Taking a Sexual History

The evaluation for sexual issues begins with a detailed medical history. The incorporation of several screening questions allows the patient to feel safe and protected about revealing very personal, and perhaps embarrassing, information. Open-ended questions may strategically elicit complaints related to sexual function (e.g., “Is there anything else you want to talk about?”), and more specific questions may also be helpful (e.g., “Are you having any problems with sexual arousal, desire, or orgasm?”). Inclusion of such questions on general intake forms is another way to offer patients the opportunity to discuss these topics.

Primary dyspareunia predates the diagnosis or treatment of cancer, while secondary dyspareunia occurs after cancer onset. It is important to elicit information regarding onset, duration, location, triggers, quality, characteristics, and associated symptoms of sexual pain (see Chapter 5). If symptoms existed prior to diagnosis or treatment for cancer, a search for other noncancer-related etiologies is important. For example, arthritis, uncontrolled diabetes, hyperglycemia, and underlying genital infections may all be associated with dyspareunia, and should be examined as possible explanations for pain that occurred prior to cancer diagnosis and treatment. In addition, if the history reveals prior sexual trauma such as rape or abuse, the utilization of mental or sexual health expertise may be required.

Symptoms can also develop aftercancer onset; in particular, certain treatments (e.g., surgery, radiotherapy [RT], medications) can lead to dyspareunia in some patients. Specifically, for some patients, genital pain with light touch can often be encountered following radiation to the pelvis, breasts, or anogenital area. Pain with vaginal penetration can be due to prior pelvic surgery or pelvic radiation, while shortening of the vaginal vault and/or scarring can lead to a decrease in elasticity. In addition, chemotherapy and endocrine therapies, which cause ovarian failure, often lead to vaginal dryness.

A medication screen can also provide clues to the etiology of sexual dysfunction and/or pain. Most drug classes can affect the sexual response cycle and cause sexual problems; for example, antidepressants and antihypertensive medications can change sexual desire, arousal, and orgasm. In addition, decreases in arousal and desire can lead to decreased vaginal lubrication and vice versa, perhaps contributing to a vicious cycle of pain and sexual issues. Health care providers should consult sexual pharmacology resources (e.g., books, online resources) to help identify a potentially offending agent(s). Illicit drug use, alcohol consumption, and relationship functioning are also important aspects to assess, because they can impact sexual function.

With respect to assessing the sexual quality of the couple’s relationship, many health care providers wrongly assume that their cancer patients are involved in heterosexual relationships. However, same-sex relationships are equally impacted by cancer. Health care providers should be sensitive to the sexual issues of all relationship types, and should be culturally aware and accepting of all individuals; as such, intake office forms should be generic and unassuming.

Physical Examination

A careful physical examination is also indicated for the evaluation of sexual complaints (see Chapter 4). For women,this includes a thorough vaginal and pelvic examination. Detailed examination of both external and internal genitalia is important. The vulva should be inspected for sores, lesions, fissures, or ulcerations. If palpation of the vestibule elicits pain, the diagnosis of provoked vestibulodynia (PVD; see Chapter 8) should be considered.

The examination should proceed with the insertion of a finger into the vaginal vault and attention to the tone of pelvic musculature. Often, penetration of the vault may elicit involuntary contraction of the muscles, which can point toward a diagnosis of vaginismus (see Chapter 35). In addition, palpation of the urethra can be performed. If pain is elicited, urethritis should enter into the differential. A speculum exam provides direct visualization of the vaginal mucosa, cervical os, or vaginal cuff in the case of a patient with a prior hysterectomy. In addition, atrophy, dryness, and fissuring of the vaginal walls can be seen and evaluated, and areas of bleeding, nodularity or abnormal appearance should be noted. Patients with vaginismus may not tolerate a normal adult-sized speculum, which warrants the use of a pediatric speculum.

Finally, a bimanual exam is important to assess the pelvis and surrounding structures. Pain that is elicited with abdominopelvic palpation may point to an extra-vaginal etiology, such as endometriosis or adnexal lesion(s). Pain involving the rectovaginal septum may point towards adhesions or endometriosis. If the cul-de-sac appears full, fluid should be suspected and aspiration should be considered to rule out infection or malignancy. This examination, in combination with the patient’s self-reported pain characteristics, can aid in determining etiology and treatment planning.

Objective Evaluation

Complete blood profile examinations should be conducted in order to rule out or confirm the involvement of other illnesses that can contribute to sexual issues. For example, a complete blood count can rule out underlying anemia as a cause of chronic fatigue. Furthermore, comprehensive tests of lipid profile, fasting glucose, prolactin levels, and thyroid function can be helpful to rule out endocrinopathies that may impact on sexual morbidity (but are less likely to cause dyspareunia).

Sexual problems are common among cancer survivors. Reported rates of sexual dysfunction range widely due to the variety of cancer patient populations studied and methodologies utilized. For example, rates of sexual dysfunction among breast cancer survivors have been reported from 15% to 64% [2–8]. The etiology of sexual dysfunction in female cancer survivors is often multifactorial and can include consequences of the cancer, side effects of treatment, psychosocial issues resulting from cancer diagnosis and treatment, and/or other issues–all of which may contribute to difficulties with sexual functioning. Factors contributing to sexual dysfunction can be categorized into local and systemic issues, although there is substantial overlap among these factors.

Local Issues

Any cancer that directly affects sexual organs or the pelvis may cause sexual dysfunction. Cancers of the female reproductive tract are associated with risk of sexual dysfunction and pain, both locally and referred. Advanced cervical cancer, in particular, may invade the corpus uteri, parametrium, and/or pelvic sidewall causing bleeding and physical discomfort. Lower gastrointestinal malignancies (e.g., anorectal cancers) can also cause dyspareunia, as can local therapy for lower abdominal or pelvic region neoplasms.