As a trusted profession, oncology nurses are critical in helping women manage genital chronic graft-versus-host disease (cGVHD). Without early identification and treatment, it can progress to severe complications, requiring surgery. This article focuses on the management of female genital cGVHD. Be sure to review the Cancer Nursing Today article “Assessing Female Genital Chronic GVHD” to learn more about assessment.
Role of Early Identification in Treatment Selection
Not all patients have symptoms, so routine pelvic exams every 3 months for the first year, then yearly, are critical. However, the risk of genital cGVHD is lifelong, so all patients must be alert to signs and symptoms.
Genital manifestations of cGVHD often co-occur with GVHD in other organs, especially the eyes, mouth, and skin. With the tapering of cGVHD immunosuppression, visible signs of cGVHD (skin, eyes, mouth) may regress, but not visible symptoms (genitals) may occur.
Grading of Genital cGVHD
Treatment selection depends on the stage of cGVHD. After a complete gynecologic exam, female genital cGVHD can be classified (or scored) as mild, moderate, or severe using a 0-3 scale.
- Mild: vulvar mucosal erythema, lichen planus or sclerosis
- Moderate: fissures or erosive changes
- Severe: fusions, adhesions
The treatment goals include symptom and disease control to prevent damage and disability.
Nonmedical Management
Some nonmedical, nonprescription tips help manage female genital cGVHD. Oncology nurses can instruct patients to:
- Use a mirror and digital self-exam several times weekly to examine the vulva and vaginal exterior for painful areas, sores, or narrowing. Alert the care team of any changes.
- Clean the vulva and vagina gently with warm water only and no soap.
- Don’t use any lotions or perfumes.
- Wear cotton or cotton-lined underwear that is a size larger.
- Do not wear tight pants.
- Use silicone-based or water-based lubricants during vaginal sexual intercourse. Choose one without alcohol, dyes, or perfumes.
- Ask about applying topical lidocaine to the opening of the vagina 15-20 minutes before intercourse.
Topical Management
Providers typically recommend water lubricants first, then other topical agents step by step.
- Hyaluronic acid with vitamin C: This product is the same as the facial agent but in a vaginal preparation. Several companies make over-the-counter, hormone-free hyaluronic acid with or without vitamin C as vaginal suppositories or gels.
- Hormone cream: Topical hormone cream (estrogens) can help maintain genital tract integrity to help with early detection by maintaining physiological characteristics of the genital tract, control symptoms, and prevent atrophy. Topical estrogens thicken the vaginal wall thickness to make it more resilient and improve normal vaginal flora. Various formulations are available: hydrocortisone 25-mg suppository, estriol 1-mg cream or 1-mg suppository, or an estrogen ring.
- Synthetic steroid cream: Prasterone is a prescription medication containing a plant-derived synthetic version of DHEA (a steroid made in the body) and coconut and palm oils. This daily vaginal insert helps vulvar and vagina atrophy with cGVHD.
- Steroid creams: Corticosteroid use is critical in combination with hormones, such as clobetasol for vulvar lesions and hydrocortisone suppositories for vaginal lesions.
- Immunosuppressants: Topical tacrolimus vaginal gel may be helpful with mild to moderate disease. Of course, controlling overall cGVHD with various agents helps to manage genital cGVHD.
Vaginal Rehabilitation
Keeping the vagina open can be a challenge. Vaginal sexual intercourse or vaginal dilators 2-3 times a week can help prevent closure. Physical therapy or a pelvic floor specialist can instruct patients on pelvic floor exercises, stretches, breathing, and ways to slow electrical signaling.
Surgical Intervention
For more severe cases of genital cGVHD, some patients may require surgical intervention. Surgical lysis of vaginal adhesions may be done in the outpatient setting.
Oncology nurses must provide patient education. Consider these BMTinfonet.org videos:
- Graft-Versus-Host Disease: Genitals by Oluwatosin Goje, MD, MSCR, FACOG, Cleveland Clinic in Cleveland, Ohio
- Managing Vaginal GVHD by Lenira Maria Queiroz Mauad, MD, Amaral Carvalho Hospital in Sao Paulo, Brazil
- Pelvic Floor Physical Therapy to Manage Vulva and Sexual Health for Women With Graft-Versus-Host Disease (GVHD) by Nikki Samms, PT, DPT, the University of Texas MD Anderson Cancer Center in Houston, Texas
Many women do not report changes because of the sensitivity of the topic. Oncology nurses are in a pivotal position to change this situation. By empowering patients to report and treat this common condition early, oncology nurses can change the trajectory of female genital cGVHD.
References
Female Genital Tract Chronic Graft-Versus-Host Disease: A Narrative Review
Fast Facts: Chronic GVHD of the Vulva and Vagina
INTRAROSE: Highlights of Prescribing Information
