Department of Obstetrics & Gynaecology University of British Columbia Vancouver, BC, Canada

Integrating quantitative and qualitative methods in the development of a psychoeducational treatment for sexual dysfunction in female cancer survivors

Lori A. Brotto, Ph.D.

©Brotto, 2005

Psychological treatments and female sexual dysfunction

 Heiman (2002) Arch Sex Beh  Efficacious psychological treatment for Female Orgasmic Disorder  Some indication of efficacious psychological treatments for Hypoactive Sexual Desire Disorder and Dyspareunia  No available data testing efficacy of a psychological treatment for Sexual Arousal Disorder

©Brotto, 2005

Sexual arousal disorder

 Most of the evidence does not support efficacy of sildenafil or other vasoactive medications for FSAD

Desire difficulties Orgasm difficulties Arousal difficulties Gynaecologic cancer survivors ©Brotto, 2005

BIOLOGICAL • medication • hysterectomy • radiotherapy • chemotherapy • oophorectomy • fatigue • stress

sexual function

PSYCHOLOGICAL • acute/chronic stress • body image • intimate relationship • depression • self-esteem • sexual-esteem • loss of reproduction SOCIOCULTURAL/ INTERPERSONAL • culture • religiosity • social support • roles • relationships

©Brotto, 2005

Specific sexual concerns in gyn cancer survivors

 From 36-60% of women undergoing radical hysterectomy for cervical cancer acquire distressing sexual arousal difficulties Bergmark, 1999; 2002  Impaired genital response on vaginal photoplethysmography Maas et al., 2002  Represents one of the most distressing side effects of cancer treatment reported by women

©Brotto, 2005

Goals of this study

 To establish the components of a psychoeducational treatment targeted to sexual arousal complaints  To test the efficacy and feasibility of this treatment in gynecologic cancer survivors  To integrate quantitative with qualitative methods of assessment to determine efficacy

Funded by a Sexuality Research Fellowship from the Social Science Research Council ©Brotto, 2005

Psychoeducational Intervention (PED)

 Psychoeducation  Cognitive challenging  Behavioural exercises  Well-established treatment for female orgasmic disorder (Becoming Orgasmic, 1988)  Progressive Relaxation  Mindfulness training (Miracle of Mindfulness, 1976)  Relationship and communication skills (Seven principles for making marriage work, 1999)

©Brotto, 2005

Participants

      Recruited from University of Washington Medical Center & Seattle Cancer Care Alliance 22 women with history of cervical or endometrial cancer, in remission Treated 1-5 years earlier by radical hysterectomy Female Sexual Arousal Disorder (DSM-IV-TR) Currently involved in a relationship Excluded: major depression, primary hypoactive sexual desire disorder

©Brotto, 2005

Procedures

• Orientation to lab • Questionnaires • Sexual Arousal

Assessment

• Segment 1 PED • Female Sexual Function • Female Sexual Function

Inventory (past 4 weeks)

• Segment 2 PED

Inventory (past 4 weeks)

• Segment 3 PED • Sexual Arousal

Assessment

• Questionnaires • Semi-structured

Interview

1

1 month

2 Session # 3

1 month 1 month

4

©Brotto, 2005

Sexual Arousal Assessment

Self-reported Arousal  perceived genital arousal  subjective sexual arousal  perceived autonomic arousal  positive and negative affect  Vaginal Pulse Amplitude (VPA)  Moment-to-moment changes in vaginal peripheral blood vessels

©Brotto, 2005

Semi-structured interview

 Semi-structured in-depth interviews on the woman’s experience of her sexuality during cancer and during/after the PED  Thematic analyses of transcripts 

Why include qualitative assessment?

©Brotto, 2005

Participant Characteristics

• 13 had early-stage cervical cancer • 9 had early-stage endometrial cancer • 17 also had bilateral salpingo-oophorectomy • 7 also had external beam radiation therapy Variable Age FSFI Desire FSFI Arousal FSFI Lubrication FSFI Orgasm FSFI Satisfaction FSFI Pain DAS FSDS BDI Mean SD 49.4 (26-68) 2.40 0.88

3.38 1.96

3.67 2.27

3.42 2.19

3.83 1.66

3.76 2.31

100.0 22.7

21.82 11.81

9.70 7.78

Scale maximum 6.0

6.0

6.0

6.0

6.0

6.0

160.0

48.0

63.0

©Brotto, 2005

Characteristics of women at pre PED

More FSFI Pain Lower overall FSFI

r = .556 r = -.429

Poorer Relationship Adjustment

r = -.462 r = .585

More sexual distress

Depression Scores

Less Energy

r = -.557 r = -.817

Poorer Social Functioning

• Not associated with Ca type, BSO, radiation, or time since surgery

©Brotto, 2005

Effects of erotic stimuli at pre-PED

Film Scale Subscale VPA (x 10 -2 mV)* Perception of genital arousal* Subjective sexual arousal Autonomic arousal* Positive affect* Negative affect Anxiety* Neutral stimulus Mean SD 5.24 2.91

6.91 2.02

7.82 1.10

8.90 3.88

9.18 3.14

13.09 3.44

2.45 1.18

Erotic stimulus Mean SD 7.85 5.41

14.09 6.21

9.82 2.04

13.38 4.07

14.77 6.70

12.20 2.59

1.55 0.60

©Brotto, 2005

Effects of PED on sexuality measures

Pre-PED Post-PED * * * * *p < .01

Desire Arousal Lubrication Orgasm Satisfaction Pain ©Brotto, 2005

Effects of PED

p = .07

p < .01

Pre-PED Post-PED p < .001

p < .01

Relationship satisfaction (DAS) Emotional well-being (SF-36) Sexual Distress (FSDS) Depression (BDI) ©Brotto, 2005

Effects of PED on VPA

80 60 40 20 d = 0.39 Pre-PED Post-PED ©Brotto, 2005

Interview feedback

“ Whereas before I was thinking that I didn’t have any genital feelings…now I’m being able to focus on them and see that its not quite like it was before, like the tingling isn’t there, but there is feeling, and I just need to focus a little more .” “The part about reminding yourself that…yes you are still a woman and they do still work.” . Yes, you do still have all of your woman parts and yes, they are still yours “The mindfulness thing. I found that I can do it anytime… to be present in what you are doing .” “In general I feel more hopeful about my sexuality. And that’s what I wanted…but it looks like its going to take some work on my part and I wanted a simpler solution.

“The mindfulness was one of the most important things…making myself really focus and be aware, and to focus a little bit more inward and to those areas that you feel badly about ”

©Brotto, 2005

Qualitative themes

 Encouraged women to move beyond a sole cancer explanation for sexual difficulties  Sexual response is not all-or-none  Genital arousal response stronger after PED  Mindfulness most helpful component

©Brotto, 2005

Conclusions

 Brief psychoeducational intervention shows promise for improving sexual response (subjective and physiological), relationship satisfaction, mood, and quality of life  Self-help format appealing to women  Mindfulness training and exercises most beneficial

©Brotto, 2005

Unanswered questions

What role do hormones play in the efficacy of the PED?

Pilot project of PED in early-stage cervical & endometrial cancer survivors with sexual arousal problems What are the mechanisms by which the PED works? Doesn’t work? Is the PED efficacious and more cost-effective in a group format? What role do ethno cultural variables play in the response to the PED? Can the PED be efficacious in an entirely self-help format, perhaps with instructional DVD or telephone support, or is the “therapist” necessary?

Is the PED effective in later-stage disease where palliative and end of-life issues compound the concerns about sexual function? Canadian Institutes of Health Research, Michael Smith Foundation for Health Research, UBC Faculty of Medicine, Department of Obstetrics & Gynaecology ©Brotto, 2005