] Table 1 summarizes sexual dysfunctions and
their causes in gynecological cancer patients.
Table 1: Sexual dysfunctions and their causes in gynecological cancer patients.
Studies show that psychological variables such as
depression, anxiety, body image, and the inability to
"feel like a full woman" negatively affect sexual functioning
in gynecological cancer.[] In addition, some
studies have shown that sexual dissatisfaction increases rates of depression and anxiety. Levin et al. (2010)[]
reported that sexual morbidity is a significant predictor
of depressive symptoms and body image-related stress.
Another study concluded that sexual dissatisfaction
has the potential to cause high levels of depression and
anxiety.[] Although there is a mutual interaction between
sexual problems and psychological symptoms,
the effects of body image problems, depression, and
anxiety on sexual problems in gynecological cancer
patients will be discussed in this article.
Body Image Concerns
Many studies have noted that gynecological cancer
diagnosis and treatment methods cause deterioration
in the body image of women.[,] Surgical interventions
are the leading cause of such deterioration.
[] After major surgical interventions such as radical
hysterectomy, vulvectomy, and total pelvic exenteration,
many women experience feeling different, such as
appearing less physically appealing to their spouses or
sensing that their attractiveness as a sexual partner will
decrease and their sexual life will deteriorate.[] The
end of reproductive capacity due to uterine deficiency
and thoughts and concerns about sexuality increases
the risk of depression in patients who have undergone
hysterectomy for gynecological cancer.[] After
hysterectomy, in particular, women may experience
intense sadness because of the meaning that women
ascribe to the uterus and their belief in losing their
feminine identity. Negative thoughts about physical
appearance and negative sexual self-perception may
develop in patients after surgical treatment and subsequent
adjuvant radiotherapy treatment.[] Alopecia,
fatigue, nausea, and vomiting have been experienced
after chemotherapy treatment, which can affect
women's self-esteem and sense of sexual attractiveness.
[] All of these problems affect women"s sexual lives
negatively by increasing their feelings of fear, anxiety,
and depression. In addition to body image problems,
fear of cancer recurrence, post-traumatic stress disorder, anxiety, and depression symptoms persist. Depressed
mood, altered self-image, and increased anxiety
due to psychiatric illness and psychopathology may
cause sexual dysfunction in women.[]
Anxiety
Anxiety is a symptom frequently observed in cancer
patients. While the anxiety levels of newly diagnosed
cancer patients may increase up to 50%, chronic anxiety
may continue in 30% of patients in the long term.
[] Psychological challenges experienced by women
during the gynecological cancer process include fear
of death, fear of being dependent on others, uncertainty
about the future, problems related to fertility,
loss of role and function, and economic issues, which
can cause anxiety.[] When the relationship between
anxiety and sexual function is examined, it can be
perceived that the presence of pain during sexual intercourse
may trigger anxieties about pain before intercourse,
and it may also reduce sexual satisfaction
and orgasm experiences.[] A study of women with
gynecological cancer reported that 69% of participants
feared that their cancer would recur, while 66%
feared that their cancer would spread, and 54% were
uncertain about their future. The same study determined
that 45% of women felt sad, and 44% felt depressed
and experienced anxiety.[] Such research
findings indicate that anxiety causes sexual dysfunction
disorders in women.[,]
Studies have shown that 50% of women with orgasm
inhibition and 88% of women with dyspareunia
and vaginismus have anxiety as defined by psychiatric
diagnostic criteria, and 44% of women with panic disorder
experience sexual dysfunction.[,] Regarding
anxiety as the cause of sexual dysfunction, the literature
explains that increased sympathetic activity brought on
by anxiety in women disrupts genital vasocongestion.
This is because the inhibition of the parasympathetic
nervous system impairs sexual stimulation.[] Impairment
of genital vasocongestion may then impede
lubrication and sexual arousal in women, and dyspareunia
and vaginismus may adversely affect the sexual
lives of couples as a result.[] Consequently, a lack of
sexual stimulation can lead to low sexual interest, sexual
reluctance, and the inability to experience orgasm.
Depression
About 25-42% increase in the incidence of depression
in gynecological cancer patients has been reported due to physical (location of the tumor and presence of
pain), psychosocial (stress and individual's maturity),
and social (interpersonal relations) factors.[] In addition,
studies investigating psychiatric comorbidities
in gynecological cancer patients have shown that approximately
one in five women treated for gynecological
cancer (cervical, endometrial, or ovarian cancer)
has depression.[] Moreover, depression can be seen
in women during the gynecological cancer treatment
process due to many factors. These include anxiety
based on uncertainty about the treatment process, fears
of the cancer spreading to other organs and of death,
changes in female identity, body image, and sexuality,
difficulty in daily living activities, and lack of emotional
support.[] Depression may also occur due to
the removal of the ovaries in radical hysterectomy and
the loss of estrogen as a result of entering menopause.
The resulting symptoms manifest themselves as genitourinary
trophic disorders and neurovegetative and
psychiatric symptoms.[,] The hormone estrogen
plays a role in the development of many organs and
tissues, and it can have permanent effects on the organization
and development of the central nervous system.
In particular, estrogens affect brain chemistry by
changing the concentration of many neurotransmitter
amines, so estrogen deficiency, hot flashes, sleep disorders,
depression, and mood changes can be seen.[]
Estrogen deficiency constitutes a biochemical basis for
the development of depression. Tryptophan, which
plays a role in serotonin metabolism, is important for
preventing depression. Although the amount of total
tryptophan does not change in postmenopausal and
post-oophorectomy women, these women experience a
decrease in free tryptophan, which causes a decrease in
serotonin. Therefore, decreased serotonin in the brain
tissue leads to depression.[,] The increase in plasma-
free tryptophan levels and a decrease in depression
complaints with estrogen treatment reveal the relationship
between estrogen and depression. The reason that
depression causes sexual dysfunction is found in the
neurotransmitter dopamine.[] Dopamine is considered
to have a facilitating effect on sexual response
and desire, and dopamine levels in the blood decrease
in individuals with depression.[] Studies conducted
with patients with gynecological cancer show the relationship
between problems in sexual life and depression.
Some studies have stated that the sexual problems
experienced by women due to radical hysterectomy can
last from 6 months to 2 years after the operation, and it
has been reported that fatigue, anxiety, and depression
continue for 5 years after the treatment.[,] A study
of women diagnosed with ovarian cancer and undergoing
oophorectomy concluded that 6% of the women had depressive symptoms for years.[] Decreased
sexual desire and arousal are associated with clinical
depression as well as low self-esteem and frequent anxious
and depressive thoughts. On the other hand, some
antidepressant drugs can negatively affect sexuality.
Antidepressants" side effects can include problems such
as decreased or loss of sexual desire, inability to reach
orgasm, painful orgasm, sexual arousal problems, decreased
sexual satisfaction, dryness in vaginal secretions,
dyspareunia, and vaginismus.[]
