Women's Health and Hormonal Treatment Options for Therapeutic Amenorrhea and Contraception during the Peri-Transplant Period

In caring for female patients undergoing hematopoietic stem cell transplant (HSCT), it is important to consider all aspects of reproductive health from fertility to contraception to sexuality and quality of life. Individual counseling on future fertility is part of routine pre-transplant care. Given the variable urgency with which a HSCT is undertaken and a patient's fertility desires, fertility preservation needs and options will vary from patient to patient. Additionally in reproductive-age women, it is important to achieve therapeutic amenorrhea as well as provide effective contraception during the HSCT process given the iatrogenic thrombocytopenia and exposure to potential teratogenic agents. Hormonal therapies such as gonadotropin-releasing hormone agonists (GnRHa), combined contraceptives, and progestin-only methods initiated prior to transplant can each provide contraceptive and non-contraceptive benefits for pre-menopausal women. In particular, GnRHa are shown to be highly effective in achieving therapeutic amenorrhea, especially when started two to four weeks prior to the conditioning regimen.  Often, a single three-month dose achieves amenorrhea from the pre-HSCT period through engraftment. A potential additional benefit of GnRHa may be preserving ovarian function, especially for those undergoing reduced-intensity conditioning, though this effect is still under investigation. Notably, the conditioning regimen is the only gonadotoxic part of the HSCT process. Given its effectiveness in achieving therapeutic amenorrhea, the availability of a three-month dose, and the potential for ovarian preservation, initiation of GnRHa warrants consideration in all pre-menopausal women prior to transplant. During the pre-transplant evaluation, gynecologists serve as valuable consultants in addressing the appropriate timing of initiating GnRHa for maximal benefit, future fertility, contraception, therapeutic amenorrhea, and peri-transplant reproductive health concerns. During the post-transplant period through long-term survivorship care, gynecologists can continue to address issues such as revaccination for HPV, screening for genital cancer and chronic graft versus host disease, hormone replacement therapy, fertility, and sexuality. Gynecologists have a role in addressing reproductive health concerns along the entire spectrum of care for women undergoing hematopoietic stem cell transplant and are critical members of the transplant team.