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• W2000650870 abstract "Approximately 14 million people have a history of cancer in the United States alone, and the number is expected to increase with time. This has prompted an appreciation of the quality of life for survivors. Women treated for cancer identify gynecologic issues as a major concern for both general health and the negative impact on sexual function that follow the cancer diagnosis and subsequent treatment. Unfortunately, issues related to sexual health continue to be underappreciated. Although comprehensive cancer centers have adopted specialized centers for survivorship issues, including those involving sexual health, consultations are not widely available in most communities. We provide background information on female sexual health, examine the impact of cancer treatment on sexual function, and discuss some of the major sexual health issues of women who have received a cancer diagnosis and been subsequently treated. Approximately 14 million people have a history of cancer in the United States alone, and the number is expected to increase with time. This has prompted an appreciation of the quality of life for survivors. Women treated for cancer identify gynecologic issues as a major concern for both general health and the negative impact on sexual function that follow the cancer diagnosis and subsequent treatment. Unfortunately, issues related to sexual health continue to be underappreciated. Although comprehensive cancer centers have adopted specialized centers for survivorship issues, including those involving sexual health, consultations are not widely available in most communities. We provide background information on female sexual health, examine the impact of cancer treatment on sexual function, and discuss some of the major sexual health issues of women who have received a cancer diagnosis and been subsequently treated. Discuss: You can discuss this article with its authors and with other ASRM members at http://fertstertforum.com/falks-sexual-dysfunction-cancer/With advances in early detection and treatments for cancer, the number of survivors continues to increase, and accordingly there has been an increased awareness of survivorship issues. It is estimated that as of January 2012 there were 13.7 million people with a history of cancer in the United States, and the number is expected to increase to 18 million by 2022 (1Siegel R. Naishadham D. Jemal A. Cancer statistics, 2013.CA Cancer J Clin. 2013; 63: 11-30Google Scholar). For female cancer survivors, gynecologic issues are a major concern, and many of these issues impact sexual function. Some tertiary care centers have developed sexual health programs specifically for this patient population, but expert consultations are not widely available. In addition, most oncologists are unable or unwilling to discuss sexuality and intimacy in the context of a follow-up oncology visit because of their lack of training in this area, personal discomfort, or time constraints. Instead, these issues are rarely addressed, and when patients ask about sexual dysfunction, it is generally to the primary care physician or gynecologist, who may be unfamiliar with these issues as they pertain to women previously treated for cancer. In this article, we will review sexual health issues in women who have had a cancer diagnosis and subsequent treatment, and we will focus in greater depth on dyspareunia and vaginal stenosis, two of the most common or significant clinical scenarios.Overview of sexual dysfunction in women treated for cancerSexual health conditions that affect women during or after cancer treatment may be considered according to the same categories as female sexual dysfunction in the general population. The American Psychiatric Association defines the following female sexual disorders: sexual interest/arousal, orgasmic, and genitopelvic pain/penetration (2American Psychiatric AssociationDiagnostic and statistical manual of mental disorders.5th ed. American Psychiatric Association, Washington, DC2013Google Scholar). Cancer and its treatments can directly cause all of these conditions.Surgical treatment can result in distortions of female anatomy, particularly for patients with breast or gynecologic cancers. In addition, the removal of the ovaries in premenopausal women leads to premature menopause with resultant hormonal and physical changes that can alter several domains of sexual function. Surgical treatment can result in sexual dysfunction for women diagnosed with other tumors as well; as an example, sexual dysfunction is occurs in 18% and 59% of women treated for early stage rectal cancer (3Barnabei V.M. Cochrane B.B. Aragaki A.K. Nygaard I. Williams R.S. McGovern P.G. et al.Menopausal symptoms and treatment-related effects of estrogen and progestin in the Women’s Health Initiative.Obstet Gynecol. 2005; 105: 1063-1073Google Scholar).Chemotherapy can result in systemic effects that dampen both sexual desire and arousal. In addition, chemotherapy may induce ovarian failure with an acute and sudden loss of estrogen. Near total alopecia resulting from the use of some agents (such as the anthracyclines and taxanes) can affect a patient's self-perception of sexual attractiveness, and some treatments may cause vaginal or rectal mucosal toxicity (4Krychman M.L. Carter J. Aghajanian C.A. Dizon D.S. Castiel M. Chemotherapy-induced dyspareunia: a case study of vaginal mucositis and pegylated liposomal doxorubicin injection in advanced stage ovarian carcinoma.Gynecol Oncol. 2004; 93: 561-563Google Scholar). For patients treated with high-dose chemotherapy as part of a stem cell transplantation protocol, the additional toxicity may induce vulvovaginal graft-versus-host disease (GVHD). Less is known about the effects of chemotherapy on the female genital tract other than the ovaries, although women may experience a persistent vaginal discharge after chemotherapy, which likely represents vaginal mucositis; also, there is some evidence that chemotherapy contributes to vulvodynia (5De Pas T.M. Mandalà M. Curigliano G. Peccatori F. Acute vulvar vestibulitis occurring during chemotherapy with cryptophycin analogue LY355703.Obstet Gynecol. 2000; 95: 1030Google Scholar). In addition, the experience of cancer diagnosis and treatment may profoundly affect a woman's body image and sense of sexuality (6Begovic-Juhant A. Chmielewski A. Iwuagwu S. Chapman L.A. Impact of body image on depression and quality of life among women with breast cancer.J Psychosoc Oncol. 2012; 30: 446-460Google Scholar).Radiation therapy (RT) can also impact sexual function in women. For example, RT for breast cancer induces local skin thickening, contractures, and/or changes in texture and color, and may result in chronic breast pain, any of which can affect a woman's body image or ability to enjoy sexual activity. Vaginal fibrosis may result from RT to the pelvis with resultant vaginal fibrosis or stenosis that limits a woman's capacity for vaginal intercourse as well as affects her genital pelvic and clitoral sensitivity during sexual activity. These changes last long after RT has been completed. For example, women treated for cervical cancer have reported sexual dysfunction up to 5 years later (7Bergmark K. Avall-Lundqvist E. Dickman P.W. Henningsohn L. Steineck G. Vaginal changes and sexuality in women with a history of cervical cancer.N Engl J Med. 1999; 340: 1383-1389Google Scholar).Addressing sexual health in cancer survivorsThe general approach to sexual health issues associated with cancer treatment, like many conditions, involves patient education, screening, diagnosis, and management. Too often, cure and control are the only goals of the oncologist, and, in the context of a busy practice, survivorship issues including sexual health are relegated to other providers such as social workers or primary care providers. Without an explicit understanding of how the care of the cancer survivor is coordinated, issues such as sexuality are often left unattended. As an example, Wiggins et al. (8Wiggins D.L. Wood R. Granai C.O. Dizon D.S. Sex, intimacy, and the gynecologic oncologists: survey results of the New England Association of Gynecologic Oncologists (NEAGO).J Psychosoc Oncol. 2007; 25: 61-70Google Scholar) conducted a survey of gynecologic oncologists and found that less than half made it a practice to take a sexual history in new patients and 80% did not feel there was sufficient time to devote to exploring sexual issues. Only 20% felt they had sufficient time to speak to their patients about these issues, which was the sentiment of both male (85%) and female (73%) respondents.Approaching Patients before TreatmentIdeally, anticipatory guidance regarding sexual health issues should be a key element of patient education before treatment for cancer, but many women who experience sexual adverse effects complain that they were not informed in advance. The typical sequence of events that accompanies cancer diagnosis and treatment requires the complete attention of the patient and her medical team, and this often does not allow for proactively addressing posttreatment quality of life issues. Therefore, the appropriate timing of this discussion cannot be easily standardized and will likely vary according to the tumor site, prognosis, and type of treatment.One approach that has worked for some oncology teams is to review the typical course of patient care and counseling for a particular tumor site. The team can then identify the most appropriate time to counsel patients about the potential for sexual health issues.Approaching Patients after TreatmentOnce active cancer treatment has been completed, patients should be screened for sexual health issues. Sexual health concerns are common among those completing treatment and while most complaints can be treated, opportunities to address them are often missed. In one study of patient follow-up observation after pelvic radiation, sexual issues were addressed in only 25% of visits (9White I.D. Allan H. Faithfull S. Assessment of treatment-induced female sexual morbidity in oncology: is this a part of routine medical follow-up after radical pelvic radiotherapy?.Br J Cancer. 2011; 105: 903-910Google Scholar).Barriers to addressing sexual health issues exist, including time constraints or a reluctance to even bring up sexual health issues on the part of clinicians, and the sense that many women feel embarrassed to ask about these issues or may be unaware that treatment is available (10Hill E.K. Sandbo S. Abramsohn E. Makelarski J. Wroblewski K. Wenrich E.R. et al.Assessing gynecologic and breast cancer survivors’ sexual health care needs.Cancer. 2011; 117: 2643-2651Google Scholar). In addition, some patients may be concerned that their oncologist will perceive that these issues are trivial or that the patient is ungrateful for their care. However, queries about sexual health can be made in a way that is comfortable for patients, and questions can be incorporated into a routine posttreatment review of systems. In addition to asking these questions, it is important to ensure that resources are available locally for patients who wish to pursue further treatment.When addressing sexual function, it is essential that assumptions not be made regarding sexual orientation or sexual practices (11Boehmer U. Potter J. Bowen D.J. Sexual functioning after cancer in sexual minority women.Cancer J. 2009; 15: 65-69Google Scholar). The patient should be asked open-ended questions that allow her to feel comfortable sharing information that is pertinent to her evaluation and management. For example, vaginal intercourse may not be the most important component of sexual activity for many women, including those who have sex with other women.DiagnosisThe diagnosis of sexual health issues requires a history of the sexual complaint and a pertinent medical history, including an oncologic and sexual history. A medication history should also be reviewed because of their impact on sexual function, including the use of antidepressants and endocrine therapies. It is important to assess the aspects of sexual dysfunction that are bothersome to the patient, including whether concomitant symptoms of anxiety or depression are present (12Aerts L. Enzlin P. Vergote I. Verhaeghe J. Poppe W. Amant F. Sexual, psychological, and relational functioning in women after surgical treatment for vulvar malignancy: a literature review.J Sex Med. 2012; 9: 361-371Google Scholar, 13Pumo V. Milone G. Iacono M. Giuliano S.R. Di Mari A. Lopiano C. et al.Psychological and sexual disorders in long-term breast cancer survivors.Cancer Manag Res. 2012; 4: 61-65Google Scholar). Detailed diagnosis and treatment of sexual desire, arousal, and orgasm issues is beyond the scope of this article, but many reviews of these topics can be found in the literature (14Basson R. Schultz W.W. Sexual sequelae of general medical disorders.Lancet. 2007; 369: 409-424Google Scholar, 15Basson R. Clinical practice: sexual desire and arousal disorders in women.N Engl J Med. 2006; 354: 1497-1506Google Scholar, 16Krychman M.L. Katz A. Breast cancer and sexuality: multi-modal treatment options.J Sex Med. 2012; 9: 5-13Google Scholar). Evaluation and treatment of these issues may necessitate referral to a behavioral health specialist or sex therapist.It is important to discuss the interaction between the patient and sexual partners, both sexually and in terms of the relationship in general. It may also be helpful to discuss whether modifications of sexual practice may help to achieve comfort and pleasure. In addition the patient should be asked about the sexual function of her partner(s).The evaluation should include a pelvic examination, in which the vulva and vagina are examined for the presence and severity of atrophy, changes in vaginal length or caliber due to surgery or pelvic radiation, or adhesions. Care should be taken to communicate with the patient regarding her ability to tolerate the examination; difficulty may be symptomatic of dyspareunia. For these women, the use of a narrow Pederson or pediatric speculum may be better tolerated. Use of a lubricating gel increases comfort and generally does not interfere with cervical samples (17Griffith W.F. Stuart G.S. Gluck K.L. Heartwell S.F. Vaginal speculum lubrication and its effects on cervical cytology and microbiology.Contraception. 2005; 72: 60-64Google Scholar, 18Hathaway J.K. Pathak P.K. Maney R. Is liquid-based Pap testing affected by water-based lubricant?.Obstet Gynecol. 2006; 107: 66-70Google Scholar).TreatmentTreatment must be individualized in keeping with the patient's goals. Although the overall goal of management is to enable women to be comfortable with their sex life, the precise objectives may differ to include achievement of orgasm, decreased pain with penetration, or improved sexual desire. Such goals may differ between the patient and her partner, which may require referral for couples therapy or sex therapy. In addition, not all women have a current sexual partner, and these patients may request an evaluation to ensure their sexual health for the future.DyspareuniaDyspareunia is the most common sexual complaint among female cancer survivors. The most common cause of dyspareunia in this population is vulvovaginal atrophy resulting from hypoestrogenism (19Siegel R. DeSantis C. Virgo K. Stein K. Mariotto A. Smith T. et al.Cancer treatment and survivorship statistics, 2012.CA Cancer J Clin. 2012; 62: 220-241Google Scholar). This may be due to menopause induced by surgery, chemotherapy, or pelvic radiation or may be caused by endocrine therapy, mainly for breast cancer (e.g., aromatase inhibitors, tamoxifen). Vulvovaginal atrophy is characterized by dryness, thinning of the epithelial lining, and inflammation. This loss of lubrication and elasticity along with the thinning of the epithelium leads to an increase in discomfort or pain either on a daily basis or during vulvovaginal contact. Women with atrophy often develop small lacerations with sexual contact, particularly at the vaginal fourchette where the labia majora converge. This often results in postcoital bleeding, which is self-limited but may result in anxiety about sexual activity.Dyspareunia is also an important quality of life issue. This was demonstrated most notably among breast cancer survivors (20Dorjgochoo T. Gu K. Kallianpur A. Zheng Y. Zheng W. Chen Z. et al.Menopausal symptoms among breast cancer patients 6 months after diagnosis: a report from the Shanghai Breast Cancer Survival Study.Menopause. 2009; 16: 1205-1212Google Scholar). In one study, dyspareunia was reported by 56.5% of women taking aromatase inhibitors and 31.3% of those taking tamoxifen (21Baumgart J. Nilsson K. Evers A.S. Kallak T.K. Poromaa I.S. Sexual dysfunction in women on adjuvant endocrine therapy after breast cancer.Menopause. 2013; 20: 162-168Google Scholar).The first-line treatment for vaginal atrophy is the nonhormonal approach of using vaginal moisturizers and lubricants. Moisturizers should be used regularly several times a week to ameliorate daily vaginal dryness. Lubricants are intended for use during sexual activity. These products are available over the counter, and there are many different brands. Women usually try several products to find the one they prefer. In general, water- or silicone-based products are preferred because they are easier to wash off and do not damage condoms, unlike petroleum-based lubricants (22Herbenick D. Reece M. Hensel D. Sanders S. Jozkowski K. Fortenberry J.D. et al.Association of lubricant use with women’s sexual pleasure, sexual satisfaction, and genital symptoms: a prospective daily diary study.J Sex Med. 2011; 8: 202-212Google Scholar). Some studies have found that the effect of a vaginal moisturizer is comparable to vaginal estrogen therapy, but many women find vaginal moisturizers and lubricants insufficient, in which case greater improvement can typically be achieved with vaginal estrogen therapy (23Bygdeman M. Swahn M.L. Replens versus dienoestrol cream in the symptomatic treatment of vaginal atrophy in postmenopausal women.Maturitas. 1996; 23: 259-263Google Scholar, 24Nachtigall L.E. Comparative study: Replens versus local estrogen in menopausal women.Fertil Steril. 1994; 61: 178-180Google Scholar).Vaginal estrogen therapy is more effective for treating vulvovaginal atrophy than systemic estrogen therapy (25Cardozo L. Bachmann G. McClish D. Fonda D. Birgerson L. Meta-analysis of estrogen therapy in the management of urogenital atrophy in postmenopausal women: second report of the Hormones and Urogenital Therapy Committee.Obstet Gynecol. 1998; 92: 722-727Google Scholar). Vaginal estrogen therapy is effective in treating the symptoms of vulvovaginal atrophy in 80% to 90% of women and can be administered as an estradiol tablet (Vagifem; Novo Nordisk FemCare AG) or a low-dose ring such as Estring (Pfizer) or Femring (Warner Chilcott, a vaginal ring that delivers a systemic dose of estrogen), or an estradiol cream (Estrace; Warner Chilcott) or conjugated estrogens cream (Premarin; Pfizer) (3Barnabei V.M. Cochrane B.B. Aragaki A.K. Nygaard I. Williams R.S. McGovern P.G. et al.Menopausal symptoms and treatment-related effects of estrogen and progestin in the Women’s Health Initiative.Obstet Gynecol. 2005; 105: 1063-1073Google Scholar, 26Long C.Y. Liu C.M. Hsu S.C. Wu C.H. Wang C.L. Tsai E.M. A randomized comparative study of the effects of oral and topical estrogen therapy on the vaginal vascularization and sexual function in hysterectomized postmenopausal women.Menopause. 2006; 13: 737-743Google Scholar). Low-dose vaginal estrogen therapy results in some systemic absorption, the level depending on the dose and the condition of the vaginal epithelium; the degree of absorption appears to decrease as the epithelium cornifies in response to estrogen stimulation. For the estradiol tablet (Vagifem, 10 μg twice weekly) and low-dose ring (Estring, 7.5 μg daily for 90 days), a steady-stage serum estradiol level of 3–11 pg/mL is achieved, comparable to the level in women after natural menopause (approximately 5 pg/mL) (27Notelovitz M. Funk S. Nanavati N. Mazzeo M. Estradiol absorption from vaginal tablets in postmenopausal women.Obstet Gynecol. 2002; 99: 556-562Google Scholar, 28Weisberg E. Ayton R. Darling G. Farrell E. Murkies A. O’Neill S. et al.Endometrial and vaginal effects of low-dose estradiol delivered by vaginal ring or vaginal tablet.Climacteric. 2005; 8: 83-92Google Scholar). The dose is more difficult to control in estrogen creams because of user variability, and the serum estrogen dose is difficult to measure in women using conjugated equine estrogens cream because it contains more than 200 compounds.The use of vaginal estrogen therapy in women with estrogen-sensitive cancers is a subject of debate. This is particularly an issue in women with breast cancer, although it may also be an issue of concern in women with advanced endometrial cancer or other hormone receptor-positive malignancies (29Barakat R.R. Bundy B.N. Spirtos N.M. Bell J. Mannel R.S. Randomized double-blind trial of estrogen replacement therapy versus placebo in stage I or II endometrial cancer: a Gynecologic Oncology Group Study.J Clin Oncol. 2006; 24: 587-592Google Scholar, 30de Giorgi V. Gori A. Gandini S. Papi F. Grazzini M. Rossari S. et al.Oestrogen receptor beta and melanoma: a comparative study.Br J Dermatol. 2013; 168: 513-519Google Scholar, 31Suriano K.A. McHale M. McLaren C.E. Li K.T. Re A. DiSaia P.J. Estrogen replacement therapy in endometrial cancer patients: a matched control study.Obstet Gynecol. 2001; 97: 555-560Google Scholar). The use of vaginal estrogen in women with estrogen-receptor-positive breast cancer has not been well studied. No increase in the risk of recurrence was found in a prospective cohort study of women with breast cancer that included 69 women treated with vaginal estrogen for an average of 1 year (range: 0.1–5.0 years) (32Dew J.E. Wren B.G. Eden J.A. A cohort study of topical vaginal estrogen therapy in women previously treated for breast cancer.Climacteric. 2003; 6: 45-52Google Scholar). A concern has been raised that vaginal estrogen may interfere with the efficacy of aromatase inhibitor therapy. Two studies of 10 or fewer women have found that use of vaginal estrogen therapy in women on aromatase inhibitors increases serum estradiol and depresses gonadotropin levels (33Kendall A. Dowsett M. Folkerd E. Smith I. Caution: Vaginal estradiol appears to be contraindicated in postmenopausal women on adjuvant aromatase inhibitors.Ann Oncol. 2006; 17: 584-587Google Scholar, 34Pfeiler G. Glatz C. Königsberg R. Geisendorfer T. Fink-Retter A. Kubista E. et al.Vaginal estriol to overcome side-effects of aromatase inhibitors in breast cancer patients.Climacteric. 2011; 14: 339-344Google Scholar). A prospective study of 60 patients on aromatase inhibitors treated with vaginal estradiol tablets is ongoing (35Serum estradiol levels in postmenopausal women with breast cancer receiving adjuvant aromatase inhibitors and vaginal estrogen. ClinicalTrials.gov, http://clinicaltrials.gov/show/NCT00984399.Google Scholar).Most physicians use an individualized approach to vaginal estrogen supplementation in cancer survivors, consistent with the position of the North American Menopause Society—namely, that some women in this population with symptomatic vaginal atrophy unresponsive to nonhormonal therapies may want to discuss the risk and benefits of this therapy, but others may wish to avoid any therapy associated with potential risk (36North American Menopause SocietyThe role of local vaginal estrogen for treatment of vaginal atrophy in postmenopausal women: 2007 position statement of the North American Menopause Society.Menopause. 2007; 14: 355-369Google Scholar).For women who decline vaginal estrogen therapy and for whom vaginal moisturizers and lubricants are insufficient, some additional relief may be obtained with the use of topical vitamin E oil. In addition, the use of vaginal dilators helps to improve elasticity, and consistent use often ameliorates dyspareunia. Dilators may also be used to improve pelvic muscle relaxation and control as part of therapy for vaginismus. Patients may be instructed on self-guided use of dilators or may be referred to a pelvic physical therapist.Women with severe pain, particularly localized to the vaginal vestibule, or pain that is not consistent with atrophy should be evaluated for vulvodynia. Localized, provoked, or generalized vulvodynia may develop after chemotherapy or menopause (5De Pas T.M. Mandalà M. Curigliano G. Peccatori F. Acute vulvar vestibulitis occurring during chemotherapy with cryptophycin analogue LY355703.Obstet Gynecol. 2000; 95: 1030Google Scholar, 37Straub R.H. The complex role of estrogens in inflammation.Endocr Rev. 2007; 28: 521-574Google Scholar). In addition, some women develop secondary vaginismus after experiencing painful sexual encounters.Vaginal StenosisVaginal stenosis is a severe complication that occurs in some women who are treated with pelvic radiation therapy or allogeneic hematopoietic stem cell transplantation (HCT). Vaginal obstruction precluding vaginal intercourse is a potentially devastating outcome.Pelvic RT is used most commonly to treat gynecologic malignancies (endometrial, cervical, vaginal, and vulvar cancer) and anal and colorectal cancers. Radiation therapy may result in radiation vaginitis or vaginal fibrosis, with possible vaginal shortening or stenosis. The development of radiation fibrosis is a result of damage to the vaginal mucosa and associated blood vessels and connective tissues (38Bahng A.Y. Dagan A. Bruner D.W. Lin L.L. Determination of prognostic factors for vaginal mucosal toxicity associated with intravaginal high-dose rate brachytherapy in patients with endometrial cancer.Int J Radiat Oncol Biol Phys. 2012; 82: 667-673Google Scholar). The vaginal tissue eventually reepithelializes, with excess collagen content and smooth muscle fibrosis. The degree of toxicity depends on the dosage, the type of radiation, and the schedule as well as factors such as previous surgery, concurrent chemotherapy, and the prior condition of the vagina. The incidence of vaginal obstruction after pelvic radiation is uncertain; the reported rate ranges widely from 1.2% to 88% (39Eltabbakh G.H. Piver M.S. Hempling R.E. Shin K.H. Excellent long-term survival and absence of vaginal recurrences in 332 patients with low-risk stage I endometrial adenocarcinoma treated with hysterectomy and vaginal brachytherapy without formal staging lymph node sampling: report of a prospective trial.Int J Radiat Oncol Biol Phys. 1997; 38: 373-380Google Scholar, 40Hartman P. Diddle A.W. Vaginal stenosis following irradiation therapy for carcinoma of the cervix uteri.Cancer. 1972; 30: 426-429Google Scholar).The natural history of vaginal stenosis associated with RT is not well documented. The process itself does not produce symptoms, and the condition may be brought to medical attention when the woman or her sexual partner note the obstruction or it is found incidentally on examination. The vaginal tissue typically develops a whitened appearance, and the vagina loses its pliability. It is uncertain whether there is an early stage during which an intervention could prevent further vaginal obstruction.Most radiation oncology teams counsel patients regarding the risks of vaginal fibrosis after pelvic RT and provide instruction in the use of a vaginal dilator. Fibrosis is a late effect of RT, and there is often poor compliance with dilator therapy. The efficacy of vaginal dilator therapy has not been proven, and some investigators have raised concerns about whether dilator use increases the risk of lower genital tract fistula. However, there is no alternative to dilator therapy, and fistula is a rare complication that can be associated with pelvic RT alone, even in the absence of dilator use.The management of women with vaginal stenosis resulting from pelvic RT depends on the degree of obstruction. Some increase in vaginal length or caliber may be gained from vaginal dilator therapy, and patients often benefit from being referred to a pelvic physical therapist. Women with severe obstruction, who have less than 5 to 6 cm of residual vaginal length, may require counseling about modifying their sexual activity to include incomplete vaginal penetration or other sexual activities.Pelvic RT also induces ovarian failure in women. Vaginal estrogen therapy may help ameliorate dyspareunia in these patients and improve vaginal elasticity. Some questions have been raised regarding whether vaginal estrogen receptors maintain their function following RT, but studies have shown that local estrogen therapy increases the vaginal maturation index in women who have been treated with pelvic RT (41Fraunholz I.B. Schopohl B. Falk S. Boettcher H.D. Cytohormonal status and acute radiation vaginitis.Front Radiat Ther Oncol. 2002; 37: 112-120Google Scholar).Women who undergo allogeneic HCT may develop vaginal GVHD. The reported incidence of vulvovaginal GVHD is 3% of bone marrow recipients and 15% of peripheral blood recipients, but this condition often goes undetected because some cases are asymptomatic and patient and clinical awareness are limited (42Lee S.J. Vogelsang G. Gilman A. Weisdorf D.J. Pavletic S. Antin J.H. et al.A survey of diagnosis, management, and grading of chronic GVHD.Biol Blood Marrow Transplant. 2002; 8: 32-39Google Scholar). Partial or complete vaginal obstruction occurs in a minority of patients, but the actual incidence is unknown (43Riera C. Deroover Y. Marechal M. Severe vaginal chronic graft-versus-host disease (GVHD): two cases with late onset and literature review.Eur J Gynaecol Oncol. 2010; 31: 703-704Google Scholar).Vulvovaginal GVHD should be suspected in any allogeneic H" @default.
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