Sexuality is a complex process coordinated by the body through its vascular, endocrine and neurologic systems. It also incorporates a wide spectrum of external factors, such as familial, societal and religious beliefs, health status and aging. In addition, each partner brings to the relationship a unique set of attitudes, needs and responses that together make up an individual sexual experience. Cancer and cancer therapy can cause a breakdown in any one of these aforementioned areas, which may lead to dyspareunia and sexual dysfunction. Dyspareunia is defined as painful sexual intercourse. It is a sensitive issue, as this type of pain involves emotionally charged behaviors, sexual intimacy and vaginal intercourse. This article focuses mainly on how dyspareunia affects sexuality in young, female breast cancer survivors. It highlights other presenting symptoms relating to chemotherapy-induced menopause and hormonal therapy, in addition to the negative effects of the disease process of breast cancer itself on sexuality. The research indicates that with these negative effects on sexuality, self-concept can be a challenge: the normal process of desire, arousal, enjoyment and the orgasmic experience is diminished and sometimes lost.
Breast cancer is the most common type of cancer among women in the United States (Burwell et al. 2006). Approximately 26% of all newly diagnosed breast cancer cases occur among women younger than age 50 (Burwell et al. 2006). Breast cancer accounts for 33% of new cancers diagnosed among women in North America and 22% of all cancer survivors (Fobair & Spiegel, 2009). Younger women are a growing group of breast cancer survivors (Avis et al., 2005). According to these statistics, more women are being treated and more will suffer sexual dysfunction in relation to treatment.
Definitive studies have associated chemotherapy with sexual problems. Sexual problems occur with considerable frequency in breast cancer patients and extend beyond the acute phase of treatment. For example, Burwell et al. (2006) conducted a study that recruited 268 women between the ages of 29 and 50 years old. These subjects completed a survey at three point intervals: twenty-four weeks after initial surgery, six weeks after baseline and six months later. The survey included items related to sexuality and quality of life, among other items. Researchers found that sexual problems were significantly greater within the first twenty-four weeks after surgery. Moreover, although sexuality problems decreased over time, they were still greater at one year compared to pre-diagnosis. The study also found that chemotherapy was related to sexual problems at baseline and more extensive for women who became menopausal as a result of chemotherapy treatment. Fobair and Spiegel (2009) state that studies reported sexual problems including vaginal pain continue to be severe at follow-up in women treated with chemotherapy for premenopausal breast cancer.
Similar studies examined the sexual experience of the female breast cancer survivor pertaining to the negative effects of treatment such as dyspareunia. Fobair and Spiegel (2009) found that 67% of 360 sexually active young female breast cancer survivors age 22-50 reported problems such as vaginal dryness which lead to dyspareunia as well as poor mental health. Furthermore, when 185 women in the same study group were re-interviewed, 69% were sexually active, with 56% reporting sexual dysfunction including problems with interest and desire as a result of dyspareunia. In addition, between interviews, hot flashes increased from 41% to 63%, and patients in menopause increased from 40% to 73%. Although surgery and radiation are responsible for some problems that breast cancer patients experience after treatment, sexual problems were worst for those women who received chemotherapy (Fobair & Spiegel, 2009).
While dyspareunia is often overlooked in clinical practice, its etiology is multifactorial. Pain may be perceived at vaginal entry, which is called introital dyspareunia, or deep in the pelvis, which is called deep dyspareunia (Graziottin, 2008). It may be lifelong, generalized, or situational, causing much personal and psychological distress (Graziottin, 2008). Furthermore, because of its solid biological etiology, dyspareunia has a frequent comorbidity with lower urinary tract infections, sex associated and recurrent cystitis, vulvodynia, recurrent candida infections, vaginal dryness, obstructive constipation, myalgia of the levator ani, endometriosis and disorders of sexual desire and arousal (Graziottin, 2008). These comorbidities are directly related to quality of life (Avis et al., 2005). These clinical conditions often require frequent medical attention including psychological consults to cope, cure or to manage the presenting symptoms.
Vaginal dryness and dyspareunia are significant estrogen-depletion symptoms that affect many breast cancer survivors. Vaginal dryness due to the loss of estrogen is the most frequent contributor to dyspareunia after menopause (Graziottin, 2008). The ovaries function as an endocrine organ as well as a reproductive organ. As an endocrine organ, the ovaries maintain health in young women by secreting steroid hormones such as estrogen, testosterone and progesterone. As a reproductive organ, the ovaries maintain a store of oocytes. An oocyte and granulosa cells are contained in the fluid-filled cystic structure in the ovary called the graafian follicle. Normal ovarian function in young women depends on the growth and development of graafian follicles. Graafian follicles arise and grow from a pool of microscopic structures known as primordial follicles. A store of primordial follicles is necessary to support normal endocrine and reproductive function of the ovary. The granulosa cells are responsible for the production of progesterone. The growing graafian follicle is the major source of estrogen production (Nelson & Popat, 2008).
Estrogen circulates in the bloodstream and binds to estrogen receptors on cells in target tissues such as the breast and uterus. According to Bachmann and Santen, (2008), estrogen is responsible for growth and development of female sexual characteristics and reproduction. Estrogens many effects include maintaining acid mucopolysaccharides and hyaluronic acid, which keeps epithelial surfaces moist; it maintains optimal vaginal blood flow and a well-epithelialized vaginal vault. Estrogen causes the non-keratinized, stratified squamous epithelium of the vagina to be thick, rugated and rich in glycogen (Bachmann & Santen, 2008). During menopause every woman experiences the effects of fluctuating hormonal levels. The estrogen imbalance induces menopause and the noticeable physical and emotional changes such as hot flashes, irregular menstrual periods, vaginal dryness and mood swings. Estrogen deprivation and vaginal atrophy make penetration and intercourse dry and painful (Schover, 2008). Testosterone causes enhanced arousal, orgasm, pleasure and responsiveness. It influences sexual feelings and behavior, boosts libido and strengthens self-confidence and an overall sexual health. Progesterone is the female fertility hormone. It prepares the uterine wall for the implantation of the fertilized egg. In conjunction with estrogen, it prepares, maintains and promotes a healthy gestation period (Bachmann & Santen, 2008).
Many chemotherapy drugs disrupt these normal hormonal processes. Chemotherapy drugs can damage the ovaries thus reducing ovarian reserve, which is the number and quality of oocytes available in the ovaries (Schover, 2008). Chemotherapy drugs can also reduce hormonal output (Schover, 2008). For example, ovarian toxicity is a predictable side effect of alkylating agent-based chemotherapy and is influence by cumulative dose and duration of therapy (Fobair & Spiegel, 2009). Alkylating chemotherapy agents have the potential to cause ovarian failure, premature menopause, and a sharp decrease in circulating estrogen and testosterone in young women (Bakewell & Volker, 2005). Aromatase inhibitors and selective estrogen receptors modulators such as tamoxifen are sometimes used as adjuvant therapy for breast cancer. Tamoxifen has been associated with reports of vaginal dryness, excessive vaginal discharge, abnormal uterine bleeding, vaginal tenderness, orgasmic changes and alterations in libido (Bakewell &Volker, 2005). Aromatase inhibitors prevent the conversion of testosterone to estrogen and also lower levels of circulating estradiol (Bakewell &Volker, 2005). The sudden onset of menopause due to chemotherapy is more symptomatic and more difficult to tolerate than when menopause happens naturally. It has a greater impact on womens quality of life because they are at a higher risk for sexual dysfunction (Bakewell &Volker, 2005). Moreover, libido is diminished as a result of the lowered amounts of circulating testosterone. Hot flashes, weight gain, fatigue, vaginal dryness and dyspareunia have a negative effect on how attractive women feel and contribute to their sexual dysfunction (Bakewell &Volker, 2005). Additionally, the impact of surgery such as mastectomy and lumpectomy and the alopecia associated with many chemotherapy drugs can have an emotional impact on sexual function.
The factors that contribute to sexual dysfunction are many. Some patients may present with all or some of the following symptoms. Emotional symptoms of sexual dysfunction include: lack of desire, lack of interest in intimacy and sexual activity, fear of pain with coitus, and/or orgasmic dysfunction are seen in patients. In addition, problems sleeping and anxiety are also presenting symptoms, or patients may simply present in a depressive mood. The physical presentation of sexual dysfunction includes: introital pain that may appear inflammatory with or without infection, as well as deep vaginal pain, vaginal dryness, redness, and painful areas on the vulva. The loss of vaginal epithelium elasticity, increased sub-epithelial connective tissue, loss of rugae, shortening and narrowing of the vaginal canal, reduction in vaginal secretions and increase in vaginal ph to greater than or equal to five are a part of physical presentation (Bachmann & Santen, 2008). Moreover, in relation to hot or cold flashes, patients may describe sudden heat intolerance; perfuse sweating, and rapid heartbeat.
Assessment of clinical presentation and symptom management is the role of the oncology nurse in relation to the cancer patient population. The oncology nurse plays a pivotal role in improving the sexual health of young women with breast cancer. Making sexual health a part of a routine assessment can help to eliminate fears, improve patients level of comfort and provide an environment for further discussion (Bakewell & Volker, 2005). Although sexual functioning is an important quality of life issue it may be difficult for women to initiate discussions; hence, these issues should be brought up by the clinician (Avis et al. 2005). The oncology nurse should readily provide interventions to help women feel more sexually attractive and be willing participants in their sexual experiences. The oncology nurse should ask open-ended questions and use normalizing language, such as: Many women express some dissatisfaction or change in their intimate relationship with their partner since their breast cancer diagnosis and treatment. Has this been an issue for you? This question can open many opportunities of communication, validate patients concerns and attest to their importance (Bakewell & Volker, 2005).
Moreover, patient education is of paramount importance. Some patients have complained that they were inadequately prepared for chemotherapy-induced menopause and were surprised by the abrupt onset. They would like relief for hot flashes, vaginal dryness, dyspareunia as well as loss of sexual desire (Fobair & Spiegel, 2009). The oncology nurse prepares and counsels the patient for their expected disease process and treatment and provides the necessary nursing interventions for management and coping. Effective nursing care and nursing education culminate in better patient satisfaction and thus better clinical outcome.
Many differential diagnoses are associated with this clinical presentation. They include, but are not limited to: chemotherapy-induced menopause, vaginal dryness, vaginismus, vaginitis, vulvar vestibulitis, vaginal atrophy, postcoital cystitis, interstitial cystitis and depression. The differential diagnosis for deep vaginal pain could include endometriosis or pelvic inflammatory disease (Graziottin, 2008).
Lack of proven, evidence-based intervention is a major barrier regarding effective treatment of sexual dysfunction. However, there are pharmacological and non-pharmacological options available for management of the presenting symptoms.
Vaginal estrogen treatment is the first choice when no contraindications are present and when dyspareunia is associated with genital arousal disorders and hypoestrogenism contributing to vaginal dryness (Graziottin, 2008). However, utilizing estrogen therapy in breast cancer patients remains controversial. The nurse may suggest the use of vaginal lubricants such as Astroglide and K-Y jelly immediately before sexual activity. A polycarbophil vaginal moisturizing gel, such as Replens, is to be inserted into the vagina three times per week but not immediately before sexual activity. Replens decreases mean vaginal pH and increases vaginal moisture and secretions, improves elasticity and improves overall vaginal health (Bakewell & Volker, 2005).
The addition of testosterone to hormone therapy has been shown to improve sexual function and libido; however, testosterone is contraindicated in hormone-dependent cancers, patients with a history of DVT and liver dysfunction (Schover, 2008). Bremelanotide is a new melanocortin receptor agonist in phase III trials and appears to be the first centrally acting aphrodisiac (Schover, 2008). It may be a future option to stimulate and bring positive change towards treatment of the loss of sexual desire in women (Schover, 2008).
For the management of hot flashes, consider premarin and provera as well as transdermal estradiol. Estrogen and progestational agents reduce hot flashes by as much as 90%; however the likelihood of an increased risk of breast cancer recurrence with their use rules them out for most women (Schover, 2008). Venlafaxine, fluoxetine and paroxetine are alternatives for hot flashes in women when hormone therapy is contraindicated, as well as a consideration for treatment of depression.
Stress management, relaxation training and cognitive-behavioral therapy may be a consideration for hot flashes. Patient education on managing hot flashes should include avoiding hot beverages, spicy foods and caffeine, as these act as triggers for some women. Regular, mild exercise, such as walking, can help relieve hot flashes. Wearing light, all-natural fiber clothing and layering of clothing to allow easy adjustment to ambient temperatures. Keeping core body temperature low may prove beneficial in the management of hot flashes. Elkins et al. (2008) in a randomized trial of sixty female breast cancer survivors concluded that hypnosis appears to reduce perceived hot flashes in breast cancer survivors and may have additional benefits such as relief for anxiety and depression as well as the improvement of sleep. Studies have also seen some success with acupuncture.
For sexual dysfunction management: sexual counseling, pelvic floor muscle relaxation, sexual communication, improving self-esteem and body image, healthy lifestyle changes, focusing on the positive and support from the partner (Schover, 2008). A referral to a marital or sexual therapist to help women process the intense distress of diagnosis and treatment and to preserve communication with their partner is also a consideration (Blakewell & Volker, 2005).
Sexuality is a vital part of human life with the potential to produce new life and create intimacy through shared pleasure in a relationship. It is an essential part of health and overall well being that cancer and cancer treatment can change tremendously. There is significant evidence in the research that breast cancer patients treated with chemotherapy experience dyspareunia and sexual dysfunction in their relationships. Yet sexual health in chronic disease is a relatively understudied area. The etiology of sexual dysfunction in breast cancer survivors has not been well studied. Sexual problems are experienced particularly by younger women who are more vulnerable to changes in healthy ovarian functioning. The success in cancer treatment for breast cancer is offset by the many problems women face during and after treatment, particularly with chemotherapy. With these concepts in mind, more research is warranted to better understand how breast cancer diagnosis and treatment impact the duration of sexual dysfunction. Research is also needed to determine when healthcare providers should intervene and which interventions are most efficacious. More knowledge is also needed to fully understand how cancer treatments contribute to this problem in sexuality. This will allow more evidence-based practice interventions to be a future possibility.
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