concerns related to the myth that radiation therapy can cause patients to be persistently 'radioactive'.

As with radiation therapy, antineoplastic agents can also lead to both physical and psychological stressors on patients that have the potential to impact sexual functioning. Many drugs cause nausea, diarrhea and mucosal membrane irritation, which can affect the mouth, throat, vagina and anus. Loss of hair on the head, eyebrows, eyelashes and genitals is distressing and may affect a female's perception of sexual attractiveness. Chemotherapy-induced early ovarian failure often leads to hot flashes, sleep disturbances, mood labiality and vaginal atrophy. These conditions may negatively impact desire, sexual interest, arousal and, ultimately, the level of pleasure that is achieved through intercourse. Premature menopause may cause many stressors including distress and anxiety when the survivor recognizes that she will no longer be able to bear children.[13]

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