Part of "Chapter 3 - Psychological Aspects of Pelvic Surgery"
The goal of psychosexual rehabilitation after gynecologic or breast surgery is to restore sexual function, sexual identity, body image, and self-esteem. Most of the work must be done by the patient herself, but she may need assistance from her doctor and other health care providers because the experience is new to her. She has no gauge to measure what is normal for her particular situation and what is aberrant. You do.
She may expect too much too soon from herself or she may head off in the opposite direction and begin to assume the role of invalid, but in most cases, she will be caught somewhere in-between these two
extremes. Once she begins to exhibit her normal patterns of relating to others, you will know she has officially begun the process of genuine healing.
You will be able to tell when she enters the healing phase because she will become less dependent on you, the nurses, and even her family members. As her strength increases, she will want to resume her usual activities. The inevitable, normal, uncomfortable grief process will commence. Encourage the patient to talk about her feelings rather than repress them and begin to brood, because worry and rumination are forms of repetitive thought that are concomitant and predictive of negative mood. Dreary thoughts fuel a depressed mood and turn it into something ugly and dangerous that has the potential to burn the thinker beyond recognition.
The patient has the power within to effect change in herself. Family members and friends should be cautioned, at this point, to allow verbal ventilation. It's a form of healthy discontent that frequently provides the impetus to hurry and lose the sick image and begin to see herself well and strong again.
Cosmetics, dress, and grooming are important parts of the rehabilitation process. When a postoperative patient combs her hair, puts on lipstick, and demands her own nightgown instead of hospital garb, she has begun to heal. When a patient feels that the surgery was disfiguring, she needs to compensate by learning new ways to dress or groom. She needs to feel whole and complete and responsible again as quickly as possible.
The surgical patient begins to see herself as a sexual person when her sexual identity is validated by her sexual partner, friends, family, and even admiring strangers she passes on the street. The woman who has had a mastectomy or other body-altering surgery needs to know her partner still finds her attractive and desirable. Without this affirmation, she may have a great deal of trouble seeing herself as a sexual being. Some sexual partners cannot accept an incomplete person. This is another potential problem.
Some surgical procedures result in loss of vulva, clitoris, or vagina. Radical pelvic surgery can leave a woman with a colostomy or urinary diversion. A severely altered body image concurrent with loss of health and vigor poses a serious threat to a woman's self-esteem. The woman who has lost her sexual identity feels damaged beyond repair. Some complain of continuing pelvic pain without obvious structural cause.
Interest in sex vanishes, and the patient may actually leave her sexual partner or force the partner to abandon her. As she terminates her sexual identity, she feels old before her time and begins to draw in the edges of her life. These women need intense psychosexual therapy if they are ever to heal
emotionally. Table 3.1 outlines the major factors that occur with psychosexual dysfunction.
TABLE 3.1. Major Factors in Psychosexual Dysfunction
Symptomatic
Interpersonal (discord with significant other)
Organic (disease, malnutrition, malfunction of body organs)
Psychiatric (anxiety, depression, schizophrenia)
Alcohol or drug abuse
Iatrogenic (suggestions, medication, surgery)
Learned
Family (childhood negative sexual associations, experiences)
Religion (imposed prohibitions internalized)
Early unpleasant sexual experiences
Gynecologic disorders (damaged genitalia, loss of breasts, uterus)
Intrapsychic conflict
Failure to develop psychosexually
Restrictive childrearing
Restrictive childrearing
Religious influences
Most of the time, the mate or lover of the woman is good to her. There is genuine concern for her health, hope for a quick recovery, and the willingness to assume many aspects of her role until she is well. Often there is a deepening of affection between the couple as gifts of love and concern are given and received.
That special someone is in the waiting room during the surgical ordeal and by the patient's bedside when she awakes. There are flowers and gifts and promises made and kept. There is an abundance of
reciprocal love. Adjustment to new roles is relatively smooth, causing new bonds to form and old ones to strengthen.
In other cases, the woman's partner becomes a bigger problem than her physical disability. It is possible her significant other constructed a fragile emotional bond with body parts rather than with the actual woman. If she had or has cancer, the partner may irrationally feel that the cancer is contagious. If she is receiving radiation treatment, he may feel that if he resumes sexual relations with her, he, too, might absorb radiation from her body and be burned. The couple may be accustomed to frequent sex and any change in the woman's availability stresses the relationship. The fear of causing pain also has an inhibiting effect. Emotional isolation and loss of nurturing occur in both partners when the woman experiences physical disability. As surgeon to the postoperative patient, you are her first line of psychosexual defense and yours will not be an easy job.
Depending on the study cited, sexual dysfunction exists in 23% to 43% of women and 31% of the men surveyed in the general population. One third of the women lacked sexual interest, one fourth were unable to experience orgasm in the menopause, one fifth reported lubrication difficulties, and another one fifth said they did not find sex pleasurable.
These figures come from members of the population willing to discuss sexual dysfunction. Many women and their physicians, who sometimes fear they are not qualified to help, are reluctant to speak of personal problems such as libido, arousal, coital pain, or past traumatic sexual events. Much of this reluctance can be overcome if the gynecologist knows what questions to ask when taking a sexual history, preferably during an initial or annual examination prior to any body-altering surgery.
Sexual Cycle Primer
Davis suggests that the physician ask the following open-ended questions to obtain a sexual history: Are you sexually active? Are you or your partner having any sexual difficulties at this time? Has there been any change in your sexual activity? Have you ever experienced any unwanted or harmful sexual activity?
Another good question is: What sort of sexual problems do you have?
Even if the patient is initially reluctant to discuss such personal issues, she will have learned that you are willing to discuss them should the need arise. Davis also believes that a physician's confidence in dealing with sexual issues increase when the cycles of sexual response (desire, arousal, plateau, orgasm, and resolution) are learned and factors that affect them (psychological, environmental, and physiologic) understood.
Davis, in a sexual and sexual dysfunction tutorial describes the following stages.
Desire is the motivation and inclination to be sexual. It is dependent on internal (fantasies) and external sexual cues and also on adequate neuroendocrine functioning.
Arousal is characterized by erotic feelings and vaginal lubrication as blood flow increases to the vagina. In addition to feelings of sexual tension, the sexually excited woman may experience tachycardia, rapid breathing, elevated blood pressure, breast engorgement, muscle tension, nipple erection, and other
physical signs of arousal such as a flush. This is the stage where the vagina lengthens, distends, and dilates, and the uterus elevates partially out of the pelvis.
During the plateau phase, sexual tension, erotic feelings, and vasocongestion reach maximum intensity.
The labia become more swollen and turn dark red, the lower third of the vagina swells and thickens to form the orgasmic platform. The clitoris becomes more swollen and elevated, and the uterus elevates fully out of the pelvis. Eventually, women reach the threshold point of orgasmic inevitability. Orgasm is a myotonic response mediated by the sympathetic nervous system and is experienced as a sudden release of the tension built up during previous phases. Women, unlike men, experience no refractory period but can experience multiple orgasms during a single cycle. They can also experience orgasms before, during, and after intercourse provided they receive enough clitoral stimulation.
The last phase is called the resolution phase. Women experience a feeling of relaxation and well-being.
The body returns to a resting state. Complete uterine descent, detumescence of the clitoris and orgasmic platform, and decongestion of the vagina and labia take about 5 to 10 minutes.
Sexual adjustment is often significantly impaired in women after pelvic exenteration and gracilis myocutaneous vaginal reconstruction. Eighty-four percent of the patients in one of the few studies that exist resumed sexual activity within the first year after surgery. A modified version of the Sexual
Adjustment Questionnaire was used and the responses outlined the most common problems patients face after the surgery: self-consciousness about a urostomy or colostomy, being seen in the nude by their partner, vaginal dryness, and vaginal discharge. It is hoped that future modifications in surgical technique, more realistic patient counseling, and aggressive postoperative support will minimize these problems in the future. Less serious matters can cause self-esteem and body image problems, too, if their aftermath includes or leads to bowel incontinence, urinary incontinence, vaginal vault prolapse, and scarring.
Bowel incontinence is rarely discussed even with a woman's physician because it is so embarrassing.
Whether from obstetric injuries, injury to the anal muscles, infections, or diminished muscle strength from aging, once the cause and severity are determined, treatments can begin that include dietary changes, constipating medications, muscle strengthening exercises, biofeedback techniques, and sometimes, surgical repair of the muscle. Some or all of these remedies help the woman control the discharge of embarrassing gas or stool. It is most important to discuss possible remedies because many women feel there is nothing that can be done for them but the frightening colostomy, when in actual fact, colostomy is a procedure that is rarely required.
As many as 50% of all women experience occasional urinary incontinence. In an attempt to lessen the blow to a woman's ego and make the event more socially acceptable, manufacturers hire movie stars to make commercials about the effectiveness of diapers for grown women. Diapers do treat the symptoms and allow for more freedom of movement, but not in an intimate setting. For many years, gynecologists have instructed patients about Kegel exercises to tighten the muscles of the pelvic floor, but this may not be enough to stop the embarrassing leakage of urine. The patient needs to know that there are tests that can determine the exact cause of the problem, and treatment using bladder retaining therapy,
medications, and surgery. Urinary incontinence may be more socially acceptable today, but it is never normal, no matter what the woman's age.
Both bowel and urinary incontinence can be caused by vaginal vault prolapse and this condition must be ruled out because it drastically affects sexual functioning. The presence of a mass can cause painful intercourse, difficulty accepting penetration, and a great deal of psychological anxiety when the tissue can be seen in the vaginal opening. This condition, if left untreated, only worsens with time, but techniques that correct female organ–supporting defects in the pelvis can restore sexual functioning and with it, a
woman's sense of vitality and feminine allure.
Patients who talk about their sex lives frequently describe four pleasures associated with sexuality. These universal elements are touching, genital caressing, orgasm, and gratifying a partner. When a patient is recovering from surgery or has experienced surgical loss of coital function, genital caressing as a receiver or giver can be satisfying. Once a woman learns early in life how to be orgasmic, she can often learn to be so again despite major genital loss, including her clitoris. When the ability to experience orgasm by one favorite means is destroyed by disease, the patient can be encouraged to experiment with alternative
methods that do not conflict with her value system. Women who will never experience vaginal intercourse again can discover they are able, with education and imagination, to fulfill their feminine role as givers of pleasure if they choose to do so.
When a patient's psychosexual rehabilitation after surgery seems to be impaired and she fails to make steady progress toward resumption of her usual role, with appropriate self-esteem, energy, identity, and ability to handle stress, she should be offered help. Help should be offered as soon as she mentions the problem. Early intervention is often easy and brief. The surgeon should be the first person to help the patient, with counseling and, if necessary, suitable medications.
Hormonal Therapy
A 16-year study that involved 60,000 postmenopausal female nurses found that those who took hormone replacement therapy for 10 years reduced their risk of dying from all causes by 37%, with the most dramatic reduction being death from cardiac disease. After 10 years, the reduced risk for all causes was 16% because of the increased risk of dying from breast cancer. That risk rose to 43% but the women who contracted breast cancer during the first 10 years had a lower death rate from the disease than women who had never taken hormones, probably because of early detection. Chances of early detection of breast cancer are probably better for hormone users because they receive regular check-ups.
Before starting therapy, patients need to be aware of their risk factors for cardiovascular disease,
osteoporosis, and breast cancer in order to make informed choices. The screening process that provides such information may include a thorough history and physical and an accurate measurement of body weight and height, blood pressure, cholesterol level, and, for some women, bone density. In an extensive review of current literature on the subject, dubbed “the New Science of Estrogen,” Hammond provides an overview of the risks and benefits of hormone replacement therapy and also includes information on therapeutic alternatives.
Current theories indicate that estrogen has extraordinarily complex biological effects that translate into a variety of actions in diverse tissues. There is growing scientific evidence that estrogen exerts its beneficial actions on tissues of the skeletal, urogenital, digestive, cardiovascular, ocular, and nervous systems.
However, many women are afraid to use it because the media repeatedly tell them that estrogen greatly increases their risk for breast cancer.
Statistics show overwhelmingly that cardiovascular disease (CVD)—not cancer—is the leading cause of mortality for postmenopausal women. In fact, one in two women will eventually die of heart disease or stroke, whereas only one in 25 women die of breast cancer. Although the incidence of heart disease, including coronary artery disease and stroke, is low in premenopausal women, heart disease is the most frequent cause of death in women over the age of 50. Since 1984, the death rate from CVD in men has decreased, whereas the death rate for women has increased. Numerous epidemiologic studies support the long-term benefit of estrogen in preventing CVD. Observational studies, such as the Postmenopausal Estrogen/Progestin Intervention Study (PEPI) sponsored by the National Institutes of Health, revealed that hormone replacement therapy (HRT) can increase high-density lipoprotein cholesterol and decrease low-density lipoprotein cholesterol. The Nurses' Health Study demonstrated a reduction in the risk of CVD of up to 50% among current HRT users. Women who use estrogen have significantly less coronary artery stenosis than women who do not use it. Moreover, patients with the most advanced coronary artery disease experience the most benefit from estrogen replacement therapy (ERT), but only 35% of women surveyed were aware of the connection between heart disease and menopause.
ERT/HRT is also first-line therapy for osteoporosis for most women, and treatment should begin as soon as possible after the menopause. Discontinuation of therapy is followed by bone loss, which could result in a subsequent increase in the occurrence of fractures. Preliminary data suggest that even the elderly respond to estrogen replacement. However, there are therapeutic alternatives and lifestyle modifications (diet and routine exercise) that perimenopausal women must be counseled about to create a
comprehensive preventive program. Such an effort can have a significant impact on long-term morbidity and mortality associated with osteoporosis.
Women have phenomenal memories because one of their jobs is to find every needle that gets lost in the proverbial haystacks of their homes. When they become less adept at remembering where they and other people put their things, they fear the worst—that they are losing their minds, and this fear is not illogical.
Women comprise 72% of the population over the age of 85 years, and roughly half of this group has Alzheimer disease (AD). Not only do women constitute a greater proportion of this older population, but AD is expressed earlier in women than men. This may be related to the estrogen loss that occurs with menopause. Hammond cites a study that found women who took estrogen for more than 1 year
experienced a dramatic delay in AD onset. But even the group of women who averaged only 4 months of estrogen therapy and most likely took the medication to control symptoms such as hot flushes
experienced a delay in AD onset. It has been speculated that a brief exposure to estrogen influenced AD expression 20 to 30 years later by preventing an irreversible loss of neurons associated with the
occurrence of hot flushes. Research is ongoing but one study found that estrogen replacement therapy in postmenopausal women is associated with a 50% reduction in the risk of developing AD because it slows the decline of visual memory.
Colon cancer occurs more often in women than men and is a leading cause of cancer incidence and cancer deaths in women. Even though mortality rates for colon cancer have decreased 25% among women in the last 20 years, it remains the third leading cause of cancer deaths in this group. The concept that postmenopausal ERT may decrease the risk of colorectal cancer has received considerable attention, even though the hormone has no indication for this use. Some 20 epidemiologic studies have been published that examined this relationship. The majority of these suggest an inverse, protective effect for estrogen, particularly with current use. Although the precise mechanism by which estrogen reduces colon cancer risk is unknown, it has been hypothesized that it affects bile acid metabolism or promotes tumor suppressor activity. The inclusion of estrogen as a measure to prevent colon cancer should be part of the discussions between menopausal women and their physicians. Counseling should include the American Cancer Society recommendations for annual digital rectal examination and fecal occult blood testing as
Colon cancer occurs more often in women than men and is a leading cause of cancer incidence and cancer deaths in women. Even though mortality rates for colon cancer have decreased 25% among women in the last 20 years, it remains the third leading cause of cancer deaths in this group. The concept that postmenopausal ERT may decrease the risk of colorectal cancer has received considerable attention, even though the hormone has no indication for this use. Some 20 epidemiologic studies have been published that examined this relationship. The majority of these suggest an inverse, protective effect for estrogen, particularly with current use. Although the precise mechanism by which estrogen reduces colon cancer risk is unknown, it has been hypothesized that it affects bile acid metabolism or promotes tumor suppressor activity. The inclusion of estrogen as a measure to prevent colon cancer should be part of the discussions between menopausal women and their physicians. Counseling should include the American Cancer Society recommendations for annual digital rectal examination and fecal occult blood testing as