Annette Hasenburg1 and Juliane Farthmann2
(1)
University Medical Center, Department of Obstetrics and Gynaecological, Langenbeckstraße 1, 55131 Mainz, Germany
(2)
Universitätsklinikum Freiburg, Klinik für Frauenheilkunde, Freiburg im Breisgau, Germany
Annette Hasenburg
Email: Annette.Hasenburg@unimedizin-mainz.de
16.1 Why Is Gynaecological Cancer a Special Situation?
Sexual function as an aspect of health-related quality of life has become an important aspect in oncological therapy. Sexual function after gynaecological cancer is a challenging issue, and both the patient with the disease and her partner deserve special attention. With the genital organs being involved, special aspects have to be considered. Patients may suffer from sexual dysfunction, not only due to chemotherapy, but also due to surgery and/or irradiation of the genital organs. In the past, little attention has been paid to the consequences of treatment on sexual function. For example, surgery for vulvar carcinoma was often mutilating. Irradiation for cervical carcinoma was aggressive, whereas now it is administered with three-dimensional fields, a technique that causes less side effects. In some cancer types, fertility may be preserved. With these new procedures, the rate of sexual dysfunction can be significantly improved. Regarding physical changes, the ability for sexual intercourse can be maintained in most cases. However, patients may suffer from dyspareunia, loss of libido, and a diminished body image [1]. It is widely accepted that an oncological diagnosis and treatment affect body image. However, with increasing length of survivorship, body image usually improves [2].
Hysterectomy is an essential part of all operations for gynaecological cancer except for vulvar carcinoma. The influence of hysterectomy on sexual function, both for benign and oncological reasons has been discussed intensely but still remains unclear. Some data show an improved sexual function after hysterectomy, whereas others state a negative impact [3].
The effect of cancer therapy on fertility through removal of the ovaries adds another aspect to health-related quality of life. Usually, initiation of cancer therapy for gynaecological cancer is not urgent and arrangements for fertility preservation may be taken. There are many options for fertility preservation that can be offered to the patients [4].
16.2 Subtypes of Cancer
Gynaecological cancer includes ovarian (36 %), endometrial (36 %), cervical (23 %), vulvar (3 %), and vaginal (1 %) cancer. The brackets show the relative incidence in the European Union.
Ovarian cancer demands the most radical surgery and has the highest mortality rate. In contrast to other cancer types, the laparoscopic approach is not an option and laparotomy is required. With extensive, often multivisceral surgery, the debilitating effect may be enormous. Furthermore, the radical retroperitoneal lymphadenectomy may impair the function of autonomous nerves comparable to the side effects of radical prostatectomy in men. Furthermore, especially in premenopausal women, the sudden loss of ovarian function may contribute to a decrease in quality of life.
Endometrial cancer has a fairly good prognosis with 5-year overall survival rates between 72 and 84 %. Surgery can often be performed by laparoscopy, with small scars and quick convalescence. If brachytherapy or external pelvic radiation is required, this treatment may lead to adhesions of the vaginal wall, making sexual intercourse difficult or painful.
In cervical cancer, surgery may be performed laparoscopically, but similar to ovarian cancer, autonomous nerves and small vessels may be impaired possibly resulting in sexual dysfunction. Recently, the radical hysterectomy has been modified as surgery within the ontogenetical borders, which is supposed to have the same oncological safety with fewer side effects [5]. The outcome regarding sexual function is being evaluated in a German multicenter trial.
For vulvar cancer, radical surgery with complete resection of the external genitals has been performed in the past, which made it nearly impossible for patients to have sexual intercourse. With a growing number of younger women with vulvar cancer, it has become increasingly important to preserve the ability of vaginal penetration. This includes reconstruction of the external genital organs with flaps taken from the thigh or local tissue. For an example of primary reconstruction in an advanced case of vulvar carcinoma see Fig. 16.1.
Fig. 16.1
Patient with vulvar carcinoma stage III. Primary reconstruction with a thigh flap
During the last years, surgery for gynaecological cancer has become less invasive with fewer side effects on sexual function. This includes:
· The laparoscopic approach in cervical and endometrial cancer – less impact of scares on body image
· Sentinel node biopsy instead of radical lymphadenectomy in cervical, vulvar, and endometrial cancer – less impact on neural function
· Reduction of the radicalness in vulvar cancer with organ preservation or primary reconstruction whenever possible
· Surgery within the ontogenetic anatomy in cervical and vulvar cancer, making radiotherapy unnecessary in many cases – with less side effects on vaginal mucosa
16.3 Factors Influencing Sexuality
16.3.1 Premature Menopause
For some women, menopause implies the beginning of severe symptoms including hot flushes, depressive symptoms, irregular bleeding, etc. With the sudden nonnatural onset of menopause, caused by surgery, chemotherapy, or irradiation, these symptoms may even be worse. Premature ovarian failure presents a risk factor for sexual dysfunction in cancer survivors [6]. Therefore, if oncologically justifiable, hormonal substitution should be offered.
However, the role of hormone replacement therapy is controversially discussed [7, 8]. In tumor entities that are not hormone dependent, systemic hormonal therapy can be suggested. After salpingo-oophorectomy, premenopausal patients are likely to suffer from premature onset of menopause after oophorectomy, while postmenopausal patients may suffer from libido loss due to the lack of androgens.
If the quality of life is severely impaired due to estrogen deprivation in hormone-dependent gynaecological cancer, hormonal therapy with sex steroids can be initiated after a careful risk-benefit assessment or at least local application can be suggested [9, 10].
After hysterectomy, estrogens alone are sufficient; for patients with the uterus in place a combination of estrogen and gestagen is necessary to protect the endometrium from unopposed proliferation. The transdermal application of estrogens is preferable to prevent thrombosis and to bypass liver metabolism. In premenopausal patients, hormonal replacement therapy can be started immediately after surgery. Otherwise, patients may experience severe symptoms due to the sudden decrease of hormones, in an already difficult and demanding situation. Hormonal replacement therapy in young cancer survivors is also important for the prevention of osteoporosis and cardiovascular events. In selected patients, low-dose testosterone as off-label therapy may help to improve sexual function. However, detailed counseling is required.
16.3.2 Age and Partner
The age of a patient does not allow estimations regarding sexual activities. A fulfilled sexual life is not restricted to younger women, and sexual activity may be defined differently for different people. Furthermore, the absence of a partner does not imply absence of sexual activity. It is important to know that sexuality is not restricted to sexual intercourse. Older women may be less open to speak about sexuality issues, but it is the challenge of the treating physician to identify whether a patient has a need to talk about this topic or not.
An oncological disease does not only affect the patient, but also the partner and the family. Therefore it is important to involve the partner when discussing sexual issues. Otherwise, a vicious circle may start. The partner may place back his desires, not wanting to compromise the woman. The woman may seek for attention but is afraid to show her needs. The vicious circle is depicted in Fig. 16.2.
Fig. 16.2
Vicious circle of communication between cancer patients and their partners
16.3.3 Fertility
Therapy of gynaecological cancer may affect a patient’s fertility if she is in her reproductive age. With the age of women at the first birth rising, this may become increasingly important. Depending on the type of cancer, fertility preserving surgery may be an option. In ovarian cancer, fertility preservation has only a chance in early stages, and completion of surgery should be performed after family planning. In cervical cancer, fertility preserving surgery may be possible as a trachelectomy in early disease. For the future, transplantation of the uterus may be discussed, but right now this technique is at its infancy [11]. As chemotherapy may affect fertility, patients should be counseled about methods for fertility preservation. Options may be the protection with GnRh analogs or even better preservation of oocytes, either fertilized or unfertilized. Another option is the cryoconservation of ovarian tissue, which may be re-transplanted later. This is especially useful, if hormonal stimulation is impossible due to the lack of time before chemotherapy or because of the type of tumor [4].
16.3.4 Physical and Psychological Problems
Treatment of gynaecological cancer is multimodal, which makes it necessary to differentiate between the side effects of the various therapeutic interventions. Some stigmata may be obvious to others like alopecia, scars, an artificial anus, or a urostomy. These can greatly alter the patient’s body image and self-esteem.
Somatic and psychological problems of sexual dysfunction are interdependent. If the patient manages to accept the disease and the associated physical changes, it is easier for her to return to a satisfactory quality of life including sexual function. The psychosocial situation of the patient can be additionally impaired if there have been psychological injuries or traumata in the past, which can be reactivated in the course of the disease, especially if there is a lack of help by the partner, family or friends.
Standardized questionnaires and paper-based brochures may help to evaluate patients’ needs and to inform women, who feel ashamed to talk about their sexuality. A number of validated questionnaires are available, allowing a quick overview on the patient’s sexual function (e.g., FSFI, SAQ). Promising experiences have also been made with Internet-based interventions [8].
For patients with an underlying depressive condition, an antidepressant medication should be taken into account, at least for a limited time. Apart from symptomatic therapy, physical interventions and physical activity should be included as supportive actions.
Patients who have undergone surgical shortening of the vagina, radiation therapy of the pelvis or brachytherapy should be informed about the available treatment options for vaginal strictures or adhesions to preserve the patient’s ability for cohabitation. These include the use of vaginal dilators or bepanthen tampons which can be combined with estrogen-containing lotions or lubricants. Comparable to “penile rehabilitation,” the concept of “vaginal or sexual rehabilitation” has been raised [12]. According to the Delphi method, information should be provided to sexually active cervical and vaginal cancer patients, preferably by specifically trained oncology nurses. The program includes vaginal dilation to prevent vaginal adhesions, tightening, and shortening. An artificial anus or a urostomy may be hidden by an attractive cover. For an example, see Fig. 16.3.
Fig. 16.3
Patient with a neo bladder, covering the stoma with a slip
Conclusion
It is of major importance to sensitize physicians working with gynaecological cancer patients to the issues of quality of life and sexuality. Each patient has to be informed about the long-term consequences of the disease and the scheduled therapy. Although sexuality is a taboo subject, the potential long-term consequences of oncological therapy on sexual function, possibly on fertility and quality of life have to be considered and discussed with the patient. Short questions like “has anything changed in your sexual life/partnership?” may function as a door opener. Even for women in a palliative setting, sexuality and intimacy should be an issue.
Physicians have to learn how to actively approach distressing topics and to be aware that the way of addressing sexual problems and counseling might be influenced by their own sexual experience [8]. A special training in sexual medicine may be helpful.
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