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Case history

image A 41-year-old woman presented 36 months after a diagnosis of grade 3 invasive ductal carcinoma: oestrogen receptor (ER)-positive, progesterone receptor (PR)-positive, human epidermal growth factor receptor 2 (HER2)-negative, lymph node-positive. Initial surgery was a lumpectomy, followed by mastectomy, chemotherapy and radiotherapy. She had been considering breast reconstruction and had been taking tamoxifen for 2 years with the expectation that it would be needed for a further 8 years.

She had returned to work but reduced her hours to half time so that she could spend more time with her young children. She is married and describes herself as being in a loving, caring relationship with good emotional support throughout her illness.

Over the previous 6 months she had mentioned to a number of health professionals that she had little interest in engaging in 'intimate relations' with her husband. Discussions with her team focused on diet, exercise and developing a good sleep pattern, and she felt they had looked at body image with her as part of her work-up for breast reconstruction. She is supremely grateful for the quality of life (QOL), and possibly the length of life, she is now able to have. She did not understand why she found it difficult to engage intimately with her husband: she did not seem to want sex, nor became aroused, and did not know why she found penetration so painful. She worried about the lack of what was previously a good sexual life and felt that eventually her husband would find a new partner. She was getting increasingly anxious but felt she could not ask more from a team who had given so much and who she perceived would find this problem frivolous.

When the oncology registrar elicited her concerns and took a full sexual history, the patient described two problems: lack of interest and vaginal pain likened to having 'razor blades' in her vagina. Initial interest in resuming sexual activity stopped when penetration pain was severe, leading to withdrawal from sexual contact, then withdrawal from affectionate contact because of anxiety that any contact might lead to sex. She recognized her avoidance and lack of communication with her husband, reporting that they now go to bed at different times to avoid contact.

Her difficulties also affected other areas of her life. Along with fatigue, the increasing vulvovaginal pain had stopped her from dancing, which led to withdrawal from her friendship group; she had become socially isolated, which affected her self-confidence. She reported discomfort when simply sitting at her computer; she had sought, and tried, online advice. She remained active as a school mum and felt it critically important to spend as much time as she could with her children.

She clearly described a good sexual history prior to diagnosis and even through the initial process of treatments, reporting no previous problems with desire and interest, arousal and orgasm. Examination revealed atrophic vaginitis.

Do sexual problems affect many cancer patients, and why are they ...

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