Sexual functioning of cervical cancer survivors: A review with a female perspective

doi:10.1016/j.maturitas.2012.05.006

Maturitas

Volume 72, Issue 4, August 2012, Pages 296-304

https://doi.org/10.1016/j.maturitas.2012.05.006 Get rights and content

Abstract

Objective

Sex is an important, often deteriorated, dimension of quality of life after cancer treatment. We conducted a systematic review on sexual functioning of cervical cancer survivors.

Methods

Studies between January 1988 and April 2010 were rated on their internal validity. Results were analyzed focusing on four major categories of sexual functioning: desire, arousal, orgasm, pain. Comparisons were made between healthy controls versus cervical cancer survivors, survivors before versus after treatment and between different treatment modalities.

Results

Twenty studies were included. Most studies showed no differences in the ability to achieve an orgasm. Cervical cancer survivors reported more dyspareunia than healthy controls and dyspareunia was more frequent and lasted longer after radiotherapy. Lack of lubrication was more frequent in cervical cancer survivors and a significant decrease in sexual interest and activity after treatment was found.

Conclusion

Cervical cancer survivors are at risk for sexual pain disorders, while sexual satisfaction (orgasm) is not impaired and radiotherapy negatively influenced sexual pain disorders. Health care providers should inform cervical cancer survivors about the possible risk of developing sexual pain disorders after cervical cancer treatment, especially after radiotherapy. As sexual satisfaction per se is not impaired, we suggest that prevention and treatment of sexual dysfunction should focus on painless and satisfactory sex instead of on resuming intercourse.

Introduction

Sexual dysfunction is an important cause of deterioration of quality of life after the treatment for early stage cervical cancer [1] and an entity in which multiple psychological and somatic factors are involved [2]. Cervical cancer is a disease, which is most commonly diagnosed during the fertile age and the majority of patients is sexually active at the time of diagnosis [3]. Treatment for women with early stage cervical cancer consists of a radical hysterectomy and pelvic lymphadenectomy. Adjuvant radiotherapy is offered in case of adverse prognostic factors. Locally advanced stage disease is treated by primary chemo radiotherapy [4]. Cervical cancer survivors have to deal with the sequelae of the treatment, which is often bothersome, both after surgery as well as after (chemo)radiation. Following radical hysterectomy, postoperative shortening of the vagina may contribute to discomfort or pain during sexual intercourse. Vaginal cuff resection requires resection of the sacrouterine ligaments and part of the hypo gastric plexus, mobilization of the bladder and the proximal part of the rectovaginal septum which causes scarring (fibrosis) around the vaginal cuff, which may bring about pain during intercourse. Damage to the autonomic nerves can cause a decrease of objective sexual arousal by reducing vaginal blood flow [5]. However, a recent study could not confirm that nerve sparing radical hysterectomy results in a better sexual functioning when compared to standard radical hysterectomy [6]. Radiotherapy may compromise intercourse due to fibrosis and vascular toxicity [7], [8]. Psychological factors caused by the cancer diagnosis may also negatively influence sexual functioning, independent of the type of treatment.

Despite this, only about 10–28% of gynecological cancer patients had been given some information with regard to sexual function from medical or paramedical personnel before start of the treatment [9], [10], [11]. During the last decades several studies of sexual functioning after treatment for cervical cancer have been published.

However, there are only a few studies concerning interventions for sexual dysfunction of cervical cancer survivors. The Cochrane review of Miles et al. [12] reported one randomized controlled trial about the effectiveness of lubricating estrogen vaginal cream in women following radiotherapy for cervical cancer. In that study significantly more women in the intervention group reported painless intercourse, but the proportion of women having sexual intercourse was not significantly different between the two groups [13]. There is an upcoming interest in psycho-educational interventions to improve the satisfaction with sexual life. Psycho-educational interventions for women following cancer treatments have been found to improve compliance with vaginal dilation, sexual desire, arousal, orgasm, sexual satisfaction and to reduce fears regarding sex after cervical cancer treatment [14], [15], [16].

A systematic overview regarding the quality of life of cervical cancer survivors is recently provided by Vistad et al. [17]. However, a review of the recent literature with regard to sexual functioning after cervical cancer treatment is lacking. The objective of this study is to conduct a systematic review of the literature with regard to sexual functioning after treatment for cervical cancer, with special attention for the different aspects of female sexual functioning, in order to find starting points for studies on prevention and treatment. We rated the studies on internal validity and paid special attention to describe separately the different aspects of female sexual functioning, i.e. sexual desire, arousal, orgasm and sexual pain disorders including pain during sexual intercourse in relation to cancer treatment.

Section snippets

Selection of literature

A literature search of Pubmed, Embase and The Cochrane database was performed by using the terms “uterine cervical neoplasm” or “cervical cancer” or “sexual function” or “sexual behavior” or “sexual dysfunctions”. Only full-text articles published in English between January 1988 and April 2010 were considered. Reference lists of identified articles were hand searched for new references. We predefined inclusion by the following criteria: studies on sexual wellbeing in patients after treatment

Included studies

The search identified 316 studies, whereof only 20 studies (6.3%) met all our inclusion criteria [1], [7], [8], [9], [20], [21], [22], [23], [24], [25], [26], [27], [28], [29], [30], [31], [32], [33], [34], [35]. The characteristics of these 20 studies are shown in Table 1.

In eight studies a generic sexual functioning questionnaire with a broad range of domains was used [21], [22], [23], [27], [28], [31], [33], [34]. In five studies a disease specific sexual functioning questionnaire was used

Main results

The ability to achieve an orgasm seems not impaired in cervical cancer survivors. However, cervical cancer survivors had significantly more dyspareunia than healthy controls. Studies comparing dyspareunia before and after treatment for cervical cancer showed various results. In most studies pain during intercourse was more frequently reported and lasted longer in patients treated with radiotherapy compared to surgery.

Sexual desire in cervical cancer survivors compared with healthy controls gave

Conclusion

Overall, we conclude that surgery for cervical cancer affects sexual functioning negatively and radio therapeutic treatment seems to amplify this effect. A closer look at the literature showed that impaired sexual functioning was always accompanied by pain during vaginal intercourse. We assume that decreased sexual desire and arousal (lubrication) are a result of painful intercourse, as sexual satisfaction, i.e. orgasm after cervical cancer treatment is not impaired. The corresponding results

Provenance and peer review

Not commissioned, externally peer reviewed.

Contributors

The contribution of individual authors was as follows: Ellen Lammerink – search of literature, writing of manuscript; Geertruida de Bock – quality control/statistical review, critical review of manuscript; Elisabeth Pras – critical review of manuscript; Anna Reyners – critical review of manuscript; Marian Mourits – writing of manuscript.

Funding

The authors declare that there is no funding.

Competing interest

The authors declare that there are no conflicts of interest.

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Cited by (67)

Primary or adjuvant chemoradiotherapy for cervical cancer with intraoperative lymph node metastasis – A review
2022, Cancer Treatment Reviews
Upon discovery of lymph node metastasis during radical hysterectomy with pelvic lymphadenectomy in early-stage cervical cancer, the gynaecologist may pursue one of two treatment strategies: abandonment of surgery followed by primary (chemo)radiotherapy (PRT) or completion of radical hysterectomy, followed by adjuvant (chemo)radiotherapy (RHRT). Current guidelines recommend PRT over RHRT, as combined treatment is presumably associated with increased morbidity. However, this review of literature suggests there are no significant differences in survival and recurrence and total proportions of adverse events between treatment strategies. Additionally, both strategies are associated with varying types of adverse events, and affect quality of life and sexual functioning differently, both in the short and long term. Although total proportions of adverse events were comparable between treatment strategies, lower extremity lymphoedema was reported more often after RHRT and symptom experience (e.g. distress from bladder or bowel problems) and sexual dysfunction more often after PRT. As reporting of adverse events, quality of life and sexual functioning were not standardised across the articles included, and covariate adjustment was not conducted in most of the analyses, comparability of studies is hampered. Accumulating retrospective evidence suggests no major differences on oncological outcome and morbidity after PRT and RHRT for intraoperatively discovered lymph node metastasis in cervical cancer. However, conclusions should be considered cautiously, as all studies were of retrospective design with small sample sizes. Still, treatment strategies seem to affect adverse events, quality of life and sexual functioning in different ways, allowing room for shared decision-making and personalised treatment.
Diagnostic Methods for Vaginal Stenosis and Compliance to Vaginal Dilator Use: A Systematic Review
2021, Journal of Sexual Medicine
Vaginal stenosis (VS) is a common side effect of pelvic radiotherapy for gynecological cancer in women. It has a high incidence variability, likely due to unstandardized and subjective assessment methods. Furthermore, even though the worldwide standard treatment for VS is vaginal dilation, low compliance rates have been noted.
To evaluate the parameters used to diagnose VS and to assess whether the lack of an objective measure of VS hampers vaginal dilator use.
A systematic review in accordance with the PRISMA reporting guidelines was conducted. PubMed, EMBASE, and Web of Science databases were searched. Randomized trials and prospective, retrospective, and cross-sectional studies published from January 2011 to February 2020 were included.
The main outcome of this study was a review of the published literature on assessment methods for VS and compliance to vaginal dilator use.
Of the 28 articles obtained, only 7 used objective methods to measure the vaginal volume. 3 studies have demonstrated patient's concern with VS development and showed a high compliance to dilator use, whereas others reported several barriers to dilator use.
Lack of an objective assessment method can be a predisposing factor for uncertain VS incidence rates and impair compliance to vaginal dilator therapy, leading to long-term VS and sexual dysfunction.
This is the first systematic review on the heterogeneity of VS evaluation methods and compliance to vaginal dilator use. All studies were comprehensively evaluated by 2 reviewers. The limitations included the heterogeneity of the study designs and the unstandardized criteria used to classify stenosis or to evaluate compliance to dilator use. Although 3 well-known databases were used, the inclusion of more data sources could have increased the number of publications included in this review.
VS is frequently diagnosed using subjective parameters. Few unstandardized objective methods are used to evaluate this condition. Regarding compliance to vaginal dilator use, there was a high dropout rate during follow-up and no consensus on starting time or ideal usage.
Haddad NC, Soares Brollo LC, Pinho Oliveira MA, et al. Diagnostic Methods for Vaginal Stenosis and Compliance to Vaginal Dilator Use: A Systematic Review. J Sex Med 2021;18:493–514.
Sexual Functioning in Long-Term Survivors of Hematopoietic Cell Transplantation
2021, Transplantation and Cellular Therapy
This investigation characterized sexual activity and sexual function in hematopoietic cell transplantation (HCT) survivors, compared them with norms, and examined factors associated with sexual dysfunction, with the goal of identifying targets for intervention to improve sexual health. Surviving adults from a large transplantation center were asked to complete an annual survey with a core of health questions and a module on sexual activity and function. Participants completed the Sexual Function Questionnaire, Cancer and Treatment Distress form, and Revised Dyadic Adjustment Scale. Clinical data were collected from the transplantation medical database. Multivariate logistic regressions identified factors associated with sexual activity and function. Participating survivors (n = 1742) were a mean of 11.9 years (range, .4 to 43.1 years) after HCT, mean age 57.6 years, and 53% male. Women were more likely than men to report being sexually inactive in the past year (39% versus 27%) and, among those sexually active, to report low sexual function (64% versus 32%). Male and female survivors reported lower rates of sexual activity and function than comparison norms (all P < .01). In regressions, factors associated with being sexually inactive included older age, having <4 years of college education, low performance status, and not being in a committed relationship. Additional factors for men included receipt of nonmyeloablative conditioning and not being employed or in school. Low sexual functioning for men and women was associated with low performance status, and, for women, a committed relationship of lower quality, while for men the association was with older age. Sexual dysfunction is common in both men and women after HCT, regardless of time since treatment. Survivors need routine evaluation and access to multimodal interventions.
The impact of uterine cancer and its treatments on sexuality
2020, Sexologies
Le retentissement des cancers utérins sur la sexualité demeure un sujet peu étudié en Tunisie, un sujet tabou et souvent négligé aussi bien par les praticiens, les malades et leurs partenaires.
Il s’agissait d’une étude transversale descriptive colligeant 100 patientes tunisiennes suivies pour un cancer de l’endomètre ou du col utérin et qui avaient une vie sexuelle active avant la maladie. Nous avons passé à ces patientes les échelles BIS et FSFI et nous nous sommes enquis de leurs données sociodémographiques.
Dans notre étude, 42 % des patientes avaient une dysfonction sexuelle. En analyse multivariée, les facteurs indépendants prédicteurs de la dysfonction sexuelle étaient la curiethérapie (OR à 37,908 ; IC95 % [1,04–1377,13] ; p = 0,047) et les troubles de l’image du corps (OR à 0,028 ; IC95 % [1,15–12,33] ; p = 3,37). À l’opposé, la perception importante de la vie sexuelle était le facteur indépendant protecteur de ce trouble (OR à 0,027 ; IC95 % [0,25–0,92] ; p = 0,27). La curiethérapie était le facteur indépendant prédisposant à la sténose vaginale (OR à 21,42 ; IC95 % [1,21–379,26] ; p = 0,037) et la chimiothérapie était le facteur indépendant prédicteur de la sécheresse vaginale (OR à 8,78 ; IC95 % [1,04–73,52] ; p = 0,04).
On recommande un dépistage précoce de troubles sexuels lors des consultations de suivi en utilisant des scores de mesure validés, simples, courts et accessibles aux praticiens en oncologie. Il faut créer un climat de confiance et ne pas hésiter à prendre l’initiative. Il serait mieux d’intégrer les partenaires à ces discussions afin de corriger l’ensemble des croyances erronées et de les responsabiliser.
The impact of uterine cancers on sexuality remains a subject little studied in Tunisia, a taboo subject and often overlooked by practitioners, patients and their partners.
It was a descriptive cross-sectional study of 100 Tunisian patients followed for endometrial or cervical cancer who had an active sex life before the disease. We passed the BIS and FSFI scales to these patients and asked about their socio-demographic data.
In our study, 42 % of patients had sexual dysfunction. In multivariate analysis, the independent predictors of sexual dysfunction were brachytherapy (OR: 37.908; 95 % CI [1.04–1377.13]; P = 0.047) and body image disorders (OR: 0.028; 95 % CI [1.15–12.33]; P = 3.37). In contrast, the important perception of sex life was the independent protective factor for this disorder (OR: 0.027; 95 % CI [0.25–0.92]; P = 0.27). Brachytherapy was the independent predisposing factor for vaginal stenosis (OR: 21.42; 95 % CI [1.21–379.26]; P = 0.037) and chemotherapy was the independent predictor for vaginal dryness (OR: 8.78; 95 % CI [1.04–73.52]; P = 0.04).
Early detection of sexual disorders is recommended during follow-up consultations using validated, simple, short measurement scores that are accessible to oncology practitioners. You have to create a climate of trust and do not hesitate to take the initiative. It would be better to integrate the partners in these discussions in order to correct all the mistaken beliefs and to make them responsible.
Cone biopsy (with pelvic lymphadenectomy) for fertility preservation in early stage cervical cancer: Ready for prime time?
2020, Gynecologic Oncology
Sexual Inactivity During the Last 4 Weeks in Long-Term Cervical Cancer Survivors: Prevalence and Associated Factors
2020, Journal of Sexual Medicine
Most studies of cervical cancer (CC) survivors describe sexual inactivity in relation to treatment modalities, but few consider that inactivity varies with age and partner status.
The aim of this study was to investigate the prevalence of sexual inactivity in long-term CC survivors according to age and partner status, and to examine cancer-related, health, demographic, and psychological factors related to sexual inactivity.
All 974 women treated for CC from 2000 through 2007 in 2 areas of Norway, who were alive and cancer-free by the end of 2013, received a mailed questionnaire. Among them, 523 delivered valid data on current sexual activity (response rate 57%). The prevalence rates of sexual inactivity in relation to age groups and partner status were compared to normative sample (NORMs).
Sexual inactivity during the 4 weeks before the survey was administered.
Median age of the sample at survey was 53 years (range 32–77) and median time since diagnosis was 11 years (range 6–15). Of the survivors aged 35–69 years, 39% (95% CI 35–44%) were sexually inactive at survey compared to 36% (95% CI 32–38%) in the NORMs. Compared with sexually active survivors, inactive ones were significantly older, more frequently had single partner status, and had less frequently been childbearing. Inactive survivors more frequently had low education, did not hold paid work at survey, had poorer self-rated health, and were more often obese. They also had higher prevalence of depression, high neuroticism, and chronic fatigue. On most cancer-related quality of life measures, sexually inactive survivors had significantly lower mean scores than sexually active ones. They significantly more often had been treated with chemotherapy and/or radiation than with conization or major surgery. In multivariable regression analysis, only older age, no prior childbearing, and single partner status remained significantly associated with sexual inactivity.
Sociodemographic variables may be more relevant than clinical and cancer-related variables concerning sexual inactivity in long-term CC survivors.
Our study had a considerable sample size and used instruments with established psychometric qualities. The moderate response rates of the study and of the NORMs imply risks for selection biases.
Close to 4 in 10 survivors were sexually inactive which is similar to the rate among NORMs. Demographic factors were most strongly associated with sexual inactivity. Some other significant factors are eventually amenable to treatment and should be checked by the health-care providers.
Dahl AA, Bentzen AG, Fosså SD, et al. Sexual Inactivity During the Last 4 Weeks in Long-Term Cervical Cancer Survivors: Prevalence and Associated Factors. J Sex Med 2020;17:1359–1369.

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ReviewSexual functioning of cervical cancer survivors: A review with a female perspective

Abstract

Objective

Methods

Results

Conclusion

Introduction

Section snippets

Selection of literature

Included studies

Main results

Conclusion

Provenance and peer review

Contributors

Funding

Competing interest

Gynecologic Oncology

Lancet

International Journal of Radiation Oncolocy, Biology and Physics

Journal of Sexual Medicine

International Journal of Radiation Oncolocy, Biology and Physics

International Journal of Radiation Oncolocy, Biology and Physics

Gynecologic Oncology

International Journal of Radiation Oncolocy, Biology and Physics

Journal of Sexual Medicine

Journal of Sexual Medicine

Gynecologic Oncology

Gynecologic Oncology

Vaginal changes and sexuality in women with a history of cervical cancer

New England Journal of Medicine

Definitions of women's sexual dysfunction reconsidered: advocating expansion and revision

Journal of Psychosomatic Obstetrics and Gynaecology

Objective assessment of sexual arousal in women with a history of hysterectomy

British Journal of Obstetrics and Gynaecology

Bladder, anorectal and sexual function after nerve-sparing radical hysterectomy for the treatment of cervical cancer; a longitudinal prospective cohort study

Early-stage cervical carcinoma, radical hysterectomy, and sexual function. A longitudinal study

Cancer

Sexual dysfunction in Thai women with early-stage cervical cancer after radical hysterectomy

International Journal of Gynecological Cancer

Lack of communication between healthcare professionals and women with ovarian cancer about sexual issues

British Journal of Cancer

Review
Sexual functioning of cervical cancer survivors: A review with a female perspective