Improving Sexual Health After Gynecological Cancer Is a Multifaceted Approach

Pluta Cancer Center clinicians discussed how to improve sexual health outcomes for patients diagnosed with gynecological cancer.

The facts don’t lie: 50% of patients with breast cancer, 65% to 90% of patients with gynecological cancers, and over 60% of patients with colorectal cancer experience sexual dysfunction.¹

“Cancer treatments, such as surgery, chemotherapy, radiation, can cause both short-term and long-term changes in the body that affect a person's ability to engage in sexual activity or feel sexually desired,” explained Jocelyn Bushart, ANO-BC, a nurse practitioner at the University of Rochester Medicine in Rochester, New York.

Bushart was part of a roundtable discussion with other experts from Pluta Cancer Center at the University of Rochester met to discuss sexual health before and after gynecological cancer treatment. The webinar focused on specific key areas to promote sexual wellness and how to address these concerns with patients.²

To begin, the panel focused on how the impact of cancer treatment can interfere with psychosocial systems associated with sexual response cycles, including that of body image, intimacy, and relationship dynamics. However, many don’t think of sexual health beyond the physical implications; it also includes social and psychological factors.

“We want to stress mental health, such as stress, anxiety, and depression can all impact sexual desire and performance. Body image and self-esteem play a crucial role in sexual competence, satisfaction, and well-being,” Bushart said in the presentation.

As mentioned, specific cancer treatments can impact a patient’s sexual function. For instance, those who undergo surgery may have nerve damage, a loss of sex hormones, or genital deformity. Radiation can be associated with vaginal atrophy, loss of genital sensation, and loss of bladder or bowel control. Additionally, hormone therapy can include pain with intercourse, a low libido, and difficulty with orgasm.

For clinicians, it’s important to know patients’ most common concerns with sexual health, the highest of which include dyspareunia (40%-100%), vaginal dryness (60%-87%), lack of libido/low desire (61%), and lack of orgasm (45%).

Barriers to proper care from providers include a lack of training, with a gap in education; provider assumptions based on patient health and their perception of illness; time constraints with limited appointment times; and biased assumptions about the patients.

“In a systematic review of 29 studies, only 10% of patients reported being screened or assessed for female sexual dysfunction during follow-up visits,” Bushart noted.

The panel then went on to discuss different sexual health concerns often experienced, and ways to best overcome them including that of dyspareunia, vaginal dryness, dilator therapy, vibrator use, benefits/uses of pelvic PT, and occupational therapy for sexual wellness.

Dyspareunia

Dyspareunia is described as pain during intercourse. Carli Kotula, PA-C, a physician assistant from the University of Rochester Medicine, said it can occur for reasons because of vaginal atrophy, vaginal stenosis, decreased tissue elasticity, loss of genital sensation, and hormonal changes.

Dyspareunia can also occur when medical menopause is implemented due to surgical removal of the ovaries or hormone therapy that suppresses estrogen levels.

“The relationship between dyspareunia and cancer is multifaceted, involving several factors related to the disease itself and its treatments,” Kotula said.

This can often lead to a cycle in which patients may anticipate the pain, and have an involuntary reaction, which can lead to painful sex, and so on. Kotula noted that the goal of a provider is to help break this cycle or better yet to stop the initial inciting pain event from occurring.

Vaginal Dryness

Vaginal dryness can cause burning or itching, bleeding after sex, soreness in the vulva, or recurrent urinary tract infections or yeast infections. The impact of vaginal dryness can lead to discomfort during sex, reduced libido, relationship strain, or even daily comfort.

There are medications and interventions that can help with vaginal dryness, such as moisturizers, lubricants, pelvic floor physical therapy, and counseling or support.

Vulvar skin care is just as important, and choosing the right moisturizers and lubricants is imperative. One tip she noted was the parts of your vulva without hair should be treated like the lips on your face and should not include soaps, perfumes, or fancy creams.

Dilator Therapy

This specific type of therapy can stretch the vagina to keep it flexible and separate bands of scar tissue. They can also be used to make intercourse more comfortable or for internal examinations to occur.

“We recommend dilator use as long as clearance is given from the oncology and pelvic teams. We can do prehabilitation before radiation and then wait several weeks after treatment to begin dilator therapy to try and get some stretch back,” Kristina L. Galton, FNP-BC, a nurse practitioner at the University of Rochester Medicine, said during the presentation.

Some tips Galton gave on helping patients to pick the correct dilators to use included having a goal size of what you want to work up to and for providers to be open with patients about what size speculums are being used during procedures so they can accurately prepare.

“It’s important for making sure that we get those tissues stretched, mainly so that we can make sure that your exams are getting done to maintain their health,” said Galton.

Vibrator Use

One note is that vibrator use can occur to help break up any adhesions in the vagina and stimulate blood flow to the vulva and vagina. The increase in blood flow will lead to more fluid and erect tissues that can help with muscle relaxation.

In Galton’s office, vibrators are considered medical devices just like a back massager would be, as it helps to relax the tissue.

Pelvic Floor Physical and Occupational Therapy

The issues that pelvic floor physical therapists most commonly focus on with patients are stress or urge of incontinence, painful sex with dilator therapy, pre- or postpartum strengthening, post-surgery, and constipation.

Occupational therapists will focus on psychosocial or physiological concerns and interventions. Psychosocial concerns may include depression, anxiety, or coping with loss of function; while physiological concerns may include changes in bodily structures, loss of sexual body parts, hormone changes, and lowered arousal.

Specific interventions to implement may be environmental modifications, assistive technology education and training, energy conservation, and motor skill training.

“When coping with loss of function, if vaginal surgery occurred, [occupational therapists] will help to figure out how to use that part of your body again…maybe adding a pelvic wedge to sit somebody in the right position. [Their job] is to figure out how to help patients have sexual pleasure and work around limitations and activity modifications,” said Galton.

References

1. Dreibelbis N. Addressing the unmet need of sexual health in oncology patients. Slack Journals. 2024;39(3):15-23. doi:0.3928/25731777-20240710-04
2. Bushaart J, Galton K, Kotula C. Sexual health before and after gynecological cancer treatment. Pluta Cancer Center Female Sexual Wellness Program Series. Accessed September 18, 2024.