DEVELOPMENT OF A PSYCHOEDUCATIONAL TREATMENT FOR SEXUAL DYSFUNCTION IN CERVICAL OR ENDOMETRIAL CANCER SURVIVORS Yvonne Erskine, MEd, Lori Brotto, PhD & Katherine Rhodes MA Department of Obstetrics and Gynaecology, University of British Columbia, Vancouver, British Columbia, Canada INTRODUCTION METHODS

Treatment of gynaecologic cancers by hysterectomy, radiation therapy, and/or oophorectomy results in persisting sexual arousal complaints in the majority of women 1 .

Although such sexual side-effects represent the most distressing symptoms during remission hysterectomy.

2 , there are no evidence-based treatments available, leaving a significant proportion of women with chronic sexual difficulty that negatively impacts quality of life. We recently developed a psychoeducational intervention (PED) tailored to the sexual complaints of gynaecologic cancer survivors. The goal of the current study is to attempt to replicate the results of Brotto and colleagues (in press) in a group of women with new-onset sexual dysfunction secondary to

RECRUITMENT

Potential participants through the British Columbia Cancer Agency patient data base, and contacted by letter from their surgeon. Interested women contacted the study’s research coordinator who performed a telephone screening to determine if they met the study’s eligibility criteria. Medical screening was performed by a registered nurse involved in the study.

were identified

PROCEDURES

Women participated in four 75-minute sessions spaced 4 weeks apart as follows: Session 1: Baseline questionnaires (sexual response, distress, relationship adjustment and mood), assessment of physiological and subjective sexual arousal to visual sexual stimulation using a vaginal photoplethysmograph, Segment 1 of PED. Approximately 5 hours of homework exercises were suggested after each session.

Session 2: Completion of Female Sexual Function Index (FSFI), Segment 2 of PED. Session 3: Completion of FSFI, Segment 3 of PED.

Session 4: Repeat assessment of physiological and subjective sexual arousal to visual sexual stimulation, 45-minute semi-structured feedback interview.

PSYCHOEDUCATIONAL INTERVENTION (PED)

The PED represents a combination of cognitive, behavioural, and educational techniques borrowed from other areas of psychological treatment. It consists of a treatment manual and participant worksheets to complete between sessions. The PED included a therapist manual plus participant handouts (52 pages total). Components include the following: •Discussion of sexuality and sexual difficulty as being multiply determined.

•Cognitive Restructuring: Challenging of maladaptive thoughts and myths around cancer, body image, partner related beliefs, surgical menopause, and cancer.

•Mindfulness 3 : Training in mindfulness integrating all the senses while observing her body, focusing on aspects that she admires and challenging negative thoughts that interfere.

•Guided masturbation 4 : Progressive behavioural exercises designed to encourage her to feel more comfortable with self-exploration, while tuning into sensations that might be missed.

•Relationship/communication exercises 5 : Gottman’s principles for making relationships work, communication exercises. •Arousal-enhancing aids: Educational information and instruction in the use of erotica, fantasy, and vibrators as tools to boost her natural sexual response.

•Education: Prevalence of sexual difficulty following cancer, physical and pharmacological treatment alternatives, and relapse prevention. Education was integrated throughout all sessions .

•Anxiety/stress reduction 6 : Progressive muscle relaxation and diaphragmatic breathing.

RESULTS IMPLICATIONS Participant Characteristics

Nine women have completed participation to date. Their average age was 52 years (range= 31-61). All women were currently in h r had early-stage endometrial cancer. Seven also had undergone 1 BSO, two had radiation therapy and one had received chemotherapy.

One participant scored in the moderate-to-severe range of depression on the Beck Depression Inventory (BDI) pre-PED.

Table 1

Beck Depression Inventory Scale Max 63 Pre-PED

Mean SD

11.83 6.14

Post – PED

Mean SD

10.06 5.54

Female Sexual Distress Scale * Dyadic Adjustment Scale (mean scores) • Consensus • Satisfaction • Cohesion • Affectional Expression 36 5 4.9

4 4.8

26.11 9.64

3.53 .35

3.81 .48

3.11 .68

1.75 .65

15.89 9.88

3.66 .50

3.44 .80

3.20 .94

1.81 .49

* p < .05

Total scores on Adjustment Scale.

Female Sexual Distress Scale significantly decreased post- PED; t(9) = 2.67, p = .03. There were no significant changes found on the Beck Depression Inventory or the Dyadic

Effects of PED on VPA

Figure 1 1 . 0 0 0 . 8 0 0 . 6 0 0 . 4 0 0 . 2 0 P re - P E D P o s t -P E D 0 . 0 0 The trend towards increased vaginal pulse amplitude (VPA) was not statistically significant, t(9) = -1.69, p >.05. There were no significant effects of depressive status, cancer or surgery type, history of radiation therapy, or BSO status.

Effects of PED on Sexuality Measures

Figure 2 * * P r e - P E D P o s t - P E D 5 4 3 2 1 0 D e s .

A r o .

L u b .

Or g .

S a t .

P a i n * p < .05; FSFI Subscale max = 6 All items on the Female Sexual Function Index (FSFI) increased pre to post PED, with a significant increase in the Lubrication subscale; t(9) = -2.843, p =.02. The total FSFI score also increased post – treatment; t(9) = -2.297, p =.05.

Effects of PED on Psychological Measures

Figure 3 2 . 5 0 2 . 0 0 1 . 5 0 1 . 0 0 0 . 5 0 P re -P E D P o s t -P E D 0 . 0 0 De p *p<.012; BSI subscales max: ‘Somatization’=28; ‘Obsession/compulsion’=24; ‘Interpersonal Sensitivity’=16; ‘Depression’ & ‘Anxiety’=24; ‘Hostility’, ‘Phobic Anxiety’ & ‘Paranoid Ideation’=20 Significant change was found on the Inventory (BSI) scores for the Brief Symptom Somatization, Interpersonal Sensitivity, Depression, Anxiety, Hostility and Paranoid Ideation.

•These preliminary data support the findings of Brotto et al.

cancer treatment.

treatment that go largely untreated.

brief psychoeducational intervention.

by treatment providers during cancer survivorship.

gynaecological cancer.

outlined.

7 which suggested that a brief, psychoeducational intervention can be effective at improving sexual health and quality of life in women with persistent sexual complaints secondary to their •Women reported distressing sexual side effects of gynecological cancer However, even in women who have experienced such acquired difficulties for several years, they are amenable to a •That several measures of sexuality and mood improved after three sessions of PED suggests that attention to women’s sexual health can be considered feasible •The trend towards increased physiological sexual arousal after only three sessions supports the psychophysiological mechanisms by which PED is effective.

•These findings indicate that a brief psychoeducational intervention is feasible and effective in women with sexual complaints following the treatment of early-stage •Although these data are preliminary, they suggest that sexual health must be discussed during the cancer experience with possible options for treatment •Plans for future studies expanding upon the brief PED and assessing it in other subgroups of gynecologic cancer survivors are currently underway.

REFERENCES

1. Bergmark K et al. (2002). Patient-rating of distressful symptoms after treatment for early cervical cancer. Acta Obstetricia et Gynecologia Scandinavica, 81, 443-450.

2. Hanh TN (1975). The miracle of mindfulness. Beacon Press: Boston. 3. Bergmark K et al. (1999). Vaginal changes and sexuality in women with a history of cervical cancer. New England Journal of Medicine, 340, 1383-1389.

4. Heiman JR & LoPiccolo J (1987). Becoming Orgasmic. Prentice Hall Press: New York.

5. Gottman JM & Silver N. (1999). The seven principles for making marriage work. Three Rivers Press: New York. 6. Barlow DH & Craske MG (1994). Mastery of your anxiety and panic II. Graywind Publications Inc: New York.

7. Brotto LA et al. (in press). A psychoeducational intervention for sexual dysfunction in women with gynecological cancer. Archives of Sexual Behavior.

Supported by the Canadian Institutes of Health Research