All women were offered “standard” interventions for their dyspareunia, including the use of vaginal dilators twice daily for 2 years, as well as the use of vaginal lubricants. Patients who experienced menopausal symptoms—hot flashes, decreased libido, dyspareunia—were referred to a menopause outpatient clinic.
Before treatment, 20% of women reported dyspareunia. Three years later, 44% of patients reported sexual activity, but 50% had dyspareunia. Twenty-one percent reported lower sexual interest relative to baseline, 8% reported vaginal dryness, and 21% reported vasomotor symptoms. Although there was a trend toward increasing sexual activity with decreasing vaginal dryness, the rise in dyspareunia from 20% to 50% over 3 years is troubling.
WHAT THIS EVIDENCE MEANS FOR PRACTICE
Radical hysterectomy and radiation therapy to the pelvis cause neurovascular disruption and sexual consequences quite similar to those found after radical prostate surgery. Sexual arousal and orgasm are dependent on both the parasympathetic and sympathetic nerves supplying the pelvis. these nerves are disrupted in Frankenhauser’s plexus during the parametrial dissection of radical hysterectomy and lie clearly within the radiation treatment field.
Dilators and lubricants may be useful in minimizing actual shrinkage of the vagina. However, the elasticity of vaginal tissues, vasodilation during arousal, and transudation across the vaginal wall may all be lost or significantly compromised.
Advise your patients of the potential for sexual side effects of cervical and endometrial cancer treatment before they undergo that therapy. Proactive management of some of the expected problems, such as reduced elasticity and lubrication, as well as treatment for arousal dysfunction (perhaps with the same pharmacotherapeutic agents that provide improvement for many men after radical prostatectomy), may help your patients avoid the distress and disappointment they often experience after successful treatment of their cancers.
FOR YOUR PRACTICE
When a patient has undergone treatment for cancer,
ask about her sexual function
A symposium on sexual health yields recommendations for your broader care of cancer patients
How likely are you to encounter a cancer survivor in your practice?
Very.
According to the Centers for Disease Control and Prevention (CDC), there were 6.3 million female cancer survivors in the United States as of 2007—and that number has likely increased by a million or more.3 In fact, the number of cancer survivors is expected to double by 2016.
How likely is that cancer survivor to have sexual dysfunction?
Highly.
According to a 2010 survey by the Lance Armstrong Foundation, 46% of cancer survivors report problems with sexual functioning after treatment—and that’s probably a conservative figure, given that 64% of all people with cancer have a malignancy that directly affects sexual organs.2
One more question for you to ponder: How likely is the cancer patient’s sexual dysfunction to go unaddressed?
Extremely.
According to speakers at the Cancer Survivorship and Sexual Health Symposium, held June 17–19, 2011, in Washington, DC, cancer survivors are ill prepared for many of the symptoms of sexual dysfunction that develop after treatment, and many physicians fail to address this dimension of their health.
The symposium, sponsored by the International Society for Sexual Medicine and the Sexual Medicine Society of North America, was organized to address these gaps in care. During the 3-day conference, speakers from oncology, gynecology, mental health, urology, and other specialties presented data and described their experience managing cancer patients. They also offered recommendations for clinicians:
- Talk about it. Address the “highly prevalent but commonly ignored” adverse sexual effects of malignancy and its treatment. Ask: “How has cancer affected your sex life?”
- Try to prevent it. Consider nerve-sparing strategies during radical hysterectomy, radical trachelectomy, and clitoral preservation, which may lead to improved sexual function
- Encourage and support use of dilators. Advise women who have gynecologic cancer to use dilators to maintain vaginal patency, and be aware that compliance is linked to support from a health-care provider
- Encourage sexual activity, which can help preserve function
- Consider local estrogen. When it is appropriate, prescribe vaginal estrogen, which is minimally absorbed, to reduce vaginal symptoms of menopause. (The safety of local estrogen remains in question for women who have breast cancer.)
- Check for problems at each follow-up appointment, and be prepared to explain function and treatment options more than once
- Promote female genital blood flow. For example, it may be appropriate to begin sexual rehabilitation, such as use of vaginal dilators, during treatment
- Consider referral to a sexual rehabilitation program that includes medical and psychological approaches
- Build a network of psychologists, sex therapists, and other professionals who can assist you in managing your patients’ complaints.
“Discomfort around human sexuality is the main reason the issue doesn’t get raised by health-care providers,” said symposium speaker Sharon L. Bober, PhD, of the Dana-Farber Cancer Institute in Boston. “No one wants to initiate the conversation.” Dr. Bober emphasized the importance of asking about sexual function when a cancer survivor presents for care. “A majority of cancer patients in the community don’t hear this question from their providers.”
—Janelle Yates, Senior Editor