Vaginal stenosis following allogeneic bone marrow transplantation for acute myeloid leukaemia

Summary:We describe a 25-year-old patient suffering from vaginal outflow obstruction which presented as secondary amenorrhea during hormone replacement therapy. The patient had undergone bone marrow transplantation for acute myelocytic leukemia, which caused ovarian failure. Oral mucositis associated with a chronic GVH reaction also occurred. For 3 years she was treated with HRT and had regular menses which gradually ceased and were associated with dyspareunia and abdominal cramps. Abdominal US examination demonstrated hematocolpus. Sonography guided adhesiolysis of a dense vaginal obstruction allowed free drainage with histologic confirmation of a graft-versus-host reaction. The possibility of vaginal stricture or obstruction should be considered in all patients after BMT who suffer from graft-versus-host disease. Keywords: graft-versus-host disease; gynecological complications; vaginal obstruction Secondary amenorrhea occurs in the majority of patients treated with high-dose radiochemotherapy followed by bone marrow transplantation (BMT), as a result of ovarian failure. 1,2 Ovarian failure rate is influenced by the patients' age at the time of chemotherapy, by the type of the primary disease and by the chemotherapy regimen given. 3 Since many of the patients are young women during their reproductive years, hormone replacement therapy (HRT) is usually recommended. 4 Menstruation induced by HRT shows that chemotherapy or BMT does not affect the endometrium.We describe a case of secondary amenorrhea in a young woman who suffered from chronic GVH after BMT. For 3 years she had HRT-induced menstruation that gradually ceased combined with the appearance of dyspareunia and period cramps. Case reportA 25-year-old female patient presented with secondary amenorrhea of 6 months duration, dyspareunia and abdomi-

Section: Discussionsupporting

confidence: 48%

Vaginal outflow tract obstruction by graft-versus-host reaction

Yanai

Shufaro

et al. 1999

“…A more refined prognostic model for chronic GVHD was recently reported, and staging of chronic GVHD based on this model may provide greater accuracy in assessing the outcomes of various treatments. 40 Clinical manifestations of chronic GVHD are similar to autoimmune collagen vascular diseases, 41,42 such as oral ulcerations (lichen planus), keratoconjunctivitis sicca, 43 xerostomia, 44 polyserositis, 45 esophagitis and stricture, 46 vaginal ulceration and stricture, 47,48 intrahepatic obstructive liver disease, obstructive pulmonary disease, scleroderma, morphea, fasciitis 49 and myositis.…”

Section: Clinical Manifestationsmentioning

confidence: 99%

“…Rarely, lichenoid chronic GVHD may involve the glans penis and foreskin (causing phimosis), 60 and not infrequently involve the vaginal mucosa (resulting in stenosis). 47 Appearing later is the sclerodermatous form which may present as inflammatory plaques over the extremities. Frequently, the progression of sclerodermatous changes is insidious.…”

Section: Skin and Soft Tissuesmentioning

confidence: 99%

Chronic graft-versus-host disease: clinical manifestation and therapy

Ratanatharathorn

Ayash

Lazarus

et al. 2001

231

149

Summary:Chronic graft-versus-host disease (GVHD) is a major cause of morbidity and mortality in long-term survivors of allogeneic stem cell transplantation. The immunopathogenesis of chronic GVHD is, in part, TH-2 mediated, resulting in a syndrome of immunodeficiency and an autoimmune disorder. The most important risk factor for chronic GVHD is prior history of acute GVHD and strategies that prevent acute GVHD also decrease the risk of chronic GVHD. Other important risk factors are the use of a non-T cell-depleted graft, and older age of donor and recipient. Whether recipients of peripheral blood stem cells are at increased risk of chronic GVHD remains unsettled. There are no known pharmacologic agents which can specifically prevent development of chronic GVHD. Agents which have efficacy in the treatment of autoimmune disorders have been utilized as therapy for established chronic GVHD and are associated with response rates of 20% to 80%. Most responses are confined to skin, soft tissue, oral mucosa and occasionally liver. Bronchiolitis obliterans responds infrequently to therapy and is associated with a dismal prognosis. Newer, promising therapeutic strategies under investigation include thalidomide, photopheresis therapy, anti-tumor necrosis factor and B cell depletion with anti-CD20 monoclonal antibody. Bone Marrow Transplantation (2001) 28, 121-129.

“…The majority of published case reports are skewed to the advanced stenosing lesions requiring surgical therapy. 2,3 As genital tract GVHD impacts on quality of life, sexual function and relationship dynamics, early recognition and treatment are an important part of post transplant management. In the late-1990s, we initiated a programme to standardize detection, grading of severity and management of female genital tract GVHD.…”

Section: Introductionmentioning

confidence: 99%

Female genital tract graft-versus-host disease: incidence, risk factors and recommendations for management

Zantomio

Grigg

MacGregor

et al. 2006

102

153

Female genital tract graft-versus-host disease (GVHD) is an under-recognized complication of allogeneic stem cell transplantation impacting on quality of life. We describe a prospective surveillance programme for female genital GVHD to better characterize incidence, risk factors and clinical features and the impact of a structured intervention policy. A retrospective audit was conducted on the medical records of all female transplant recipients surviving at least 6 months at a single centre over a 5-year period. Patients commenced topical vaginal oestrogen early post transplant with hormone replacement as appropriate for age, prior menopausal status and comorbidities. A genital tract management programme included regular gynaecological review and self-maintenance of vaginal capacity by dilator or intercourse. The incidence of genital GVHD was 35% (95% confidence interval (CI) (25, 50%)) at 1 year and 49% (95% CI (36, 63%)) at 2 years. Topical therapy was effective in most cases; no patient required surgical intervention to divide vaginal adhesions. The main risk factor was stem cell source with peripheral blood progenitor cells posing a higher risk than marrow (hazard ratio ¼ 3.07 (1.22, 7.73), P ¼ 0.017). Extensive GVHD in other organs was a common association. We conclude that female genital GVHD is common, and early detection and commencement of topical immunosuppression with dilator use appears to be highly effective at preventing progression.