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The treatment of menorrhagia in female stem cell transplant recipients

Bone Marrow Transplantation volume 35, page 827 (2005)Cite this article

We read with interest the paper from Amsterdam et al1 recently published in this journal. We are pleased to share with the authors the importance of what is normally considered a not very stringent issue after stem cell transplantation, but we do not agree with the statement proposed by the authors. First of all the definition of menorrhagia may vary from mild to severe or intractable; therefore, the approach may vary from supportive measures to emergency measures including high-dose oral contraceptives or i.v. conjugated estrogens or even surgery. We do not hold, in fact, that menorrhagia should always be treated aggressively. Conjugated estrogens and oral contraceptives are known to increase liver toxicity after stem cell transplantation, producing an increase in the frequency of veno-occlusive disease, which was statistically significant when lynesterol or norethisterone were routinely adopted after stem cell transplantation.2, 3, 4, 5 Obviously, this increase was observed mainly after allogeneic stem cell transplantation. In the series reported by Amsterdam et al, the patients included in the study were mainly recipients of allogeneic transplantation. Since hormonal treatment is significantly associated with an increased risk of VOD, probably interfering with hemostasis or inducing cholestasis and transaminitis, we were also interested in the incidence of transplant-related toxicity and mortality and, particularly, in the observed rate of VOD in these patients. The length of hormonal treatment, either at low or high dose, is also an important issue, which is not addressed by the authors. While we do recommend hormonal therapy after either autologous or allogeneic transplantation for long-term sequelae of ovarian failure,6 we do not routinely give OC before or during transplantation and we recommend instead gonadotropin-releasing hormone (GnRH) agonists such as leuprorelin as prophylaxis or treatment of menorrhagia.7, 8 A first dose of GnRH analogue (leuprorelin depot 3.75 mg) at least 30 days before the conditioning regimen followed by a second injection 28 days later is sufficient to prevent uterine bleeding8 or to reduce menorrhagia in acute leukemia patients.9 Of course, as also stated by the authors, prospective randomized trials are needed as well as surveys of local policies from transplant centers worldwide in order to ensure awareness of this specific issue and to promote guidelines for prophylaxis and treatment of menorrhagia after stem cell transplantation.

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  1. Istituto di Ematologia, Università Cattolica Sacro Cuore, Roma, Italia

    S Sica, F Sorà, L Laurenti, P Chiusolo, N Piccirillo & P Scirpa

  2. Istituto di Ginecologia ed Ostetricia, Università Cattolica Sacro Cuore, Roma, Italia

    G Leone

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Sica, S., Sorà, F., Laurenti, L. et al. The treatment of menorrhagia in female stem cell transplant recipients. Bone Marrow Transplant 35, 827 (2005). https://doi.org/10.1038/sj.bmt.1704890

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