Cancer treatment, especially hormonal therapy and therapy directed toward the pelvis, can contribute to sexual problems, as can depression and anxiety, which are common in cancer survivors. Thus, sexual dysfunction is common in survivors and can cause increased distress and have a significant negative impact on quality of life. This section of the NCCN Guidelines for Survivorship provides screening, evaluation, and treatment recommendations for female sexual problems, including those related to sexual desire, arousal, orgasm, and pain.

Abstract

Cancer treatment, especially hormonal therapy and therapy directed toward the pelvis, can contribute to sexual problems, as can depression and anxiety, which are common in cancer survivors. Thus, sexual dysfunction is common in survivors and can cause increased distress and have a significant negative impact on quality of life. This section of the NCCN Guidelines for Survivorship provides screening, evaluation, and treatment recommendations for female sexual problems, including those related to sexual desire, arousal, orgasm, and pain.

NCCN Categories of Evidence and Consensus

Category 1: Based upon high-level evidence, there is uniform NCCN consensus that the intervention is appropriate.

Category 2A: Based upon lower-level evidence, there is uniform NCCN consensus that the intervention is appropriate.

Category 2B: Based upon lower-level evidence, there is NCCN consensus that the intervention is appropriate.

Category 3: Based upon any level of evidence, there is major NCCN disagreement that the intervention is appropriate.

All recommendations are category 2A unless otherwise noted.

Clinical trials: NCCN believes that the best management for any cancer patient is in a clinical trial. Participation in clinical trials is especially encouraged.

Overview

Cancer treatment, especially hormonal therapy and therapy directed toward the pelvis, can often impair sexual function. In addition, depression and anxiety, which are common in survivors, can contribute to sexual problems. Thus, sexual dysfunction is common in survivors and can cause increased distress and have a significant negative impact on quality of life.1-5 Nonetheless, sexual function is often not discussed with survivors.6,7 Reasons for this include a lack of training of health care professionals, discomfort of providers with the topic, and insufficient time during visits for discussion.1 However, effective strategies for treating both female and male sexual dysfunction exist,8-11 making these discussions a critical part of survivorship care.

Female Aspects of Sexual Dysfunction

Female sexual problems relate to issues such as sexual desire, arousal, orgasm, and pain.12,13 Sexual dysfunction after cancer treatment is common in female survivors.4,14-20 A survey of 221 survivors of vaginal and cervical cancer found that the prevalence of sexual problems was significantly higher among survivors than among age- and race-matched controls from the National Health and Social Life Survey (mean number of problems 2.6 vs 1.1; P<.001).18 A survey of survivors of ovarian germ cell tumors and age-, race-, and education-matched controls found that survivors reported a significant decrease in sexual pleasure.21

Female sexual dysfunction varies with cancer site and treatment modalities.15,16 For example, survivors of cervical cancer who were treated with radiotherapy had worse sexual functioning scores (for arousal, lubrication, orgasm, pain, and satisfaction) than those treated with surgery, whose sexual functioning was similar to that of age- and race-matched noncancer controls.15 A recent systematic review of sexual functioning in cervical cancer survivors found similar results, except that no differences in orgasm/satisfaction were observed.22 In contrast, chemotherapy seems to be linked to female sexual dysfunction in breast cancer survivors,16 possibly related to the prevalence of chemotherapy-induced menopause in this population.13 In addition, survivors with a history of hematopoietic stem cell transplantation (HSCT) may have multiple types of sexual dysfunction, even after 5 to 10 years.23-25 Some of the sexual dysfunction associated with HSCT is related to graft-versus-host disease (GVHD), which can result in vaginal fibrosis, stenosis, mucosal changes, vaginal irritation, bleeding, and increased sensitivity of genital tissues.24,26 In addition, high-dose corticosteroids use for chronic GVHD can increase emotional lability and depression, affecting feelings of attractiveness, sexual activity, and quality of sexual life.

F1NCCN Clinical Practice Guidelines in Oncology: Survivorship: Sexual Dysfunction (Female),Version 1.2013

Version 1.2013, 03-08-13 ©2014 National Comprehensive Cancer Network, Inc. All rights reserved. The NCCN Guidelines® and this illustration may not be reproduced in any form without the express written permission of NCCN®.

Citation: Journal of the National Comprehensive Cancer Network J Natl Compr Canc Netw 12, 2; 10.6004/jnccn.2014.0019

F2NCCN Clinical Practice Guidelines in Oncology: Survivorship: Sexual Dysfunction (Female),Version 1.2013

Version 1.2013, 03-08-13 ©2014 National Comprehensive Cancer Network, Inc. All rights reserved. The NCCN Guidelines® and this illustration may not be reproduced in any form without the express written permission of NCCN®.

Citation: Journal of the National Comprehensive Cancer Network J Natl Compr Canc Netw 12, 2; 10.6004/jnccn.2014.0019

Evaluation and Assessment for Female Sexual Function

At regular intervals, female cancer survivors should be asked about their sexual function, including their sexual functioning before cancer treatment, their present activity, and how cancer treatment has impacted their sexual functioning and intimacy. The age and relationship status of the survivor may also affect sexual functioning (ie, some women may not be sexually active because of the physical health of their partner or quality of their relationship). The Brief Sexual Symptom Checklist for Women can be used as a primary screening tool.27 Inquiries into treatment-related infertility should be made if indicated, with referrals as appropriate.

Patients with concerns about their sexual function should undergo a more thorough evaluation, including screening for possible symptoms and psychosocial problems (ie, anxiety, depression, relationship issues, drug or alcohol use) that can contribute to sexual dysfunction. It is also important to identify prescription and over-the-counter medications (especially hormone therapy, narcotics, and serotonin reuptake receptor inhibitors) that could be a contributing factor. Traditional risk factors for sexual dysfunction, such as cardiovascular disease, diabetes, obesity, smoking, and alcohol abuse, should also be assessed, as should the oncologic and treatment history. If anticancer treatments have resulted in menopause, menopausal symptoms and effects on sexual function should be assessed. Risks and benefits of hormone therapy should be considered in women who have not had hormone-sensitive cancers and who are prematurely postmenopausal. In addition, a physical and gynecologic examination should be performed to note points of tenderness, vaginal atrophy, and anatomic changes associated with cancer and cancer treatment.

For a more in-depth evaluation of sexual dysfunction, the Female Sexual Function Index can be considered.28 This instrument has been validated in patients with cancer and cancer survivors.29,30

Interventions for Female Sexual Dysfunction

Overall, the evidence base for interventions to treat female sexual dysfunction in survivors is weak, and high-quality studies are needed.31,32 Based on evidence from other populations, evidence from survivors when available, recommendations from the American College of Obstetricians and Gynecologists,12 and consensus among NCCN Survivorship Panel members, the panel made recommendations for treatment of female sexual dysfunction in survivors. The panel recommends that treatment be guided to the specific type of problem. The evidence base for each recommendation is described herein.

Water-, oil-, or silicone-based lubricants and moisturizers can help alleviate symptoms such as vaginal dryness and sexual pain.33 In one study of breast cancer survivors, the control group used a nonhormonal moisturizer and saw a transient improvement in vaginal symptoms.34

Pelvic floor muscle training may improve sexual pain, arousal, lubrication, orgasm, and satisfaction. A small study of 34 survivors of gynecologic cancers found that pelvic floor training significantly improved sexual function.35

Vaginal dilators are recommended for vaginismus, sexual aversion disorder, vaginal scarring, or vaginal stenosis from pelvic surgery or radiation and associated with GVHD. However, evidence for the effectiveness of dilators is limited.36

Vaginal estrogen (pills, rings, or creams) has been shown to be effective in treating vaginal dryness, itching, discomfort, and painful intercourse in postmenopausal women.37-42 Small studies have looked at different formulations of local estrogen, but data assessing the safety of vaginal estrogen in survivors are limited.

Psychotherapy may be helpful for women experiencing sexual dysfunction, although evidence on efficacy is limited.43 Options include cognitive behavior therapy, for which some evidence of efficacy exists in survivors of breast, endometrial, and cervical cancer.44,45 Referrals for psychotherapy, sexual/couples counseling, or gynecologic care should be given as appropriate, and ongoing partner communication should be encouraged.46

Currently, the panel does not recommend the use of oral phosphodiesterase type 5 inhibitors (PDE5i) for female sexual dysfunction because of the lack of data regarding their effectiveness in women. Although thought to increase pelvic blood flow to the clitoris and vagina,47,48 PDE5i showed contradictory results in randomized clinical trials of various noncancer populations of women being treated for sexual arousal disorder.49-54 More research is needed before a recommendation can be made regarding the use of sildenafil for the treatment of female sexual dysfunction.

Individual Disclosures for the NCCN Survivorship Panel

T1

References

  • 1.

    BoberSLVarelaVS. Sexuality in adult cancer survivors: challenges and intervention. J Clin Oncol2012;30:37123719.

  • 2.

    DonovanKAThompsonLMHoffeSE. Sexual function in colorectal cancer survivors. Cancer Control2010;17:4451.

  • 3.

    LaumannEOPaikARosenRC. Sexual dysfunction in the United States: prevalence and predictors. JAMA1999;281:537544.

  • 4.

    MorrealeMK. The impact of cancer on sexual function. Adv Psychosom Med2011;31:7282.

  • 5.

    VomvasDIconomouGSoubasiE. Assessment of sexual function in patients with cancer undergoing radiotherapy—a single centre prospective study. Anticancer Res2012;32:657664.

    • Search Google Scholar
    • Export Citation
  • 6.

    ForbatLWhiteIMarshall-LucetteSKellyD. Discussing the sexual consequences of treatment in radiotherapy and urology consultations with couples affected by prostate cancer. BJU Int2012;109:98103.

    • Search Google Scholar
    • Export Citation
  • 7.

    WhiteIDAllanHFaithfullS. Assessment of treatment-induced female sexual morbidity in oncology: is this a part of routine medical follow-up after radical pelvic radiotherapy?Br J Cancer2011;105:903910.

    • Search Google Scholar
    • Export Citation
  • 8.

    FinkHAMac DonaldRRutksIR. Sildenafil for male erectile dysfunction: a systematic review and meta-analysis. Arch Intern Med2002;162:13491360.

    • Search Google Scholar
    • Export Citation
  • 9.

    GanzPAGreendaleGAPetersenL. Managing menopausal symptoms in breast cancer survivors: results of a randomized controlled trial. J Natl Cancer Inst2000;92:10541064.

    • Search Google Scholar
    • Export Citation
  • 10.

    NehraA. Erectile dysfunction and cardiovascular disease: efficacy and safety of phosphodiesterase type 5 inhibitors in men with both conditions. Mayo Clin Proc2009;84:139148.

    • Search Google Scholar
    • Export Citation
  • 11.

    MilesCLCandyBJonesL. Interventions for sexual dysfunction following treatments for cancer. Cochrane Database Syst Rev2007:CD005540.

  • 12.

    ACOG Practice Bulletin No. 119: female sexual dysfunction. Obstet Gynecol2011;117:9961007.

  • 13.

    GilbertEUssherJMPerzJ. Sexuality after breast cancer: a review. Maturitas2010;66:397407.

  • 14.

    BarniSMondinR. Sexual dysfunction in treated breast cancer patients. Ann Oncol1997;8:149153.

  • 15.

    FrumovitzMSunCCSchoverLR. Quality of life and sexual functioning in cervical cancer survivors. J Clin Oncol2005;23:74287436.

  • 16.

    GanzPADesmondKABelinTR. Predictors of sexual health in women after a breast cancer diagnosis. J Clin Oncol1999;17:23712380.

  • 17.

    GanzPARowlandJHDesmondK. Life after breast cancer: understanding women’s health-related quality of life and sexual functioning. J Clin Oncol1998;16:501514.

    • Search Google Scholar
    • Export Citation
  • 18.

    LindauSTGavrilovaNAndersonD. Sexual morbidity in very long term survivors of vaginal and cervical cancer: a comparison to national norms. Gynecol Oncol2007;106:413418.

    • Search Google Scholar
    • Export Citation
  • 19.

    ParkSYBaeDSNamJH. Quality of life and sexual problems in disease-free survivors of cervical cancer compared with the general population. Cancer2007;110:27162725.

    • Search Google Scholar
    • Export Citation
  • 20.

    RodriguesACTeixeiraRTeixeiraT. Impact of pelvic radiotherapy on female sexuality. Arch Gynecol Obstet2012;285:505514.

  • 21.

    GershensonDMMillerAMChampionVL. Reproductive and sexual function after platinum-based chemotherapy in long-term ovarian germ cell tumor survivors: a Gynecologic Oncology Group Study. J Clin Oncol2007;25:27922797.

    • Search Google Scholar
    • Export Citation
  • 22.

    LammerinkEAde BockGHPrasE. Sexual functioning of cervical cancer survivors: a review with a female perspective. Maturitas2012;72:296304.

    • Search Google Scholar
    • Export Citation
  • 23.

    SyrjalaKLKurlandBFAbramsJR. Sexual function changes during the 5 years after high-dose treatment and hematopoietic cell transplantation for malignancy, with case-matched controls at 5 years. Blood2008;111:989996.

    • Search Google Scholar
    • Export Citation
  • 24.

    ThygesenKHSchjodtIJardenM. The impact of hematopoietic stem cell transplantation on sexuality: a systematic review of the literature. Bone Marrow Transplant2012;47:716724.

    • Search Google Scholar
    • Export Citation
  • 25.

    WatsonMWheatleyKHarrisonGA. Severe adverse impact on sexual functioning and fertility of bone marrow transplantation, either allogeneic or autologous, compared with consolidation chemotherapy alone: analysis of the MRC AML 10 trial. Cancer1999;86:12311239.

    • Search Google Scholar
    • Export Citation
  • 26.

    ZantomioDGriggAPMacGregorL. Female genital tract graft-versus-host disease: incidence, risk factors and recommendations for management. Bone Marrow Transplant2006;38:567572.

    • Search Google Scholar
    • Export Citation
  • 27.

    HatzichristouDRosenRCDerogatisLR. Recommendations for the clinical evaluation of men and women with sexual dysfunction. J Sex Med2010;7:337348.

    • Search Google Scholar
    • Export Citation
  • 28.

    RosenRBrownCHeimanJ. The Female Sexual Function Index (FSFI): a multidimensional self-report instrument for the assessment of female sexual function. J Sex Marital Ther2000;26:191208.

    • Search Google Scholar
    • Export Citation
  • 29.

    BaserRELiYCarterJ. Psychometric validation of the Female Sexual Function Index (FSFI) in cancer survivors. Cancer2012;118:46064618.

  • 30.

    JefferyDDTzengJPKeefeFJ. Initial report of the cancer Patient-Reported Outcomes Measurement Information System (PROMIS) sexual function committee: review of sexual function measures and domains used in oncology. Cancer2009;115:11421153.

    • Search Google Scholar
    • Export Citation
  • 31.

    FlynnPKewFKiselySR. Interventions for psychosexual dysfunction in women treated for gynaecological malignancy. Cochrane Database Syst Rev2009:CD004708.

    • Search Google Scholar
    • Export Citation
  • 32.

    KatzA. Interventions for sexuality after pelvic radiation therapy and gynecological cancer. Cancer J2009;15:4547.

  • 33.

    SuttonKSBoyerSCGoldfingerC. To lube or not to lube: experiences and perceptions of lubricant use in women with and without dyspareunia. J Sex Med2012;9:240250.

    • Search Google Scholar
    • Export Citation
  • 34.

    BigliaNPeanoESgandurraP. Low-dose vaginal estrogens or vaginal moisturizer in breast cancer survivors with urogenital atrophy: a preliminary study. Gynecol Endocrinol2010;26:404412.

    • Search Google Scholar
    • Export Citation
  • 35.

    YangEJLimJYRahUWKimYB. Effect of a pelvic floor muscle training program on gynecologic cancer survivors with pelvic floor dysfunction: a randomized controlled trial. Gynecol Oncol2012;125:705711.

    • Search Google Scholar
    • Export Citation
  • 36.

    MilesTJohnsonN. Vaginal dilator therapy for women receiving pelvic radiotherapy. Cochrane Database Syst Rev2010:CD007291.

  • 37.

    AytonRADarlingGMMurkiesAL. A comparative study of safety and efficacy of continuous low dose oestradiol released from a vaginal ring compared with conjugated equine oestrogen vaginal cream in the treatment of postmenopausal urogenital atrophy. Br J Obstet Gynaecol1996;103:351358.

    • Search Google Scholar
    • Export Citation
  • 38.

    FooladiEDavisSR. An update on the pharmacological management of female sexual dysfunction. Expert Opin Pharmacother2012;13:21312142.

    • Search Google Scholar
    • Export Citation
  • 39.

    KrychmanML. Vaginal estrogens for the treatment of dyspareunia. J Sex Med2011;8:666674.

  • 40.

    RaghunandanCAgrawalSDubeyP. A comparative study of the effects of local estrogen with or without local testosterone on vulvovaginal and sexual dysfunction in postmenopausal women. J Sex Med2010;7:12841290.

    • Search Google Scholar
    • Export Citation
  • 41.

    RossouwJEAndersonGLPrenticeRL. Risks and benefits of estrogen plus progestin in healthy postmenopausal women: principal results From the Women’s Health Initiative randomized controlled trial. JAMA2002;288:321333.

    • Search Google Scholar
    • Export Citation
  • 42.

    SucklingJLethabyAKennedyR. Local oestrogen for vaginal atrophy in postmenopausal women. Cochrane Database Syst Rev2006:CD001500.

  • 43.

    DavisonSL. Hypoactive sexual desire disorder. Curr Opin Obstet Gynecol2012;24:215220.

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    BrottoLAErskineYCareyM. A brief mindfulness-based cognitive behavioral intervention improves sexual functioning versus wait-list control in women treated for gynecologic cancer. Gynecol Oncol2012;125:320325.

    • Search Google Scholar
    • Export Citation
  • 45.

    DuijtsSFvan BeurdenMOldenburgHS. Efficacy of cognitive behavioral therapy and physical exercise in alleviating treatment-induced menopausal symptoms in patients with breast cancer: results of a randomized, controlled, multicenter trial. J Clin Oncol2012;30:41244133.

    • Search Google Scholar
    • Export Citation
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    MeanaMJonesS. Developments and trends in sex therapy. Adv Psychosom Med2011;31:5771.

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    CavalcantiALBagnoliVRFonsecaAM. Effect of sildenafil on clitoral blood flow and sexual response in postmenopausal women with orgasmic dysfunction. Int J Gynaecol Obstet2008;102:115119.

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    CarusoSIntelisanoGLupoLAgnelloC. Premenopausal women affected by sexual arousal disorder treated with sildenafil: a double-blind, cross-over, placebo-controlled study. BJOG2001;108:623628.

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    CarusoSRugoloSAgnelloC. Sildenafil improves sexual functioning in premenopausal women with type 1 diabetes who are affected by sexual arousal disorder: a double-blind, crossover, placebo-controlled pilot study. Fertil Steril2006;85:14961501.

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    NCCN Clinical Practice Guidelines in Oncology: Survivorship: Sexual Dysfunction (Female),Version 1.2013

    Version 1.2013, 03-08-13 ©2014 National Comprehensive Cancer Network, Inc. All rights reserved. The NCCN Guidelines® and this illustration may not be reproduced in any form without the express written permission of NCCN®.

  • View in gallery
    NCCN Clinical Practice Guidelines in Oncology: Survivorship: Sexual Dysfunction (Female),Version 1.2013

    Version 1.2013, 03-08-13 ©2014 National Comprehensive Cancer Network, Inc. All rights reserved. The NCCN Guidelines® and this illustration may not be reproduced in any form without the express written permission of NCCN®.

References

  • 1.

    BoberSLVarelaVS. Sexuality in adult cancer survivors: challenges and intervention. J Clin Oncol2012;30:37123719.

  • 2.

    DonovanKAThompsonLMHoffeSE. Sexual function in colorectal cancer survivors. Cancer Control2010;17:4451.

  • 3.

    LaumannEOPaikARosenRC. Sexual dysfunction in the United States: prevalence and predictors. JAMA1999;281:537544.

  • 4.

    MorrealeMK. The impact of cancer on sexual function. Adv Psychosom Med2011;31:7282.

  • 5.

    VomvasDIconomouGSoubasiE. Assessment of sexual function in patients with cancer undergoing radiotherapy—a single centre prospective study. Anticancer Res2012;32:657664.

    • Search Google Scholar
    • Export Citation
  • 6.

    ForbatLWhiteIMarshall-LucetteSKellyD. Discussing the sexual consequences of treatment in radiotherapy and urology consultations with couples affected by prostate cancer. BJU Int2012;109:98103.

    • Search Google Scholar
    • Export Citation
  • 7.

    WhiteIDAllanHFaithfullS. Assessment of treatment-induced female sexual morbidity in oncology: is this a part of routine medical follow-up after radical pelvic radiotherapy?Br J Cancer2011;105:903910.

    • Search Google Scholar
    • Export Citation
  • 8.

    FinkHAMac DonaldRRutksIR. Sildenafil for male erectile dysfunction: a systematic review and meta-analysis. Arch Intern Med2002;162:13491360.

    • Search Google Scholar
    • Export Citation
  • 9.

    GanzPAGreendaleGAPetersenL. Managing menopausal symptoms in breast cancer survivors: results of a randomized controlled trial. J Natl Cancer Inst2000;92:10541064.

    • Search Google Scholar
    • Export Citation
  • 10.

    NehraA. Erectile dysfunction and cardiovascular disease: efficacy and safety of phosphodiesterase type 5 inhibitors in men with both conditions. Mayo Clin Proc2009;84:139148.

    • Search Google Scholar
    • Export Citation
  • 11.

    MilesCLCandyBJonesL. Interventions for sexual dysfunction following treatments for cancer. Cochrane Database Syst Rev2007:CD005540.

  • 12.

    ACOG Practice Bulletin No. 119: female sexual dysfunction. Obstet Gynecol2011;117:9961007.

  • 13.

    GilbertEUssherJMPerzJ. Sexuality after breast cancer: a review. Maturitas2010;66:397407.

  • 14.

    BarniSMondinR. Sexual dysfunction in treated breast cancer patients. Ann Oncol1997;8:149153.

  • 15.

    FrumovitzMSunCCSchoverLR. Quality of life and sexual functioning in cervical cancer survivors. J Clin Oncol2005;23:74287436.

  • 16.

    GanzPADesmondKABelinTR. Predictors of sexual health in women after a breast cancer diagnosis. J Clin Oncol1999;17:23712380.

  • 17.

    GanzPARowlandJHDesmondK. Life after breast cancer: understanding women’s health-related quality of life and sexual functioning. J Clin Oncol1998;16:501514.

    • Search Google Scholar
    • Export Citation
  • 18.

    LindauSTGavrilovaNAndersonD. Sexual morbidity in very long term survivors of vaginal and cervical cancer: a comparison to national norms. Gynecol Oncol2007;106:413418.

    • Search Google Scholar
    • Export Citation
  • 19.

    ParkSYBaeDSNamJH. Quality of life and sexual problems in disease-free survivors of cervical cancer compared with the general population. Cancer2007;110:27162725.

    • Search Google Scholar
    • Export Citation
  • 20.

    RodriguesACTeixeiraRTeixeiraT. Impact of pelvic radiotherapy on female sexuality. Arch Gynecol Obstet2012;285:505514.

  • 21.

    GershensonDMMillerAMChampionVL. Reproductive and sexual function after platinum-based chemotherapy in long-term ovarian germ cell tumor survivors: a Gynecologic Oncology Group Study. J Clin Oncol2007;25:27922797.

    • Search Google Scholar
    • Export Citation
  • 22.

    LammerinkEAde BockGHPrasE. Sexual functioning of cervical cancer survivors: a review with a female perspective. Maturitas2012;72:296304.

    • Search Google Scholar
    • Export Citation
  • 23.

    SyrjalaKLKurlandBFAbramsJR. Sexual function changes during the 5 years after high-dose treatment and hematopoietic cell transplantation for malignancy, with case-matched controls at 5 years. Blood2008;111:989996.

    • Search Google Scholar
    • Export Citation
  • 24.

    ThygesenKHSchjodtIJardenM. The impact of hematopoietic stem cell transplantation on sexuality: a systematic review of the literature. Bone Marrow Transplant2012;47:716724.

    • Search Google Scholar
    • Export Citation
  • 25.

    WatsonMWheatleyKHarrisonGA. Severe adverse impact on sexual functioning and fertility of bone marrow transplantation, either allogeneic or autologous, compared with consolidation chemotherapy alone: analysis of the MRC AML 10 trial. Cancer1999;86:12311239.

    • Search Google Scholar
    • Export Citation
  • 26.

    ZantomioDGriggAPMacGregorL. Female genital tract graft-versus-host disease: incidence, risk factors and recommendations for management. Bone Marrow Transplant2006;38:567572.

    • Search Google Scholar
    • Export Citation
  • 27.

    HatzichristouDRosenRCDerogatisLR. Recommendations for the clinical evaluation of men and women with sexual dysfunction. J Sex Med2010;7:337348.

    • Search Google Scholar
    • Export Citation
  • 28.

    RosenRBrownCHeimanJ. The Female Sexual Function Index (FSFI): a multidimensional self-report instrument for the assessment of female sexual function. J Sex Marital Ther2000;26:191208.

    • Search Google Scholar
    • Export Citation
  • 29.

    BaserRELiYCarterJ. Psychometric validation of the Female Sexual Function Index (FSFI) in cancer survivors. Cancer2012;118:46064618.

  • 30.

    JefferyDDTzengJPKeefeFJ. Initial report of the cancer Patient-Reported Outcomes Measurement Information System (PROMIS) sexual function committee: review of sexual function measures and domains used in oncology. Cancer2009;115:11421153.

    • Search Google Scholar
    • Export Citation
  • 31.

    FlynnPKewFKiselySR. Interventions for psychosexual dysfunction in women treated for gynaecological malignancy. Cochrane Database Syst Rev2009:CD004708.

    • Search Google Scholar
    • Export Citation
  • 32.

    KatzA. Interventions for sexuality after pelvic radiation therapy and gynecological cancer. Cancer J2009;15:4547.

  • 33.

    SuttonKSBoyerSCGoldfingerC. To lube or not to lube: experiences and perceptions of lubricant use in women with and without dyspareunia. J Sex Med2012;9:240250.

    • Search Google Scholar
    • Export Citation
  • 34.

    BigliaNPeanoESgandurraP. Low-dose vaginal estrogens or vaginal moisturizer in breast cancer survivors with urogenital atrophy: a preliminary study. Gynecol Endocrinol2010;26:404412.

    • Search Google Scholar
    • Export Citation
  • 35.

    YangEJLimJYRahUWKimYB. Effect of a pelvic floor muscle training program on gynecologic cancer survivors with pelvic floor dysfunction: a randomized controlled trial. Gynecol Oncol2012;125:705711.

    • Search Google Scholar
    • Export Citation
  • 36.

    MilesTJohnsonN. Vaginal dilator therapy for women receiving pelvic radiotherapy. Cochrane Database Syst Rev2010:CD007291.

  • 37.

    AytonRADarlingGMMurkiesAL. A comparative study of safety and efficacy of continuous low dose oestradiol released from a vaginal ring compared with conjugated equine oestrogen vaginal cream in the treatment of postmenopausal urogenital atrophy. Br J Obstet Gynaecol1996;103:351358.

    • Search Google Scholar
    • Export Citation
  • 38.

    FooladiEDavisSR. An update on the pharmacological management of female sexual dysfunction. Expert Opin Pharmacother2012;13:21312142.

    • Search Google Scholar
    • Export Citation
  • 39.

    KrychmanML. Vaginal estrogens for the treatment of dyspareunia. J Sex Med2011;8:666674.

  • 40.

    RaghunandanCAgrawalSDubeyP. A comparative study of the effects of local estrogen with or without local testosterone on vulvovaginal and sexual dysfunction in postmenopausal women. J Sex Med2010;7:12841290.

    • Search Google Scholar
    • Export Citation
  • 41.

    RossouwJEAndersonGLPrenticeRL. Risks and benefits of estrogen plus progestin in healthy postmenopausal women: principal results From the Women’s Health Initiative randomized controlled trial. JAMA2002;288:321333.

    • Search Google Scholar
    • Export Citation
  • 42.

    SucklingJLethabyAKennedyR. Local oestrogen for vaginal atrophy in postmenopausal women. Cochrane Database Syst Rev2006:CD001500.

  • 43.

    DavisonSL. Hypoactive sexual desire disorder. Curr Opin Obstet Gynecol2012;24:215220.

  • 44.

    BrottoLAErskineYCareyM. A brief mindfulness-based cognitive behavioral intervention improves sexual functioning versus wait-list control in women treated for gynecologic cancer. Gynecol Oncol2012;125:320325.

    • Search Google Scholar
    • Export Citation
  • 45.

    DuijtsSFvan BeurdenMOldenburgHS. Efficacy of cognitive behavioral therapy and physical exercise in alleviating treatment-induced menopausal symptoms in patients with breast cancer: results of a randomized, controlled, multicenter trial. J Clin Oncol2012;30:41244133.

    • Search Google Scholar
    • Export Citation
  • 46.

    MeanaMJonesS. Developments and trends in sex therapy. Adv Psychosom Med2011;31:5771.

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