Understanding sexuality in women with gynaecological cancer

doi:10.1016/j.ejon.2010.05.008

European Journal of Oncology Nursing

Volume 15, Issue 1, February 2011, Pages 38-45

https://doi.org/10.1016/j.ejon.2010.05.008 Get rights and content

Abstract

Purpose

To develop a better understanding of the term “sexuality” in the context of gynaecological cancer and to examine the applicability of Woods (1987) conceptual framework of sexuality when examining changes in sexuality following a gynaecological cancer diagnosis.

Methods

A comprehensive search for literature focusing on sexuality in gynaecological cancer patients, published in English from 1998 to 2009, was performed in the electronic databases CINAHL, Pubmed and ISI Web of Knowledge.

Key Results

Results revealed that a lack of conceptual frameworks exist which aim to describe the concept of sexuality in cancer care. In addition, a greater emphasis exists in the literature on the physical aspect of sexual functioning with a neglect of other broader dimensions. However, Woods (1987) proposes a holistic view of sexuality which is composed of three inter-related dimensions 1) Sexual Function 2) Sexual Self Concept and 3) Sexual Relationships. Through the examination of empirical literature surrounding sexuality in a gynaecological cancer context, this framework was further developed to create a neo-theoretical framework of sexuality.

Conclusions

The main conclusion that can be drawn from this review of the literature is that sexuality is a multidimensional construct and must be assessed in this way. The neo theoretical framework of sexuality provides a holistic view towards sexuality which is lacking in the literature surrounding sexuality in the female cancer care context. Healthcare professionals could use this holistic approach when providing information and support to patients with gynaecological cancer.

Section snippets

Background

Cancer survivors are at a high risk of developing altered sexuality (Krychman et al., 2006). Unlike other physiological side effects of cancer which diminish over time, altered sexuality can persist for many years into survivorship (Tierney, 2008). Even though controversy exists surrounding the issue of whether symptoms of cancer can cause alterations in sexuality, there is no dispute that the multimodal therapy which is used to treat cancer has a negative effect on a person’s sexuality (Katz,

Methods

In order to meet this objective a comprehensive literature search was performed in the electronic databases CINAHL, Pubmed and ISI Web of Knowledge. The search terms, limits used and results of this comprehensive search are outlined in Table 1.

The search was limited to articles published within the past 10 years to ensure only the most up to date literature was sourced. Inclusion criteria consisted of publications which were based on primary research published in peer-reviewed journals,

Sexual self concept

In Woods (1987 p. 1) framework of sexuality, sexual self concept refers to:

“the image one has of oneself as a man or a woman and the evaluation of one’s adequacy in masculine or feminine roles. Sexual self concept also includes body image, reflecting the abstract representation of one’s body and the evaluation of that image against personal and cultural standards”.

This definition can be interpreted to suggest that sexual self concept is made up of numerous dimensions, including 1) body image 2)

Sexual relationships

Sexual relationships have the potential to be significantly altered by changes in health status such as a gynaecological cancer diagnosis (Woods, 1987). Sexual relationships are defined as, “the interpersonal relationships in which one’s sexuality is shared with another.” (Woods, 1987, p. 1) Shell et al. (2008) suggest that difficulties in relationships may arise following cancer and its treatment when couples fail to communicate feelings and do not share the same need for intimacy.

Sexual function

In Woods (1987 p. 1) framework, sexual function refers to, “the ability of an individual to give and receive sexual pleasure.” Included in sexual function is a cycle of various physical and psychological stages through which a person progresses during sexual activity known as the sexual response cycle. Kaplan (1979) suggests that the sexual response cycle consists of three stages: desire, arousal/excitement, and orgasm. During the desire phase sexual thoughts and desires cause a woman to become

Implications for practice and research

Sexuality is an important part of a woman’s health and is thus a legitimate concern for healthcare professionals. Lack of knowledge leading to patient misunderstanding can play a contributory role in causing altered sexuality (Maughan et al., 2002). Therefore timely and appropriate information is essential to increase patient satisfaction and promote best sexual health outcomes (Maughan et al., 2002). This is an extremely important issue as the provision of information is recognised as a

Conclusion

In conclusion, sexuality is a multidimensional construct composed of numerous dimensions which have the potential to be negatively affected by a diagnosis of gynaecological cancer. The neo-theoretical framework of sexuality is a relevant and suitable framework for healthcare professionals to use when addressing the concept of sexuality in patients with gynaecological cancer. Healthcare professionals must endeavour to provide information to women on how cancer and its treatment have the

Conflicts of interest

None declared.

Acknowledgement

We acknowledge Professor Nancy F. Woods and Professor Joyce Fitzpatrick for their support of this study and Professor Geraldine McCarthy for her invaluable guidance. We would also like to thank Mrs Helen Donovan, Director of Nursing, and all the medical and nursing staff of the South Infirmary Victoria University Hospital, for their encouragement of research endeavours.

References (97)

A. Amsterdam et al.
Sexual dysfunction in patients with gynaecologic neoplasm: a retrospective pilot study
Journal of Sexual Medicine
(2006)
L. Bernhard et al.
Redefining sexuality from women’s own experiences
Women’s Health
(1986)
J. Carter et al.
Radical trachelectomy for cervical cancer: postoperative physical and emotional adjustment concerns
Gynecologic Oncology
(2008)
J. Carter et al.
Gynecologic cancer treatment and the impact of cancer-related infertility
Gynecologic Oncology
(2005)
V. Champion et al.
Quality of life in long-term survivors of ovarian germ cell tumors: a gynecologic oncology group study
Gynecologic Oncology
(2007)
Y. Chan et al.
Psychosocial adjustment in gynaecologic cancer survivors: a longitudinal study on risk factors for maladjustment
Gynecologic Oncology
(2001)
B. Curbow et al.
Self concept and cancer in adults: theoretical and methodological issues
Social Science & Medicine
(1990)
J. DeGroot et al.
Do single and partnered women with gynaecologic cancer differ in types and intensities of illness-and treatment-related psychosocial concerns? A pilot study
Journal of Psychosomatic Research
(2007)
K. Donovan et al.
Sexual health in women treated for cervical cancer: characteristics and correlates
Gynecologic Oncology
(2007)
S. Faithfull et al.
Delivering sensitive health care information: challenging the taboo of women’s sexual health after pelvic radiotherapy
Patient Education and Counselling
(2008)

M. Green et al.

Sexual dysfunction following vulvectomy

Gynecologic Oncology

(2000)

A. Hordern et al.

Constructions of sexuality and intimacy after cancer: patient and health professional perspectives

Social Science & Medicine

(2007)

M. Hughes

Alterations of sexual function in women with cancer

Seminars in Oncology Nursing

(2008)

P. Jensen et al.

A longitudinal study of sexual function and vaginal changes after radiotherapy for cervical cancer

International Journal of Radiation Oncology Biology Physics

(2003)

I. Korfage et al.

Health-related quality of life in cervical cancer survivors: a population based survey

International Journal of Radiation Oncology Biology Physics

(2009)

U. Kullmer et al.

Self-concept, body image, and use of unconventional therapies in patients with gynaecological malignancies in the state of complete remission and recurrence

European Journal of Obstetrics & Gynecology

(1999)

M. Lavin et al.

Sexuality as an aspect of nursing care for women receiving chemotherapy for breast cancer in an Irish context

European Journal of Oncology Nursing

(2006)

A. Liavaag et al.

A controlled study of sexual activity and functioning in epithelial ovarian cancer survivors. A therapeutic approach

Gynecologic Oncology

(2008)

S. Lindau et al.

Sexual morbidity in very long term survivors of vaginal and cervical cancer: a comparison to national norms

Gynecologic Oncology

(2007)

K. Maughan et al.

In the shadow of risk. How men cope with a partner’s gynaecological cancer

International Journal of Nursing Studies

(2002)

M.A. Quinn

Sexual function after treatment of gynaecological cancer

Sexologies

(2007)

M. Serati et al.

Sexual function after radical hysterectomy for early-stage cervical cancer: is there a difference between laparoscopy and laparotomy?

Journal of Sexual Medicine

(2009)

M. Stead et al.

Psychosexual function and impact of gynaecology cancer

Best Practice & Research Clinical Obstetrics and Gynaecology

(2007)

D. Stewart et al.

“What doesn’t kill you makes you stronger”: an ovarian cancer survivor survey

Gynecologic Oncology

(2001)

D. Thaler-DeMers

Intimacy issues: sexuality, fertility and relationships

Seminars in Oncology Nursing

(2001)

M. Van de Klundert et al.

Comparison of the effect of non-surgical treatment modalities on sexual functioning and quality of life of patients with carcinoma of the cervix: a pilot study

Sexologies

(2007)

C. Warnock

Patient’s experiences of intracavity brachytherapy for the treatment of gynaecological cancer

European Journal of Oncology Nursing

(2005)

L. Wenzel et al.

Quality of life in long term cervical cancer survivors

Gynecologic Oncology

(2005)

A. Akyuz et al.

Living with gynecologic cancer: experience of women and their partners

Journal of Nursing Scholarship

(2008)

B. Andersen

Surviving cancer: the importance of sexual self-concept

Medical and Pediatric Oncology

(1999)

J. Annon

The PLISSIT Model: a proposed conceptual scheme for the behavioural treatment of sexual problems

Journal of Sexual Education and Therapy

(1976)

M. Bartoces et al.

Quality of life and self esteem of long term survivors of invasive and noninvasive cervical cancer

Journal of Women’s Health

(2009)

K. Bergmark et al.

Patient rating of distressful symptoms after treatment for early cervical cancer

Acta Obstetricia et Gynecologica Scandinavica

(2002)

L. Bernhard

Sexuality and sexual health care for women

Clinical Obstetrics and Gynecology

(2002)

G. Bourgeois-Law et al.

Sexuality and gynaecological cancer: a needs assessment

The Canadian Journal of Human Sexuality

(1999)

D. Bruner et al.

Assessing women’s sexuality after cancer therapy: checking assumptions with the focus group

Cancer Nursing

(1999)

D. Bukovic et al.

Sexual functioning and body image of patients treated for ovarian cancer

Sexuality and Disability

(2008)

M. Burns et al.

Assessing the impact of late treatment effects in cervical cancer: an exploratory study of women’s sexuality

European Journal of Cancer Care

(2007)

L. Butler et al.

Conceptualizing sexual health in cancer care

Western Journal of Nursing Research

(1998)

C. Carmack Taylor et al.

Predictors of sexual functioning in ovarian cancer patients

Journal of Clinical Oncology

(2004)

K. Carpenter et al.

Sexual self schema as a moderator of sexual and psychological outcomes for gynecologic cancer survivors

Archives of Sexual Behaviour

(2009)

J. DeFrank et al.

Body image dissatisfaction in cancer survivors

Oncology Nursing Forum

(2007)

A. Ditto et al.

Quality of life and sexual, bladder, and intestinal dysfunctions after class 3 nerve sparing and class 2 radical hysterectomies

International Journal of Gynecological Cancer

(2009)

E. Ekwall et al.

Important aspects of health care for women with gynecologic cancer

Oncology Nursing Forum

(2003)

M. Fitch et al.

Women’s perspectives regarding the impact of ovarian cancer

Cancer Nursing

(2000)

M. Frumovitz et al.

Quality of life and sexual functioning in cervical cancer survivors

Journal of Clinical Oncology

(2005)

C. Gamel et al.

Informational needs about the effects of gynaecological cancer on sexuality: a review of the literature

Journal of Clinical Nursing

(2000)

D. Gershenson et al.

Reproductive and sexual function after platinum-based chemotherapy in long-term ovarian germ cell tumor survivors: a gynecologic oncology group study

Journal of Clinical Oncology

(2007)

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Citation Excerpt :
The intervention in the present study relies mainly on the clinical practice model of IBM of FAM-SOTC. To provide the necessary background and comprehensive understanding of sexuality, the CO-SOTC intervention additionally uses two frameworks: neo-theoretical framework of sexuality and New View Manifesto of women's sexual problems (Cleary and Hegarty, 2011; Kaschak and Tiefer, 2001). Both frameworks assist the nurse to attend, as a minimum, to the three main domains of sexuality (sexual identity, sexual relationship, and sexual function).
To evaluate the effectiveness of a strenghts-oriented therapeutic conversation intervention on confidence about how illness beliefs affect sexuality and intimacy and on perceived relationship quality among women in active cancer treatment and their partners.
A quasi-experimental single-group pre-post-follow-up design was used. Women in active cancer treatment and their intimate partners were randomly assigned to a nurse-managed couple-based intervention (experimental group, n = 30 couples) or wait-list (delayed intervention) control group (n = 27 couples) plus 4 additional couples who pilot tested feasibility of the intervention, prior to the RCT. However, baseline differences in demographic and clinical variables prevented comparisons between groups. Therefore, a repeated-one-group pre-post test setup was used, comparing women with cancer and their partners over three time points. The intervention consisted of three Couple-Strengths-Oriented Therapeutic Conversations (CO-SOTC) sessions. The participants also had access to web-based evidence-based educational information. Data were collected before intervention (T1, baseline), one to two weeks post-intervention (T2), and after a follow-up session at three months (T3). Data from 60 couples (N = 120) were analyzed.
Significant differences were observed, for both women and intimate partners, over time in more confidence about how illness beliefs affected sexuality and intimacy (T1 versus T2, and T1 versus T3), and increased overall quality of the relationship (T1 versus T2, and T1 versus T3). No differences were found between dyad members’ scores on illness beliefs or relationship quality at any time point.
The CO-SOTC intervention was effective in supporting sexual adjustment among women in cancer treatment and their intimate partners.
NCT03936400 at clinicaltrials.gov.
A Prospective Single-Arm Study Evaluating the Effects of a Multimodal Physical Therapy Intervention on Psychosexual Outcomes in Women With Dyspareunia After Gynecologic Cancer
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Dyspareunia affects most women after treatment for gynecologic malignancies. However, to date, evidence-based interventions remain limited and no study has examined the effects of multimodal physical therapy on psychosexual outcomes in these patients.
To assess the effects of multimodal physical therapy on psychosexual outcomes including sexual distress, body image concerns, pain anxiety, pain catastrophizing, pain self-efficacy and depressive symptoms in women with dyspareunia after treatment for gynecologic malignancies.
Thirty-one gynecologic cancer survivors with dyspareunia enrolled in this prospective single-arm interventional study. The participants undertook 12 weekly sessions of physical therapy incorporating education, pelvic floor muscle exercises with biofeedback, manual therapy and home exercises. Outcome measures were evaluated pre- and post-treatment. Paired t-tests were conducted to investigate the changes from pre-treatment (P-value ˂ 0.05) while effect sizes (Cohen's d) were calculated to measure the magnitude of the change.
Sexual distress (Female Sexual Distress Scale-Revised), body image concerns (Body Image Scale), pain anxiety (Pain Anxiety Symptoms Scale), pain catastrophizing (Pain Catastrophizing Scale), pain self-efficacy (Painful Intercourse Self-Efficacy Scale) and depressive symptoms (Beck Depression Inventory-II).
Significant changes were found from pre- to post-treatment for all psychosexual outcomes. Women reported reductions in sexual distress (P ˂ 0.001, d = 1.108), body image concerns (P ˂ 0.001, d = 0.829), pain anxiety (P ˂ 0.001, d = 0.980), pain catastrophizing (P ˂ 0.001, d = 0.968) and depression symptoms (P = 0.002, d = 0.636) with an increase in pain self-efficacy (P ˂ 0.001, d ≥ 0.938) following the intervention.
The results suggest that multimodal physical therapy significantly improves sexual distress, body image concerns, pain anxiety, pain catastrophizing, pain self-efficacy and depressive symptoms in our sample of women with dyspareunia after treatment for gynecologic malignancies. The medium to large effect sizes obtained with the high proportion of women presenting meaningful changes according to the known minimal clinically important difference or clinical cut-off underlines the significance of these effects.
The current study used validated questionnaires to assess the psychosexual outcomes of a well-designed physical therapy intervention using multiple modalities to address the multifaceted aspect of dyspareunia in cancer survivors. This study did not include a control group, which may limit drawing definitive conclusions.
Findings showed that multimodal physical therapy yielded significant improvements in psychosexual outcomes in gynecologic cancer survivors with dyspareunia. A randomized controlled trial is indicated to confirm these results.
Cyr M-P, Dumoulin C, Bessette P, et al. A Prospective Single-Arm Study Evaluating the Effects of a Multimodal Physical Therapy Intervention on Psychosexual Outcomes in Women With Dyspareunia After Gynecologic Cancer. J Sex Med 2021;18:946–954.
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Pelvic floor disorders (PFD) are common conditions impacting quality of life and sexuality may worsen after ovarian cancer therapies. Our objective was to describe the prevalence of PFD and sexuality in women with ovarian cancer (OC).
We reviewed articles indexed in the MEDLINE database until June 2020 and selected articles assessing UI, POP, FI and sexual dysfunction in a population of women with OC.
Of 360 articles, 18 were included: four assessed UI, two assessed POP, three FI, and 13 sexual dysfunction. PFD findings were highly heterogeneous due to the definitions used and the populations studied. The prevalence of any type of UI in patients with OC before treatment is around 50%, and about 17% report feeling a bulge in their vagina. These rates are similar to those reported in women without cancer. Similarly, the main post-treatment UI scores were not significantly different from women without cancer. Fecal incontinence has been less studied in women with OC but reported as affecting 4% of patients preoperatively and 16% postoperatively. About half of the women are sexually active after surgical treatment with high reported rates of dyspareunia (40–80%) and vaginal dryness (60–80%). Compared with healthy women, some authors found that OC patients had greater problems with loss of desire and poorer sexual function scores; other authors did not find a significant difference.
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Citation Excerpt :
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This cross-sectional study included 136 Taiwanese long-term partnered women with gynecologic cancer treated in a large medical center. DSA was measured with the Diversity of Sexual Activities Scale, which assesses the number of sexual activities adopted in the past 6 months. Covariates included sexual knowledge and sexual attitudes, perceived changes in relationships of intimacy since treatment, and demographic and clinical factors.
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Understanding sexuality in women with gynaecological cancer

Abstract

Purpose

Methods

Key Results

Conclusions

Section snippets

Background

Methods

Sexual self concept

Sexual relationships

Sexual function

Implications for practice and research

Conclusion

Conflicts of interest

Acknowledgement

Journal of Sexual Medicine

Women’s Health

Gynecologic Oncology

Gynecologic Oncology

Gynecologic Oncology

Gynecologic Oncology

Social Science & Medicine

Journal of Psychosomatic Research

Gynecologic Oncology

Patient Education and Counselling

Gynecologic Oncology

Social Science & Medicine

Seminars in Oncology Nursing

International Journal of Radiation Oncology Biology Physics

International Journal of Radiation Oncology Biology Physics

European Journal of Obstetrics & Gynecology

European Journal of Oncology Nursing

Gynecologic Oncology

Gynecologic Oncology

International Journal of Nursing Studies

Sexologies

Journal of Sexual Medicine

Best Practice & Research Clinical Obstetrics and Gynaecology

Gynecologic Oncology

Seminars in Oncology Nursing

Sexologies

European Journal of Oncology Nursing

Gynecologic Oncology

Living with gynecologic cancer: experience of women and their partners

Journal of Nursing Scholarship

Surviving cancer: the importance of sexual self-concept

Medical and Pediatric Oncology

The PLISSIT Model: a proposed conceptual scheme for the behavioural treatment of sexual problems

Journal of Sexual Education and Therapy

Quality of life and self esteem of long term survivors of invasive and noninvasive cervical cancer

Journal of Women’s Health

Patient rating of distressful symptoms after treatment for early cervical cancer

Acta Obstetricia et Gynecologica Scandinavica

Sexuality and sexual health care for women

Clinical Obstetrics and Gynecology

Sexuality and gynaecological cancer: a needs assessment

The Canadian Journal of Human Sexuality

Assessing women’s sexuality after cancer therapy: checking assumptions with the focus group

Cancer Nursing

Sexual functioning and body image of patients treated for ovarian cancer

Sexuality and Disability

Assessing the impact of late treatment effects in cervical cancer: an exploratory study of women’s sexuality

European Journal of Cancer Care

Conceptualizing sexual health in cancer care

Western Journal of Nursing Research

Predictors of sexual functioning in ovarian cancer patients

Journal of Clinical Oncology

Sexual self schema as a moderator of sexual and psychological outcomes for gynecologic cancer survivors

Archives of Sexual Behaviour

Body image dissatisfaction in cancer survivors

Oncology Nursing Forum

Quality of life and sexual, bladder, and intestinal dysfunctions after class 3 nerve sparing and class 2 radical hysterectomies

International Journal of Gynecological Cancer

Important aspects of health care for women with gynecologic cancer

Oncology Nursing Forum

Women’s perspectives regarding the impact of ovarian cancer

Cancer Nursing

Quality of life and sexual functioning in cervical cancer survivors

Journal of Clinical Oncology