Due to the improved survival of post transplant recipients we are beginning to see an increasing number of patients with chronic graft versus host disease (GvHD). This is a multi system disorder which can effect up to 70% of long term survivors.
Vaginal problems affecting women with GvHD were first described in 1982 but most gynaecologists are not familiar with this phenomenon. Female sufferers complain of vulval irritation, vaginal scarring and narrowing (stenosis). Vaginal stenosis is a late manifestation of GvHD but the exact incidence is not really known. The type of stem cell transplant may also be a factor with the female genital tract being more frequently involved in patients undergoing peripheral blood stem cell transplant (PBSCT) in comparison with those receiving bone marrow transplant (BMT).
The time to onset of vulval symptoms of genital GvHD is approximately 10 months from the time of transplant. The vulval symptoms tend to be first noted with the vaginal stenosis occurring 9 months later. As the vaginal GvHD occurs after the vulval GvHD this time lag gives the opportunity to institute preventative measures and treatments in an attempt to avoid surgery to the vagina.
After the surgical treatment for vaginal stenosis patients are recommended to use dilators with topical oestrogens, steroids or cyclosporin with a maintenance frequency of 3 times per week to prevent further stenosis.
As PBSCT becomes more commonly practised the incidence of vulvovaginal GvHD may increase. Furthermore, women survivors are at increased risk of human papillomavirus (HPV) diseases including low or high grade squamous intraepithelial lesions (CIN I-III). This is due to the loss of T-cell immunity to HPV and therefore these women should have annual smears. Consideration should also be given to vaccinating them with Gardasil a quadrivalent HPV vaccine.