Academic articles, November

Rattiya Phianpiset, MD

Faculty of Medicine, Chiang Mai University

Holistic Approach to Sexual Health Care in Gynecologic Cancer Patients

      As gynecologic oncologists, we have expertise in standard cancer treatments – surgery, chemotherapy, and radiation therapy. However, one crucial dimension of care which often remains overlooked is patients’ sexual wellness. While 60% of cancer patients experience sexual health issues, only 25% receive appropriate care. This disparity largely stems from patients’ reluctance to discuss these concerns due to stigma, and physicians’ hesitation to proactively address potential sexual complications during follow-up visits.

Impact of cancer treatment on sexual health

      Cancer treatments affect sexual wellness through multiple mechanisms. In female patients, the most prevalent issue is decreased sexual desire and arousal, primarily attributed to chemotherapy, immunotherapy, and aromatase inhibitors, which induce estrogen deficiency and alter neurotransmitter functions. Treatment side effects such as fatigue, pain, nausea and vomiting indirectly impact sexual desire. Additionally, vaginal dryness and dyspareunia frequently occur due to surgical menopause from surgery, chemotherapy, radiation, and post-treatment fibrosis in the pelvic region.

      In male patients, erectile dysfunction predominates, mainly resulting from autonomic nerve injury during pelvic surgery and radiation therapy, affecting penile blood flow. Scarring and fibrosis may further alter penile anatomy and venous return during erection, particularly common in prostate cancer patients.

      Both male and female patients may experience anorgasmia and issues with urinary and fecal continence, especially those with ostomy or who have undergone pelvic surgery. These problems significantly impact body image and confidence, key factors in overall sexual wellness.

Management

      Guideline from The American Cancer Society 2017 for post-treatment care emphasize several key aspects:

1. Early Assessment: Sexual health evaluation should begin at diagnosis. Physicians should discuss potential sexual health impacts and treatment expectations, enabling appropriate surgical technique selection (e.g., nerve-sparing procedures) and radiation planning to minimize collateral damage.

2. Psychological Support: Patients frequently struggle with body image issues, anxiety, and relationship challenges. Psychosocial counseling and referral to sexual health specialists form crucial components of holistic care.

3. Physical Interventions: Current evidence supports hormone therapy in specific patient groups. Studies show that low-dose vaginal estrogen in breast cancer patients doesn’t increase recurrence risk, while cervical cancer patients can safely use systemic hormone replacement. New technologies like vaginal laser therapy for genitourinary syndrome and appropriate lubricant use have shown promising results in sexual health rehabilitation.

4. Behavioral Interventions: Cognitive behavioral therapy, breathing exercises, hypnosis, and appropriate medication can effectively manage various symptoms.

   Conclusion

         Sexual health care should be integrated into standard gynecologic cancer treatment protocols. This requires systematic development of specialized clinics and multidisciplinary teams. Early assessment and intervention not only prevent and minimize complications but significantly impact patients’ overall quality of life. As gynecologic oncologists, we must recognize this crucial aspect of care and develop more comprehensive treatment approaches.

   References

   1. Lehmann V, Laan ETM, den Oudsten BL. Sexual health-related care needs among young adult cancer patients and survivors: a systematic literature review. J Cancer Surviv. 2022;16(4):913-24.

   2. Ratner ES, Foran KA, Schwartz PE, Minkin MJ. Sexuality and intimacy after gynecological cancer. Maturitas. 2010;66(1):23-6.

   3. Sinno AK, Pinkerton J, Febbraro T, Jones N, Khanna N, Temkin S, et al. Hormone therapy (HT) in women with gynecologic cancers and in women at high risk for developing a gynecologic cancer: A Society of Gynecologic Oncology (SGO) clinical practice statement. Gynecol Oncol. 2020;157(2):303-6.