Vaginal / Vulvar Graft Versus Host Disease
Dear OncoLink "Ask The Experts,"
I'm a 35-year-old allogeneic bone marrow transplant patient (transplant was in May '04) who is having trouble with vaginal stenosis. I'm told that this condition is probably the result of the total body radiation that I was given, but that it could also have something to do with post-transplant Graft-Versus-Host disease.
I've been trying to get some information on this condition or contacts to people who might be able to tell me more. The only information I have found so far has to do with preventing stenosis by using dilators. But that's not very helpful, because my stenosis is bad enough that using dilators isn't working. Can you help?
Carolyn Vachani RN, MSN, AOCN, OncoLink's Nurse Educator, responds:
Graft versus host disease (GVHD) is a common occurrence after allogeneic bone marrow transplant . It is a result of the donor bone marrow attacking the recipient's body essentially seeing it as foreign and thus launching an immune response. This most commonly presents in the skin (with a rash), the gastrointestinal tract (with diarrhea), or the liver (with elevated liver function tests).
After allogeneic transplant, women frequently report vaginal or vulvar dryness and irritation, pain with intercourse, and bleeding after intercourse. The symptoms are often attributed to the fact that these women have been put into premature menopause by the chemotherapy. (They are then treated with hormone replacement therapy.) Recent research has proposed that these symptoms may be related, at least in part, to vaginal or vulvar GVHD. A recent article reviewed the cases of 11 patients. Treatment included topical cyclosporine, or tacrolimus, which was mixed by the pharmacist. The authors point out that this can be expensive and is most likely not covered by insurance, sometimes leading to poor compliance with this therapy. The women could also be treated with surgery to relieve adhesions in the vaginal canal, followed by graduated dilator use (starting small and getting larger). The majority of the women required a combination of these treatments, and at least one woman required increased doses of oral anti-rejection meds to ultimately resolve her symptoms. Some women had flares of these symptoms after initial treatment, but the flares were able to be treated with topical cyclosporine or tacrolimus. The authors point out that these GVHD flares were not associated with flares in any other parts of the body (skin, liver or GI tract).
Reference: Spyrida, L, Laufer, M et al. (2003) Graft-versus-Host Disease of the Vulva and/or Vagina: Diagnosis and Treatment. Biology of Blood and Marrow Transplantation 9:760-765.