Elsevier

Maturitas

Volume 105, November 2017, Pages 30-32
Maturitas

Review article
Gynaecological care after stem cell transplant: An overview

https://doi.org/10.1016/j.maturitas.2017.05.009Get rights and content

Highlights

  • Comprehensive, multidisciplinary care after a stem cell transplant involves gynaecological follow-up.

  • Menopausal hormone therapy should be considered for women with menopausal symptoms after a stem cell transplant.

  • After a stem cell transplant, regular gynaecological follow-up should be undertaken by an experienced specialist.

Abstract

Haematopoietic stem cell transplants are an important treatment for haematological malignancies. With increasing efficacy of treatment, it has become important to provide comprehensive long-term follow-up by experienced specialists in a multidisciplinary setting. This article gives an overview of the gynaecological implications of haematopoietic stem cell transplants, including appropriate pre-treatment counselling, the development of menopausal symptoms, bone loss, genital graft-versus-host disease and secondary genital malignancies. The evidence surrounding the occurrence, symptoms and management of these complications is outlined based on current clinical guidelines where possible. Although high-level data regarding this specific patient population are generally lacking, observational data and data from other immunocompromised populations are discussed. This article provides a clear and clinically focused framework for care for clinicians involved in the gynaecological management of these patients and outlines areas for further research to improve patient care.

Introduction

Haematopoietic stem cell transplants (HSCT) are a vital treatment in the management of haematological malignancies. Earlier detection of cancers and increasing efficacy of treatment is resulting in longer survival for patients, emphasising the importance of comprehensive, multidisciplinary, follow-up with experienced clinicians. This article provides an overview of routine gynaecological care for patients undergoing HSCT. It provides a clinical checklist for clinicians to consider and identifies areas for further research in the HSCT-specific population.

Section snippets

Pre-transplant gynaecological care

Prior to pre-transplant chemotherapy HSCT patients should have a baseline gynaecological review with a specialist experienced in post-transplant gynaecological care. This review should involve counselling regarding the likely gynaecological implications of therapy for the patient, including menopausal symptoms, genital graft-versus-host-disease (GVHD), fertility preservation and the importance of pregnancy prevention during and for six months after treatment [1], [2].

A thorough history and

Menopausal symptoms

Primary gonadal failure in women is almost inevitable following high dose chemotherapy and radiotherapy required for SCT [3], [4], [5], [6]. Current guidelines suggest annual assessment of gonadal function in women post-SCT [4]. Given the likelihood of gonadal failure, clinically this may be more appropriate for women with fertility goals and not receiving hormone replacement.

In women who are premenopausal prior to SCT, up to 90% will report vasomotor symptoms (hot flushes and night sweats) and

Bone health

High-level studies assessing the prevalence of osteopaenia and osteoporosis in patients post-SCT are lacking. However, observational data suggests bone loss post-SCT may be as high as 75% of patients at the lumbar spine and almost 60% at the femoral neck [1], [13]. The cause of bone loss in this population is multifactorial, involving chemotherapeutic agents, irradiation, corticosteroid therapy and hypogonadism as well as lifestyle factors such as inactivity [14].

Current guidelines recommend

Genital GVHD

The prevalence of genital GVHD post-SCT is unclear, which may reflect both patients’ reluctance to discuss genital symptoms and practitioners’ failure to inquire. There is evidence to suggest the occurrence may be approximately 50% of HSCT patients [18].

Genital GVHD may present with a range of symptoms including genital discomfort, itch, paraesthesia, pain, dryness and dyspareunia. Most commonly, genital GVHD is preceded by cutaneous, oral, ocular or gastrointestinal disease. However, it is

Genital tract malignancies

The risk of secondary solid tumours is increased following-SCT, including vulvovaginal, cervical, and endometrial malignancies [4], [24], [25], [26]. In particular, immunocompromised patients post-SCT are more likely to develop HPV-related disease [25], [27]; in one study up to one third of HSCT survivors were affected by HPV-related cervical dysplasia [25].

Women who have not yet received human papilloma virus (HPV) vaccination should receive this post-treatment. Whilst there is no data on

Practice points

Routine gynaecological care in the HSCT patient should be multidisciplinary, involving experienced specialists. Comprehensive care should include the following:

  • Pre-transplant counselling of the likely gynaecological implications of therapy, including menopausal symptoms.

  • Thorough gynaecological history and examination to identify potential issues of concern.

  • MHT should be considered for menopausal symptoms. Individual risk factors will determine its use, route of administration and duration of

Research agenda

  • Further information is needed regarding the safe length of MHT treatment in HSCT patients. How do we interpret MHT safety data in this population?

  • The relationship between GVHD across different organ systems needs to be explored. In particular, does non-genital GVHD predict risk for genital disease?

  • The safety and efficacy of HPV vaccination in the HSCT population should be examined in order to determine optimal vaccination timing and dose intervals.

  • High-level studies examining the role of

Contributors

Adrafted the initial version of the manuscript and critically revised the manuscript.

MH critically revised the manuscript.

Both authors saw and approved the final version.

Conflict of interest

The authors declare that They have no conflict of interest.

Funding

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Provenance and peer review

This article has undergone peer review.

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