Representations of Vaginal Symptoms in Cervical Cancer Survivors

Jennifer M. Tornatta MSN, RN; Janet S. Carpenter PhD, RN; Jeanne Schilder, MD; Higinia R. Cardenes, MD, PhD

Disclosures

Cancer Nurs. 2009;32(5):378-384. 

In This Article

Abstract and Introduction

Abstract

No research has investigated patients' representations of the vaginal symptoms commonly experienced after cervical cancer treatment. Leventhal's Self-regulation or Common Sense Model was used to explore these representations and their relationships with quality of life after cervical cancer. Women posttreatment for cervical cancer (n = 26) from a Midwest cancer center provided information on symptom representations for their 3 most bothersome symptoms and also completed a quality-of-life scale. Women perceived vaginal symptoms as mild to moderate overall but rated approximately one-third of 11 different symptoms as severe. Symptoms identified most frequently as the most bothersome were painful intercourse (23%), decrease in sexual desire (15%), and vaginal dryness (12%). On average, symptoms were mildly distressing and acute, had a minimal effect on life, and were associated with an indeterminate degree of perceived control. Cause was attributed equally to treatment and to the cancer. Quality of life was below normed data, to a degree consistent with a minimally important difference for total well-being scores and physical, emotional, and functional well-being. Emotional and consequence representations were significantly related to quality of life. Understanding and altering symptom representations may improve quality of life for women treated for cervical cancer.

Introduction and Literature Review

In 2008, it was estimated that 11,070 new cases of invasive cervical cancer were diagnosed in the United States, with nearly 3,870 deaths.[1] Cervical cancer mortality rates have declined over the past decades for American women, although it is still prevalent in underdeveloped countries as the number 1 killer of young women.[2] The primary cause of cervical cancer is the human papillomavirus, found in 90%of squamous cell cervical cancers.[3] The cancer is most prevalent in Hispanic and African American women, and it usually occurs between the ages of 35 and 55 years, although nearly 20% of women are diagnosed when they are older than 65 years.[1]

Current therapy for advanced cervical cancer involves the concurrent administration of radiation therapy and chemotherapy using a cisplatin-based regime.[2,4–7] Adverse effects from treatment often include vaginal dryness, vaginal stenosis, pelvic fibrosis, dyspareunia, sexual disinterest, vaginal atrophy, sensation of a short or narrow vagina, and vaginal discharge.[8–10] Several of these symptoms are caused by tissue, hormonal, and/or glandular changes within the vaginal region, which in turn can affect psychosocial and sexual function.[8]

No studies have specifically examined the vaginal effects of cervical cancer treatment and how these affect quality of life. Although several studies have focused on gynecological oncology patients, these studies have limited applicability to understanding the specific symptoms and quality of life in cervical cancer patients.[11–16] For example, these studies have often reported information for the group as a whole, not for the subgroup of women with cervical cancer.[13,17–20] Not all findings apply to those with cervical cancer because of differences in treatments. These studies were further limited because they did not always assess symptoms or vaginal symptoms in particular.[14–16,18,19] When symptoms were assessed, quality of life was not always assessed.[16,19]

Other studies that have focused on cervical cancer patientshave tended to omit detailed assessment of both vaginalsymptoms and quality of life.[9,12,14,21–26] Some studies focused on sexual dysfunction but did not assess quality of life.[9,12,21,23,24,26] When quality of life was addressed, only a limited number of vaginal symptoms were assessed.[22] One other study excluded an assessment of vaginal symptoms altogether.[25] Although one of the above studies did include a detailed analysis of vaginal changes, it did not assess symptom representations or the relationship between vaginal symptoms and quality of life, and it included only long-term survivors (>5 years posttreatment).[24]

Vaginal symptoms are common after treatment for cervical cancer. Symptoms reported by women with cervical cancer include lack of interest in sexual intercourse (45%-85%),[14,22–24,26] dyspareunia (21%-79%),[8,9,14,22–24] vaginal dryness (26%-74%),[8,9,14,22–24] inability to achieve orgasm (9%-60%),[8,22,24] less frequent orgasm (32%-50%),[8,14,24,26] less enjoyable intercourse (19%-45%),[8,14,24,26] less frequent intercourse (32%-72%),[8,24,26] vaginal shortening or stenosis (24%-79%),[8,9,26] vaginal narrowing (13%),[8,9] vaginal bleeding after intercourse (8%-25%),[21,24] and feeling less feminine or desirable (13%-32%).[8,23,24] Studies also report anxiety related to sexual performance (71%),[14,22] distress associated with sexual function (15%-48%),[14,21,23,24] and sexual dysfunction (20%-30%).[21,23] One study comparing cervical cancer survivors to the general population found survivors to have more clinically severe symptoms, poorer body image, lower sexual and/or vaginal functioning, and more sexual worry.[22]

Many of these studies suggest that there is a strong link between sexual health and psychological health.[2,11,21,27] This may indicate that a woman's perceptions of vaginal symptoms can negatively influence quality of life.[8,9,14,21,22,26,28]

Previous work completed by Donovan and Ward[29] is among the first to explore the dimensions of gynecologic cancer symptoms beyond severity, bother, and prevalence. However, although symptoms are commonly experienced by gynecological oncology patients,[4,8,21,22] there has been no research investigating patients' representations of vaginal symptoms experienced after treatment for cervical cancer. Therefore, the study purpose was to explore the dimensions of vaginal symptom representations (identity, timeline, consequence, cause, control, and cure) and their relationships with quality of life among women treated for cervical cancer. The study's specific aims were to describe symptom representations, describe quality of life, and explore the relationships between symptom representations and quality of life.

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