The number of women surviving gynecological cancer is increasing. Gynecological cancer survivors often develop sexual and pelvic floor dysfunctions following surgery, radiation therapy and chemotherapy. Dyspareunia is one of the most common sexual concerns and causes marital difficulties and psychological distress. Although dyspareunia impedes the quality of life of many women, treatment avenues supported by evidence to alleviate this chronic pelvic pain condition are lacking. Clinical guidelines recommend multimodal pelvic floor physiotherapy (PFPT) as a first-line treatment for dyspareunia in women with no history of cancer. Multimodal PFPT includes education, myofascial release techniques and pelvic floor muscle exercises that target the underlying mechanisms of dyspareunia. Our group completed the only study that has investigated multimodal PFPT in gynecological cancer survivors with dyspareunia. This recent multicenter, prospective, single-arm study provided evidence that multimodal PFPT significantly reduced dyspareunia while improving sexual function as well as psychological and muscle outcomes immediately after treatment (1-3). However, it is unknown whether these effects are sustained over time. Furthermore, as the effects of multimodal PFPT are multidimensional, using quantitative and qualitative approaches helps to better understand how the treatment led to these changes. Thus we conducted a mixed-method research study aimed to evaluate the effects of multimodal PFPT at 12-month follow-up on pain, sexual function and sexual distress and to explore women’s perceptions of treatment effects.

A total of 31 gynecological cancer survivors were deemed eligible following a telephone screening and a standardized pelvic examination performed by one of the gynecologic oncologists in our research team. Women were included if they had completed oncological treatments for at least three months. They also had to have experienced a minimal vulvovaginal pain intensity of five on the 0-10 numeric rating scale (NRS) in the majority of sexual intercourse attempts for more than three months. The multimodal PFPT treatment entailed 12 weekly individual sessions comprising education, myofascial release techniques and pelvic floor muscle exercises with biofeedback as well as home exercises. In parallel, the physiotherapist provided support to women for resuming pain-free sexual intercourse. Further details about the treatment protocol are available elsewhere (1).

Quantitative approach. Participants underwent baseline and post-treatment assessments in addition to a 12-month follow-up that were carried out by a physiotherapist not involved in the treatment. Pain intensity was measured with the NRS, pain quality with the McGill Pain Questionnaire (MPQ), sexual function with the Female Sexual Function Index (FSFI) and sexual distress with the Female Sexual Distress Scale-Revised (FSDS-R). Intention to treat analyses (e.g. including all participants in the analysis regardless of their adherence to treatment) were conducted to determine whether the treatment gains on all quantitative outcome measures were sustained at 12-month follow-up. Outcome measures at baseline, post-treatment and 12-month follow-up are reported and expressed as mean estimated values (95% confidence interval) according to linear mixed modeling with Bonferroni correction. P-values relating to changes from baseline to post-treatment and from baseline to 12-month follow-up are shown.

Qualitative approach. At 12-month follow-up, all women were invited to participate in an individual telephone interview to explore their perceptions of treatment effects. Interviews followed a semi-structured guide and were conducted by a physiotherapist not involved in the treatment. All interviews were recorded and transcribed for analysis. A thematic analysis was adopted to ensure data-driven analyses and interpretations. The research team members responsible for interviewing and coding the transcriptions were blinded to the participants’ responses in the questionnaires. Coding disagreements were discussed until a consensus was achieved. The research team reviewed the codes during meetings. Codes were then grouped into themes, and relationships between themes were explored by observing patterns across themes.

Twenty endometrial cancer survivors (64.5%) and 11 cervical cancer survivors (35.5%) with dyspareunia participated in the study. One woman withdrew for family reasons, one was lost at follow-up and one woman was not available to take part in the qualitative interview. The mean age of our sample was 55.9 (SD 10.8) years and the mean body mass index was 28.5 (SD 5.3) kg/m2. Women were diagnosed at various cancer stages. Consequently, they received different oncological treatments: 24 (77%) had surgery, 19 (61%) had brachytherapy, 15 (48%) had external beam radiation therapy, and 16 (52%) had chemotherapy. Participants confirmed that they did not undertake other treatments during the multimodal PFPT and the follow-up period.

Table 1 shows quantitative outcome measures at baseline, post-treatment and 12-month follow-up as well as the changes from baseline to 12-month follow-up. Significant improvements were found from baseline to post-treatment and from baseline to 12-month follow-up on all outcome measures (p ≤ 0.009). It should be noted that no changes were found from post-treatment to 12-month follow-up, supporting that the effects found at post-treatment were sustained throughout follow-up.

During the interviews, participants highlighted the reduction in dyspareunia and the improvements in sexual function as the most significant effects of multimodal PFPT. Women attributed these effects to the treatment and described them through biological, psychological and social changes. They reported a reduction in muscle tension and vaginal dryness as well as an increase in vaginal dimensions and tissue flexibility, with improved pelvic floor muscle awareness and function (biological changes). Moreover, women detailed a reduction in fear of pain and distress along with an increase in self-efficacy, self-esteem, body re-appropriation and femininity (psychological changes). Participants also described that they became more comfortable talking about sexuality with their partner and that the intimacy with their partner improved (social changes). It should be underlined that some women expressed that adherence to home exercises or the frequency of regular sexual intercourse modulated the reduction in dyspareunia and the improvements in sexual function they perceived after treatment. The higher their adherence to home exercises or the frequency of regular sexual intercourse, the greater the effects they perceived and the more they retained these treatment gains over time.

The findings of this mixed-method research study suggest that the reduction in dyspareunia and the improvements in sexual function following multimodal PFPT are sustained and meaningful for gynecological cancer survivors from post-treatment up to 12 months after treatment. These effects were reported by participants through biological, psychological and social changes attributable to multimodal PFPT. Consequently, our work is providing support to the biopsychosocial role of multimodal PFPT in gynecological cancer survivors suffering from dyspareunia. Furthermore, our results stress that promoting adherence to home exercises and frequency of regular sexual intercourse may be important for women to retain treatment gains. It is noteworthy that the integration of quantitative and qualitative approaches allowed us to fully capture the treatment effects while providing means for data triangulation and complementarity.

Even though a randomized controlled trial is required to confirm the efficacy of multimodal PFPT to reduce dyspareunia in gynecological cancer survivors, the beneficial biopsychosocial effects of this treatment avenue emphasize that it should be considered in multidisciplinary cancer follow-up to address dyspareunia and sexual dysfunction.

Cyr MP, Dumoulin C, Bessette P, Pina A, Gotlieb WH, Lapointe-Milot K, Mayrand MH, Morin M. Feasibility, acceptability and effects of multimodal pelvic floor physical therapy for gynecological cancer survivors suffering from painful sexual intercourse: a multicenter prospective interventional study. Gynecol Oncol. 2020;159:778-784.
Cyr MP, Dumoulin C, Bessette P, Pina A, Gotlieb WH, Lapointe-Milot K, Mayrand MH, Morin M. A prospective single-arm study evaluating the effects of a multimodal physical therapy intervention on psychosexual outcomes in women with dyspareunia after gynecologic cancer. J Sex Med. 2021;In press.
Cyr MP, Dumoulin C, Bessette P, Pina A, Gotlieb WH, Lapointe-Milot K, Mayrand MH, Morin M. Changes in pelvic floor morphometry and muscle function after multimodal physiotherapy for gynaecological cancer survivors suffering from dyspareunia: a prospective interventional study. Physiotherapy. 2020;Submitted.