Cervical cancer rates have fallen in the United States; regardless, thedisease remains a significant concern for women, especially those whoare premenopausal. The management of cervical cancer is dependenton stage of disease at diagnosis, and specific needs emerge for patientsboth during and following treatment. Over the past decade, the focus hasbeen to maintain adequate tumor control while reducing long-termnegative consequences. However, problems with sexuality and fertilitypersist for women treated for cervical cancer despite these advances.Sexual dysfunction following treatment for gynecologic cancer hasbeen well documented in the literature, and recent studies demonstratethe success of brief psychosexual interventions. Treatment of sexualdifficulties in cancer patients can be achieved through the provision ofinformation, support, and symptom management, ideally as part of asexual health program. Resources are not always available to developsuch a program. However, medical professionals can identify individualsand organizations with expertise in treating sexual and fertilityconcerns, which can be provided to their patients, making help withthese problems more accessible as needs arise.
ABSTRACT: Cervical cancer rates have fallen in the United States; regardless, thedisease remains a significant concern for women, especially those whoare premenopausal. The management of cervical cancer is dependenton stage of disease at diagnosis, and specific needs emerge for patientsboth during and following treatment. Over the past decade, the focus hasbeen to maintain adequate tumor control while reducing long-termnegative consequences. However, problems with sexuality and fertilitypersist for women treated for cervical cancer despite these advances.Sexual dysfunction following treatment for gynecologic cancer hasbeen well documented in the literature, and recent studies demonstratethe success of brief psychosexual interventions. Treatment of sexualdifficulties in cancer patients can be achieved through the provision ofinformation, support, and symptom management, ideally as part of asexual health program. Resources are not always available to developsuch a program. However, medical professionals can identify individualsand organizations with expertise in treating sexual and fertilityconcerns, which can be provided to their patients, making help withthese problems more accessible as needs arise.
Although cervical cancer rateshave fallen to 12,200 new casesper year in the United States,this tumor type remains a significantconcern for women, especially thosewho are premenopausal. It has beenestimated that 45% of surgically treatedstage IB cervical cancers occur inwomen who are under age 40. As aresult, many women with a diagnosisof cervical cancer will not have the opportunityto complete childbearing andare at risk of sexual dysfunction followingtreatment. The management ofcervical cancer is dependent on stageof disease at diagnosis, and specificissues can emerge for patients duringand after treatment. The trend over thepast decade has been to maintain adequatetumor control while attemptingto reduce long-term negative consequences. Despite advances alongthese lines, problems with sexualityand fertility persist for many womentreated for cervical cancer.The phenomenon of sexual dysfunctionfollowing treatment for gynecologiccancer has been welldocumented in the literature.[3-5] Recentstudies have noted the success ofbrief psychosexual interventions andof addressing the informational needsof cancer patients.[6-8] An effectivemethod of treating sexual difficulties in cancer patients would be throughthe coordinated provision of information,support, and symptom managementat one site, for example, in asexual health program. The resourcesto develop such a program are notalways available, but medical professionalscan identify local practitionerswith expertise in the treatment ofsexual and fertility concerns-bothphysical and psychological-and mayprovide their patients with a referrallist of such practitioners, making helpwith these problems more accessibleas needs arise.Gynecologic Cancer andTreatment ConsequencesThe American Cancer Society(ACS) estimates that 12,200 new casesof cervical carcinoma will be diagnosedin the United States in 2003.Once considered the most commonreproductive tract carcinoma in theUnited States, cervical carcinoma hasfallen to the rank of third, comprising16% of reproductive tract cancers.The lifetime risk of developing cervicalcarcinoma is 1 in 123 women,and 10% to 15% of cases will occur inpremenopausal women in their childbearingyears. It has been foundthat approximately 45% of surgicallytreated stage IB cervical cancers occurin women who are under age 40.As a result, many women with a diagnosisof cervical cancer will not havethe opportunity to complete childbearing,and are at risk of developing sexualdysfunction following treatment.A woman receiving treatment forgynecologic cancer may undergo multipletreatment modalities, often deliveredsequentially. Therefore, itis not uncommon for the woman tocope with recovery from surgery, aswell as the side effects of cumulativechemotherapy and/or radiationtherapy. The side effects of treatmentfor gynecologic cancer may includechanges in hormonal function, impairedor lost fertility, sexual morbidity,and bowel and bladder changes,in addition to potential emotional andrelationship alterations.[12-14] Treatmentfor cancer can negatively affectfemale fertility in several ways: by surgicalremoval of all or part of the reproductiveorgans, through chemotherapywith alkylating drugs that are toxic tothe ovary, and by radiation therapy,which, at high doses, causes sterility(via permanent ovarian failure).Sexual Dysfunction
Sexual dysfunction is a common,enduring consequence of cancer treatment.Andersen has reported thatsignificant sexual morbidity can occurin up to 90% of cancer patients.Other authors have reported the incidenceof sexual dysfunction after treatmentfor gynecologic cancer to rangefrom 40% to 100%, compared to 25% of individuals with a history ofleukemia or Hodgkin's disease.[15-17]The sexual dysfunction followingcancer treatment includes both physicaland psychological components.The reproductive organs, the vagina,and vulvar areas are central to femaleidentity, and problems of any sort withthese tissues and their functioning canadversely affect sexual interest andresponse. A woman's sense of herreproductive status and fertility, regardlessof her actual childbearing history,is an integral part of her identity,and the loss or threat of loss of fertilitybrought on by surgery, radiation,and chemotherapy is a powerful adversereality with many ramifications,including effects on sexual expression.Ovarian failure secondary totreatment signifies both reproductiveloss and the advent of menopause, astate with its own profound significanceand a host of symptoms.A woman's sense of herself andher sexuality is therefore vulnerableto the consequences of a range of treatmentsin the setting of cervical cancer. In general, risk factors forsexual difficulties following a diagnosisof cancer include disease siteand treatment, but also time of diagnosis,age, menopausal status, presenceof a partner, pretreatment sexualfunctioning status, and sexual selfschemas.[19,20]Sexual functioning is identified bycancer survivors as a critical componentof quality of life.[21,22] Typically,sexual problems have an acuteonset, appearing shortly after treatmentends or when sexual intercourseis resumed. Sexual morbidity for cancerpatients can include a decrease inthe desire for sex. Studies investigatingthe interaction between awoman's sexual self-concept and hersexual functioning show that thosewith a negative self-concept are morelikely to have greater sexual morbidity. For many cancer survivors,sexual intimacy serves as a painfulreminder of the changes in their body.Many patients report that sadness andgrief emerge during sexual experiences,leaving them vulnerable to sexualdysfunction and a sense of sexual inadequacy.It is important to assess sexual functioning, because impairments in sexualfunctioning have an impact on overallquality of life. For women withpartners, sexual dysfunction maythreaten the integrity of their relationships,limiting this source of socialsupport at a time when it is mostneeded.[12,23]Early-Stage Cervical CancerThe management of cervical carcinomasis dependent on the stage ofdisease at diagnosis. The AmericanCollege of Obstetricians and Gynecologistsrecommends surgical techniquesand/or radiation therapy forearly-stage disease. Traditionally,women with an early-stage cervicallesion receive the standard treatmentof radical hysterectomy with pelviclymphadenectomy and/or radiationtherapy. In this type of hysterectomy,the cervix, uterine fundus,parametria, and upper vagina are removed,which allows for preservationof ovarian function or hormonalsufficiency, but results in the loss offertility due to removal of the uterus.In addition, open surgical techniquescreate the potential for intraperitonealadhesions, which can have a negativeaffect on reproductive ability evenwhen fertility is spared.Modified Surgical Techniques
The emerging trend over the pastdecade has been to provide adequatecancer treatment while attempting toreduce long-term negative consequences. The advent of tissue-sparingsurgical techniques has beenfostered by growing awareness ofquality-of-life concerns. One exampleof this concern has been the widespreadacceptance of modifiedsurgical techniques used in the treatmentof breast cancer (once it waswell-documented that breast-sparingtechniques offered adequate tumorcontrol as well as improved qualityof-life outcomes). This thinking hasbeen incorporated into gynecologiconcologic research and practice, andtissue-sparing techniques that betterpreserve possible reproductive andsexual function while maintaining tumorcontrol now receive keen clinicalattention.
To date, several investigators haveevaluated this procedure, the primaryoutcome of survival.[2,26,28, 29,31]It is viewed as a safe alternative toradical hysterectomy, with comparablerecurrence rates. The overall recurrencerate for women who haveundergone laparoscopic vaginalradical trachelectomy is estimated tobe 3%, which is not significantlydifferent from that for radicalhysterectomy. Dargent et al reportedan approximately 18% infertilityrate and 24% fetal loss rate,particularly in the form of late miscarriage.This procedure then carriesan increased relative risk of infertilityand fetal loss but also allows somewomen to become pregnant and givebirth to a child.[26,27,29,30]Radical trachelectomy is an excitingoption for young women with early-stage cervical cancer that holdspromise for improving cancer survivorship.However, further research is needed to evaluate empirically theimpact of radical trachelectomy onsexual functioning and quality of life.
Advanced Cervical Cancer
For more advanced carcinomas,primary treatment with radiation therapymay be indicated. The NationalCancer Institute recentlyadvocated the use of concurrent cisplatin-based chemotherapy and radiationtherapy in women who requireirradiation for the treatment of cervicalcancer. The correlation betweenradiation therapy and sexualdysfunction is documented in the literature.[5,33,34] Women experienceproblems with vaginal stenosis, lossof lubrication, and pain due to postirradiationscarring. In addition, itis not uncommon for women to fearthe emergence of bleeding and pain-symptoms that may be associated withinitial diagnosis and elicit concernsabout recurrence.Chemotherapy can also have a negativeimpact on sexual functioning.Pre- and perimenopausal women whoare receiving chemotherapy may abruptly experience menopausalsymptoms resulting from estrogendeficiency. These symptoms can contributeto sexual difficulties andimpairments in quality of life.Questions about hormonal status andsexual health are integral to qualityof-life concerns for those coping withthe treatment of advanced cancer.Improvements in cancer treatment andthe likelihood of long-term survival ofcancer patients, including those withadvanced disease, have made qualityof-life issues a priority.[12,14,33]
Recurrent Cervical Cancer
Women with recurrent cervicalcancer centrally located in the pelvismay choose the radical surgical approachof pelvic exenteration. Thecurrent literature on pelvic exenterationprimarily addresses the medicalaspects of the procedure, with fewstudies addressing its psychosocialimpact. Although a limited areaof investigation, it has been noted thatthe consequences of exenteration aredramatic, not only to the integrity ofthe body but also to the emotional, functional, social, and sexual wellbeingof individuals who undergo theprocedure. Faced with the idea of radicalsurgery, a discussion of postoperativesexuality may seem a lowpriority, but sexual dysfunction ismore than likely to occur, and beingadequately prepared for such an eventmay facilitate adjustment.
Effect of Exenterationon Sexual Functioning
Patients who undergo pelvic exenterationexperience irreversible sexualconsequences. Radical surgery notonly affects sexual functioning butalso a woman's sexual self-perception.Following surgery, the woman'sbody image, self-esteem, and feminineidentity may alter,[40-44] andseveral studies have reported thatsome women experience a significantloss in sexuality.[39,43,45,46] Withthe loss of sexually responsive tissue,many women report having no interestin sex or no ability to achievesexual satisfaction.[41,45-47]Other studies have found that somewomen and their partners choose notto undergo vaginal reconstruction, althoughwhen these studies were conducted,vaginal reconstruction wasavailable only as an additional operationperformed at a later date.[45,47]Today, the construction of a neovaginais an option available at the time ofpelvic exenteration, reflecting thegrowing awareness of this quality-oflifeconcern.
Regardless of the stage of cancer,issues of sexuality and fertility mayemerge. Recently, Zegwaard and colleagues investigated the informationalneeds of women with a historyof gynecologic cancer. These authorsidentified three time periods in whichinformation was needed, couplingeach period with specific events inthe patient's cancer experience.The first period occurs at the timeof diagnosis and treatment. Duringthis period, questions about the possibleside effects of treatment on sexualityemerge. Following treatment,recovery begins and, with it, thoughtsabout resuming intercourse. It is during this second period that concernsabout possible complications such asvaginal changes arise and may influencesexual activities. At this point,patients usually desire informationabout how to manage complications.The final period at which informationis needed occurs when womenhave identified problems and are tryingto regain or rebuild their sexuallife. Information about symptom managementand strategies to improvesexual functioning are important duringthis third phase of the cancerexperience.
Brief Psychosocial Interventions
Most female cancer patients canbenefit from brief psychosexualinterventions including education,counseling/support, and symptommanagement. Robinson and colleaguesconducted an intervention toincrease compliance with vaginal dilationrecommendations, a recognizedmethod of maintaining vaginal healthand good sexual functioning after radiationtherapy. The interventionconsisted of a psychoeducationalgroup that provided information, support,and behavioral skills regardingeffective use of dilators and lubricants.Women who attended the interventionwere significantly more likely to followrecommendations for vaginal dilationthan the control group.Ganz and colleagues reported anotherexample of benefit from a briefsexual intervention in a group of breastcancer patients. The interventionfocused on providing information,support, and symptom managementand demonstrated significant improvementin menopausal symptoms,including hot flashes and vaginal dryness,in addition to improved sexualfunction.
Assessing Sexual Dysfunction
Sexual dysfunction is a commonconsequence of cancer treatment thatmay persist after treatment is completed,but sexual assessment and/orcounseling are not routinely providedto oncology patients for several reasons.These include time constraintsand the need to prioritize critical andcomplex treatment issues, practitionerdiscomfort in initiating a conversation regarding sexual functioning, andpatient discomfort or embarrassmentwith the subject.[22,48] However, ina study of sexual function after treatmentfor gynecologic cancer, investigatorsfound that 78% of the womenwanted to discuss sexual matters butdid not ask questions because theyfeared rejection or thought the settingwas inappropriate for such discussion. This finding indicates thatdiscussion about sexual functioningwould be welcomed by patients if conductedin a sensitive manner.Basic questions about sexual functioningshould be part of any completemedical history. It is importantto gather psychiatric and medical informationabout significant illnesses(eg, hypertension, heart disease, vasculardisease, diabetes), surgeries inaddition to those needed for cancertreatment, and all medications, includingchemotherapy, radiation therapy,psychotropics, and nonprescriptiondrugs. It is also important to determinewhether the patient has ahistory of tobacco and/or alcohol use,as this can negatively affect sexualfunctioning.Questions to keep in mind whenassessing sexual difficulties includethose about a woman's precancer sexualfunctioning, as well as her currentsexual functioning. This will help determinethe degree of dysfunction. Thephases of the sexual response cycle-desire, excitement, orgasm, and resolution-should be kept in mind duringan evaluation, and it is also importantto pay attention to a patient's relationshipwith her partner. Sexual interactionis a form of support, andproblems in the relationship can disruptthis support process.
Approaches to SexualRehabilitation
There are various models of sexualrehabilitation for working with thecancer patient experiencing changesin her sexuality, intimacy, and/or fertility.One method involves presentingthe psychologist or mental healthprofessional as a functioning and integralpart of the oncology team, ie, onewho routinely sees patients or, alternatively,as a liaison, with referral beingmade by other health practitioners.At Memorial Sloan-Kettering CancerCenter, we use a combinationapproach to address the sexual difficultiesof our gynecologic patients.The Gynecology Service establisheda comprehensive, multidisciplinaryprogram to help female cancer patientscope with the sexual difficultiesthey may experience during or followinga cancer diagnosis and treatment.This model focuses on both thepsychosexual and physical aspects ofsexuality by providing an evaluationthat includes both a medical examinationby a gynecologist and a psychosexualevaluation by a licensedpsychologist/American Association ofSex Educators, Counselors, and Therapists(AASECT)-certified sex therapist.The program allows for patientsto be referred by other gynecologiconcology team members, but it is alsopresented as an integral part of theGynecology Service.In many hospitals and physicians'offices, the concept of a sexual healthteam or program is neither feasiblenor practical. In these settings, a referralnetwork of local professionalswith experience in the treatment ofsexual difficulties and fertility concernscan be identified; this might includeany mental health professionalswith training and certification in sexualtherapy or counseling, as well asthose who have experience with cancerpatients and their families, and agynecologist with interest in the managementof sexual dysfunction relatedto medical illness. A listing of localand national organizations that providesupport, sexual education, andinformation regarding fertility mayalso be useful. Patients may be providedwith a list of these resources,for use as need arises over the courseof the cancer experience.
Cervical cancer, regardless of thestage at presentation, may cause difficultieswith sexuality, intimacy, andfertility. It has been well establishedin the literature that women with ahistory of gynecologic cancer experiencedisturbances in sexuality secondaryto their cancer treatment. However, cervical cancer patients tend to have additional issues, as thisdisease affects premenopausal womenmore so than do other gynecologiccancers (ie, ovarian and uterine).The professionals working with thesepatients are aware of this fact and, inresponse, have developed the radicalvaginal trachelectomy. This procedureoffers a select group of youngwomen with early-stage disease theopportunity to preserve their fertilitywhile receiving the necessary cancertreatment. That said, issues of sexualityalso need to be addressed inwomen with advanced and recurrentdisease.
Programs and Resources
The literature notes that the needfor information about sexuality andfertility emerges for women specificto the phase of a woman's cancer (ie,diagnosis/treatment, recovery, andsurvivorship) and that brief psychosexualinterventions can be successfulin treating the troublesome sideeffects that have an impact on intimacy.[6,7] A comprehensive approachto addressing the sexuality, intimacy,and fertility concerns of patients involvesthe development of a coordinated,multidisciplinary team withina sexual health program that focuseson both the physical and psychologicalfactors contributing to the sexualproblems of patients during and/orafter cancer treatment.Within a given hospital or practicesetting, the considerable financial andprofessional resources for such a programmay remain allocated elsewhere.The many patients with concerns inthis area may still be helped by receivingaccess to a resource networkof local professionals with experiencein treating sexual difficulties. Localand national support organizations(such as the American Cancer Society;American Association of Sex Educators,Counselors, and Therapists;and the Association of ReproductiveHealth Professionals) can provide additionalinformation and support tohelp patients achieve greater comfortwith these issues.
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.
Covens A, Rosen B, Murphy J, et al:Changes in the demographics and perioperativecare of stage IA(2)/IB(1) cervical cancerover the past 16 years. Gynecol Oncol 81:133-137, 2001.
Plante M, Roy M: Radical trachelectomy.Operative Techniques in Gynecologic Surgery2:187-199, 1997.
Andersen BL: How cancer affects sexualfunctioning. Oncology 4:81-94 (incl discussion),1990.
Casey C: Psychosexual morbidity followinggynecological malignancy. Ir Med J89:200, 202, 1996.
Schover LR, Fife M, Gershenson DM:Sexual dysfunction and treatment for early stagecervical cancer. Cancer 63:204-212, 1989.
Ganz PA, Greendale GA, Petersen L, etal: Managing menopausal symptoms in breastcancer survivors: Results of a randomized controlledtrial. J Natl Cancer Inst 92:1054-1064,2000.
Robinson JW: Sexuality and cancer.Breaking the silence. Aust Fam Physician27:45-47, 1998.
Zegwaard MI, Gamel CJ, Durgis DJ, etal: The experience of sexuality and informationreceived in women with cervical cancerand their partners. Verpleegkunde 15:18-27,2000.
Jemal A, Murray T, Samuels A, et al:Cancer statistics. CA Cancer J Clin 53:5-26,2003.
ACOG practice bulletin: Diagnosis andtreatment of cervical carcinomas, number 35.Obstet Gynecol 99:855-867, 2002.
Van der Vange N, Weverling GJ, KettingBW, et al: The prognosis of cervical cancerassociated with pregnancy: A matchedcohort study. Obstet Gynecol 85:1022-1026,1995.
Schover LR: Sexuality and Fertility AfterCancer. New York, John Wiley and Sons,1997.
Schover LR: Sexuality and Cancer forthe Woman Who Has Cancer and Her Partner.Atlanta, American Cancer Society, 2001.
Auchincloss S, McCartney CF: Gynecologiccancer, in Holland J (ed): Psych-oncology,pp 359-370. New York, OxfordUniversity Press, 1998.
Mumma GH, Mashberg D, Lesko LM:Long-term psychosexual adjustment of acuteleukemia survivors: Impact of marrow transplantationversus conventional chemotherapy.Gen Hosp Psychiarty 14:43-55, 1992.
Bloom JR, Fobair P, Gritz E, et al:Psychosocial outcomes of cancer: A comparativeanalysis of Hodgkin's disease and testicularcancer. J Clin Oncol 11:979-988, 1993.
van Tulder MW, Aaronson NK, BruningPF: The quality of life of long term survivorsof Hodgkin’s disease. Ann Oncol5:153-158, 1994.
Lagana L, McGarvey EL, Classen C, etal: Psychosexual dysfunction among gynecologicalcancer survivors. J Clin Psych MedSetting 8:73-83, 2001.
Cyranowski JM, Andersen BL: Schemas, sexuality, and romantic attachment. JPers Soc Psychol 74:1364-1379, 1998.
Ganz PA, Desmond KA, Belin TR, etal: Predictors of sexual health in women aftera breast cancer diagnosis. J Clin Oncol17:2371-2380, 1999.
Andersen BL, Cyranowski JM: Women'ssexuality: Behaviors, responses, and individualdifferences. J Consult Clin Psychol63:891-906, 1995.
Schover LR: Counseling cancer patientsabout changes in sexual function. Oncology13:1585-1592, 1595-1596, 1999.
van de Wiel HB, Weijmer Schultz WC,Wouda J, et al: Sexual functioning of partnersof gynecological oncology patients. Sex MaritalTher 5:123-130, 1990.
Dargent D: Using radical trachelectomyto preserve fertility in early invasive cervicalcancer. Contemp Ob Gyn 45:23-49, 2000.
Dargent D, Brun JL, Roy M, et al:Pregnancies following radical trachelectomyfor invasive cervical cancer. Gynecol Oncol52:105, 1994.
Dargent D, Martin X, Sacchetoni A, etal: Laparoscopic vaginal radical trachelectomy:A treatment to preserve the fertility ofcervical carcinoma patients. Cancer 88:1877-1882, 2000.
Roy M, Plante M: Pregnancies afterradical vaginal trachelectomy for early-stagecervical cancer. Am J Obstet Gynecol179:1491-1496, 1998.
Covens A, Shaw P, Murphy J, et al: Isradical trachelectomy a safe alternative to aradical hysterectomy for patients with stageIA-B carcinoma of the cervix? Cancer86:2273-2279, 1999.
Shepherd JH, Mould T, Oram DH: Radicaltrachelectomy in early stage carcinoma ofthe cervix: Outcome as judged by recurrenceand fertility rates. Br J Obstet Gynaecol108:882-885, 2001.
Covens A: Preserving fertility in earlycervical cancer with radical trachelectomy.Contemp Ob Gyn 48:46-66, 2003.
Shepherd JH, Crawford RA, Oram DH:Radical trachelectomy: A way to preserve fertilityin the treatment of early cervical cancer.Br J Obstet Gynaecol 105:912-916, 1998.
National Cancer Institute: PDQ treatmentsummary for health professionals. CervicalCancer. Available at http://www.cancer.gov/cancerinfo/pdq/treatment/cervical/healthprofessional.Accessed July 30, 2003.
Andersen BL, Andersen B, deProsse C:Controlled prospective longitudinal study ofwomen with cancer: Sexual functioning outcomes.J Consult Clin Psychol 57:683-691,1989.
Bruner DW, Lanciano R, Keegan M,et al: Vaginal stenosis and sexual dysfunctionfollowing intracavitary radiation for thetreatment of cervical and endometrial carcinoma.Int J Radiat Oncol Biol Phys 27:825-830, 1993.
Gamel C, Hengeveld M, Davis B: Informationalneeds about the effects of gynecologicalcancer on sexuality: A review of theliterature. J Clin Nurs 9:678-688, 2000.
Ganz PA, Coscarelli A, Fred C, et al:Breast cancer survivors: Psychosocial concernsand quality of life. Breast Cancer Res Treat38:183-199, 1996.
Crowe PJ, Temple WJ, Lopez MJ, et al:Pelvic exenteration for advanced pelvic malignancy.Semin Surg Oncol 17:152-160, 1999.
Turns D: Psychosocial issues: Pelvicexenterative surgery. J Surg Oncol 76:224-236, 2001.
Gleeson N, Baile W, Roberts WS, et al:Surgical and psychosexual outcome followingvaginal reconstruction with pelvic exenteration.Eur J Gynaecol Oncol 15:89-95, 1994.
Andersen BL: Sexual functioning complicationsin women with gynecologic cancer.Cancer 60:2123-2128, 1987.
Andersen BL, Hacker NF: Psychosexualadjustment following pelvic exenteration.Obstet Gynecol 61:331-338, 1983.
Corney RH, Crowther ME, Everett H,et al: Psychosexual dysfunction in women withgynaecological cancer following radical pelvicsurgery. Br J Obstet Gynaecol 100:73-78,1993.
Fisher SG: Psychosexual adjustment followingtotal pelvic exenteration. Cancer Nursing2:219-225, 1979.
Sewell HH, Edwards DW: Pelvic genitalcancer: Body image and sexuality. FrontRadiat Ther Oncol 14:35-41, 1979.
Dempsey GM, Buchsbaum HJ, MorrisonJ: Psychosocial adjustment to pelvic exenteration.Gynecol Oncol 3:325-334, 1975.
Vera MI: Quality of life following pelvicexenteration. Gynecol Oncol 12:355-366,1981.
Brown RS, Haddox V, Posada A, et al:Social and psychological adjustment followingpelvic exenteration. Am J Obstet Gynecol114:162-171, 1972.
Schover L: Psychosocial aspects of infertilityand decisions about reproduction inyoung cancer survivors: A review. Med PediatrOncol 33:53-59, 1999.
Lancaster J: Women's experiences ofgynecological cancer treated with radiation.Curationis 16:37-42, 1993.
Weijmer Schultz WC, Van de Wiel HB:Sexuality, intimacy, and gynecological cancer.J Sex Marital Ther 29(suppl 1):121-128,2003.
Rieger E, Touyz SW, Wain GV: Therole of the clinical psychologists in gynecologicalcancer. J Psychosom Res 45:201-214,1998.