How to talk about sexual issues with cancer patients: Beginning the dialogue

Key Points

Sexual dysfunction is defined as a recurrent sexual problem that causes personal distress-distress being the level of dissatisfaction regarding the sexual difficulty. If a patient has sexual concerns but is not distressed by them, then her sexual concerns are not considered to fit this definition.¹

The PRESIDE study reported that 44.2% of women have a sexual problem and that 22.8% of these women are distressed by it.¹ Sexual complaints can occur in up to 90% of women with a history of diagnosed cancer and in at least 50% of women with gynecologic and breast cancer.^2,3 It's important to inform patients early in the course of their treatment that issues of sexuality may be relevant and that discussions on the topic are appropriate.

Effect of gynecologic cancer on sexuality

Issues related to intimacy and sexuality are recognized as essential components of quality of life by women with cancer and by cancer survivors. As more women achieve long-term survival after cancer, quality-of-life discussions become imperative. Sexual dysfunction is increasingly recognized as having negative consequences that greatly affect quality of life.³ The Sexual Function Health Council of the American Foundation of Urologic Diseases subcategorized female sexual distress into 4 categories: hypoactive sexual disorder, sexual arousal disorder, orgasmic disorder, and sexual pain disorders.⁴

A woman's sexual response can be affected in a number of ways. The causes of sexual dysfunction are often physiological and psychological. Physical factors include fatigue and pain, alopecia, weight change, loss of control over bodily functions, and symptoms of menopause. These changes occur because of the anatomic changes of surgery and radiation, effects of chemotherapy and endocrine therapy, underlying disease, or, frequently, a combination of these. The premature ovarian failure that results from cancer treatment by surgery, radiation, or certain chemotherapy agents is a frequent antecedent to female sexual dysfunction.²

Additionally, psychological effects on sexuality can stem from anxiety, depression, fear of dying or cancer recurrence, feelings of isolation and perceived vulnerability, and feelings associated with the end of reproductive opportunity.

A woman's perception of herself as a sexual person, as well as her sexual self-schema as an important, sexually relevant parameter, can predict her sexual behavior and responsiveness.⁵ This sexual self-schema was tested in an assessment of sexuality in 175 women with gynecologic cancer.⁶ The results demonstrated that sexual self-schema accounted for significant differences in predicting sexual behavior, responsiveness, and satisfaction, as well as quality of life.

Further, a woman's feelings of loss in regard to the change in her sexuality as a result of cancer or treatment are vast. Whereas the most common sexual problem in men is erectile dysfunction, in women, it is the loss or decrease of desire for sexual activity as well as dyspareunia.⁷ Studies comparing patients with gynecologic cancer to healthy controls/norms have shown that these patients may have resumed intercourse, but report diminished sexual responsiveness and lower sexual satisfaction. In addition, they are found to have higher rates of sexual dysfunction than healthy women or women with benign gynecologic disease.^8-11 Etiologies of sexuality and intimacy dysfunction in women with gynecologic cancers vary somewhat, too, by the underlying cancer and treatment.¹²

Changes in sexuality have been reported in several studies using different populations of women receiving radiation treatment, surgery, chemotherapy, and immunotherapy.^13-15 Systemic chemotherapy and radical pelvic surgery have been reported to have the greatest effect on sexual functioning. Premature ovarian failure caused by oophorectomy is a frequent precedent of sexuality dysfunction.¹⁴ Additionally, hysterectomy is described to affect women by changing the perception of the vaginal length, ceasing hope for future fertility, and affecting their self-concept.⁸

When comparing women treated 1 year previously for cervical cancer by radical hysterectomy and/or radiation therapy versus a noncancer surgery control group, those with cancer experienced significant impairment in genital arousal and negative genital sensations, despite similar frequency of intercourse for both groups.¹⁶ Genital arousal problems reported included lubrication difficulties, reduced vaginal length and elasticity, and absence of genital swelling more than half the time during sexual arousal.

Chemotherapy frequently affects female sexuality, depending on the type of agent, dose, length of treatment, and drug combinations.¹⁷ Although a variety of chemotherapy regimens with various adverse effects are being used to treat gynecologic and breast cancer, several studies have reported chemotherapy to be a significant contributor to sexual dysfunction. One study reported that women with breast cancer treated with chemotherapy were 3 times more likely than those receiving endocrine therapy to report decreased libido, 7 times more likely to report trouble reaching orgasm, and 6 times more likely to report pain with intercourse and vaginal dryness.¹⁷ Pelvic radiation affects women's sexuality by causing vaginal stenosis, vaginal dryness, and symptoms of menopause because of loss of ovarian function.^18,19