GÖTEBORG, SWEDEN — Virtually every woman treated for a gynecologic cancer has sexual problems during or after therapy. Yet sexual consequences are rarely addressed by clinicians or investigators.
Sexual dysfunction is “the silent issue,” Dr. Karin Bergmark said, piercing the silence in a symposium at the ESTRO 27 meeting of the European Society for Therapeutic Radiation and Oncology. Many patients accept it as “the price of a cure,” she said, but few are told what to expect before treatment or what they can do about their problems afterward.
The hesitancy of clinicians to discuss sexual consequences stems in part from a lack of knowledge, said Dr. Bergmark, a gynecologic oncologist at the Karolinska Institute in Stockholm. Whereas sexual impact is studied in men being treated for prostate cancer, it is little explored in women with gynecologic cancers.
“We don't know,” she said repeatedly in an overview of how radical surgery, radiotherapy, chemotherapy, and hormonal treatment cause sexual dysfunction in an estimated 50%-75% of gynecologic cancer survivors. The level of distress varies among individuals and over time, she said, but 100% of patients are affected at some point.
Surgery may remove the top of the vagina and the uterus. It leaves scarring and fibrosis, and it can have vascular and neurologic effects. Among the sexual consequences, she listed vaginal shortening, vaginal inelasticity, insufficient lubrication, reduced sensation, and dyspareunia. And there can be psychological consequences, as women deal with issues related to sense of loss, body image, self-esteem, identity, and femininity.
Histologic and physiologic effects of radiotherapy, she continued, include inflammation, mucositis, necrosis, fibrosis (of the vaginal epithelium, pelvic connective tissues, and pelvic floor), telangiectasia, stenosis, vaginal shortening, and end-artery stenosis leading to reduced vascular capacity.
Neurologic effects have not been studied, she said, but 50%-80% of men treated for prostate cancer report effects. Among the known sexual consequences of radiotherapy in women are vaginal shortening, vaginal inelasticity, insufficient lubrication, and dyspareunia, she said.
Turning to chemotherapy, hormonal treatments, and hormonal changes (including those from oophorectomy), Dr. Bergmark said investigators have not much explored sexual consequences beyond the impact on vasomotor symptoms (such as hot flushes, sweating, and insomnia), vaginal dryness, fertility issues, early menopause, and body image (the last relative to chemotherapy).
Yet again, however, neurologic and vasomotor effects—in particular, reduced vasoconstriction, sensation, and feedback—have been studied in men. “Probably it is the same in women. Their anatomy is absolutely the same when it comes to nerves and function,” she said of chemotherapy's neurologic impact, adding that she could not find any studies on the additive effects of chemoradiation or on neurotoxic effects such as pain in women with gynecologic cancers.
“In women without cancer there are some reports that the reduced hormones may have vasomotor effects, and that might be altering genital response,” she said. “There are estrogen and androgen receptors in the vagina both in the epithelium and in the primary vessels. And that might have an impact on lubrication or sensation, but we don't know.”
Ultimately, researchers need to ask how all this affects sexual desire and sexual satisfaction, she concluded, with emphasis on the complexity of sexual desire. “It is biology, and psychology, and sexual function,” she said. “And in contrast to that is a different entity—sexual satisfaction.”
Lisa Punt, Macmillan Consultant radiographer in gynecologic oncology at Addenbrooke's Hospital in Cambridge (England), also called on clinicians to address sexual issues, address them early, and address them with sensitivity to the complex mix of psychological, physiologic, social, and cultural factors involved.
Women should be advised of the potential for sexual consequences up front when they are told of possible complications and asked to give informed consent to procedures, she said. “Timing is essential. Information should be given at the point of consent.”
Clinical staff need to learn to feel comfortable with the topic, and to ask questions—both open questions and cue questions—throughout treatment and follow-up in a way that is empathetic and confidential, she continued. Some are afraid to, she suggested, for fear they will not be able to handle serious emotional problems. The solution is not to dodge these problems, but to be prepared to refer patients when necessary for appropriate counseling.
“Even if we have a patient who is psychologically performing well post treatment and they are able to move from excitement to arousal … the physical changes and the nerve damage and the scar tissue, the pain, postcoital bleeding may all lead back to negative experiences,” she said. “We need to be addressing the patient holistically to ensure we get the best function for the patient post treatment.”
Finally, posttreatment care should include rehabilitation in women with sexual dysfunction, Ms. Punt continued, outlining three common problems and how they can be addressed.
Vaginal stenosis can be prevented or treated with dilation, by encouraging resumption of sexual intercourse, and—in cases of vaginal adhesions—with surgical intervention. Dilator use should be started 2-4 weeks after completion of treatment and continued indefinitely, Ms. Punt said. She recommended consulting “best practices on the use of vaginal dilators in women receiving pelvic radiotherapy,” guidelines developed by the National Forum of Gynaecological Oncology Nurses in the United Kingdom and downloadable online at www.owenmumford.com/en/download.asp?id=59. For vaginal dryness, she suggested oral hormone replacement therapy, topical estrogens, and lubrication. Topical estrogens can also be used to treat vaginal atrophy, she said.
The symposium ended with a brief question-and-answer session, after which Dr. Bergman and Ms. Punt were thronged by attendees. Noting how few questions had been asked when the microphones were on, one attendee opined that people know the issue is important but are too embarrassed to speak up.
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