The Impact of Staged Sexual Health Education on Sexual and Mental Health in Breast Cancer Patients: A Randomized Controlled Study

The Impact of Staged Sexual Health Education on Sexual and Mental Health in Breast Cancer Patients: A Randomized Controlled Study | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article The Impact of Staged Sexual Health Education on Sexual and Mental Health in Breast Cancer Patients: A Randomized Controlled Study Rongfei Suo, Fulan Li, Mengjun Liu, Shumin Kuang, Xiao Chen, Rongli Yang, and 1 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-5242426/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background: Patients with breast cancer have a great need for staged sexual health education. This study aimed to assess the impact of staged sexual health education on improving the sexual and mental health of patients with breast cancer. Methods: This was a randomized controlled trial (RCT). 94 patients with breast cancer were assigned the control or intervention group, which received standard and staged sexual health education, respectively. The Quality of Sexual Life questionnaire (QSL), Female Sexual Function Index (FSFI), Self-rated Depression Scale (SDS), and Self-rated Anxiety Scale (SAS) were used to assess the sexual and mental health status of breast cancer patients before (T1) and after the intervention (T2, T3). Repeated-measures ANOVA was employed to compare the differences in outcome scale scores between the groups at each time point. Results: The QSL scores in the intervention group were significantly higher than those in the control group at T3 ( P <0.05). The FSFI scores in the intervention group were significantly higher than those in the control group at both T2 and T3 ( P <0.05). Furthermore, the proportion of patients who resumed sexual activity in the intervention group (3%) was significantly greater than that in the control group (2%) ( P 0.05). Conclusions: Staged sexual health education can help patients with breast cancer to correctly understand sexual health related knowledge, restore normal sexual life, improve FSFI and QSL. breast cancer sexual health mental health intervention 1. Introduction Breast cancer has become the most common cancer among women worldwide [ 1 ]. In China, there were 357,200 new breast cancer cases in 2022, with incidence rates continuing to rise and the age of patients trending younger [ 1 ]. Nevertheless, the survival rate for patients with breast cancer has steadily improved, reaching for a 5-year survival rate of 83.2% [ 2 ]. Given that breast cancer is closely linked to female secondary sexual characteristics and hormone levels, the diagnosis of and surgery and adjuvant therapies for breast cancer can significantly impact patients' sexual lives [ 3 , 4 ]. In China, 75.37% of women with breast cancer experience sexual dysfunction, a rate notably higher than that of 53.17% reported among the general female population [ 5 , 6 ]. Studies have shown that 56.1–64.2% of patients experience feelings of loss regarding their breasts following breast cancer surgery, which negatively impacts their sexual activity and mental health [ 5 ]. During chemotherapy and endocrine treatment, patients often experience side effects such as vaginal dryness, reduced sexual desire, and distorted self-image, which further affect their sexual and mental well-being [ 4 , 7 ]. Additionally, owing to a lack of accurate information on sexual health, breast cancer patients frequently associate their breast cancer status with their sexual life , leading to misconceptions that hinder their sexual health [ 4 , 7 , 8 ]. A survey of Chinese female patients who had undergone breast cancer surgery revealed that 71.4% believed that sexual activity may result in adverse health outcomes, and 21.89% feared that it could lead to breast cancer recurrence [ 9 ]. Additionally, patients must contend with the side effects of medications during adjuvant therapy, yet many are unaware of these impacts; for example, 71.9% of patients do not recognize the effects of endocrine therapy on sexual behavior [ 10 , 11 ] Researchers have also noted that breast cancer survivors often have limited information about reproductive health, leading to concerns about pregnancy posttreatment, which further affects their sexual health and overall quality of life [ 12 ]. Research indicates that effective sexual health education can significantly improve sexual health outcomes and mental well-being for breast cancer patients, which in turn benefits their overall prognosis [ 13 ]. However, several factors hinder the delivery of such education, including a lack of established sexual health education practices, insufficient knowledge among clinical staff, and traditional Chinese cultural attitudes that view discussions of sex as taboo [ 8 ]. Consequently, only 13.43% of patients who have undergone breast cancer surgery report having received sexual health education, whereas 61.69% express a need for such guidance postsurgery [ 9 ]. Furthermore, 73% of patients would like to discuss the potential impacts of breast cancer treatment on sexual health at the time of diagnosis or shortly thereafter, and 34% seek ongoing guidance during treatment [ 14 ]. Thus, the provision of continuous sexual health education at various stages of the cancer journey is crucial. According to the Health Belief Model (HBM), the primary factors that influence behavior are individuals' knowledge, attitudes, and beliefs [ 15 ]. To support breast cancer patients in restoring a healthy sexual life, it is crucial to address and correct any misconceptions about sexual health. Research by de Almeida et al [ 16 ]. demonstrated that sexual health interventions can enhance sexual function in breast cancer patients. However, most previous studies on the sexual health of Chinese female breast cancer patients were cross-sectional and focused primarily on aspects such as sexual health awareness, behavior, and needs, with a relative lack of intervention research [ 16 , 17 ]. Current sexual health needs for breast cancer patients include understanding the effects of treatment, receiving guidance on communication with partners, and managing changes posttreatment [ 18 ]. Guided by the HBM and considering the unique characteristics of different treatment stages for breast cancer patients, this study aimed to provide targeted sexual health education, including information on breast cancer and its treatments, communication skills, and strategies for managing treatment-related changes. This study is anticipated to enhance both sexual and mental health outcomes for breast cancer patients and provides a theoretical foundation for Chinese clinical staff to improve sexual health education for these patients in the future. 2. Methods 2.1 Study design This was a single-center, randomized, controlled study. Patients were randomly assigned to the intervention group or the control group according to their order of admission via the random number table method. A nurse who was not involved in the study was asked to place the grouping information into separate envelopes, which were opened to determine each patient's group assignment when they were determined to meet the inclusion criteria. This study was registered in the Chinese Clinical Trials Registry ( https://www.chictr.org.cn/ ) (No. ChiCTR2400085763). 2.2 Research funding and ethics This study was supported by the Nursing Youth Talent Cultivation Fund of the School of Nursing, Sun Yat-sen University (No. N2020Y08). This study adhered to the ethical standards for clinical medical research and received approval from the Ethics Committee of the Fifth Affiliated Hospital of Sun Yat-sen University (No. 2021K94-1). 2.3 Participants This study included breast cancer patients treated at the Fifth Affiliated Hospital of Sun Yat-Sen University from January 2021 to December 2023. The inclusion criteria were as follows: ① female patients with a pathological diagnosis of breast cancer within the past 2 weeks; ② patients with planned admission for modified radical mastectomy; ③ patients who were married; ④ patients with at least a primary school education; and ⑤ patients aged between 18 and 60 years. The exclusion criteria were as follows: ① breast cancer with distant metastases to the liver, brain, or other organs; ② history of mental illness or current use of antipsychotic drugs; ③ recurrent breast cancer; ④ divorce or widowhood; and ⑤ sexual dysfunction. The termination criteria included the following: ① no need for chemotherapy or adjuvant endocrine therapy after surgery; ② withdrawal from the study for personal reasons; and ③ the diagnosis of other serious life-threatening diseases during the study.The formula for calculating the sample size in experimental research is as follows: n = On the basis of previous studies, values of S = 7.04 and δ = 5.68 were used for this study [ 19 ], which required a total of 74 patients. Considering a potential 20% loss to follow-up, approximately 47 patients were needed in each group (calculated as 37/(1-0.2) ≈ 47). In this study, sample loss occurred as follows: In the intervention group, 6 patients were lost, including 4 patients who no longer required chemotherapy or adjuvant endocrine therapy after surgery and 2 patients who withdrew from the study for personal reasons. In the control group, 5 patients were lost, with 3 patients no longer needing chemotherapy or adjuvant endocrine therapy after surgery and 2 patients withdrawing from the study for personal reasons. 2.4 Intervention In the control group, sexual health education was limited to routine health guidance [ 20 ], consisting of two main points: (1) informing patients before discharge that sexual activity can typically be resumed 1–2 months after surgery and that contraception is required for 5 years following the completion of treatment (this information was provided alongside other discharge instructions, lasting approximately 10–20 minutes); and (2) informing patients about potential drug side effects that could affect sexual health, such as vaginal dryness or decreased libido (this was included with other drug-related education, lasting approximately 5–10 minutes). The researchers did not proactively provide additional sexual health education and only responded to patient inquiries. During the study, patients in the control group asked questions twice, both concerning whether sexual activity could impact cancer prognosis. The HBM is an effective framework for designing educational interventions and promoting preventive behaviors. This model suggests that when individuals have accurate knowledge about diseases and health, they are more likely to adopt healthy behaviors and change unhealthy ones [ 21 , 22 ]. Initially, in this study, content for a staged sexual health education program was developed for breast cancer patients on the basis of a literature review and preliminary investigation. In the next phase, experts—two breast surgeons, two sexual health education specialists, two breast specialist nurses, and a mental health counsellor—were consulted to provide feedback and revisions. After finalizing the staged sexual health education content, three nurses with expertise in scientific research and clinical practice were trained in the breast surgery inpatient department. They successfully implemented a staged sexual health education program for breast cancer patients (location: health education room, format: one-on-one health guidance). The detailed mission content is presented in Table 1 . Table 1 Staged sexual health education related to the breast cancer protocol Stage Time Content Length Perioperative period 1–3 days before surgery (1) Knowledge Related to Breast Cancer and Sexual Life : This section covers breast cancer symptoms, pathogenesis, risk factors, and epidemiological characteristics. Patients should understand that sexual activity does not disrupt hormone levels in the body and is unlikely to cause breast cancer recurrence or metastasis. In fact, a harmonious sexual life can benefit both treatment and prognosis [ 23 ]. Issues such as breast loss and scarring from surgery can be addressed through implanting prostheses, wearing artificial breasts, and using scar removal medications. 10–20 min 1–3 days after surgery (2) Precautions for Postoperative Sexual Life : Breast cancer patients should be informed that they can typically resume sexual activity 1–2 months after surgery, once their wounds have healed. Pregnancy should be avoided for 5 years after treatment ends, and assisted fertility technology can be considered for those with fertility needs [ 20 ]. Additionally, patients should be aware of the risk of edema in the affected limb postsurgery and take care to avoid straining the affected area during sexual activity [ 24 ]. 10–20 min One day before discharge (3) Sexual Health Psychological Counseling : This counseling aims to help patients recognize that sexual activity is a fundamental human need, and discussing sexual health is not shameful. It emphasizes the importance of a healthy sexual life in strengthening the marital relationship and promoting physical and mental well-being [ 25 ]. Patients are guided on how to communicate with their spouses about sexual life and encouraged to seek medical advice when issues arise [ 26 , 27 ]. 10–20 min Adjuvant treatment period 1 month ± 7 days after surgery (1) Side Effects of Drugs on Sexual Life : Patients should be informed about the potential side effects of chemotherapy or endocrine therapy on sexual health, which may include fatigue, reduced immunity, decreased sexual desire, vaginal dryness, and atrophy [ 28 ]. (2) Coping with Adverse Reactions : Patients should be guided to adjust the frequency of sexual activity based on their physical recovery. It is important to prevent infections when immunity is low. For issues such as decreased sexual desire and vaginal dryness, several strategies can be helpful, including adjusting lighting, watching films or animations, performing Kegel exercises, or increasing intimate contact with their spouse [ 29 , 30 ]. Additionally, vaginal lubricants or moisturizers can be used to alleviate vaginal dryness [ 29 , 31 ]. 20–30 min 3 months ± 7 days after surgery (3) Sexual Health and Psychological Counseling : Encourage patients to resume normal sexual activity and actively communicate any challenges they face. Sexual needs should be acknowledged as normal and important aspects of overall well-being [ 32 ]. 10–20 min Table 2 Analysis of Baseline Data on General Information and Main Outcome Variables in Breast Cancer Patients( n 1 = 41, n 2 = 42) Variable Intervention group Control group Z/x 2 / t P M ± SD /n 1 ( % ) M ± SD /n 2 ( % ) Education level -0.055 0.956 Primary school 21 23 Middle school 10 7 College degree or higher 10 12 Residence -1.345 0.179 Village 9 17 Town 12 8 City 20 17 Average monthly income (Yuan) -0.877 0.381 <2000 10 14 2000–3999 9 9 4000–5999 9 8 ≥ 6000 13 11 Have gone through menopause༟ 0.579 0.447 Yes 22 26 No 19 16 Stage of cancer -0.687 0.492 Ⅰ 7 9 Ⅱ 24 25 Ⅲ 10 8 Age 46.63 ± 7.59 48.21 ± 7.80 0.935 0.352 Age of Marriage 21.44 ± 9.02 24.74 ± 9.17 1.652 0.102 FSFI total score 26.79 ± 3.39 26.32 ± 2.89 0.679 0.499 Desire 3.78 ± 0.62 3.70 ± 0.66 0.538 0.592 Arousal 4.07 ± 0.59 4.07 ± 0.99 0.017 0.986 Lubrication 4.66 ± 0.75 4.76 ± 0.75 0.585 0.560 Orgasm 4.69 ± 0.77 4.58 ± 0.79 0.668 0.518 Satisfaction 4.99 ± 0.85 4.84 ± 1.03 0.710 0.480 Pain 4.61 ± 1.10 4.37 ± 0.87 1.075 0.285 SAS total score 34.73 ± 5.62 35.86 ± 6.41 0.850 0.398 SDS total score 36.68 ± 6.21 36.43 ± 6.51 0.182 0.856 Table 3 Efects and interaction between intervention and control group on FSFI, QSL, MAT, SAS and SDS by intent to treat analysis expressed by Mean ± SD . Groups Times Intervention P -value Time P -value Interaction P -value T 1 T 2 T 3 FSFI 0.001 P <0.001 0.033 Control 26.32 ± 2.89 9.07 ± 6.81 a 14.36 ± 8.09 a Intervention 26.79 ± 3.39 12.49 ± 8.02 a 19.70 ± 6.64 a Desire 0.057 P <0.001 0.351 Control 3.70 ± 0.66 2.30 ± 0.85 2.57 ± 0.78 Intervention 3.78 ± 0.62 2.52 ± 0.90 2.97 ± 0.97 Arousal P <0.001 P <0.001 P <0.001 Control 4.07 ± 1.00 2.30 ± 0.85 a 1.68 ± 1.47 a Intervention 4.07 ± 0.59 2.52 ± 0.90 a 3.17 ± 1.19 a Lubrication 0.003 P <0.001 0.006 Control 4.76 ± 0.75 1.06 ± 1.76 2.26 ± 1.88 a Intervention 4.66 ± 0.75 1.79 ± 2.14 3.40 ± 1.48 a Orgasm 0.001 P <0.001 0.009 Control 4.58 ± 0.79 0.87 ± 1.48 a 2.14 ± 1.83 a Intervention 4.69 ± 0.77 1.65 ± 1.98 a 3.45 ± 1.62 a Statisfaction 0.005 P <0.001 0.233 Control 4.84 ± 1.03 2.85 ± 1.18 a 3.52 ± 1.19 a Intervention 4.99 ± 0.85 3.49 ± 1.19 a 4.16 ± 1.41 a Pain 0.618 P <0.001 0.925 Control 4.37 ± 0.87 1.08 ± 1.75 2.19 ± 1.92 Intervention 4.61 ± 1.10 1.45 ± 1.72 2.56 ± 1.50 QSL 0.014 0.308 0.215 Control —— 78.40 ± 7.37 77.60 ± 5.59 a Intervention —— 85.00 ± 11.63 92.95 ± 11.14 a SDS 0.590 0.004 0.622 Control 36.43 ± 6.51 40.31 ± 7.54 39.74 ± 8.11 Intervention 36.68 ± 6.21 39.66 ± 7.07 38.22 ± 8.24 SAS 0.618 0.810 0.770 Control 35.86 ± 6.41 36.00 ± 7.40 35.31 ± 6.05 Intervention 34.73 ± 5.62 35.49 ± 5.91 35.32 ± 7.03 a There was a statistically significant difference in scores between the intervention group and the control group at the same time point. Table 4 Number of Patients Resuming Sexual Activity Group Time T 2 T 3 Resumed sexual life Have not resumed sexual life Resumed sexual life Have not resumed to sexual life Intervention group 21 20 35 6 Control group 14 28 17 25 x 2 2.722 17.866 P 0.099 P <0.001 2.5 Data collection and measurements In this study, each patient completed questionnaires at three different times: before the first intervention (T1); 3 + 10 days after surgery (T2); and 6 months after surgery (T3). Alternatively, patients could be instructed to complete electronic questionnaires at home. Each data collection session took approximately 20 minutes and was conducted by an investigator (who was not involved in the intervention and did not know the outcome of the patient’s assignment) using standardized guidance. This study utilized a general information questionnaire consisting of seven items: age, age at marriage, education level, income, residence, cancer stage, and menopausal status. To measure sexual health outcomes in breast cancer patients, this study employed the Quality of Sexual Life questionnaire (QSL) and the Female Sexual Function Index (FSFI). The QSL, developed by Jing Liwei [ 33 ], includes five dimensions and 28 items; higher scores indicate better sexual quality of life. This questionnaire has demonstrated good reliability and validity in breast cancer patients, with a Cronbach's α coefficient of 0.93 [ 33 ]. The FSFI, developed by Rosen et al.,[ 34 ] includes 19 items across six dimensions, with higher scores indicating better sexual function. The Chinese version of the FSFI has shown good reliability and validity in breast cancer patients, with a Cronbach's α greater than 0.80 [ 35 ]. In this study, the Zung Self-rated Depression Scale (SDS) and the Self-rated Anxiety Scale (SAS) were used to evaluate the mental health of breast cancer patients [ 36 ]. The total score of the SDS ranges from 20 to 80 points, with higher scores indicating more severe depression. The total score of the SAS ranges from 20 to 80 points, with higher scores indicating more severe anxiety. 2.6 Statistical analysis An independent samples t test was used to analyze differences in age at baseline, age at marriage, and outcome scale scores between the two groups, confirming that these variables met the assumptions of a normal distribution and homogeneity of variance. A chi-square test was conducted to examine differences in the number of patients who had experienced menopause between the two groups. The Wilcoxon W test was employed to assess differences in the remaining general data between the groups. Furthermore, repeated-measures ANOVA was used to explore differences in outcome scale scores between the two groups at 3 and 6 months after confirming a normal distribution and homogeneity of variance for all scores. Multivariate analysis of variance (MANOVA) was also conducted to compare differences in outcome variables between the two groups at each time point. All the statistical analyses were performed via SPSS version 21.0, with the significance level set at P 0.05) between the two groups in terms of the baseline data, general information or main outcome variables for postoperative breast cancer patients. These findings indicate that the baseline characteristics of the two groups did not impact the effectiveness of the intervention. 3.2 Comparisons of the main outcome variables between the intervention and control groups The results indicated that, three months after surgery (T 2 ), the intervention group had significantly higher FSFI total scores, as well as higher scores in terms of sexual arousal, orgasm, and satisfaction, than did the control group ( P < 0.05). Additionally, six months after surgery (T 3 ), the intervention group had significantly higher FSFI total scores, along with increased scores in terms of sexual desire, arousal, lubrication, orgasm, satisfaction, and sexual quality of life, than did the control group ( P < 0.05). In addition, the results of this study revealed that three months after surgery (T 2 ), there was no statistically significant difference between the two groups in terms of the number of patients who resumed sexual activity ( P > 0.05). However, at six months after surgery (T 3 ), 17 patients (40.48%) in the control group and 35 patients (85.37%) in the intervention group had resumed sexual activity, with a statistically significant difference between the two groups ( P < 0.05). 4. Discussion The primary aim of this study was to explore the impact of staged sexual health education on improving the sexual and mental health of Chinese women after breast cancer surgery. In addition, our findings suggest that this approach can significantly improve sexual health outcomes for female patients following breast cancer surgery. We found that the FSFI scores, along with sexual satisfaction, orgasm, and arousal scores, were higher in the intervention group than in the control group at both 3 and 6 months after surgery. These findings demonstrate that staged sexual health education can effectively improve sexual function in breast cancer patients. However, our findings differ from those of de Almeida et al. [ 16 ], which may be attributed to differences in the study subjects and the form of health education provided. In the de Almeida study, the subjects were female breast cancer patients who had undergone surgery more than 6 months prior [ 16 ], whereas our study focused on patients newly diagnosed with breast cancer (≤ 2 weeks). This finding might suggest that early sexual health education for breast cancer patients can significantly improve their sexual function and may indirectly indicate that these patients desire early intervention [ 14 ]. In addition, the sexual health education in de Almeida’s study relied primarily on patients’ initiative to ask questions and seek consultation [ 16 ]. In contrast, our nursing staff provided proactive sexual health education tailored to the needs of patients at different stages, a method that was more suitable for Chinese women who may feel "ashamed to talk about sex" in our study [ 8 , 37 ]. However, our study also revealed that staged sexual health education did not significantly improve physical symptoms such as sexual desire and pain in breast cancer patients. Addressing these issues—increasing sexual desire and reducing pain—will be crucial in future sexual health interventions for breast cancer patients. Additionally, at 6 months after surgery, the QSL score of patients in the intervention group was significantly higher than that of patients in the control group. However, there was no difference in the QSL score between the two groups at 3 months after surgery. This difference may arise because patients’ sexual health issues, primarily caused by treatment side effects, are not a major concern for patients in the early stages of treatment. Studies indicate that the unmet information needed for medical examination results, treatment options, and health promotion for patients with breast cancer gradually increases, peaking within 10 weeks after surgery; however, unmet information on treatment-related side effects increases to the greatest degree only after these first 10 weeks [ 38 ]. This lack of an early difference may also be attributed to the impact of illness and the persistent physical pain experienced by patients in the early stages of treatment [ 39 ]. Furthermore, a greater number of patients in the intervention group than in the control group had resumed sexual activity at 6 months after surgery. These findings suggest that staged sexual health education effectively helps female breast cancer patients overcome their worries and fears about sexual activity, facilitating a return to normal sexual life. These findings also support previous research indicating that a lack of knowledge about sexual health after breast cancer surgery can lead to misconceptions, such as the belief that sexual activity could lead to cancer recurrence or negatively impact cancer prognosis, resulting in patients avoiding sexual activity [ 5 , 8 ]. Moreover, contrary to the study hypothesis, periodic sexual health education did not reduce anxiety or depression in patients after breast cancer surgery. This lack of impact may be attributed to the fact that the patients in this study were still undergoing treatment. Their primary sources of anxiety and depression were likely the physical effects and economic burdens of cancer treatment [ 40 ], with sexual health playing a relatively minor role. Furthermore, the staged sexual health education in this study included limited psychological counseling, indicating a need for more comprehensive psychological support, such as mindfulness-based stress reduction and cognitive behavior therapy, in future interventions [ 41 , 42 ]. This study demonstrated that staged sexual health education can assist breast cancer patients in resuming sexual activity and significantly improve their sexual function and sexual quality of life after surgery. It also underscores the importance of proactively providing sexual health education to patients at various stages of treatment, addressing misconceptions about sexual health, and fostering a correct understanding of sexual well-being. This study had several limitations: (1) Data were collected only at 3 and 6 months after surgery, which may not be sufficient to observe long-term changes in sexual and mental health outcomes after the completion of treatment. (2) The single-center design may have introduced sampling bias, potentially affecting the representativeness of the subjects. Despite these limitations, the study also had notable advantages: (1) as a randomized controlled trial, this study demonstrated comparable baseline data between the two groups, minimizing bias from confounding factors; and (2) this study employed staged sexual health education tailored to the specific needs of breast cancer patients at different stages of treatment, effectively addressing their sexual health concerns. Declarations Acknowledgments Acknowledgments of the fund: Nursing Research Fund, Affiliated Hospital of Sun Yat-sen University (2021hlky08) . Conflict of interest No conflict of interest has been declared by the authors. 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Support Care Cancer 2022;30(5):4315-4325. Soleymani MM, et al. An investigation of the effect of mindfulness-integrated cognitive behavior therapy on demoralization, body image, and sexual function in Iranian women with breast cancer: a randomized controlled trial. J Cancer Res Clin Oncol 2024;150(3):128. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-5242426","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":371468495,"identity":"0028e179-a60e-4c55-b17f-13a683dd28b2","order_by":0,"name":"Rongfei Suo","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAAy0lEQVRIiWNgGAWjYBACfvbmww8+VNTIARkHiNMi2XMszXDGmWPGQEYCcVoMbuQYSPO2MCcazMgxINJlBxIMjHkb2BIMGHI+3njDYCen20BAB2PDgYSHc3fI5JkznN1sOYch2djsAAEtzEA9Bm/PsBVbNvZuk+ZhOJC4jZAWNqAeCd425sQNh3meEaeFh42ZQRKs5RgPG3FaJHjY2KCBzGZsOceACL/Y33//GRKV8o8f3nhTYSdHUAualcRGDZIWUnWMglEwCkbBiAAA6jNFsjBDAjQAAAAASUVORK5CYII=","orcid":"https://orcid.org/0000-0003-1574-7003","institution":"The Fifth Affiliated Hospital of Sun Yat-sen University","correspondingAuthor":true,"prefix":"","firstName":"Rongfei","middleName":"","lastName":"Suo","suffix":""},{"id":371468496,"identity":"adbdfaee-e3e0-47e2-b686-da6d9b8832e4","order_by":1,"name":"Fulan Li","email":"","orcid":"","institution":"The Fifth Affiliated Hospital of Sun Yat-sen University","correspondingAuthor":false,"prefix":"","firstName":"Fulan","middleName":"","lastName":"Li","suffix":""},{"id":371468497,"identity":"bd996b19-6e71-4517-ba31-f1e574bb4081","order_by":2,"name":"Mengjun Liu","email":"","orcid":"","institution":"The Fifth Affiliated Hospital of Sun Yat-sen University","correspondingAuthor":false,"prefix":"","firstName":"Mengjun","middleName":"","lastName":"Liu","suffix":""},{"id":371468498,"identity":"81320a2d-be26-4954-a7a6-0b025b4a0d66","order_by":3,"name":"Shumin Kuang","email":"","orcid":"","institution":"The Fifth Affiliated Hospital of Sun Yat-sen University","correspondingAuthor":false,"prefix":"","firstName":"Shumin","middleName":"","lastName":"Kuang","suffix":""},{"id":371468499,"identity":"c326f4c6-f9ac-4971-9f33-f6669509256a","order_by":4,"name":"Xiao Chen","email":"","orcid":"","institution":"The Fifth Affiliated Hospital of Sun Yat-sen University","correspondingAuthor":false,"prefix":"","firstName":"Xiao","middleName":"","lastName":"Chen","suffix":""},{"id":371468500,"identity":"ad9c7042-daa5-4805-8457-9928bf3579da","order_by":5,"name":"Rongli Yang","email":"","orcid":"","institution":"The Fifth Affiliated Hospital of Sun Yat-sen University","correspondingAuthor":false,"prefix":"","firstName":"Rongli","middleName":"","lastName":"Yang","suffix":""},{"id":371468501,"identity":"461d7d2a-0125-4e8f-be1f-406fbf470779","order_by":6,"name":"Fenglian Ye","email":"","orcid":"","institution":"The Fifth Affiliated Hospital of Sun Yat-sen University","correspondingAuthor":false,"prefix":"","firstName":"Fenglian","middleName":"","lastName":"Ye","suffix":""}],"badges":[],"createdAt":"2024-10-11 00:25:05","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-5242426/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-5242426/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":69174404,"identity":"adfbd7a4-64e7-4708-aa7d-98e3db4a2b8a","added_by":"auto","created_at":"2024-11-17 09:19:34","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":817627,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-5242426/v1/714f298c-d644-4eee-b280-bf8ae67aa58e.pdf"}],"financialInterests":"","formattedTitle":"The Impact of Staged Sexual Health Education on Sexual and Mental Health in Breast Cancer Patients: A Randomized Controlled Study","fulltext":[{"header":"1. Introduction","content":"\u003cp\u003eBreast cancer has become the most common cancer among women worldwide [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. In China, there were 357,200 new breast cancer cases in 2022, with incidence rates continuing to rise and the age of patients trending younger [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. Nevertheless, the survival rate for patients with breast cancer has steadily improved, reaching for a 5-year survival rate of 83.2% [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. Given that breast cancer is closely linked to female secondary sexual characteristics and hormone levels, the diagnosis of and surgery and adjuvant therapies for breast cancer can significantly impact patients' sexual lives [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. In China, 75.37% of women with breast cancer experience sexual dysfunction, a rate notably higher than that of 53.17% reported among the general female population [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eStudies have shown that 56.1\u0026ndash;64.2% of patients experience feelings of loss regarding their breasts following breast cancer surgery, which negatively impacts their sexual activity and mental health [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. During chemotherapy and endocrine treatment, patients often experience side effects such as vaginal dryness, reduced sexual desire, and distorted self-image, which further affect their sexual and mental well-being [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. Additionally, owing to a lack of accurate information on sexual health, breast cancer patients frequently associate their breast cancer status with their sexual \u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003elife\u003c/span\u003e, leading to misconceptions that hinder their sexual health [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eA survey of Chinese female patients who had undergone breast cancer surgery revealed that 71.4% believed that sexual activity may result in adverse health outcomes, and 21.89% feared that it could lead to breast cancer recurrence [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. Additionally, patients must contend with the side effects of medications during adjuvant therapy, yet many are unaware of these impacts; for example, 71.9% of patients do not recognize the effects of endocrine therapy on sexual behavior [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e] Researchers have also noted that breast cancer survivors often have limited information about reproductive health, leading to concerns about pregnancy posttreatment, which further affects their sexual health and overall quality of life [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eResearch indicates that effective sexual health education can significantly improve sexual health outcomes and mental well-being for breast cancer patients, which in turn benefits their overall prognosis [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. However, several factors hinder the delivery of such education, including a lack of established sexual health education practices, insufficient knowledge among clinical staff, and traditional Chinese cultural attitudes that view discussions of sex as taboo [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. Consequently, only 13.43% of patients who have undergone breast cancer surgery report having received sexual health education, whereas 61.69% express a need for such guidance postsurgery [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. Furthermore, 73% of patients would like to discuss the potential impacts of breast cancer treatment on sexual health at the time of diagnosis or shortly thereafter, and 34% seek ongoing guidance during treatment [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. Thus, the provision of continuous sexual health education at various stages of the cancer journey is crucial.\u003c/p\u003e \u003cp\u003eAccording to the Health Belief Model (HBM), the primary factors that influence behavior are individuals' knowledge, attitudes, and beliefs [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. To support breast cancer patients in restoring a healthy sexual life, it is crucial to address and correct any misconceptions about sexual health. Research by de Almeida et al [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. demonstrated that sexual health interventions can enhance sexual function in breast cancer patients. However, most previous studies on the sexual health of Chinese female breast cancer patients were cross-sectional and focused primarily on aspects such as sexual health awareness, behavior, and needs, with a relative lack of intervention research [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. Current sexual health needs for breast cancer patients include understanding the effects of treatment, receiving guidance on communication with partners, and managing changes posttreatment [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e].\u003c/p\u003e \u003cp\u003e Guided by the HBM and considering the unique characteristics of different treatment stages for breast cancer patients, this study aimed to provide targeted sexual health education, including information on breast cancer and its treatments, communication skills, and strategies for managing treatment-related changes. This study is anticipated to enhance both sexual and mental health outcomes for breast cancer patients and provides a theoretical foundation for Chinese clinical staff to improve sexual health education for these patients in the future.\u003c/p\u003e"},{"header":"2. Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003e2.1 Study design\u003c/h2\u003e \u003cp\u003eThis was a single-center, randomized, controlled study. Patients were randomly assigned to the intervention group or the control group according to their order of admission via the random number table method. A nurse who was not involved in the study was asked to place the grouping information into separate envelopes, which were opened to determine each patient's group assignment when they were determined to meet the inclusion criteria. This study was registered in the Chinese Clinical Trials Registry (\u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.chictr.org.cn/\u003c/span\u003e\u003cspan address=\"https://www.chictr.org.cn/\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e) (No. ChiCTR2400085763).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003e2.2 Research funding and ethics\u003c/h2\u003e \u003cp\u003eThis study was supported by the Nursing Youth Talent Cultivation Fund of the School of Nursing, Sun Yat-sen University (No. N2020Y08). This study adhered to the ethical standards for clinical medical research and received approval from the Ethics Committee of the Fifth Affiliated Hospital of Sun Yat-sen University (No. 2021K94-1).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003e2.3 Participants\u003c/h2\u003e \u003cp\u003e This study included breast cancer patients treated at the Fifth Affiliated Hospital of Sun Yat-Sen University from January 2021 to December 2023. The inclusion criteria were as follows: ① female patients with a pathological diagnosis of breast cancer within the past 2 weeks; ② patients with planned admission for modified radical mastectomy; ③ patients who were married; ④ patients with at least a primary school education; and ⑤ patients aged between 18 and 60 years. The exclusion criteria were as follows: ① breast cancer with distant metastases to the liver, brain, or other organs; ② history of mental illness or current use of antipsychotic drugs; ③ recurrent breast cancer; ④ divorce or widowhood; and ⑤ sexual dysfunction. The termination criteria included the following: ① no need for chemotherapy or adjuvant endocrine therapy after surgery; ② withdrawal from the study for personal reasons; and ③ the diagnosis of other serious life-threatening diseases during the study.The formula for calculating the sample size in experimental research is as follows: \u003cem\u003en\u003c/em\u003e =\u003c/p\u003e \u003cp\u003eOn the basis of previous studies, values of S\u0026thinsp;=\u0026thinsp;7.04 and δ\u0026thinsp;=\u0026thinsp;5.68 were used for this study [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e], which required a total of 74 patients. Considering a potential 20% loss to follow-up, approximately 47 patients were needed in each group (calculated as 37/(1-0.2)\u0026thinsp;\u0026asymp;\u0026thinsp;47).\u003c/p\u003e \u003cp\u003eIn this study, sample loss occurred as follows: In the intervention group, 6 patients were lost, including 4 patients who no longer required chemotherapy or adjuvant endocrine therapy after surgery and 2 patients who withdrew from the study for personal reasons. In the control group, 5 patients were lost, with 3 patients no longer needing chemotherapy or adjuvant endocrine therapy after surgery and 2 patients withdrawing from the study for personal reasons.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003e2.4 Intervention\u003c/h2\u003e \u003cp\u003eIn the control group, sexual health education was limited to routine health guidance [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e], consisting of two main points: (1) informing patients before discharge that sexual activity can typically be resumed 1\u0026ndash;2 months after surgery and that contraception is required for 5 years following the completion of treatment (this information was provided alongside other discharge instructions, lasting approximately 10\u0026ndash;20 minutes); and (2) informing patients about potential drug side effects that could affect sexual health, such as vaginal dryness or decreased libido (this was included with other drug-related education, lasting approximately 5\u0026ndash;10 minutes). The researchers did not proactively provide additional sexual health education and only responded to patient inquiries. During the study, patients in the control group asked questions twice, both concerning whether sexual activity could impact cancer prognosis.\u003c/p\u003e \u003cp\u003eThe HBM is an effective framework for designing educational interventions and promoting preventive behaviors. This model suggests that when individuals have accurate knowledge about diseases and health, they are more likely to adopt healthy behaviors and change unhealthy ones [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. Initially, in this study, content for a staged sexual health education program was developed for breast cancer patients on the basis of a literature review and preliminary investigation. In the next phase, experts\u0026mdash;two breast surgeons, two sexual health education specialists, two breast specialist nurses, and a mental health counsellor\u0026mdash;were consulted to provide feedback and revisions. After finalizing the staged sexual health education content, three nurses with expertise in scientific research and clinical practice were trained in the breast surgery inpatient department. They successfully implemented a staged sexual health education program for breast cancer patients (location: health education room, format: one-on-one health guidance). The detailed mission content is presented in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eStaged sexual health education related to the breast cancer protocol\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eStage\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eTime\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eContent\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eLength\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003ePerioperative period\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1\u0026ndash;3 days before surgery\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e(1) Knowledge Related to Breast Cancer and Sexual Life\u003c/b\u003e: This section covers breast cancer symptoms, pathogenesis, risk factors, and epidemiological characteristics. Patients should understand that sexual activity does not disrupt hormone levels in the body and is unlikely to cause breast cancer recurrence or metastasis. In fact, a harmonious sexual life can benefit both treatment and prognosis [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. Issues such as breast loss and scarring from surgery can be addressed through implanting prostheses, wearing artificial breasts, and using scar removal medications.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e10\u0026ndash;20 min\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1\u0026ndash;3 days after surgery\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e(2) Precautions for Postoperative Sexual Life\u003c/b\u003e: Breast cancer patients should be informed that they can typically resume sexual activity 1\u0026ndash;2 months after surgery, once their wounds have healed. Pregnancy should be avoided for 5 years after treatment ends, and assisted fertility technology can be considered for those with fertility needs [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. Additionally, patients should be aware of the risk of edema in the affected limb postsurgery and take care to avoid straining the affected area during sexual activity [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e].\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e10\u0026ndash;20 min\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eOne day before discharge\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e(3) Sexual Health Psychological Counseling\u003c/b\u003e: This counseling aims to help patients recognize that sexual activity is a fundamental human need, and discussing sexual health is not shameful. It emphasizes the importance of a healthy sexual life in strengthening the marital relationship and promoting physical and mental well-being [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]. Patients are guided on how to communicate with their spouses about sexual life and encouraged to seek medical advice when issues arise [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e, \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e].\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e10\u0026ndash;20 min\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eAdjuvant treatment period\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1 month\u0026thinsp;\u0026plusmn;\u0026thinsp;7 days after surgery\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e(1) Side Effects of Drugs on Sexual Life\u003c/b\u003e: Patients should be informed about the potential side effects of chemotherapy or endocrine therapy on sexual health, which may include fatigue, reduced immunity, decreased sexual desire, vaginal dryness, and atrophy [\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e].\u003c/p\u003e \u003cp\u003e\u003cb\u003e(2) Coping with Adverse Reactions\u003c/b\u003e: Patients should be guided to adjust the frequency of sexual activity based on their physical recovery. It is important to prevent infections when immunity is low. For issues such as decreased sexual desire and vaginal dryness, several strategies can be helpful, including adjusting lighting, watching films or animations, performing Kegel exercises, or increasing intimate contact with their spouse [\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e, \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e]. Additionally, vaginal lubricants or moisturizers can be used to alleviate vaginal dryness [\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e, \u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e].\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e20\u0026ndash;30 min\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3 months\u0026thinsp;\u0026plusmn;\u0026thinsp;7 days after surgery\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e(3) \u003cb\u003eSexual Health and Psychological Counseling\u003c/b\u003e: Encourage patients to resume normal sexual activity and actively communicate any challenges they face. Sexual needs should be acknowledged as normal and important aspects of overall well-being [\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e].\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e10\u0026ndash;20 min\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eAnalysis of Baseline Data on General Information and Main Outcome Variables in Breast Cancer Patients(\u003cem\u003en\u003c/em\u003e\u003csub\u003e\u003cem\u003e1\u003c/em\u003e\u003c/sub\u003e\u0026thinsp;=\u0026thinsp;41, \u003cem\u003en\u003c/em\u003e\u003csub\u003e\u003cem\u003e2\u003c/em\u003e\u003c/sub\u003e\u0026thinsp;=\u0026thinsp;42)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"6\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colspan=\"2\" morerows=\"1\" nameend=\"c2\" namest=\"c1\" rowspan=\"2\"\u003e \u003cp\u003eVariable\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eIntervention group\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eControl group\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u003cem\u003eZ/x\u003c/em\u003e\u003csup\u003e\u003cem\u003e2\u003c/em\u003e\u003c/sup\u003e\u003cem\u003e/ t\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u003cem\u003eP\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cem\u003eM\u0026thinsp;\u0026plusmn;\u0026thinsp;SD /n\u003c/em\u003e\u003csub\u003e\u003cem\u003e1\u003c/em\u003e\u003c/sub\u003e (\u003cem\u003e%\u003c/em\u003e)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cem\u003eM\u0026thinsp;\u0026plusmn;\u0026thinsp;SD /n\u003c/em\u003e\u003csub\u003e\u003cem\u003e2\u003c/em\u003e\u003c/sub\u003e (\u003cem\u003e%\u003c/em\u003e)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eEducation level\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-0.055\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.956\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePrimary school\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e21\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e23\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMiddle school\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCollege degree or higher\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eResidence\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-1.345\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.179\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eVillage\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e17\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eTown\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCity\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e17\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eAverage monthly income (Yuan)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-0.877\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.381\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026lt;2000\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2000\u0026ndash;3999\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4000\u0026ndash;5999\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026ge;\u0026thinsp;6000\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eHave gone through menopause༟\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.579\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.447\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e22\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e26\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e19\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e16\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eStage of cancer\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-0.687\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.492\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eⅠ\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eⅡ\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e24\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e25\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eⅢ\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAge\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e46.63\u0026thinsp;\u0026plusmn;\u0026thinsp;7.59\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e48.21\u0026thinsp;\u0026plusmn;\u0026thinsp;7.80\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.935\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.352\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAge of Marriage\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e21.44\u0026thinsp;\u0026plusmn;\u0026thinsp;9.02\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e24.74\u0026thinsp;\u0026plusmn;\u0026thinsp;9.17\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e1.652\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.102\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFSFI total score\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e26.79\u0026thinsp;\u0026plusmn;\u0026thinsp;3.39\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e26.32\u0026thinsp;\u0026plusmn;\u0026thinsp;2.89\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.679\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.499\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eDesire\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3.78\u0026thinsp;\u0026plusmn;\u0026thinsp;0.62\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3.70\u0026thinsp;\u0026plusmn;\u0026thinsp;0.66\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.538\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.592\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eArousal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4.07\u0026thinsp;\u0026plusmn;\u0026thinsp;0.59\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e4.07\u0026thinsp;\u0026plusmn;\u0026thinsp;0.99\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.017\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.986\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eLubrication\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4.66\u0026thinsp;\u0026plusmn;\u0026thinsp;0.75\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e4.76\u0026thinsp;\u0026plusmn;\u0026thinsp;0.75\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.585\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.560\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eOrgasm\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4.69\u0026thinsp;\u0026plusmn;\u0026thinsp;0.77\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e4.58\u0026thinsp;\u0026plusmn;\u0026thinsp;0.79\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.668\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.518\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSatisfaction\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4.99\u0026thinsp;\u0026plusmn;\u0026thinsp;0.85\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e4.84\u0026thinsp;\u0026plusmn;\u0026thinsp;1.03\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.710\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.480\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePain\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4.61\u0026thinsp;\u0026plusmn;\u0026thinsp;1.10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e4.37\u0026thinsp;\u0026plusmn;\u0026thinsp;0.87\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e1.075\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.285\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSAS total score\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e34.73\u0026thinsp;\u0026plusmn;\u0026thinsp;5.62\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e35.86\u0026thinsp;\u0026plusmn;\u0026thinsp;6.41\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.850\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.398\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSDS total score\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e36.68\u0026thinsp;\u0026plusmn;\u0026thinsp;6.21\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e36.43\u0026thinsp;\u0026plusmn;\u0026thinsp;6.51\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.182\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.856\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eEfects and interaction between intervention and control group on FSFI, QSL, MAT, SAS and SDS by intent to treat analysis expressed by Mean\u0026thinsp;\u0026plusmn;\u0026thinsp;\u003cem\u003eSD\u003c/em\u003e.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"8\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colspan=\"2\" morerows=\"1\" nameend=\"c2\" namest=\"c1\" rowspan=\"2\"\u003e \u003cp\u003eGroups\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"3\" nameend=\"c5\" namest=\"c3\"\u003e \u003cp\u003eTimes\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eIntervention\u003c/p\u003e \u003cp\u003e\u003cem\u003eP\u003c/em\u003e-value\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eTime\u003c/p\u003e \u003cp\u003e\u003cem\u003eP\u003c/em\u003e-value\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c8\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eInteraction\u003c/p\u003e \u003cp\u003e\u003cem\u003eP\u003c/em\u003e-value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eT\u003csub\u003e1\u003c/sub\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eT\u003csub\u003e2\u003c/sub\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eT\u003csub\u003e3\u003c/sub\u003e\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eFSFI\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u003cem\u003eP\u003c/em\u003e\u0026lt;0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0.033\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eControl\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e26.32\u0026thinsp;\u0026plusmn;\u0026thinsp;2.89\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e9.07\u0026thinsp;\u0026plusmn;\u0026thinsp;6.81\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e14.36\u0026thinsp;\u0026plusmn;\u0026thinsp;8.09\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eIntervention\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e26.79\u0026thinsp;\u0026plusmn;\u0026thinsp;3.39\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e12.49\u0026thinsp;\u0026plusmn;\u0026thinsp;8.02\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e19.70\u0026thinsp;\u0026plusmn;\u0026thinsp;6.64\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eDesire\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.057\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u003cem\u003eP\u003c/em\u003e\u0026lt;0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0.351\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eControl\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3.70\u0026thinsp;\u0026plusmn;\u0026thinsp;0.66\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2.30\u0026thinsp;\u0026plusmn;\u0026thinsp;0.85\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e2.57\u0026thinsp;\u0026plusmn;\u0026thinsp;0.78\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eIntervention\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3.78\u0026thinsp;\u0026plusmn;\u0026thinsp;0.62\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2.52\u0026thinsp;\u0026plusmn;\u0026thinsp;0.90\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e2.97\u0026thinsp;\u0026plusmn;\u0026thinsp;0.97\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eArousal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cem\u003eP\u003c/em\u003e\u0026lt;0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u003cem\u003eP\u003c/em\u003e\u0026lt;0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e\u003cem\u003eP\u003c/em\u003e\u0026lt;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eControl\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4.07\u0026thinsp;\u0026plusmn;\u0026thinsp;1.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2.30\u0026thinsp;\u0026plusmn;\u0026thinsp;0.85\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1.68\u0026thinsp;\u0026plusmn;\u0026thinsp;1.47\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eIntervention\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4.07\u0026thinsp;\u0026plusmn;\u0026thinsp;0.59\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2.52\u0026thinsp;\u0026plusmn;\u0026thinsp;0.90\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e3.17\u0026thinsp;\u0026plusmn;\u0026thinsp;1.19\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eLubrication\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.003\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u003cem\u003eP\u003c/em\u003e\u0026lt;0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0.006\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eControl\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4.76\u0026thinsp;\u0026plusmn;\u0026thinsp;0.75\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.06\u0026thinsp;\u0026plusmn;\u0026thinsp;1.76\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e2.26\u0026thinsp;\u0026plusmn;\u0026thinsp;1.88\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eIntervention\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4.66\u0026thinsp;\u0026plusmn;\u0026thinsp;0.75\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.79\u0026thinsp;\u0026plusmn;\u0026thinsp;2.14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e3.40\u0026thinsp;\u0026plusmn;\u0026thinsp;1.48\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eOrgasm\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u003cem\u003eP\u003c/em\u003e\u0026lt;0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0.009\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eControl\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4.58\u0026thinsp;\u0026plusmn;\u0026thinsp;0.79\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.87\u0026thinsp;\u0026plusmn;\u0026thinsp;1.48\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e2.14\u0026thinsp;\u0026plusmn;\u0026thinsp;1.83\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eIntervention\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4.69\u0026thinsp;\u0026plusmn;\u0026thinsp;0.77\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.65\u0026thinsp;\u0026plusmn;\u0026thinsp;1.98\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e3.45\u0026thinsp;\u0026plusmn;\u0026thinsp;1.62\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eStatisfaction\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.005\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u003cem\u003eP\u003c/em\u003e\u0026lt;0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0.233\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eControl\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4.84\u0026thinsp;\u0026plusmn;\u0026thinsp;1.03\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2.85\u0026thinsp;\u0026plusmn;\u0026thinsp;1.18\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e3.52\u0026thinsp;\u0026plusmn;\u0026thinsp;1.19\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eIntervention\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4.99\u0026thinsp;\u0026plusmn;\u0026thinsp;0.85\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3.49\u0026thinsp;\u0026plusmn;\u0026thinsp;1.19\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e4.16\u0026thinsp;\u0026plusmn;\u0026thinsp;1.41\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003ePain\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.618\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u003cem\u003eP\u003c/em\u003e\u0026lt;0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0.925\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eControl\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4.37\u0026thinsp;\u0026plusmn;\u0026thinsp;0.87\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.08\u0026thinsp;\u0026plusmn;\u0026thinsp;1.75\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e2.19\u0026thinsp;\u0026plusmn;\u0026thinsp;1.92\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eIntervention\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4.61\u0026thinsp;\u0026plusmn;\u0026thinsp;1.10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.45\u0026thinsp;\u0026plusmn;\u0026thinsp;1.72\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e2.56\u0026thinsp;\u0026plusmn;\u0026thinsp;1.50\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eQSL\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.014\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.308\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0.215\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eControl\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026mdash;\u0026mdash;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e78.40\u0026thinsp;\u0026plusmn;\u0026thinsp;7.37\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e77.60\u0026thinsp;\u0026plusmn;\u0026thinsp;5.59\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eIntervention\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026mdash;\u0026mdash;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e85.00\u0026thinsp;\u0026plusmn;\u0026thinsp;11.63\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e92.95\u0026thinsp;\u0026plusmn;\u0026thinsp;11.14\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eSDS\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.590\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.004\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0.622\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eControl\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e36.43\u0026thinsp;\u0026plusmn;\u0026thinsp;6.51\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e40.31\u0026thinsp;\u0026plusmn;\u0026thinsp;7.54\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e39.74\u0026thinsp;\u0026plusmn;\u0026thinsp;8.11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eIntervention\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e36.68\u0026thinsp;\u0026plusmn;\u0026thinsp;6.21\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e39.66\u0026thinsp;\u0026plusmn;\u0026thinsp;7.07\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e38.22\u0026thinsp;\u0026plusmn;\u0026thinsp;8.24\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eSAS\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.618\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.810\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0.770\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eControl\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e35.86\u0026thinsp;\u0026plusmn;\u0026thinsp;6.41\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e36.00\u0026thinsp;\u0026plusmn;\u0026thinsp;7.40\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e35.31\u0026thinsp;\u0026plusmn;\u0026thinsp;6.05\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eIntervention\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e34.73\u0026thinsp;\u0026plusmn;\u0026thinsp;5.62\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e35.49\u0026thinsp;\u0026plusmn;\u0026thinsp;5.91\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e35.32\u0026thinsp;\u0026plusmn;\u0026thinsp;7.03\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"8\"\u003ea There was a statistically significant difference in scores between the intervention group and the control group at the same time point.\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eNumber of Patients Resuming Sexual Activity\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eGroup\u003c/p\u003e \u003cp\u003eTime\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003eT\u003csub\u003e2\u003c/sub\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003eT\u003csub\u003e3\u003c/sub\u003e\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eResumed sexual life\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eHave not resumed sexual life\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eResumed sexual life\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eHave not resumed to sexual life\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIntervention group\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e21\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e35\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eControl group\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e28\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e17\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e25\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003ex\u003c/em\u003e\u003csup\u003e2\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003e2.722\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003e17.866\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eP\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003e0.099\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003e\u003cem\u003eP\u003c/em\u003e\u0026lt;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003e2.5 Data collection and measurements\u003c/h2\u003e \u003cp\u003eIn this study, each patient completed questionnaires at three different times: before the first intervention (T1); 3\u0026thinsp;+\u0026thinsp;10 days after surgery (T2); and 6 months after surgery (T3). Alternatively, patients could be instructed to complete electronic questionnaires at home. Each data collection session took approximately 20 minutes and was conducted by an investigator (who was not involved in the intervention and did not know the outcome of the patient\u0026rsquo;s assignment) using standardized guidance.\u003c/p\u003e \u003cp\u003eThis study utilized a general information questionnaire consisting of seven items: age, age at marriage, education level, income, residence, cancer stage, and menopausal status.\u003c/p\u003e \u003cp\u003eTo measure sexual health outcomes in breast cancer patients, this study employed the Quality of Sexual Life questionnaire (QSL) and the Female Sexual Function Index (FSFI). The QSL, developed by Jing Liwei [\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e], includes five dimensions and 28 items; higher scores indicate better sexual quality of life. This questionnaire has demonstrated good reliability and validity in breast cancer patients, with a Cronbach's α coefficient of 0.93 [\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e]. The FSFI, developed by Rosen et al.,[\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e] includes 19 items across six dimensions, with higher scores indicating better sexual function. The Chinese version of the FSFI has shown good reliability and validity in breast cancer patients, with a Cronbach's α greater than 0.80 [\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eIn this study, the Zung Self-rated Depression Scale (SDS) and the Self-rated Anxiety Scale (SAS) were used to evaluate the mental health of breast cancer patients [\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e]. The total score of the SDS ranges from 20 to 80 points, with higher scores indicating more severe depression. The total score of the SAS ranges from 20 to 80 points, with higher scores indicating more severe anxiety.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003e2.6 Statistical analysis\u003c/h2\u003e \u003cp\u003eAn independent samples \u003cem\u003et\u003c/em\u003e test was used to analyze differences in age at baseline, age at marriage, and outcome scale scores between the two groups, confirming that these variables met the assumptions of a normal distribution and homogeneity of variance. A chi-square test was conducted to examine differences in the number of patients who had experienced menopause between the two groups. The Wilcoxon W test was employed to assess differences in the remaining general data between the groups.\u003c/p\u003e \u003cp\u003eFurthermore, repeated-measures ANOVA was used to explore differences in outcome scale scores between the two groups at 3 and 6 months after confirming a normal distribution and homogeneity of variance for all scores. Multivariate analysis of variance (MANOVA) was also conducted to compare differences in outcome variables between the two groups at each time point.\u003c/p\u003e \u003cp\u003eAll the statistical analyses were performed via SPSS version 21.0, with the significance level set at \u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05.\u003c/p\u003e \u003c/div\u003e"},{"header":"3. Results","content":"\u003cdiv id=\"Sec10\" class=\"Section2\"\u003e \u003ch2\u003e3.1 Baseline data on general information and main outcomes\u003c/h2\u003e \u003cp\u003eIn this study, there were no statistically significant differences (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026gt;\u0026thinsp;0.05) between the two groups in terms of the baseline data, general information or main outcome variables for postoperative breast cancer patients. These findings indicate that the baseline characteristics of the two groups did not impact the effectiveness of the intervention.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003e3.2 Comparisons of the main outcome variables between the intervention and control groups\u003c/h2\u003e \u003cp\u003eThe results indicated that, three months after surgery (T\u003csub\u003e2\u003c/sub\u003e), the intervention group had significantly higher FSFI total scores, as well as higher scores in terms of sexual arousal, orgasm, and satisfaction, than did the control group (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05). Additionally, six months after surgery (T\u003csub\u003e3\u003c/sub\u003e), the intervention group had significantly higher FSFI total scores, along with increased scores in terms of sexual desire, arousal, lubrication, orgasm, satisfaction, and sexual quality of life, than did the control group (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05).\u003c/p\u003e \u003cp\u003eIn addition, the results of this study revealed that three months after surgery (T\u003csub\u003e2\u003c/sub\u003e), there was no statistically significant difference between the two groups in terms of the number of patients who resumed sexual activity (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026gt;\u0026thinsp;0.05). However, at six months after surgery (T\u003csub\u003e3\u003c/sub\u003e), 17 patients (40.48%) in the control group and 35 patients (85.37%) in the intervention group had resumed sexual activity, with a statistically significant difference between the two groups (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05).\u003c/p\u003e \u003c/div\u003e"},{"header":"4. Discussion","content":"\u003cp\u003eThe primary aim of this study was to explore the impact of staged sexual health education on improving the sexual and mental health of Chinese women after breast cancer surgery. In addition, our findings suggest that this approach can significantly improve sexual health outcomes for female patients following breast cancer surgery.\u003c/p\u003e \u003cp\u003eWe found that the FSFI scores, along with sexual satisfaction, orgasm, and arousal scores, were higher in the intervention group than in the control group at both 3 and 6 months after surgery. These findings demonstrate that staged sexual health education can effectively improve sexual function in breast cancer patients. However, our findings differ from those of de Almeida et al. [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e], which may be attributed to differences in the study subjects and the form of health education provided. In the de Almeida study, the subjects were female breast cancer patients who had undergone surgery more than 6 months prior [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e], whereas our study focused on patients newly diagnosed with breast cancer (\u0026le;\u0026thinsp;2 weeks). This finding might suggest that early sexual health education for breast cancer patients can significantly improve their sexual function and may indirectly indicate that these patients desire early intervention [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. In addition, the sexual health education in de Almeida\u0026rsquo;s study relied primarily on patients\u0026rsquo; initiative to ask questions and seek consultation [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. In contrast, our nursing staff provided proactive sexual health education tailored to the needs of patients at different stages, a method that was more suitable for Chinese women who may feel \"ashamed to talk about sex\" in our study [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e]. However, our study also revealed that staged sexual health education did not significantly improve physical symptoms such as sexual desire and pain in breast cancer patients. Addressing these issues\u0026mdash;increasing sexual desire and reducing pain\u0026mdash;will be crucial in future sexual health interventions for breast cancer patients.\u003c/p\u003e \u003cp\u003eAdditionally, at 6 months after surgery, the QSL score of patients in the intervention group was significantly higher than that of patients in the control group. However, there was no difference in the QSL score between the two groups at 3 months after surgery.\u003c/p\u003e \u003cp\u003eThis difference may arise because patients\u0026rsquo; sexual health issues, primarily caused by treatment side effects, are not a major concern for patients in the early stages of treatment. Studies indicate that the unmet information needed for medical examination results, treatment options, and health promotion for patients with breast cancer gradually increases, peaking within 10 weeks after surgery; however, unmet information on treatment-related side effects increases to the greatest degree only after these first 10 weeks [\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e]. This lack of an early difference may also be attributed to the impact of illness and the persistent physical pain experienced by patients in the early stages of treatment [\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e]. Furthermore, a greater number of patients in the intervention group than in the control group had resumed sexual activity at 6 months after surgery. These findings suggest that staged sexual health education effectively helps female breast cancer patients overcome their worries and fears about sexual activity, facilitating a return to normal sexual life. These findings also support previous research indicating that a lack of knowledge about sexual health after breast cancer surgery can lead to misconceptions, such as the belief that sexual activity could lead to cancer recurrence or negatively impact cancer prognosis, resulting in patients avoiding sexual activity [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eMoreover, contrary to the study hypothesis, periodic sexual health education did not reduce anxiety or depression in patients after breast cancer surgery. This lack of impact may be attributed to the fact that the patients in this study were still undergoing treatment. Their primary sources of anxiety and depression were likely the physical effects and economic burdens of cancer treatment [\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e], with sexual health playing a relatively minor role. Furthermore, the staged sexual health education in this study included limited psychological counseling, indicating a need for more comprehensive psychological support, such as mindfulness-based stress reduction and cognitive behavior therapy, in future interventions [\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e, \u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThis study demonstrated that staged sexual health education can assist breast cancer patients in resuming sexual activity and significantly improve their sexual function and sexual quality of life after surgery. It also underscores the importance of proactively providing sexual health education to patients at various stages of treatment, addressing misconceptions about sexual health, and fostering a correct understanding of sexual well-being.\u003c/p\u003e \u003cp\u003eThis study had several limitations: (1) Data were collected only at 3 and 6 months after surgery, which may not be sufficient to observe long-term changes in sexual and mental health outcomes after the completion of treatment. (2) The single-center design may have introduced sampling bias, potentially affecting the representativeness of the subjects. Despite these limitations, the study also had notable advantages: (1) as a randomized controlled trial, this study demonstrated comparable baseline data between the two groups, minimizing bias from confounding factors; and (2) this study employed staged sexual health education tailored to the specific needs of breast cancer patients at different stages of treatment, effectively addressing their sexual health concerns.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e \u003ch2\u003eAcknowledgments\u003c/h2\u003e \u003cp\u003eAcknowledgments of the fund: Nursing Research Fund, Affiliated Hospital of Sun Yat-sen University (2021hlky08) .\u003c/p\u003e \u003c/p\u003e\u003cp\u003e \u003ch2\u003eConflict of interest\u003c/h2\u003e \u003cp\u003eNo conflict of interest has been declared by the authors.\u003c/p\u003e \u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eZheng RS, et al. Cancer incidence and mortality in China, 2022. 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BMC Womens Health 2023;23(1):326.\u003c/li\u003e\n\u003cli\u003eGrusdat NP, et al. Routine cancer treatments and their impact on physical function, symptoms of cancer-related fatigue, anxiety, and depression. Support Care Cancer 2022;30(5):3733-3744.\u003c/li\u003e\n\u003cli\u003eChang YC, et al. Impact of mindfulness-based stress reduction on female sexual function and mental health in patients with breast cancer. Support Care Cancer 2022;30(5):4315-4325.\u003c/li\u003e\n\u003cli\u003eSoleymani MM, et al. An investigation of the effect of mindfulness-integrated cognitive behavior therapy on demoralization, body image, and sexual function in Iranian women with breast cancer: a randomized controlled trial. J Cancer Res Clin Oncol 2024;150(3):128.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"breast cancer, sexual health, mental health, intervention","lastPublishedDoi":"10.21203/rs.3.rs-5242426/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-5242426/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground: \u003c/strong\u003ePatients with breast cancer have a great need for staged sexual health education. This study aimed to assess the impact of staged sexual health education on improving the sexual and mental health of patients with breast cancer.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods:\u003c/strong\u003e This was a randomized controlled trial (RCT). 94 patients with breast cancer were assigned the control or intervention group, which received standard and staged sexual health education, respectively. The Quality of Sexual Life questionnaire (QSL), Female Sexual Function Index (FSFI), Self-rated Depression Scale (SDS), and Self-rated Anxiety Scale (SAS) were used to assess the sexual and mental health status of breast cancer patients before (T1) and after the intervention (T2, T3). Repeated-measures ANOVA was employed to compare the differences in outcome scale scores between the groups at each time point.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults: \u003c/strong\u003eThe QSL scores in the intervention group were significantly higher than those in the control group at T3 (\u003cem\u003eP\u003c/em\u003e\u0026lt;0.05). The FSFI scores in the intervention group were significantly higher than those in the control group at both T2 and T3 (\u003cem\u003eP\u003c/em\u003e\u0026lt;0.05). Furthermore, the proportion of patients who resumed sexual activity in the intervention group (3%) was significantly greater than that in the control group (2%) (\u003cem\u003eP\u003c/em\u003e \u0026lt; 0.001). However, there were no significant differences in the SDS and SAS scores between the intervention and control groups at T2 or T3 (\u003cem\u003eP \u003c/em\u003e\u0026gt; 0.05).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusions:\u003c/strong\u003e Staged sexual health education can help patients with breast cancer to correctly understand sexual health related knowledge, restore normal sexual life, improve FSFI and QSL.\u003c/p\u003e","manuscriptTitle":"The Impact of Staged Sexual Health Education on Sexual and Mental Health in Breast Cancer Patients: A Randomized Controlled Study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-11-07 14:56:09","doi":"10.21203/rs.3.rs-5242426/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"bd8a75e1-9a17-468f-85ca-6c9383efcdb3","owner":[],"postedDate":"November 7th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2024-11-17T09:11:27+00:00","versionOfRecord":[],"versionCreatedAt":"2024-11-07 14:56:09","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-5242426","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-5242426","identity":"rs-5242426","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}