HOUSTONThe severity of sexual and fertility problems
experienced by women after treatment for ovarian cancer is as diverse
as the patient population, Leslie Schover, PhD, said at the First
Annual International Conference for Ovarian Cancer, co-sponsored by
M.D. Anderson Cancer Center and Memorial Sloan-Kettering Cancer Center.
Ovarian cancer patients include postmenopausal women with
epithelial tumors, women in their childbearing years with borderline
or germ-cell cancer, and young women who have, or who are at risk
for, a familial form of ovarian cancer, said Dr. Schover,
Department of Urology, Taussig Cancer Center, Cleveland Clinic
Foundation. The sexual problems these women experience and the
decisions they make regarding childbearing are unique to each
womans particular situation.
In each instance, she said, the type of cancer, the disease stage,
and the prescribed treatment have a profound impact on the
womans sexual well-being and childbearing potential.
Epithelial Ovarian Cancer
Women with sporadic epithelial ovarian tumors usually have advanced
disease at diagnosis. The standard treatment is surgery to remove the
uterus and the ovaries, which is typically followed by chemotherapy.
Such radical treatment, Dr. Schover said, can result in a long period
of post-treatment difficulties, including fatigue, nausea, changes in
body image due to surgical scarring, vaginal atrophy because of
estrogen loss, and pelvic adhesions from surgery.
A common complaint among women with epithelial ovarian tumors
is loss of sexual desire and pain with intercourse, Dr. Schover
Fertility is usually not an issue for women in this patient group,
because most of them are beyond childbearing age. However, in some
instances, older women are emotionally affected by the loss of what
they consider a biologic privilege. Today, many women are
postponing raising a family until they reach their late 30s,
Dr. Schover pointed out. When these women discover that their
plans have been altered by cancer, they feel cheated.
Few studies have examined sexual well-being and childbearing
potential in women who have early-stage borderline or germ-cell
cancer, but sexual functioning and fertility do not appear to be a
problem for these patients. Women in this patient group
typically have a good prognosis, Dr. Schover said. This
is fortunate, because due to their age, they have greater
expectations regarding their sexual health and fertility.
Conservative surgery is the standard first-line treatment for both
borderline and germ-cell cancer. For germ-cell tumors, it often is
followed by platinum-based chemotherapy. After treatment, women
in this patient group usually resume their menstrual cycle and are
able to become pregnant, she said. Studies cited in the
literature do not report any excess birth defects or any difficulties
during pregnancy following treatment for borderline or germ-cell cancers.
In cases in which the recommended adjuvant treatment is pelvic
radiotherapy, a technique called ovarian transposition can be applied
to spare the ovaries with the intent of preserving fertility.
In this process, Dr. Schover said, the ovaries are
transposed behind the uterus to shield them from radiation
exposure. In a study conducted at M.D. Anderson, Dr. Schover
said, women who underwent radiotherapy without ovarian
transposition needed estrogen replacement to maintain
menstruation. These women generally reported that they were
sexually satisfied, but there was a slight increase in the number of
women who reported pain with intercourse.
Certainly women who have had breast or ovarian cancer at an
early age, women who have tested positive for the BRCA1 mutation, and
women from families with a history of breast or ovarian cancer have
special issues to confront, Dr. Schover commented.
Breast cancer treatment involving mastectomy followed by adjuvant
chemotherapy or radiotherapy can cause premature menopause.
Furthermore, women who know they carry the trait for breast or
ovarian cancer sometimes elect to have prophylactic mastectomy or
oophorectomy. Early menopause can result in a high rate of
sexual problems, including loss of desire for sex, dyspareunia, and
negative self-image, Dr. Schover said.
She added that some women in this high-risk group choose not to have
children for fear the pregnancy will trigger an episode of breast
cancer or because they do not want to put their own child at risk of
inheriting an autosomal dominant cancer syndrome.
It is certainly possible to continue a mutually satisfying sex
life after cancer, Dr. Schover said, although
modifications may be needed in some cases.
One particularly important issue clinicians should address with their
patients is adjustments and options regarding intercourse.
Patients should experiment with positions that minimize the
effects of deep thrusting, she said.
These women and their partners should also be encouraged to
experiment with alternative forms of intimacy, such as bringing each
other to orgasm through oral and manual stimulation, and intensifying
touching and caressing techniques.
Studies of ovarian cancer survivors show that the quality of a
womans relationship with her partner is as important a
predictor of sexual satisfaction as the effects of treatment. If
intimacy between the patient and her partner was intense before
cancer, they will be able to make the transitions necessary to
preserve that intimacy, Dr. Schover said.
Problems associated with the womans attitude about sex may stem
from hormonal and other physical changes that occur after treatment.
Estrogen replacement therapy may be appropriate for some women who
are undergoing treatment or who have finished treatment and are in a
state of menopause. However, estrogen replacement therapy is not
recommended for women who have had breast cancer because it is
associated with an increased risk of recurrence.
A product called the Estring is available for women with premature
menopause who suffer from vaginal atrophy, and is being tested for
safety in breast cancer survivors. The Estring is similar to the ring
of a diaphragm, Dr. Schover said, but it is filled with 2 mg of
estradiol released slowly over 90 days.
The Estring is inserted into the vagina and replaced every 3
months, she said. A burst of systemic estrogen is
released when the ring is first inserted, but as the vaginal lining
cornifies, very little estrogen is released into the systemic
Dr. Schover said that the Estring works quite well for vaginal
atrophy and is effective in relieving stress incontinence.
Women can also be advised to use Replens, a gel-like vaginal
moisturizer that replaces natural vaginal lubricants that are
depleted due to premature menopause. Replens is applied to the vagina
three times a week using a tampon-type applicator. Studies show
that when women use Replens properly for up to 2 months, the vagina,
on clinical examination, appears to be producing a healthy level of