Academic articles, February

Lakhana Chakkaphak, M.D., Pariwat Pawanna, M.D. Asst. Prof. Awassada Punyashthira, M.D., Assoc. Prof. Atiwut Kamudhamas, M.D., Ph.D.,
Department of Obstetrics and Gynecology, Faculty of Medicine, Thammasat University, Thailand

Integrative Sexual Health Management in Gynecologic Oncology

Gynecologic malignancies, including cervical, ovarian, endometrial, vulvar, and vaginal cancers, pose challenges that extend beyond oncologic management, significantly impacting sexual health. Cancer treatments have profound physical and psychological repercussions, necessitating an integrative, evidence-based approach to optimize care.

Impact of Gynecologic Cancer on Sexual Health
Physiological Sequelae of Treatment
1. Surgical Interventions
Radical hysterectomy and pelvic exenteration often disrupt pelvic autonomic nerves, leading to hypoesthesia, anorgasmia, and incontinence. Oophorectomy causes abrupt estrogen deprivation, resulting in vasomotor symptoms, urogenital atrophy, and osteopenia, which exacerbate sexual morbidity ^(1-3).

2. Radiotherapy
Pelvic radiation often causes mucosal atrophy, fibrosis, and vaginal stenosis, with 7.5-60% of patients reporting vaginal toxicity ^(4-5). Ovarian ablation further contributes to hypoactive sexual desire disorder (HSDD) ⁽⁵⁾.

3. Chemotherapy
Cytotoxic agents cause neurotoxicity, peripheral neuropathy, and chemotherapy-induced menopause, affecting up to 80% of premenopausal women ⁽⁶⁾.

Psychological and Relational Dynamics
Body image distress from disfigurement, alopecia, and lymphedema lowers sexual self-esteem ⁽¹⁾, while psychosexual dysfunction driven by fear of recurrence, partner rejection, and performance anxiety often leads to sexual aversion ⁽⁷⁾.

Integrating Sexual Health into Oncologic Care
Clinical Assessment and Communication
Routine sexual health evaluations using tools like the Female Sexual Function Index (FSFI) are essential. Proactive discussions are vital, as 70% of patients withhold concerns unless prompted ⁽⁸⁾.

Multi-disciplinary Approach
A collaborative team addresses various aspects of gynecologic and sexual health. Gynecologic oncologists stratify dysfunction risks and ensure timely referrals, while gynecologists and urogynecologists manage hormonal depletion, incontinence, and prolapse. Sexual medicine physicians tackle complex sexual disorders like Female Sexual Arousal Disorder (FSAD) and Genito-Pelvic Pain/Penetration Disorder (GPPPD), and aesthetic gynecologists restore vaginal function for improved comfort and self-esteem. Psychosexual therapists use CBT to enhance body image and intimacy, and rehabilitation specialists employ pelvic floor physiotherapy and biofeedback to relieve pain and restore function.

Evidence-Based Interventions
Pharmacologic Modalities
Hormone Replacement Therapy (HRT) with localized estrogen enhances vaginal elasticity and lubrication without significant systemic absorption, estrogen creams (if not contraindicated) enhance mucosal healing ⁽¹⁾. Non-hormonal agents like vaginal moisturizers and hyaluronic acid serve as effective alternatives ⁽⁵⁾. Neuropathic pain management includes gabapentinoids and topical lidocaine to alleviate radiation-induced neuropathy ⁽⁹⁾.

Mechanical Interventions
– Vaginal dilators: Maintain vaginal patency and elasticity post-radiotherapy ⁽⁵⁾.
Recommend: 3-5 times weekly for 5-10 minutes per session for at least 6-12 months.
– Pelvic floor physiotherapy: optimizes outcomes and alleviates discomfort ⁽⁴⁾.
– Laser therapy: promotes tissue regeneration of vaginal wall ⁽¹⁰⁾.

Psychological and Relational Interventions
Interventions focus on enhancing emotional and relational aspects of sexual health. Couples-based therapy fosters communication, intimacy, and reduces sexual avoidance. Cognitive Behavioral Therapy (CBT) addresses maladaptive beliefs, aids emotional regulation, and supports gradual sexual reintroduction. Body image counseling improves self-esteem and body acceptance, alleviating emotional distress ⁽³⁾.

Surgical Interventions
Reconstructive Surgery: Vaginoplasty and similar procedures restore functionality and improve quality of life in severe cases ⁽³⁾.

Conclusion
Sexual health is a critical component of quality of life for gynecologic cancer patients. A structured, multidisciplinary approach can enhance sexual and emotional well-being. Future research should refine therapeutic modalities and establish standardized guidelines for sexual health management in gynecologic oncology.

Integrative Sexual Health Management for Gynecologic Cancer Patients: Interventions
Intervention	Mechanism	Benefit	Reference
Evidence-Based Intervention
HRT **	-Localized estrogen therapy	-Improves vaginal elasticity and lubrication	Roussin, 2021
Non-Hormonal	-Polycarbophil-based & Hyaluronic acid	-Maintaining vaginal hydration.	Plagens, 2024
Neuropathic Pain	-Gabapentin &Topical lidocaine	-Relief pain in radiation-induced neuropathy.	Farrell, 2019
Vaginal Dilators	-3-5 times weekly for 5-10 minutes per session, starting 2-4 weeks at least 6-12 months	-Maintains vaginal elasticity, prevents vaginal stenosis	Plagens, 2024
PFT	-Strengthening of the pelvic floor muscles	-Relieves discomfort, improves sexual function	Barcellini, 2022
Laser Therapy	-Promotes tissue regeneration of vaginal wall	-Heat improve blood flow, elasticity in vaginal tissues	Oria, 2022
Psychological Intervention
Couples-Based	-Focus on mutual communication	-Improves intimacy/satisfy -Reduces sexual avoidance	Arthur, 2020
CBT	-Reframe maladaptive thoughts, -Emotional regulation,	-Improves intimacy/satisfy -Reduces distress	Arthur, 2020
Body Image	-Physical appearance, in patients with stomas or scars.	-Enhances self-esteem confidence.	Plagens, 2024
Surgical Intervention
Reconstructive Surgery	-Vaginoplasty & reconstructive	-Restores vaginal function, improves QoL	Arthur., 2020

References

Roussin, M., Lowe, J., Hamilton, A., & Martin, L. (2021). Factors of sexual quality of life in gynecological cancers: A systematic literature review. Archives of Gynecology and Obstetrics, 304(4), 791–805.
Dirakwaranon W, Suwannarurk K, Chitkoolsamphan Y, Wisarnsirirak P, Bhamarapravatana K, Pattaraarchachai J. (2024). Sexual dysfunction in patient’s diagnosed with cervical cancer in comparison to the healthy female population. Asian Pacific Journal of Cancer Prevention, 25(12), 4391-4396.
Arthur, A., et al. (2020). A systematic review of interventions for sexual dysfunction in cancer survivors. Cancer Nursing, 43(4), 1-10.
Barcellini, A., Dominoni, M., Dal Mas, F., Biancuzzi, H., Venturini, S. C., Gardella, B., Orlandi, E., & Bø, K. (2022). Sexual health dysfunction after radiotherapy for gynecological cancer: Role of physical rehabilitation including pelvic floor muscle training. Frontiers in Medicine, 8, 813352.
Plagens-Rotman, K., Merks, P., Pisarska-Krawczyk, M., et al. (2024). Oncosexology: Selected issues considering the problem of sexological care of patients with cancer. Menopause Review, 19(1), 21-30.
Palaia, I., et al. (2022). Long-term quality of life and sexual function after neoadjuvant chemotherapy and radical surgery for locally advanced cervical cancer. The Journal of Sexual Medicine, 19(4), 613–619.
Ren, H., et al. (2025). Dyadic effects of illness perception and maladaptive cognitive-emotional regulation strategies on fear of cancer recurrence in breast cancer patients and spouses: An actor-partner interdependence mediation model. BMC Psychiatry, 25, 41.
Logan, S., Perz, J., Ussher, J. M. (2018). The taboo of sexuality during cancer treatment: Barriers and facilitators in patient-clinician communication. Supportive Care in Cancer, 26(2), 577-586.
Farrell, R., Lloyd, K., Brunsting, L. A. (2019). Neuropathic pain management in cancer survivors: A focus on gabapentinoids. Pain Medicine, 20(2), 222-230.
D’Oria, O., Giannini, A., Buzzaccarini, G., Tinelli, A., Corrado, G., Frega, A., Vizza, E., & Caserta, D. (2022). Fractional CO2 laser for vulvo-vaginal atrophy in gynecologic cancer patients: A valid therapeutic choice? A systematic review. European Journal of Obstetrics & Gynecology and Reproductive Biology, 277, 84–89.