engleski

Importance of gynecological examination in female patients with chronic graft versus host disease

Chronic Graft-Versus-Host Disease (cGVHD) is multisystemic disease and major complication after allogeneic hematopoietic cell transplantation. Although genital cGVHD is one of the frequent manifestations of cGVHD, it is still not well investigated. The goal of this study was to assess prevalence of genital cGVHD and genital human papillomavirus infection (HPV) in female patients with cGVHD. A multidiscipinary cGVHD team was established at the University Hospital Center Zagreb in collaboration with the National Cancer Institute, National Institutes of Health. From 2013 to 2014, eight adult female patients were examined by a gynecologist skilled in genital cGVHD assessments as part of the protocol "Clinical and biological factors determining severity and activity of cGVHD after allogeneic hematopoietic cell transplantation". NIH grading criteria was used to determine global cGVHD score as a measure of cGVHD severity. An extensive hystory, physical and laboratory analyses were obtained at study entry. In all patients, cervical cytology, human papillomavirus testing, vaginal swab for bacterial and fungal colonisation were done. Diagnosis of genital cGVHD was made using Stratton-Turner criteria. HPV were detected by polymerase chain reaction (PCR). Blood was collected to determine the level of luteinizing hormone, follicle stimulating hormone and estradiol in order to define menopause. Three patients (37.5%) underwent myeloablative conditioning. In 5 patients (62.5%) peripheral stem blood cells (PSBC) were used as stem source. Median age was 43.5 (range 23-57). Global cGVHD was severe in 6/8 (75%) and moderate in 2/8 (25%) patients. All patients had other organs involved. At the time of evaluation, 4/8 (50%) patients had genital cGVHD. All 4 patients with genital cGVHD had severe genital changes (vaginal adhesions, shortened vagina). Gynecological symptoms suggestive of genital cGVHD were reported by all affected patients. Cervical cytology was normal in 8/8 (100%) patients. HPV infection was observed in 3/8 (37, 5%) patients, two without genital cGVHD and one with genital cGVHD. Menopausal status was noted in 7/8 (88%) patients. All menopausal patients without genital cGVHD reported dryness and had signs of urogenital atrophy. One patient with vaginal shortening to depth of 5 cm suggesting genital cGVHD but who lacked signs of active genital cGVHD was initiated on dilator therapy. Topical estrogen cream and 4% topical lidocaine was applied to the dilator to reduce pain during dilation. In two months, the vaginal depth was successfully increased from 5 to 12 cm. Conclusion: In this small series of women with global cGVHD severity classified as moderate to severe, the prevalence of severe vaginal genital cGVHD was 50%. All women with genital cGHVD had vaginal adhesions or shortened vagina. Dilator therapy with topical estrogen cream and topical 4% lidocaine successfully improved vaginal shortening attributed to cGVHD in a patient without signs of active genital cGVHD. Patient without genital cGVHD who reported symptoms of vulvar/vaginal dryness and with signs of urogenital atrophy should be treated with topical estrogen. HPV infection is frequently present in women with cGVHD. Genital cGVHD should be considered and gynecologic assessment with genital HPV and cervical cytology testing performed in all women with cGVHD. Disclosure of Interest: None declared.

cGVHD ; gynecological examination

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