Expert Reviews ajog.

org

Management of sexuality, intimacy, and

menopause symptoms in patients with
ovarian cancer
Margaret Whicker, MD1; Jonathan Black, MD1; Gary Altwerger, MD; Gulden Menderes, MD;
Jacqueline Feinberg, MD; Elena Ratner, MD

Introduction
Sexuality, intimacy, and menopausal Issues of sexuality, intimacy, and early menopause significantly impact the quality of life
symptoms (SIMS) are common among of patients following the diagnosis and treatment of ovarian cancer. These are under-
women treated for ovarian cancer,1-4 with treated problems. Successful treatment requires the provider’s awareness of the
almost 50% of women experiencing problem, ability to identify it, and willingness to treat it. Unfortunately many providers do
some dysfunction.5 Ovarian cancers are a not address these issues in the pretreatment or perioperative period. Furthermore,
histologically diverse set of malignancies patients do not often alert their providers to their symptoms. While systemic hormone
that affect women across the age spec- therapy may improve many of the issues, they are not appropriate for all patients given
trum and necessitate treatment that can their action on estrogen receptors. However, other nonhormonal treatments exist
range from the removal of 1 ovary to an including selective serotonin reuptake inhibitors, antiepileptics, natural remedies, and
extensive debulking surgery combined pelvic floor physical therapy. In addition psychological care and the involvement of the
with chemotherapy (often multiple lines) partner can be helpful in managing the sexual health concerns of these patients. At the
and radiation. The degree of sexual time of diagnosis or at initial consultation, women should be informed of the potential
dysfunction a patient experiences is physiologic, hormonal, and psychosocial effects of ovarian cancer on sexuality and that
directly related to the extent of the there is a multimodal approach to dealing with symptoms.
treatment she has undergone. As a result
of their treatments, patients experience Key words: intimacy, menopause, ovarian cancer, sexuality
physical and psychological morbidity
including vaginal dryness, dyspareunia,
loss of sensation in the genital area, Sexual dysfunction in women with highlighting the need for appropriate
decreased libido, hot flashes, decreased ovarian cancer interventions to enable ovarian cancer
sexual desire, decreased ability to achieve SIMS encompasses a broad range of patients to maintain a high quality of life
orgasm, depression, anxiety, changes in physical and psychological symptom- with satisfactory sexual function.6
self-image, and interpersonal relation- atology. Many premenopausal women
ship changes with their partners and will experience abrupt menopausal Cancer treatments effects on sexual
loved ones. While many of these changes symptoms secondary to hypo- health
can be attributed to the change in circu- estrogenemia after cytoreductive surgery Sexual dysfunction most commonly oc-
lating hormones and hormone regulation or gonadotoxic chemotherapy, inducing curs after treatments involving surgical
after oophorectomy, chemotherapy and hot flashes, mood changes, and vaginal cytoreduction, chemotherapy, and radi-
radiation also influence SIMS. dryness or atrophy.2,4 Regardless of ation.7 Surgical management of gyne-
menopausal status, when sexual activity cologic malignancies can bring about
is attempted, ovarian cancer survivors sexual dysfunction by altering physi-
report significantly higher levels of ology and perceived body image. While
From the Department of Obstetrics, discomfort and decreased pleasure with ovarian cancer encompasses a number of
Gynecology, and Reproductive Sciences, Yale sexual activity in comparison to age- histologically diverse cancers, the surgi-
University, New Haven, CT. matched controls in the general popu- cal treatment of ovarian cancer usually
1
These authors contributed equally to this lation.6 Many women struggle with consists of removing the cervix, uterus,
article. initiation or maintenance of sexual fallopian tubes, and ovaries. Interest-
Received Feb. 9, 2017; revised April 3, 2017; arousal and with attainment of orgasm.1 ingly, after total hysterectomy, women
accepted April 4, 2017. have no difference in sexual function
Apart from the physical symptoms,
The authors report no conflict of interest. >50% of ovarian cancer patients re- when compared to supracervical hys-
Corresponding author: Jonathan Black, MD. ported decreased libido and lack of terectomy.8 Therefore, after cytoreduc-
[email protected] tive surgery, sexual dysfunction is
desire to initiate intercourse, compared
0002-9378/$36.00 to 25% of healthy controls. However, thought to be secondary to loss of sys-
ª 2017 Elsevier Inc. All rights reserved.
http://dx.doi.org/10.1016/j.ajog.2017.04.012 both groups place similar value on the temic hormones. After oophorectomy,
importance of sexual activity, there is a clear decrease in sexual

OCTOBER 2017 American Journal of Obstetrics & Gynecology 395

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function and desire, particularly in the chemotherapeutic agents (including frequency of sex and intimacy in 79% of
younger premenopausal patients.7,9-12 platinum-based therapies used in the male partners of women affected by
The effect of oophorectomy on sexual majority of ovarian cancer patients) cancer. Changes to sexuality were asso-
function in a postmenopausal women is target dividing cells, which can affect the ciated with feelings of self-blame,
less clear. The studies evaluating the production of estrogen and androstene- reflection, sadness, anger, and lack of
impact of oophorectomy of sexual dione in granulosa and theca cells. sexual fulfillment.28 In the same study,
function in postmenopausal women Similar to surgery, chemotherapy can male partners of women diagnosed with
have been inconsistent. One cross- place a patient into menopause, and gynecological cancer expressed conflict-
sectional study involving 1352 women these patients may have similar symp- ing emotional states including worry
ages 57-85 years who had either bilateral toms as their surgical cohort. They about their significant other’s health,
oophorectomy or retention of their experience vaginal dryness, atrophy, hot desire to engage in sexual activity, and
ovaries showed that oophorectomy may flashes, and decreased libido. Practically, guilt about wanting to increase sexual
not play a strong role in function and patients report decreased sexual pleasure intimacy. Understandably, these con-
sexual ideation in older women.9,13 and decreased sexual activity.16 In the flicting emotional states can lead to
Conversely, another survey showed second group, sexual dysfunction is also resentment and withdrawal from sexu-
75% of patients reported orgasmic reported. This is most pronounced in ality and intimacy, subsequently causing
dysfunction and 62% had issues with patients with recurrent disease and in overall relationship discord.29,30 While
dyspareunia following surgery for married patients.17 Qualitatively, these studies were based on male-female
ovarian cancer in postmenopausal women report decreased desire for sex- relationships, the findings can be
women.5 Additional studies reported ual intercourse, increased pain and dry- generalized to same-sex relationships as
that removal of postmenopausal ovaries ness, and difficulty in discussing these well.
reduces sex steroid levels, in turn leading topics with their partners and their
to a decline in sexual function.9 physicians.18 Barriers to identifying and treating
Regardless of these opposing studies, sexual dysfunction
the removal of postmenopausal ovaries The effect of cancer treatments on Multiple barriers to identification and
decreases testosterone and androstene- intimacy treatment of sexual dysfunction in
dione. Loss of androgenic hormones It is now well known that cancer and its ovarian cancer patients exist. The ob-
leads to decreases in estrogen levels as treatment can have significant conse- stacles begin with the initiation of the
both testosterone and androstenedione quences on the quality of life of patients discussion about sexual dysfunction be-
are converted in the periphery to and their family members, particularly tween a patient and her provider. A 2007
estrogen.14 The loss of these androgenic the patient’s intimate partner.19 Sexuality survey of the members of the New En-
hormones exacerbate the hypoestro- and intimacy are important components gland Association of Gynecologic On-
genic state but also further contribute to of quality of life,20 and there is a growing cologists revealed that while a majority
sexual dysfunction as they are implicated body of evidence reporting that cancer of gynecologic oncologists reported
in libido. Given these findings, oopho- can result in dramatic changes to sexu- comfort with the topic of sexual health,
rectomy in a postmenopausal woman ality, intimacy, and sense of self, therefore 85% of male providers and 73% of fe-
will lead to a decline in levels of andro- negatively affecting relationships.21,22 male providers stated that time con-
gens and estrogens. This hypogonadal These changes can lead to emotional straints limited their ability to formally
state results in decreased libido, hot disruptions between couples23 and feel- address sexuality and sexual function
flashes, mucosal atrophy, and vaginal ings of isolation, anxiety, depression,24 or with their patients.31 Furthermore,
dryness. These symptoms, along with inadequacy.25 Reported disruptions stem many health care providers report beliefs
changes in patient’s body image percep- from decreases in sex drive of the patient that patients will independently raise the
tion following surgery, will lead to and/or the partner, fear of initiating sex, topic of sexual dysfunction if they are
worsening of sexual dysfunction.15 losing “normality” within the sexual experiencing symptoms.32 In contrast,
Patients receiving chemotherapy for relationship, and feeling unwanted patients report hesitancy to broach the
ovarian cancer can be separated into 2 because of cessation of sex.22,26,27 The subject and report feeling similar time
groups: (1) those with at least 1 ovary new dynamics between the patient and constraints during visits with their
remaining in situ (ie, fertility-sparing the partner in the context of a caregiving providers.33
surgery with unilateral oophorectomy relationship as well as the new definition Once the need for treatment of sexual
in a minority of patients and recipients of “appropriate” sexual conduct after dysfunction is identified, effective treat-
of neoadjuvant chemotherapy); and (2) cancer might have an adverse effect on ment presents distinct challenges. Sexual
those who are status postbilateral oo- the couple’s private life. dysfunction in ovarian cancer survivors
phorectomy, representing the majority In a study evaluating the changes in is often multimodal, and single-
of patients. In the patients with 1 ovary, sexuality and intimacy after the diag- approach treatment is frequently insuf-
chemotherapy can have a host of effects nosis and treatment of cancer, Hawkins ficient. Many providers, while agreeing
on sexual function. Most notably, et al28 reported cessation or decreased with the importance of addressing these

396 American Journal of Obstetrics & Gynecology OCTOBER 2017

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issues, feel poorly equipped to manage available in a cream, ring, or tablet form, different methods of therapy initiation.
them.33,34 has been helpful for patients with In this setting, we recommend following
Many of the physical changes induced ovarian malignancies. In women with guidelines laid out by professional or-
by cytoreductive surgery and subsequent ovarian cancer, topical estrogen can be ganizations for menopausal women in
chemotherapy result in abrupt hormonal used safely and easily following surgery. general and then optimizing the indi-
changes and premature menopause in For these patients, topical estrogen vidual patient’s symptoms. Per Amer-
previously premenopausal patients. Sex- therapy is a fast way for patients to regain ican Congress of Obstetricians and
ual pain, often attributable to hypo- elasticity, blood flow, and lubrication to Gynecologists and North American
estrogenemia and vaginal dryness (but the vaginal tissue. Topical estrogen Menopause Society current guidelines,
may also result from postoperative therapy is safe for women with gyneco- local estrogen is the first-line advisable
changes), can lead to profound anxiety logic malignancies, including women therapy for alleviation of vaginal
about sexual activity and negatively with estrogen receptor (ER)-positive symptoms.48,49 Low-dose systemic
impact sexual desire, even when a patient cancers.42 Some studies have shown low therapy can be used in those who failed
expresses an interest in intercourse. levels of systemic estrogen following local therapy. When choosing oral vs
However, hormone replacement in gyne- initiation of topical therapy secondary to transdermal systemic administration,
cologic cancer patients remains contro- the poor barrier properties of atrophic transdermal is chosen for patients with
versial, and many providers are hesitant to vaginal epithelium.43 Following initial higher cardiovascular or thromboem-
prescribe it. However, to date no evidence topical estrogen treatment of the vaginal bolic risk and with more years elapsed
exists that hormone replacement therapy epithelium, however, vaginal atrophy since menopause. Given the elevated
(HRT) adversely affects progression or improves and systemic absorption de- risk of thromboembolic disease in pa-
survival in a majority of ovarian cancer creases as thickened epithelium prevents tients with ovarian cancer, transdermal
patients, although substantial further direct contact with underlying vessels is likely the best first line, although
research is needed.35-39 that can be exposed when the epithelium future research in this area is needed. No
Beyond the physical sequelae of treat- is atrophic. With these findings, there are studies to date addressed the timing of
ment, the psychosocial ramifications of few contraindications to topical estrogen initiation of vaginal or systemic estro-
dealing with their disease and treatment therapy in cancer survivors.7 Contrain- gen replacement therapy in the post-
are complex. Many patients are dealing dications are vaginal bleeding of un- operative period, however we would
with depressive symptoms, fatigue, or known etiology, active or recent arterial advise adhering to standard post-
profound changes in their self-image as a or venous thrombosis, or active liver operative recommendations for post-
consequence of diagnosis and treatment disease. Even for patients with ER- operative pelvic rest prior to initiating
and addressing mental health and positive ovarian cancers, which typi- vaginal therapy in particular.
emotional well-being is often instru- cally includes granulosa cell tumors or In terms of nonestrogen therapies,
mental in improving a patient’s sexual low-grade serous carcinomas, physicians several options have been evaluated.
function.40,41 Furthermore, as previously do not need to be concerned about Ospemifene, an oral estrogen agonist/
discussed, the patient herself is not the adverse effects of topical estrogen ther- antagonist was shown to improve vaginal
only person impacted by her disease. apy given the lack of long-term systemic symptoms, although this is contra-
Partners of ovarian cancer patients often absorption through healthy vaginal indicated in patients with past or current
become the primary caregivers, assisting epithelium. Vaginal estrogen can be used thromboembolic disease.50 Testosterone
with basic activities of daily living, in women with an additional history of was shown to increase libido and thus
including toileting and hygiene. Apart ER-positive breast cancer at the discre- improve sexual function and sexual
from the physical exhaustion partners tion of the oncologist and assuming that satisfaction among postmenopausal
can experience from the constant provi- all nonhormonal options have been women, however this is not Food and
sion of care, the patient may be reposi- exhausted and the patient has been Drug Administration (FDA) approved
tioned as a cancer patient rather than a adequately counseled.42,44,45 for use in women in the United States
sexual partner.28 For these reasons, a Systemic HRT may also be considered although there are reports of it being used
multimodal approach, encompassing in this population. Multiple studies have off-label.51-54 At higher doses, testos-
management of physical symptoms, in- confirmed that systemic HRT in ovarian terone supplementation can induce male
dividual psychosocial support and treat- cancer survivors does not increase dis- pattern hair growth, acne, and hyper-
ment, and partner engagement may be ease recurrence or mortality, and in fact cholesterolemia, but at low doses it is very
necessary to fully address sexual may have a survival benefit.46,47 Sys- well tolerated. Tibolone is a synthetic
dysfunction in some patients. temic HRT is available in multiple for- steroid with estrogenic, progestogenic,
mulations, including oral and and weak androgenic effects that was
Hormonal therapies transdermal. When it comes to opti- proposed for treatment of these symp-
Topical estrogen therapies are helpful in mizing HRT for posttreatment ovarian toms, however it has not been shown to
patients with vaginal stenosis and atro- cancer patients with sexual dysfunction, improve sexual function and is not FDA
phic symptoms. This topical therapy, no major studies have compared approved for use in the United States.55

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Nonhormonal therapies (Enzymatic Therapy, Green Bay, WI). sexual activity.73 Vaginal moisturizers,
In addition to hormonal preparations, These extracts have been preliminarily such as polycarbophilic moisturizers (eg,
there are a number of nonhormonal shown to have a positive effect on libido, Replens, Church & Dwight Co. Inc.,
therapies that can improve SIMS. The sexual dysfunction, and sexual perfor- Ewing, NJ) or vaginal pH-balanced gels
first one to consider is black cohosh mance and pleasure.61-65 Although more (eg, RepHresh, Church & Dwight Co.
extract (eg, Remifemin, Enzymatic research is needed, these product can Inc.) can be recommended to patients
Therapy, Green Bay, WI). An extract certainly be considered as an alternative who experience these symptoms. The
from a member of the buttercup family or adjunct to other pharmacotherapies literature is mixed on the effectiveness of
(Cimicifuga racemosa or Actaea race- in patients with sexuality or intimacy these moisturizers vs placebo but given
mosa), black cohosh is the most exten- issues. As discussed previously, herbal the null side-effect profile and our pos-
sively used and researched natural preparations are not FDA regulated for itive experience with it clinically, it is
alternative to HRT. The mechanism of purity and scant research exists on recommended as a first-line approach if
black cohosh has not been clearly eluci- possible side effects, so patient coun- the provider is trying to avoid hormonal
dated, as it was previously thought to seling and frank discussion of what is and therapy.74,75 Vaginal lubricants (eg, Pjur,
exhibit a phytoestrogenic effect, however is not based in evidence is paramount. Pjur Group USA, Miami Beach, FL or
this has been refuted.56 There is some Selective serotonin re-uptake in- K-Y, Reckitt-Benckiser, Bershire, UK)
disagreement among experts on the hibitors (SSRIs) and serotonin- can also be helpful during sexual activity.
utility of black cohosh in the treatment norepinephrine reuptake inhibitors They are used to minimize dryness, pain,
of menopausal symptoms. While a 2012 (SNRIs) were initially used for manage- irritation, and mucosal tears. They come
Cochrane Review found insufficient ev- ment of vasomotor symptoms occurring in a variety of forms but most commonly
idence to support the use of black secondary to gonadotropin-releasing are water or silicone based.
cohosh for menopausal symptoms at hormone agonist treatment for men Vaginal dilators can also be used for
this time, the authors did report with prostate cancer and women with women with vaginal atrophy or steno-
“adequate justification for conducting breast cancer.29,66,67 Although this class sis. They come in various sizes, shapes,
further studies in this area.”57 There have of antidepressants can have some effi- and colors and are usually made of
been many other studies that suggested cacy in managing vasomotor symptoms, silicone or plastics, of which the sili-
otherwise.56-59 For example, in a ran- they may also worsen sexual functioning cone ones are the most well tolerated.
domized, double-blind, placebo- by decreasing libido.29 Besides decreased They can be used a few times a week or
controlled, multicenter study of 340 libido, there is a spectrum of sexual even daily and should be used with
postmenopausal women, Remifemin dysfunction associated with various an- estrogen cream if allowed or else
was found to improve hot flashes, tidepressants. Therefore, providers vaginal lubricants. They can be left in
vaginal atrophy, and psyche when should take the likelihood of adverse place anywhere between 10-60 minutes
compared to placebo.56 The most com- sexual effects into account when pre- to achieve optimal results. It can often
mon side effects reported are gastroin- scribing SSRIs or SNRIs.68 Among many take up to a month before significant
testinal distress and mild rash.57 SSRIs and SNRIs that are frequently results are achieved. Although adher-
Hepatotoxicity has been raised as a prescribed, citalopram and escitalopram ence to recommendations for vaginal
concern, however a 2011 review of the have proven better efficacy in controlling dilator use has been reported to be low
published literature concluded that vasomotor symptoms with a more toler- in this population due to factors such as
black cohosh itself was unlikely to result able side-effect profile when compared aversion to the practice and intrusive-
in liver damage; although, as with any to venlafaxine and fluoxetine.69,70 ness of the mechanism,76,77 counseling
non-FDA-regulated product, impurities Additionally, limited uncontrolled prior to initiation of treatment and
and adulteration remain a risk.60 Given studies of mirtazapine, a structurally educating women about dilator use may
the conflicting evidence and need for unique SSRI, and bupropion, which acts increase adherence.29,78 In the general
further research, black cohosh may on dopamine and norepinephrine, population, vibrator use has been
certainly be considered in this popula- were associated with better control of associated with positive sexual func-
tion with extensive patient counseling hot flashes with decreased adverse tioning from both an arousal and pain
and education. Anecdotally, from our effects on sexual functioning than standpoint and poses no risks to the
extensive experience with patients SSRIs/SNRIs.29,71,72 patient, and can certainly be considered
experiencing SIMS, there is a clear Vaginal atrophy and dryness can be in this population.79
benefit from using black cohosh extract debilitating. Vaginal moisturizers are
and the side-effect profile is null. nonhormonal products used several Physical therapy
For the natural treatment of decreased times a week to improve tissue quality Pelvic floor physical therapy has become
libido and sexual pleasure, providers can whereas vaginal lubricants are liquids or an increasingly utilized modality for
consider preparations using extract of gels applied to the external genitalia and treatment of pelvic floor dysfunction,80
maca root or ashwagandha root. One vaginal introitus to minimize dryness but is understudied for sexual dys-
such product is Hot Plants for Her and discomfort temporarily during function.81,82 Pelvic floor muscle

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TABLE
Summary of treatment modalities for sexuality, intimacy, and menopausal symptoms
Vaginal Vaginal Vasomotor Loss of Sexual Vaginal
atrophy dryness symptoms libido dysfunction stenosis References
Lubricants Polycarbophilic May attempt May attempt / / / Beneficial if 75,76
moisturizers use prior to use prior to used with
(Replens) first line first line dilators
pH-balanced May attempt May attempt / / / Beneficial if 75,76
gels (RepHresh) use prior to use prior to used with
first line first line dilators
Vaginal dilators May help to May help to / / / Improves 77,78
increase increase elasticity of
blood flow blood flow tissue when
used 15-60
min/night
Black cohosh Remifemin May attempt May attempt May attempt / / / 58-61
extract use prior to use prior to use prior to
hormone hormone hormone
therapy therapy therapy
Maca root or Hot Plants / / / May attempt / / 62-66
ashwagandha use prior to
root hormone
therapy
Vaginal First line First line / / / / 7,45,47,50,51
estrogena
Transdermal Second or Second or Attempt use / / Beneficial if
estrogenb third line third line after herbal used with
remedies dilators
Oral estrogen Second or Second or Attempt use / / Beneficial if
third line third line after herbal used with
remedies dilators
Oral estrogen Ospemifenec Second or Second or / / / / 52
agonist/ third line third line
antagonist
Testosteroned Low dose / / / Not FDA / / 53-56
approved but
shown to
improve
functioning
Synthetic Tibolone / / / / / / 57
steroids
Antidepressants SSRIs and SNRIse / / Use as May cause loss / / 30,67,68
alternative in of libido
patients who
are unable to
take hormone
therapy
Physical Biofeedback and / / / / RCT showing RCT showing 30,81,83,84
therapy pelvic floor improvement in improvement
strengthening function
Psychological Psychoeducational / / / / Associated with / 92
therapy sessions positive effect
on sexual
desire, arousal,
orgasm
Whicker. SIMS in ovarian cancer patients. Am J Obstet Gynecol 2017. (continued)

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TABLE
Summary of treatment modalities for sexuality, intimacy, and menopausal symptoms (continued)
Vaginal Vaginal Vasomotor Loss of Sexual Vaginal
atrophy dryness symptoms libido dysfunction stenosis References
CBT / / / / RCT with / 30,90
improvement
immediately
and at 6 mo
Table summarizes interventions reviewed in article and lays out sequential approach to treatment.
CBT, cognitive behavioral therapy; FDA, Food and Drug Administration; RCT, randomized controlled trial; SNRI, serotonin-norepinephrine reuptake inhibitor; SSRI, selective serotonin re-uptake
inhibitor.
a
Contraindicated when vaginal bleeding of unknown etiology, active or recent thromboembolic event, active liver disease; b May be chosen for vaginal atrophy if patient has higher risk of
cardiovascular or thromboembolic events; c Contraindicated in patients with past or current thromboembolic disease; d May lead to voice deepening, acne, male pattern baldnessepatient needs to
be aware of side effects; e Citalopram and escitalopram were shown to work better for vasomotor symptoms than venlafaxine and fluoxetine; mirtazapine, structurally unique SSRI, was shown to
reduce vasomotor symptoms and has reduced sexual dysfunction profile.
Whicker. SIMS in ovarian cancer patients. Am J Obstet Gynecol 2017.

strengthening, relaxation techniques self-reported sexual dysfunction, Brotto In a study of ovarian cancer survivors 5
with biofeedback, stretching, and mas- et al90 randomized patients to either years posttreatment, overall patients had
sage are promising strategies that can three 90-minute CBT sessions or to a an excellent quality of life, but sexual
benefit cancer survivors.29,80 Among control group wait-list arm. Patients symptoms persisted, with as many as
these strategies, biofeedback has been who underwent the CBT sessions re- 57% of patients reporting a decline in
studied for treatment of sexual ported significant improvements in their sexuality since their diagnosis of
dysfunction in vulvar pain syndrome sexual arousal and desire both at the cancer.96 In another study, it was iden-
patients.83 A small randomized immediate completion of the therapy tified that symptoms were more severe in
controlled trial evaluated the use of pel- and at 6-month follow-up. On the other women <45 years old.97 They experi-
vic floor muscle training in gynecologic hand, patients in the wait-list arm enced worse sexual activity, poorer
cancer survivors and found that the experienced no significant changes in body image, perceived worse vaginal
intervention group reported improve- sexual dysfunction.29,90 function, and more severe menopausal
ment in sexual functionality and quality Another promising approach to symptoms. With proper interventions
of life.84 Given the safety of this therapy, address sexual dysfunction in gyneco- and time, however, ovarian cancer sur-
pelvic floor physical therapy can be a logical cancer survivors is psychoeduca- vivors can approach an acceptable qual-
helpful addition to a multidisciplinary tional intervention, or sessions ity of life compared to age-matched
approach to treating sexual dysfunction combining cognitive and behavioral counterparts.98
in gynecologic cancer patients.29 therapy with education and mindfulness
training.41,91 In a clinical trial of 22 Conclusions
Psychological therapy women with early-stage gynecological Many ovarian cancer survivors have
Gynecological cancer survivors experi- cancer and female sexual arousal disor- SIMS and these symptoms can be
ence many changes in body image and der, Brotto et al evaluated the impact of debilitating to many aspects of their lives.
feelings of well-being, which in turn psychoeducation on sexuality and re- Using a multimodal and interdisci-
affect sexuality and intimacy.29 Anxiety lationships. In this trial, psycho- plinary approach can be helpful in
and negative feelings associated with a education was associated with positive treating SIMS, and the full array of
cancer diagnosis can cause further dete- effect on sexual desire, arousal, orgasm, treatment modalities reviewed in this
rioration in sexual functioning. Subse- satisfaction, sexual distress, depression, article are summarized in the Table.
quently, patients might develop overall and overall well-being. By implementing Psychotherapy can assist with lack of
decreased quality of life and depressive CBT and psychosocial interventions in a desire and orgasms and help address
symptoms.85-87 multidisciplinary platform, cancer care other psychological and interpersonal
Cognitive behavioral therapy (CBT), providers can improve patient satisfac- issues. These issues need to be addressed
which focuses on mindfulness and the tion and quality of life for their early by providers with nonbiased in-
impact of maladaptive thoughts on hu- patients.29,92 formation. A lack of knowledge about
man behavior, has been shown to have the sexual problems patients can expe-
efficacy in treating psychosocial con- Long-term outcomes rience or a discomfort with the topic in
cerns of gynecological cancer pa- For women who undergo treatment of general can no longer be an excuse for
tients.88,89 In a study with 31 ovarian cancer, SIMS can persist years allowing women to experience the
gynecological cancer survivors with after they complete their therapy.16,93-95 morbidity associated with SIMS. We

400 American Journal of Obstetrics & Gynecology OCTOBER 2017

ajog.org Expert Reviews

suggest that at an initial consultation, the 11. Leiblum SR, Koochaki PE, Rodenberg CA, cancer: long-term intimacy needs and concerns
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