Cancer, Sexual Health & IntimacyWHEC Practice Bulletin and Clinical Management Guidelines for healthcare providers. Educational grant provided by Women's Health and Education Center (WHEC). Sexual health is a state of physical, emotional, mental and social well-being in relation to sexuality; it is not merely the absence of disease, dysfunction or infirmity. Sexual health requires a positive and respectful approach to sexuality and sexual relationships, as well as the possibility of having pleasurable and safe sexual experiences, free of coercion, discrimination and violence. Sexuality is a central aspect of being human throughout life and encompasses sex, gender identities and roles, sexual orientation, erotic expression, pleasure, intimacy and reproduction. Sexuality is experienced and expressed in thoughts, fantasies, desires, beliefs, attitudes, values, behavior, practices, roles and relationships. It is clear that these issues go far beyond medical concerns. Sexual concerns are common among patients in the process of diagnosing, treating, and recovering from cancer. The purpose of this document is to understand successful promotion of sexual health in patients diagnosed with cancer. As patients move away from the acute phase of illness, healthy sexual functioning is an important step toward re-establishing their sense of well-being. Several physiologic and psychological factors specific to oncology patients (eg, advanced disease, radical surgery, pelvic irradiation, symptoms related to menopause, pre-morbid sexual dysfunction, and negative self-concept) can promote sexual morbidity. These issues may place cancer survivors at increased risk for the development of sexual problems. Prevalence: Approximately 50% of women who survive breast or gynecologic malignancy report severe, long-term sexual problems. Several studies have shown that sexual dysfunction is highly prevalent in the population of cancer patients and sexual morbidity occurs in up to 90% of women with cancer (1). Most of the studies have reported the range 30% to 100%. Breast cancer survivors note that sexual problems are bothersome and disheartening exceptions to the restoration of their high level of functioning. For patients who have survived other types of cancer (eg, Hodgkin's lymphoma, leukemia), at least 25% are left with sexual complaints. Most commonly, these patients report hypoactive desire disorder, and/or dyspareunia. Women at greatest risk for sexual problems include those with cancer of the vulva or vagina and those who have had a pelvic exenteration. Physicians and nurses need to be informed about the potential sexual outcomes for patients with gynecologic cancer. Patients make few inquires, despite their concerns, healthcare providers need to initiate discussion of sexuality topics. When question do arise, an informed and understanding response encourages future disclosure of questions and concerns. Body image concerns impose psychological barrier to intimacy and sexual desire, and the resulting partner conflicts and relationship miscommunications can be severe, debilitating, and painful. Misconceptions among patients and their partners, such as the fear of being "radioactive", are also encountered. Assessment: Technologic advances have changed our perceptions concerning malignancy. It is now often viewed as chronic illness. The medical community continues to improve therapeutic modalities by focusing on techniques that not only improve cancer survival rates, but decrease long-term side effects and suffering as well. New surgical techniques and adjunctive therapies reflect the growing emphasis on quality of life. Even for the older woman or the woman who is not currently sexually active, such information is desirable. The most important determiner factor of the frequency of sexual activity for a woman is the presence of a healthy and interested sexual partner, not age per se. A pre-treatment sexual history is best obtained by questioning the patient directly. A brief sexual history should be obtained from all patients before treatment (2). Obtaining a sexual assessment can achieve three goals: Questionnaires can be used to assess such topics as sexual behavior or sexual arousal. The following areas can be briefly surveyed during a discussion with a patient: marital status and availability of current sexual partner(s); frequency of sexual activity; presence of female sexual dysfunction (e.g., lack of desire, orgasmic difficulties) and presence of sexual dysfunction in the partner (e.g., premature ejaculation, erectile difficulties). Survivorship initiatives are now a critical focus for many cancer institutions and governmental organizations. These programs formulate comprehensive treatment plans for cancer survivors and promote research in this area. Post-treatment resources and sexual health programs are integral parts of these survivorship initiatives. Management: Sexual dysfunction is a common consequence of cancer therapy that may persist after treatment is completed. Patients make few inquires, despite their concerns, healthcare providers need to initiate discussion of sexuality topics. When questions do arise, an informed and understanding response encourages future disclosure of questions and concerns. Departments caring for patients with gynecologic cancer need to determine how they will provide psychosexual help. For the individual patient, preventive rather than rehabilitative efforts are desirable. Women at greatest risk for problems include those with cancer of the vulva or vagina and those who have had a pelvic exenteration. In contrast to preventive services, rehabilitative services may be considered for women at less risk. The assessment of the cancer patient includes a detailed history, physical examination, psychological evaluation, and when appropriate laboratory and radiologic studies. Sexual status, orientation, and history are also assessed (3). Patients are encouraged to see both the gynecologist and psychologist for initial and follow-up evaluation and follow-up surveillance. Once the comprehensive assessment is completed, a therapeutic management plan is formulated. A number of issues should be considered before any type of therapy instituted: Medical Therapy: Specific medical interventions may enhance sexual functioning for selected patients. Concerns regarding hormonal manipulation are common in breast and gynecologic cancer patients. Patients with estrogen-sensitive tumors rarely use hormone Patients and oncologists are now using topical estrogen more often to treat vaginal atrophy. The use of 17-beta estradiol tablet (Vagifem) that is minimally absorbed into the systemic circulation is helpful in many patients. Estrogens administered vaginally are well absorbed, and the required effective topical dosages are minimal. Patient feedback indicates that these vaginal tablets are easy to use, less messy than cream preparations, and technically simpler to insert than estrogen rings (4). Patients should be educated about their genital anatomy and how cancer therapy and surgical procedures can affect their sexual functioning. The debunking of many long-standing sexual myths and the instructional guidance of trained professionals is an important part of this educational process. Sexual devices for patients who have undergone pelvic surgery and/or radiation therapy, vaginal shortening, narrowing, and scar tissue can often impede penetration, causing dyspareunia. This may lead patients to avoid many types of sexual activity. Vaginal dilators with water- or hormone-based lubricants can help to lengthen and widen the vagina and stretch the scar tissue that contributes to the discomfort associated with vaginal intercourse. In addition, devices such as the EROS clitoral stimulator can be prescribed for patients who have had cervical, rectal or vaginal cancer. Preliminary data shows promise that this device may be helpful in combating arousal difficulties after cervical cancer therapy (5). Alternative and Complementary Medicine: Many non-medical pharmacologic therapies have potentially detrimental side effects, and have no scientific data supporting their ability to alleviate sexual dysfunction. Although patients try agents such as chocolate, ginseng, oysters, and black cohosh to enhance sexuality; randomized controlled clinical trials are needed to ensure safety and efficacy and to demonstrate a low side-effect profile. Referral for an evaluation by a sub-specialist may be appropriate for certain clinical conditions. Consultants may include oncologists, social service providers, nutritionists, exercise therapists, and psychiatrists. Psychotherapy: Certified sexual therapists are trained to deal with cancer patients and their body-image issues and changes in intimacy, sexuality, self-esteem, and mood. Marital, individual, couples and group therapy by a trained therapist to deal with cancer-related sexual issues are helpful. Behavior techniques offer a useful place to begin. This should be conducted by a professional who is trained broadly in sexual therapy and familiar with the specific difficulties of the patient with gynecologic cancer. Conclusion: Departments caring for patients with gynecologic cancer need to determine how they will provide psychosexual help. For the individual patient, preventive rather than rehabilitative efforts are desirable. This should include the routine provision of sexual information to patients, particularly those at high risk for sexual problems. In contrast to preventive services, rehabilitative services may be considered for women at less risk. With such a system, women would usually be seen only after sexual problems had developed. Although they might be more difficult to treat them, the positive benefit of having a readily available treatment program would be important to the patients. Patients returning for follow-up need to be informed of the availability of such a resource. Educating patients about sexual myths and the potential impact of cancer treatment on sexual function and providing instructional guidance and support are all integral parts of treatment. Research has shown that compliance with therapeutic modalities and preventive measures is more likely if education and close follow-up are undertaken prior to the initiation of cancer treatment. Individual treatment plans created and implemented by the professional sexual health care team to educate patients and their partners so they can enjoy fulfilling, pleasurable sexual activity during and after cancer therapy. Quality-of-life concerns in cancer survivorship are paramount for both clinicians and patients. It helps women to take a more active role in her sexuality, gives her an improved body concept, and allows her to discover new modes of experiencing sexual pleasure. The woman should be oriented to focus on the positive aspects of her sexual life, such as the continued ability to engage in sexual activity, the experience of physical closeness and intimacy with her partner, and the sharing of alternative sexual activities with her partner. References: |