Tips for Sexual Well-Being After Treatment for Ovarian Cancer

HOUSTON—The severity of sexual and fertility problems experienced by women after treatment for ovarian cancer is as diverse as the patient population, Leslie Schover, PhD, said at the First Annual International Conference for Ovarian Cancer, co-sponsored by M.D. Anderson Cancer Center and Memorial Sloan-Kettering Cancer Center.

“Ovarian cancer patients include postmenopausal women with epithelial tumors, women in their childbearing years with borderline or germ-cell cancer, and young women who have, or who are at risk for, a familial form of ovarian cancer,” said Dr. Schover, Department of Urology, Taussig Cancer Center, Cleveland Clinic Foundation. “The sexual problems these women experience and the decisions they make regarding childbearing are unique to each woman’s particular situation.”

In each instance, she said, the type of cancer, the disease stage, and the prescribed treatment have a profound impact on the woman’s sexual well-being and childbearing potential.

Epithelial Ovarian Cancer

Women with sporadic epithelial ovarian tumors usually have advanced disease at diagnosis. The standard treatment is surgery to remove the uterus and the ovaries, which is typically followed by chemotherapy.

Such radical treatment, Dr. Schover said, can result in a long period of post-treatment difficulties, including fatigue, nausea, changes in body image due to surgical scarring, vaginal atrophy because of estrogen loss, and pelvic adhesions from surgery.

“A common complaint among women with epithelial ovarian tumors is loss of sexual desire and pain with intercourse,” Dr. Schover said.

Fertility is usually not an issue for women in this patient group, because most of them are beyond childbearing age. However, in some instances, older women are emotionally affected by the loss of what they consider a biologic privilege. “Today, many women are postponing raising a family until they reach their late 30s,” Dr. Schover pointed out. “When these women discover that their plans have been altered by cancer, they feel cheated.”

Few studies have examined sexual well-being and childbearing potential in women who have early-stage borderline or germ-cell cancer, but sexual functioning and fertility do not appear to be a problem for these patients. “Women in this patient group typically have a good prognosis,” Dr. Schover said. “This is fortunate, because due to their age, they have greater expectations regarding their sexual health and fertility.”

Conservative surgery is the standard first-line treatment for both borderline and germ-cell cancer. For germ-cell tumors, it often is followed by platinum-based chemotherapy. “After treatment, women in this patient group usually resume their menstrual cycle and are able to become pregnant,” she said. “Studies cited in the literature do not report any excess birth defects or any difficulties during pregnancy following treatment for borderline or germ-cell cancers.”

Ovarian Transposition

In cases in which the recommended adjuvant treatment is pelvic radiotherapy, a technique called ovarian transposition can be applied to spare the ovaries with the intent of preserving fertility.

“In this process,” Dr. Schover said, “the ovaries are transposed behind the uterus to shield them from radiation exposure.” In a study conducted at M.D. Anderson, Dr. Schover said, “women who underwent radiotherapy without ovarian transposition needed estrogen replacement to maintain menstruation.” These women generally reported that they were sexually satisfied, but there was a slight increase in the number of women who reported pain with intercourse.

“Certainly women who have had breast or ovarian cancer at an early age, women who have tested positive for the BRCA1 mutation, and women from families with a history of breast or ovarian cancer have special issues to confront,” Dr. Schover commented.

Breast cancer treatment involving mastectomy followed by adjuvant chemotherapy or radiotherapy can cause premature menopause. Furthermore, women who know they carry the trait for breast or ovarian cancer sometimes elect to have prophylactic mastectomy or oophorectomy. “Early menopause can result in a high rate of sexual problems, including loss of desire for sex, dyspareunia, and negative self-image,” Dr. Schover said.

She added that some women in this high-risk group choose not to have children for fear the pregnancy will trigger an episode of breast cancer or because they do not want to put their own child at risk of inheriting an autosomal dominant cancer syndrome.

Counseling Patients

“It is certainly possible to continue a mutually satisfying sex life after cancer,” Dr. Schover said, “although modifications may be needed in some cases.”

One particularly important issue clinicians should address with their patients is adjustments and options regarding intercourse. “Patients should experiment with positions that minimize the effects of deep thrusting,” she said.

These women and their partners should also be encouraged to experiment with alternative forms of intimacy, such as bringing each other to orgasm through oral and manual stimulation, and intensifying touching and caressing techniques.

Studies of ovarian cancer survivors show that the quality of a woman’s relationship with her partner is as important a predictor of sexual satisfaction as the effects of treatment. “If intimacy between the patient and her partner was intense before cancer, they will be able to make the transitions necessary to preserve that intimacy,” Dr. Schover said.

Estrogen Therapy

Problems associated with the woman’s attitude about sex may stem from hormonal and other physical changes that occur after treatment. Estrogen replacement therapy may be appropriate for some women who are undergoing treatment or who have finished treatment and are in a state of menopause. However, estrogen replacement therapy is not recommended for women who have had breast cancer because it is associated with an increased risk of recurrence.

A product called the Estring is available for women with premature menopause who suffer from vaginal atrophy, and is being tested for safety in breast cancer survivors. The Estring is similar to the ring of a diaphragm, Dr. Schover said, but it is filled with 2 mg of estradiol released slowly over 90 days.

“The Estring is inserted into the vagina and replaced every 3 months,” she said. “A burst of systemic estrogen is released when the ring is first inserted, but as the vaginal lining cornifies, very little estrogen is released into the systemic circulation.”

Dr. Schover said that the Estring works quite well for vaginal atrophy and is effective in relieving stress incontinence.

Women can also be advised to use Replens, a gel-like vaginal moisturizer that replaces natural vaginal lubricants that are depleted due to premature menopause. Replens is applied to the vagina three times a week using a tampon-type applicator. “Studies show that when women use Replens properly for up to 2 months, the vagina, on clinical examination, appears to be producing a healthy level of estrogen.”