Understanding Post-Cancer Challenges with Gina Franco, MSN, ANP-C

Gina Franco, MSN, serves as Director of the Center for Integrative Oncology and Survivorship and the Center for Cancer Prevention and Wellness at Prisma Health – Upstate Cancer Institute. She brings extensive experience as an oncology nurse practitioner and in oncology operations across academic, private, and acute care settings. Gina has developed multiple cancer programs and contributed significantly to survivorship research, advancing care models that address the physical, emotional, and psychosocial needs of patients. Under her leadership, CIOS provides specialized clinics in survivorship, oncology rehabilitation, genetics, nutrition, and counseling, ensuring patients receive comprehensive, integrative support throughout and beyond cancer treatment.

What changes women can expect following cancer treatments, particularly for vaginal health and sexual function?

There are many variables to consider with regard to female sexual changes that occur from cancer treatments. A starting point is the actual age of the woman. Younger premenopausal women may have periods stop and become menopausal from chemotherapy as a side effect, once chemo is complete – their periods may return but the closer they are to menopausal age, the likely they will remain peri or post-menopausal. There are also drugs that intentionally stop the ovaries from functioning called gonadotropin-releasing hormone (GnRH) agonists as an aid to treatment or they may have their ovaries removed surgically as a treatment. These drugs and surgeries place a woman in menopause in a dramatic fashion. Either scenario, the vaginal environment changes without the estrogen and other hormones with ensuing vaginal dryness, rising pH, clitoral atrophy, pelvic floor muscle changes often leading to decreased vaginal muscle tone and other far worse clinical issues of incontinence, prolapse and dyspareunia. Prior health of these sexual organs also need to be considered and if a women had incontinence or some type of prolapse issue prior to her cancer, they could become far worse.

Older women that are postmenopausal, sexual changes are not as dramatic unless they have been on systemic hormonal replacement and this had to be stopped because of their new cancer. Again, prior sexual health is always a factor, prior pelvic floor prolapses, or incontinence issues. Sexual function is variable as well. Libido is compromised with any loss of estrogen whether from medications or surgical removal of the ovaries–the same as noted above. However, hysterectomy complicates this with interruption of the vascular supply to the clitoris and vaginal. We now know how important it is to revascularize this area post-surgery by self-stimulation with clitoral stimulators or the newer type of clitoral vibrators until communal sexual activity is allowed. Sexual function also deteriorates as other factors post treatment occur, i.e. fatigue, body part grieving, distress as well as many others.

Very hard to describe all the scenarios here. I would impress to all professionals the need for assessment and including sexual function and health into your physical and psychosocial assessment. Also knowing what resources are available virtually and locally.

What solutions or approaches do you recommend for supporting vaginal health rehabilitation?

One of the most important things I would like to convey to other professionals is the need for earlier assessment and intervention. Many women receive some information as they begin treatment or surgery but often do not have the follow-up. Understandably, the acute team is focused on getting women through the treatment with minimal complications. However, patients that had prior sexual organ issues have even bigger sexual issues later without intervention and even those with mild issues left unaddressed, these sexual organs lose health and loss of functionality follows.

Any surgery or radiation to gynecologic organs or areas close like the urethra, vulva, and rectum need close follow-up and likely increased attention from specialists such as pelvic floor therapists, gynecologists trained to assess these issues and even uro-gynecologists. Ideally, sexual health clinics embedded in cancer centers are ideal to help patients navigate when and what they need.

Far too often, I have seen patients simply given vaginal dilators with an instruction sheet to go home and use. The patient is often afraid, bewildered, and afraid to ask how to even use these correctly. I have learned so much from listening to pelvic floor therapists and now always encourage the patient to see the pelvic floor therapists at least once to get an assessment and understand how to use the dilaters and even if there are different ones that may work better as well as exercises and other aides.

I would love to see more embedded sexual health clinics with professionals or a minimum of a sexual health navigator in cancer centers. There are so many pre-emptive activities that patients can learn that including, monitoring vaginal pH, what lubricants and moisturizers would be helpful, what professionals are in the community if they need more help, what medications might be helpful for libido and vaginal health.

How can providers create opportunities to talk about cancer more openly and reduce the stigma around these conversations?

Our society has such an issue about talking about sex as it related to us just being a whole person. Our sexual conversations are so unrehearsed and uncomfortable, it really presents to be a challenge to address in a medical assessment and clinic. Patients don’t know how much to share or what will be for everyone to see in their chart. Medical professionals assume things are fine or that patients is single or old and therefore not sexually active. We even can’t even mention self-stimulation comfortably. I was one of the above and then was asked why we did not have this service in our survivorship area several years ago.

I also was an aging female breast cancer survivor and certainly could appreciate we needed better navigation for our patients. Our team found some national leaders in sexual health that helped us to first learn how to normalize the conversation with the patient and even other staff. We learned about products and how varied products could be and how to purchase these products safely and how to empower women that these items were “OK” to have and use. We helped women by listing helpful websites, books, podcasts, models in the office, pictures, quick facts. We showed patients helpful sexual position diagrams, frequent questions and answers. Lastly, we learned how to meet each patient where they were at which could range from a woman that was reliving her childhood sexual traumatization to an elderly couple that were navigating how to manage the sexual dryness.

What emerging advancements or approaches in post-cancer care are helping to better support patients’ overall quality of life, including their sexual health?

As stated above, we need more sexual health presence in cancer centers whether it be in an actual clinic or through navigation. Patients are enduring these changes sexually often alone and not knowing all the products and resources available. I am intrigued by the virtual pelvic floor care/therapy options since many communities do not have this resource or patients cannot pay for it. Also, virtual sexual counseling for the same reasons especially for those women that were traumatized but never treated.

Products have really evolved for sexual activity. Our oncology community is finally using vaginal estrogen and prasterone for vaginal dryness and we have these interventions added to our national guidelines in most clinical situations. The newer external vibrators that are more like a funnel design as a clitoral stimulator are very helpful for women with clitoral atrophy but still have a functioning clitoris. Some of the newer vaginal weights the pelvic floor therapists are using look extremely innovative–these could even be used in patients with no pathology to maintain vaginal tone.

We are moving the needle slowly in sexual care of our cancer survivors. I often say to patients, most items we will talk about have about a 5-10% improvement whether it be a different lubricant, moisturizer, position, pelvic floor therapy, vibrator, vaginal estrogen, libido drug–however, if we use a few of these together, we can get a 30-40% improvement or more. We can’t get you back to what you were before treatment or surgery, but you can enjoy intimacy and do something that feels normal after a cancer that has changed so many things in your life.