A. What is already known about the topic?

Patients with gynecologic cancer may experience distress due to sexual dysfunction.

Those that have been diagnosed with and treated for gynecologic cancers are commonly filled with fear and perplexity as they face the unknowns of their diseases and therapies.

Particularly in the early phases of chemotherapy, patients anticipate members of the healthcare team to inform them how their disease and treatment will affect their sexuality.

B. What does this paper add?

Participants expressed unhappiness with their sexual life, claiming they have reduced sex drive and poor sexual function. They saw a loss in femininity as well as a negative body image.

The survivors and their spouses benefitted from the psychosexual intervention after cancer treatment because it helped them adjust and better manage sexual dysfunction.

Better information provision would enhance gynecologic cancer patients’ coping ability in terms of sexual functioning.

Approximately 11% of newly diagnosed malignancies in women in the United States and 18% worldwide are gynecologic in nature [ 1]. The uterus and endometrium, ovary, and cervix are where gynecologic cancers are most frequently seen. Uterine and ovarian cancers often manifest during the perimenopausal or menopausal era, but cervical cancer is more common in premenopausal women during their childbearing year while less commonly, trophoblastic neoplasms, also known as gestational trophoblastic tumors, affect the vagina and vulvar [ 2].

Sexuality is considered to be one of the most significant markers of quality of life by the World Health Organization (2019) [ 3]. This is due to the fact that sexuality is linked to ideas, feelings, behaviors, social integration, and therefore, a person's physical and mental health and well-being but with patients who have gynecologic cancers, there are significant challenges when it comes to matters of sexuality and intimacy in their intimate relationships [ 4,5,6]. Regardless of the cause or age at which the malignancy first appeared, the disease and its treatment may have both short- and long-term side effects, such as sexual dysfunction, which lowers quality of life. Cancer has been shown to have a significant influence on a female's sexual functioning, libido, sense of self and personal relationships [ 7]. Women who have had a history of gynecologic cancer and who have lost their fertility as a result of therapy for that illness report experiencing a range of negative emotions, including despair, bereavement, stress, and dysfunction in their sexual lives [ 8]. There is a vast quantity of research to support this claim. Illness, pain, worry, rage, stressful conditions, and medicines are all examples of things that might interfere with sexual functioning and treatment for cancer is one of them [ 9].

With these pieces of information at hand, this qualitative synthesis delves deeper into the sexual concerns of patients with gynecological cancer. It presents multiple perspectives on the plights of women as they battle cancer, particularly involving one of the most important aspects of their humanity, which is their sexuality. To the researchers’ knowledge, there are limited studies which account to the sexual functioning of patient with gynecologic cancers. It also takes into consideration other factors that need further exploration, such as the impacts of these malignancies on the quality of life (QOL) of women, and it emphasizes areas that a further research is needed.

This study aims to assess how gynecological cancer impacts women's sexual experiences and sexual expression, which is a key factor in determining quality of life. The researchers set out to answer the following questions: 1) What is the impact of the diagnosis and treatment of gynecologic cancer on women’s quality of life sexually? 2) How do women deal with the sexual side effects that come along with cancer treatment? and lastly 3) What is the implication of this study in nursing practice?

A qualitative systematic review was conducted to gather the results of several studies on a subject by conducting a systematic search of relevant literature [ 10]. The researchers used the existing empirical evidence to produced a secondary thematic analysis to explore the concept within the existing themes to provide new insights about the lived experience of patients with gynecological cancers in regard to their sexual functions.

The researchers used various online resources such as SCOPUS, CINAHL, SAGE, World of Science, ScienceDirect, and PubMed. The researchers carried out the search in August 2022 and utilized the PRISMA (Preferred Reporting Items for Systematic reviews and Meta-Analyses) diagram (Figure 1) employing systematic and clear methods to select, identify, and evaluate relevant studies as well as gather and analyze information from the research that are included in the review [ 11]. The use of the following keywords were considered: gynecological cancer (OR neoplasm OR carcinoma) OR gestational trophoblastic tumors OR trophoblastic neoplasm OR vulvar cancer OR cervical cancer OR uterine cancer OR endometrial cancer, ovarian cancer OR vaginal cancer, AND sexual functioning OR sexual health OR sexual response.

The inclusion criteria is centered on sexual functioning of patient with different kinds of gynecologic cancer. The exclusion criteria are non-gynecologic cancer-related articles, unrelated to sexual function, non-qualitative studies.

The initially identified studies based on title yielded 395 results; 60 abstracts were screened against the inclusion and exclusion criteria to identify potential papers. 29 identified full-text articles were carefully evaluated by the researchers.

Two researchers were assigned in the identification phase, while two researchers were assigned in the screening process. All researchers participated in the selection and quality appraisal process. A matrix method was used to extract the following: Primary Author, Year And Country, Title Design, Settings, Participants, Sampling Technique, Methods/Instruments, Level of Evidence, Aim, Findings, Themes and Relevance. To assist and enhance upcoming assessment sessions outlined by the instrument, the researchers employed the Critical Appraisal Skills Programme Checklist [CASP] (2018) in qualitative studies [ 12]. The use of the CASP explored the applicability and usefulness of this appraisal tool as a qualitative checklist tool for quality assessment in the synthesis of qualitative evidence. As shown onTable 1 (Appendix A), This tool comprises 10 questions concerning the aim of the research, ethical issues, data analysis, valuable research, data collection, relationship between participants and researcher, research design and appropriateness of qualitative methodology, findings and overall significance of the research. The main 10 items were scored ‘yes’ = 1, ‘no’ = 0.5, ‘not met’ = -1 and ‘not applicable’ = 0 whereas the additional prompts were used to facilitate summarizing the main strengths, limitations, and concerns. The hierarchy of evidence using Melnyk and Fineout-Overholt (2022) were also assessed [ 13]. In addition, an expert colleague reviewed the included studies to further validate the selection. All disagreements concluded were resolved through a consensus which allowed for the resolution of finalizing the tally of the included studies. Finally, a total of 19 studies were considered in the review based on quality appraisal process.

Nineteen (19) out of ninety-five (95) articles. Table 2 summarized the details of the studies. The settings of the articles included took place in several government and private in different outpatient clinics, hospitals and medical centers in Oncology settings which were conducted in different countries: six in Asia (China, Hongkong, Indonesia, Malaysia, Taiwan, Turkey), four in Africa (Ethiopia, Ghana, two in South Africa), four in South America (three from Canada, one in USA) and five in Europe (Netherlands, Spain, three in United Kingdom) in different healthcare facilities such as in medical centers, public health facility, . Participants ranged from 8 to 102 consisting of different patients that were diagnosed with gynecologic cancers such as cervical, endometrial, ovarian, cervical, vulvar, and uterine cancer. Sampling techniques used are purposive sampling, and convenience sampling method. Instruments or methods used are semi-structured interview, in-depth interview, face-to-face in-depth interview, focus group interview, and individual interview and designs that were used are descriptive analysis, phenomenological design, and interpretative design. All studies (n=19) generated Level of Evidence VI or, evidences from single descriptive or qualitative studies. All studies revolved around the experiences of patients with gynecologic neoplasm during their diagnosis and treatment processes.

Two main themes were produced, namely (A.) Issues with sexual experience and (B.) Physical and emotional burden. Each of these central topics was informed by a number of subthemes.

Theme 1: Issues with Sexual Experiences

Eleven of the studies mentioned that gynecologic cancer patients frequently cause changes in sexual function, including lack of orgasm, difficulty evoking physical arousal, loss of desire in sexual activity, and discomfort during sexual activities [ 14,15,16,17,18,19,20,21,22,23]). The majority of women who reported their sexual experiences said that the illness process made them unwilling to engage in sexual activity after receiving cancer therapy and treatment [ 14].

Subtheme 1A: Desire

Gynecologic cancer-related sexual desire was one of the most frequently reported patient complaints; it was mentioned in ten of the studies that were included [ 16,17,18,19,21,22,24,25,26,27] . Sexual desire is impacted in women who have gynecologic cancer and several treatment modalities such as chemotherapy or surgery [ 19,25]. One of the participants said:

“It feels like I am empty inside because my uterus was removed. My husband says that he also feels like he feels empty during intercourse. My hus-band is very fond of sex. I am worried that he will become distant to me if I cannot satisfy him. After the surgery, I didn’t have any sexual desire left. I experience sexuality as a duty for my husband [ 27].”

Subtheme 1B: Pain

According to eight studies, patients' sexual activities involved a considerable great deal of pain and that their sexual relationships had changed immensely [ 16,17,18,19,20,21,22]. Cancer and its potentially long treatment had a detrimental effect on people's capacity to recuperate and regain the same functional levels, and the pain that people experienced during their sexual contacts frequently led to a decrease in their partners' frequency of sexual activity [ 20,25]. One of the participants mentioned:

“Every time we have sex . . . now its got to a point that I get this sensation because if I’ve got pain there I need a wee (to pass urine) as well so I can’t relax to have an orgasm either [ 15].”

Subtheme 1C. Sexual relationship with partner

Twelve studies stated that due to gynecologic cancer, numerous partners believed that their sexual interactions had changed, which caused significant changes in the women's intimate relationships.[ 15,19,16,17,18,20,21,22,24,25,26,28,29] Because sex is crucial for most relationships, some women never had sex with their partner again, which had a severe impact on their sexual relationships [ 19,24] as stated by one of the participants:

“For now we don’t have any sex . . . since that [surgery]. Because sometimes my wound still hurts. But, when I went back to the gynecologist, she said “Well, you can have sex with your husband.” But then I told him sometimes when I even put my hand on the wound it hurts. I think he doesn’t want to hurt me [ 29].”

Theme 2: Physical and Emotional Burden

Ten of the reported studies that gynecological cancer patients have an impact on women's physical and psychological aspects of their lives [ 15,17,18,22,24,19,28,29,30,32] These conditions can be traumatic and life-altering because they cause changes in physical structures and functions, fear, and psychosexual distress that affected sexual activity, which was typically reduced by cancer treatment and psychological trauma [ 19,22,24]. Furthermore, gynecologic cancer patients frequently fear about becoming dependent, and they may feel like a burden [ 29]

Subtheme 2A: Physical Changes

The physical changes brought on by their gynecologic cancer and the associated treatments, such chemotherapy, radiation therapy, and surgical management, were discussed in eight studies [ 14,15,19,20,21,25,28,29,32]. These management techniques significantly affected the women's physical changes, which led to discomfort and prevented them from engaging in intimate relationships [ 29] which was answered by one of the participants:

“And now that I’ve got [ovarian cancer] again…I’m just so scared, you’ve got the portal... he doesn’t want to touch that, he even looks at it and goes, “Aah!” you know?” These findings point to body image as an important aspect of sexual desire and satisfaction for women with ovarian cancer [ 16].”

Subtheme 2B: Fear

For women who have any type of gynecological cancer, fear is a normal and primal human feeling. This fear was reported in twelve studies. Due to some variables that contributed to the development of this gynecologic cancer, some of these patients may feel fear, self-doubt, social anxiety disorder, and panic attacks [ 16,18,19,20,21,22,23,24,25,28,29,30]. Due to the inadequate information they received on their prognosis and therapy, some patients are struggling with uncertainty and the dread that their condition may reoccur at any time and cause an early death. [ 28,29]. However, some patients openly express their feelings to their friends, family, or loved ones in order to alleviate their anxieties and fears [ 28,30] as stated by one of the participants:

“My relatives did not know I was sick. Women with this kind of cancer are pitiful. People gossip.... Only three of my friends knew I was sick.... This kind of thing spreads quickly.... There are no cancer genetics in our family. It is unfortunate for me. People think cancer is a bad thing when they hear of it [ 28].”

Subtheme 2C: Femininity

Six reported studies show the attributes and behavior of a woman when they lose their femininity such as infertility and loss of identity as a mother degree of being feminine [ 16,18,21,23,29,30]. Patients described feeling empty, feeling criticized about their femininity and sexuality, feeling depressed and the need to hide it and their quality of life was negatively impacted by losing their sexual function [ 18,30] which was aforementioned by one of the participants:

“Maybe I can see it separately from all the medical things that have happened, but I cannot disentangle it from the impact on my femininity.” (Vermeer et al., 2016)

The participants discussed a range of events after the cancer diagnosis and throughout treatment. In particular, it affected the physical and psychological elements of their life, as stated by the respondents. These conditions may be painful and life-altering because they produce changes in bodily structures and functions, infuse dread, and have psychosexual repercussions, which impact a person's sexual desire and performance. It was found that many respondents had one or more sexual dysfunctions, which frequently caused discomfort.

Gynecologic cancer has repercussions for women's lives that go beyond the necessity for them to simply survive; these repercussions include their sexual function and their quality of life. It is vital that medical practitioners educate women who have been diagnosed with ovarian cancer about the challenges that they will experience and provide them with information and resources to aid in enhancing their sexuality and quality of life. While it is true that gynecologic cancer has repercussions for women's lives, the impact can be abetted if the healthcare team and the patient and their partners collaborate closely to attain the goal which is a better quality of life.

The fact that sexual activity is linked to discomfort is not something that should come as a surprise to anyone. The unease that people experienced during sexual encounters frequently led to a reduction in the quantity of sexual activity that took place between the partners. This was one of the consequences of the uncomfortable feelings that people experienced during sexual interactions. Many of the patient's partners do believed that their sexual encounters had become less satisfying as a direct result of the gynecologic cancer that their spouse had been diagnosed with. The women's relationships with their partners went through profound changes as a direct consequence of this event. Also, the women's self-confidence and their perceptions of their bodies were compromised, which resulted in a decline in their desire to engage in sexual activity. The women's outward appearance suffered greatly as a consequence of the physical changes brought on by their gynecologic cancer as well as the treatments that were required, which included chemotherapy, radiation therapy, and surgical management, among others. Chemotherapy, radiation therapy, and surgical management were the many treatments that were utilized which affects the patient physically and emotionally causing detriment in their sexual aspect.

If there is a connection between the different aspects of one's quality of life and the variables that make up that quality, then providing individualized therapy that places an emphasis on, for example, emotional and social support may have the effect of reducing the influence that the physical and functional aspects have, and vice versa. The treatment of a patient's fear and anxiety may benefit from the use of positive adaptation approaches. It may be able to improve quality of life in other aspects by concentrating on and treating tiredness, which is both a symptom of the illness and a side effect of the therapy for cancer.

Therefore, actions that enhance the quality of life in certain specified zones may also raise the quality and quantity of general survival. This discussion showed a clear message that the sexual lives of women are influenced by the physical changes brought about by cancer treatment, information gaps, or knowledge deficits connected to cervical cancer and pelvic radiation. In this regard, there should be widespread promotion, including the establishment of counseling services and integrated service provision, with the goal of reducing the number of sexually-related issues and the negative effects of therapy for cervical cancer.

Women can never go back to living their lives the way they did before they had treatment for cervical cancer since the treatment has long-term impacts and implications. They were forced to contend with physical adjustments, shifts and changes that made an already challenging financial position much more difficult for them, and they were forced to live with unmet health care demands as well. Sexual dysfunction caused a shift in their personal ties with their life partners, which led to increased anxiety over the possibility of losing them. In spite of everything, their faith and religion helped them tremendously. They were given hope for the future via their religion. During these situations, it is then the responsibility of nurses to screen their patients for the late consequences of gynecologic cancers and provide them with the necessary treatment.

According to the information that was gathered, some of these women's interest in the sexual feelings experienced by their partners decreased at the same time as their willingness to participate in sexual activity. Because of this, they were never able to come to an agreement with their wives about their disagreements. Those who were in a position to make this observation were those who had endured a great deal as a direct result of cervical cancer. The majority of individuals, especially those with advanced cervical cancer, reported experiencing reduced sexual sensitivity, which led to a decrease in their desire. This was particularly pertinent information for the individuals of the group whose cervical cancer had grown to a more advanced stage. The vagina, which is considered to be one of a woman's most important sexual organs, has the potential to sustain catastrophic damage if she has irregular discharges that are both painful and bloody. Because of this, it is difficult for the great majority of participants to engage in sexual behavior. The severe mental pressure that a lot of people were putting themselves through, according to their own accounts, was the exact cause of their low or nonexistent sexual desire. Some of the respondents said that their general unhappiness with sexual relationships could be traced back to the acute pain and bleeding that they endured during sexual encounters. As a result, the number of sexual encounters that they had with their partners was restricted.

These patients are assisted in dealing with the physical and psychological side effects of cancer treatment that affect their sexual function by receiving continuous counseling from healthcare professionals such as the oncologist, nurses, and counselors. According to the findings of an earlier study conducted by Chee Kuan (2022), it is imperative that gynecologic cancer patients be informed about the potential negative effects of the treatment they are receiving. A crucial part of cancer supportive care is the provision of sexual healthcare services, such as counseling and clinical therapy for sexual dysfunction. These services may include sexual dysfunction counseling and clinical therapy. A number of coping methods, such as reframing sexual activity as a duty, reprioritizing sexual activity, utilizing sexual aids, participating in other sorts of intimacy, and engaging in other types of closeness, were also suggested.

For many women who have gynecologic cancer, life after cancer treatment includes learning to cope and serious long-term sexual problems (Bodurka and Sun, 2006). Cancer can significantly alter a person's sexuality (Mütsch et al, 2019). The results of this study will help oncology nurses better understand ways to address the sexual problems of their patients following the myriad of events following their diagnosis and treatment of their gynecologic cancers. In addition, with the aid of this study, oncology nurses will be better able to provide comprehensive care for patients' sexual well-being, which they will understand to be a crucial part of their general health. Nurses will likewise be able to recognize their patients treat holistically and place a high priority on sexual wellness. This enables nurses to provide these women with gynecologic cancers with comprehensive sexual health treatment and support. Nurses can help their patients prepare for the physical changes that are likely to occur during the disease and its treatment, as well as the difficult or negative emotions that may also arise. In addition, nurses may provide them guidance or recommend them to an allied health specialist who can assist them in coping with the circumstance thus maintaining an intimate relationship.

The results of this qualitative synthesis unequivocally showed that women diagnosed with and treated for gynecologic cancers suffer from sexual dysfunctions. However, each of these patients has individualized needs in terms of overall health and in sexual health. From the findings of this study, the researchers make the following recommendations for further research such as exploration of interventions for post-treatment sexual functioning and the management thereof, supply of better information regarding expected outcomes to promote patients’ acceptance of their condition and boost their coping mechanisms and provision of support from the healthcare team for patients with gynecologic cancer. There is a scope of opportunity for research regarding this topic that is yet to be explored. The researchers recommend further investigation, particularly on how nurses and other members of the healthcare team address the sexual wellness of patients being treated for other types of cancer and in general.

This qualitative synthesis provides insight that many women who have been diagnosed and treated with gynecologic cancer suffer from sexual dysfunctions. The researchers have identified that women with cancers in the gynecological form experience inhibited desires and libido, vaginal dryness, curbed orgasms and dyspareunia. During sex, many of these women experience pain and frustration with how they now respond to their husbands or partners in comparison to when they were cancer-free.

Changes in the women’s quality of life in the sexual aspect due to their disease takes a toll not just on the physical but in other facets as well. They become anxious and distressed on how their malady will affect their bodies and how they will move on to sexually connect with their husbands or partners during the venereal act despite their condition. In that regard, they also agonize over their femininity, and question if or how the cancer attributes to being less of a woman. They yield to self-image issues and capitulate to a decline of confidence.

Another matter in question is the effectiveness of communication between the patients and the members of the healthcare team. Many patients anticipate discussions not just of the disease and its expected outcomes but also of its repercussions on their sexual health and wellness. This qualitative synthesis finds that there is a big room for improvement in this aspect. The participants believe that better provision of information from doctors and nurses will benefit patients such as them to make determined efforts in dealing with the effects of their condition and allow them to cope accordingly.

Interventions for gynecological cancers and its effect on the abatement of carnal eroticism come in many forms. Treatment of sexual dysfunction includes behavioral, psychological, medical, surgical, complementary and alternative medicine, and physical interventions. Furthermore, this study finds that the key to enforcing these interventions is for nurses and members of the healthcare team to ascertain that patients receive the pertinent information they need. A strong support system must also be secured for these patients in order for them to gradually and progressively improve their sexual quality of life after treatment.

Author Contributions: BRA: Conceptualization, Methodology, Formal analysis, Investigation, Data curation, Writing – original draft, Project administration. DC: Conceptualization, Methodology, Formal analysis, Investigation, Data curation, Writing – original draft, Project administration. MML: Conceptualization, Methodology, Formal analysis, Investigation, Data curation, Writing – original draft, Project administration. .GM: Conceptualization, Methodology, Formal analysis, Investigation, Data curation, Writing – original draft, Project administration. RAN: Formal analysis, Investigation, Supervision, Validation, Visualization, Writing – review & editing,

Funding: none

Data Availability Statement: none

Acknowledgments: The authors acknowledged the moral support and guidance of St. Paul University of the Philippines – Graduate School

Conflicts of Interest: nil