Study was designed to assess the sexual experience, thoughts, and problems of women who were treated with pelvic radiotherapy due to cervical cancer.
METHODS
Twenty-six sexually active patients with the history of a minimum three-month interval of pelvic radiotherapy between March 20 ? June 20, 2014, for routine follow ups and gave consent for trial were enrolled to the study.Sexual life before cancer, diagnosis, and treatment period and its effect on sexual
life were assessed with semi-configurated score scale created by researcher group.
RESULTS
The main themes were postcoital and postmenopausal bleeding as a diagnosis finding, vaginal stricture, vaginal dryness, decreased sexual desire either in partners and in patients as main sexual problems.
CONCLUSION
Health caregivers should be aware of this situation and should encourage to express their problems and should present individual, effective consultancy to each patient.
Keywords: Cervical canser; pelvic radiotherapy; sexual life
According to Turkish cancer statistics in 2009, cervical
cancer incidence seen in women in Turkey has the
ratio of 4.5/100,000.[
Sexual relations which is one of the most important
element of life quality, includes the following concepts; being desirable, being able to reproduce, body image
as well as emotional, intellectual and socio-cultural elements.
There are many factors such as psychology, sociology
and many more that effects the individuals with
cancer or during the treatment in multiple ways.[
Cancer diagnosis and treatments are negatively
effecting individual"s sexual functionalities as well as
sexual health. Therefore, in terms of cancer diagnosis
and individual meaning of the diagnosis, sexual lives
of cancer patients are negatively affected from physical
effects of treatment and variation of treatment in short
and long term.[
Cancer diagnosis and treatments are causing important
health problems that are negatively affecting
individuals" sexual functionalities as well as sexual
health. Invasive cervical cancers are treated with radical
hysterectomy in a surgical way. Menopausal complaints
such as heat complaints, oofectomy, vaginal
dryness are significantly effecting sexual functions.
50% of patients that are receiving an early cervical cancer
treatment experience significant decrease in sexual
activities in addition to exhaustion, depression, gaining
wait, anxiety and dyspareunia. At the same time treatments
such as hysterectomy and radiotherapy are causing
important health problems by negatively affection
body image of woman, individual respect and sexual
life with her partner.[
Radiotherapy in cervical cancer is applied as intracavitary
(Brachytherapy) or externally according to
patients" general health status, type of cancer and intensity
of cancer. Radiotherapy use in treatment causes
significant and continuous changes in woman"s sexuality
and fertility. Radiation dose applied during the
treatment stops the functionalities of overs and causes
permeant sterility.[
After radiotherapy in vagina epithelium; inflammation,
mucosal atrophy, elasticity loss and ulceration in
vaginal tissue can be observed. As a result of traumas
caused by the radiation on vagina epithelium; reduction
in vaginal lubricity, dryness, stenosis in vagina
canal and shortening in length are observed. These
changes in vagina increase the risk of infection and
trauma. Vaginal changes can be observed in first 3
months and continue for almost a year.[6,7] Woman
who undergo radiotherapy generally complain about
decrease in vaginal sensitivity and orgasm capacity,
decrease in vaginal elasticity and dyspareunia. In a definitive
study on this subject, it is identified that 40% of
woman with sexually active life complain about dyspareunia
and 50% of woman with sexually active life
complain about decrease in vagina length.[
In the study of White et al. on 60 women who undergo
radiotherapy, it is found that 42% of women have
experienced vaginal toxicity due to radiotherapy. It is
established that vaginal bleeding during sexual intercourse
has increased 17 times after radiotherapy. It
is found that 15.9% experiences vaginal stenosis and
decrease in the length of vagina and 13% experienced
vaginal dryness after radiotherapy. 32.2% of women
immediately experienced vaginal symptoms, 55.5% experienced 6 months after the treatment and 48.2%
experienced 12 months after the treatment.[
In a similar study of Freeman and Graves (1982)
they found that the most common problem woman
who had radiotherapy due to cervical cancer, experiences
decrease in desire/lust, dyspareunia, difficulty in
penetration and difficulty of orgasm.[
In quantitative studies in literature on woman who
had radiotherapy due to cervical cancer, generally evaluates
sexual functions. Qualitative researches on partner
effects and consultancy requirements of patients
with cervical cancer and radiotherapy treatment are
limited.
Identifying patient experiences and consultancy
needs of patients who have cervical cancer and got a
treatment could be beneficial for problem based effective
consultancy.
Purpose:
This study is structured to determine the sexual life experiences,
thoughts and problems of women who has
pelvic radiotherapy.
The subjects of the study are 17 women with active
sexual life and willing to participate the study who have
applied to Istanbul Cerrahpaşa Medical University,
Gynaecology and Obstetrics Department, Gynaecologic
Oncology Unit at least 3 months after pelvic radiation
treatment and who applied the clinic for control.
To collect data semi-structured interview forms are developed
by researchers that questions effects of sexual
relations after pelvic radiotherapy due to cervical CA
diagnosis and these surveys are used and questionnaire
questions asked are shown in Table
Findings
Characteristics of Subject Group
Participants ranged between 42?69 years old (median: 55±11.7). 9 of the subject have elementary school education,
1 middle school, 6 high-school and 1 university
graduate. 9 of the women had abdominal hysterectomy
and bilateral salingy oophorectomy (TAH+BSO) surgery.
Participant have given birth to 1?6 children (median:
2.47±0.5). The women who participated to the
research have 3.17±0.6 years of treatment.
7 participants had hypertension, 3 have diabetes, 2
have thyroid and 1 have heart disease. Treatment and
radiotherapy of women ranges between 1?16 years and
each participant had 5 sessions of radiotherapy. Before
cervical cancer diagnosis 14 women consulted to hospital
with over bleeding, 2 with post-menopausal bleeding
and 1 with bleeding after intercourse (Table
Table
It was found that 76.47% of the women participated in the study with vaginal bleeding, 11.76% with bleeding during intercourse and 11.76% with pain during intercourse. All of the women were diagnosed by cervical biopsy.
Women who participated in the study had vaginal pain in 41.17%, vaginal dryness in 11.76%, vaginal dryness in 29.41%, and vaginal dryness in 11.46% and vaginal dryness and pain in 11.66% 5,88% were not a problem. Vaginal pain was the most common problem with 41.17% after radio therapy.
Women"s sexual experience before cancer diagnosis
For most of the woman, sexuality is a complex feeling
with physical appearance, feeling like a woman, having
children and continuing sexual functionalities. In fact
sexuality is effected from various factors.
Mrs B. Z. explains the sexual life before the cancer diagnosis as follows: "I never had an orgasm during my marriage, I don"t know if all woman are like this or maybe my full-grown composition blocked me, I don"t know. We are good with my husband, we have similar ideas but we are not going out with holding hands. I guess we never had sexual chemistry and maybe that is why I never had orgasm."
Menopause period may be the most effective period on sexual life. D.A. who has 60 years old and in menopause period states sexuality before cancer as follow: "we didn"t have any problem in our sexual life until menopause. In this period I had pains and my willingness was decreased."
Symptoms and Effects Related with
Cervical Cancer Before Cancer Diagnosis
In this study first complains before cervical cancer
diagnosis is asked to the patients. Diagnosis and
complains to go to a clinic are long term vaginal bleeding,
post-coital bleeding, vaginal secretion and post-menopausal bleeding. In diagnosis pap smear test and
cervical biopsy methods are used. In our study women
with cervical cancer diagnoses visit a doctor with most
common complain of post-menopausal bleeding and
bleeding after sexual intercourse.
Mrs. K. B age 65, describes what has happened
before diagnosis: "I had lots of pain. Especially in my
pubic, it was like labour pain and I felt it on by back.
Recently I have started to lose weight. I went to the doctor;
they took samples and then the diagnosis is made."
Mrs. F. K. age 52 in post-menopausal period describes
the difficulties in diagnosis stage as follows: "I
was in menopause and I didn"t have bleeding for a long
time. After the menopause when I have bloody secretion
I was very afraid and I went to the doctor. They
made some tests and took some samples. The result
from the samples show that I have cervical cancer. I feel
lucky that the treatment start immediately and I have
early diagnosis."
A. Y. describes the problems and diagnosis process
as follows: "I had excessive vaginal bleeding and went
to control it, biopsy is made and I had a diagnosis. I was
devastated when I hear the disease, It affected me greatly.
My psychology was negatively affected and I thought
if my womb and overs are taken I will never have an
intercourse again and my womanhood will end.
C. G. defines the diagnosis process as follows: "I
had good sexual life with my husband but after every
intercourse there was yellow secretion and then bleeding.
Therefore I went to doctor, smear test is conducted
and diagnosis is made."
K. B. who has her first sexual experience in 16 and
is now 65 tells about the complaints before diagnosis " I
had too much pain during intercourse and this complain
increased recently. That is why I went to see a doctor."
In addition to physiologic and psychologic complains
with cancer diagnosis, cervical cancer can prevent
women from having children especially for women
in reproduction age. Two participants who came to
clinic for infertility treatment and diagnosed as cervical
cancers, tell about their dreams of having children
are ended with cervical cancer.
B. Z. who has her first sexual intercourse in age 15
describes diagnosis process: "I went to control for invitro
fertilization, they told me I have a bigger problem
than infertility, I had a biopsy and cervical cancer diagnosis
is made. After that I had surgery and my chance
of having a child is gone forever. Me and my husband
were greatly affected, and idea of not having a child
devastated us."
B. Z. tells about what happened when she went for infertility treatment "we went to the doctor to have
children but after the tests, cancer diagnosis is made.
When I heard my uterus and ovum will be taken, me
and my husband were devastated again. It means that
we will never have a child. We had difficulties in decision
stage but we should do what is best for my health..."
Effect on Sexual Life Of Surgical Treatment
After Cervical Cancer Diagnosis
In a study of Taejong Song et al. where they have
investigated effects of surgical treatment in cervical
cancer patients on sexual functionality, they have
compared 39 cotter conisations, 18 radical trachelectomy
and 24 radical hysterectomy surgery and their effect
on sexual functionality, and it is seen that women
with radical hysterectomy have significant decrease in
sexual functions. The results show that women with
radical hysterectomy have difficulty in sexual arousal,
difficulty in orgasm, decrease in sexual lust, decrease in
sexual satisfaction and labial lubrication than women
with other operations. It is identified that radical trachelectomy
and radical hysterectomy conducted on early
stage cervical cancer significantly threatens sexual
functions of women.[
P. Ş. states the anxiety about the surgery: "I thought
I would never have an intercourse and my womanhood
is ended. After the surgery, I had painful sexual intercourse.
It took a long time to accept is and I had bad
psychological mood."
B. Z. defines sexual life after the surgery as follows:
"I had serious pain in sexual intercourse after the surgery.
I only felt pain..."
Sexual Problems and Effects After Pelvic
Radiotherapy Due to Cervical Cancer
In a study by Krychman et al. on 179 women with pelvic
radiotherapy, they determined that 57% experience
dryness, 59% dyspareunia and 38% vaginal narrowness,
85% decrease in sexual desires, 35& vaginal dryness,
45% shortening in vaginal length problems are
identified and it is seen that 63% of participants can
have active sexual treatment after treatment.[
L. M. states sexuality after treatment as follows: "I
didn"t have sexual intercourse until my control. In the
examination doctor told me that my vagina is narrowing
and if I don"t have sexual intercourse it will close
and I couldn"t have examination. We are having mandatory
sexual intercourse. Since my vagina is really
narrow, I have excessive pain before and after the intercourse."
İ. M. tells sexual life after radiotherapy: "I had vaginal
dryness complaints. I used vaginal gel and I didn"t experience
any problems. My sexual desire and lust are continuing.
At first I was afraid of the intercourse but now
the fear has decreased and I am starting enjoy it again."
Schover et al. conducted a study on 61 women with
26 radical hysterectomy and 35 radiotherapy treatment
found that sexual desire losses are 24% in the first examination,
25% in 6th month and 25% in 12th month.
Similarly in 12th month orgasm problems are recorded
as 27%. The number of sexual complains are high. It
is stated that in 12 months" vaginal penetration is 21%
and 45% of women are suffering from excessive pain
during intercourse and 24% of women have post coital
vaginal pain. Additionally, 29% of women have
experienced vaginal bleeding after intercourse for 12
months. These types of sexual problems are significant
and there is sexual functionality disorder diagnosis in
other studies.[
E. S. states sexual life after radiotherapy: "I didn"t
have any sexual life during process. I was ashamed of
myself. I think my emotions are also effected. My mum
also died from cancer, and I guess it is also effecting.
But after the surgery sexual desire has decreased significantly
and I am too tired. I think it is because of the
treatment."
N. B age 49 and having a treatment for 5 years feels
the sexuality as: "I don"t feel a desire for sexual intercourse.
I don"t want to have sexual intercourse. Tiredness
is too high, I guess it is because of the treatment. I
didn"t experienced any other problem that decrease in
sexual desire."
C. G. stated the sexual problems after the treatment
as follows: "It is like there is a wall inside and we cannot
move further. At entrance, there is excessive pain and
pressure, just like you are going to burst, but then you get used to it. During ejaculation there is the feeling of
burning like you are spraying pepper. I don"t know how
long it will take but it hurts too much. My vagina is not
wet as before and it makes it harder."
In literature study of Ellen A. G. Lammerinka et al.
on sexual functionality of patients with cervical cancer,
when they investigated pain during sexual intercourse
(dyspareunia) after cervical cancer, they have concluded
that patients are describing pain during intercourse.[
In a study of Schover et al. they have found that
women who took radiotherapy have decrease in sexual
desires compared to women who only had surgical operation.
On contrast in a study by Frumovitz et al. there
is no significant difference between surgical treatment
and radiotherapy.[
A. Y. age 42 states sexuality as follows: "I thought I
will not have sexual intercourse because of my disease,
my morale was low and I think I didn"t desire because
I was effected too much. After 6 months I was more
comfortable. Now I don"t have any decrease in my sexual
desire and I think I have good sexuality."
The Most Effective Events on Sexual Life of
Women After Cervical Cancer Treatment
In the study of Park et al. it is found that women
who had radiotherapy has intensive pain compared to
other treatments. On the contrary the study of Hsu et
al. show no significant difference. Pieterse et al. found
that radiotherapy after surgical treatment increased
sexual functionality disorders and pain during sexual
intercourse.[
In the research of Soymak and Matthews conducted
with 16 women from New Zealand who had stage
III cervical cancer and the treatment is continued with
surgical operations or radiotherapy, 14 weeks after the radiotherapy approximately two third of women experiences
decrease in desire activities and in terms of arousal
and satisfaction, they have experienced low or medium
degree of satisfaction.[
B. Z. tells the sexuality after treatment as follows: "After
the treatment I had excessive pain. Since I have painful
sexual intercourse my sexual desire decreased. I previously
had orgasm problems and I felt that this problem
has increased. I can define sexual intercourse as pain,
pain, and more pain. It has a hard process for me."
In literature study of Ellen A. G. Lammerinka et al.
on sexual functionality of patients with cervical cancer,
when they investigated pain during sexual intercourse
(dyspareunia) after cervical cancer, they have concluded
that patients are describing pain during intercourse.[
In the study of Park et al. it is found that women
who had radiotherapy has intensive pain compared to
other treatments.
55 years old G. C. described sexuality as: "I felt like
my vagina is narrow. During intercourse, there was
dryness and pain. I even had pain when I go to toilet.
When we try too hard during intercourse I had bleeding.
And now I can tell that I don"t have sexual life."
Behaviour of Husbands During
Disease and Treatment
During cancer diagnosis and treatment communication
and relation with the husband can be effective.
In the research of Michelle S. Williams et al. 220
women are investigated, the participants consist of 49
cervical cancer patients and 171 healthy people. The
study is made to evaluate psychological obstructs in
cervical cancer. They have stated husbands behaviours
as follows; "after cancer, my partner will be loyal to me,
I would leave and marry my partner since I will experience
sexual problems, I need a strong partner for
sex, there is love between us and we should search for
treatment options, I should support my wife emotionally".[
Husbands behaviour and attitude toward sex after cervical cancer diseases caused women to get distant
from sex and the fear of divorce. F. K. is explaining
what she has gone through this process: "my husband
left me as he thought I would give the disease to him. I
was forced to obtain a written report from my doctor
that the disease is not contagious. In this hard period,
trying to save my marriage was also devastating."
Cancer patients require social support for diagnosis
and treatment process. They are expecting the support
mostly from their husbands. Some men didn"t care
about the situation and some men support their wife.
E. S. tells the diagnosis as follows: "I had great support
from my husband. The angry man was replaced
with a new one. When I asked him how did he feel
while I was gone for treatment, he said that the house
was empty without me."
Husbands Reaction to Sexual
Life After Pelvic Radiotherapy
A. Y. stated how her husband ignored her status:
"my husband was only doing for him and then gone.
We are having sexual intercourse because he wants to."
K. B. claims that her husband was not effected: "my
husband did not get effected. He still has desire. At the
beginning of the treatment doctor forbid us to have
sexual intercourse. Now there is not a problem, and my
pain does not affect him."
F. K. states that her husband was not supportive:"
my husband left me for the disease. He said you are
sick and you will get me infected and filed for divorce."
C. G. explains the problems of her husband as :"at
first as my vagina is narrow he also had problems until
we get used to it, but after 3-4 minutes the problem disappears
and it is like my vagina is extended. There was
also decrease in desire in him. It is like we don"t have
our old freedom. I guess he felt like he would harm me."
Having Support for Sexual Problems
In many researches the reasons why nurses do not
discuss sexual anxiety and problems with oncology patients
are stated as follows; lack of time, focusing on
cancer treatment and patient do not desire to discuss,
lack of information, beliefs and behaviours toward
sexuality and anxiety to harm patients privacy.[
In the study by Kotronoula et al. (2009) which evaluated
18 researches in systematic review, it is emphasized
that taboos and prejudices of nurses are preventing
the discussion of sexual related subjects.[
In our study although women are coming to regular
controls for cancer and radiation treatment, they find
it embarrassing to talk about sexual problems, they do
not know how to ask, they did not see sexuality as a
significant problem, the insufficient time during examination,
there is no comfortable area to talk about
the problem, not reaching the nurses because of work
load type of reasons are causing them not to get help
and they are trying to find their own solutions. Only
1 in 17 participants stated that she was getting support
and 16 claimed that they were getting informed during
anamnesis in the examination. The patients have not
identified their sexual problems and complains before
they were asked and did not think of taking and support
or consultancy.
K. B. explains why she did not share her sexual
problems: "I haven"t talked to anyone about this subject.
I cannot tell anyone. I am really ashamed. You
were the first one to share."
B. Z. stated that they have support: "at first I did get
support. We have a psychotherapist. She said we will
come through our problems by spending good time
with my husband. We are better now."
L. M. told that she did not have support because
she was ashamed: "I haven"t talked to anyone since I
was ashamed. You were the first one to share. I was informed
during examination but it was not much. Now
I have more information. Thank you."
One of the most common complains before cervical
cancer diagnosis is excessive bleeding and pain.[
Women who participated to the study stated that due
to surgical treatment for cancer they have problems
such as body image, fear of losing womanhood, fear
of ending the sexual life and not having a child again.
In the study of Carpenter et al. (2009) on 175 women
identified that there are significant differences between
sexual ego schema and gynaecologic cancer.[
It is known that pelvic radiotherapy for cervical cancer
effects sexual life significantly. Women who participated
to this study state that vaginal dryness, vaginal narrowness,
shortening in length of vagina, dyspareunia
and excessive bleeding during intercourse after pelvic
radiotherapy has effected the sexual life significantly.
Especially at first diagnosis stages patients experience
anxiety or depression. In literature, it is stated that cancer
patients with high distress have identified sexual
problems more and in these patients, it is claimed that
there are decrease in interest towards sexual relationship,
decrease in sexual arousal and decrease in orgasm.
Additionally related with the disease there are physical
functionality disorders, feeling tired and intense sexual
function disorders and relationship with the husband
can make these problems worse. Treatment Process after
the first diagnosis effects patients" sexual functions
and sexual lives negatively.[
Sexuality is a concept involving emotional states in addition
to sexual intercourse. In another word sexuality
is a complex concept that covers individuals behaviour,
interpersonal relations, psychosocial and physical
properties and it can change according to each patients
and partners age, behaviour and cultural values.[
In this study women who had pelvic radiotherapy
claimed that their husbands are effected from vaginal
narrowness, vaginal dryness and decrease in sexual desire.
The women claimed that the husbands either didn"t
understand them, continued to sexual intercourse no
matter what or being supportive during the process.
Sexuality is still a taboo for our people. Nurses have the
key role to determine and guide the patients with sexual
anxieties and problems.[
In every period sexual lives of women are effected due to various reasons and pelvic radiotherapy for the treatment of cervical cancer makes the situation more complex. Health professional should be aware that after pelvic radiotherapy care and treatment cancer cause sexual problems and women should be encouraged to talk about the problems and individual based consultancy should be presented.
Disclosure Statement
The authors declare no conflicts of interest.
