Gynecologic cancer survivors experience a higher prevalence of sexual problems than do women in the general population, with difficulties reported across cancer sites, treatment types, and time since diagnosis. Importantly, these problems often persist over the long term, and may even intensify rather than improve over time [1,2]. Surgical, radiotherapeutic, and chemotherapeutic treatments can adversely affect sexual function by inducing menopausal symptoms, vaginal changes, body image concerns, psychological distress, and fear of recurrence. These consequences contribute to a high prevalence of sexual dysfunction among survivors and may hinder the resumption of sexual activity after treatment [3,4]. Treatments such as vulvectomy or hysterectomy may further contribute to pain, reduced genital sensation, altered body image, vaginal dryness, and impaired orgasmic function, all of which negatively affect sexual health [1].

As advances in cancer therapy extend survival, sexual dysfunction has emerged as an increasingly prevalent adverse effect of treatment [1]. Moreover, women with gynecologic malignancies have been shown to experience higher levels of anxiety than patients with other tumor types [5,6], and, overall, women report higher levels of anxiety than men [7].

Female sexual dysfunction (FSD) encompasses a range of disturbances involving sexual desire, arousal, orgasm, and pain during intercourse. These difficulties may arise from biological, psychological, or relational factors and can have a substantial impact on women’s quality of life and overall wellbeing [7,8].

Despite its clinical importance, FSD in gynecologic cancer survivors frequently remains underrecognized and insufficiently managed [9-12]. As the population of cancer survivors continues to grow, more attention should be directed toward women who experience sexual health concerns. In the context of gynecologic cancer, enhancing awareness and education regarding sexual health is particularly important for improving long-term quality of life [13]. These findings highlight the need for routine screening and integration of sexual health assessments into survivorship care, along with multidisciplinary interventions aimed at addressing both the physical and psychosocial aspects of sexual function [9-12].

A Thai study [14] conducted in 2021 reported that FSD affected 74.6% of gynecologic cancer survivors, highlighting the high prevalence of this issue in Thai clinical settings. However, effective communication and interventions remain limited and hindered by cultural stigma, insufficient sexual health education, and low levels of provider engagement. Accordingly, this study aimed to assess the prevalence of FSD and anxiety in a broader survivor population and to examine the associations between FSD and anxiety, as well as sociodemographic and treatment-related factors, using validated assessment tools.

This prospective, cross-sectional study was approved by the Institutional Ethics Committee before participant enrollment. The eligible participants were women diagnosed with gynecologic cancer who received treatment at a university hospital between July 11, 2024, and May 15, 2025. The inclusion criteria comprised women aged ≥18 years who had undergone surgery, radiotherapy, chemotherapy, or multimodal treatment and had completed therapy for at least 6 months prior to enrollment. The exclusion criteria included progressive gynecologic cancer; severe pain, fatigue, or significant disease-related discomfort; pregnancy; other malignancies; current systemic hormonal therapy; a history of thromboembolic disorders, psychiatric illness, or neurological conditions; inability to read, write, or understand the Thai language; and either no history of sexual intercourse or the absence of a sexual partner during the study period.

All participants were fully informed about the study and provided written informed consent prior to enrollment. Data were collected in a private setting within the gynecologic outpatient clinic to ensure confidentiality and comfort. Each participant completed a structured self-administered questionnaire with three sections.

Of the women approached for participation, 79.0% (160/202) agreed to enroll in the study. The most common reason for declining participation was the absence of sexual activity. Among the participants, 84.38% were postmenopausal and 67.50% reported no history of metabolic disease. The majority did not consume alcohol and most had completed education up to the high school level. Cervical cancer was the most common diagnosis, followed by ovarian and uterine cancers. Most participants (78.12%) had early-stage disease. Surgery was the predominant treatment modality (90.00%), while 13.75% of patients received radiation therapy (Table 1).

In most cases, the interval between treatment completion and survey participation was less than 5 years. Sixty-three percent of the participants reported abstaining from sexual activity during the preceding 4 weeks. The most frequently reported reasons for sexual inactivity were diminished sexual desire (50.00%), health-related issues (45.10%), absence of a cohabiting partner (43.31%), and fear or anxiety related to sexual activity (23.53%). Additional reasons included apprehension about engaging in intercourse, pain or discomfort before or after sexual activity, and reduced sexual interest (Table 2).

Based on the Thai version of the FSFI, 135 participants (84.38%) were classified as having FSD, with total scores below the 26.55 cutoff. The median total FSFI score was 5.6 (range, 3.6-23.3). Among the cancer types, FSD was the most prevalent in women with uterine cancer (95.12%), followed by those with ovarian cancer (80.77%) and cervical cancer (79.66%). Analysis of domain-specific FSFI scores revealed the following median values (interquartile range): desire 2.4 (1.2-3.0), arousal 0.3 (0.0-3.3), lubrication 0.0 (0.0-3.9), orgasm 0.0 (0.0-4.0), satisfaction 3.0 (1.8-4.8), and pain 0.0 (0.0-3.6). These findings indicate particularly low scores in the arousal, lubrication, orgasm, and pain domains (Table 3).

Most gynecologic cancer survivors (77.78%) reported mild anxiety, with only one participant (0.74%) reporting severe anxiety. Sexual dysfunction was not significantly associated with anxiety levels (P=0.730) (Table 4).

Factors associated with FSD are presented in Table 5. The univariable analysis identified age, comorbidities, alcohol consumption, education level, and cancer type as factors associated with FSD. However, in the multivariable analysis using a backward stepwise approach, only age and alcohol consumption remained independently and significantly associated with FSD after adjusting for these variables (P<0.001 and P=0.033; respectively).

This study demonstrated a notably high prevalence of FSD among gynecologic cancer survivors at a Thai tertiary hospital, with 84.38% of participants affected according to their FSFI scores. These results are consistent with those of previous studies conducted in comparable Thai populations [14]. However, this prevalence is higher than that reported in other countries such as Malaysia [11]. This variation may be attributed to differences in cultural contexts, access to healthcare, and sociodemographic profiles. The high prevalence of FSD observed in this study should be interpreted with caution as a substantial proportion of participants reported no sexual activity during the recall period. The FSFI scoring system assigns a score of zero to sexually inactive individuals, which may lead to lower total scores and potentially overestimate the prevalence of FSD when applied to the entire cohort. Nevertheless, sexual inactivity itself may reflect underlying sexual health concerns or disease-related factors and therefore remains an important aspect of survivorship that warrants attention.

Moreover, most participants had completed secondary school or less, whereas more than half of the Malaysian cohort had completed higher education. Previous studies have reported that lower educational levels are associated with an increased risk of sexual dysfunction [11,18]. One possible explanation for this is that patients with lower educational attainment may lack awareness or understanding of their sexual health concerns, making it more challenging to communicate these issues to healthcare providers. In contrast, those with higher levels of education often have better access to healthcare resources and information, allowing them to manage their conditions more effectively and maintain healthier lifestyles [19].

In this study, age was the most significant predictor of sexual dysfunction among gynecologic cancer survivors. Participants aged ≥50 years had nearly a tenfold higher likelihood of experiencing sexual dysfunction than those aged <50 years. Consistent with previous research [20], advanced age was a strong determinant of FSD. This association may be attributed to age-related hormonal decline and vascular changes that can lead to reduced sexual arousal, diminished vaginal lubrication, and decreased sexual desire in older women.

Alcohol consumption was associated with a lower likelihood of FSD in this study. Although previous evidence suggests that moderate alcohol use may enhance sexual desire and arousal through anxiolytic and disinhibitory effects [21], this finding should be interpreted with caution. Given the cross-sectional design and the potential for residual confounding, the observed association may reflect underlying differences in demographic or lifestyle factors rather than a true protective effect. Accordingly, these results should not be interpreted as supporting alcohol consumption for improving sexual function.

Emerging epidemiological evidence indicates that metabolic syndrome is associated with an increased risk of common gynecologic cancers and may contribute to increased cancer-related morbidity and mortality [22]. In addition to its role in carcinogenesis, metabolic diseases may adversely affect survivorship outcomes including sexual function. In our study, the univariable analysis demonstrated that women without metabolic conditions had a lower risk of FSD than those with metabolic diseases. However, this association was not statistically significant in the multivariable analysis. This finding contrasts with a 2023 systematic review and meta-analysis [23] that reported a significant association between metabolic syndrome and FSD. The proposed mechanism involves vascular dysfunction related to the metabolic syndrome, which leads to impaired tissue oxygenation and subsequent structural and functional alterations in the female reproductive system [24]. The discrepancy between our findings and those of the previous studies may be attributed to the limited sample size of the present study.

The results of the multivariable analysis should be interpreted with caution. The high prevalence of FSD in this cohort resulted in an unbalanced outcome distribution that may have affected the stability of the regression model. In addition, the cross-sectional design precludes causal inference, and residual confounding factors cannot be excluded. Therefore, the observed associations, including the strong effect of age and apparent protective association of alcohol use, should be interpreted cautiously.

In this study, no significant association was found between anxiety and FSD. A possible explanation is that most participants reported only mild anxiety, which may not have been severe enough to affect their sexual function. In contrast, Minnen and Kampman [8] reported a strong association between anxiety and FSD in clinical populations with conditions such as obsessive-compulsive disorder or panic disorder, which differed substantially from the survivor population evaluated in the present study.

FSD was not significantly associated with disease-related factors such as International Federation of Gynecology and Obstetrics stage or treatment modality (surgery, chemotherapy, or radiation therapy). This finding is consistent with those of previous studies [14,25] that found no significant association between these clinical variables and sexual function outcomes. Although a higher prevalence of FSD was observed among women who received pelvic radiation, this difference was not statistically significant. This finding should be interpreted with caution as only a small proportion of participants (approximately 13%) received pelvic radiation, which may have limited the statistical power to detect a significant association. Prior research [26] has indicated that radiation-induced alterations in vaginal tissues may lead to persistent sexual dysfunction, even when overall sexual satisfaction remains largely unchanged.

This study has several strengths: it addresses an underexplored aspect of survivorship (FSD) and its psychological correlates; it employs validated, standardized instruments (FSFI and GAD-7), enhancing validity and comparability; and it was conducted in a real-world clinical setting, improving applicability. Additionally, this study demonstrated the feasibility of implementing a brief self-administered FSFI in outpatient settings to identify otherwise unrecognized cases of FSD.

The limitations of this study include its cross-sectional design, which precludes causal inference; single-center recruitment, which may limit generalizability; variability in time since treatment completion; and unassessed psychosocial factors such as body image, depression, relationship satisfaction, and financial stress. Due to the relatively small number of sexually active participants, defined as those reporting at least one episode of sexual intercourse within the preceding 4 weeks, a subgroup analysis was not performed. Therefore, the findings should be interpreted in the context of the overall cohort, and further studies with a larger proportion of sexually active participants are required to provide more clinically meaningful estimates. Moreover, the absence of a distress- specific measure such as the female sexual distress scale may limit the interpretation of FSD in terms of its clinical significance, because sexual distress is a key component of clinically meaningful sexual dysfunction. It should be noted that while anxiety and sexual distress are related, they represent distinct constructs; therefore, the use of the GAD-7 does not fully capture distress specific to sexual function. Nevertheless, the GAD-7 is a validated and widely used instrument with good reliability and sensitivity, allowing for a standardized assessment of anxiety and the exploration of its association with FSD in this population.

Future research should focus on developing and evaluating the effectiveness, feasibility, and cost-effectiveness of FSD screening programs and comprehensive multidisciplinary interventions. Additionally, exploring barriers and facilitators from both the provider and patient perspectives is crucial for promoting successful clinical integration.

Given the high prevalence of FSD observed in this cohort, these findings underscore the potential clinical relevance of sexual health in gynecologic cancer survivorship. While routine assessment of sexual function may be considered a part of holistic care, these results should be interpreted with caution owing to the cross-sectional design. Further prospective and interventional studies are warranted to confirm these findings and provide evidence-based clinical recommendations.