Sexual quality of life in men and women after cancer.

More than 60% of people treated for cancer have long-term sexual dysfunction. However, fewer than 25% of those with sexual problems get help from a health professional. Although cancer-related sexual problems usually begin with physiological damage from cancer treatment, a patient's coping skills and the quality of the sexual relationship are crucial in sexual rehabilitation. Barriers to care for people treated for cancer include a lack of discussion with the oncology team. In repeated surveys, fewer than half of patients recall discussing sex or fertility with their care providers, even during informed consent. Practice guidelines on sexuality and cancer were published in 2017 by the American Society for Clinical Oncology (ASCO) and the National Comprehensive Cancer Network (NCCN). Both agree the following: The oncology team should initiate discussions of sexuality and cancer during treatment planning and at follow-up visits. Psychosocial and medical assessment should take place when a concern or problem is identified. Referrals should be offered for multidisciplinary treatment, since sexual problems frequently have both psychosocial and physiological causes.This article describes a system of care that can meet the guidelines while providing sustainable revenue.

Multiaxial problem-oriented system for sexual dysfunctions: an alternative to DSM-III.

In a multiaxial system for classifying the sexual dysfunctions, the axes specify sexual problems associated with the desire, arousal, and orgasm phases of the sexual response cycle, as well as types of coital pain, dissatisfaction with the frequency of sex, and certain other information relevant to sexual functioning. In contrast to DSM-III and other existing diagnostic systems for sexual dysfunctions, this new multiaxial system is based on highly specific empirical descriptions of sexual behavior. There are no inferences made about the cause of the dysfunctions.

Sexuality and body image in younger women with breast cancer.

Breast cancer has the potential to be most devastating to the sexual function and self-esteem of premenopausal women. Nevertheless, not one study has systematically compared the impact of breast cancer treatment on sexual issues across age groups. Research shows that younger women with breast cancer have more severe emotional distress than older cohorts. In a group of patients seeking sexual rehabilitation in a cancer center, younger couples were more distressed, but also had the best prognosis with treatment. In theory, loss of a breast or poor breast appearance would be more distressing to women whose youth gives them high expectations for physical beauty. Seeking new dating relationships after breast cancer treatment is a special stressor for single women. Potential infertility also may impact on a woman's self-concept as a sexual person. Systemic treatment disrupts sexual function by causing premature menopause, with estrogen loss leading to vaginal atrophy and androgen loss perhaps decreasing sexual desire and arousability. Research on mastectomy versus breast conservation across all ages of women has demonstrated that general psychological distress, marital satisfaction, and overall sexual frequency and function do not differ between the two treatment groups. Women with breast conservation do rate their body image more highly and are more comfortable with nudity and breast caressing. There is some evidence that breast conservation offers more psychological "protection" for younger women. Research on the impact of breast reconstruction is sparse, but reveals similar patterns. Future studies should use rigorous methodology and focus on the impact of premature menopause and the effectiveness of sexual rehabilitation for younger women.

Psychosocial issues associated with cancer in pregnancy.

Although one of 1,000 pregnant women will receive a diagnosis of cancer, there is a dearth of empirical research on the psychosocial impact. Clinical experience suggests that most women are highly distressed at having to cope with cancer during pregnancy. The efficacy of psychologic intervention in relieving emotional distress or in preventing long-term emotional sequelae has not been studied. Women who terminate a pregnancy or experience a spontaneous pregnancy loss during cancer treatment may be particularly vulnerable. Even after cancer treatment is finished, women may have continued anxiety about the health of children exposed in utero to chemotherapy or radiation, about future fertility, and about the safety of another pregnancy. Oncology professionals must educate women about reproductive health after cancer and be aware of indications for a mental health referral.

Establishment of an oocyte donor program. Donor screening and selection.

IVF with donated oocytes, followed by embryo placement in the uterus of a recipient who has been primed with exogenous steroids, is a successful treatment for special cases of infertility. Preliminary results indicate that the success rate in this situation is even greater than that usually seen with normal IVF (with placement of the embryos back into the uteri of the women from whom the oocytes were recovered). Although different sources for donated oocytes have been identified, the use of "excess" oocytes from IVF cycles and the attempted collection of oocytes at the time of otherwise indicated pelvic surgery have ethical and practical problems associated with their use. We have herein described the establishment of a successful program relying on anonymous volunteers who go through ovarian stimulation, monitoring, and oocyte recovery procedures solely to donate oocytes. The potential donors go through an exhaustive screening and education process before they are accepted in the program. Psychological evaluation of our potential donors indicated a great degree of turmoil in their backgrounds and a wide variety of motivations for actually participating. Despite the extensive educational and screening process, a substantial percentage of the donors did not complete a donation cycle, having either voluntarily withdrawn or been dropped because of lack of compliance. Further investigation of the psychological aspects of participating in such a program is certainly warranted. The use of donated oocytes to alleviate specific types of infertility is quite successful, but the application of this treatment is likely to be limited by the relative unavailability of suitable oocyte donors.

Sexual function in women with uterovaginal prolapse and urinary incontinence.

OBJECTIVE: To compare sexual function in women with and without uterovaginal prolapse and urinary incontinence. METHODS: Eighty women with prolapse and with or without incontinence and 30 continent women without prolapse completed questionnaires assessing sexual function and underwent a physical examination. RESULTS: Women with prolapse were older than those without prolapse (mean age +/- standard deviation 58.2 +/- 13.0 versus 49.2 +/- 8.4 years, respectively; P < .001). The proportions of sexually active women were similar in both groups (56 and 57% for those with and those without prolapse, respectively). Measures of sexual function were not significantly different between the two groups. The mean global sexual function score was 0.58 +/- 0.15 in the prolapse group and 0.55 +/- 0.14 in the comparison group, a nonsignificant difference. The proportion of women with vaginal dryness or dyspareunia did not differ significantly between the two groups. Interest in sexual activity was unchanged in 70% of sexually active women with prolapse and incontinence, and 84% reported satisfaction with their sexual relationship. Twenty of 45 (44%) sexually active women with prolapse reported incontinence during sexual activity, and 14 (31%) reported that incontinence or prolapse interfered with sexual activity. After multivariate analysis, increasing age was the only significant factor predictive of a higher global sexual function score (P = .02), indicating worse sexual function. Increasing grade of prolapse predicted interference with sexual activity (P = .05), although this did not affect frequency of intercourse or description of satisfaction with the sexual relationship. CONCLUSION: Women with prolapse and urinary incontinence do not differ from continent women without prolapse in measures of sexual function; age is the most important predictor of sexual function.

Vaginal anatomy and sexual function.

OBJECTIVE: To describe vaginal anatomy related to sexual function in women. METHODS: One hundred four women presenting for gynecologic care (mean age 55.8 years) completed questionnaires assessing sexual function and underwent measurements of vaginal caliber and length, and grading of vulvovaginal atrophy. RESULTS: Women who were not currently sexually active had a higher mean body mass index. Current sexual activity was not associated with differences in vaginal length or introital caliber. Among 73 sexually active women, 30 had one or both symptoms of dyspareunia and vaginal dryness, and 43 had neither symptom. Menopausal status, current use of estrogen, introital caliber, and vaginal length were not different in women with dyspareunia, vaginal dryness, or both when compared to women having neither symptom. Premenopausal women with dyspareunia, vaginal dryness, or both had significantly higher global sexual function scores, reflecting worse sexual function, when compared with premenopausal women without these symptoms (0.61 +/- 0.16 versus 0.46 +/- 0.15, respectively; P = .02); however, there was no significant difference in postmenopausal women (0.60 +/- 0.12 versus 0.61 +/- 0.12). CONCLUSION: Vaginal anatomy, measured by introital caliber, length, and vulvovaginal atrophy, does not correlate well with sexual function, particularly symptoms of dyspareunia and vaginal dryness.

Sexual and marital relationships after treatment for nonseminomatous testicular cancer.

Data from 121 patient questionnaires suggest that treatment for nonseminomatous testicular cancer not only causes sterility but also disrupts marital and sexual happiness in 10 to 20 per cent of patients. Treatment included unilateral orchiectomy and retroperitoneal lymphadenectomy alone in 47 men; 30 had additional chemotherapy, 8 had additional radiotherapy, and 26 were treated with all three modalities. Erectile and orgasmic problems were more prevalent when radiotherapy was included. Compared with healthy men, patients reported less sexual activity, lower sexual desire, more erectile dysfunction, more difficulty achieving orgasm, reduced orgasmic intensity, and, for 82 per cent, a greatly reduced semen volume. The longer the time since treatment, the more likely the patient was to have antegrade ejaculation. Although the patients' 12.8 per cent divorce and/or separation rate is not unusually high, those whose marriages ended cited sexual dysfunction and cancer treatment as significant sources of stress. Sterility was a frequent source of anxiety for one quarter of the patients.

Sexual and marital relationships after radiotherapy for seminoma.

Questionnaires on sexual function, marital status, and fertility were returned by 84 men who received radiotherapy for seminoma (Stage I, II, or III). The mean length of follow-up was ten years. Although 93 per cent were married, 19 per cent had low rates of sexual activity, 12 per cent reported low sexual desire, 15 per cent had erectile dysfunction, 10 per cent had difficulty reaching orgasm, and 14 per cent had premature ejaculation. The most common problems were reduced intensity of orgasm (33%) and reduced semen volume (49%). Twenty-one men remained childless, and 30 per cent of men worried at least occasionally about infertility. Thirteen children were conceived after cancer therapy. The data suggest that sexual dysfunction and infertility are important concerns for a subgroup of men treated for seminoma.

Psychological aspects of donor insemination: evaluation and follow-up of recipient couples.

OBJECTIVE: To evaluate the utility of psychological screening for couples entering a donor insemination program. DESIGN: Each spouse completed questionnaires. A psychologist reviewed them and rated the psychological fitness of the couple for participation in the program. Follow-up questionnaires were sent to each couple at a mean of 11 months after entry into the program. SETTING: Applicants for donor insemination were studied in an infertility program in a large, tertiary referral center. PATIENTS, PARTICIPANTS: Consecutive applicants to enter the donor insemination program were required to participate in the initial evaluation. INTERVENTIONS: Couples judged by the psychologist to be at risk for a poor psychological outcome had an assessment and counseling interview with the psychologist before proceeding with insemination. MAIN OUTCOME MEASURES: Initially, the Stress and Infertility Questionnaire measured specific anxieties related to donor insemination, marital and sexual impact, and attitudes about confidentiality; the Brief Symptom Inventory measured psychological distress; and the Dyadic Adjustment Inventory assessed marital satisfaction. At follow-up, 48% of couples returned a modified version of the Stress and Infertility Questionnaire and the other two questionnaires. RESULTS: The psychologist's rating was predictive of pregnancy rates (59% for excellent candidates, 41% for acceptable couples, and 14% for couples psychologically at risk). At-risk couples were more likely to drop out of the program (50% versus only 20% of other couples). Sexual problems were reported by 59% of women and 53% of men. Couples believed that a child should not be told of the donor insemination (74% of wives and 80% of husbands). Initially, 64% of wives and 70% of husbands chose total secrecy with families or friends, and these attitudes shifted little over time. CONCLUSION: This screening procedure is cost-effective and suggests that psychological intervention should be attempted with at-risk couples.

A program for matched, anonymous oocyte donation.

The authors' program for matched, anonymous oocyte donation has resulted in two successful pregnancies among the first eight oocyte recipients. All oocyte recipients to date have had ovarian failure or absence with premature ovarian failure the most common cause. All recipients were cycled on a program of incremental oral micronized estradiol and intramuscular progesterone-in-oil. Thirteen candidates for oocyte donation were screened to obtain 8 donors. One donor candidate was excluded because of her medical history. The psychological screening of 2 of the other donor candidates (who subsequently did not complete the donation cycle) revealed a primary motive of financial gain. In general, the psychological profiles of donor candidates revealed a high incidence of troubled families and either reproductive loss or loss of a parent. Ovarian stimulation of the donors followed our standard in vitro fertilization protocol. The recipients' exogenous steroid replacement continued until days 97 and 101, respectively, of the two gestations. Both pregnancies resulted in the delivery of normal singleton males--the first at 40 weeks, the second at 35 weeks.

Sex therapy for the penile prosthesis recipient.

In conclusion, the evidence for technical success of the penile prosthesis is clear, but more detailed follow-up studies suggest that a large minority of patients and partners fail to achieve sexual satisfaction. If the goal of surgery is to restore sexual frequency, variety, and pleasure to optimal levels, an integrated treatment program that incorporates sex therapy may be more successful than implantation alone. The type of sex therapy required depends on the risk factors present for postsurgery sexual dissatisfaction. A majority of patients can benefit from several sessions of brief sexual counseling preoperatively, with routine follow-up at 3 and 6 months after surgery to identify problems in resuming sex successfully. I also would point out that an integrated treatment approach is just as applicable to home intracavernosal injection programs. Including sex therapy in the package might reduce the large drop-out rates currently being seen and might decrease the risk of misuse of these medications.

Counseling cancer patients about changes in sexual function.

Cancer treatments often cause sexual dysfunctions that remain severe long after therapy is over. Nevertheless, sexual counseling is not routinely provided in most oncology treatment settings. Most patients and their partners can benefit from brief counseling that includes education on the impact of cancer treatment on sexual functioning; suggestions on resuming sex comfortably and improving sexual communication; advice on how to mitigate the effects of physical handicaps, such as having an ostomy, on sexuality; and self-help strategies to overcome specific sexual problems, such as pain with intercourse or loss of sexual desire. Brief counseling can be provided by one of the allied health professionals on the oncology treatment team. A minority of patients will need specialized, intensive medical or psychological treatment for a sexual dysfunction. In a large cancer center, such treatment could be provided as part of a reproductive health clinic serving the special needs of cancer patients. In smaller settings, the oncologist should build a referral network of specialists. Not all managed care organizations reimburse for these services, however.

Overselectivity, developmental level, and overtraining in autistic and normal children.

Thirteen autistic children were compared to 13 normal children matched to them in mental age, on performance of a visual discrimination task. Form, color, and size were relevant and redundant cues. The groups did not differ significantly in mean trials to reach criterion or in breadth of learning, and both groups increased their breadth of learning after 50 trials of overtraining. Form was preferred to color and size by both autistic and normal children. Within each group, rank on mental age was highly correlated with rank in breadth of learning. Verbal and nonverbal autistic children did not differ in breadth of learning or in dimensional preference. Even nonverbal autistics equaled the performance of their normal controls. Our results suggest that overselective attention is better understood as part of a general developmental lag in cognition in autistic children than as a specific deficit underlying psychotic behavior.

Recognizing the stress of infertility.

Although infertility is often blamed on stress, the evidence that psychological factors interfere with conception is slim. Far more salient is the stress that infertility imposes on patients and their marriages. Primary care physicians can help by recognizing stress associated with infertility and making appropriate referrals for psychological support.

Psychological factors in men with genital pain.

Among 48 men with genital pain and no organic findings, psychological disorders were diagnosed frequently, including somatization disorder in 56%, nongenital chronic pain syndromes in 50%, major depression in 27%, and chemical dependency in 27%. About one third of the group were socially isolated and 18% had had an important emotional loss at the time of pain onset. Despite their mean age of 41, only half of the men were married. These data suggest that genital pain without organic findings is often related to psychological disorders, life stress, and poor social support. Treatment planning should take these factors into account.

Multidisciplinary treatment of an unconsummated marriage with organic factors in both spouses.

Successful treatment of a case of unconsummated marriage involved the expertise of a urologist, gynecologist, and psychologist working together in an interdisciplinary clinic to treat sexual dysfunction. Total duration of treatment was 18 months, and components included surgical correction of congenital chordee, surgical excision of a hymenal remnant blocking the vaginal introitus, laser treatment of endometriosis, and sex therapy evaluation and follow-up totalling five sessions for both partners. At the end of treatment the couple was having pleasurable sexual intercourse.

Circulating lipid and lipoprotein concentrations with oral estrogen-androgen hormone replacement therapy.

The goal of this study was to determine whether the administration of an oral combined estrogen-androgen preparation would influence the lipid and lipoprotein profile of postmenopausal women. There were no pretreatment to posttreatment differences in triglycerides, total cholesterol, or in low density lipoproteins and very low density lipoproteins. However, high density lipoprotein values decreased significantly after treatment. Although further study is warranted, these preliminary findings suggest that the potential beneficial effects of oral estrogen-androgen on sexual and psychological well-being may need to be weighed against the possible cardiovascular risks of adverse lipid changes in postmenopausal women.