1. Vulvovaginal GvHD – rare but significant
Vulvovaginal GvHD – rare but significant
Brigitte Frey Tirri, Switzerland

2. cvvGvHD? Allogenic HSZT?
Chronic vulvovaginal Graft versus host disease
Allogenic Hematopoietic stem cell transplantation
Glanduläre Läsionen, B. Frey Tirri,

3. Why woud it make sense to know about this disease as a gynecologist?
Allogenic HSZT is used mostly for patients with leucemia, lymphoproliferativ diseases, aplastic anemia, inherited severe immunodeficencies etc.
8 .4 Mio inhabitants in Switzerland
About 200 allogenic HSZT in Switzerland a year
About 50% are going to die the next 5 years
The survivors need a follow- up care all their life because of complications like GvHD, relapse of the disease.
They often need long time immunosuppression, that provokes subsequent disease.
Glanduläre Läsionen, B. Frey Tirri,

4. Gynecologic aspects after allogenic HSZT
Chronic vulvovaginal GvHD
Secondary malignancies
premature ovarian failure
Sexual and reproductive health

5. Chronic vulvovaginal GvHD

6. Special aspects of chronic vulvovaginal GvHD
% of all survivors of allogenic HSZT
Coming up after 7 – 10 months ( months) after allogenic HSZT
68% at the vulva
26% Vulva and Vagina affected
27% have no symptoms of systemic GvHD
than cvvGvHD
Zantomio et al.:female genital tract GvHD: incidence, risk factors and recommondations for management. Bone Marrow Transplant 2006;38:567-72

7. Bone marrow transplantation vs. Peripheral blood transplantation
Zantomio D. et al.: female genital tract graft-versus-host disease: incidence, risk factors and recommendations for management

8. Possible symptoms and signs
Dryness, burning, itching
vulvodynia
dyspareunia
fissures, erosions
Vaginal adhesions
(tiny lines, or in ringform around the vagina, ditoriation of the portio)
Vaginal stenosis
Female genital GVHD presents a median of 7 to 10 months after allo-HSCT, affects the vulva and/or vagina and is reported in 25% to 49% of allo-HSCT patients. Female genital GvHD is underreported. The most common vulvar complaint is burning when urine touches the vulva.
Shanis, Seminars in Hematology 2012

9. Signs and severity scoring
Stratton P. et al, Ob&Gyn Nov. 2007

10. Signs and severity scoring Grade I

11. Grade II
Stratton P. et al, Ob&Gyn Nov. 2007

13. Vaginal lesion – cg GvHD
dysplasia and secondary malignancies in the genital tract and breast after aHSCT –

14. Grade III
Stratton P. et al, Ob&Gyn Nov. 2007

15. Diagnosis by histology rearly needed
Lichen planus like features

16. Follow-up Visit before Inducing CT and HSZT therapy
Excluding vaginal infection, PAP-smear if necessary
Timing of initiating menses suppression agents
Talking about, future fertility, contraception, peri- transplant reproductive health concerns
Visits after transplantation
3 month
6 to 9 month
Every year – if every things works well

17. Treatment

19. Risk factors for Dysplasia and secondary malignancies of the genital tract and Breast after allogeneic HSCT

20. >40 % will have a dysplasia Reason: immunosuppression, lost of
Its own antibodies through aHSZT
Will lead to reactivation of HPV-infection
Y.Inamoto et al.; BMT 2015; 50(8):

21. prevention of secondary malignancies by colposcopy

22. Vaginal Dysplasia

23. Vulvar Dysplasia

24. Other vulvar lesions

25. Anal Dysplasia

26. Risk of HPV- related cancer in aHSZT vs. HIV/AIDS
Grulich 2007

27. prevention HPV-vaccination recommended No reactivation of a cGvHD seen
6 to 12 months after transplantation
Question open:
how long does this vaccine last in these patient group?