Addressing the Sexual Health Concerns of Women with Gynecologic Cancer: Guidance for Primary Care Physicians

In gynecologic cancer patients, sexual and quality of life outcomes can vary. For example, Kim el al recently compared quality of life and sexual functioning in ovarian cancer survivors with no evidence of disease after primary treatment and a cohort of health women. Sexuality, both in terms of desire, arousal, lubrication, orgasm, satisfaction, and pain and in terms of interest in sex, sexual activity, and enjoyment of sex were similar between the groups; however social functioning deteriorated in cancer patients [12]. Other women report different experiences. Women with a history of vulvar, vaginal, or cervical cancer who may have had extensive pelvic surgery, lymphadenectomy, and radiation treatment to the pelvis typically report greater alterations in quality of life and sexual activity depending on the extent of their treatment [13].

Patients undergoing chemotherapy often report significant changes in quality of life due to the physical symptoms of fatigue, nausea, hair loss, diarrhea, etc. as well the psychological effects of cancer diagnosis, changes in body image, and poor coping [14]. Sexual side effects are common due to alterations in the HPA axis, direct gonadal toxicity and neuropathies [15].

Impact of Gynecologic Cancer on Sexuality

Gynecologic cancer and treatment can alter sexuality through a variety of effects. The impact of anatomical changes may alter a women’s self-esteem, body image, and sense of femininity, resulting in a reluctance to engage in intimate behaviors. Furthermore, if the partnership is disrupted by changes in roles in the household or within the relationship, relationships dynamics may be tested and result in mental distress for the patient, thus effecting sexuality and intimacy.

Surgical or chemical withdrawal of sex hormones, new medications, and postoperative sequelae can contribute to sexual arousal problems. The emotional and psychological components of a cancer diagnosis also can hinder the sexual response [16]. Depression and anxiety, the rates of which increase with cancer diagnosis, can also significantly affect sexual function [17].

Sexual pain is common in this population due to hormonal considerations as well as post-treatment side effects and a frequent cause of sexual dysfunction for these patients. Pelvic radiation may result in adverse physical changes to the vagina including vaginal stenosis, thinning of vaginal mucosa, loss of lubrication, and loss of elasticity [18,19]. A recent review of 20 studies of cervical cancer survivors found that patients were at risk for lack of lubrication and had high rates of dyspareunia [20]. Psychosocial factors have been found to be important predictors of sexual desire and more important than hormones in predicting low sexual desire in middle age [21]. These factors include emotional and physical closeness to the partner, satisfactory communication, and a positive relation to one’s own body [16].

Effects on Relationships and Partners

Women whose sexual capacity is compromised may be worried about their partners’ quality of life and overall well-being. Indeed, the partners of women with gynecologic cancer are also impacted by the changes to sexual function and loss of sexuality and intimacy. Hawkins et al found that cessation or decreased frequency of sex and intimacy was reported in 79% of male partners of women affected by cancer. Among partners of the persons with cancer in this study, changes to sexuality were associated with feelings of self-blame, reflection, sadness, anger and lack of sexual fulfillment [22]. Further, male partners of women diagnosed with gynecological cancer often express conflicting emotional states including feeling worried about their significant other’s health, having the desire to engage in sexual activity, and feeling guilty about wanting to increase sexual intimacy. These feelings, in turn, can lead to resentment and withdrawal from their partner and overall relationship discord [23].