Treatment of early stage cervical and endometrial cancer
is associated with significant sexual difficulties and at least half of women
following hysterectomy. The success in treating these cancers has resulted in
a focus on quality of life issues during remission. What can we do to help
these women? Welcome to the clinician’s roundtable. I am your host, Dr.
Leslie Lundt, and with me today is Dr. Lori Brotto. Dr. Brotto, an Assistant
Professor in the University of British Columbia Department of Obstetrics and
Gynecology as well as a Registered Psychologist in Vancouver, Canada. She is a
Director of the UBC Sexual Health Laboratory where research primarily focuses
on developing and casting psychological and psychoeducational interventions for
women with sexual desire and arousal difficulties. She is also the Associate
Editor for Sexual and Relationship Therapy and on the editorial boards of the
Archives of Sexual Behavior, the Journal of Sex and Marital Therapy, and the
International Journal of Sexual Health.
DR. LESLIE LUNDT:
Welcome to ReachMD, Lori.
DR. LORI BROTTO:
Thank you very much. I am happy to be here.
DR. LESLIE LUNDT:
How big of a problem is sexual dysfunction in women that
have gynecological cancer?
DR. LORI BROTTO:
Well, it is a common problem that affects many women across
ages and across gynecologic cancer types. Common changes are in (01:30) the
area of sexual arousal where women will say that they have lost sensitivity
when their genitals are stimulated. Many of the women may say that it feels as
though as their partner is touching their elbow, does not feel like their
partner is touching their genitals, so there is a real loss of genital
sensation that is specific to sexual stimulation, and as a result of the
changes in arousal, many of these women also have difficulties reaching orgasm
or have orgasm that is by their description somewhat muted in its intensity.
We also know that pain with sexual intercourse otherwise known as dyspareunia
is another very common problem especially in women who received radiation
therapy to the pelvic region, but I think that the most common problem that we
see in certainly if the literature is in the area of sexual drive or sexual
interest where these women will say they are no longer interested in being
sexual, perhaps they are now avoidant of sexual activity, they moan the loss of
their spontaneous sexual desire that they once had, and again I think this is
probably the most common complaint that we see with gynecologic cancers.
DR. LESLIE LUNDT:
I wonder Lori is it the disease or the cure, so is it the
cancer, is it result to the hysterectomy, or the radiation therapy, or can we
even know?
DR. LORI BROTTO:
Yeah, that is a very good question and when that has been
studied in a variety of different ways in the literature, and although the
literature is not completely consistent, it does appear that there are some
(03:00) effects that are due to the hysterectomy itself and some effects that
are due to the cancer itself. For example, we know that in women who are
receiving hysterectomy for benign condition such as fibroids, there is often an
improvement in their sexual response. Now they are no longer bleeding and they
are no longer experiencing abdominal pain or bloating; however, for women with gynecologic
cancer, hysterectomies are more often and not likely to be radical and involved
more nerve damage, so of course, with that there is more of a negative effect
on sexual function. We also know that women who are at risk for ovarian cancer
or who are completing their childbearing may also have their ovaries removed
along with hysterectomy, so bilateral salpingo-oophorectomy, and with removal
of the androgen hormones and the estrogens that comes along with this surgery,
this has detrimental effects on sexual function, but we do know that even
<_____> on the effects of either of these surgeries, there is certainly a
negative impact of having the cancer diagnosed as itself and all of the
different ways that this might effect a women’s sense of who she is as a
person, as a sexual woman, etc., so it really is multifaceted, the ways in
which cancer can affect a women’s sexuality.
DR. LESLIE LUNDT:
So, psychosocial issues, hormonal issues, nerve damage
issues, the whole ball of wax.
DR. LORI BROTTO:
That’s right, exactly (04:30).
DR. LESLIE LUNDT:
Tell us about your work in this area.
DR. LORI BROTTO:
Sure. So, I am very interested in psychological
interventions, and in part this is because the data that have looked at Viagra
and other hormonal agents for sexual problems <_____> cancer has not been
very promising, so we know that simply increasing blood flow to women’s
genitals is not sufficient for restoring or even improving their sexual
function. So, I am really interested in psychological techniques that are
borrowed from other areas of sexuality and sex therapy and how they can be
adapted to women with the experience of cancer. So, we have a number of
treatment outcome studies here at the University of British Columbia where we
recruit women at various points after they have been treated for gynecologic
cancers, so we have some studies that are specific to women with earlier stage
cancers, seems like cervical and endometrial, and then we have a different
study that is following women with more advanced stage cancer such as ovarian
cancer, and essentially what the treatments involve, some are in group format
and some are in an individual one-on-one format, but essentially they involve a
combination of giving women information. Information such as here are some
common changes in sexuality that we know happen with gynecologic cancer. There
is also a component on cognitive therapy, so addressing many of them in midst
(06:00) or maladaptive beliefs that have now risen as a result of the cancer,
so some women adopt the belief that if they have intercourse, they can pass
cancer onto their partner or being sexual may increase the risk of having
cancer recur and it is the list that goes on and on with respect to the number
of maladaptive beliefs these women have. There is also behavioral component to
the treatment where we have women go home and practice a number of exercises,
both alone and with their partner that are designed to improve the awareness of
their bodies and really to tap into their remaining sexual response, and the
last component is mindfulness and this is mindfulness mediation that is rooted
in eastern philosophies. Teaching women how to be very much in the present,
free of distractions, or at least how to deal with distractions when they are
coming up. So, we have pieced together these different components and put them
together into a structured treatment program and we have been testing this
treatment program about over the past 5 years or so in different groups alone
with gynecologic cancer with some pretty promising findings in terms of
benefits.
DR. LESLIE LUNDT:
If you are joining our discussion, you are listening to
the ReachMD XM 157, the channel for medical professionals. I am Dr. Leslie
Lundt, your host and with me today is Dr. Lori Brotto, the recipient of the
Scholar Career Award from the Michael Smith Foundation (07:30) for health
research. We were discussing interventions for sexual dysfunction in female
cancer patients.
Lori what have you found in terms of results, outcomes in
these women?
DR. LORI BROTTO:
Pretty promising findings. Before I tell you what the main
results are, I will practice that by saying that we ask women in a variety of
ways how they may have responded to treatment. So, the traditional route of
having them fill out questionnaires, we also do an in-depth personal interview
where they can tell us in their own words how they may or may not have
benefited, and then we also bring them into our laboratory and measure their
actual genital responses, so they come into the laboratory, they insert
something called as vaginal photoplethysmograph, which is inserted vaginally
and provides an indirect measure of genital sexual arousal. They will then
watch some films. Some of which contain erotic content and then we administer
this measure both before, after, and 6 months after the treatment to see if
there has been any actual change in physiological ability to become sexually
aroused, and across the studies we certainly see evidence of an improvement on
a number of different domains. Mood is improved. Sense of well-being goes
up. Amount of sexual distress dramatically decreases and then the domain of
specific aspects of sexual response, we have seen an improvement in sexual
desire, physical arousal, subjective arousal, orgasmic function. In some of
the (09:00) research we have done, we have seen a decrease in pain. In one of
our studies, we found an improvement in physiological sexual arousal, and then
across the studies the qualitative feedback or the interview feedback from
these women has been very positive along the lines of, you know, this really
should be packaged in a way that can be given to women at the time of their
diagnosis or as they are going through cancer as the way to preempt any sexual
difficulties that may occur.
DR. LESLIE LUNDT:
In speaking of that, so for those of us that do not have the
luxury of referring you in Vancouver, how can we incorporate what you do in
your center in our private practices seeing these women?
DR. LORI BROTTO:
I think one of the important things in this was certainly
bowing out and the feedback was the importance of talking about sexuality right
from the beginning. This does not mean that there is going to be an in-depth
discussion about all of the different ways the cancer might impact the women
because there are some women who are not impacted sexually following a
gynecologic cancer, but some mention of it in some way in a normalizing way that
it is common to experience sexual changes and if you do there are resources
available for you. Also, to that end, having resources available at your
fingertips on knowing whether the sexual medicine physicians or the sexual
counselors or sex therapist or nurses in your area that you could be able to
refer these patients to say (10:30) if they want more information and talking
to them about it at different stages throughout their treatment at the
beginning, during, after because it is not one of those things that is very
easy to bring up. There is a lot of taboo and a lot of embarrassment around
talking about it. So, it may take a number of times of gently broaching the
issue before the patient feels comfortable enough to say you know I am having
some real problems in this area and I need help.
DR. LESLIE LUNDT:
So, bottom line is you don't wait for the patient to bring
it up we need to continually bring it up.
DR. LORI BROTTO:
Exactly yes.
DR. LESLIE LUNDT:
What further research are you hoping to do in this area?
DR. LORI BROTTO:
We are very intrigued by the findings with mindfulness, so
one of our plans is to expand the mindfulness component and look at it in much
more detail. Another aspect that I am very interested in is what role the
partner plays, so until now the treatment itself has been just with the women.
Of course, she is asked to go home and include her partner in the information
and in the exercises, but the partner has not been present today in the
treatment sessions. So, in the future that directs I would like to expand on
is incorporating the partner, having some specific targeted information to the
partner him or herself throughout the treatment.
DR. LESLIE LUNDT:
It makes sense. Thank you so much for sharing your work
with us today.
DR. LORI BROTTO:
Thank you very much for having me.
We have been talking with Dr. Lori Brotto from the
University of British Columbia about interventions in Women with sexual
dysfunction secondary to gynecological cancers. Again, the bottom line is
don’t wait for the cancer patients to tell you about their sexual problems,
intervene early and often. I am Dr. Leslie Lundt. You have been listening to
the clinician’s roundtable on ReachMD XM 157, the channel for medical
professionals. To listen to our on-demand library, visit us at
www.reachmd.com. If you register with the promo code radio, you will receive 6
months free <_____> to your home or office. If you have comments or
suggestions or questions, give us a call at 888-MDXM-157. Thank you for
listening.
Hi, this is Dr. James Jones with Rutgers University at
New Jersey, and you are listening to ReachMD XM 157, the channel for medical
professionals.
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