Table 2.

Care and Screening Recommendations for Women Post-Hematopoietic Stem Cell Transplantation

Assessments at the time of transplant Ovarian preservation and potential for ovarian failure Address prior to transplant as part of transplant care Options include: Ovulation induction with fertilization and cryopreservation of oocytes GnRH agonist treatment Oocyte or ovarian tissue cryopreservation - experimental Contraception Encourage use of effective method with minimal side effects at time of transplant Prescribe contraception while woman being assessed for engraftment, on multiple transplant medications, and at risk of disease recurrence Assess need for continuing contraception annually Obtain pregnancy test in routine follow-up If amenorrhea occurs after menses have resumed Obtain pregnancy test Consider hypothalamic pituitary axis testing

Long-term follow-up assessments Bone Dual-energy X-ray absorptiometry (DEXA) at beginning of follow-up period Continue calcium and vitamin D Treat osteoporosis with bisphosphonates or hormone therapy Breast Annual clinical breast exam at puberty and mammogram annually starting at age 40 Patients who underwent chest radiation begin annual mammography at age 25 or 8 years after treatment HPV assessment Inspect vulva, vagina and cervix for evidence of HPV disease Perform cervical cytology testing annually Perform reflex HPV DNA testing for high risk types when cytology report is normal cytology or atypical cells of undetermined significance Refer for colposcopy for cytology reports of atypical cells suggestive of high grade dysplasia or worse Consider HPV vaccination STD Perform annual screening based on risk factors Vulvovaginal symptoms Assess for vulvovaginal symptoms in the setting of other GVHD Refer for gynecologic evaluation if patient has vulvovaginal symptoms Assess for signs of genital GVHD at annual pelvic exam Consider gynecologic examination every 3 months for patients with severe GVHD or known genital GVHD Treat any genital GVHD with topical immunosuppression, dilators and, if no contraindication, topical estrogens Treat labial fusion or complete vaginal stenosis with surgery followed by dilators, topical immunosuppression, and topical estrogens Assess for HPV disease if topical immunosuppression is used Hypothalamic pituitary ovarian axis Assess pubertal status with tanner stage at time of transplant Consider ovarian function at annual history and physical Check FSH, LH, estradiol Consider performing transvaginal ultrasound Check TSH when indicated Hormone therapy in the setting of ovarian failure Assess contraindications to hormone therapy such as blood clots, liver function abnormalities, severe mucositis compromising absorption, hormone-dependent tumors Consider hormone therapy in women with ovarian failure less than age 35 May improve bone mass Likely improve sexual function Sexual function Assess for dyspareunia, hypoactive sexual desire, and dysfunction with arousal or orgasm Treat any underlying endocrine or medical conditions Consider vaginal estrogen or lubricants for dyspareunia from atrophic vaginitis Refer to psychologist for individual or couples therapy

GnRH is gonadotropin-releasing hormone; HPV is human papillomavirus; STD is sexually transmitted disease; GVHD is graft-versus-host-disease, FSH is follicle-stimulating hormone; LH is luteinizing hormone; TSH is thyroid-stimulating hormone