Originally published in the Journal of Gynecologic Oncology Nursing, April 1996. Reprinted here with permission from the editor.
The diagnosis of cancer is an overwhelming experience for a woman and her family. Then, before the woman has had time to work through her feelings of shock and grief, she must begin treatment. The short and long term side effects of treatment may also impact on a woman's self worth and sexuality. Many recent studies on the impact of gynecologic cancer on a woman's quality of life find that an important outcome criterion has become measuring survival without significant morbidity (Anderson & Lutgendorf, 1997). The oncology nurse has an important role in patient education and managing side effects, thereby helping each woman maintain her sexuality and quality of life.
Surgery is often used to diagnose, stage and treat gynecologic cancer. A total abdominal hysterectomy or a radical hysterectomy is used to treat ovarian, uterine or cervical cancer. These procedures carry the usual surgical risks of pain, infection, hemorrhage and pulmonary complications. In addition, a hysterectomy can affect a woman's psychological and emotional well-being. Women of childbearing age have been found to experience sadness and anger at the loss of fertility, and women of all ages view the loss of female organs as a loss of femininity (Steginga & Dunn, 1997). Radical vulvectomy and pelvic exenteration are two extensive surgeries that dramatically change a woman's physical appearance and alter her sexuality.
Women who are scheduled to have surgery for gynecologic cancer require careful preoperative needs assessment and teaching. The oncology nurse must help the woman and her partner to understand the surgical procedure and prepare for the postoperative phase. The staff nurse can lessen the likelihood of postoperative complications by encouraging pulmonary hygiene and ambulation. Women are better able to learn and more willing to participate in self-care if their pain is well controlled. The nurse's knowledge of pain medication and non-pharmacologic pain control techniques can increase the patient's comfort, decrease anxiety and help ease recovery (Mann, 1996).
During the postoperative period the patient will need help adjusting to her altered body image. Many women will have to learn to care for a new colostomy or how to catheterize a continent urostomy. Women who have had a vulvectomy will need sensitive counseling to understand that she can still respond sexually. Patients who have had a vaginectomy with reconstruction as part of a pelvic exenteration will need extensive teaching to help them achieve successful sexual functioning.
Gynecologic surgeries can be very painful and disfiguring. The oncology nurse must be willing to consult the endostomal therapist, licensed sex therapist, psych liaison nurse or any member of the health care team to ensure the woman the highest quality of life possible.
Chemotherapy also has an impact on a woman's quality of life and sexuality. Many women find it difficult to respond sexually when they are feeling the fatigue, nausea and diarrhea that are common side effects of some chemotherapeutic agents. As part of the ongoing assessment of a patient, the nurse should ask if the treatments are interfering with the woman's relationship with her family and partner or her ability to respond sexually. Using this information, the nurse can intervene appropriately by obtaining pain medication, antiemetics or antidiarrheals. If fatigue is a hindrance to sexual activity, the nurse may suggest a rest period before sex, the avoidance of a large meal or alcohol or positioning that requires less exertion (Lamb & Wood, 1996.) The nurse may also suggest alternate forms of loving such as cuddling, kissing and massage.
Many chemotherapeutic agents cause bone marrow suppression. When appropriate, the nurse must instruct the patient on neutropenic and thrombocytopenic precautions. If a woman is instructed to avoid people with colds or infections because of neutropenia or to avoid vaginal/anal penetration due to risk of thrombocytopenia, it can increase her feelings of isolation (Boyle, Bertin & Bratschi, 1994). Again the nurse can suggest alternate forms of lovemaking. It may also help the couple to let the partner know that handwashing and wearing a mask will allow them to be close while still protecting the woman from infection.
Alopecia is another common side effect of chemotherapy. The loss of hair is a constant reminder to a woman that she is living with cancer. She may also feel embarrassed because she appears "different." The nurse can provide information about wigs, and many cancer centers have information about local suppliers that are knowledgeable in working with cancer patients. When doing prechemotherapy teaching, the nurse should suggest choosing hats and wigs before the woman begins to lose her hair. Also, nurses may direct patients to support groups that provide classes in choosing colors and make-up to help cancer patients feel more self-confident. It is important for the nurse to let the woman discuss her feelings regarding her loss of hair and the reactions of those around her.
Radiation therapy can be used to cure or control gynecological malignancies. Radiation is usually delivered as 6-7 weeks of external beam treatments. It is important for the nurse to reassure the woman and her partner that the patient is not radioactive and the partner cannot be contaminated by close physical contact. Some women require brachytherapy. This procedure consists of an implanted radioactive source at the tumor site for a period usually lasting 1-4 days. The patient is hospitalized with minimal contact with family or staff. Again, it is important for the nurse to stress that after the implant is removed there is no risk of contamination.
The primary function of the oncology nurse in the radiotherapy setting continues to be patient education, support and symptom management. Fatigue is the primary side effect the radiation patient will experience (Baumann, 1992). The nurse encourages patients to take frequent rest periods to conserve energy for their most important activities.
Radiation causes irritation to the intestinal lining, which causes diarrhea. Women receiving pelvic radiation are encouraged to modify their diets to bland and low residue while on treatment and for one month to six weeks after treatments end. Prescriptions for antidiarrheals are often given to help maintain normal elimination. Careful weekly assessment will also aid in the early detection of cystitis and vaginitis and will lead to prompt treatment.
Radiation also causes changes to occur in the vagina. External beam radiation and implants damage both the vaginal epithelium and the basal layer of the mucosa. It also diminishes the size and number of small blood vessels in the vagina. All of these factors lead to vaginal stenosis and much drier, friable tissue (Bruner, Lanciano, Keegan, Corn, Martin & Hanks, 1993; Keegan & Lanciano, 1992).
Vaginal stenosis and scarring can lead to long term sexual dysfunction and painful pelvic examinations. To help prevent these complications, the oncology nurse should obtain a sexual assessment as early as possible. If the patient has a partner, it is beneficial to involve them in the counseling.
As a means to preventing vaginal stenosis, all patients are given a vaginal dilator and instructions for use. Patients who are sexually active may continue to have intercourse throughout treatment. Couples are instructed to use a water based personal lubricant to protect the dry vaginal tissues. Also, adjusting positions for the woman's increased comfort may be suggested. Vaginal penetration with either the dilator or intercourse has been found to significantly decrease the occurrence of vaginal stenosis and dyspareunia (Bruner, et al., 1993).
Many women do experience vulvar and vaginal inflammation to such a degree toward the end of treatment that intercourse may be too painful. The nurse should reassure the patient that healing will take place and, in the meantime, she and her partner may want to use other forms of lovemaking.
Gynecologic cancers and treatments have many emotional as well as physical side effects that can greatly change a woman's sexuality and quality of life. One Australian study found that 52% of the study participants reported persistent physical difficulties after cancer treatment. The same study demonstrated that the amount of teaching, counseling and practical support made a difference in the quality of life of cancer survivors (Steginga & Dunn, 1997). Oncology nurses need to be knowledgeable in the management of the physical side effects of surgery, chemotherapy and radiotherapy. Nurses must also be comfortable with their own sexuality, so that they are better able to help women overcome fears related to body image and sexual function.