How to Address Sexual Problems in Female Cancer Patients
How to Address Sexual Problems in Female Cancer Patients
Sexual health is an important aspect of human life, and cancer does not (and should not) change that. Data suggest that issues related to sexual function are quite common among women treated for cancer. However, clinicians often spend little to no time on the topic. This article provides a concise summary on the importance of sexual health among women treated for cancer, as well as an approach that general cancer clinicians can adopt in order to normalize sexual health issues for their patients. Finally, we provide an overview of sexual health therapeutics available in the United States and in Europe.
In 2015, 1,658,370 new cases of cancer were diagnosed and 589,430 persons died of cancer in the United States. However, the proportion of people living with and surviving cancer is growing. More than 7.5 million out of 14.5 million cancer survivors in the United States are women, and that number is expected to grow to 9,602,590 by 2024. The increase in survival rates reflects both earlier diagnosis and improvement in treatment. Despite the data showing that most survivors have a good prognosis, current treatments can result in problems, including symptoms related to sexual health.
In 2007, Beckjord and Campas documented significant disruption in sexual quality of life that was the result of treatments and of emotional distress—rather than of age—in women with a diagnosis of breast cancer. Estimates of the incidence of sexual dysfunction range from 30% to 100% among female cancer survivors, depending on the population queried and on how sexual dysfunction is characterized.[3,4] Sexual dysfunction affects both women with illness and women in the general population, and discussing sexual health in both populations remains difficult—for both patients and providers.
What Are the Components of Sexual Function in Women?
Female sexual function is not exclusively a physiologic phenomenon; it is influenced by both physiologic and psychosocial factors. This has been best illustrated in a model proposed by Rosemary Basson, in which sexual health is characterized as a self-propagating circle of wanting intimacy, stimuli, arousal, desire, and satisfaction; importantly, physical acts, such as intercourse, are not inherent in the concept of sexual function. However, recognizing that some women may not be motivated by a desire for intimacy, Basson has also proposed an alternative model in which the intimacy component can be “bypassed,” and in which sexual function is motivated by hunger.
What Constitutes Female Sexual Dysfunction?
Sexual dysfunctions are characterized by a disturbance in sexual desire and by disturbances in the psychological and physiologic changes involved in the sexual response.
The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) recognizes three types of sexual dysfunction in women: sexual interest/arousal disorder, genito-pelvic pain/penetration disorder, and female orgasmic disorder. However, the presence of symptoms is not sufficient for the diagnosis (Table 1). Rather, symptoms must be present for a minimum of 6 months and must be severe enough to cause distress or the inability to respond sexually or experience sexual pleasure. Finally, each type of sexual dysfunction should be subcategorized based on two factors: whether it is “lifelong vs acquired,” and whether it is “generalized vs situational.” It should be noted that a diagnosis of female sexual dysfunction must be arrived at after careful consideration of a differential diagnosis that includes other possible etiologies (eg, drug or substance side effects, or consequences of another disease process).
Evaluating Female Cancer Survivors for Sexual Health Issues
Despite the impact of cancer treatments on female sexual health, this issue is often ignored, probably for a variety of reasons. For example, patients may be uncomfortable discussing such a sensitive topic with their oncologist. In addition, oncologists may not have the background, knowledge, or comfort level to engage in discussions of sexual health. In a recent review, Halley et al suggested that there were three main barriers that needed to be overcome in order for women with breast cancer to be able to discuss and get help with their issues in sexual functioning: 1) the assumption on providers’ part that sexuality is primarily a physical issue, rather than a global one; 2) the fact that patients—in particular, those being treated at cancer-specific centers—have difficulty in identifying the right person to ask for an evaluation of sexual problems; and 3) patients may migrate away from cancer care providers after the end of treatment or due to other factors, and as such, may not be able to discuss it with them after sexual issues arise.
One suggested approach to initiating a discussion of sexual health is the PLISSIT (“Permission, Limited Information, Specific Suggestions, and Intensive Therapy”) model (Figure 1).[10,11] However, it is also important to ensure that a standard medical history is obtained, with particular attention paid to other medical problems; medications; and social conditions, including issues related to a patient’s partner (where applicable) and to stressors that can potentially affect sexual health.
Sexual health can also be evaluated using questionnaires designed for patient-reported outcomes. An example is the Brief Sexual Symptom Checklist for Women (SSFF-A), which evaluates three domains in women (libido, sexual activity, and sexual satisfaction). One of the most widely used such questionnaires is the Female Sexual Function Index (FSFI), which consists of 19 items that cover 6 domains in female sexuality: desire, arousal, lubrication, orgasm, satisfaction, and pain. It should be noted that the relevance of the FSFI is limited in women who are not actively engaged in sexual activity, especially since the recall period is the preceding 4 weeks. In addition, some research indicates that the FSFI does not take into consideration certain psychological issues that are relevant in women with cancer, such as the role of the partner and a woman’s precancer sexual functioning. In 2015, Bartula and Sherman reported on an adaptation of the FSFI for use in women with breast cancer (FSFI-BC); this version added cancer and distress subscales and included items applicable to women who are not sexually active. The investigators reported that the FSFI-BC had favorable psychometric properties and was acceptable for use in this population, irrespective of whether or not women were currently sexually active. Whether the FSFI-BC can be utilized in women with other types of cancers is an open question.