Sexual quality of life between healthy women and women with gynecological cancer: Results of a hospital‐based case–control study in Türkiye

Gynecological cancers among women were both chronic and vitally health problems. The increasing prevalence of women with surviving gynecological cancers and the receiving treatments of cancer negatively affected the sexual quality of life.


INTRODUCTION
Gynecologic cancers contribute to almost 16% of all female cancers worldwide.According to the Global Cancer Surveillance Data (GLOBOCAN) 1 report, among the top 10 cancer types, the cervix (15.6%) ranks fourth, the uterus sixth (10.8%), and ovary cancer eighth (8.1%).One important topic which is left in the background but which affects women with gynecological cancer is sexuality and sexual life.3][4][5] In a qualitative study conducted on the sexual lives of women with gynecological cancer, Alinejad Mofrad et al. 2 determined themes which disrupted the quality of sexual life: the struggle to The institution where the research was conducted Oncology Unit/Surgical Oncology Clinic/Gynecology Unit, Tepecik Training and Research Hospital, Izmir Health Sciences University, Izmir, Türkiye.maintain sexuality, the disruption of closeness, and unpleasant sexual experiences.The problems which women with gynecological cancers face in their lives go largely unseen and not discussed. 6The reason for this may be that women with gynecological cancer think it is not proper to discuss their sexual problems, that it is not necessary to intervene in what is a private subject, and that there are more important things needing to be dealt with.Also, it is reported that women with gynecological cancers see sexuality as private, and that they are shy and feel uncomfortable when talking about sexuality. 2,7][12] Studies have shown that the sexual dysfunctions experienced by women with gynecological cancer have a negative effect on the quality of their sex lives. 6,13,14At the same time, it is reported in the literature that the age, menopause status, relationship status, and treatment status of women with gynecological cancer and their quality of sexual life are related to each other. 46][7] Gynecological cancers have a negative effect on the quality of women's sexual lives.The Sexual Quality of Life Questionnaire (SQOL) was used in the research to assess the sexual quality of life of healthy women and those with gynecological cancer. 15his is an important scale which is frequently used not only with women with cancer but also with healthy women. 16,17Studies conducted with women with gynecological cancer using this scale have reported that women's sexual quality of life is low in Türkiye. 8,9However, there were very few studies examining the sexual quality of life in women with gynecological cancer in Türkiye and in the World. 4,8,9[16][17][18] In this context, this is the first study to be conducted in Türkiye on this topic.In this way, our study has shown the effect of gynecological cancers on the Turkish women's sexual quality of life in comparison with healthy women and identified predictors of sexual quality of life in Turkish women with gynecological cancer.For this reason, it is predicted that the study will benefit health professionals and particularly oncology nurses and the women with gynecological cancer with whom they are in contact.Also, it is thought that this study will serve as a guide to other researchers and that it will contribute to the literature.In this regard, the aim of this study was to determine the sexual quality of life of healthy women and women with gynecological cancer and to determine the predictors of sexual quality of life in women with gynecological cancer.

Study design and participants
A hospital-based case-control study was conducted in the Department of Gynecology and Obstetrics of a training and research hospital in the Izmir, in western Türkiye, in an effort to identify sexual quality of life for women with gynecological cancer and healthy woman, between March 2022 and January 2023.Cases included 65 women with a histologically confirmed diagnosis of gynecological cancer, who were admitted to the oncology policlinic of oncological institute of a training and research hospital in Izmir in Türkiye.Between these dates, we visited the oncology policlinic of the hospital every 2 days of the week (Tuesday and Thursday), and 145 women were invited to the case group of the study.During the study, 21 women were not included in the patient sample because they did not meet the inclusion criteria, 34 women refused the study, and 25 women did not complete the questionnaires.The patient sample of the study was selected by simple random sampling method and included women who were diagnosed with gynecological cancer, who came to the oncology policlinic for control or treatment, were not in the terminal stage, were literate, had no neurological or psychiatric disorders, were sexually active in the last 6 months, and voluntarily accepted to participate in the study.Cases were conducted with 65 patients.
Controls included 75 healthy women residing in the same geographical regions, and they were admitted to the gynecology policlinic of the same hospital during the same interval.The corresponding controls were recruited women over the age of 40 without endometrial, cervical, ovarian, vagina-vulvar, or breast cancer anamnesis, respectively.In between these dates, we visited the gynecology policlinic every 2 days of the week (Monday and Wednesday) and a total of 260 women were interviewed.The healthy sample of the study was selected by simple random sampling method and included women who came to the gynecology policlinic of the same hospital, were literate, had no neurological or psychiatric disorders, were sexually active in the last 6 months, and voluntarily agreed to participate in the study.During the study, 124 women were not included in the healthy sample because they did not meet the inclusion criteria, 36 women refused the study and 25 women did not complete the questionnaires.Controls were conducted with 75 healthy women.In addition, none of the relatives of the patients applying to the oncology department were admitted to the control group.
Finally, 65 cases and 75 controls remained in the final analysis.The introductory characteristics of the case and control groups were similar.All participants signed the informed consent, and all procedures were according to the Helsinki Declaration's ethical standards.Before starting the research, preapplication was performed with five women with gynecological cancer and five healthy women.As a result of the preapplication, the language of the two questions that were not understood in the individual introduction form was made more understandable.Preapplication women were not included in the sample.The study was implemented and reported in line with the STROBE statement.

Data collection tools
The data of the study were collected using the "Individual Identification Form" and SQOL.All forms were collected by face-to-face interview and filled out by the participants.The completion of forms took $15 min.

Individual identification form
,14,19 The form consists of two parts.The first part consisted of 10 questions about the introductory characteristics of women (age, education, employment status, family income, family type, number of living children, menopause status, menopause duration [years], smoking, and alcohol use).The first part was applied to both healthy women and women with gynecological cancer.The second part consisted of seven questions about the characteristics of women with gynecological cancer diagnosed with cancer (type, stage, metastasis, time of diagnosis, status of receiving treatment, difficulty with cancer, difficulty experienced).The second part was applied only to women with gynecological cancer.

Sexual Quality of Life Questionnaire
The SQOL was developed by Symonds et al. 15 to measure women's sexual quality of life.The Turkish validity and reliability of the scale was performed by Tu gut and Gülbaşı. 20The scale was six-likert type (1-I completely agree; 2-I agree considerably; 3-I agree partially; 4-I do not agree partially; 5-I do not agree considerably; 6-I do not agree at all) and consisted of 18 items.For scores of 1, 5, 9, 13, and 18, items must be inverted before calculation of the total score.While the minimum score on the scale is 18, the maximum score is 108.The total score is converted to 100.In order to convert the total score to 100, the following formula should be used: (crude score-18) Â 100/90.High scores indicate a good sexual life.SQOL was used in the research to assess the sexual quality of life of healthy women and those with gynecological cancer. 156,17 The Turkish version of the SQOL included the items "When I think about my sexual life, I think it is a fun/enjoyable part of my life," "When I think about my sexual life, I feel angry," and "I worry about the future of my sexual life," and so forth.The Cronbach's alpha reliability coefficient, which shows the internal consistency of the scale, was found to be 0.75.In the study of Tu gut and Gölbaşı, 20 the Cronbach's alpha coefficient of the scale was calculated as 0.83.In this study, the Cronbach's alpha value of the scale was 0.83.

Ethical considerations
The study was conducted in accordance with the principles of Good Clinical Practice and the Declaration of Helsinki.This study was approved by the ethics review committee.Institutional permission was obtained from the hospital that cooperated with this study.The study protocol was approved by the institutional review board of the Provincial Health Directorate.The women were informed about the research (informed consent), and their verbal and written consent was obtained.

Informed consent
The participants were informed about the research (informed consent), and their verbal and written consent was obtained.The research was conducted in accordance with the Principles of the Declaration of Helsinki.

Data collection
After obtaining ethical approval from the university and the study hospital, the first researcher contacted the relevant nursing departments at the hospital to support this study.The first researcher interviewed the nurses in charge of the oncology and gynecology policlinic of the hospital and obtained their approval.The researchers interviewed women who came to the oncology policlinic (diagnosed with gynecological cancer) and gynecology policlinic (healthy women) of a training and research hospital.Before giving the forms, the researchers made explanations about the purpose of the study, the benefits to be obtained from the research, the time they would spend for the interview, and obtained verbal and written consent from the women.Informed consent was obtained from all women included in the study.After signing the consent forms, the recruited women filled out an individual identification form, the Turkish version of SQOL.Filling out the forms took $15 min.Researchers were ready to explain the women's questions.All forms were collected by face-to-face interview and filled out by the women in a suitable room of the hospital.The privacy of women was taken care of.

Data analysis
The analysis of the data obtained from the research was carried out in the SPSS 25.0 statistical package program.Comparison of introductory characteristics of women with gynecological cancer and healthy women were used to Chi-square (X 2 ) and t-tests (n, %, mean, standard deviation).For assessment of women's sexual quality of life, the Turkish version of the SQOL was also used. 20Normal distribution was measured with the Kolmogorov-Smirnov test.Comparison of clinical characteristics and SQOL scores of women with gynecological cancer were used to t-test (two groups) and one-way ANOVA test (three or more groups).Comparison of SQOL scores of healthy women and women with gynecological cancer were used to t-test.Linear Regression analysis was performed to determine the predictive effect of gynecological cancer on sexual quality of life.In addition, Multiple linear regression analysis was performed to determine the predictors of sexual quality of life in women of gynecological cancer.In order to calculate the effect size coefficient of determinations in the linear models, we employed R 2 (Coefficient of determination).The results were evaluated at the 95% confidence interval and the significance level of p < 0.05.

Population characteristics
Among the women who agreed to participate in the study, 65 women with gynecological cancer and 75 healthy women provided informed consent and completed the questionnaires.After the propensity score matching, introductory characteristics, including age, education, employment status, family income, family type, number of living child, menopausal status, duration of menopause (years), smoking, and alcohol use were not significantly different between the women with gynecological cancer and healthy women ( p > 0.05; Table 1).

Factors affecting the SQOL scores and clinical characteristics of women with gynecological cancer
The clinical characteristics of women with gynecological cancer are given in

SQOL scores of healthy women and women with gynecological cancer
The comparison of the SQOL scores of healthy women and women with gynecological cancer is given in Table 3.The SQOL score of women with gynecological cancer was 60.12 ± 9.01 and healthy women was 78.92 ± 7.08.SQOL scores of women with gynecological cancer were significantly lower than healthy women (p < 0.05; Table 3).Linear regression analysis of the factors associated with sexual quality of life in healthy women and women with gynecological cancer Linear regression analysis of the factors associated with sexual quality of life in healthy women and women with gynecological cancer was given in Table 4.It was determined that women with gynecological cancer affected the sexual quality of life 18.8 times more negatively than healthy women (B = À18.797,p = 0.000).It was determined that women with gynecological cancer were responsible for 58% of the variance in their sexual quality of life (p < 0.05, R 2 = 0.580; Table 4).

Multiple regression analysis of the factors associated with sexual quality of life in women with gynecological cancer
Finally, a multiple regression analysis was used to detect any variation independently related to sexual quality of life (dependent variables) in women with gynecological cancer.

DISCUSSION
Comparison of SQOL score of healthy women and women with gynecological cancer The study was conducted to determine the sexual quality of life of healthy women and women with gynecological cancer and to determine the effect of gynecological cancers on women's sexual quality of life.In this study conducted in the west of Türkiye, SQOL score of the women with gynecological cancer (60.12 ± 9.01) was significantly lower than that of the healthy women (78.92 ± 7.08; Mean of age: 41.99 ± 8.86, p = 0.000).In our study, when women with gynecological cancer and healthy women were compared in terms of SQOL score; the devastating effect of gynecological cancer on women's sexual life had come to light.Gynecological cancers also greatly affected women's sexual life quality and sexual health.Previous studies mostly reported on women's sexual dysfunctions in Türkiye. 5,18However, our study reported the neglected sexual quality of life of women by comparing them with healthy women.Thus, our study determined the negative effect of gynecological cancers on the sexual quality of life.

SQOL score women with gynecological cancer
In this study, SQOL score of the women with gynecological cancer was 60.12 ± 9.01, the mean age of the women was 44.32 ± 6.14 years, and 47.7% had received chemotherapy treatment.In a study conducted in the center of Türkiye, the mean age of the women with gynecological cancer was 52.16 ± 10.14 years, 60% had had chemotherapy treatment, and their SQOL score was 52.50 ± 22.87, which was lower than in the our study. 8In a study in Iran, the mean age of women with gynecological cancer was 52.9 ± 11.8 years, 46.2% had received chemotherapy and 33% radiotherapy, and their SQOL score was 46.84 ± 11.86, which was lower than in the our study. 9In previous studies, we wish to draw attention to the mean age of the women with gynecological cancer and the proportions of women who had received treatment.In previous studies compared with our study, women with gynecological cancer had a higher mean of age and rates of receiving chemotherapy. 8,9It is thought that this difference in SQOL scores derives from their age and their rates of having received treatment.It is reported in a systematic review by Roussin et al. 4 that age and the status of receiving treatment lower the sexual quality of life.

SQOL score of healthy women
In the our study, the mean age of the healthy women was 41.99 ± 8.86 years, and their SQOL score was 78.92 ± 7.08.Kim and Kang reported an SQOL score of 74.25 ± 13.65 in healthy women aged 45-60 years, which is lower than in our study. 16Maasoumi et al. 17 reported an SQOL score of 86.4 ± 1.78 in healthy women aged 33 ± 8.07 years, which is higher than in our study.As Roussin et al. 4 reported in a systematic review, age is an important factor negatively affecting sex life.At the same time, studies show that increased age lowers the sexual quality of life in healthy women. 4,16,17inical characteristics affecting sexual quality of life of women with gynecological cancer Furthermore, the sexual quality of life of the women with gynecological cancer receiving treatment in our study (47% had chemotherapy) was lower than that of those who were not receiving treatment, and the difference between them was significant.Similarly, Yarandi et al. 9 found that cancer treatment negatively affected the sexual quality of life of women with gynecological cancer.Hubbs et al. 7 reported that after treatment (63.5% had chemotherapy), 33.3% of women with gynecological cancer rarely engaged in sexual activity, sexual enjoyment fell from 64.7% to 27.4%, and sexual function was disrupted.Blake et al. 10 reported double the rate of sexual dysfunction after chemotherapy compared with before treatment (before treatment 26%; after treatment 51%).Dandamrongrak et al. 11 reported that 89.6% of women with gynecological cancer experienced sexual dysfunction after treatment; according to de Morais Siqueira et al., 12 the proportion was 88% for women with cervical cancer, and 91% for those with endometrial cancer.It was reported in a qualitative study by Bilge et al. 3 that women with gynecological cancer experienced sexual dysfunctions following treatment, and that their sexual quality of life was reduced.The number of studies examining the sexual quality of life of Turkish women with gynecological cancer receiving chemotherapy was very few. 3,21revious studies in the general literatüre generally focused on sexual dysfunctions.Although there are different predictors of sexual quality of life and sexual dysfunctions, it has been reported that sexual dysfunctions negatively affect the quality of sexual life.Sexual dysfunctions are one of the significant problems, which reduce the sexual quality of life of women with gynecological cancer.Studies have found a negative correlation between sexual dysfunction in women with gynecological cancer and their sexual quality of life.It has been reported that women with gynecological cancer experience more sexual dysfunction particularly after cancer treatment, and their sexual quality of life deteriorates. 6,13,14In this way, it can be said that the treatments which women receive for gynecological cancers and the side-effects of the treatments disrupt sexual functioning and thus sexual quality of life.
It was found in this study that women with cervical cancer had lower SQOL scores (56.68 ± 7.31) than women with other kinds of gynecological cancers, and that the type of cancer significantly affected sexual quality of life.Another study conducted in Türkiye was similar to our study. 8The higher incidence of cervical cancer than of other gynecological cancers and the increase in the survival rates of women with cervical cancer 1 may be the reason why these women experience problems in their sexual lives for longer and why their sexual quality of life is reduced.Also, there are studies which report that women with cervical cancer experience more sexual dysfunction than women with other gynecological cancers. 10,19As stated in the paragraph above, sexual functioning is an important factor lowering the sexual quality of life. 6,13,14For this reason, it is thought that the type of cancer and its progress and survival rate affect sexual life.
In the research, the SQOL scores of women with third and fourth stage gynecological cancer were lower, and the difference was found to be significant.Increasing fear of death as the cancer stage advances, the addition of new treatments at advanced stages, the side effects of treatments, additional health problems, and the medications used may all cause a further deterioration in the sexual quality of life. 3,4,7Different from our study, it was reported in studies by Blake et al. 10 and Dandamrongrak et al. 11 that women at an early stage of gynecological cancer experienced greater problems in sexual life.Also, the age of the women receiving treatment for gynecological cancer in these studies was greater than in our study.It is reported in the literature that the age of women with gynecological cancers, their menopause status, their relationship status, and their treatment status are related to their sexual quality of life. 4For this reason, it is thought that the difference in research results is related to the women's age, menopause status, relationship status, cancer type, time of diagnosis, and cancer treatment.
The SQOL scores of women with gynecological cancer with metastasis were lower, and the difference was significant (p = 0.001).1][12] Therefore, it is thought that the sexual quality of life of women with metastasized gynecological cancer is worse.
Linear regression analysis of the factors associated with sexual quality of life in healthy women and women with gynecological cancer One of the important findings of this research was that women with gynecological cancer negatively affect their sexual quality of life by 18.8 times compared with healthy women, and are responsible for 58% of the variance ( p < 0.05).This result clearly shows the negatively effect of gynecological cancers on women's sexual quality of life.A healthy sexual life is as important for cancer patients as it is for healthy people.Gynecological cancers disrupt women's sexual quality of life.1][12] At the same time, the biology of cancer disrupts sexual functions and causes sexual problems for women and a decline in the sexual quality of life.Along with this biological process, many factors such as psychological and interpersonal factors, the religious beliefs of the patient and their families, and the cultural norms of the society in which they live may affect the sexual quality of life of cancer patients. 2,5,6ltiple regression analysis of the factors associated with sexual quality of life in women with gynecological cancer According to the results of multiple regression analysis of factors associated with sexual quality of life in women with gynecological cancer, the best-fit regression model revealed five variables that explained 40% of the variance in their sexual quality of life.Age, working, smoking, diagnosed with cervical cancer, and receiving chemotherapy were determined as predictors of sexual quality of life.
In our study, we found that age negatively affects the sexual quality of life, but the result was not statistically significant.However, most of the previous studies reported a negative relationship between age and sexual quality of life. 22,23The reason for this result may be the profile of the participants.In this study, the majority of the participants were between the ages of 40-45.This may have given priority to other predictors for quality of sexual life.
This study was determined that working at a job was a predictor of sexual quality of life in women of gynecological cancer.Sexual quality of life was significantly higher of working women with gynecological cancer.Working is an important factor that improves the social environment.Working women have higher socioeconomic status and social support than nonworking women.In a previous study, it was stated that women who working and have social support have better sexual quality of life. 22Since working is a factor that increases socioeconomic status and social support, these women can be more self-confident and can easily solve their problems.For this reason, we think that working women can overcome the problems they experience in their sexual lives more easily and their sexual quality of life is better.In addition, working women can more easily access health institutions and can receive more support from their social environment regarding their health problems. 24Therefore, in our study, we think that it is better sexual quality of life of working women with gynecological cancer.
Women with gynecological cancer who smokers had worse sexual quality of life.Smoking was causing chronic diseases by disrupting the function of many systems, including the genital system. 25Because gynecological cancers had a negative impact on women's sexual quality of life in our study and other chronic diseases associated with cancer worsen the quality of sexual life. 22,23,26herefore, in our study, smokers with gynecological cancer had worse sexual quality of life when compared with nonsmokers.
It was determined in our study that cervical cancer was a predictor of sexual quality of life in women with gynecological cancer.In our study, we also stated in the above paragraph that women with cervical cancer had the lowest SQOL scores when compared with other types of gynecological cancer.Previous studies in Türkiye 8 and Iran 9 were similar.The reasons for this result may be the high survival rate of women in cervical cancer, their exposure to more problems related to their sexual life, and the negative effects of cervical cancer on the vagina and vulva.
Women with receiving chemotherapy had worse sexual quality of life.Receiving chemotherapy decreased the sexual quality of life scores of women with gynecological cancer by 4.7 U. Chemotherapy drugs and their side effects impair the quality of sexual life in women with gynecological cancer and cause sexual dysfunctions.Most of the previous studies reported that the quality of sexual life and sexual functions of women with gynecological cancer were worse after chemotherapy treatment. 6,13,14,24However, there were very few studies in Türkiye that determined the quality of sexual life of women with gynecological cancer after chemotherapy. 3,21his result in our study was important.Because our study revealed current results about the sexual quality of life experienced by women with gynecological cancer receiving chemotherapy.
The main limitation of our study was the low sample.In larger sample groups and follow-up studies are recommended.Although our study lasted 11 months, it was not an experimental study.Changes in sexual life of women with gynecological cancer should be followed in the future.Another limitation of our study was that the subject of the research was about sexuality and sexual life, which has a high level of privacy in Türkiye.Therefore, some of the women did not want to answer the questions or refused to participate in the study.This caused sample loss in both the case and control groups.However, it also revealed that this issue should be discussed with both women with gynecological cancer and healthy women.While we were conducting this study, we realized that women with gynecological cancer had many problems with their sexual life.Women with gynecological cancer could not discuss and ignore the problems they experienced in their sexual life.In addition, women who came to the gynecology policlinic for routine control (healthy women) were also experiencing problems in their sexual lives.All women needed support, education, and counseling on issues related to their sexual lives.After filling out the questionnaires, we had the women ask us their questions and we answered their questions.We only provided support, education, and counseling about sexuality and sexual life to the women who participated in the study during the research.This was the third limitation of our study.The fourth limitation was that the sample of the research being limited to one hospital.All women, whether or not they are diagnosed with gynecological cancer, should be provided with support, education, and counseling on sexuality and sexual life through health professionals and especially nurses (regularly in all health institutions and organizations).
In conclusion, this study determined the sexual quality of life of healthy women and women with gynecological cancer, and revealed current data on the effect of gynecological cancers on the quality of sexual life and identify predictors of sexual quality of life of women with gynecological cancer.According to this study, women with gynecological cancer had 18 times worse sexual quality of life scores than healthy women.It was determined that women with gynecological cancer had low SQOL scores and healthy women had moderate SQOL scores.In addition, it was determined that there was a significant difference between cancer type, stage, metastasis status, receiving treatment status, and SQOL scores.In our study, age, working, smoking, diagnosed with cervical cancer, and receiving chemotherapy were determined as predictors of sexual quality of life and were responsible for 40% of the variance.Gynecological cancers are important and vital diseases that need multidimensional evaluation.During this difficult process, sexual quality of life is mostly in the background, not discussed and ignored.However, it should be known that sexuality and sexual life are a need, and every individual has the right to enjoy it and experience sexuality with quality. 1,2,6Health professionals, especially nurses (oncology nurses), need to know the possible sexual problems that women with gynecological cancer may experience and nurses have the necessary infrastructure in this regard.Thus, nurses can minimize the problems that patients will experience, develop coping strategies, and find solutions.Nurses, who are in one-to-one communication with patients, should provide education, support and counseling to all women about sexual health and sexual life.But then, women will be able to freely express the problems they experience regarding their sexual health and sexual life, cope with the problems and find solutions to the problems they experience.In this way, women's sexual life quality will increase.In this context, nurses should be given educational trainings on sexual health and sexual life, and gaps in supportive care practices should be eliminated (regularly in all health institutions and organizations).
Comparison of the introductory characteristics of healthy women and women with gynecological cancer.
Comparison of clinical characteristics and sexual quality of life of women with gynecological cancer.
T A B L E 2Note: SD, Standard deviation; t, independent two sample "t" test.F, one-way ANOVA test, p < 0.05.p < 0.001.Bold indicates significant value.a All patients received chemotherapy.b Calculated over n = 28.
Linear regression analysis of the factors associated with sexual quality of life in healthy women and women with gynecological cancer.Multiple regression analysis of the factors associated with sexual quality of life in women with gynecological cancer.
T A B L E 3 Comparison of SQOL score of healthy women and women with gynecological cancer.t=13.791/p=0.000Note: SD, standard deviation; SQOL, Sexual Quality of Life Questionnaire; t, independent two sample "t"' test, p < 0.05.T A B L E 4 T A B L E 5Note: Backward selected.Excluded variables: Education, income, family type, menopause status, alcohol use, living child, stage of cancer, metastasis status and difficulty with cancer.B, unstandardized coefficient; CI, confidence interval; R 2 , Coefficient of determination; SQOL, Sexual Quality of Life Questionnaire; β, standardized coefficient.