Topics:

Cervical Cancer: Issues of Sexuality and Fertility

Cervical Cancer: Issues of Sexuality and Fertility

ABSTRACT: Cervical cancer rates have fallen in the United States; regardless, the disease remains a significant concern for women, especially those who are premenopausal. The management of cervical cancer is dependent on stage of disease at diagnosis, and specific needs emerge for patients both during and following treatment. Over the past decade, the focus has been to maintain adequate tumor control while reducing long-term negative consequences. However, problems with sexuality and fertility persist for women treated for cervical cancer despite these advances. Sexual dysfunction following treatment for gynecologic cancer has been well documented in the literature, and recent studies demonstrate the success of brief psychosexual interventions. Treatment of sexual difficulties in cancer patients can be achieved through the provision of information, support, and symptom management, ideally as part of a sexual health program. Resources are not always available to develop such a program. However, medical professionals can identify individuals and organizations with expertise in treating sexual and fertility concerns, which can be provided to their patients, making help with these problems more accessible as needs arise.

Although cervical cancer rates have fallen to 12,200 new cases per year in the United States, this tumor type remains a significant concern for women, especially those who are premenopausal.[1] It has been estimated that 45% of surgically treated stage IB cervical cancers occur in women who are under age 40.[1] As a result, many women with a diagnosis of cervical cancer will not have the opportunity to complete childbearing and are at risk of sexual dysfunction following treatment. The management of cervical cancer is dependent on stage of disease at diagnosis, and specific issues can emerge for patients during and after treatment. The trend over the past decade has been to maintain adequate tumor control while attempting to reduce long-term negative consequences.[ 2] Despite advances along these lines, problems with sexuality and fertility persist for many women treated for cervical cancer. The phenomenon of sexual dysfunction following treatment for gynecologic cancer has been well documented in the literature.[3-5] Recent studies have noted the success of brief psychosexual interventions and of addressing the informational needs of cancer patients.[6-8] An effective method of treating sexual difficulties in cancer patients would be through the coordinated provision of information, support, and symptom management at one site, for example, in a sexual health program. The resources to develop such a program are not always available, but medical professionals can identify local practitioners with expertise in the treatment of sexual and fertility concerns-both physical and psychological-and may provide their patients with a referral list of such practitioners, making help with these problems more accessible as needs arise. Gynecologic Cancer and Treatment Consequences The American Cancer Society (ACS) estimates that 12,200 new cases of cervical carcinoma will be diagnosed in the United States in 2003.[9] Once considered the most common reproductive tract carcinoma in the United States, cervical carcinoma has fallen to the rank of third, comprising 16% of reproductive tract cancers.[10] The lifetime risk of developing cervical carcinoma is 1 in 123 women,[9] and 10% to 15% of cases will occur in premenopausal women in their childbearing years.[11] It has been found that approximately 45% of surgically treated stage IB cervical cancers occur in women who are under age 40.[1] As a result, many women with a diagnosis of cervical cancer will not have the opportunity to complete childbearing, and are at risk of developing sexual dysfunction following treatment. A woman receiving treatment for gynecologic cancer may undergo multiple treatment modalities, often delivered sequentially.[12] Therefore, it is not uncommon for the woman to cope with recovery from surgery, as well as the side effects of cumulative chemotherapy and/or radiation therapy. The side effects of treatment for gynecologic cancer may include changes in hormonal function, impaired or lost fertility, sexual morbidity, and bowel and bladder changes, in addition to potential emotional and relationship alterations.[12-14] Treatment for cancer can negatively affect female fertility in several ways: by surgical removal of all or part of the reproductive organs, through chemotherapy with alkylating drugs that are toxic to the ovary, and by radiation therapy, which, at high doses, causes sterility (via permanent ovarian failure).[13] Sexual Dysfunction
Sexual dysfunction is a common, enduring consequence of cancer treatment. Andersen[3] has reported that significant sexual morbidity can occur in up to 90% of cancer patients. Other authors have reported the incidence of sexual dysfunction after treatment for gynecologic cancer to range from 40% to 100%,[4] compared to 25% of individuals with a history of leukemia or Hodgkin's disease.[15-17] The sexual dysfunction following cancer treatment includes both physical and psychological components. The reproductive organs, the vagina, and vulvar areas are central to female identity, and problems of any sort with these tissues and their functioning can adversely affect sexual interest and response. A woman's sense of her reproductive status and fertility, regardless of her actual childbearing history, is an integral part of her identity, and the loss or threat of loss of fertility brought on by surgery, radiation, and chemotherapy is a powerful adverse reality with many ramifications, including effects on sexual expression. Ovarian failure secondary to treatment signifies both reproductive loss and the advent of menopause, a state with its own profound significance and a host of symptoms. A woman's sense of herself and her sexuality is therefore vulnerable to the consequences of a range of treatments in the setting of cervical cancer.[ 18] In general, risk factors for sexual difficulties following a diagnosis of cancer include disease site and treatment, but also time of diagnosis, age, menopausal status, presence of a partner, pretreatment sexual functioning status, and sexual selfschemas.[ 19,20] Sexual functioning is identified by cancer survivors as a critical component of quality of life.[21,22] Typically, sexual problems have an acute onset, appearing shortly after treatment ends or when sexual intercourse is resumed. Sexual morbidity for cancer patients can include a decrease in the desire for sex.[12] Studies investigating the interaction between a woman's sexual self-concept and her sexual functioning show that those with a negative self-concept are more likely to have greater sexual morbidity.[ 21] For many cancer survivors, sexual intimacy serves as a painful reminder of the changes in their body. Many patients report that sadness and grief emerge during sexual experiences, leaving them vulnerable to sexual dysfunction and a sense of sexual inadequacy.[ 12] It is important to assess sexual functioning, because impairments in sexual functioning have an impact on overall quality of life. For women with partners, sexual dysfunction may threaten the integrity of their relationships, limiting this source of social support at a time when it is most needed.[12,23] Early-Stage Cervical Cancer The management of cervical carcinomas is dependent on the stage of disease at diagnosis. The American College of Obstetricians and Gynecologists recommends surgical techniques and/or radiation therapy for early-stage disease. Traditionally, women with an early-stage cervical lesion receive the standard treatment of radical hysterectomy with pelvic lymphadenectomy and/or radiation therapy.[10] In this type of hysterectomy, the cervix, uterine fundus, parametria, and upper vagina are removed, which allows for preservation of ovarian function or hormonal sufficiency, but results in the loss of fertility due to removal of the uterus. In addition, open surgical techniques create the potential for intraperitoneal adhesions, which can have a negative affect on reproductive ability even when fertility is spared.[24] Modified Surgical Techniques
The emerging trend over the past decade has been to provide adequate cancer treatment while attempting to reduce long-term negative consequences.[ 2] The advent of tissue-sparing surgical techniques has been fostered by growing awareness of quality-of-life concerns. One example of this concern has been the widespread acceptance of modified surgical techniques used in the treatment of breast cancer (once it was well-documented that breast-sparing techniques offered adequate tumor control as well as improved qualityof- life outcomes). This thinking has been incorporated into gynecologic oncologic research and practice, and tissue-sparing techniques that better preserve possible reproductive and sexual function while maintaining tumor control now receive keen clinical attention.

  • Radical Vaginal Trachelectomy-
    The ability of women in their childbearing years to receive adequate surgical treatment of gynecologic tumors while preserving their potential for fertility is an important treatment option that was not available in the past. One technique that has gained recognition in the field of gynecologic oncology is the fertility-preserving treatment of radical vaginal trachelectomy with laparoscopic pelvic lymphadenectomy.[25-29] This procedure- entailing removal of the cervix and lymph nodes but preservation of the uterus-was first performed by Daniel Dargent, MD, in 1987 and has been described in the literature since 1994.[25] Radical trachelectomy is a conservative but locally radical procedure for a highly select group of women with early-stage cervical cancer who have a strong desire to preserve fertility, providing that strict selection criteria are met (Table 1) and access to a specially trained surgeon is available.[25-30]
To date, several investigators have evaluated this procedure, the primary outcome of survival.[2,26,28, 29,31] It is viewed as a safe alternative to radical hysterectomy, with comparable recurrence rates. The overall recurrence rate for women who have undergone laparoscopic vaginal radical trachelectomy is estimated to be 3%, which is not significantly different from that for radical hysterectomy. Dargent et al[26] reported an approximately 18% infertility rate and 24% fetal loss rate, particularly in the form of late miscarriage. This procedure then carries an increased relative risk of infertility and fetal loss but also allows some women to become pregnant and give birth to a child.[26,27,29,30] Radical trachelectomy is an exciting option for young women with early- stage cervical cancer that holds promise for improving cancer survivorship. However, further research is needed to evaluate empirically the impact of radical trachelectomy on sexual functioning and quality of life. Advanced Cervical Cancer For more advanced carcinomas, primary treatment with radiation therapy may be indicated.[10] The National Cancer Institute recently advocated the use of concurrent cisplatin- based chemotherapy and radiation therapy in women who require irradiation for the treatment of cervical cancer.[32] The correlation between radiation therapy and sexual dysfunction is documented in the literature.[ 5,33,34] Women experience problems with vaginal stenosis, loss of lubrication, and pain due to postirradiation scarring.[34] In addition, it is not uncommon for women to fear the emergence of bleeding and pain- symptoms that may be associated with initial diagnosis and elicit concerns about recurrence.[35] Chemotherapy can also have a negative impact on sexual functioning. Pre- and perimenopausal women who are receiving chemotherapy may abruptly experience menopausal symptoms resulting from estrogen deficiency. These symptoms can contribute to sexual difficulties and impairments in quality of life.[36] Questions about hormonal status and sexual health are integral to qualityof- life concerns for those coping with the treatment of advanced cancer. Improvements in cancer treatment and the likelihood of long-term survival of cancer patients, including those with advanced disease, have made qualityof- life issues a priority.[12,14,33] Recurrent Cervical Cancer Women with recurrent cervical cancer centrally located in the pelvis may choose the radical surgical approach of pelvic exenteration.[37] The current literature on pelvic exenteration primarily addresses the medical aspects of the procedure, with few studies addressing its psychosocial impact.[38] Although a limited area of investigation, it has been noted that the consequences of exenteration are dramatic, not only to the integrity of the body but also to the emotional, functional, social, and sexual wellbeing of individuals who undergo the procedure. Faced with the idea of radical surgery, a discussion of postoperative sexuality may seem a low priority, but sexual dysfunction is more than likely to occur, and being adequately prepared for such an event may facilitate adjustment.[39] Effect of Exenteration on Sexual Functioning
Patients who undergo pelvic exenteration experience irreversible sexual consequences. Radical surgery not only affects sexual functioning but also a woman's sexual self-perception. Following surgery, the woman's body image, self-esteem, and feminine identity may alter,[40-44] and several studies have reported that some women experience a significant loss in sexuality.[39,43,45,46] With the loss of sexually responsive tissue, many women report having no interest in sex or no ability to achieve sexual satisfaction.[41,45-47] Other studies have found that some women and their partners choose not to undergo vaginal reconstruction, although when these studies were conducted, vaginal reconstruction was available only as an additional operation performed at a later date.[45,47] Today, the construction of a neovagina is an option available at the time of pelvic exenteration, reflecting the growing awareness of this quality-oflife concern.[39] Sexual Rehabilitation Regardless of the stage of cancer, issues of sexuality and fertility may emerge. Recently, Zegwaard and colleagues[ 8] investigated the informational needs of women with a history of gynecologic cancer. These authors identified three time periods in which information was needed, coupling each period with specific events in the patient's cancer experience. The first period occurs at the time of diagnosis and treatment. During this period, questions about the possible side effects of treatment on sexuality emerge. Following treatment, recovery begins and, with it, thoughts about resuming intercourse. It is during this second period that concerns about possible complications such as vaginal changes arise and may influence sexual activities. At this point, patients usually desire information about how to manage complications. The final period at which information is needed occurs when women have identified problems and are trying to regain or rebuild their sexual life. Information about symptom management and strategies to improve sexual functioning are important during this third phase of the cancer experience.[8] Brief Psychosocial Interventions
Most female cancer patients can benefit from brief psychosexual interventions including education, counseling/support, and symptom management. Robinson and colleagues conducted an intervention to increase compliance with vaginal dilation recommendations, a recognized method of maintaining vaginal health and good sexual functioning after radiation therapy.[7] The intervention consisted of a psychoeducational group that provided information, support, and behavioral skills regarding effective use of dilators and lubricants. Women who attended the intervention were significantly more likely to follow recommendations for vaginal dilation than the control group. Ganz and colleagues reported another example of benefit from a brief sexual intervention in a group of breast cancer patients.[6] The intervention focused on providing information, support, and symptom management and demonstrated significant improvement in menopausal symptoms, including hot flashes and vaginal dryness, in addition to improved sexual function. Assessing Sexual Dysfunction
Sexual dysfunction is a common consequence of cancer treatment that may persist after treatment is completed, but sexual assessment and/or counseling are not routinely provided to oncology patients for several reasons. These include time constraints and the need to prioritize critical and complex treatment issues, practitioner discomfort in initiating a conversation regarding sexual functioning, and patient discomfort or embarrassment with the subject.[22,48] However, in a study of sexual function after treatment for gynecologic cancer, investigators found that 78% of the women wanted to discuss sexual matters but did not ask questions because they feared rejection or thought the setting was inappropriate for such discussion.[ 49] This finding indicates that discussion about sexual functioning would be welcomed by patients if conducted in a sensitive manner. Basic questions about sexual functioning should be part of any complete medical history. It is important to gather psychiatric and medical information about significant illnesses (eg, hypertension, heart disease, vascular disease, diabetes), surgeries in addition to those needed for cancer treatment, and all medications, including chemotherapy, radiation therapy, psychotropics, and nonprescription drugs. It is also important to determine whether the patient has a history of tobacco and/or alcohol use, as this can negatively affect sexual functioning. Questions to keep in mind when assessing sexual difficulties include those about a woman's precancer sexual functioning, as well as her current sexual functioning. This will help determine the degree of dysfunction. The phases of the sexual response cycle- desire, excitement, orgasm, and resolution- should be kept in mind during an evaluation, and it is also important to pay attention to a patient's relationship with her partner. Sexual interaction is a form of support, and problems in the relationship can disrupt this support process.[50] Approaches to Sexual Rehabilitation
There are various models of sexual rehabilitation for working with the cancer patient experiencing changes in her sexuality, intimacy, and/or fertility. One method involves presenting the psychologist or mental health professional as a functioning and integral part of the oncology team, ie, one who routinely sees patients or, alternatively, as a liaison, with referral being made by other health practitioners.[51] At Memorial Sloan-Kettering Cancer Center, we use a combination approach to address the sexual difficulties of our gynecologic patients. The Gynecology Service established a comprehensive, multidisciplinary program to help female cancer patients cope with the sexual difficulties they may experience during or following a cancer diagnosis and treatment. This model focuses on both the psychosexual and physical aspects of sexuality by providing an evaluation that includes both a medical examination by a gynecologist and a psychosexual evaluation by a licensed psychologist/American Association of Sex Educators, Counselors, and Therapists (AASECT)-certified sex therapist. The program allows for patients to be referred by other gynecologic oncology team members, but it is also presented as an integral part of the Gynecology Service. In many hospitals and physicians' offices, the concept of a sexual health team or program is neither feasible nor practical. In these settings, a referral network of local professionals with experience in the treatment of sexual difficulties and fertility concerns can be identified; this might include any mental health professionals with training and certification in sexual therapy or counseling, as well as those who have experience with cancer patients and their families, and a gynecologist with interest in the management of sexual dysfunction related to medical illness. A listing of local and national organizations that provide support, sexual education, and information regarding fertility may also be useful. Patients may be provided with a list of these resources, for use as need arises over the course of the cancer experience. Conclusions Cervical cancer, regardless of the stage at presentation, may cause difficulties with sexuality, intimacy, and fertility. It has been well established in the literature that women with a history of gynecologic cancer experience disturbances in sexuality secondary to their cancer treatment. However, cervical cancer patients tend to have additional issues, as this disease affects premenopausal women more so than do other gynecologic cancers (ie, ovarian and uterine). The professionals working with these patients are aware of this fact and, in response, have developed the radical vaginal trachelectomy. This procedure offers a select group of young women with early-stage disease the opportunity to preserve their fertility while receiving the necessary cancer treatment. That said, issues of sexuality also need to be addressed in women with advanced and recurrent disease. Programs and Resources
The literature notes that the need for information about sexuality and fertility emerges for women specific to the phase of a woman's cancer (ie, diagnosis/treatment, recovery, and survivorship) and that brief psychosexual interventions can be successful in treating the troublesome side effects that have an impact on intimacy.[ 6,7] A comprehensive approach to addressing the sexuality, intimacy, and fertility concerns of patients involves the development of a coordinated, multidisciplinary team within a sexual health program that focuses on both the physical and psychological factors contributing to the sexual problems of patients during and/or after cancer treatment. Within a given hospital or practice setting, the considerable financial and professional resources for such a program may remain allocated elsewhere. The many patients with concerns in this area may still be helped by receiving access to a resource network of local professionals with experience in treating sexual difficulties. Local and national support organizations (such as the American Cancer Society; American Association of Sex Educators, Counselors, and Therapists; and the Association of Reproductive Health Professionals) can provide additional information and support to help patients achieve greater comfort with these issues.

Disclosures

The author(s) have no significant financial interest or other relationship with the manufacturers of any products or providers of any service mentioned in this article.

References

1. Covens A, Rosen B, Murphy J, et al: Changes in the demographics and perioperative care of stage IA(2)/IB(1) cervical cancer over the past 16 years. Gynecol Oncol 81:133- 137, 2001.
2. Plante M, Roy M: Radical trachelectomy. Operative Techniques in Gynecologic Surgery 2:187-199, 1997.
3. Andersen BL: How cancer affects sexual functioning. Oncology 4:81-94 (incl discussion), 1990.
4. Casey C: Psychosexual morbidity following gynecological malignancy. Ir Med J 89:200, 202, 1996.
5. Schover LR, Fife M, Gershenson DM: Sexual dysfunction and treatment for early stage cervical cancer. Cancer 63:204-212, 1989.
6. Ganz PA, Greendale GA, Petersen L, et al: Managing menopausal symptoms in breast cancer survivors: Results of a randomized controlled trial. J Natl Cancer Inst 92:1054-1064, 2000.
7. Robinson JW: Sexuality and cancer. Breaking the silence. Aust Fam Physician 27:45-47, 1998.
8. Zegwaard MI, Gamel CJ, Durgis DJ, et al: The experience of sexuality and information received in women with cervical cancer and their partners. Verpleegkunde 15:18-27, 2000.
9. Jemal A, Murray T, Samuels A, et al: Cancer statistics. CA Cancer J Clin 53:5-26, 2003.
10. ACOG practice bulletin: Diagnosis and treatment of cervical carcinomas, number 35. Obstet Gynecol 99:855-867, 2002.
11. Van der Vange N, Weverling GJ, Ketting BW, et al: The prognosis of cervical cancer associated with pregnancy: A matched cohort study. Obstet Gynecol 85:1022-1026, 1995.
12. Schover LR: Sexuality and Fertility After Cancer. New York, John Wiley and Sons, 1997.
13. Schover LR: Sexuality and Cancer for the Woman Who Has Cancer and Her Partner. Atlanta, American Cancer Society, 2001.
14. Auchincloss S, McCartney CF: Gynecologic cancer, in Holland J (ed): Psych-oncology, pp 359-370. New York, Oxford University Press, 1998.
15. Mumma GH, Mashberg D, Lesko LM: Long-term psychosexual adjustment of acute leukemia survivors: Impact of marrow transplantation versus conventional chemotherapy. Gen Hosp Psychiarty 14:43-55, 1992.
16. Bloom JR, Fobair P, Gritz E, et al: Psychosocial outcomes of cancer: A comparative analysis of Hodgkin's disease and testicular cancer. J Clin Oncol 11:979-988, 1993.
17. van Tulder MW, Aaronson NK, Bruning PF: The quality of life of long term survivors of Hodgkin’s disease. Ann Oncol 5:153-158, 1994.
18. Lagana L, McGarvey EL, Classen C, et al: Psychosexual dysfunction among gynecological cancer survivors. J Clin Psych Med Setting 8:73-83, 2001.
19. Cyranowski JM, Andersen BL: Schemas, sexuality, and romantic attachment. J Pers Soc Psychol 74:1364-1379, 1998.
20. Ganz PA, Desmond KA, Belin TR, et al: Predictors of sexual health in women after a breast cancer diagnosis. J Clin Oncol 17:2371-2380, 1999.
21. Andersen BL, Cyranowski JM: Women's sexuality: Behaviors, responses, and individual differences. J Consult Clin Psychol 63:891-906, 1995.
22. Schover LR: Counseling cancer patients about changes in sexual function. Oncology 13:1585-1592, 1595-1596, 1999.
23. van de Wiel HB, Weijmer Schultz WC, Wouda J, et al: Sexual functioning of partners of gynecological oncology patients. Sex Marital Ther 5:123-130, 1990.
24. Dargent D: Using radical trachelectomy to preserve fertility in early invasive cervical cancer. Contemp Ob Gyn 45:23-49, 2000.
25. Dargent D, Brun JL, Roy M, et al: Pregnancies following radical trachelectomy for invasive cervical cancer. Gynecol Oncol 52:105, 1994.
26. Dargent D, Martin X, Sacchetoni A, et al: Laparoscopic vaginal radical trachelectomy: A treatment to preserve the fertility of cervical carcinoma patients. Cancer 88:1877- 1882, 2000.
27. Roy M, Plante M: Pregnancies after radical vaginal trachelectomy for early-stage cervical cancer. Am J Obstet Gynecol 179:1491-1496, 1998.
28. Covens A, Shaw P, Murphy J, et al: Is radical trachelectomy a safe alternative to a radical hysterectomy for patients with stage IA-B carcinoma of the cervix? Cancer 86:2273-2279, 1999.
29. Shepherd JH, Mould T, Oram DH: Radical trachelectomy in early stage carcinoma of the cervix: Outcome as judged by recurrence and fertility rates. Br J Obstet Gynaecol 108:882-885, 2001.
30. Covens A: Preserving fertility in early cervical cancer with radical trachelectomy. Contemp Ob Gyn 48:46-66, 2003.
31. Shepherd JH, Crawford RA, Oram DH: Radical trachelectomy: A way to preserve fertility in the treatment of early cervical cancer. Br J Obstet Gynaecol 105:912-916, 1998.
32. National Cancer Institute: PDQ treatment summary for health professionals. Cervical Cancer. Available at http://www.cancer.gov/ cancerinfo/pdq/treatment/cervical/healthprofessional. Accessed July 30, 2003.
33. Andersen BL, Andersen B, deProsse C: Controlled prospective longitudinal study of women with cancer: Sexual functioning outcomes. J Consult Clin Psychol 57:683-691, 1989.
34. Bruner DW, Lanciano R, Keegan M, et al: Vaginal stenosis and sexual dysfunction following intracavitary radiation for the treatment of cervical and endometrial carcinoma. Int J Radiat Oncol Biol Phys 27:825- 830, 1993.
35. Gamel C, Hengeveld M, Davis B: Informational needs about the effects of gynecological cancer on sexuality: A review of the literature. J Clin Nurs 9:678-688, 2000.
36. Ganz PA, Coscarelli A, Fred C, et al: Breast cancer survivors: Psychosocial concerns and quality of life. Breast Cancer Res Treat 38:183-199, 1996.
37. Crowe PJ, Temple WJ, Lopez MJ, et al: Pelvic exenteration for advanced pelvic malignancy. Semin Surg Oncol 17:152-160, 1999.
38. Turns D: Psychosocial issues: Pelvic exenterative surgery. J Surg Oncol 76:224- 236, 2001.
39. Gleeson N, Baile W, Roberts WS, et al: Surgical and psychosexual outcome following vaginal reconstruction with pelvic exenteration. Eur J Gynaecol Oncol 15:89-95, 1994.
40. Andersen BL: Sexual functioning complications in women with gynecologic cancer. Cancer 60:2123-2128, 1987.
41. Andersen BL, Hacker NF: Psychosexual adjustment following pelvic exenteration. Obstet Gynecol 61:331-338, 1983.
42. Corney RH, Crowther ME, Everett H, et al: Psychosexual dysfunction in women with gynaecological cancer following radical pelvic surgery. Br J Obstet Gynaecol 100:73-78, 1993.
43. Fisher SG: Psychosexual adjustment following total pelvic exenteration. Cancer Nursing 2:219-225, 1979.
44. Sewell HH, Edwards DW: Pelvic genital cancer: Body image and sexuality. Front Radiat Ther Oncol 14:35-41, 1979.
45. Dempsey GM, Buchsbaum HJ, Morrison J: Psychosocial adjustment to pelvic exenteration. Gynecol Oncol 3:325-334, 1975.
46. Vera MI: Quality of life following pelvic exenteration. Gynecol Oncol 12:355-366, 1981.
47. Brown RS, Haddox V, Posada A, et al: Social and psychological adjustment following pelvic exenteration. Am J Obstet Gynecol 114:162-171, 1972.
48. Schover L: Psychosocial aspects of infertility and decisions about reproduction in young cancer survivors: A review. Med Pediatr Oncol 33:53-59, 1999.
49. Lancaster J: Women's experiences of gynecological cancer treated with radiation. Curationis 16:37-42, 1993.
50. Weijmer Schultz WC, Van de Wiel HB: Sexuality, intimacy, and gynecological cancer. J Sex Marital Ther 29(suppl 1):121-128, 2003.
51. Rieger E, Touyz SW, Wain GV: The role of the clinical psychologists in gynecological cancer. J Psychosom Res 45:201-214, 1998.
 
Loading comments...

By clicking Accept, you agree to become a member of the UBM Medica Community.