Sexual dysfunction in women

with cancer
,.b .d
Sandy J. Falk, M.D. and Don S. Dizon, M.D.
a Sexual Health Program, Dana Farber Cancer Intitute!
b
De"artment o# $btetric, %ynecology, and &e"roducti'e
Medicine, Har'ard Medical School, Har'ard (ni'erity,
c
De"artment o# Internal Medicine, Har'ard Medical School,
Har'ard (ni'erity, and
d
$ncology Sexual Health, Maachuett %eneral Ho"ital Cancer Center, )oton, Maachuett
*""roximatel
y
+, million "eo"le ha'e a hitory o# cancer in the (nited State alone, and the number i ex"ected to increae -ith time.
.hi ha "rom"ted an a""reciation o# the /uality o# li#e
for
ur'i'or. 0omen treated #or cancer identi#y gynecologic iu
e
a a ma1or
concern for both general health and the negati'e im"act on exual #unction that #ollo- the cancer diagnoi and ube/uent
treatment. Unfortunately, issues related to sexual health continue to be undera""reciated. *lthough com"reheni'e
cancer center ha2e ado"ted specialized centers for survivorship issues, including thoe in'ol'ing exual health,
conultation are not -idely a'ailable in mot
communities. We provide background information on treatment exual health,
examine the im"act
women who have received a cancer diagnosis and been ube/uently treated.
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With ad'ance in early detec2 t i o n
a n d t r e a t me n t # o r c a n c e r , t h e
n u mb e r o # u r ' i ' o r rnntinues
to increase' and accordingly there
has been an increased awareness of
survivorship issues. It i
etimated t hat a o# January 9:+9
t here -ere +;.< million "eo"le -ith a
hitory o# cancer in the (nited
State, and the number i ex"ected to
increae to += million by 9:99 3+5. For
#emale cancer ur'i'or, gynecologic
iue are a ma1 or concern, and
many o# t hee iue im"act exual
#unction. Some tertiary care center
ha'e de'elo"ed exual health
"rogram "eci#icall y #or thi "atient
"o"ulation, but ex"ert conultation are
not -idely a'ailable. In addition, mot
oncologit are unable or un-illing to
dicu exuality and i nt i macy i n
t he cont ext o# a #ollo-2u" oncology
'iit becaue o# their lack o# training in
thi area, "er
onal dicom#ort, or time contraint.
Int ead, t hee i ue are rarel y ad2
dreed, and -hen "atient ak about
exual dy#unction, it i generally to
the primary care physician or gyneco-
logist, -ho may be un#amiliar -i th
thee iue a they "ertain to -omen
"re'iouly treated
-
#or cancer. In thi
article, -e -ill re'ie- exual health
iue in -omen -ho ha'e had a cancer
diagnoi and ube/uent treatment,
and -e -ill #ocu in greater de"th on
dy"areunia and 'aginal tenoi, t-o o#
t he mot common or i gni #i cant
clinical cenario.
OVERVIEW OF SEXUAL
DYSFUNCTION IN WOMEN
TREATED FOR CANCER
Sexual health condition that a##ect
-omen during or a#ter cancer treatment may
be considered according to the
ame cat egori e a #emal e exual
dy#unction in the general "o"ulation.
.he *merican Pychiatric *ociation
de#ine the #ollo-ing #emale exual
di order7 exual i nt eret 8 aroual ,
orgamic, and genito"el'ic "ain8"ene2
tration 395. Cancer and it treatment
can directly caue all o# thee condition.
Surgical treatment can reult in
ditortion o# #emale anatomy, "articu2
larly #or "atient -ith breat or gyneco2
logic cancer. In addition, the remo'al
o# t he o'ar i e i n "r emeno"au al
-omen lead to "remature meno"aue
-ith reultant hormonal and "hyical
change that can alter e'eral domain
o# exual #unction. Surgical treatment
can reult in exual dy#unction #or
-omen diagnoed -ith other tumor
a -ell! a an exam"le, exual dy#unc2
t i on i occur i n +=> and ?@> o#
-omen treated #or earl y tage rectal
cancer 3;5.
Chemotherapy can result in sys-
temic efects that dampen both sexual
desire and arousal. In addition, chemo-
therapy may induce ovarian failure
with an acute and sudden loss of
estrogen. Near total alopecia resulting
from the use of some agents (such as
the anthracyclines and taxanes) can
afect a "atien
t
el#2"erce"tion o# exual attracti'ene, and
oue treatment may caue 'aginal or rectal mucoal toxicity
3,5. For "atient treated -ith high2doe chemothera"y a "art o#
a tem cell tran"lantation "rotocol, the additional toxicity may
induce 'ul'o'aginal gra#t2versus-host disease 3%AHD5. Be i
kno-n about the effects of chemotherapy on the #emale
genital tract other than, the ovaries, although women may
ex"erience a persistent vaginal discharge after chemothera"y,
-hich likely re"reent 'aginal mucoiti! alo, there i ome
e'idence that chemothera"y contribute to 'ul'odynia 3?5. In
addition, the ex"erience o# cancer diagnosis and treatment may
profoundly afect a woman's body image and sense of
sexuality (6).
Radiation therapy (RT) can also impact sexual #unction in
-omen. For exam"le. &. #or breat cancer induce local kin
i&ening, conuacture, andior change in texture and color.
a" may result m chronic breast pain, an) of which can a##ect a
v s body unage or ability to enjoy sexual activity.
V!" fdtas# away result from $% to the pelvis with
re&ailaat vaginal fibrosisor stenosis that limits a woman's
capacity for vaginal intercourse as well as affects her genital
pelvic and clitoral sensitivity during sexual acti'ity. .hee
changes last long after $% has been com"leted. For exam"le,
-omen treated #or cer'ical cancer ha'e re"orted exual
dy#unction u" to ? year later 3<5.
ADDRESSING SEXUAL HEALTH IN CANCER
SURVIVORS
.he general a""roach to exual health iue aociated -ith
cancer treatment. like many condition, in'ol'e "atient
edmcafio(# screening, diagmmis. and management %oo often,
=W ad aae
)

*
are %he only goat of the oncolog+ and, in
the context of a busy practice, survivorship iue including
exual health are relegated to other "ro'ider uch a ocial
-orker or "rimary care "ro'ider. 0ithout an ex"licit under2
tanding o# ho- the care o# the cancer ur'i'or i coordinated,
iue uch a exualit y are o#ten le#t unattended. * an
exam"le, 0iggin et al. 3=5 conducted a ur'ey o# gynecologic
oncologit and #ound that le than hal# made it a "ractice to
take a exual hitory in ne- "atient and =:> did not #eel
there -a u##icient time to de'ote to ex"loring exual iue.
$nly 9:> #elt they had u##icient time to "eak to their
"atient about thee iue, -hich -a the entiment o# both
male 3=?>5 and #emale 3<;>5 re"ondent.
Approaching Patients beore Treat!ent
Ideally, antici"atory guidance regarding exual health iue
hould be a key element o# "atient education be#ore treatment
#or cancer, but many -omen -ho ex"erience exual ad'ere effects
complain that they were not informed
in
advance. %he typical
se,uence ofcvvnb that accompanies ancer diagnosis and
treatment re,uires the complete attention o# the "atient and
her medical team, and thi o#ten doe not allo- #or
"roacti'ely addreing "ottreatment /uality o# li#e iue.
.here#ore, the a""ro"riate timing o# thi dicuion cannot
be eaily tandardized and -ill likely 'ary according to the
tumor ite, "rognoi, and ty"e o# treatment.
"erti#it$ an% Steri#it$&
' $ne a""roach that ha -orked for
"
ine oncology darts
i to re'ie- the ty"ical coure o# "atient care and counseling
for a particular tumor ite. .he team can ther, identi#ythe
mot a""ro"riate time to counel "atient about the "otential
#or exual health iue.
Approaching Patients ater Treat!ent
$nce acti'e cancer treatment ha been com"leted, "atient
hould be creened #or exual health iue. Sexual health
concern are common among thoe com"leting treatment
and -hile mot com"laint can be treated, o""ortunitie to
addre them are o#ten mi ed. In one t udy o# "at ient
follow-up observation after pelvic radiation, exual iue
were addressed in only 9?> o# 'iit 3@5.
)arrier t o addressing sexual healt h iue exi t ,
including time contraint or a reluctance to e'en
bring u" exual health iue on the "art o# clinician,
and the ene that many -omen #eel embarraed to ak
about thee iue or may be una-are that treatment i a'ailable
3+:5. In addition, ome "atient may be concerned that their
oncologit -ill "ercei'e that thee iue are tri'ial or that
the "atient i ungrate#ul #or their care. Ho-e'er, /uerie
about exual health can be made 2in a -ay that i2
com#ortableC #or "at i ent , and /uet i on can be
i ncor"orat ed i nt o a routine "ottreat ment re'ie- o#
ytem. In addition to aking thee /uetion, it i
im"ortant to enure that reource are a'ailable locally #or
"atient -ho -ih to "urue #urther treatment.
0hen addreing exual #unction, it i eential that
aum"tion not be made regarding exual orientation or ex2
ual "ractice 3++5. .he "atient hould be aked o"en2ended
,uestions that allow her to feel com#ortable haring in#orma2
tion that is pertinent to her e'aluation and management. For
exam"le, 'aginal intercoure may not be the mot im"ortant
com"onent o# exual acti'ity #or many -omen, including
thoe -ho ha'e ex -ith other -omen.
DIAGNOSIS
.he diagnoi o# exual health iue re/uire a hitory o# the
exual com"laint and a "ertinent medical hitory, including
an oncologic and exual hitory. * medication hitory hould
alo be re'ie-ed becaue o# their im"act on exual #unction,
including the ue o# antide"reant and endocrine thera"ie.
It i im"ortant to ae the a"ect o# exual dy#unction that
are botherome to the "atient, including -hether concomitant
ym"tom o# anxiety or de"reion are "reent 3+9, +;5.
Detailed diagnoi and treatment o# exual deire, aroual,
and orgam iue i beyond the co"e o# thi article, but
many re'ie- o# thee to"ic can be #ound in the literature
3+,2+D5. E'aluat ion and t reat ment o# t hee i ue may
necessitate referral to a behavioral health "ecialit or sex
therapist.
It i im"ortant to dicu the interaction bet-een the
"atient and exual "artner, both exually and in term o#
the relationhi" in general. it may alo be hel"#ul to dicu
-hether modi#ication o# exual "ractice may hel" to achie'e
com#ort and "leaure. In addition the "atient hould be aked
about the exual #unction o# her "artner35.
) 13 1 VOL. 100 NO. 4 / OCTOBER 2013
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