Sexual dysfunction in Spanish women with breast cancer

Purpose To determine whether there are changes in sexuality after breast cancer, to better understand the sexual function of women with breast cancer, and to investigate the potential relationship between sexual dysfunction and socio-demographic and clinical variables. Methods A cross-sectional study. This study included 514 women with breast cancer between 21- and 66-years-old. The cases were gathered between June 2016 and January 2017. The instruments used were the questionnaire on Women’s Sexual Function and a questionnaire to collect socio-demographic and clinical data. Results The average age (± standard deviation, SD) of participants was 46.34 ± 8.28 years. Their average age at date of diagnosis was 42.26 ± 8.56 years, and the average time suffering from cancer was 4.05 ± 5.23 years. There were significant differences (p = 0.002) in the presence of sexual dysfunction before (32.1%) and after (91.2%) cancer. The primary sexual dysfunctions were due to penetration pain (50.6%), lubrication (50.6%), dysfunctional desire (44.6%), and dysfunctional excitement (44.6%). Two-thirds of participants were satisfied with their sexual relations. The women who presented most sexual dysfunction were those that had a bilateral mastectomy (p = 0.009) and those who received chemotherapy, radiotherapy and hormonal-therapy (p < 0.001). Conclusion Sexual function was changed in women with breast cancer. The main problems included penetration pain, desire, lubrication, and dysfunctional excitement. It is important that Health professionals recognize which circumstances influence the sexual function of women with breast cancer and to make interventions that facilitate sexual adjustment.


Sample size
The sample size was determined using Granmo software (version 7.12, Barcelona, Spain, 2012). This was calculated using a population estimate based on the study carried out by Panjari et al. (2011) [6], in which 70% of women with breast cancer suffered from sexual dysfunction, as well as the data offered by the Spanish Society for Medical Oncology [2] in which 27,747 women had breast cancer in Spain. Therefore, a sample of 355 women would be expected to be sufficient for an expected prevalence of 70%, a precision of 5%, a level of confidence of 95%, and a replacement rate of 10%.
To determine whether the women had any sexual problem before cancer, the online survey had two questions: 1) "Before suffering cancer, have you had any sexual problem?"; 2) If your answer is "YES", could you specify what type of sexual problem you have had?"

Variable of type of sexual dysfunction
Desire, excitation or arousal, lubrication, orgasm, penetration pain, anticipatory anxiety, sexual initiative, communication and sexual satisfaction (categorical variables).

Procedure
Before the study, the FECMA directors were contacted and invited to participate in the study. They sent to their members an email with information about the study. The email included a direct access link to fulfill the online questionnaire available on Google Forms. When clicking on the link, the participants had to read the information sheet and provide informed consent to proceed with the questionnaire. The application respected the participant's anonymity.
This study conformed to the main principles of the Helsinki Declaration, the Universal Declaration of the UNESCO, and the Spanish Organic Law 15/1999, 13 th of December, on the Protection of Personal Data. The study was approved by FECMA. The participants were provided with an information sheet and gave informed consent. We respected the participants' anonymity at all times. The Ethical Committee authorized this study (CEITO N˚Exp 138).

Data analysis
The statistics program IBM SPSS (version 22.0, licensed by the University of Castile La-Mancha, IBM Corp, Armonk, NY, USA) was used for statistical analysis. A descriptive analysis of the variables was performed by counting of recounts (n) and proportions (%) of the qualitative variables and by the average (m) and the standard deviation (SD) of quantitative variables.
Also, a proportional comparison of categorical variables through chi-square tests for contingency tables was provided. The variables, which were significates with sexual dysfunction in the contingency tables, were included in the regression model. A multiple logistic regression was performed to identify possible factors related to sexual dysfunction after suffering from breast cancer. We used the Wald statistic, such that the variables for which p ! 0.15 were eliminated one-by-one from the model. The odds ratios (OR) was calculated with their confidence intervals. All hypotheses were bilateral, and the level of confidence was 95% (p < 0.05).

Results
Five-hundred-twenty-seven women responded to the questionnaire, 13 of these completed the test incorrectly or incompletely. Finally, 514 women with breast cancer composed the size. The study participants were aged between 21-and 66-years-old (mean 46.34 ± 8.276 years), an average age at the date of diagnosis of 42.26 ± 8.563 years, and time suffering cancer of 4.05 ± 5.226 years. Table 1 shows the socio-demographic characteristics related to cancer treatment.
Regarding sexual activity (Table 2), the majority of women did not present any sexual dysfunction before breast cancer diagnosis (66.9%). However, after having breast cancer (when the data were collected), 91.2% suffered from some type of sexual dysfunction. There are significant differences (p = 0.002) between the presence of sexual dysfunction before and after cancer. Table 2 shows the types of sexual dysfunctions that women suffer after breast cancer. The most frequent dysfunctions were dysfunction due to penetration pain (50.6% of participants), dysfunction due to lubrication (50.6%), dysfunctional desire (44.6%), and dysfunctional excitation or arousal (44.6%). Regarding their sexual activity in the last 4 weeks, the majority usually had 1-2 instances of sexual activity per month (60.7%) and were satisfied with their sexual relations (66.3%). Finally, the most frequent reasons why these women did not want penetration during their sexual relations were a lack of interest in vaginal penetration (34.1%) and pain (30.3%).
The relationship between socio-demographic and clinical variables and the different types of sexual dysfunction in participants after cancer were studied (Table 3). We found that women who received adjuvant treatments, radiotherapy, and hormonal therapy had a higher percentage of sexual dysfunction (p < 0.001) compared to women who received other adjuvant treatments. Women who had a bilateral mastectomy (p = 0.009) had greater dysfunction than those who had a lumpectomy.
Using the significant variables, we created a multiple logistic regression model to understand whether the variables affected every type of sexual dysfunction (Tables 4 and 5). In general, sexual dysfunction after cancer is associated with the age of women at the date of diagnosis (OR = 0.959; p = 0.029; 95%CI = 0.923-0.006) and surgical intervention. The probability of sexual dysfunction in women who have had a bilateral mastectomy is 4.684-times greater than those that had a lumpectomy (OR = 0.042; 95%CI = 1.056-20.784).
After analyzing the data related to the type of sexual dysfunction (Table 5), we observed the following: Sexual dysfunction related to desire is associated with the age of women at date of diagnosis, the type of surgical intervention (women who had a bilateral mastectomy had a 2.28-fold greater probability of dysfunction than those who had a lumpectomy), breast reconstruction (women who did not receive breast reconstruction had a 1.84-fold greater probability than those who did) and cohabitation (women with a partner but who are not living together had a 0.54-fold reduction in probability compared to women living with a partner).
Sexual dysfunction related to excitation is associated with the age of women at date of diagnosis, the type of surgical intervention (women who had a bilateral mastectomy had a 2.02-fold greater probability than those who had a lumpectomy), cohabitation (women with a partner but who are not living together have a 0.45-fold reduction in probability compared to women living with a partner) and profession (women who work have a 0.48-fold reduction in probability than those who are retired).
Sexual dysfunction related to lubrication is associated with the age of women at date of diagnosis, the time elapsed after cancer diagnosis, the type of surgical intervention (women who had a bilateral mastectomy had a 2.30-fold greater probability than those that had a lumpectomy), cohabitation (women with a partner but who are not living together have a 0.51-fold  reduction in probability compared to women living with a partner), and hormonal therapy (women who had hormonal therapy have a 1.63-fold increased probability compared to those who have not been treated with hormones). Sexual dysfunction related to orgasm is associated with the age of women at date of diagnosis, the type of surgical intervention (women who had a bilateral mastectomy have a 2.93-fold greater probability than those who had a lumpectomy), breast reconstruction (women who have not received a breast reconstruction have a 2.57-fold greater probability than those who had), and cohabitation (women with a partner but who are not living together have a 1.79-fold increased probability compared to women living with a partner).
Sexual dysfunction related to penetration is associated with the age of women at date of diagnosis, the time elapsed after cancer diagnosis, cohabitation (women with a partner but who are not living together have a 2.55-fold reduction in probability compared to women living with a partner), and hormonal therapy (women who have had hormonal therapy have a 0.58-fold increased probability compared to those who have not been treated with hormones).
Anticipatory sexual anxiety is associated with the time elapsed after cancer diagnosis, cohabitation (women with partner but who are not living together have a 2.01-fold reduction in probability compared to women living with a partner), occupation (women who work have a 2.10-fold increase in probability than those who have retired), and hormonal therapy (women who have had hormonal therapy have a 0.62-fold reduction in probability compared to those who have not been treated with hormones).

Discussion
According to other studies [6,9,10,11,12], women who have suffered from breast cancer report that their sexuality is changed. However, before cancer, 66.9% did not have any type of sexual difficulty. After breast cancer, 91.2% reported that they had some type of sexual difficulty. This incidence is higher than other studies, where it was found to vary from 40 to 80% [5,6,9,13,14]. This could be because women participating in this study were young; the average age was 46.34-years-old.
After cancer, the majority of women in this study (70.2%) confirmed that they continued to have sexual activity, with is consistent with the literature [14,15,16]. Although the frequency of sexual relations is lower after cancer, 60.7% reported that they have sexual relationships 1-2 times per month [5,9,12,16].
In our study, the majority of women were treated with hormonal therapy (75.7%) (e.g., aromatase inhibitors or tamoxifen), which led to early menopause. As found in other studies, the use of these drugs is related to reduced vaginal lubrication, decreased sexual satisfaction, and loss of sexual desire [6,13,17,18,24,25].
The type of surgical intervention is associated with the presence of sexual dysfunction. Women with lumpectomy present fewer dysfunctions that those who have a unilateral mastectomy or a bilateral mastectomy [6,9,26,27]. Women without breast reconstruction have the greatest probability of sexual dysfunction [28].
Women who were old at the age of diagnosis reported that they had more sexual problems [29,30]. However, the young women after treatment had less sexual dysfunction, because their ovaries can continue to work properly. On the other hand, in premenopausal and perimenopausal women, ovarian function is usually affected for a long period following chemotherapy and hormonal therapy [31].
Civil status is associated with the presence of several sexual dysfunctions. Women without a partner do not have problems related to orgasm and penetration. Another finding is that women who have a steady partner but do not cohabitate have fewer problems related to desire, excitement, and lubrication compared to married women or couples living together. Although we found no study similar to ours, Morais et al. [14] reported that women without a steady partner have better sexual satisfaction due to multiple partners.
The study has some limitations. First, a cross-sectional design was used, so it is not possible to establish causal relationships. Second, a convenience sample was used. Finally, the online questionnaire prevents women from asking about any doubts they might have, and the analyzed data are self-reported information. However, on the other hand, the online questionnaire has the strength that the women can provide detailed answers about their sexuality more freely and without shame, which is not always possible in a face-to-face interview.
Furthermore, although the sample was recruited for convenience, it has a large size (more than 500 women). Also, we believe that the women can adequately respond to questions addressing their clinical situation. This is because, in Spain, the Health System is public and the physicians are obligated to give to their patients (in this case, women with breast cancer) a report that includes specific information about their type of cancer, type of surgery, and type of treatment. Our findings highlight the impact of breast cancer treatments on female sexuality and the impact in women with breast cancer.
Based on our findings, it is necessary that health professionals recognize which variables influence sexual function in women with breast cancer. A multidisciplinary team should plan interventions to facilitate sexual adjustment. Furthermore, women with breast cancer are capable of choosing whether to be sexually active or not. It is the duty of health professionals to guarantee that women with breast cancer and their partners receive accurate information about sexuality, treatment, and emotional support [32].

Conclusion
Sexual function changes after breast cancer. Ninety percent of cases suffer from some type of sexual dysfunction. The most frequent problems are dysfunction due to penetration pain, lubrication, desire, and excitation. The type of surgical intervention, hormonal therapy, age, and civil status are associated with the presence of sexual dysfunction.