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Optimizing Reproductive Health After Cancer

The Children's Oncology Group outlines principles for managing reproductive complications in women who survive cancer while young.

Reproductive and sexual dysfunction is common in women who survive cancer during childhood, adolescence, or young adulthood. Adverse sequelae vary depending on cancer type, age at diagnosis, and treatment. Because complications can arise during or long after treatment, clinicians should counsel patients and their parents in a developmentally appropriate way before initiating therapy, and then evaluate patients periodically for abnormalities.

The Children's Oncology Group has reviewed the current recommendations for management of asymptomatic cancer survivors who present for follow-up >2 years after completing therapy. Highlights of the guidelines are as follows:

• Hypogonadism can result from radiation to the ovaries or hypothalamic-pituitary (HP) unit as well as from chemotherapeutic drugs (especially alkylating agents and heavy metals).
• Ovarian radiation at doses >10 Gy, procarbazine exposure at any age, and cyclophosphamide exposure from age 13 to 20 years are independent risk factors for acute ovarian failure (AOF). Even patients who retain ovarian function are at risk for premature ovarian failure (POF).
• Patients at risk for hypogonadism should be screened regularly to identify gonadotropin deficiency, delayed or arrested puberty, AOF, or POF. Those who received gonadotoxic therapy should be counseled about the associated risk for POF.
• If gonadal failure is identified, age-appropriate treatment to normalize estrogen levels should be provided.
• Precocious puberty may occur in girls after cranial irradiation that includes the hypothalamus; risk rises with doses 18 Gy and with younger age at radiotherapy.
• If hormonal levels and bone age indicate premature activation of the hypothalamic-pituitary-gonadal axis, treatment with gonadotropin-releasing hormone analogs is warranted to preserve final adult height, delay menarche, and optimize development of secondary sex characteristics.
• Regardless of cancer type and therapy, fertility is commonly diminished after damage to the reproductive organs or disruption of HP function. Survivors who become pregnant after pelvic irradiation at an early age have excess risk for pregnancy loss and fetal growth restriction.
• Knowledge in the field of fertility preservation is evolving rapidly; thus, it is important to consult with clinicians who are aware of the latest developments, appreciating that many options are experimental.
• For survivors with infertility, third-party reproduction (egg donation or surrogacy) and adoption are possibilities, although expensive.
• Sexual dysfunction arising from cancer-related depression, poor body image, or psychosocial issues is common in young cancer survivors. Counseling is warranted, as is use of vaginal lubricants and low-dose vaginal estrogen (where appropriate) in sexually active young women with dyspareunia.

Comment: Discussion of future fertility in girls who have cancer is often difficult, but most young women and their families want to know this information. Because gonadal toxicity of treatments varies, many young cancer survivors can still become pregnant; thus, these women also should be counseled about their contraceptive options.

— Robert W. Rebar, MD

Published in Journal Watch Women's Health February 14, 2013

Citation(s):

Metzger ML et al. Female reproductive health after childhood, adolescent, and young adult cancers: Guidelines for the assessment and management of female reproductive complications. J Clin Oncol 2013 Feb 4; [e-pub ahead of print]. (http://dx.doi.org/10.1200/jco.2012.43.5511)

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