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

Evidence suggests partners of cancer patients greatly benefit from increased social support even years after an apparent cure [24]. Specifically, male partners who take on a new role as caregiver in the relationship experience difficulties with emotional changes, challenges to their masculinity, and new stressors [25]. These new roles and feelings also contribute to changes in sexuality and intimacy in relationships, making support for partners all the more necessary.

Menopausal Symptoms Following Cancer Treatment

Gynecologic cancer treatment invariably affects the female hormonal balance, sometimes suddenly with surgical excision of the gonads or via radiation treatment or chemotherapy. It is well known that the sudden withdrawal of estrogen and testosterone, especially in the premenopausal postoperative population, can lead to significant acute menopausal symptoms. Given the many emotional and physical issues affecting patients during treatment, it can be difficult to delineate what proportion of sexual problems are caused by or enhanced by vasomotor symptoms, sleep disorders, and vaginal atrophy.

In general, premenopausal women who experience abrupt surgical menopause may often have immediate severe symptoms. Many agree that the younger a woman is when going through this process, the more severe her symptoms may be. Although the average age of endometrial cancer diagnosis is 67, approximately 25% of women who are diagnosed are premenopausal, and 5% of cases occur in women under 40. As the obesity epidemic worsens and more women are exposed to higher levels of estrogen at younger ages, it is expected that the number of premenopausal women who are diagnosed will continue to rise. The average age of diagnosis for ovarian cancer is 63, however, there is a large cohort of women diagnosed with borderline and malignant tumors in the premenopausal period [26]. These patients often experience vasomotor symptoms in the hours to days following surgery.

Interventions for Survivors of Gynecologic Cancer with Sexual Dysfunction

Systemic Hormone Therapy

Systemic hormonal therapy to treat menopausal symptoms remains controversial following the release of findings from the Women’s Health Initiative, which showed a number of adverse effects, including an increased risk of breast cancer in healthy postmenopausal women who received systemic hormonal therapy for menopausal symptoms. While views have changed since that time, providers are often reluctant to prescribe hormonal therapy, and patients are reticent to take it, due to fears of cancer recurrence. However, there is no evidence showing hormones negatively influence survival after treatment for epithelial ovarian, squamous cervical, or vulvar cancer [27]. With the exception of endometrial cancer, there is no biological evidence that HRT may increase recurrence risk [28]. Approach to clinical decision making should be individualized, taking into consideration the patients’ symptoms, quality of life, tumor histology, and overall prognosis.

Cervical cancer, vulvar cancer, and vaginal cancer are not considered hormonally responsive tumors. While the data are limited, a study published in 1987 of cervical cancer survivors treated with systemic hormone replacement therapy showed no increase in relapse rates and showed an increase in quality of life [29]. There are no studies regarding systemic HRT in patients with vulvar or vaginal cancer though it is generally accepted they can be treated with HRT. No significant data exists for cervical adenocarcinoma patients, and most oncologists suggest treating these patients the same as those with endometrial cancer primary.