Fertility and Sexuality Concerns for Women After Pelvic Radiation for Childhood Cancers
Risks Related to Pelvic Radiation for Childhood Cancer
Radiation to a girl or woman's pelvis can cause long term changes to the vagina, uterus, and ovaries. The job of the ovaries is to produce eggs and to make female hormones that support growth, puberty, and menstruation.
What is the risk to fertility?
A female baby has all of 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 damaged. This means that a woman/girl who has had pelvic radiation may have difficulty getting pregnant later in life. The risk of fertility problems is increased with higher doses of radiation.
What are the risks to puberty?
Ovaries make hormones. After radiation that involves the ovaries, girls who have not yet gone through puberty are at risk for late-onset puberty, or for not going through normal puberty at all. Young women who have gone through puberty and begun menstruating before radiation treatment are at risk for premature ovarian failure (early menopause).
What monitoring should I have?
All girls and young women should be monitored by their healthcare provider after pelvic radiation. This exam should include:
- Measuring growth and determining where they are in the stages of puberty each year.
- Asking about the onset of puberty, menstruation history, sexual function, and symptoms of menopause.
- Girls and young women who do not have signs of puberty by age 13, who begin puberty that does not progress, 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 to should be seen by a reproductive endocrinologist to talk about parenting options.
- Low levels of ovarian hormones can cause osteoporosis. You should have a 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 as well as a decrease in elasticity (stretch) and scarring. These changes in the uterine muscle can cause survivors to be at 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 suffer from 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 managing these issues include:
- Personal lubricants can be helpful and 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 in the vagina may cause the size of the vagina to decrease.
- All female survivors who have had radiation to the vulvar or vaginal pelvic area should learn how to use vaginal dilators. 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 difficult, 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, discuss this with your healthcare provider. Medicines such as amitriptyline (tricyclic antidepressants) and psychological consultation may be helpful in managing 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 the management of lymphedema.
Questions and concerns about fertility and sexuality are common for women who have been treated with pelvic and abdominal radiation for childhood cancers. Discussing your concerns with your healthcare team can help you get help and learn how to manage issues.
Long-Term Follow Up Guidelines for Survivors of Childhood, Adolescent, and Young Adult Cancers. Version 5.0, 2018. Accessed at: http://www.survivorshipguidelines.org/pdf/2018/COG_LTFU_Guidelines_v5.pdf