Fertility and Sexuality Concerns for Women After Pelvic Radiation for Childhood Cancers

Risks of Pelvic Radiation for Childhood Cancer

Radiation to a female's pelvis or abdomen (belly) can cause changes to the vagina, uterus, and ovaries. The ovaries make eggs and female hormones that help with growth, puberty, and menstruation.

What are the risks to fertility?

A female baby has all the eggs in her ovaries that she will have for her lifetime. When the ovaries are exposed to radiation (at any age), this lifetime supply of eggs (oocytes) can be affected. This means that a woman/girl who has had pelvic radiation may have a hard time getting pregnant later in life. The higher the dose of radiation to the ovaries, the higher the risk of fertility problems.

What are the risks to puberty?

Ovaries make hormones. If a girl has radiation to her ovaries and she has not gone through puberty yet, she is at risk for late-onset puberty, or for not going through normal puberty at all. Young women who have gone through puberty and have begun menstruating before radiation treatment are at risk for early-onset ovarian failure (early menopause).

What should I do to monitor for these risks?

All girls and young women should be monitored by their healthcare provider after pelvic radiation. This should include:

• Measuring growth and finding out where they are in the stages of puberty each year.
• Asking about when puberty started, her menstruation history, sexual function, and any symptoms of menopause.
• Girls and young women who do not have signs of puberty by age 13, who begin puberty that does not keep progressing or have abnormal menstrual patterns or symptoms of menopause should be seen by an endocrinologist or reproductive endocrinologist.
• If you are sexually active and pregnancy is NOT desired, you should use reliable birth control. While your provider does their best to predict if you will be able to get pregnant, this is not a guarantee.
• Those who would like to become pregnant and are not able should be seen by a reproductive endocrinologist to talk about parenting options.
• Low levels of ovarian hormones can cause osteoporosis. You should have yearly bone density testing (DEXA scan) if you have low levels.

What are the risks with pregnancy?

Radiation to the uterus (womb) can lead to a decrease in the size of the uterus. It can also lead to a decrease in elasticity (stretch) and scarring. These changes in the uterine muscle can cause an increased risk of miscarriage, preterm labor, and having a baby born at low birth weight. If you wish to become pregnant, you should see a high-risk pregnancy specialist. An ultrasound of the uterus and other reproductive organs may be helpful. Women who become pregnant after pelvic radiation should receive high-risk obstetrical (OB) care.

What are the risks to my vaginal and groin area?

Survivors may have vaginal dryness and some other symptoms that are often part of menopause – these can include atrophy (a decrease in the size of your vagina) and vaginal pain. Some tips for helping these issues are:

• Personal lubricants that can make intercourse more comfortable.
• Regular use of vitamin E on and around the vaginal tissue may help to strengthen the tissue and reduce friction to sensitive tissue.

Scarring may cause the size of the vagina to get smaller or narrower. You should be taught how to use a vaginal dilator. These are put in the vagina for short periods of time to help prevent scar tissue, increase blood flow to the area, and keep the vagina open. Keeping the vaginal space open allows menstrual blood to drain out of the uterus and helps make intercourse or vaginal exams more comfortable.

• If dilator or tampon insertion is hard, referral to a gynecologist or pelvic floor physical therapist may be helpful.
• If you are having chronic pain (continuous or on and off) in the vulva, which can be a sign of a vulvar pain syndrome, bring this up with your healthcare provider. Medicines such as amitriptyline (tricyclic antidepressants) and psychological consultation may be helpful in helping vulvar pain.

Radiation to the groin can cause swelling (lymphedema) in the groin or legs. Any swelling should be reported to your healthcare provider. Starting physical therapy at the first sign of swelling can improve lymphedema.

Questions and concerns about fertility and sexuality are common for women who have been treated with pelvic and abdominal (belly) radiation for childhood cancers. Talking about your concerns with your healthcare team will help you know what to expect and how to handle these risks.