Introduction
There is increasing interest in the functioning of sexuality for oncological patients, caused mostly by improvements in the results of cancer treatments and the increasing number of convalescents.
Sexual health is one of the determinants of quality of life and the feeling of happiness in a relationship with a partner. Care in the context of sexual life includes not only the issue of reproduction, but also prophylaxis, diagnostics, and treatment of sexual disfunctions [1, 2] or sexually transmitted diseases [3, 4], and also specific psychosexological assistance for persons with cancer [5–10].
Sexual health is a vital part of the overall health condition of couples and families. Studies have proven that sexuality is linked to better mental health and satisfaction, while an increased level of intimacy and love in relationships improves the ability to perceive, identify, and express emotions, as well as to reduce the use of defence mechanisms [11].
Therefore, in gynaecology, as a science about woman, a holistic attitude to taking care of women is essential, and this care should take into consideration not only diagnostics and treatment, but also health-promoting actions, including actions that promote sexual health.
The quality of sexual life is not irrelevant for the general category of the quality of human life, and the practice of sexologists and gynaecologists shows that although most patients perceive the quality of their sexual life as an essential element of general quality of life, patients do not always confess to it during medical visits, and this especially concerns persons with cancer. Health is physical, mental, and social well-being, and this concerns also sexual health. Care in the context of sexual health includes not only the issue of reproduction, but also prophylaxis, diagnostics, and treatment of sexual disfunctions or sexually transmitted diseases, and also specific psychosexological assistance for persons with cancer. Sexual health is also one of the determinants of quality of life and the sense of happiness in a relationship with a partner [6, 7, 12].
The quality of sexual life of persons with cancer has became specific enough that a new area emerged: oncosexology [12–14].
Oncosexology is interdisciplinary field of science, in which oncologists, sexologists, psychologists and physiotherapist cooperate.
Oncosexology includes wide range of issues: body image at patients, sexual disorders related to disease and therapy, partner relationships, the quality of life, sexual rehabilitation and education [15].
Material and methods
Two independent reviewers searched medical and public databases including PubMed, Google Scholar, and MEDLINE using search terms and MeSH terms such as “Oncosexology”, “sexual health”, “chemotherapy”, and “radiotherapy”. The inclusion criterion was the publication of the article in a peer-reviewed journal in the last 10 years (2012–2022).
The data were then reviewed to eliminate papers with different meanings of the keywords. Failure to meet the inclusion criterion was equivalent to an exclusion from the analysis.
The records were assessed in terms of compliance with the inclusion and exclusion criteria based on an analysis of the abstracts. Of 460 articles initially qualified for analysis, 390 were rejected at that stage. The remaining 70 articles were subjected to analysis with 15 being rejected as duplicates. The remaining 45 articles were subjected to further analysis in terms of the following parameter content: what actions did health care professionals undertake to protect female sexual health in oncological diseases, and what conclusion was drawn from the review?
Why do people with cancer have no sexual desire?
At the beginning of treatment, fear for life and health are so intensive that our interest in sex decreases significantly. In this period the presence of a close person, his or her devotion, and the feeling of common worry about the health of an ill person and mutual relations are important. Additionally, oncological treatment disturbs the hormone management of the organism, which can also cause a loss of desire for sex.
Some people go through early menopause in this period, which also influences their intime life. In turn, as a result of surgical operations that not infrequently leave a lasting trace of injury and disability, many people lose self-esteem and their sense of attractiveness, which affects everyday functioning, including intimate relations. In such a situation, time and the involvement of both partners in rebuilding the image of the ill person are needed.
Oncological patients struggle with a number of problems that make continuing a satisfying sexual life difficult for them.
According to data from literature and from clinical observations, such problems of oncological patients make continuing a satisfying sexual life difficult for them: reduced sense of attraction, decrease in libido, disorders of the course of sexual functions [16], hypersensitivity of skin after chemotherapy or radiotherapy, and also depressed mood and weakening partner relationships [17–19].
Many oncological patients resign from intercourse from the moment of diagnosis and the beginning of treatment. However, despite cancerous disease, it is still possible to lead an active sexual life.
Kancer Sutra, i.e. the art of love in cancerous disease, shows that even during oncological therapy it is possible to have energy and joy in being together. And although sexual activity can cause some concerns in ill persons, the most important is openness of partners to seek forms of intimacy that will be satisfying for both parties. There are hundreds of ways of successful sex – even after mastectomy or with ostomy.
Oncological patients wrestle with a number of problems that make continuing a satisfying sexual life difficult for them.
How does chemotherapy affect sex?
Some elements that are related to side effects of treatment with cytostatics can influence the possibility of sexual activity during chemotherapy:
side effects of chemotherapy: nausea and vomiting, hair loss and baldness, rash, harmful effects of chemotherapy for mucous membranes, skin and nails, diarrhoea, constipation,
bone marrow failure (neutropaenia, thrombocytopaenia, anaemia),
disorders of reproductive system and libido,
injuries of nervous system (neurotoxicity),
injuries of heart (cardiotoxicity) and lung parenchyma (pneumotoxicity),
flu-like symptoms, swellings, risk of allergic reactions.
It is estimated that tiredness related to cancerous disease can concern up to 90% of ill persons during oncological treatment or in the advanced phase of disease. Chronic tiredness as a side effect of therapy can remain also during convalescence. Its causes are seen in a balance disturbance between inflammatory mechanisms and mechanisms that stop inflammatory reaction or in changes in brain activity.
Diagnosis is made on the basis of symptoms: significant, onerous, and chronic feeling of tiredness, decrease of energy or increased need of rest, impairment of concentration, reduced motivation to action, insomnia, and lack of feeling of relaxation after leisure.
Nausea and vomiting are one of more frequent side effects of the application of chemotherapy. They can be the effect of treatment, but they can also result from the appearance of cancer itself. Nausea and vomiting significantly deteriorate the quality of life of ill persons. Their reason can be irritation of throat and gullet caused by mycosis or difficult coughing up bronchial secretion, disorders of the digestive system resulting from cancer, metabolic disorders, infections, paraneoplastic syndromes, increased intracranial pressure, and pain.
There is a wide group of medicaments applied to eliminate nausea and vomiting: antagonists of receptor 5-HT3 [20], antagonists of NK-1, corticosteroids, and additional medicaments as metoclopramide, prochlorperazine, or chlorpromazine. It is also worth applying non-pharmacological agents – reduction of odour stimuli in the environment of the patient, preparation of meals without the presence of the ill person, or an individually chosen menu.
In oncological patients, diarrhoea can be caused by the cancer itself, chemotherapy, or the appearance of coexisting diseases. In the case of diarrhoea, it is necessary to determine its reason and involve causal treatment. Diarrhoea that is a side effect of applied chemotherapy can occur in the case of application of almost each medicaments; however, mostly it is a complication of therapy with 5-fluorouracil, irinotecan, and inhibitors of tyrosine kinases. In the first stadium of treatment loperamide is usually applied.
Inflammation of the mucous membrane of the oral cavity as am effect of chemotherapy occurs at about 20–40% of ill persons who undergo treatment [21]. This percentage increases at patients who are subject to high-dose chemotherapy. and this concerns almost 100% of ill persons who undergo radiotherapy due to cancer of the head and neck. The following symptoms are typical: rubefaction, dryness, erosions and ulcerations in oral cavity, strong pains requiring application of opioids, difficult food intake [21]. Unpleasant side effects of chemotherapy related to inflammation of the mucous membrane of the mouth can remain even some months after the end of treatment.
Education of ill persons about proper hygiene of the oral cavity, application of soft tooth brushes, or avoiding irritating agents play an important role. Pharmacotherapy is based on pain treatment.
The most frequent reason of constipation among ill persons who suffer from cancer is the application of opioids. In the case of chronic problems with constipations it is necessary to preclude the presence of a tumour in the abdominal cavity and obstruction of the digestive system caused by another reason. In the treatment of constipations, laxatives have various mechanisms of operation. It is worth considering also natural methods of fight against constipations, such as proper physical activity, appropriate hydration, and supply of cellulose.
Loss of hair as a side effect of treatment with systemic chemotherapy concerns about 65% of patients. The loss of hair concerns also the skin of the head and eyebrows, eyelashes, and pubic hair and appears usually about 2–4 weeks after application of chemotherapy and can last up to 3 months after its end. Hair begins to grow back some months after therapy. But it can have different structure, thickness, colour, or texture (straight/curly).
The loss of hair as a side effect of chemotherapy is related to the fact that cytostatic medicaments act toxically on quickly dividing cells, including cells that build hair follicles. Currently there are no precisely stated therapeutic recommendations concerning prevention of loss of hair after chemotherapy. The best-known method is local hypothermia of the skin of the head, which is currently applied in selected oncological hospitals in our country.
Increasing application of medicaments oriented on molecular aims has caused a growth in interest in skin toxicity and methods of its treatment. Especially intensified skin complications are observed in patients who undergo therapy with antibodies directed against receptors for growth factor of cuticle (eGFR). Application of eGFR inhibitors is a source of atrophy of skin and the appearance of inflammatory infiltration from mononuclear cells in 70% of patients.
How does radiotherapy affect sex?
Radiotherapy is an effective method of treatment of many cancers, including cervical cancer and endometrial cancer. Unfortunately, like other methods it has its side effects. They concern not only the organ that is exposed to radiation, but also surrounding structures. It is because radiation damages cancerous cells as well as healthy cells.
Side effects depend on the age of the patient, her body weight (obesity), coexisting diseases, such as diabetes, atherosclerosis, and hypertension, and the level of advancement of cancer. These side effects include, among other things, irritation and rubefaction of skin in the region exposed to radiation, and so-called “syndrome of humidity” can also appear, which encompasses also that skin is wet and it can be very painful.
During radiotherapy it is necessary to treat the region exposed to radiation especially carefully. It is not allowed to scratch, rub, or expose the treated area to mechanical damage. Clothes should be loose and non-adherent. Many patients suffer during radiotherapy from emotional disorders. Therefore, the desire for sexual intimacy can disappear. Feeling of tiredness and changes in hormonal balance appear, which has a big impact on intimate life.
The influence of radiotherapy over sexual functions depends on which organs are exposed to radiation. Usually, most side effects do not last long and finish after the end of treatment. If partners decide to lead a sexual life during radiotherapeutic treatment, they have to remember about the application of contraception, because radiation can damage the foetus. Patients who are exposed to radiation in the region of the pelvis can have menstrual disorders and symptoms that resemble menopause.
Radiotherapy-induced vaginal changes are often reported by sexually active patients as one of the most troublesome consequences of treatment, by affecting their sexual functioning, body image, and quality of life. The pathophysiology of chronic vaginal changes is to a large extent in compliance with the general principles of the chronic complications of treatment. Changes in microcirculation related to the loss of capillaries and microcirculation disorders are the cause of the mucosal atrophy, while pathological dilation of capillaries contributes to haemorrhagic telangiectasia. An increased production of collagen within the fibrous connective tissue may lead to shortening and tightening of the vagina. Treatment-induced ovarian failure and the resulting hormone deficiencies can intensify lesions in the mucosal membranes and cause menopausal changes in perimenopause [22]. Due to intensified symptoms lasting 1–3 months and recurrences after the cessation of treatment, it is recommended that polycarbophil-based moisturisers be used at least 2–3 times a week for a minimum of 12 weeks [23].
Sexual life during radiotherapeutic treatment should be limited to gentle caresses.
Normal intercourse is mostly possible after some weeks from the end of treatment. However, then sexual intercourse can also bring discomfort for woman due to fibrosis and scarring resulting in shortening or narrowing of the vagina. To eliminate these complaints, special vaginal dilators are applied. Their application should be preceded by consultation with gynaecologist – oncologist or radiotherapist [24].
Couples therapy, such as counselling on cancer, sexual health, and communication, can also play a significant role in improving sexual satisfaction [23].
How do surgical operations influence sex?
Surgical operations related to oncological treatment, especially operations during which ostomy is made, influence in an essential way the sexual activity of patients.
At most, such persons depressed mood, reduction of sex drive, and problems with sexual functioning are observed. In women it manifests itself in frigidity, dryness of the vagina, and pain during intercourse, while in men it results in erection disorders, retrograde ejaculation, or lack of ejaculation.
During an operation there can be damage also of innervation (pelvic plexus) that is responsible for erection and ejaculation as well as vascularity of sex organs. Perioperative supplementary treatment, including radiotherapy, especially within the pelvis, can contribute additionally to damage of nerves and vessels of the genitourinary system.
Sexual dysfunctions that appear after operation in persons with stoma are also a result of mental reactions due to the fact of possession of ostomy. Intestinal fistula influences the changes of image of one’s own body. It is because after operation the anus is on the front surface of the abdominal cavity and it is often an uncovered and a visible place. The lack of control of passing gases and stool deteriorates the situation additionally. Such a situation translates into reduced self-evaluation of the human being with ostomy. While understated self-assessment causes fear of lack of acceptance of a sexual partner, it is the main psychological reason for resignation from sexual contact and reduction of sex drive in a significant proportion of operated patients.
Making ostomy negatively influences the perception of one’s own body and self-confidence. The process of acceptance of a changed body image can be long-lasting and complex, especially if the social perception of beauty is usually related to youth and health.
Persons with ostomy avoid looking at their own body and think that their appearance after the operation is repulsive. Many patients can report a “feeling of otherness” after making an intestinal fistula [25].
A critical image of one’s own body leads to a less satisfying sexual life. Embarrassment resulting from possession of ostomy induces some persons to changes sexual practices, such as turning off the light during sexual intercourse.
Numerous studies have confirmed the role of a sexual partner in the process of adaptation to life with intestinal ostomy. Often persons with an ostomy worry about it that their partners will not accept changes in image of their body and will lose sexual interest. The support of a partner is necessary, so that patients accept their body with an ostomy. It is positive if the process of adaptation to ostomy contributes to developing and strengthening their relationship with their partner [25].
Besides the importance of the partner in therapy, cooperation between the patient and medical personnel is a key element of assistance for patients in their adaptation to life with a stoma. The partnership helps to maintain continuity of care, increases the ability to develop practical skills of care of the ostomy, reduces the time of stay of the patient in the medical institution, and decreases the risk of repeated admission to hospital [25].
Gynaecological oncosexology
Cancerous diseases, especially of sex organs and breasts, cause patients to feel less feminine and less attractive, and lose interest in their intimate life.
The side effects of some oncological therapies lead to early ovarian failure, hot flushes, sleep disorders, depressed mood, and irritation. Patients can also feel pain and dryness of the vagina. All these factors can negatively influence sex life, desire, and intimate contact with a partner.
Ano operation of making an intestinal ostomy is a reason for disorders and failures in sexual life. Persons with an ostomy experience changes in body image together with a decrease in sexual desire. The most frequent sexual disfunction appearing in men comprise erection disorders, while in women it is pain during sexual intercourse (dyspareunia). Patients expect support and consultations related to sexual functioning. However, medical staff pay less attention to the sexual sphere of patients.
Making an ostomy is related to changes in physical appearance and in psychosocial functioning, which influences body image, sleep, mood, social life, career, and quality of sex life [5, 6]. Many patients with an ostomy accept with time the changes resulting from the conducted operation. This group returns much quicker to their everyday duties and do not have problems with building relationships with other people. However, for some patients, information about the necessity of making an ostomy is source of great anxiety that results in disorders of mental health.
Patients with an ostomy feel during intimate intercourse mostly anxiety related to leaking ostomy equipment, unpleasant odour, and noisy passing of gasses. These symptoms lead some persons to have an inability to take pleasure of sexual intercourse.
In research conducted by Smith et al. it was proven that lack of control of passing gases and stool caused, in the researched persons, shame and embarrassment. It is necessary to point out that the research included only persons with an ileostomy made in the upper section of the digestive tract, which results in a large volume of secreted liquid. This fact additionally intensifies the fear of dirtying and contributes to increased sexual aversion.
Paula et al. stated that participants of research with a newly appearing ostomy after operation are afraid of the beginning of intimate life. However, 15 months after making an ostomy, patients admitted that level of their fear related to uncontrolled passing gases and stool decreased, which had a positive impact on the quality of their sexual life. According to the opinions of patients, ostomy apparatus can be a problem in specific sexual positions [26].
Kimura et al. pointed out that participants of research often reported anxiety related to leaking ostomy apparatus during sexual intercourse. In many cases it was stated that these problems can be mitigated through proper education. Giving detailed information by medical staff can help patients and their partners with adaptation to the new situation. In the research of Cardoso et al. respondents admitted that lack of knowledge intensified their aversion to a return to sexual life.
It was proven that the opinion of society about excretion contributed to shaping negative experiences in persons with an intestinal ostomy.
Cultural perception of breasts
Breasts are an essence of femininity. They are associated with the physical advantages of a woman, and with her sexual attractiveness.
From the perspective of sexology, breasts are one of places on the map of the female body thanks to which it is possible to get to know in which phase of excitement a woman is. Independently of symbolics, femininity does not have to be destroyed together with the disease that is breast carcinoma.
Sexual activity of women after amputation of breasts was for a long time a taboo subject. While, according to the literature, the “breastless” (Greek Amazónes, Latin Amazones, Polish Amazones) were extraordinarily active, brave, and beautiful. The name “Amazones” has numerous associations of women with cancer of mammary gland aimed at expressing the fight against disease and triumph of femininity over cancer. This fight is very difficult, because it includes libido disorders, oversensitive skin after chemotherapy or radiotherapy, and also a feeling of loss of attractiveness and a number of complex issues related to breast cancer.
After diagnosing breast cancer femininity and perception of sensuality are usually significantly stricken from the moment of making diagnosis. In the next stages of therapy the applied methods of treatment also have an influence over them. So, diagnosing cancer, its treatment, and the medical and psychological consequences of disease have a huge negative impact on sexuality and intimacy of women [27].
It is a huge and essential problem, because breast cancer is the most commonly occurring malignant tumour among women and is responsible for about 23% of malignant cancers. It is estimated that 1 in 8 women will have breast cancer.
There is optimism that innovative methods of treatment contribute to improving the comfort of life of women with breast cancer. It is important that problems of a sexual nature of women are taken into account in the whole process of diagnostics and therapy. It is wonderful that, together with progress of diagnostic methods, early detection, operational treatment, and adjuvant therapy of gynaecological tumours, it manages increasingly to obtain long-term survival and healing and that care of comfort of life is growing also in the sexual sphere of women.
In the case of unpleasant complaints appearing, it is worth using specialist preparations with hydrating and sliding operations for a long time with small-molecule hyaluronic acid, which are available on the market. They make intimate contact easier, and thanks to this they allow partners to enjoy their sexual life.
There is optimism that innovative methods of treatment have improved the comfort of life of women with breast cancer, and simultaneously it is very important that their sexuality issues are taken into consideration throughout the whole process of diagnostics, therapy, counselling, and educational strategies [28–30].
Influence of physiotherapy on the functioning of oncological patients
Physiotherapy is an integral part of oncological therapy in patients after cancer treatment, as they often report musculoskeletal pain [5, 6]. Other side effects are problems with walking, balance disorders, and fractures due to falls, which is reflected in their physical activity and life during the day [31]. It has been stated that one side effect of chemotherapy for breast cancer can be a loss of postural stability, and therefore balancing exercises are recommended to prevent the risk of falls [30]. Muscle weakness (in the upper extremities in the case of breast cancer) is observed in patients following oncological treatment [7]. To strengthen these muscles, closed chain exercises are recommended, which simultaneously activate the agonist, antagonist, and synergist muscle groups. This can be achieved by using proprioceptive neuromuscular facilitation patterns [6, 7]. Another crucial element of physiotherapy is treating the fascial system to relieve pain and release fascial muscles to improve their range of motion [32, 33]. Another functional problem in oncological patients is lymphoedema [34, 35]. It is of key importance to use lymphatic drainage techniques and to educate patients on how to do so themselves, how to position the extremity, apply a compression bandage, and perform active exercises [36, 37]. One effective treatment of lymphoedema is lymphatic kinesiotaping [38]. Oncological treatment in the area of the lower abdomen requires visceral and manual therapy that improve blood and lymph circulation in the small pelvis [32, 33]. It is extremely important to provide pelvic floor muscle training and to educate oncological patients on how to exercise themselves. This training is vital to reduce and eliminate sexual dysfunctions [39, 40]. Performing a multimodal programme (consisting of education, pelvic floor exercises with biofeedback, manual therapy, and home exercises) for 12 weeks by patients after gynaecological cancer with dyspareunia had a positive impact on psychosexuality [41]. As mentioned above, education plays a key role in improving the mobility of patients [42]. When proceeding to physiotherapy for oncological patients, cardiorespiratory functioning should be taken into account [7]. If a patient is unable to attend a medical facility, tele-rehabilitation can be a solution [8]. Patients should be covered by a rehabilitation programme that helps them regain their active social, professional, and sexual life [43]. This also concerns psychological, psychosexual, and nursing support [9, 44, 45].
Conclusions
For ill persons with tumours, both men and women, deterioration of the quality of life is observed. It concerns not only physical symptoms, but also a higher intensification of fear, mood disorders, and libido disorders; problems related to sexual activity also occur.
Oncological patients comprise a special group of ill persons that require specific medical and psychological support, which is an important issue in gynaecological practice.
