Patients receiving treatment for cancer often experience changes in sexual functioning but may be hesitant to ask questions. This article focuses on ways in which nurses can support patients and their partners and address their concerns through various evidence-based interventions.
At a Glance
- Sexuality, as well as how it is affected by cancer and its treatment, is an important aspect of holistic nursing care.
- Sexuality is not often brought up by nurses because of concern about a lack of evidence-based interventions.
- Many of the skills needed to inquire about sexual concerns are those that nurses use daily: active listening, sensitivity, and knowledge about how cancer and its treatment can physiologically affect sexual functioning.
Soon after 54-year-old M.J. was diagnosed with unresectable ovarian cancer, for which she would be receiving chemotherapy, a clinical nurse specialist (CNS) was consulted by M.J.’s gynecologic oncologist to work with her. After the CNS handed M.J. and her husband a business card at their intial meeting, M.J. raised her eyebrows and shushed her husband when he commented that the card mentioned “human sexuality.” M.J. also noted that she and her husband were deeply religious. The CNS explained that sexuality often can be affected by cancer and its treatment, and then stopped the conversation about sexuality and focused on working with the couple to provide support and information about the diagnosis, possible side effects, and coping. As trust built, M.J. asked, “How can cancer affect sexuality?” but immediately noted she did not have time to discuss that subject at the moment.
When M.J. experienced bleeding and pain with coitus, the couple made an appointment with the CNS. During the assessment, M.J. noted that prior to diagnosis, she had vaginal dryness and pain during coitus with deep thrusts. When asked about changes in her libido, M.J. became highly offended, remarking that, as a wife, she absolutely wanted to engage in coitus with her husband. M.J.’s husband reminded his wife that the CNS had to ask such questions to help the couple. In addition, the CNS explained that she had asked about libido because having pain with intercourse can affect libido and has nothing to do with how much a woman loves her husband.
Tearful, M.J. stressed that, as a Puerto Rican Catholic woman, the subject was very difficult to discuss and that it was her first time doing so. The CNS acknowledged M.J.’s comments and thanked M.J. for the honor of working with her and her husband during their cancer journey. The verbal acknowledgement seemed to help M.J., and the CNS explored the couple’s understanding of how the cancer and the chemotherapy treatment could affect sexual functioning. The CNS emphasized that the brain is the most important sex organ, and that M.J. needed to teach her brain that sexual activity is safe, not painful.
Because cancer and its treatment can have a significant impact on sexual functioning, every oncology nurse must be comfortable with the topic to be able to appropriately assess, intervene, or refer patients. To normalize the topic, nurses should create an environment that provides opportunities for discussion and encourages patients to ask about changes in sexuality (e.g., business cards, books about sexuality in the clinic office).
During patient assessments, nurses should remain aware of patients’ cultural background, as well as employ sensitivity when asking questions about sexuality to learn about patients’ specific ways of discussing the topic. Exploration of patients’ knowledge of cancer and its treatment, perception of the cause of cancer and of how sexual functioning has changed because of the diagnosis, and goals surrounding sexual functioning is also essential; asking about patients’ perception of the cause of cancer can be critical if they believe their cancer resulted fromsexual activity. Nurses should also ask patients how they experience sexuality and how they find meaning in their experience. However, nurses’ knowledge of factual data surrounding these issues is not enough to effectively care for patients. The data will prove useless if patients are not treated in a way that includes a shared understanding of needs and concerns. Numerous resources are available for nurses and patients (see Figure 1).
Etiology of the Problem
Dyspareunia, vaginal dryness, and decreased libido are very common (reportedby more than 90% of patients) in women treated for gynecologic malignancies (Demirtas & Pinar, 2014). For example, dyspareunia can result from chemotherapy (effects include decreased vaginal lubrication, vaginal wall thinning, and gonadal failure), pelvic or intracavity vaginal brachytherapy (effects include shortened vagina, radiation-induced urethral irritation or stenosis, decreased vaginal lubrication, and gonadal failure), and surgery (effects include impacted vaginal innervation or lubrication, scar tissue [contractures], and gonadal failure resulting in decreased elasticity and increased friability) (Nishimoto & Marks, 2015). Other potential causes of dyspareunia are muscle tension, genital infections or ulcers, increased sensitivity to vaginal barrel distention, weight loss causing loss of fat around the mons pubis, decreased vaginal lubrication because of aging, psychosocial factors, tobacco use, and fear that cancer was caused by previous sexual behavior (Nishimoto & Marks, 2015). Documenting the exact site of pain, type of pain, and perception of what causes or increases the pain will help the nurse or, if referred, the team member who will be working with the patient for intervention.
Case Study Continuation
The CNS explored acceptable interventions with M.J., who found the idea of using vaginal dilators to be repugnant. To empower her, a plan was formulated in which M.J. would ensure that her husband’s finger was liberally lubricated; he was to carefully insert it to the first finger joint, and then hold it in place. The couple was instructed not to attempt coitus. Respecting M.J.’s desire not to talk directly about sexuality, written brochures and articles were provided to the couple so they could work in private with each other (e.g., how to increase insertion diameter, use of lubrication and moisturizer). They verbalized understanding and agreed to work together with implementation. At the clinic meetings that followed, M.J. would avoid one-on-one conversations with the CNS but would tell her that she and her husband were trying various interventions and that the situation was improving.
Four months later, M.J.’s husband told the CNS that her help had had a significant impact on their situation. He noted that the written information provided was extremely useful, as well as that it helped the couple to realize that similar situations happen to other patients undergoing chemotherapy and their partners, not just to them.
After the nursing assessment, treatment is provided by the team member who has expertise in this area of care. Teaching and counseling are necessary interventions when caring for patients with cancer, and they can be provided by the nurse. Explanations of what to expect, how to accept and deal with changes, possible fertility problems, and emotional struggles within intimate relationships are all challenges that patients may experience.
Whether the nurse is just beginning to develop skills in this area or has specialized training, knowing the levels of evidence for the treatments commonly used for women with dyspareunia is helpful (see Figure 2). Primary treatment of mild to moderate dyspareunia is the use of moisturizers and lubricants (UpToDate, Inc., 2015). The addition of dilator use or intercourse can add to the successful treatment of mild atrophic vagina or dyspareunia because of vaginal dryness. Estrogen for moderate to severe dryness is helpful when hormone use is not contraindicated. Estrogen can be delivered in multiple ways and is usually started at a low dose (i.e., vaginal estrogen as 50 mcg estradiol or less, or 0.3 mg conjugated estrogens or less/0.5 g cream or less) (UpToDate, Inc., 2015).
Cancer and its treatment can affect multiple areas of patients’ lives. When exploring dyspareunia, oncology nurses need to complete an initial assessment examining patients’ sexual history and perception of current functioning while also normalizing the topic of sexuality. This allows patients to voice legitimate concerns about their current sexual identity, intimacy issues, and understanding of the changes they are experiencing regarding sexuality. Nurses must be knowledgeable about the side effects of cancer treatments, have access to additional resources for the patient, and be open-minded and nonjudgmental toward patients’ beliefs. Armed with knowledge of evidence-based interventions, nurses can no longer hesitate to help their patients address these issues, claiming that nothing can be done.
Demirtas, B., & Pinar, G. (2014). Determination of sexual problems of Turkish patients receiving gynecologic cancer treatment: A cross-sectional study. Asian Pacific Journal of Cancer Prevention, 15, 6657–6663. doi:10.7314/apjcp.2014.15.16.6657
Nishimoto, P.W., & Marks, D. (2015). Sexuality and reproductive issues. In C.G. Brown (Ed.), A guide to oncology symptom management (2nd ed., 551–597). Pittsburgh, PA: Oncology Nursing Society.
UpToDate, Inc. (2015). Treatment of vaginal atrophy. Retrieved from http://bit.ly/1QQunpu
About the Author(s)
Patricia Nishimoto, DNS, FT, FAAN, is an adult oncology clinical nurse specialist at Tripler Army Medical Center and Una Starr, LMHC, is a fourth-year clinical psychology practicum student in the Hawaii School of Professional Psychology at Argosy University, both in Honolulu, HI. The authors take full responsibility for the content of the article. The authors did not receive honoraria for this work. No financial relationships relevant to the content of this article have been disclosed by the authors or editorial staff. Nishimoto can be reached at email@example.com, with copy to editor at CJONEditor@ons.org.