This Article Abstract Full Text (PDF) Purchase Article View Shopping Cart Alert me when this article is cited Alert me if a correction is posted Services Email this article to a colleague Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Save to my personal folders Download to citation manager Rights & Permissions Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Carmack Taylor, C. L. Articles by Bodurka, D. C. Search for Related Content PubMed PubMed Citation Articles by Carmack Taylor, C. L. Articles by Bodurka, D. C. Social Bookmarking                            What's this?

Predictors of Sexual Functioning in Ovarian Cancer Patients

From the Departments of Behavioral Science and Gynecologic Oncology, the University of Texas M.D. Anderson Cancer Center, Houston, TX

Address reprint requests to Cindy L. Carmack Taylor, PhD, Department of Behavioral Science, Box 243, University of Texas M.D. Anderson Cancer Center, 1515 Holcombe Blvd, Houston, TX 77030; e-mail: ccarmack{at}mdanderson.org

	ABSTRACT

TOP ABSTRACT INTRODUCTION PATIENTS AND METHODS RESULTS DISCUSSION Authors' Disclosures of... REFERENCES

 
PURPOSE: To characterize sexual functioning of ovarian cancer patients and identify factors predicting sexual activity, functioning or satisfaction, discomfort, and habit or frequency.

PATIENTS AND METHODS: Data were collected on 232 women with epithelial ovarian cancer, 47% of whom were receiving treatment.

RESULTS: Fifty percent of the patients had engaged in sexual activity in the past month. Of those who were sexually active, 47% reported no or little desire, 80% reported problems with vaginal dryness, and 62% reported pain or discomfort during penetration. Of those who were sexually inactive, reasons included no partner (44.1%), lack of interest (38.7%), physical problems making sex difficult (23.4%), and fatigue (10.8%). Partner factors also were identified, including physical problems (16.2%), lack of interest (15.3%), and fatigue (5.4%). A multivariate model was used to predict sexual activity and included demographic, medical, and psychosocial factors as predictors. Women who were married (P < .001), were younger than 56 years (P < .001), were not receiving active treatment (P < .01), had a longer time since original diagnosis (P = .104), and liked the appearance of their bodies (P = .004) were more likely to be sexually active. Univariate analyses indicated that demographic, medical, and psychosocial factors are significantly associated with sexual functioning or satisfaction, sexual discomfort, and sexual frequency or habit.

CONCLUSION: Sexual rehabilitation for ovarian cancer patients should address management of physical and psychologic symptoms and include the patient's partner when appropriate.

	INTRODUCTION

TOP ABSTRACT INTRODUCTION PATIENTS AND METHODS RESULTS DISCUSSION Authors' Disclosures of... REFERENCES

 
Sexual functioning is the most enduringly compromised quality-of-life (QOL) issue after treatment for gynecologic cancer, affecting up to 50% of patients [1,2]. Problems include loss of sexual desire, dyspareunia, sensation loss in the genital area, and decreased ability to achieve orgasm. Unfortunately, there is limited knowledge of specific sexual functioning problems of ovarian cancer patients because they are usually grouped with other gynecologic cancer patients. Unlike cervical and endometrial cancers, which tend to be diagnosed at earlier stages, ovarian cancer is frequently diagnosed after it has spread into the abdomen. It usually is not curable, requires aggressive treatment including multiple surgeries and repeated chemotherapy regimens, and has a low 5-year survival [3].

Only one study has assessed ovarian cancer survivors' sexuality [4]. In a sample of 200 survivors at least 2 years after treatment, 57% reported worsened sex lives, with younger and married women reporting more negative effects. Furthermore, 44.5% characterized their sense of loss regarding their sexuality as moderate (19%) or great (25.5%).

There are medical reasons for sexual dysfunction after treatment. Oophorectomy, performed to treat most ovarian cancers, triggers menopause in premenopausal women. The resulting decrease in estrogen and androgen production causes vaginal atrophy, thinned vulvar and vaginal tissues, decreased tissue elasticity and vaginal lubrication, hot flashes, and more frequent urinary tract infections, mood swings, fatigue, and irritability. Chemotherapy can also influence sexual desire by increasing fatigue and nausea [5].

Psychosocial factors have not been examined in ovarian cancer patients, but may contribute to sexual problems after treatment. Hysterectomy and abdominal scarring may negatively influence body image. Studies of other female cancers show that body image predicts sexual interest and satisfaction [6]. In addition, ovarian cancer patients have high rates of psychologic distress [7], including depression and anxiety [8]. Depression decreases sexual desire, an effect potentially exacerbated by serotonergic reuptake inhibitor antidepressants [9]. Finally, partner factors may influence sexual activity after treatment. Because ovarian cancer risk increases with age and peaks in the eighth decade [10], patients' partners also are older, increasing their risk for medical problems that contribute to sexual inactivity or dysfunction. The partner's psychologic reaction to cancer and its treatment also may affect their sexual relationship because most couples find it difficult to communicate about sexual problems during illness and stress [11].

The one identified study of sexual functioning in ovarian cancer assessed only survivors' perceptions of change in their sex lives after cancer [4]. A more thorough approach would assess dyspareunia, vaginal dryness, and all domains of the sexual response cycle in survivors and in women receiving treatment. Identifying predictors of sexual functioning allows healthcare workers to offer preventive rehabilitation to women at risk for developing sexual problems. The purpose of this study was to characterize the sexual functioning of ovarian cancer patients and identify factors predicting their sexual activity, as well as those associated with sexual functioning or satisfaction, sexual discomfort, and sexual habit.

	PATIENTS AND METHODS

TOP ABSTRACT INTRODUCTION PATIENTS AND METHODS RESULTS DISCUSSION Authors' Disclosures of... REFERENCES

 
Sample
The data reported here were part of a larger study that determined the psychometric properties of the Functional Assessment of Cancer Therapy–Ovarian (FACT-O) [12]. Participants were drawn from a consecutive series of 329 outpatients with epithelial ovarian cancer diagnoses confirmed by a gynecologic oncologist (D.C.B) and who had appointments at the University of Texas M.D. Anderson Gynecologic Oncology Center (Houston, TX) over a 6-month period. The women primarily attended the center for posttreatment surveillance (50%), chemotherapy clearance (26%), or physician consultation about additional treatment or clinical trials (14%). Of these 329 women, 232 (71%) completed the survey; 53 (16%) refused participation; and 44 (13%) were not approached, either because they could not be contacted or the patients' physicians asked that they be excluded.

Procedure
The study was approved by the M.D. Anderson Institutional Review Board for the protection of human participants; each participant provided written informed consent. Patients completed QOL questionnaires during a clinic appointment.

Measures
Sexual functioning and activity were measured with the Sexual Activity Questionnaire (SAQ) [13]. The section assessing sexual functioning includes 10 items. Including nine of the 10 items, factor analysis yields a three-factor structure: pleasure, discomfort, and habit. The pleasure subscale assesses desire, enjoyment, and satisfaction. The discomfort subscale assesses vaginal dryness and dyspareunia. The habit subscale assesses how frequency of sexual behavior in the past month compares with what is typical. Test-retest reliability (Pearson's r) for the individual items ranges from 0.68 to 1.00. The SAQ discriminates between groups expected to differ on sexuality (eg, premenopausal and postmenopausal women) [13], and has been used in breast cancer survivors [14]. For this study, we added two items assessing arousal and orgasm, components of the sexual response cycle not included in the instrument. The second section assesses reasons for sexual inactivity and gives participants space to add reasons not listed. Included as reasons for inactivity are the partner issues of fatigue, lack of interest in sex, and a physical problem making sexual relations difficult or uncomfortable.

We also administered questionnaires on demographic, medical, and psychosocial factors. Demographic factors included marital status, education, ethnicity, and age.

Two categories of medical factors were assessed: disease-related factors and physical factors. Disease-related factors included disease stage, treatment status, and time since original diagnosis. Physical factors included physical symptoms and performance status. To assess physical symptoms, we used the physical symptom subscales of the Memorial Symptom Assessment Scale [15], which assess cancer patients' high- and low-prevalence physical symptoms. Internal consistency reliability is high for the high-prevalence symptoms subscale (Cronbach's = .88) and moderate for the low-prevalence symptoms subscale ( = .58). Memorial Symptom Assessment Scale summary scale and subscale scores correlate with other measures of symptoms, QOL, performance status, and mental health [15]. To assess performance status, we used the Eastern Cooperative Oncology Group Performance Status Rating (Zubrod score) [16]. Patients categorized themselves as fully ambulatory without symptoms, fully ambulatory with some symptoms, requiring less than 50% of awake time to rest, requiring more than 50% of awake time to rest, or bedridden.

Psychosocial factors assessed included depression, anxiety, three questions we refer to collectively as body image, and partner issues. Depression was measured with the Center for Epidemiologic Studies Depression Scale [17]. Internal consistency reliability is high in the general population (Cronbach's = .85) and psychiatric inpatients ( = .90). It has been used extensively with cancer populations [18,19]. The state subscale of the Spielberger State-Trait Anxiety Inventory was used to measure anxiety [20]. It has high internal consistency reliability (median = .93) and is frequently used in medical patient populations. Body image was assessed using three items from the FACT-O, [12], an ovarian cancer–specific QOL measure. These items are "I am bothered by hair loss," "I like the appearance of my body," and "I am able to feel like a woman." The FACT-O has adequate internal consistency and test-retest reliabilities [12]. Finally, partner issues were assessed with the SAQ previously described [13].

Data Analyses
Descriptive statistics were computed on demographic and medical variables. In addition, percentages of women having sexual functioning problems were calculated.

We performed an exploratory principal components factor analysis on the SAQ because it had never been administered to ovarian cancer patients and because we had added two items. An oblique rotation was used because we expected the factors to be conceptually related. Items loading heavily on each factor were combined into a scale score, and the internal consistency reliability of each scale was calculated.

The conceptual framework guiding our analyses included variables known to affect sexual functioning in healthy women and women with cancer [2,5,9,21], predicting the outcome of sexual activity. Predictor variables were the demographic, medical, and psychosocial factors described in the Measures section. The significance of univariate relationships between sexual activity and predictor variables was tested using ² tests for categoric variables and t tests for continuous variables. Pearson's correlation coefficients between the outcome measures of functioning or satisfaction, discomfort, and habit or frequency and predictor variables also were calculated. Predictor variables of sexual activity that were significantly related to the outcome variable at P < .10 in the univariate analyses were included in the multivariate analyses. Multivariate logistic regression analyses with backward elimination were used to identify independent predictors of sexual activity.

Univariate associations between predictor variables and SAQ scale scores also were conducted.

	RESULTS

TOP ABSTRACT INTRODUCTION PATIENTS AND METHODS RESULTS DISCUSSION Authors' Disclosures of... REFERENCES

 
Descriptive Statistics
Demographic and disease status data in Table 1 show that participants were primarily white (85.0%), married (72.1%), and diverse in education and income.

Comparisons to Healthy Women and Breast Cancer Survivors
Figure 1 shows the prevalence of sexual activity comparing ovarian cancer patients with that of healthy women; across all subgroups, ovarian cancer patients are much less likely to be sexually active. Table 2 lists data using the original nine-item SAQ comparing our sample to healthy women and breast cancer survivors. Because of low sample size for those with disease not receiving treatment (n = 15), cautious interpretation of these data is recommended. Although ovarian cancer patients with no evidence of disease fare better, overall our patients show greater dysfunction and lower frequency of sexual activity compared with healthy women and breast cancer survivors. Differences related to discomfort seem most striking.

View larger version (60K): [in this window] [in a new window]   Fig 1. Prevalence of sexual activity comparing ovarian cancer patients to healthy women. Data on healthy women from the Sexual Activity Questionnaire validation study [13]. NED, no evidence of disease; HRT, hormone replacement therapy.

Factor Analysis of the SAQ
Factor analysis of the SAQ, using the original nine items plus two additional items, revealed a three-factor structure conceptually comparable to that of the original SAQ. Factor loadings representing the correlation between a variable and a factor are provided in Table 3. Loadings greater than ± 0.40 are considered high, indicating variables important to that factor.

Predictors of Sexual Activity
Half of the participants had engaged in sexual activity at least once in the previous month. Of the sexually inactive participants, reasons included having no partner (44%), lack of interest (38%), physical problems that made sex difficult (23%), and fatigue (10%). Partner issues also were identified, including partners' physical problems (16%), fatigue (5%), and lack of interest (15%). Other reported explanations included religious beliefs, concern about causing physical harm, and reluctance to date.

Table 4 compares sexually active and inactive women on demographic, medical, and psychosocial characteristics. In the univariate analyses, women who were married, were younger than 56 years, were not receiving treatment, and liked the appearance of their bodies were more likely to be sexually active. Women with more time since diagnosis were also more likely to be sexually active (P = .059).

Regarding medical variables, physical symptoms was the most consistent correlate, with those having more symptoms reporting lower functioning or satisfaction, greater discomfort, and lower sexual frequency. Performance status was significantly correlated with discomfort and frequency or habit, indicting those with poorer performance status had greater discomfort and lower sexual frequency. Treatment status had a positive relationship with discomfort, although the correlation was low. Those in active treatment had greater discomfort.

Regarding psychologic variables, depression and "able to feel like a woman" were the most consistent correlates. Higher depression was associated with lower functioning or satisfaction, greater discomfort, and lower sexual frequency. Being able to feel like a woman was associated with higher functioning or satisfaction, lower discomfort, and higher sexual frequency. Consistent with these findings, higher anxiety was associated with greater discomfort and lower sexual frequency, and liking the appearance of one's body was associated with higher functioning or satisfaction and lower discomfort.

We considered conducting multivariate models predicting each of the three SAQ scale scores including only sexually active participants. Because this would reduce our sample size to 90 to 100 participants, we did not perform these analyses.

	DISCUSSION

TOP ABSTRACT INTRODUCTION PATIENTS AND METHODS RESULTS DISCUSSION Authors' Disclosures of... REFERENCES

 
This is the first study to comprehensively examine the sexual functioning of ovarian cancer patients. Our results indicated that 50% had not engaged in sexual activity in the previous month. Reasons for sexual inactivity were quite similar to those provided by breast cancer survivors [22]. Of the ovarian cancer patients who reported being married or in an intimate relationship, almost half reported low desire for sex with their partners, consistent with previous evidence that loss of sexual desire is a problem for gynecologic cancer patients [2,23]. This percentage was even greater for patients in active treatment. For 80% of those sexually active in the previous month, vaginal dryness was a problem. Although problems with lubrication are expected as women age, this percentage is much higher than the 27% of women aged 50 to 59 years reporting this problem in the National Health and Social Life Survey (NHSLS) [21]. Similarly, pain or discomfort during penetration and inability to reach orgasm were more common in our sample than in the NHSLS sample, 8% of whom reported pain during sex and 23% of whom reported inability to reach an orgasm. Interestingly, if we used the measurement methods from the NHSLS, our percentages would have been even larger because the NHSLS study recorded percentages of women having the problems in the past 12 months (much longer than the 1-month period we assessed).

Compared with healthy postmenopausal women [13] and breast cancer survivors [14], ovarian cancer patients seem to have greater problems with loss of desire and sexual discomfort, and greater reductions in sexual activity frequency. However, similar factors appear to be related to sexual problems across healthy and cancer survivor populations. Consistent with the conceptual framework proposed by Ganz et al [6] for managing sexual health after breast cancer, our results showed that both medical and psychosocial factors should be considered.

Regarding medical factors, results indicated a woman's treatment status affected whether she was sexually active. These results were not surprising because chemotherapy side effects such as nausea and fatigue reduce sexual desire [5]. In our study, the more physical symptoms a woman experienced, the less sexual desire and satisfaction she had. Fatigue and physical problems making sex difficult were frequently cited as reasons for sexual inactivity.

Psychosocial factors including body image, mood, and partner issues also play a role in sexual functioning. In terms of body image, liking the appearance of her body was a significant predictor of whether a woman was sexually active. It also was correlated with sexual functioning or satisfaction and discomfort; the more a woman liked the appearance of her body, the higher the satisfaction and the lower the discomfort she reported. Similarly, being able to feel like a woman was positively related to satisfaction and frequency and negatively related to discomfort. Researchers currently note the importance of assessing body image in cancer patients [24]. According to one heuristic model [25], self-schemas (or cognitive views about oneself), along with the degree of emotional investment in the changed body feature, can result in a discrepancy between how one sees oneself and how one thinks one should be. This discrepancy and associated dysfunctional thoughts about one's appearance can have negative emotional and behavioral consequences—in this case, problems with sexual functioning. In a study of posttreatment sexual functioning in gynecologic cancer patients, pretreatment sexual self-schemas predicted postdiagnosis sexual behavior and responsiveness when precancer intercourse frequency, extent of disease and treatment, and menopausal symptoms were controlled for [2].

Depression also was negatively correlated with satisfaction and frequency and positively correlated with discomfort, a finding consistent with research documenting the association between depression and sexual dysfunction. Depression has been associated with decreased sexual frequency, dyspareunia, and all aspects of the sexual response cycle [9], and is common in people seeking treatment for sexual problems [26].

Several partner factors were identified as reasons for sexual inactivity and may be a result of the partner's age and possible medical comorbidities contributing to sexual dysfunction. Unfortunately, our study did not directly assess partner functioning. However, our results underscore the importance of assessing the partner when developing sexual rehabilitative programs for ovarian cancer patients.

Although not amenable to change, certain demographic characteristics may alert healthcare workers to those at risk for problems after ovarian cancer. Our results indicate a patient's age and relationship status may be important; being younger and married were significant predictors of sexual activity. Of those sexually active patients, higher education was associated with greater sexual functioning or satisfaction. This is consistent with data from the NHSLS, which indicated that high educational level is negatively associated with low desire and problems achieving orgasm [21], two components of our sexual functioning or satisfaction factor. Several factors we identified may be potential targets for intervention. Sexual rehabilitation, delivered during or after treatment, must consider the patient's individual needs.

When intercourse is possible, but physically challenging, medical management may suffice. For instance, estrogen may help eliminate hot flashes and mood swings and increase libido. Antidepressants may be appropriate if estrogen is contraindicated. Vaginal dryness can be treated with lubricants to minimize discomfort associated with intercourse.

When women or their partners are physically unable to have intercourse, other dimensions of the spousal relationship, especially intimacy, assume a prominence in maintaining relationship quality. Some couples who decrease or discontinue sexual relations also reduce expressions of nonsexual intimacy [27]. Alternative expressions of intimacy may compensate for decreased or discontinued sexual relations. For these couples, sexual rehabilitation counseling would emphasize developing communication skills and learning alternative ways to express intimacy.

When women have negative self-schemas regarding their sexuality or are depressed, sexual rehabilitation may be more challenging. Those with negative self-schemas may resist trying new sexual activities to cope with physical problems or may feel more negatively about body changes [2]. Likewise, depressed women may lack motivation for sexual rehabilitation counseling. In either case, cognitive behavioral therapy targeting these issues may be necessary before beginning a sexual rehabilitation program.

Although we identified key factors to consider when assessing and treating sexual problems after ovarian cancer, our assessment could have been more comprehensive in terms of medical and psychosocial factors. The conceptual model developed for breast cancer patients seems applicable for ovarian cancer patients and could assist in dictating a thorough assessment [6]. For example, medical evaluations should include use of estrogen replacement therapy (ERT). At the time our data were collected, ERT was routinely prescribed to women without a history of breast cancer, and vaginal lubricants were recommended for vaginal dryness; no data were collected regarding adherence to these recommendations. Such data collection and assessment may be challenging because although ERT is frequently prescribed, many women are noncompliant [28]. Estrogen use may decline given the recent data regarding risk of breast cancer and potential increase in ovarian cancer [29,30]. In addition, a more thorough psychosocial assessment should be used. For example, our body image assessment was limited; a comprehensive assessment might include the Body Image Scale [24], developed for cancer patients, plus an evaluation of the woman's sexual self-schema [31]. If the woman has a partner, the partner should be assessed directly rather than through patient report. Because of our study's cross-sectional design, and hence correlational results, future longitudinal research is necessary to delineate factors influencing sexual functioning of ovarian cancer patients over time. These factors probably change, depending on where a woman is in the treatment process. Furthermore, given our sample size, we were limited to correlational analyses when examining the relationships between predictor variables and sexual functioning. Results of this study should be considered hypotheses generating for larger studies examining predictors of sexual functioning in ovarian cancer patients and survivors.

	Authors' Disclosures of Potential Conflicts of Interest

TOP ABSTRACT INTRODUCTION PATIENTS AND METHODS RESULTS DISCUSSION Authors' Disclosures of... REFERENCES

 
The authors indicated no potential conflicts of interest.

	Acknowledgment

 
We thank Maureen E. Goode, PhD, ELS, from the Department of Scientific Publications at the University of Texas M.D. Anderson Cancer Center.

	NOTES

 
Supported by the University of Texas M.D. Anderson Physicians Referral Service institutional grant, the Blanton-Davis Ovarian Cancer Research Fund, and a cancer prevention fellowship supported by a National Cancer Institute grant (R25 CA57730, Robert Chamberlain, PhD, principal investigator).

Authors' disclosures of potential conflicts of interest are found at the end of this article.

	REFERENCES

TOP ABSTRACT INTRODUCTION PATIENTS AND METHODS RESULTS DISCUSSION Authors' Disclosures of... REFERENCES

 
1. Andersen BL: Quality of life for women with gynecologic cancer. Curr Opin Obstet Gynecol 7:69-76, 1995[Medline]

2. Andersen BL, Woods XA, Copeland LJ: Sexual self-schema and sexual morbidity among gynecologic cancer survivors. J Consult Clin Psychol 65:221-229, 1997[CrossRef][Medline]

3. Ozols RF, Rubin SC, Thomas GM, et al: Epithelial ovarian cancer, in Hoskins WJ, Perez CA, Young RC (eds): Principles and Practice of Gynecologic Oncology (ed 3). Philadelphia, PA, J.B. Lipincott, 2000

4. Stewart DE, Wong F, Duff S, et al: "What doesn't kill you makes you stronger": An ovarian cancer survivor survey. Gynecol Oncol 83:537-542, 2001[CrossRef][Medline]

5. National Cancer Institute: Sexuality and Reproductive Issues. Bethesda, MD, National Cancer Institute, 2002

6. Ganz PA, Desmond KA, Belin TR, et al: Predictors of sexual health in women after a breast cancer diagnosis. J Clin Oncol 17:2371-2380, 1999[Abstract/Free Full Text]

7. Kornblith AB, Thaler HT, Wong G, et al: Quality of life of women with ovarian cancer. Gynecol Oncol 59:231-242, 1995[CrossRef][Medline]

8. Bodurka-Bevers DC, Basen-Engquist K, Carmack CL, et al: Depression, anxiety, and quality of life in patients with epithelial ovarian cancer. Gynecol Oncol 78:302-308, 2000[CrossRef][Medline]

9. Michael A, O'Keane V: Sexual dysfunction in depression. Hum Psychopharmacol 15:337-345, 2000[CrossRef][Medline]

10. American Cancer Society: Cancer Facts & Figures 2002. Atlanta, GA, American Cancer Society, 2002

11. McNeff E: Issues for the partner of the person with a disability, in Sipski M, Alexander C (eds): Sexual Function in People with Disability and Chronic Illness. Gaithersburg, MD, Aspen, 1997, pp 595-616

12. Basen-Engquist K, Bodurka-Bevers D, Fitzgerald M, et al: Reliability and validity of the Functional Assessment of Cancer Therapy—Ovarian (FACT-O). J Clin Oncol 19:1809-1817, 2001[Abstract/Free Full Text]

13. Thirlaway K, Fallowfield L, Cuzick J: The Sexual Activity Questionnaire: A measure of women's sexual functioning. Qual Life Res 5:81-90, 1996[CrossRef][Medline]

14. Ganz PA, Desmond KA, Leedham B, et al: Quality of life in long-term, disease-free survivors of breast cancer: A follow-up study. J Natl Cancer Inst 94:39-49, 2002[Abstract/Free Full Text]

15. Portenoy RK, Thaler HT, Kornblith AB, et al: The Memorial Symptom Assessment Scale: An instrument for the evaluation of symptom prevalence, characteristics and distress. Eur J Cancer 30:1326-1336, 1994

16. Zubrod CG, Schneiderman M, Frei E, et al: Appraisal of methods for the study of chemotherapy of cancer in man: Comparative therapeutic trial of nitrogen mustard and triethylene thiophosphoramide. J Chronic Dis 11:17-33, 1960

17. Radloff LS: The CES-D scale: A self-report depression scale for research in the general population. Appl Psychol Measure 1:385-401, 1977[CrossRef]

18. Hann D, Winter K, Jacobsen PJ: Measurement of depressive symptoms in cancer patients: Evaluation of the Center for Epidemiological Studies Depression Scale (CES-D). J Psychosom Res 46:437-443, 1999[CrossRef][Medline]

19. Gotay CC, Stern JD: Assessment of psychological functioning in cancer patients. J Psychosoc Oncol 13:123-160, 1995[CrossRef]

20. Spielberger CD, Gorsuch RL, Lushene R, et al: State-Trait Anxiety Inventory for Adults: Sampler Set Manual, Test, Scoring Key. Palo Alto, CA, Consulting Psychologists Press, 1983

21. Laumann EO, Paik A, Rosen RC: Sexual dysfunction in the United States: Prevalence and predictors. JAMA 281:537-544, 1999[Abstract/Free Full Text]

22. Meyerowitz BE, Desmond KA, Rowland JH, et al: Sexuality following breast cancer. J Sex Marital Ther 25:237-250, 1999[CrossRef][Medline]

23. Portenoy RK, Thaler HT, Kornblith AB, et al: Symptom prevalence, characteristics and distress in a cancer population. Qual Life Res 3:183-189, 1994[CrossRef][Medline]

24. Hopwood P, Fletcher I, Lee A, et al: A body image scale for use with cancer patients. Eur J Cancer 37:189-197, 2001

25. White CA: Body image dimensions and cancer: A heuristic cognitive behavioural model. Psychooncology 9:183-192, 2000[Medline]

26. Fagan P, Schmidt C, Wise T, et al: Sexual dysfunction and dual psychiatric diagnoses. Compr Psychiatry 29:278-284, 1988[Medline]

27. Schover LR: Sexual rehabilitation after treatment for prostate cancer. Cancer 71:1024-1030, 1993 (suppl 3)[Medline]

28. Connelly MT, Richardson M, Platt R: Prevalence and duration of postmenopausal hormone replacement therapy use in a managed care organization, 1990-1995. J Gen Intern Med 15:542-550, 2000[CrossRef][Medline]

29. Lacey JV, Mink PJ, Lubin JH, et al: Menopausal hormone replacement therapy and risk of ovarian cancer. JAMA 288:334-341, 2002[Abstract/Free Full Text]

30. Writing Group for the Women's Health Initiative Investigators: Risk and benefits of estrogen plus progestin in healthy postmenopausal women: Principal results from the Women's Health Initiative randomized controlled trial. JAMA 288:321-333, 2002[Abstract/Free Full Text]

31. Andersen BL, Cyranowski JM: Women's sexual self schema. J Pers Soc Psychol 67:1079-1100, 1994[CrossRef]

Submitted August 23, 2002; accepted December 21, 2003.

CiteULike    Complore    Connotea    Del.icio.us    Digg    Facebook    Reddit    Technorati    Twitter    What's this?

This article has been cited by other articles:

				K. Absolom, C. Eiser, L. Turner, W. Ledger, R. Ross, H. Davies, R. Coleman, B. Hancock, J. Snowden, D. Greenfield, et al. Ovarian failure following cancer treatment: current management and quality of life Hum. Reprod., November 1, 2008; 23(11): 2506 - 2512. [Abstract] [Full Text] [PDF]

				D. L. Barton, D. B. Wender, J. A. Sloan, R. J. Dalton, E. P. Balcueva, P. J. Atherton, A. M. Bernath Jr, W. L. DeKrey, T. Larson, J. D. Bearden III, et al. Randomized Controlled Trial to Evaluate Transdermal Testosterone in Female Cancer Survivors With Decreased Libido; North Central Cancer Treatment Group Protocol N02C3 J Natl Cancer Inst, May 2, 2007; 99(9): 672 - 679. [Abstract] [Full Text] [PDF]

				S. L. Spunt, T. A. Sweeney, M. M. Hudson, C. A. Billups, M. J. Krasin, and A. L. Hester Late Effects of Pelvic Rhabdomyosarcoma and Its Treatment in Female Survivors J. Clin. Oncol., October 1, 2005; 23(28): 7143 - 7151. [Abstract] [Full Text] [PDF]

This Article Abstract Full Text (PDF) Purchase Article View Shopping Cart Alert me when this article is cited Alert me if a correction is posted Services Email this article to a colleague Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Save to my personal folders Download to citation manager Rights & Permissions Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Carmack Taylor, C. L. Articles by Bodurka, D. C. Search for Related Content PubMed PubMed Citation Articles by Carmack Taylor, C. L. Articles by Bodurka, D. C. Social Bookmarking                            What's this?