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

Other Agents

Other pharmaceutical options for menopausal vasomotor symptoms include gabapentin and adrenergic agonists. Gabapentin can yield impressive reductions in vasomotor symptoms. A recent double-blind randomized trial in 50 patients revealed a 60% reduction in hot flashes as 12 weeks and an 80% reduction in self-reported composite symptom scores [67]. However, side effects such as palpitations, edema, and fatigue, lead to high study withdrawal rates and limit its widespread clinical use for this indication [68]. Clonidine has been assessed versus venlafaxine in several clinical trials with breast cancer patients. These trials have shown mixed results, with findings of both inferiority and superiority to venlafaxine, but with consistent significant improvement in symptoms over placebo. Side effects, such insomnia, constipation and dry mouth, occurred but did not lead to higher dropout rates than venlafaxine [69,70].

Long-Term Sexual Outcomes

For women treated for gynecological cancers, alterations in sexual function may persist in the long term. A study following cervical cancer patients managed with radical hysterectomy up to 2 years post treatment showed they had more sexual dysfunction compared with healthy controls, although at rates similar to those who underwent radical hysterectomy for benign disease [71]. A 2007 review of quality of life studies revealed that although ovarian cancer survivors 5 years past diagnosis had excellent overall quality of life, sexual symptoms persisted, with as many as 57% of patients reporting a decline in sexual function due to their cancer [72].

Studies show some differences in outcomes based on treatment modality. A recent review of cervical cancer outcomes revealed that women who received radiotherapy as a component of their treatment have a higher risk of long-term sexual side effects [73]. In contrast, a study assessing endometrial cancer patients 5 years after initial diagnosis between those patients who had received surgery alone and those who had received surgery and vaginal brachytherapy. There was no significant difference in any measures of quality of life and sexual function between these 2 groups [74].

Age appears to play a role in long-term sexual outcomes regardless of diagnosis. Bifulco and colleagues assessed quality of life in survivors of gynecological cancer, comparing women under age 45 to those over 45 after nearly 3 years of survival. After controlling for age and other factors, younger patients were found to have worse sexual activity, including significantly higher rates of poor body image, perceived worse sexual vaginal function, and more severe menopausal symptoms, probably related to the effects of surgical menopause [75].

Despite enduring sexual dysfunction, symptoms tend to improve over time. A cohort study of 103 gynecological cancer patients undergoing radiation therapy were followed for 3 years. Patients were offered standard interventions for sexual dysfunction, including vaginal lubricants, dilators, and menopausal symptomatic therapy, although adherence to these measures was not assessed. Three years after initial therapy, the percentage of sexually active women increased from 21.5% to 44.2% [76]. In the subset of patients who successfully return to sexual activity, outcomes can be comparable to healthy peers. Kim and colleagues compared disease-free sexually active ovarian cancer patients with demographically matched healthy controls on standardized self-report measures. Sexual functioning did not differ between the 2 groups, despite lower social functioning in cancer survivors [12].