A brief mindfulness-based cognitive behavioral intervention improves sexual functioning versus wait-list control in women treated for gynecologic cancer

Abstract

Goal

The goal of this study was to evaluate a mindfulness-based cognitive behavioral intervention for sexual dysfunction in gynecologic cancer survivors compared to a wait-list control group.

Methods

Thirty-one survivors of endometrial or cervical cancer (mean age 54.0, range 31–64) who self-reported significant and distressing sexual desire and/or sexual arousal concerns were assigned either to three, 90-minute mindfulness-based cognitive behavior therapy sessions or two months of wait-list control prior to entering the treatment arm. Validated measures of sexual response, sexual distress, and mood, as well as laboratory-evoked physiological and subjective sexual arousal were assessed at pre-, one month post-, and 6-months following treatment.

Results

There were no significant effects of the wait-list condition on any measure. Treatment led to significant improvements in all domains of sexual response, and a trend towards significance for reducing sexual distress. Perception of genital arousal during an erotic film was also significantly increased following the intervention despite no change in physiologically-measured sexual arousal.

Conclusions

A brief mindfulness-based intervention was effective for improving sexual functioning. Geographic restrictions permitted only a select sample of survivors to participate, thus, the generalizability of the findings is limited. Future studies should aim to develop online modalities for treatment administration to overcome this limitation.

Introduction

Cancer and its treatment have detrimental effects on sexual functioning regardless of cancer type, stage, gender, and age of the cancer patient [1]. Among the subtypes of cancer that have been most studied in regards to sexual functioning, gynecologic cancers have a particularly negative effect, with 40-100% of patients experiencing some type of distressing sexual sequelae [2]. Recent Canadian data indicate that in 2011 there will be 4,700 new cases of endometrial cancer and 1,300 new cases of cervical cancer in this country alone [3]. Figures for the United States suggest 46,470 new cases of endometrial cancer and 12,710 new cases of cervical cancer [4]. Improvements in the field's treatment of these cancers plus increasing life expectancy has shifted the focus on quality of life issues, including sexual health during survivorship. Unfortunately, there are no established treatments for these distressing sexual problems, often leaving women and their partners with long-term difficulties that interfere significantly with many aspects of their personal and interpersonal well-being [5].

Since the approval of sildenafil citrate (Viagra) for men's sexual dysfunction in 1998, there has been an aggressive research effort aimed at developing and testing sexual pharmaceuticals for women—particularly since the prevalence of sexual concerns in women is significantly higher than in men [6], [7]. Indeed, although testosterone significantly improves sexual desire in pre- and post-menopausal women with distressing low desire [8], a randomized controlled trial of transdermal testosterone in estrogen-deplete breast cancer survivors did not significantly increase low libido [9]. A review of psychological treatments for sexual difficulties after cancer concluded that such treatments significantly improve relationship satisfaction, resumption of sexual activity following cancer treatment, and compliance with vaginal dilation [10]. However, the most common sexual sequelae, low sexual desire and impaired arousability [11], have been the focus in only one non-controlled experimental trial to date [12].

This previous published trial was based on a psychoeducational intervention that incorporated mindfulness meditation skills. Mindfulness has a 3,500 year history within Buddhist tradition, and has been widely embraced within Western healthcare over the past three decades. Mindfulness has been defined as non-judgmental, present-moment awareness and is comprised of two components: (1) self-regulation of attention so that there is focus on the current experience, and (2) adoption of a curious, open, and accepting orientation to the present [13]. A review of mindfulness-based stress reduction programs for a variety of health conditions (e.g., pain, cancer, heart disease, depression, and anxiety) found a very good effect size of 0.5 [14]. Because of evidence that mindfulness-based strategies may be especially suitable for addressing sexual difficulties in women [15], [16], it formed the basis for the intervention previously and currently tested.

Previously, a structured 3-session mindfulness-based psychoeducation significantly improved self-reported sexual desire, arousal, orgasm, and satisfaction in a pilot study of women with cervical or endometrial cancer and sexual difficulties [12]. In response to laboratory-evoked erotic stimuli, there was a trend towards increased ability to perceive genital sexual arousal. There was also a significant reduction in sex-related distress and symptoms of depression. Sexual arousal domains of mental sexual excitement and genital tingling/throbbing also significantly improved after treatment. Overall, women were extremely compliant with the suggested homework exercises (homework compliance ranged from 82% to 90% across the three sessions). Although these data depict a promising intervention targeting low sexual desire and arousal, the lack of a control group leaves open the possibility that non-specific therapeutic factors, the passage of time since cancer treatment, or some other variables may have accounted for these improvements. Moreover, whether gains were maintained over time after the intervention was discontinued is unknown.

The goal of the present study was to examine the efficacy of this same brief structured mindfulness-based intervention compared to a control group, and to test whether improvements were retained after follow-up among women who had been previously treated for cervical or endometrial cancer.

We hypothesized (1) no significant effect of wait-list on any outcome; (2) a significant effect of the intervention on sexual response, sexual distress, treatment impact and relationship domains of a cancer-specific measure of sexual functioning, and depressive symptoms; and (3) no significant loss of gains from post-treatment to a 6-month follow-up point.