Management of menstrual bleeding and cycle control after hematopoietic stem cell transplant

Abstract

Menorrhagia during hematopoietic stem cell transplant (HSCT) can be a serious management complication. Therefore, many of these patients receive hormonal therapy to suppress menstruation prior to and during transplantation [1]. There remains no current standard regarding current practices among physicians for inducing amenorrhea during HSCT. As an initial step to design comparative studies of therapies for menstrual suppression, this survey was designed to assess current practices for menstrual suppression in post-menarchal HSCT recipients. Practicing HSCT physicians were identified via the websites for the Center for International Blood and Marrow Transplant Research (CIBMTR) registry, the Bone and Marrow Transplant Information network (www.bmtinfonet.org), and the Pediatric Blood and Marrow Transplantation Consortium (PBMTC). A webbased survey (www.zoomerang.com; Zoomerang, San Francisco, CA, USA) was designed to obtain information regarding physicians' attitudes and practices towards menstrual regulation in HSCT patients. Of 256 email addresses, 110were active. The survey had a 46% response rate (51/110). The transplant unit demographics are summarized in Table 1. Oncologists or HSCT physicians (75%)were primarily responsible for menstrual control. These physicians chose one of the following as their preferred method: combined oral contraceptive pills (COC, 33%) dosed continuously; depot medroxyprogesterone acetate (DMPA, 29%; Depo-Provera, Pfizer, New York, NY, USA) at 150 mg every three months; or oral medroxyprogesterone acetate (MPA, 16%; Provera, Pfizer, New York, NY, USA) at 5 to 20 mg every day for menstrual suppression prior to transplant. The preferred method did not differ by practice location (P=0.67), by age (P=0.62), or by gender (P=0.62) of the respondent (χ test). Methods to control breakthrough bleeding included increasing the dose of oral contraceptives (56%) or adding intravenous estrogen (12%). If a patient started bleeding and was not on hormonal therapy, 90% of respondents would initiate hormonal therapy with COCs (38%), DMPA (11%), or MPA (29%). During the transplant process, if patients were unable to take oral medication secondary to mucositis and/or nausea, respondents reported that they either switched patients to transdermal estradiol/norelgestromin (Ortho Evra patch, Ortho-McNeil Pharmaceutical, Raritan, NJ, USA) (29%), started intravenous estrogen (22%), or held the medication until oral medication could be tolerated (29%). Most felt that these adjunctive therapies ⁎ Corresponding author. Division of Pediatric Hematology and Oncology, Doernbecher Children's Hospital, OHSU, 3181 SW Sam Jackson Park Road, Portland, OR, USA. Tel.: +1 503 494 1543; fax: +1 503 494 0714. E-mail address: changb@ohsu.edu (B.H. Chang).