Sexual Function in Gynecologic Cancer Survivors

Alison Amsterdam; Michael Krychman


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

In This Article

Typical Multimodal Therapeutic Management Scheme

Sexual desire and subjective arousal disorders are most effectively diagnosed and treated using a psycho-behavioral approach.[27] The physiology of the female sexual response cycle is not well understood.[28] However, studies have shown that perceived sexual satisfaction and dissatisfaction in women largely correlates with mental health, past sexual experiences, emotional relationship with her partner and thoughts during sexual activity.[29] Thus, a strong partnership with an experienced psychiatry or psychology department is essential. Psychological and behavioral therapy, in addition to sex therapy, should be encouraged with the female patient and her partner both individually and together.[30] Comprehensive care for the cancer patient entails sexual counseling and therapy preferably by a certified sexual therapist who is knowledgeable and qualified to deal with oncology-related psychosexual complaints. Therapists can also be extremely helpful to enforce compliance with medically ordered sexual-enhancement directives.

Although numerous hormonal and pharmacological therapies are marketed to treat sexual desire and arousal disorders, none have been approved by the FDA or have been proved effective by clinical trials.[29] Despite this, hormonal manipulation has been the mainstay of treatment and comprehensive reviews are available elsewhere. Until 5 years ago, systemic and local estrogen replacement had been key components for the pharmacological management of female sexual dysfunctions. When the results of the Women's Health Initiative were published and showed the potential for an increase in breast cancer and cardiovascular disease,[29] many providers ceased providing these agents systemically for the treatment of female sexual dysfunction.[30] In addition, certain uterine and ovarian neoplasms have estrogen receptors and can grow in its presence. Thus, its use systemically is contraindicated due to the risk of promoting recurrence or spread of disease.

However, female arousal, centrally, peripherally or in the genitals, is dependent on estrogen levels,[31] which puts patients and providers in a quandary regarding treatment for female sexual dysfunction. Estrogen has a direct effect on the urogenital system by enhancing epithelial maturation and proliferation, increasing vascularity and stimulating blood flow. It may also stimulate glandular secretions.[32] Lowered estrogen levels impact the reproductive tract by increased atrophic vaginitis causing painful intercourse or dyspareunia and may progress to a reactive lowered desire.[33,34,35] But, as stated above, for most survivors of uterine or ovarian malignancies, systemic hormonal treatment is neither warranted nor acceptable as treatment.

Local treatments with minimally absorbed vaginal estrogen preparations, such as the 17-β-estradiol tablet, have recently gained attractiveness within the gynecologic oncology community for the treatment of atrophic vaginitis.[36] Patients have reported that the tablets are easier to use and less messy than cream preparations and are technically easier to insert than estrogen rings.[37] However, there are no studies to date that evaluate the safety and efficacy of these agents in patients with a history of cancer. In addition, because of the location of these preparations to the region of primary tumor in gynecologic oncology patients, special attention to safety should be taken if recommending these agents and close follow-up, monitoring and counseling should be maintained.

Nonhormonal medications have been shown in randomized controlled trials to help ease hot flashes. Bupropion, a dopamine agonist antidepressant medication with low sexual side effects, has shown in a small double-blind, placebo-controlled trial to increase sexual arousal, orgasm completion and sexual satisfaction in women. Nonsexual side effects that should be monitored include insomnia, nervousness, mild-to-moderate increases in blood pressure and the risk of lowering seizure thresholds.[36] Phosphodiesterase inhibitors, which have been approved for the treatment of erectile dysfunction in men, have not been shown to have efficacy in women in randomized clinical trials. Basson et al. studied more than 500 women with sexual arousal disorder in a randomized clinical trial and showed no significant benefit between those treated with sildenafil and the control group.[38] Other options that have been investigated include venfexetine, transdermal clonidine and megestrol acetate.

As part of the comprehensive sexual dysfunction treatment schema, an educational program that fosters open discussions concerning alternate forms of sexual expression, should be included. Patients with sexual complaints are often given specific sexually structured tasks such as sensate focusing, squeeze stop technique to enhance intimacy, guided imagery, relaxation techniques and the exploration of sexual fantasies. Patients may be given home-study tasks in the structure of sexual exploration with nongenital touching, self-stimulation techniques and self-esteem-enhancing exercises.[39] In addition, alternative sexual positions should be explained with illustrations and diagrams. The most common sexual position is the missionary position, which may facilitate deep penetration. This sexual position is often painful for women with a foreshortened vagina as a result of treatment for a gynecologic malignancy. Couples should be encouraged to have sexual intercourse in alternative positions including the side-to-side[40] or female superior positions. These sexual positions may limit deep pelvic thrusting, which can minimize vaginal discomfort during penetration. Alternate sexual positioning should also be encouraged, because it may enhance direct clitoral stimulation and female genital arousal. For patients with mobility issues, pillows can be used to help facilitate a comfortable sexual situation.

The gynecologic cancer survivor should be encouraged to use local nonmedicated, nonhormonal vaginal moisturizers including vitamin E suppositories. These agents, which should be used two- to three-times weekly, can provide alternative relief for the symptoms of vaginal atrophy by maintaining the elasticity and pliability of the vaginal mucosal lining. Patients should be instructed to wear a light pad when using vitamin E suppositories, because the oil may stain undergarments. In addition, the adjunctive use of water-based vaginal lubricants with intercourse should be encouraged. With both classes of vaginal agents, patients should be educated regarding the irritative nature of preparations that include microbicides, perfumes, coloration and flavors.

Various devices can be used to decrease pain or discomfort during sexual activity, as well as improve sexual desire, sensitivity and orgasm. Graded, nonrigid vaginal dilators are prescribed to help facilitate lengthening and widening of the vagina in patients with shortening, narrowing and/or scarring, such as those who have received radiation to the pelvis or extensive surgical procedures.[40] Dilators need to be used on a regular basis, once daily for 10—15 min with a lubricant. Commercially available vibrators/self stimulators can also be helpful for women who need extra stimulation in the sensitive erotic areas of the vagina and clitoris. Due to the risk of perforation, rigid dilators are not recommended in the postradiation patient population.[41] In addition, clitoral stimulators can be prescribed for patients with a history of cervical, rectal and vaginal cancers. These hand-held sexual devices are battery-operated and contain a vacuum suction that attaches to the clitoral area. It is presumed to help facilitate vasocongestion in clitoral tissue. A small study, in patients who had previously undergone radiation therapy for cervical cancer, showed that several months of this therapy improved sexual desire, arousal, orgasm and satisfaction.[42] However, larger randomized clinical trials need to be undertaken.

Cancer patients with sexual complaints are often encouraged to make lifestyle changes. A well-balanced diet, aerobic exercise, discontinuation of tobacco and illicit drugs, and minimized alcohol consumption are all encouraged to improve oxygenation of tissues, increase metabolism, reduce body mass indices and promote endorphin release.[28] If fatigue is problematic for the cancer survivor, patients are encouraged to take numerous naps and arrange sexual contact or intimacy when they are rested and exhaustion is minimal. Stress and time management skills are also important in the management of female sexual complaints. Bodenmann et al. found that stress within an intimate relationship is a greater cause of sexual dysfunction than general daily and work responsibilities and nonintimate relationships.[43] Thus, the patient and partner should prioritize engagement in emotional communication, nonsexual affection, resolving conflicts and coping with disease together.[44]

Complaints of chronic discomfort or pain after cancer treatment can influence a woman's sexual response.[45] Sexual health programs often incorporate techniques to help loosen tense muscles,[28] such as warm soaks, physical therapy and stretching exercises. Other options include guided imagery, meditation, deep muscle relaxation, acupuncture and the avoidance of lethargy. When appropriate, patients should be referred to pain management specialists. Medication management can include adjusting or reducing opioid regimens, adding adjunctive or alternative analgesics and the modification of existing dosing schedules with the goal of reducing lethargy while maintaining satisfactory pain relief.[45]

Palliative and terminal care of the female cancer patient may primarily be focused on self-image, dignity, pain and stress management. Intimacy, sexuality and relationship concerns are rarely discussed, remain under-researched and are under-reported in the palliative care setting.[46] Providers need to reassure patients and their partners that even at the end of life, when intercourse may not be feasible, intimacy and emotional closeness should be encouraged. The exchange of intimacy and sexual pleasure can be accomplished with sensual massage, oral and digital stimulation and noncoital touching. Gentle caressing can be very pleasurable and should not be ignored at the end of life.


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