Saketh R. Guntupalli, MD, FACS, University of Colorado
The impact of a cancer diagnosis on sexual and marital health is a topic that is too often overlooked in the greater picture of cancer and its treatment, and patients may be reluctant or unwilling to bring it up. At this year’s ESMO 2022 Review conference in Denver Colorado, Dr Saketh Guntupalli from University of Colorado highlighted the sobering statistics relating to sex and women with gynecologic cancers, and why it’s important to get patients talking.
Sexual dysfunction has been defined as “a problem during any phase of the sexual response cycle that prevents the individual or couple from experiencing satisfaction from the sexual activity.” Causes of sexual dysfunction are numerous, and can be both organic (e.g., diabetes, heart disease, hormonal imbalances, menopause, alcohol and drug abuse, antidepressant use), or inorganic (e.g., work-related stress, anxiety, depression, marital/relationship problems). Also important to remember for some women, sexual problems may result from a history of prior sexual trauma.
Some Hard Facts
Gynecologic cancers, including cancers of the cervix, uterus, ovary, fallopian tube, vagina, and vulva, represent the 3rd most common malignancy for women. Although survival with many gynecologic cancers can be as high as 70% or more with improved diagnosis and treatment, their impact on sexual dysfunction remains one of the least addressed issues in long-term cancer survivorship. Some of the reasons for this include embarrassment, ignorance and/or lack of awareness of the impact of cancer on sex, a failure to prioritize this issue (relative to the greater issue of treating the cancer), and a lack of available resources.
In the setting of gynecologic cancers, one study reported that up to 70% of women had significant sexual dysfunction, and often patients experienced significant embarrassment talking about sexual problems. Moreover, there was often the impression from their providers that “nothing could be done” and only 14% of physicians asked their patients about sexual problems after they had completed their treatment. In terms of the impact of sexual dysfunction on marriages/relationships, one study of patients with brain tumors found that, while divorce/separation rates were similar to the baseline population of 12%, one of the main factors associated with divorce/separation was female sex, such that women had a 10-fold higher risk relative to men, of their partner leaving them. In addition, those women who separated or divorced from their spouses were significantly more likely to be hospitalized, less likely to participate in clinical trials, and less likely to receive or complete essential treatments such as radiation and chemotherapy for their tumors. Results such as these, Dr Guntupalli emphasized, highlight the disparate clinical impact on women of a divorce/separation as a result of their cancer diagnosis.
A large study conducted by Dr Guntupalli and coworkers sought to assess the impact of cancer and its treatment on sexual function in women with gynecologic cancers, and also examined the impact of this dysfunction on their marital relationships and overall well-being. The study utilized a 181-item questionnaire conducted pre-cancer and post-treatment, using two validated clinical tools, the female sexual function index (FSFI) and the Intimate Bond Measure, to assess sexual health and relationships. The FSFI pre- and post-treatment was the primary outcome measure.
The study enrolled 320 patients, 208 of whom completed the survey at the time of analysis. Overall, sexual dysfunction was reported in 39% of the women, 42% of whom were under 50 and 95% of whom were in relationships. The vast majority of women in the study had uterine/endometrial or ovarian cancers, and 61% had Stage I or II disease. Treatment was surgery and chemotherapy in 38%, and surgery only in 29% of the patients.
The results showed a significant, 29% decline in sexual function, and a 57% decline in sexual activity after treatment (both P<0.001). Sex was significantly less pleasurable after cancer (P<0.001) and all types of sexual activity (oral, vaginal, anal) were decreased (P<0.001 for all). Some of the risk factors for significant sexual dysfunction in the study following diagnosis/treatment were age under 50 years, receiving chemotherapy, an ovarian or cervical cancer diagnosis, and being in a significant relationship. Interestingly, after treatment, 15% of women with sexual dysfunction reported the need to go to relationship counseling, and the frequency of sexual activity was significantly decreased.
There was no significant association of sexual dysfunction with overall marital function when comparing pre-diagnosis and after treatment. There was also no apparent impact of sexual dysfunction on affair, separation and divorce rates after cancer; a total of 3% of women in the study reported their partner had an affair, 9% reported separating for some time, and 5% reported divorcing after cancer, although none of these outcomes were statistically significant. From a psychosocial perspective, as compared to before cancer, women in the study reported that, after cancer, sex was less enjoyable, there were feelings of depression, frustration with their sex life, feelings of being “less of a woman”, losing confidence in their sex life, and worry about the future of their sex life.
The overall conclusions of the study were that, irrespective of their diagnosis, women with gynecologic cancers undergoing treatment are at significant risk for impaired sexual function. In particular, younger women, those with ovarian or cervical cancer, those receiving chemotherapy, and those in relationships are at especially high risk for a decline in sexual function. Those experiencing sexual dysfunction in the study were more prone to a decline in sexual activity and a greater incidence of relationship counseling after treatment.
So What Can Be Done?
Beyond increasing awareness, and encouraging/inviting patients into an open discussion of sexual problems if they should exist, Dr Guntupalli emphasized that communication between partners about intimacy and realistic expectations is the first and foremost way to begin to address sexual issues in cancer. The expectation of a change in sexual function after a cancer diagnosis, and relating to your partner, for example, that sex is the last thing that comes to mind after a chemotherapy infusion, is a good way to start a discussion about other ways to feel closeness and intimacy with your partner. In addition, while not mentioning any particular brand by name, Dr Guntupalli also notes that the use of “high-end” suave, water-based lubricant is essential, and can help make sex more pleasurable for patients with gynecologic cancers, so he encourages his patients to find a formulation that works for them. Lastly, Dr Guntupalli noted that, while we all have been conditioned to think of sex in the traditional way (i.e., foreplay, intercourse, orgasm, resolution), in the setting of cancer, it may be necessary to “think outside the box” and redefine our thoughts about sex and intimacy. For some older cancer survivors in their 50s and 60s, for example, he suggests that intimacy can be a simple as holding hands and going for a long walk.
For further reading on this topic, Dr Guntupalli also recommends his book Sex and Cancer, which relates a series of stories on how to address sexual function from the patient’s perspective following a diagnosis of cancer.
See more from the 2022 ESMO Colorado Conference here.
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