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Sexual dysfunction in women with cancer

,.b .dSandy J. Falk, M.D. and Don S. Dizon, M.D.a Sexual Health Program, Dana Farber Cancer In titute! b De"artment o# $b tetric , %ynecology, and &e"roducti'eMedicine, Har'ard Medical School, Har'ard (ni'er ity, c De"artment o# Internal Medicine, Har'ard Medical School,Har'ard (ni'er ity, and d $ncology Sexual Health, Ma achu ett %eneral Ho "ital Cancer Center, )o ton, Ma achu ett

*""roximatel y + million "eo"le ha'e a hi tory o# cancer in the (nited State alone, and the number i ex"ected to increa e -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 i u e a a ma1or

concern for both general health and the negati'e im"act on exual #unction that #ollo- the cancer diagno i and ub e/uenttreatment. Unfortunately, issues related to sexual health continue to be undera""reciated. *lthough com"rehen i'ecancer center ha2e ado"ted specialized centers for survivorship issues, including tho e in'ol'ing exual health,con ultation are not -idel a'ailable in mo tcommunities. We provide background information on treatment exual health,

women who have received a cancer diagnosis and been ub e/uently treated.3Forti Steril4 !"#$"!!%"&' ". ! !"# by (merican )ociety for &e"roducti'e

Discuss: 6ou can di cu thi article -ith it author and -ith other *S&M member at htt"788#ert tert#orum.,c%m8#alk 2 exual2dy2sfune*om'canmd' 2 22

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W ith ad'ance in early detec2 t i o na n d t r e a t m e n t # o r c a n c e r , t h en u m be r o # u r ' i ' o r rnntinuesto increase' and accordingly therehas been an increased awareness of

survivorship issues. It ie timated tha t a o# January 9 :+9there -ere +;.< million "eo"le -ith ah i to ry o # c an ce r i n t he ( ni te dState , and the number i ex"ected toincrea e to += million by 9:99 3+5. For #emale cancer ur 'i'or , gyneco logici ue a re a m a1 o r c o nc er n , a n dmany o# the e i ue im"act exual#unction. Some tertiary care centerha'e de'elo"ed exual health

"r ogr am " ec i# ic al ly #or thi "atient "o"ulation, but ex"ert con ultation arenot -idely a'ailable. In addition, mo toncologi t are unable or un-illing to

d i c u ex ua li ty a n d i n t i m a c y i nthe con text o# a #ol lo-2u" oncology'i i t bec au e o# their lack o# training inthi area, "er

onal di com#ort, or time con traint .In tead , the e i ue a re ra re ly ad2dre ed, and -hen "atient a k about

exual dy #unction, it i generally tothe primary care ph ysician or gyneco-logist, -ho may be un#amil iar - i th

the e i ue a they "ertain to -omen "re' iou ly treat ed - #or cancer. In thiarticle, -e -ill re'ie- exual healthi ue in -omen -ho ha'e had a cancer diagno i and ub e/uent treatment,and -e -ill #ocu in greater de"th ondy "areunia and 'aginal teno i , t-o o# t he m o t c om mo n o r ig ni #i ca ntclinical cenario .

OVERVIEW OF SEXUALDYSFUNCTION IN WOMENTREATED FOR CANCER

Sexual heal th condit ion that a##ect

omen during or a#ter cancer treatment may

a m e c a t e g o ri e a # e m a le e x u aldy #unction in the general "o"ulation.

he *merican P ychiatric * ociation

de#ine the #ollo-ing #emale exuald i o rder 7 exua l in te re t8arou a l ,

orga mic, and genito"el'ic "ain8"ene2tration 395. Cancer and it treatmentcan directly cau e all o# the e condition .

Surgical treatment can re ult in

di tortion o# #emale anatomy, "articu2larly #or "atient -ith brea t or gyneco2logic cancer . In addition, the remo'alo # t h e o ' a r i e i n " r e m en o " a u a l

-omen lead to "remature meno"au e-ith re ultant hormonal and "hy icalchange that can alter e'eral domain

o# exual #unction. Surgical treatmentcan re ul t in exual dy #unct ion #or -omen diagno ed -ith other tumora -ell! a an exam"le, exual dy #unc2

t i o n i o c c u r i n + = > a n d ? @ > o # -omen treated #or early tage rectalcancer 3;5.

Chemotherapy can result in sys-

temic effects that dampen both sexual

desire an d arousal. In addition, chemo-

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affect a "atien t el#2"erce"tion o# exual attracti'ene , andou e treatment may cau e 'aginal or rectal muco al toxicity

3 5. For "atient treated -ith high2do e chemothera"y a "art o# a tem cell tran "lantation "rotocol, the additional toxicity mayinduce 'ul'o'aginal gra#t2 versus-host disease 3%AHD5. Be ikno-n about the effects of chemotherapy on the #emalegenital tract other than, the ovaries, although women may

ex"erience a persistent vaginal discharge after chemo thera"y,-hich likely re"re ent 'aginal muco iti ! al o, there i omee'idence that chemothera"y contribute to 'ul'odynia 3?5. Inaddition, the ex"erience o# cancer diagnosis and treatment m ayprofoundly affect a woman's body image and sense ofsexuality (6).

Radiation therapy (RT) can also impact sexual #unction in-omen. For exam"le. & #or brea t cancer induce local kini&ening, conuacture , andior change in texture and color.a" may result m chronic breast pain, an) of which can a##ect av s body unage or abi l ity to enjoy sexual act ivi ty.V !" fd tas# away result from $% to the pelvis withre ailaat vaginal fibrosisor stenosis that limits a woman'scapacity for vaginal intercourse as well as affects her genital

pelvic and clitoral sensitivity during sexual acti'ity. he echanges last long after $% has been com"leted. For exam"le,-omen treated #or cer'ical cancer ha'e re"orted exualdy #unction u" to ? year later 3 o# 'i it 3@5.)a rr i er to addressing sexual heal th i ue exi t ,

including t ime con t ra in t o r a re luc tance to e 'enbring u" exual health i ue on the "art o# clinician ,and the en e that many -omen #eel embarra ed to a k about the e i ue or may be una-are that treatment i a'ailable3+:5. In addition, ome " atient may be concerned that their oncologi t -ill "ercei'e that the e i ue are tri'ial or thatthe "atient i ungrate#ul #or their care. Ho-e'er, /uerieabout exual hea lth can be made 2 in a -ay that i 2c om #o rta bl e # or " at ie nt , a nd / ue t io n c an b eincor"orated in to a rout ine "o t t rea tment re 'i e - o#

y tem . In addi t ion to a king the e /ue tion , i t iim"ortant to en ure that re ource are a'ailable locally #or

"ati ent -ho -i h to "ur ue #urther treatment.

0hen addre ing exual #unction, it i e ential thata um"tion not be made regarding exual orientation or ex2ual "ractice 3++5. he "atient hould be a ked o"en2ended

uestions that allow her to feel com#ortable haring in#orma2tion that is pertinent to her e'aluation and management. For exam"le, 'aginal intercour e may not be the mo t im"ortantcom"onent o# exual acti'ity #or many -omen, includingtho e -ho ha'e ex -ith other -omen.

DIAGNOSIS

he diagno i o# exual health i ue re/uire a hi tory o# theexual com"laint and a "ertinent medical hi tory, including

an oncologic and exual hi tory. * medication hi tory houldal o be re'ie-ed becau e o# their im"act on exual #unction,including the u e o# antide"re ant and endocrine thera"ie .

It i im"ortant to a e the a "ect o# exual dy #unction that

are bother ome to the "atient, including -hether concomitantym"tom o# anxiety or de"re ion are "re ent 3+9, +;5.

Detailed diagno i and treatment o# exual de ire, arou al,

and orga m i ue i beyond the co"e o# thi article, butmany re'ie- o# the e to"ic can be #ound in the literature3+ 2+ 5. E 'aluat ion and t reatment o# the e i ue may

necessitate referral to a behavioral health "eciali t or sextherapist.

It i im"ortant to di cu the interaction bet-een the "a tien t and exual "a rtne r , bo th exual ly and in ter m o# the relation hi in eneral. it ma al o be hel #ul to di cu

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VIEWS AND REVIEWS

he e'aluation hould include a "el'ic, examination, in-hich the 'ul'a and 'agina are examined #or the "re enceand e ' e r i ty o# a t ro"hy, change in ' ag ina l l eng th o r cal iber due to urgery or "el ' ic radiation, or adhe ion .Care hould be taken to communicate - i th the "at ientregarding her ability to tolerate the examination! di##icultymay be ym"tomatic o# dy "areunia. For the e -omen, theu e o# a narro- Peder on or "ediatr ic "eculum may be

better toler ated. ( e o# a lubr ica tin g gel increa e com#o rtand general ly doe not inter#ere - i th cer ' ical am"le3+

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ameliorates d y spareunia. Di lators may also be used toimpr ove "e l' ic mu cle relaxation and control as part oftherapy for vaginismus. Patients may be instructed o n self-guided use of dilators or m ay b e ref erred to a pelvicself-guided -

physical therapist.

Women with severe pain. particularly localized to the

vaginal vestibule, or pain

should be evaluated for vu lvodynia. Loca lized, provoked , or

generalized vulvodynia may develop after chemotherapy or

menopause (5, 37). In addition, some women develop

secondary vaginismus after experiencing painful sexual

encounters.

Vaginal Stenos is

Vaginal teno i i a seve re com"lication that occur in ome

women ho are treated with pelvic radiation thera"y or

ogninc hematopowtic stem cell transplantation 3 C