Author:
Alessandra Graziottin
Gynaecologist
Last Review: 21/02/2003

• BREAST CANCER - QUALITY OF LIFE & SEXUAL ISSUES
• GYNAECOLOGICAL CANCER - QUALITY OF LIFE AND SEXUAL ISSUES
• LEUKEMIA & HODGKIN'S DISEASE - QUALITY OF LIFE AND SEXUALITY

BREAST CANCER - QUALITY OF LIFE & SEXUAL ISSUES

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Your questions on Breast cancer and:

• female sexual identity
  
• female sexual function
  
• libido
  
• sexual arousal
  
• orgasm
  
• satisfaction
  
• sexual relationship
  
• challenging outcomes in cancer survivors
  

Key words
breast cancer; female sex identity; female sexual function; sexual relationship; biological factors; age; lymphedema; side-effects of surgery, radio or chemotherapy; pregnancy-related problems; infertility; iatrogenic menopause

The following information focuses on the biological factors that may impair a woman’s sexuality after the diagnosis and treatment of breast cancer. These factors are unfortunately usually considered less in respect to the psycho-social ones.

What are the consequences of breast cancer on femininity? Female sexual identity, sexual function and sexual relationship may be dramatically wounded, physically and emotionally, by the many changes and challenges the woman has to face when breast cancer diagnosis and treatment (BCD&T) disrupts her life and that of her relatives.

FEMALE SEXUAL IDENTITY

What factors contribute to female sexual identity?

• Femininity
• Maternity
• Eroticism
• Social role

All these factors maybe variably affected by breast cancer diagnosis and treatment

Femininity may suffer a major insult due to a number of biological reasons:

• 1. The breast is a prominent personal and social sign of femininity
  What effect does surgery have on body image?
  Body image is the parameter most affected by the type of surgery performed. Short term impact depends on the type of surgery performed: lumpectomy versus mastectomy, with immediate or delayed reconstruction and their cosmetic result and the need or not of adjuvant radio or chemotherapy. However, more conservative treatments do not appear to significantly modify quality of life (QOL) nor female sexuality in the long term.
  
  
• 2.Arm lymphedema
  What exactly is arm lymphedema?
  This word indicates the gradual swelling of the arm, on the side of the affected breast, due to a reduced lymphatic drainage. The impairment of this drainage is usually caused by the disruption of the lymphatic vessels and stations (Lymphnodes), secondary to the removal of axillary lymphnodes  consensual to breast surgery.
  
  How many women with breast cancer also suffer from arm lymphedema?
  Although still an under-diagnosed and under-treated side effect of breast cancer treatment, there is an average reported incidence of 30-40% of breast cancer survivors who may develop lymphedema up to 20 years after the breast surgery.
  
  How do these symptoms affect femininity?
  Lymphedema may cause a massive swelling of the affected arm. In parallel, it diminishes the functional competence of the arm, thus undermining autonomy  & indipendence, more so if the affected arm is the dominant one, say the right for the majority of qomen. Disfigured body image and self perception may wound the inner sense of femininity, leading to depression and avoidant coping strategies.
  
  What can a woman do to prevent lymphedema?
  Special attentions in the daily life may riduce the risk of increasing the  increase of liquid passage into the interstitial space. The “don’t” series includes:
  
  • don’t cut yourself (ie the cuticles around nails during manicure)
    
  • don’t burn yourself (be ware in the kitchen work, wear protective glove when removing hot pots from the oven, do not sunbath…)
    
  • don’t’ prick yourself
    
  • don’t knock yourself
    
  • don’t make sudden efforts
    
  • don’t carry  bags with the affected hand/arm
    
  • don’t have an intravenous injection in the side affected by lymphedema
    
  • don’t have your blodd pressure taken on that same side
    
    
  How can we cure lymphedema?
  Three  major treatments are available:
  • lymphatic drainage, through manual massage
  • compressive bandages
    
  • drugs that improve the lymphatic drainage: the complex diosmine-hesperidine has proven to significantly reduce lymphedema’s signs and symptoms in the affected arm
    
    
  Paci E.Cariddi A. Barchielli A. Bianchi S.Cardona G.Distante V.
  Long term sequelae of breast cancer surgery
  Tumori, 82; 321-324,1996
  
  Runowicz CD, Lymphedema:patients and provider education-Current status and future trends
  Cancer 83/12: 2874-2876, 1998
  
  
• 3. Iatrogenic menopause
  What is the difference between iatrogenic menopause and “normal” menopause?
  Iatrogenic menopause is an anticipated menopause caused by medical treatment, i.e. chemotherapy in the case of breast cancer patients.
  
  Who feels the effect of iatrogenic menopause the most?
  Younger patients (25% of breast cancer patients are premenopausal) are overall more vulnerable to the complex impact of breast cancer, and to the biological states that its treatment can lead to, due to the loss of precious fertile years.
  
  Why else?
  Oestrogen modulates the quality of both brain and sensory organ ageing. A lack of oestrogen therefore has a negative effect on these sexual targets and determinants of libido.
  
  
• 4.Age
  As well as the potential impact of the menopause why is the age of the breast cancer patients so significant?
  Women have different individual and social tasks and goals in the reproductive years that have different priorities in different decades.
  
  Schover LR, Yetman RJ, Tuason LJ et al
  Partial mastectomy and breast reconstruction. A comparison of their effects on psychosocial adjustement, body image, and sexuality
  Cancer 75(1):54-64; 1995
  
  Graziottin A
  Libido
  John Studd (ed), Yearbook of the Royal College of Obstetricians and Gynaecologists, RCOG Press-Parthenon Publishing Group, p.235-243; 1996
  
  Graziottin A. Castoldi E.
  Sexuality and breast cancer: a review
  In Studd J. The management of the Menopause.The Millennium Review, Parthenon Publishing, London, 201-20, 2000
  
  Ganz PA, Coscarelli A, Fred C et al
  Breast cancer survivors: psychosocial concerns and quality of life 
                                                                           Breast Cancer Res Treat 38(2):183-99;1996
  
  Dorval M, Maunsell E, Deschenes L et al 
    Type of mastectomy and quality of life for long term breast carcinoma survivors
  Cancer 83:2130-8; 1998
  
  Schover LR  
  Sexuality and body image in younger women with breast cancer
  J Natl Cancer Inst Monogr (16):177-82; 1994
  
  

Maternity may become the core of a major identity crisis for the 25% who is diagnosed during the fertile age.

Important points that must be considered regarding maternity after breast cancer

• Conception should be delayed for at least two years after breast cancer treatment, as recurrence risk is at its highest in this lag-time
  
• Fertility is variably reduced by chemotherapy
  
• The risk of congenital abnormalities following chemotherapy fortunately does not seem to exceed normal incidences
  
• Milk production is reduced in the irradiated breas
  
  

Does pregnancy increase the risk of recurrence of breast cancer?
A number of studies deny such a risk. However, some studies have demonstrated a detrimental effect of pregnancy on subclinical breast cancer. Effects of antiestrogen tamoxifen on human pregnancies  are not reported so far.

Guinee VF, Olsson H, Moller T et al
Effect of pregnancy on prognosis for young women with breast cancer
Lancet 343:1587-89; 1994

Collichio FA, Agnello R, Staltzer J
Pregnancy after breast cancer: from psychosocial issues through conception
Oncology (Huntingt) 12(5):759-65, 769; discussion 770, 773-5; 1998


Eroticism Breast cancer may effect sensuality, sexiness and receptiveness through:

• The major insult of breast surgery on breast eroticism: 44% of women with partial mastectomy and 83% of those with breast reconstruction (p<0.001) report that pleasure with breast caresses had decreased.
  
• The menopause. A woman’s sense of eroticism may be dramatically affected by the following menopausal symptoms :
  • Hot flushes
    
  • Sweatings
    
  • Mood swings
    
  • Insomnia
    
  • Depression
    
  • Loss of libido
    
  • Arousal difficulties
    
  • Orgasmic difficulties
    
  • Dyspareunia
    
    
  and signs :
  
  • Wrinkles
    
  • Weight gain
    
  • Modified body shape
    
  • Mouth dryness
    
  • Vaginal dryness
    
  • An overall worsened sexual response
    
    

What other effects can chemotherapy have on a woman’s sense of eroticism?

• A tendency to desire less frequently
  
• More vaginal dryness and dyspareunia, because of the systemic mucositis
  
• Having sex less frequently
  
• A reduction in reaching orgasm through intercourse, although their ability to reach orgasm through non coital caressing did not differ from that of other women. Coital receptiveness is therefore selectively damaged.
  
  

Depression and anxiety
Breast cancer affects self-perception and the sexual function via non-hormonal pathways, in a reported average 17 to 25% of breast cancer patients.

Social role
This may represent an area relatively safe from BC, particularly in well educated women, except in the acute phase or in the more severe and aggressive cases.
However 20% of breast cancer patients do report the following symptoms that can affect them socially:

• A reduction of energy
  
• Psychological distress
  
• Difficulty in concentrating, remembering and thinking clearly
  
  

Chemotherapy for breast cancer can have a negative effect on the following cognitive functions:

• Attention span
  
• Mental flexibility
  
• Speed of information processing
  
• Visual memory
  
• Motor function
  
  

Ganz PA, Coscarelli A, Fred C et al
Breast cancer survivors: psychosocial concerns and quality of life
Breast Cancer Res Treat 38(2):183-99; 1996

Dorval M, Maunsell E, Deschenes L et al
Type of mastectomy and quality of life for long term breast carcinoma survivors
Cancer 83:2130-8; 1998

Schover LR
Sexuality and body image in younger women with breast cancer
J Natl Cancer Inst Monogr (16):177-82; 1994

Runowicz CD   
Lymphedema:patients and provider education-Current status and future trends
Cancer 83/12:2874-2876

Graziottin A
The biological basis of female sexuality
Int Clin Psychopharm 13(suppl 6): 15S-22S; 1998

Graziottin A
Sexuality and the menopause
in John Studd (ed) Management of the menopause-Annual Review, RCOG Press-Parthenon Publishing Group p.49-58; 1998

Graziottin A. Castoldi E.
Sexuality and breast cancer : a review
In Studd J. The management of the Menopause.The Millennium Review, RCOG Press- Parthenon Publishing, London, 201-20, 2000

FEMALE SEXUAL FUNCTION Various models have been used in the past to describe human sexual function. More recently, Dr.Graziottin suggested that human sexual function can be considered as a circuit, with four main stations: libido, arousal, orgasm, and satisfaction.


This model, contributes to the understanding of:

1) the frequent overlapping ("co-morbidity")of sexual symptoms reported in clinical practice, as different dimensions of sexual response are correlated from a physiopathologic point of view;

2) the potential negative or positive feedback mechanisms operating in sexual function

LIBIDO Libido has three major dimensions that have a complex interplay with both an inhibiting or enhancing role:

• Biological / Instinctual
  
• Motivational – Affective
  
• Cognitive
  
  

Biological roots of libido depend firstly on sexual hormones, which are necessary but not sufficient factors to maintain a satisfying human libido. They seem to control the intensity of libido and sexual behaviour, rather than its direction , i.e. a lack of libido towards any partner could be considered a hormonal problem, however towards the partner concerned is obviously a couple problem.
What effect does breast cancer treatment have on female hormone production?
After breast cancer treatment, the loss of oestrogens, secondary to iatrogenic or naturally occurring menopause, may contribute to the inhibition of sexual drive and physical receptiveness; loss of androgens, secondary to chemotherapy, may further worsen the picture.

Can the loss of libido be a multi factorial problem?
Yes. It may be secondary to a number of different factors, for example :

• Arousal disorders, due to biological and/or psychological causes
  
• Orgasmic disorders
  
• Sexual dissatisfaction – physical, emotional or both
  
  

Motivational-affective and cognitive aspects of libido may be impaired by:

• The negative impact breast surgery has on self-image
  
• Self-esteem
  
• The perception itself of being an object of sex drive
  
• The shift of couple relationship towards more affective dynamics may increase emotional intimacy but reduce sexual drive
  
  

Graziottin A
Libido

John Studd
(ed), Yearbook of the Royal College of Obstetricians and Gynaecologists, RCOG Press-Parthenon Publishing Group, London p.235-243; 1996

Barni S, Mondin R
  Sexual dysfunction in treated breast cancer patients
Ann Oncol 8(2):149-53; 1997

SEXUAL AROUSAL
What exactly is sexual arousal?
Sexual arousal indi­cates a state with specific feelings, usually attached to the genitals. In women, arousal difficulties  may be (a) central, (b) non-genital peripheral and (c) genital. Breast cancer survivors may suffer from complex arousal disorders, secondary to:

• Biological central difficulties
  What causes these difficulties?
  Biological sexual difficulties are caused by the loss of sexual hormones, secondary to iatrogenic or spontaneous menopause, that may be made worse by depres­sion, anxiety, chronic stress and insomnia, triggered by the cancer diagnosis.
  
  Reduced frequency of erotic dreams, of fantasies, of sexual day dreams and of spontaneous mental arousal are frequently reported in breast cancer patients.
  
  
• Problems in non-genital peripheral arousal could also be called "touch-impaired" disorders.
  
  What causes these disorders?
  Nipple erection my be reduced both by decreased breast sensitivity, secondary to surgery, and inhibition, for the shame some women feel  in exposing the operated breast . A negative effect of the loss of sexual hormones on the function of peripheral nerves leading to distorted sensations (Parethesias) has been uggested by some researchers.
  
  
• Genital arousalis brought about by the action of the Vaso Intestinal Peptide, the most important neurotransmitter that "translates" sexual drive into vaginal lubri­cation.
  
  What effect does the lack of oestrogen have on genital arousal?
  * Without oestrogen, vaginal dryness and dyspareunia are complained of by 35 to 45% of normal postmenopausal women.
  * Pre-existing arousal disorders may be further worsened by the menopausal loss of estrogens and loss of libido many women complain of after breast cancer.
  * A defensive spasm of the pubococcygeal muscle can be secondary to vaginal dryness and dyspareunia thus reducing genital arousal due to the pain
  
  What can be done to improve genital arousal?
  * Pain attention to the hypertonic condition of the pelvic floor secondary to dyspareunia is mandatory in breast cancer patients
  * Learning to relax the levator ani muscle
  * Self-massage with a medicated oil may rapidly cure dyspareunia and arousal disorders secondary to hypoestrogenism that may not be treated with estrogens  because of breast cancer
  
  What other factor affects female sexual arousal?
  Vascular problems have recently been claimed as critical factors in female arousal problems
  
  What can be done?
  Breast cancer patients, with persistent good libido, and vascular arousal disorders might have a significant clinical improvement with vasoactive drugs such as sildenafil, that would not be contraindicated in breast cancer patients. Ongoing studies will evaluate how this possibility can effectively be useful for breast canecr survivors
  
  How many breast cancer patients have difficulties in becoming sexually aroused?
  Studies show that:
  * Difficulty in becoming sexually aroused was reported by 61% of BC patients
  * Difficulty in getting lubricated was found in 57% of the patients
  
  Interestingly, studies also found that breast cancer survivors attain maximum recovery from the physical and psychological trauma of cancer treatment by one year after surgery. A gradual worsening in the quality of sexual response is persisting up to three years after surgery, with one in two women reporting a significant worsening if their sexual life
  
  

Ganz PA, Coscarelli A, Fred C et al
Breast cancer survivors: psychosocial concerns and quality of life
Breast Cancer Res Treat 38(2):183-99; 1996

Graziottin A. Castoldi E.
Sexuality and breast cancer : a review
In Studd J. The management of the Menopause.The Millennium Review, Parthenon Publishing, London, 201-20, 2000

ORGASM

How many breast cancer patients have difficulties in reaching orgasm?
In breast cancer patients difficulty in reaching orgasm is reported in 55% of patients

Studies have also shown, the ability to reach orgasm through intercourse tended to be  significantly reduced in women who received chemotherapy although their ability to reach orgasm through non coital caressing did not differ from other women.

Why do breast cancer patients have difficulties in reaching orgasm?
The inhibitory and painful effect of dyspareunia on vaginal orgasm might explain this

SATISFACTION

How can we define satisfaction?
Satisfaction is a comprehensive and yet elusive word. It includes both physical and emotional satisfaction, that should probably be considered separately.

What explains a reduction in satisfaction for breast cancer patients?
Pain and an overall disappointing sexual experience might be responsible for the significantly reduced satisfaction reported by breast cancer survivors.

Schover LR, Yetman RJ, Tuason LJ et al
Partial mastectomy and breast reconstruction. A comparison of their effects on psychosocial adjustement, body image, and sexuality
Cancer 75(1):54-64; 1995

SEXUAL RELATIONSHIP

• The quality of affective bonds, and specifically of sexual relationships, both homo or heterosexual, is a critical part of human adult satisfaction.
  
• A good quality of emotional intimacy may explain why 62% of breast cancer patients found it easier to discuss their sexual problems with their partner during their illness than with doctors and psychologists, to whom only 15% of breast cancer patients dared to openly express their concerns. This figures indicate how important a good preparation is on the part of the patient, so as to be able to confront with confidence the subject of sexual relationships during a medical visit.
  
• Cancer diagnosis is a tremendous strain factor on the couple relationship and on the family.
  
• Young women and couples may be particularly vulnerable: studies indicate that younger women experience more emotional distress than older women.
  
• Younger husbands reported more problems carrying out domestic roles and more vulnerability to the number of life stressors they were experiencing in comparison to  older husbands.
  
• When breast cancer is diagnosed the demands of illness are superimposed on the normal demands of family life and this may have a different impact on the family relationships depending on the phase of the family life cycle when the cancer is diagnosed.
  
  

What about the physical aspects of the problem on sexual relationships? How can the male partner be affected?
Breast surgery may affect physical attractiveness and reduce easiness with breast foreplay, although this is difficult to be openly admitted as it seems rough, insensitive and/or unfeeling.

• Loss of oestrogen may also make penetration more difficult  because of vaginal dryness.
  
• An erective deficit may occur when dryness itself challenges the quality of the erection, or when the partner perceives vaginal dryness as a sign of refusal or somehow an indication of the "insensitivity" of his sexual request and approach.
  
• Male physical and emotional satisfaction may be impaired when the instinctual drive is braked by physical difficulties and emotional concerns.
  
• More balanced help must also be given to partners of breast cancer patients. If these issues are not spontaneously raised by the physician during the consultation, a thorough preparation of questions that need to be asked on the part of the male partner should be done to overcome physical and emotional problems
  

Northouse LL
Breast cancer in younger women: effects on interpersonal and family relations
Monogr Natl cancer Inst 16:183-190; 1994

Haddad P, Pitceathly C, Maguire P 
Psychological morbidity in the partnersof cancer patients
Baider, L.  & Cooper, CL.(Eds) Cancer and the family. John Wiley & Sons, England UK 1996, 257-268



CHALLENGING OUTCOMES IN CANCER SURVIVORS
Some patients report an increase in their sexuality in spite of the dramatic physical and emotional impact of cancer treatments.

Who are the patients who have the best outcome in terms of  survival, quality of life and sexual life, among those having the  same cancer and stage, treatment program and overall prognosis? Do they have:

• a better understanding of the forces of adaptation?
  
• better coping mechanisms?
  
• a stronger network of support?
  
• particular rehabilitative strategies?
  
• and/or or maybe, some invisible and uncountable forces like spirituality, hope, faith and the ability to re-shape values and priorities, the meaning of enjoying life and of sexual intimacy in front of the challenge ahead…?
  
  

On a final note

The fact that overall adjustment and quality of life of breast cancer survivors is positive in an average 70-80 per cent of cases should not mask the fact that this is true for many areas of QOL, except for sexual function and satisfaction.

By finding an understanding and competent physician who could help not only the woman, but also the couple to cope better with the tremendous strain of breast cancer, also from the sexual point of view is vital so as not to give up sexual intimacy, that is such a critical part of QOL, particularly in younger women and couples.

Ganz PA,Shag AC, Lee JJ et Al.
Breast conservation  versus mastectomy: is there a difference in psychological adjustment or quality of life in the year after surgery?
Cancer 69: 1729-1738,1992

Dorval M, Maunsell E, Deschenes L et alType of mastectomy and quality of life
for long term breast carcinoma survivors
Cancer 83:2130-8; 1998

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GYNECOLOGICAL CANCER - QUALITY OF LIFE & SEXUAL ISSUES

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YOUR QUESTIONS ON QUALITY OF LIFE AND SEXUALITY AFTER

• cervical cancer
  
• endometrial cancer
  
• ovarian cancer
  
• vulvar cancer
  
• rare cancers, such as salpings tumours and vaginal cancer
  
• iatrogenic menopause
  
• depression and anxiety
  
• feminity and female sexual identity
  
• female sexual function: libido, sexual arousal, orgasm, satisfaction
  
• couple and sexual relationship
  
• challenging
  
• outcomes in cancer survivors
  

Key words: gynecologic cancer; female sexual identity; sexual function; sexual relationship; female sexual disorders (FSD); surgical, radio or chemotherapic side-effects;  infertility; iatrogenic menopause

Cancer has become much more of a chronic, than a fatal disease. This positive shift in patients outcomes has resulted in an increased emphasis on quality of life (QOL) issues, of which sexuality is a leading aspect.

The following information focuses on the biological factors that may impair a woman’s sexuality after the diagnosis and treatment of gynaecological cancer. These factors are unfortunately usually considered less in respect to the psycho-social ones.

What are the gynaecological cancers?

• Cervical, which involves the part of the uterus facing into the vagina
  
• Endometrial, which arises from the inner layer of mucosa inside the uterus, called endometrium
  
• Ovarian, which arises from the ovaries
  
• Vulvar, originating from the tissues of the external genitalia, ie the vulva
  
• Vaginal, very rare, which arises from the vagina
  
• Salpingal, very rare as well, originating from the tubes, called “salpings”
  

What effect does gynaecological cancer have on femininity?
Gynaecological cancers may all affect the three critical domains of female sexuality: female sex identity, sexual function and sexual relationship.

FEMALE SEXUAL IDENTITY
Female sex identity may be variably affected by gynecologic cancer diagnosis and treatment, depending on:

• Age at diagnosis (and at potential recurrences)
  
• Age is the first biological factor that may modify the outcome of Gynecologic Cancer diagnosis and treatment, when sexuality is considered as an independent variable in the QOL evaluation
  
• The impact of Gynecologic Cancer Diagnosis and treatment is increasingly worse in younger patients, expecially if radical surgery, adjuvant systemic chemotherapy  consequences and/or local radiotherapy further reduce the biological chances of a fulfilling life
  

Andersen BL, Anderson B, de Prosse C
Controlled prospective longitudinal study of women with cancer: Sexual functioning outcomes

J Consult Clin
Psychol  1989; 75(6):683-91

Graziottin A.
Sexual function in women  with gynecologic cancer. A review

Italian Journal
of Gynecology and Obstetrics, 2001; 2: 61-68

Type of cancer :

• CERVICAL CANCER
  Who is mostly at risk of cervical cancer?
  Cervical cancer usually appears in younger women (median age 51.5 years), with increasingly younger patients: 15% of cervical cancer survivors are under 40 years.
  
  What type of treatment is usually carried out?
  In situ tumors still consent conservative treatments (ie removing only the uterus with a “simple” hysterectomy) and close follow-up in youngest patients. However, invasive tumors require radical hysteroannessiectomy, with larger surgery aiming at removing all tissues potentially interested by the tumor invasion, including the regional  parametrial and lymphnodal removal. This radical surgerycauses premature menopause  and a significant shortening of the vagina.
  
  Does Hormone Replacement Therapy (HRT) help to reduce the impact of treatment-induced biological modifications?
  YES.
  Immediate use of hormonal replacement therapy (HRT), at least locally, best systemic,  soon after surgery will prevent the acute dramatic symptoms of a premature menopause.
  HRT reduces as well vaginal retraction, vaginal dryness and vascular involution.
  
  What biological effects does radiotherapy have?
  Pelvic radiotherapy may cause bladder and rectal complications that may further impair sexual self schema, body image and self-confidence, as continence is one of the critical aspects of personal and social autonomy.
  
  What other personal problems can be brought about by diagnosis of a cervical cancer and the  treatment it requires?
  
  • Because of the frequent etiological HPV (Papillomavirus) infection, this cancer may be burdened with fear of being contagious to the partner.
    
  • Guilty feelings may be pervading, rooted in the past personal sex life.
    
  • In other cases, aggressive feelings against the partner considered responsible for the infection (of having "caught" it) and the subsequent cancer may dominate the clinical picture.
    
  • Individual and couple counselling is critical to address these feelings that may affect the motivational-affective roots of libido and couple commitment
    
    
  Di Benedetto P, Graziottin A.
  Piacere e dolore
  Atti del Sesto Congresso SIMFER, Trieste, Libreria Goliardica Editrice, Trieste, 1997
  
  Andersen BL, Anderson B, de Prosse C
  Controlled prospective longitudinal study of women with cancer: I. Sexual functioning outcomes
  J Consult Clin
  Psychol  1989; 75(6):683-91
  
  Graziottin A.
  Sexual function in women  with gynecologic cancer. A review
  
  Italian Journal of Gynecology and Obstetrics, 2001; 2: 61-68
  
  
  
  
• 2. ENDOMETRIAL CANCER
  Who is mostly at risk of endometrial cancer?
  Endometrial cancer is typical of the postmenopausal years, with a peak around the sixties. Obese women have a higher risk of developing endometrial cancer. Fat tissues produces an estrogen, the “estrone”, from a modification of androgens. At high doses these estrogens may cause  endometrial proliferation up to cancer.
  
  What kind of treatment is usually carried out?
  When diagnosed in early stages, it requires a simple hysteroannessiectomy, ie the removal of the uterus
  
  How do women feel after being diagnosed of an endometrial cancer?
  Subjective feelings are overall dominated by the relief of a curing surgery, in a life stage when the majority of human female tasks and goals- particularly having children-  have already been accomplished.
  
  However, and contrary to common beliefs, a significant number of "old" patients still have active sexual life. Shyness, reservation, privacy, embarrassment and cultural inhibitions shouldn’t make it difficult for this age cohort, particularly over 65, to openly raise this issue, that deserves to be objectively recognized and properly addressed
  
  Therefore have the courage to confront these sexual issues with your doctor so as to maintain a fulfilling life even after being cured by a gynecologica cancer!
  
  
• 3. OVARIAN CANCER
  Who is mostly at risk of ovarian cancer?
  There are two age groups mostly at risk. The smaller of the two being during the second decade of life. The second larger group being in the post menopausal years
  
  What impact does this disease have on quality of life and femininity?
  The impact on QOL and femininity is dramatically determined  by the aggressiveness of the disease and of the necessary treatments.
  
  Weight loss, because of the loss of appetite due to the disease itself and/or to chemotherapy up to a frank anorexia,  increased abdominal girth, change in bowel function, vague persistent abdominal pain may all affect the level of vital energy, the quality of life and deeply impair physical expression of love
  
  Alopecia, anorexia, weight loss, plus the impact of menopause may all affect body image,  self-perception, esthetic self-confidence
  
  What kind of treatment is usually carried out?
  Cancers of the dysgerminoma type, typical of younger women, sometimes admit a monolateral conservative surgery, or bilateral ovariectomy with conservation of the uterus. Sparing the uterus, when oncologically possible, is important so as to still experience periods with hormonal replacement therapy (HRT) and a potential pregnancy through ovodonation, ie the donation of an egg to be fertilized, from an healthy woman-donor
  
  
• 4. SALPINGS TUMOURS
  Salpings tumours are rare. They are similar to ovarian tumours and are therefore considered together.
  
  
• 5. VULVAR CANCER
  Who is mostly at risk of vulvar cancer?
  Precancerous lesions (vulvar intraepithelial neoplasia, VIN, usually related to HPV, Papillomavirus  infection) have a peak in younger women. Invasive cancer usually appears in postmenopausal years.
  
  What kind of treatment is usually carried out?
  Precancerous lesions are usually treated with more conservative treatments (with CO2 laser, 5-FU) that nevertheless may cause both physical and sexual consequences in a significant number of patients due to the potential sideffects  of laser surgery. Patients with invasive cancer can undergo a radical vulvectomy.
  
  
• 5. VAGINAL CANCER
  This is a rare tumour, more frequently derived from a carcinogenetic process induced during pregnancy. Its most frequent form is the clear cell adenocarcinoma, secondary to the prolonged use during pregnancy of diethilstilbestrol. This hormone was use as antiabortive drug in the fifties. Its use has been completely abandoned.
  
  

NOTE :

In Gynaecological cancer patients, short term impact on quality of life depends on the type of surgery performed

Hysterectomy   Vs  Hysteroannessiectomy Vs  Radical surgery

And the need or not of adjuvant radio or chemotherapy, or vulvar conservative versus radical treatment

In Gynaecological cancer patients, long term impact on quality of life depends on:

• Absence of recurrencies
  
• Woman’s overall psychological health
  
• Satisfaction with her relationship and previous sex life
  
• The extent of the pelvic surgery
  

Iatrogenic menopause

What is iatrogenic menopause?
Iatrogenic menopause is an anticipated menopause caused by medical treatment

Which treatments can lead to iatrogenic menopause?
- Bilateral ovariectomy deprives the woman of the possibility of being mother, unless ovodonation is accepted, a distressing factor in younger patients. It also causes loss of both estrogens and androgens, leading to the so called "female androgen deficiency syndrome" (FADS)

- Systemic Chemotherapy, as this treatment may destroy the follicles in the ovary

- Radiotherapy of the pelvis, ie focused on the genital area, that may damage the ovaries

What does the Female Androgen  Deficiency Syndrome cause?
It may determine:

• Loss of libido
  
• Reduced assertiveness
  
• Low vital energy
  
• Loss of pubic hair
  
• Reduced muscle mass
  

All these changes may wound physically and symbolically the sensuality and sexiness, leading to a self perception of being defective, broken or damaged, mostly if radiotherapy has caused a painful narrowing and shortening of the vagina, impairing or preventing intercourse and coital pleasure.

What further effect can chemotherapy have on female sexual identity?
Sexuality may be acutely affected also after chemotherapy, usually combined with surgery for ovarian cancers, for its general impact on well being (fatigue, hair loss, weight changes, nausea and diarrhoea, secondary depression and anxiety)

What can be done to lessen the impact of the menopause?
Except for endometrial cancer, HRT, with androgens in selected cases, may reduce both the impact of the menopause and of the local scarring after radiotherapy.

Depression and anxiety

Reactive to gynaecological cancer treatment per se and secondary complications (e.g. after radiation-induced diarrhoea or voiding disorders, when they persist after radiotherapy) may further affect erotic perception, self-esteem and sexual self-schema.

FEMALE SEXUAL FUNCTION
LIBIDO
Biological, motivational-affective and cognitive dimensions of libido, ie sexual drive may be differently affected by gynaecological cancer treatment.

• Biological roots of libido depend firstly on sexual hormones, which are necessary but not sufficient to maintain a satisfying human sexual drive.
  What happens to libido when there is a loss of sexual hormones?
  Loss of oestrogens, secondary to ovariectomy or spontaneous menopause, may reduce libido, mostly through a secondary effect mediated by vaginal dryness and dyspareunia, made worse after radiotherapy.
  
  Androgens have a definite thrilling role, in women as well as in men. The loss of ovarian androgens after bilateral ovariectomy may lead to FADS.
  
  What can be done to improve a lack of libido?
  - Androgen supplementation improves libido, arousal, assertiveness and well-being in ovariectomized patients. With the exception of the group of adenocarcinomata, that requires individual decision, HRT with oestrogen and androgen is indicated in these patients.
  
  - HRT may improve libido both directly and indirectly, by relieving rectal, bladder and vaginal complications.
  
  
• Motivational-affective and cognitive aspects of libido  may further modulate the clinical picture by affecting :
  
  • The negative impact gynaecological surgery has on self-image
    
  • Self-esteem
    
  • The perception itself of being an object of sex drive
    
  • The shift of couple relationship towards more affective dynamics may increase emotional intimacy but reduce sexual drive
    

Sands R. Studd J
Exogenous androgens in postmenopausal years
AmJ Med 1995; 98:76-79

Graziottin A.
Sexual function in women  with gynecologic cancer. A review

Italian Journal
of Gynecology and Obstetrics, 2001; 2: 61-68

SEXUAL AROUSAL

What is sexual arousal?
Sexual arousal  indicates a state with specific feelings, usually attached to the genitals. Arousal  may be:

• central, ie mental
  
• non- genital peripheral, causing skin vasodilatation,  nipple erection,  salivary secretion…
  
• genital, leading to genital congestion and vaginal lubrication
  
  

In gynaecological cancer patients, arousal  may be affected by a number of biological reasons:

• Estrogen and androgen loss, secondary to iatrogenic menopause;
  
• Vascular and neurological impairment
  
  

Who is most vulnerable to vascular and neurological impairment?
Women treated for cervical cancer, with combined surgery and radiotherapy

Why?
Radiotherapy determines a major insult to the vascular and neurological bases of the lubrication process and to the elasticity of the mucosal and submucosal tissues leading to a dry, retracting, narrow and rigid "tube", causing  a "radiation vaginitis"

What can be done to improve vascular and neurological impairments?

• Topical and systemic ERT may improve the recovery process and is one of the crucial therapeutic steps to be performed during radiotherapy, to minimized retraction and irreversible loss of vaginal elasticity
  
  
• Vascular factors  might  have  a significant clinical improvement with vasoactive drugs such as sildenafil, the drug which became worldwide known as Viagra. This drug is useful to improve arousal difficulties in men, which otherwise  lead to erectile deficit
  
  
• The synergy between appropriate HRT and sildenafil might theoretically significantly reduce dyspareunia in gynaecological cancer patients (studies show the high prevalence of dyspareunia in gynaecological cancer patients - varying from 50% to 80% when vaginal shortening due to combined surgery and radiotherapy was a leading complaint), to 82% of women under 50 years that had radiotherapy). New studies are ongoing to evaluate this possibility.
  
  

Why else are gynaecological cancer patients at risk from neurological impairment?

• Clitoral responsiveness in the arousal phase may be impaired after the menopause
  
  
• Clitoral arousability may be specifically and directly compromised in vulvar cancer, when vulvectomy is performed
  
  

Dyspareunia

Either primary or, more frequently, secondary to vaginal dryness with secondary defensive spasm of pubococcygeal muscle

Urinary incontinence

Urinary incontinence may cause genital arousal difficulties during and after the menopause

Why?
Voiding disorders are more frequent after radical hysterectomy for cervical cancer

Bladder dysfunction may be a direct consequence of the disruption of the sensory and motor nerve supply of the detrusor, with damage of the detrusorial and urethral sphincter competence, leading to dysuria with urine residual volume, urgency and/or stress incontinence

Urinary incontinence may also be a complication after radical vulvectomy. Studies show that 28% of vulvectomy patients developed a change of continence; the percentage raised to 40% after radical vulvectomy

How can urinary incontinence can be reduced in gynaecological cancer patients?
By using nerve sparing techniques, aiming at reducing the risk of a nerve damage during surgery

• HRT
  
• Pelvic floor rehabilitation
  
  

Baker PK
Musculoskeletal origins of chronic pelvic pain. Diagnosis and treatment
Obstet.Gynecol.Clin. North.Am. 1993; 20 (4): 719-742

Carenza L, Nobili F, Giacobini S
Voiding disorders after radical hysterectomy

Gynecol Oncol. 1982; 13: 213-19

Graziottin A
Sexuality and the menopause in John Studd (ed) Management of the menopause-Annual Review, RCOG, London, Press-Parthenon Publishing Group, 1998 (a) : 49-58;

ORGASM
Orgasmic difficulties  may be the end point of a number of biological, as well as motivational-affective and cognitive factors  particularly in gynaecological cancer patients

Why?
After radical surgery and/or radiotherapy, anatomic and functional modifications of orgasm trigger points and areas may deeply affect the orgasmic gynaecological cancer patients

Hypertonic conditions, muscle retraction, increased fibrosis, vascular and neurological damages after radiotherapy, may cause dyspareunia, vaginismus and post-coital cystitis, thus impairing the formation of  the "orgasmic platform"

How many gynaecological cancer patients suffer from orgasm difficulties?
In gynaecological cancer patients difficulty in reaching coital orgasm was reported in 16.5% (10/61) of patients at initial diagnosis of cervical cancer and in 60% (24/40) of patients reassessed one year later

Masters WH, Johnson VE, Kolodny RC
Heterosexuality
Glascow, Harper Collins, 1994

SATISFACTION
Satisfaction includes both physical and emotional satisfaction.

Why do gynaecological cancer patients particularly have a reduced level of sexual  satisfaction?
The negative memory of dyspareunia, and the persistent experience of it, may cause loss of libido, increase arousal difficulties with reduced lubrication, contributing to the significant worsening trend of the sexual function of gynaecological cancer patients

Pain and an overall disappointing sexual experience might also be responsible for the significant reduced frequency of sex, reduced type of sex activities, reduced willingness of women to initiate sex

However, on a positive note, studies show that emotional "satisfaction" is reported intact across time. Acceptance of the "sexual price of survival" is probably responsible for this positive evaluation, in spite of the referred objective sexual impairment. A second explanation could be that an improved quality of emotional intimacy with the partner (reported in average 60-70% of married couples) is so gratifying for the majority of women, that its value softens the impact of the specific sexual limits. Other studies show that whilst frequency of intercourse dropped from 10/mth to 5/mth one year after treatment, other sexual or affectionate behaviours, such as kissing, remained constant over time.

What treatment can be carried out to improve sexual satisfaction?
Women should be encouraged to continue HRT - at least, topical oestrogen in the vagina or topical androgen, when indicated - in the vulvar area

Rehabilitation training of the pelvic floor (particularly in hypertonic conditions leading to dyspareunia and/or in case of levator ani myalgia) at least for six months after the clinical improvement

Use a lubricant to ease penetration and avoid pain and to get optimal  recovery

Graziottin A
Organic and psychological factors in vulval pain: implications for management
Sexual & Marital Therapy, 1998 (d); 13,3: 329-338

SEXUAL RELATIONSHIP
Quality of affective bonds, and specifically of sexual relationships, both homo or heterosexual, is a critical part of Quality of life. There are five important variables that influence the impact of cancer on a sexual relationship:

• the status of the relationship before the cancer developed
  
• the longevity of the marriage/ relationship
  
• the stage of the cancer and the treatment choice
  
• the point in the course of the illness when the evaluation is made
  
• the interpersonal skills of the partner
  
  

Cancer diagnosis is a tremendous strain factor on the couple relationship and on the family.

Young women and couples may be particularly vulnerable also from this point of view. Studies indicate that younger women experience more emotional distress than older women.

Family experts contend that when families face an excessive number of demands, a "pile-up" of stress occurs and the well being of family members and family life is threatened.

How is the male partner affected by the cancer diagnosis and treatment?

• The impact of gynaecological cancer diagnosis may affect the overall husband's well-being, more so in loving partners, potentially leading to psychosomatic problems
  
• The impact of gynaecological cancer diagnosis and treatment on male sex drive may  depend also on the type and extension of treatment. It is usually minimal in simple hysteroannessiectomies and maximal in radical hysterectomy, more so when vaginal elasticity and responsiveness are markedly impaired after radiotherapy, or when radical vulvectomy dramatically affects the aesthetic appearance of female genitals
  
• Loss of oestrogen may also make penetration more difficult because of vaginal dryness and further complicate the stenosis, retraction and the feeling of vaginal shortness
  
• There may also be an erectile deficit, when dryness itself challenges the quality of the erection or when the partner perceives vaginal dryness as a sign of refusal or somehow an indication of the "insensitivity" of his sexual request and approach
  

What can be done to help couples cope with the cancer trauma together?
Studies show that 50% of younger patients felt that more information about sexual changes should have been given to their husbands, so as to prepare them in advance for the changes ahead

Psychosexual and informative counselling is a critical preventive measure, all the more as husbands and couples express their relief and gratefulness when these issues and potential difficulties and/or misunderstandings are openly and spontaneously raised by the physician during the consultation and when practical suggestions are given to overcome physical and emotional problems

Graziottin A
Sexuality and the menopause
in John Studd (ed) Management of the menopause-Annual Review, RCOG, London, Press-Parthenon Publishing Group, 1998 (a) : 49-58;

Graziottin A.
Sexual function in women  with gynecologic cancer. A review

Italian Journal of Gynecology and Obstetrics, 2001; 2: 61-68

Helstrom L, Sorbom D, Backstrom T
Influence of partner relationship on sexuality after subtotal hysterectomy Acta Obstet Gynecol Scand 1995; 74: 142-146

McCubbin HI,Patterson JM
Family adaptation to crises
In McCubbin H, Cauble A, Patterson J Eds: Family stress, Coping and Social Support,
Springfield, Charles Thomas Ed,  1982

CHALLENGING OUTCOMES IN CANCER SURVIVORS
Some patients report an increase in their quality of life and  sexuality in spite of the dramatic physical and emotional impact of cancer treatments.

Who are the patients who have the best outcome in terms of  survival, quality of life and sexual life, among those having the  same cancer and stage, treatment program and overall prognosis?Do they have :

• a better understanding of the forces of adaptation?
  
• better coping mechanisms?
  
• a stronger network of support?
  
• particular rehabilitative strategies?
  
• and/or, maybe,some invisible and uncountable forces like spirituality, hope, faith and the ability to re-shape values and priorities, the meaning of enjoying life and of sexual intimacy in front of the challenge ahead…?
  
  

On a final note …

• Gynecological cancers may affect female sexual function, female sexual response and couple relationship in a complex way, involving both psychosocial and biological factors
  
• All the following must be considered when addressing the individual quality of life of a cancer patient :
  Age, side effects of surgery, chemo and radiotherapy, pregnancy related problems during cervical cancer, infertility, iatrogenic premature menopause with its cohort of damages secondary to the chronic loss of oestrogen on the brain, on the sensory organs, on the physiopathology of sexual response and on the function of the pelvic floor.
• The fact that overall adjustment and QOL of GC survivors is positive in an average 70-80 per cent of cases should not mask the complete truth: that this is true for many areas of QOL, except for sexual function
  
• Attention to the anatomy and function of the pelvic floor should become a mandatory part of a thorough clinical gynaecological and sexological examination, to give gynecologic cancer survivors  the right to a full diagnosis and  competent help, to enjoy love and sexual happiness again
  

[Back to the Top]

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LEUKEMIA & HODGKIN'S DISEASE - QUALITY OF LIFE & SEXUAL ISSUES

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SEXUALITY, AGE AND CHRONIC DISEASE:
YOUNG CANCERS SURVIVORS and IATROGENIC MENOPAUSE 
Key messages: Young Cancer Survivors, Acute Leukaemia, Hodgkin’s Disease, Bone Marrow Transplantation, Challenging Outcomes In Cancer Survivors, Transition From Adolescence To Adulthood In Cancer Survivors,  Menopause, Female Sexual Hormones And Health, Female Sexual Function In Young Cancer Survivors Affected  By Iatrogenic Menopause, Sexual Desire, Sexual Arousal, Sexual Pain Related Disorders, Orgasm And Pleasure, Sexual Satisfaction, Hormonal Replacement Therapy, Infertility Issues  In Young Cancer Survivors, Guidelines For Preserving Sexual Function In Young Cancer Survivors  Affected With Iatrogenic Menopause

Key words: cancer survivors; hematologic malignances; iatrogenic menopause; psychosexual problems; female sexual disorders;

Female sexuality is extremely complex, resulting from the interplay of biological, psychosexual and context-dependent factors, either relational and sociocultural. Human sexuality is very complex, and even more so when a serious adverse event like cancer affects the individual well-being - sexual and non-sexual - in all its dimensions.

Cancer, today, is more of a chronic than a fatal disease. Survival rate, at five years, may be as high as 72%, up to 90% for some cancers. The price of survival, however, may be extremely high, for a number of factors directly and indirectly related to the cancer  and cancer treatment per se, to the age when it was diagnosed and treated and the quality of family, medical, psychological and social support.

The following information focuses on young cancer survivors, with special attention to younger women treated for hematologic neoplasias (Hodgkin’s disease, acute lymphoblastic or leukaemia), in a life-span perspective.

YOUNG CANCER SURVIVORS

A strong biological event like iatrogenic menopause can be better understood if put in perspectives with the many changes and challenges young cancer survivors have to face  - and cope with - in different emotional, affective, relational, cultural and existential domains.

Why do young cancer patients have a particular difficulty in attaining a satisfying sexual identity?
Attachment needs may be deeply frustrated in children and adolescents, due to long lasting hospitalization, separation from parents, friends, school and playtime, invasive and painful tests and treatments, anxiety and anguish, fears about the future, long hours of loneliness without tenderness. The average time involved in treatment and close follow-up in hematologic cancers  is three years: this critical suspension from normal life and the shift to emergency survival may disrupt the basic psychosexual maturity process.

The frustration of attachment needs delays the growth of autonomy and independence and complicates the attainment of a satisfying sexual identity.

The impact of cancer on self perception and the need of invasive treatments may further affect body image and self-confidence, intimacy issues, physically and emotionally (“what can or can’t be said”) - with the weight of silences, lies or the anguish of telling -, coping strategies (“locus of control” and/or “illusion of control”),expectations on interpersonal relationships and hope in the future.

Significant findings include:

• excessive dependency on parents
  
• extreme behaviour concerning relationships: some patients demonstrate a lowered interest in interpersonal relationships,whilst others stress the conflict between high expectations for relationships and a difficulty to feel them satisfied in the “real life”, with consequent dissatisfaction with important relationships
  
• increased emotional and behavioural disturbances
  
• suboptimal functioning at school and work, mainly due to the neurological damage of cranial irradiation and/or intensive chemotherapy
  
• denial as a dominant defense mechanism
  
  

ACUTE LEUKAEMIA

What are the survival rates for Acute Leukaemia?
Today there is an overall 5-year survival rate of 70% for acute lymphoblastic leukaemia.
What are the major long term consequences of  the disease and treatment?
Second tumors, gonadal dysfunction and infertility, and cardiac dysfunction.

Survivors of the cancer who underwent cranial irradiation may suffer from deficits in non verbal intelligence and perceptual abilities short term memory psychological distress and poor body image
br> Psychosexual outcomes of survivors of acute lymphoblastic  leukaemia indicate no increased rates of psychiatric disorders, but significant poorer functioning in: love/sex relationship, friendship, non-specific social contacts, day-to-day  coping .

The recency of the disease increases combination of deficits in love & friendship.

Intimacy issues and emotional vulnerability may lead to shorter relationships and lack of involvement in confiding.

The relational area seems therefore to be very sensitive to the long term effect of cancer and cancer related treatment, affecting the inner scenario of emotions and love that prelude a satisfying couple relationship and sexual expression.

Studies show that young women surviving cancer are significantly different in specific domains to healthy women, as the prove to be:

• less feminine in sexual identity & more infantile
• more restrictive, passive and submissive images of sexuality
• lower confidence with masturbation
• less experience of sexual intercourse
• less initiative in sexual intercourse
• minor ability to express personal sexual desires to the partner
• less enjoyment of sexual intercourse

Confirming that cancer experience may affect sexual identity, sexual function and sexual relationship.

Clinical diagnosis and well tailored psychosexual support seem to be critical for the subsets of survivors with poor body image and increased sexual vulnerability.

HODGKIN’S DISEASE
Hodgkin’s disease is a malignant cancer arising from lymphnodal cells.

What are the recent survival rates for Hodgkin’s Disease?
Improvement in chemotherapy and treatment strategies have lead to a dramatic improvement in survival: from the  5%- five years survival in the 1960s for advanced stage, to the present 80%- five years survival, with 61% surviving after fifteen years. 30 to 50% of younger adults are in complete remission from 3 to 8 yrs.

What is the down-side to these positive results?
There is a 17.6-20% mean actuarial risk of any second cancer (both for the presence of a genetic vulnerability and the effect of treatment itself)

All males become permanently sterile, whilst  80% of women over 25 undergo premature menopause.

Different studies show evidence of the difficult adjustment many Hodgkin’s patients complain of in comparison to other  type of haematologic cancers

In comparison to acute leukemia survivors, Hodgkin’ s disease survivors have significantly poorer adaptation in:

• impact of cancers upon their family life
• sexual relationship with spouse or partner
• reduced energy level and fatigue
• greater  hostility and somatisation scores in women
• greater conditioned nausea .

What can be done to help improve the quality of life of these patients?
A comprehensive perception, with medical and psychosexual support, tailored on the emerging individual  needs, seems to offer the best possibility of improvement.   

Kornblith AB Herndon JE Zuckerman E Cella DF Cherin E Wolcok S  et Al
Comparison of psychosocial adaptation of advanced stage Hodgkin diseaes and acute leukemia survivors
Ann Oncol 9: 297-306, 1998

Cella DF Tross S
Psychosocial adjustment to survival  from Hodgkin’s disease
J. Consul Clin. Psychol 54: 616-22,1986

BONE MARROW TRANSPLANTATION

BMT is an aggressive, high technology medical procedure, associated with psychological and physical stressors usually including total body irradiation, isolation in a germ free environment, rapid and uncertain fluctuations in medical status, prolonged hospitalisation, frequent invasive medical procedures, treatment-related physical side-effects including sterility, pulmonary and neurological complications, extreme dependence on medical staff, repeated infections, graft versus host disease (GVHD) related morbidity and possibility of death.

• Allogeneic bone marrow transplantation (Allo BMT), autologous bone marrow transplantation (ABMT) or intensive consolidation therapy (ICC) are currently proposed for patients with acute myelogenous leukemia (AML) and other hematologic cancers once they enter into complete remission (CR).
  
• Treatment results show a lower risk of relapse and a longer disease free survival (DSF) after AlloBMT and ABMT, than after ICC.
  
• However, the overall survival after CR is similar in the three treatment groups, patients relapsing after ICC being more easily salvaged and frequently receiving an ABMT during second CR.
  
• The final results being hampered by long term toxicity and other consequences, including the psychosocial and sexual ones, make it mandatory to evaluate the treatment options also from the quality of life (QOL) point of view, of which sexuality is a hallmark .
  
• BMT, being increasingly proposed in advanced or rapidly progressing cancers other than hematologic ones, is becoming a more familiar issue in cancer patients. Its impact on QOL, besides survival, is currently being intensively investigated.
  
  

Andrykowski MA
Psychosocial factors in bone marrow transplantation: a review and recommendations for research
Bone Marrow Transplantation 13:357-375, 1994


CHALLENGING OUTCOMES IN CANCER SURVIVORS
Some patients report an increase in their sexuality in spite of the dramatic physical and emotional impact of cancer treatments.

Who are the patients who have the best outcome in terms of  survival, quality of life and sexual life, among those having the  same cancer and stage, treatment program and overall prognosis? Do they have:

• a better understanding of the forces of adaptation?
• better coping mechanisms?
• a stronger network of support?
• particular rehabilitative strategies?
• or maybe,some invisible and uncountable forces like spirituality, hope, faith and the ability to re-shape values and priorities, the meaning of enjoying life and of sexual intimacy in front of the challenge ahead…?

TRANSITION FROM ADOLESCENCE TO ADULTHOOD IN CANCER SURVIVORS  
A successful transition requires the ability to:

• separate from parents
• establish a satisfactory sexual identity and functional independence
• form intimate relationships 

Among young cancer survivors, marriage or cohabiting depends on achieving both a biological cure and a positive psychological adaptation.

Marriage or living as married may be considered (with due limitations) as a comprehensive indicator of psychosexual function and social competence

Today the 5-year survival for all malignancies in childhood and adolescence is  72%  (up to 90% for some cancers), and this positive overall outcome increases the interest in global psychosocial functioning.

Studies carried out in US and Canada provide data on marriage, cohabiting and divorce of adult survivors of cancer compared to the US population according to age specific cohort groups. Overall

• 32%  of survivors were married or common low  (much less than US population) )
• 6%  divorced or separated (women less and men more than US pop.)
• 0.07% widowed   (less than US pop)
• 62% never married (significantly more than US population in each cohort group).

In general, compared to the US population, survivors were less likely to have ever married, particularly female & white,  but once married, female & white were less likely to divorce/separate.  Black survivors were more likely to have married, with males and blacks more likely to  divorce/separate once married. Hispanic have  similar rate to US population. With sufficient numbers, ethnicity is proven to be an important variable in modulating  the adaptation to cancer disease and the social perception of it, contributing to the context-dependent factors that may be relevant in the individual outcome.

Rauck A Green DM Yasui Y Mertens A Robinson LL
Marriage  in the survivors of childhood cancer: a preliminary study description from the Childhood Cancer Survivor Study
Medical and Pediatric Oncology 33: 60-63, 1999

What is the menopause?
Menopause defines the disappearance of menstrual cycle as a consequence of  physiologic  ovarian involution (spontaneous menopause), with follicle exhaustion and gradual fading of female sexual hormones production.

Mean age of spontaneous menopause is 50 years and four months.
Oestrogen and progesterone disappear in the first two years after a spontaneous menopause whilst ovarian androgens have a much lower slope of reduction.

What is Iatrogenic Menopause?
Iatrogenic menopause defines the appearance of  menopause as a consequence of medical treatment, for benign or malignant conditions. In cancer patients, it may be the consequence of surgery (bilateral ovariectomy),  chemotherapy and/or  radiotherapy.

FEMALE SEXUAL HORMONES AND HEALTH

Why do the loss of loss of female sexual hormones have a negative effect on femininity?

• Loss of oestrogens deprives the woman  of a lymph that nourishes all the  female body.
  
• Recent data on the widespread tissue distribution of alpha and beta oestrogen receptors explains why oestrogen loss affects all organs and functions.
  
  

Which treatments for cancer reduce female hormone production?

• Bilateral ovariectomy reduces androgen production by average 50%, leading to the so called “Female Androgen Deficiency Syndrome”, characterized by loss of libido, loss of vital energy, loss of assertiveness, loss of pubic hair, changes in body shape, possibly contributing to the “fatigue” so often complained of by cancer survivors,  a symptom  that may be rooted both in biological and psychodynamic factors.
  
  
• Chemotherapy and radiotherapy may not only destroy ovarian follicles, thus causing the oestrogen loss, but they may affect  the Leydig cells,  present in the inner part of the ovary and responsible for  androgen production
  
  

Sands R Studd J
Exogenous androgens in postmenopausal women
Am J Med 98:76-9,1995

FEMALE SEXUAL FUNCTIONIN YOUNG CANCER SURVIVORS AFFECTED  BY IATROGENIC MENOPAUSE

What effect does the Iatrogenic Menopause have on femininity?

• Iatrogenic menopause, because of the sudden onset at a younger age, and its association with major health problems, may deeply affect female sexuality in all its dimensions: sexual identity, function and relationship.
  
  
• Comorbidity is frequently reported in cancer survivors. Biological, motivational and relational aspects of sexuality may be all affected, the younger the patient, the worse the adaptation because of the number of adjustments she has to cope with, when iatrogenic menopause is an issue, independently of the type of cancer whose treatment lead to it.
  
  

Graziottin A. Castoldi E.
Sexuality and breast cancer: a review
In Studd J. (Ed)The management of the menopause. The millennium review 2000, London,  Parthenon Publishing, 211-220, 2000

SEXUAL DESIRE may be affected by:

• sex identity crisis, because of the body image impairment, the iatrogenic amenorrhea requiring long lasting HRT (when oncologically adequate),  sterility, missed accomplishment of life cycle goals being more relevant in nulliparous younger patients
  
• loss of sexual hormones & FADS contributing to Female Sexual Dysfunction (FSD), that may consistently worsen over time
  
• severe fatigue and worse quality of life that seem to be correlated with more menopausal symptoms  overall  and  more psychological and psychosomatic symptoms. Poorer sleep quality and depression, usually worsened by loss of sexual hormones, may further contribute to the global loss of vital energy and the specific loss that fuels sex drive
  
• cancer treatment long lasting side effects: fatigue, cognitive impairment, conditioned nausea, mouth sores, cough, hair loss, headache, especially in post Bone Marrow Transplant patients
  
• post-traumatic stress disorder (considering cancer  a major traumatic experience);
  
• secondary loss because of sexual arousal disorders, orgasmic difficulties and/or sexual pain disorders, particularly when HRT is not prescribed for oncological reasons and/or in not adequate to individual needs, when survival coping strategies fade over time and/or when high expectations about love relationship are frustrated, younger patients being the more vulnerable to this outcome, for personal and partner related factors;
  
  

Graziottin A.
Sexual function in women with gynecologic cancer: a review
Italian Journal of Gynecology and obstetrics, 2:61-68, 2001 (a)

Ganz PA Coscarelli A. Fred C, Kahn B, Polinsky ML Petersen L
Beast cancer survivors: psychosocial concerns and quality of life
Breast Cancer Res Treat, 38, 183-199, 1996

SEXUAL AROUSAL may be affected by the impairment of :

• genital arousal
  Why does the loss of female sexual hormones affect sexual arousal?
  
  • estrogens are permitting factors for the VasoIntestinal Peptide (VIP), which  “translates” sex drive into vaginal lubrication
    
  • Androgens are permitting factors for the Nitric Oxide (NO), involved in clitoral and cavernosal congestion 
    
    
  What other biological changes could affect sexual arousal?
  
  • In patients treated for gynecologic cancer, and/or pelvic cancer-related treatments arousal disorder may be complicated by biological and morphological changes (vaginal shortening and retraction, reduced elasticity and vascularity, mucosal atrophy…) that may cause dyspareunia, other sexual pain disorders or bleeding.
    
  • These symptoms may become the strongest reflex inhibiting factors that prevent penetration, thus contributing to worsen the arousal disorder on a multifactorial basis
    
    
• non-genital-peripheral arousal
  the reduced sexual repertoire  and loss of sexual hormones has a complex effect on the skin and mucosae
  
  
• central arousal
  caused by the deprivation of sexual hormones – specifically androgens -, mostly in women suffering from FADS  and the overlapping effect of factors inhibiting sexual drive.
  
  Couple problems, stronger in younger couples, may worsen the sexual arousal response, affecting motivation, self confidence, intimacy and closeness, even more if infertility is a struggling issue in the family project.
  
  

Levin RJ
The impact of the menopause on the physiology of genital function
In Graziottin A. (ed) Menopause and sexuality, Menopause Review, Eska Ed, Saint Etienne (France) 4,4, 23-32, December 1999

SEXUAL PAIN RELATED DISORDERS may be determined by:

• vaginal dryness, secondary to arousal disorders of mixed origin
  
• vaginal anatomical impairment, in consequence of pelvic surgery or radiotherapy
  
• defensive contraction of the pelvic floor muscles, leading to myalgia with tender and trigger points triggering pain at penetration
  

ORGASM and PLEASURE may be affected by the impairment of:

• sex drive and arousal disorders, of mixed origin;
  
• specific effect of FADS  on clitoral  responsiveness;
  
• reduced “orgasmic platform” for the loss of estrogens, vaginal anatomical damages (more frequent in cervical cancer survivors)
  
  

Graziottin A.
Psychosexual role of the skin at the climacteric
In Brincat M.P. (ed). Hormonal Replacement Therapy and the Skin, Parthenon Publishing, London , 57-64, 2001 (b)

SEXUAL SATISFACTIONmay be physically and emotionally affected.

• Physical satisfaction is more vulnerable in younger women.
  
• Emotional satisfaction may be a safety area when closeness and quality of intimacy and support are increased after cancer in all age cohorts he highest vulnerability being described in younger, single, and of low socio-economic status or women living in a  couple with  conflicts and family disruption.
  
  

HORMONAL REPLACEMENT THERAPY: HOW TO CHOOSE?

• HRT is necessary in preventing short and long term consequences of oestrogen loss, particularly in young cancer survivors affected by iatrogenic menopause.
  
• Oestrogens (estradiol),  and progestins if the uterus is conserved, should be prescribed when oncologically adequate (i.e. with the exception of hormone dependent cancers) in doses adequate to the age, to induce regular periods with good cycle control and to maintain optimal stimulation of different tissue estrogen receptors, the endpoint being the woman’s well-being, which guarantees the best compliance .
  
• Androgens should be considered when symptoms and plasmatic levels are suggestive of FADS, although national limitations exist in relation to the limited availability of approved preparations.
  
• Type and pharmaceutical form should be discussed with the patients to help them to feel “natural” and to increase compliance.
  
• In the author’s experience, contraceptive pill formulation (although metabolically slightly heavier and not indicated “per se” as the patient is already menopausal) may be considered to satisfy the need of the young woman to feel normal (“the same pill like my sister and my best friend”) instead of insisting on classic HRT choices, more medically adequate but maybe less fitting the individual need of feeling “a bit more normal” and not ”continuously reminded of my being already menopausal, like an old lady”).  
  
  

Robertson D van Amelsvoort T Murphy D
Hormone Replacement Therapy and the brain
In Studd J. (Ed)The management of the menopause. The millennium review  2000,  London, Parthenon Publishing, 103-114, 2000

INFERTILITY ISSUES  IN YOUNG CANCER SURVIVORS
What can be done to improve the fertility chances of cancer patients?

• The possibility of ova-criopreservation, with successful further  in vitro fertilization and embryo-transfer, is still in its infancy.  It should  be considered, or at least discussed in implications and objective limits, before cancer treatment, in young, fertile women, especially nulliparous.
  
  
• In women with established iatrogenic menopause, HRT and ovodonation may be the choice (in Countries admitting it).
  
  

What are the consequences of ovodonation?

• If ovodonation is successful, non significant differences in pregnancy and delivery are reported.
  
• Breast feeding possibility is in the normal range (except for patient who underwent breast irradiation)
  
• Pregnancy per se does not increase the risk of recurrences in non hormone dependent cancers.
  
• The higher risk of second tumors in cancer survivors seems to remain unaffected (not increased nor reduced).
  
• In young breast cancer patients, seven studies deny and one study suggest a relationship between  pregnancy and breast cancer. The pregnancy desire should be openly discussed in the medical setting.
  
  

Collichio FA Agnello R Staltzer MD
Pregnancy after breast cancer: from psychosocial issues through conception
Oncology, 12; 5:759-775, 1998

GUIDELINES FOR PRESERVING SEXUAL FUNCTION IN YOUNG CANCER SURVIVORS  AFFECTED WITH IATROGENIC MENOPAUSE

Medical :

• appropriate and timely HRT, local and systemic, except for  hormone-dependent cancers, in all young cancer survivors affected by iatrogenic menopause )
  
• in patients treated for gynecologic and or other pelvic cancers:  post-operative rehabilitation of the pelvic floor, with treatment of inflammatory and/or dystrofic disorders; moulds or dilators & lubricants to  improve vaginal shortening and reduced elasticity;  local vaginal self-massage with medicated oil, to improve elasticity and  restore positive attention to this part of the body.
  
• specific treatments of medical basis of FSD
  
  

Psychosexual:

• individual and couple psychosexual  support open to body image  and intimacy issues
  
• improvement of survival skills
  
• good doctor-patient relationship, open to listening (up to 80% of physician never raise the sexual issues in oncological consultations)
  
  

ON A FINAL NOTE:

• Increasing successful treatments of cancer with higher survival rates make QOL, quality of sexual life and fertility increasingly important issues, particularly in young cancer survivors.
  
• Cancer experience may affect sexual identity, sexual function and sexual relationship.
  
• Clinical diagnosis and well tailored psychosexual support seem to be critical for the subsets of survivors with poor body image and increased sexual vulnerability.
  
• Cancer survivors need to be understood in the individual needs, acknowledged that cognitive deficits and fatigue exist, and are serious issues as others more evident post treatment deficits.
  
• They need to be helped in improving the interpersonal difficulties and intimacy related fears and offered medical and psychosexual help when specific sexual problems are referred to. In case of irreversible gonadal damage, and iatrogenic menopause, they should be prescribed well tailored HRT (ERT and/or ART) when oncologically adequate, to improve long term quality of life. Infertility issues treatment-related should be hopefully discussed before treatment starts.
  
• Patients with best outcomes, in spite of average prognosis, know from their personal experience what this fight means and what may be precious – both in the countable and visible as well as in the uncountable and invisible domains – to make life worth living.
  
• Overall, patients need the best human understanding and compassion possible to give utmost meaning to their day-to-day coping effort not only  to survive, but to feel fully alive again.
  
  

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Copyright © Alessandra Graziottin 2002