Today we present Part II of Michelle Lyons' discussion on sex after gynecologic cancer. Michelle will be teaching a course on this topic in White Plains in August!
In Part One of this blog, I looked at the sexual health issues women face after gynecologic cancer. In Part Two, I want to explore different treatment options that we as pelvic rehab specialists can employ to help address the many implications of cancer and cancer treatment
Treatment for gynecologic cancers, including vulvar, vaginal, cervical, endometrial and ovarian cancers, may include surgery, radiation therapy, chemotherapy, and/or hormonal therapy. We know that any of these approaches can have an adverse effect on the pelvic floor, as well as systemic effects on a woman’s body. Issues can include pain, fibrosis, scar tissue adhesions, diminished flexibility, fatigue and feeling fatigued and unwell. The effects on body image should not be under-estimated either. In their paper ‘Sexual functioning among breast cancer, gynecologic cancer, and healthy women’, Anderson & Jochimsen explore how ‘…body-image disruption may be a prevalent problem for gynecologic cancer patients…more so than for breast cancer patients’. The judicious use of manual therapy and local and global exercise prescription may be excellent pathways for a women to re-integrate with her body.
Many women will have to learn to care for a new colostomy or how to catheterize a continent urostomy. A woman who has had a vulvectomy will need sensitive counselling to understand that she can still respond sexually. Patients who have had a vaginectomy with reconstruction as part of a pelvic exenteration will need extensive rehab to help them achieve successful sexual functioning. We as pelvic rehab practitioners are in a uniquely privileged position – not only can we ask the questions and discuss the options but we are licensed to be ‘hands on’ professionals, using our core skills of manual therapy, bespoke exercise advice and educating our patients about a range of issues from the correct usage of lubricants, dilators, sexual ergonomics and brain/pain science. I am in the habit of describing pelvic rehab as the best specialty in physical therapy but I think this is especially true when it comes to the junction of oncology and pelvic health. This is where we can integrate our knowledge of neuro-science, orthopaedics, the lymphatic system and pelvic health to deal with the effects of pelvic cancers and their treatment.
In Farmer et al’s 2014 paper, ‘Pain Reduces Sexual Motivation in Female But Not Male Mice’ , the authors found that ‘Pain from inflammation greatly reduced sexual motivation in female mice in heat -- but had no such effect on male mice’. Unfortunately ongoing pelvic pain is a common sequela of treatment for gynecologic cancers – reasons ranging from post-operative adhesions, post-radiation fibrosis or vaginal stenosis or genital lymphedema. It is also worth bearing in mind the ‘rare but real’ scenario of pudendal neuralgia following pelvic radiation, as discussed by Elahi in his 2013 article ‘Pudendal entrapment neuropathy: a rare complication of pelvic radiation therapy.’
The good news is that we have much to offer. Yang in 2012 (‘Effect of a pelvic floor muscle training program on gynecologic cancer survivors with pelvic floor dysfunction: A randomized controlled trial’) showed that pelvic rehab improved overall pelvic floor function, sexual functioning and QoL measures for gynecological cancer patients. Yang’s pelvic rehab group (administered by an experience physiotherapist) displayed statistically significant differences in physical function, pain, sexual worry, sexual activity, and sexual/vaginal function. Gynecological cancer and treatment procedures are potentially a fourfold assault: on sexual health, body image, sexual functioning, and fertility. Sexual morbidity is an undertreated problem in gynecological cancer survivorship that is known to occur early and to persist beyond the period of recovery (Reis et al 2010). We have a good and growing body of evidence that pelvic rehab, delivered by skilled therapists, has the potential to address each of these issues. And perhaps, most encouraging, here is Yang’s conclusion: ‘…‘Pelvic Floor Rehab is effective even in gynecological cancer survivors who need it most.’ (Yang 2012)
Interested in learning more about the role of pelvic rehab in gynecologic cancer survivorship? Join me in White Plains in August!