Addressing the Sexual Health Concerns of Women with Gynecologic Cancer: Guidance for Primary Care Physicians

Psychoeducational interventions are another promising avenue for addressing sexual dysfunction in this population [53]. In a 2008 therapeutic trial, Brotto and colleagues combined elements of CBT with education in 3 one-hour sessions featuring written materials on sexuality and relationships. The intervention enrolled 22 women with early stage gynecologic cancer who met criteria for female sexual arousal disorder. The psychoeducational intervention was associated with positive effect on sexual desire, arousal, orgasm, satisfaction, sexual distress, depression, and overall well-being [16]. Psychoeducation can also be used to augment other therapeutic modalities. Robinson and colleagues used such an intervention to improve adherence to vaginal dilator use in 32 women with early stage endometrial cancer who were being treated with radiotherapy [48].

Some gynecologic cancer patients may have significant alterations in their anatomy and thus penetrative intercourse may not be possible. In patients even without these physical changes, some may prefer to avoid intercourse due to pain or anxiety. Thus patients can have significant benefits from discussing their concerns with a therapist specializing in these issues as many patients are concerned about their ability to engage in intimate behavior. Therapy can assist with the changing sexual relationship and assist the partners in different ways of engaging in intimate acts. It is important to avoid stressing penetrative intercourse as the goal for sexual function with these or any patients with anxiety relating to their disease as there are many ways to engage in mutually pleasurable experiences for both partners, thus removing anxiety about inability to resume vaginal intercourse post-treatment. Discussing this with patients can be challenging but can often reduce anxiety surrounding body image issues following treatment.

Studies have shown that cancer care providers often do not adequately address sexual concerns [54] but that when these concerns are appropriately managed, patient satisfaction and quality of life significantly improve [55]. Several studies have focused on how providers can incorporate the approaches of CBT and psychoeducation to better address the sexual concerns of patients without requiring external psychiatric care [56,57]. Barbera et al have described a successful model in which multidisciplinary care teams provide education and counseling for gynecological cancer patients in a sexuality clinic [58]. patients had a significant symptom burden, including menopausal symptoms, the effects of radiation therapy, chemotherapy, and surgical operation as well as psychological responses to cancer, and reported high levels of satisfaction with their experience at the clinic.

Involvement of the partner in interventions has not been well studied; however, involving the partner in in psychological therapies to address sexual dysfunction should be beneficial.

Alternative Therapies for Vasomotor Symptoms

Gynecologic cancer patients suffering prominent vasomotor symptoms have limited alternatives to hormone therapy. Clinicians must balance potential medication benefit with potential exacerbation of other medical and psychological issues, including sexual dysfunction.

Antidepressants

The use of SSRIs and SNRIs for vasomotor symptoms was pioneered by medical oncologists for men with hot flashes secondary to GnRH agonist therapy for prostate cancer and women with breast cancer [59,60]. Limited studies have shown that antidepressant medications do not increase cancer recurrence risk in ovarian cancer patients and are relatively well tolerated [61]. However, these medications are known to have partial efficacy in improving vasomotor symptoms and may worsen sexual symptoms, a well-known side effect of antidepressants. There is variation of the reported rates of sexual dysfunction associated with various antidepressants and clinicians may take the likelihood of sexual side effects into account when prescribing SSRIs or SNRIS [62]. More recently developed SSRIS, such as citalopram and its enantiomer escitalopram, have shown significant improvements in vasomotor symptoms and were better tolerated than venlafaxine and fluoxetine [63,64]. Additionally, limited uncontrolled studies of mirtazipine, a structurally unique SSRI, and bupropion, which acts on dopamine and norepinephrine, have shown significant decreases in hot flash symptoms and are less associated with sexual side effects than SSRIS/SNRIS [65,66].