Current practices in menstrual management in adolescents with cancer: A national survey of pediatric oncology providers

Abstract

Background Adolescents and young adult (AYA) women with cancer are at risk of heavy menstrual bleeding (HMB) due to thrombocytopenia, coagulopathy, and/or disruption of the hypothalamic‐pituitary‐gonadal axis. Currently, little is known about current practices to help prevent and treat HMB in AYA women with cancer. Methods We surveyed providers from 100 pediatric oncology centers. Face and content validity were assessed prior to distribution. Descriptive statistics, Chi‐squared and Fisher exact tests were used for analysis. Results Ninety‐four percent of respondents have recommended preventative menstrual suppression. More than half of respondents agreed that patients with the following types of cancers should receive preventative menstrual suppression: sarcomas, acute leukemias, lymphomas, and germ cell tumors. The most preferred form of menstrual suppression was GnRH agonists. Almost 95% of respondents felt that it is important to consider menstrual suppression and that a formal guideline about initiation of menstrual suppression would be helpful. Only 46% felt comfortable personally managing menstrual suppression. Conclusions The vast majority of pediatric oncologists who responded to this national survey have used preventative menstrual suppression and feel that it is important to consider in many types of AYA cancers. Although pediatric oncologists are most often managing menstrual suppression, they do not feel comfortable doing so and desire guidelines to help with management. Future studies to assess which patients require menstrual suppression and which menstrual suppression is best tolerated and efficacious is needed.

Fertility preservation in pediatric leukemia and lymphoma: A report from the Children's Oncology Group

“…38,39 Pubertal females should understand that the benefits of GnRH agonists in the adolescent young adult population are unknown, and the use of GnRH agonists should not be thought of as fertility preservation and used in place of established forms of fertility preservation. There are data for the use of these agents for menstrual suppression, 40 which may be considered in a variety of patients but are of particular interest for patients expected to have prolonged thrombocytopenia or with a history of heavy menses. 40,41 Due to the limitations of available fertility preservation options in the leukemia/lymphoma population, many young women may not be able to undergo upfront fertility preservation.…”

Fertility Preservation in Female Pediatric Patients With Cancer: A Clinical and Regulatory Issue

“…It is noteworthy that in adolescents and young women with malignancies GnRHa are widely used as an alternative to estroprogestinic combinations for menstrual suppression (36)(37)(38)(39)(40)(41), in order to reduce the risk of heavy menstrual bleeding associated with hematologic malignancies or myelosuppression induced by chemotherapy. In this setting, despite significant side-effects simulating the physiology of menopause and the risk of loss of bone mineral density with prolonged use (usually > 6 months) (42), GnRHa are well tolerated and effective option for menses suppression (43,44) and are generally preferred to oral contraceptives for several reasons.…”

“…Furthermore, the efficacy of oral contraceptives can be reduced by an erratic absorption due to mucositis, diarrhea, and emesis. Moreover, the use of estrogen-based oral contraceptives for menstrual suppression is associated with an increased risk of venous thromboembolism (41,45). However, one of the most important reason for choosing GnRHa is represented by their possible gonadal protective effect (41).…”

Rates of Menstrual History-Taking and Counseling With Anticancer Treatments Are Low: People Who Menstruate Deserve Gender-Specific Cancer Care

“…32 Prior research has found that people with cancer wish they had been better prepared for potential reproductive issues by their cancer providers. 5 Treatment-induced amenorrhea can be a sign of adversely affected fertility 33 and premature menopause, which warrants consideration of HRT, calcium, vitamin D, bisphosphonates, and exercise to manage menopausal symptoms and negative cardiovascular sequelae. 4,34,35 In some patients, HRT may be contraindicated due to the underlying malignancy (eg, hormonesensitive breast cancer); however, evidence supports an individual risk-benefit assessment.…”

“…3,4 Chemotherapy predisposes people who menstruate to heavy menstrual bleeding due to thrombocytopenia, coagulopathy, or disruption of the hypothalamic-pituitarygonadal axis. [5][6][7] Other disturbances, such as anovulatory bleeding and amenorrhea, are also prevalent. Menorrhagia, typically defined by .80 mL of blood loss per cycle or bleeding for .7 days, increases infection risk in immunosuppressed patients with associated neutropenia, 6 and potentiates iron deficiency, anemia, and thrombocytopenia, necessitating transfusion.…”