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