Ob-Gyns Address Gynecologic Concerns in Children and Adolescents With Cancer

Washington, DC—Advancements in cancer treatment have dramatically improved childhood cancer survival, with research showing that five-year survival rates for children with cancer reaching almost 80 percent in recent years.

However, these treatments may lead to serious, adverse effects on reproductive health, as well as a potential effect on the outcome of future pregnancies. Recognizing the role of gynecologists in helping to address these complications in female patients, the American College of Obstetricians and Gynecologists (The College) has released new recommendations for ob-gyns to identify and treat gynecologic concerns in female children and adolescents before, during and after cancer treatment.

The new Committee Opinions outline some of the specific issues that should be addressed by gynecologist and patient, as well as treatments that can help young cancer patients and survivors to potentially preserve their reproductive health. Importantly, says the new Committee Opinion, “Gynecologic Concerns in Children and Adolescents With Cancer," gynecologists should be aware of the effects of cancer and its treatments and should be consulted regarding a patient’s current and future reproductive health.

Julie Lubker Strickland, MD, the chair of the College’s Committee on Adolescent Health Care, which developed the Committee Opinions stated, “As ob-gyns and advocates for women’s reproductive health, it is our important role to help patients and families understand the effects of their treatment on fertility and optimize the potential for childbearing if that young woman so chooses after treatment is complete.”

For instance, gynecologists should discuss potential options for fertility preservation before cancer treatment of young girls and women who might be at risk of infertility. Recognition and diagnosis of an impending ovarian insufficiency associated with cancer treatment may allow female patients to maintain their reproductive possibilities and prevent the effects of estrogen deficiency. Additionally, childhood cancer survivors who do maintain fertility should be counseled on the potential effects of cancer and cancer treatment on their future pregnancies.

Moreover, the Committee Opinion says that, since the science of fertility preservation is a rapidly evolving field, a referral to a reproductive endocrinologist is recommended to explore the full range of available options. In addition, because of the complex nature of cancer care, particularly when addressing menstrual issues, collaboration with the young woman’s oncologist is highly recommended.

Among the additional concerns addressed in the Committee Opinion are:

• Pubertal concerns
• Heavy menstrual bleeding and anemia (See Committee Opinion Number #606, “Options for Prevention and Management of Heavy Menstrual Bleeding in Adolescent Patients Undergoing Cancer Treatment,” below)
• Sexuality
• Contraception
• Ovarian function (including fertility preservation)
• Breast and cervical cancer screening

The College released a second Committee Opinion on cancer in adolescents, “Options for Prevention and Management of Heavy Menstrual Bleeding in Adolescent Patients Undergoing Cancer Treatment.”

Normal menstrual blood loss can pose a risk to adolescents undergoing cancer treatment, who are also at a high risk of heavy menstrual bleeding. In order to tailor strategies for menstrual suppression to each patient, her cancer diagnosis, and her treatment plan, gynecologists should work collaboratively with a patient’s oncologist. Specifically, the Committee Opinion lays out strategies for prophylactic menstrual suppression as well as urgent therapy for acute bleeding.

In discussing the new pair of guidelines, Strickland emphasized the importance of the gynecologist’s role in consulting patients, “Cancer and its treatment may have immediate or delayed adverse effects on the reproductive health of our young patients. As gynecologists, we must be prepared with the most up-to-date information to help manage and treat the gynecological issues and be willing to work in collaboration with other specialties, such as oncologists and reproductive endocrinologists, to ensure the best options for our patients.”

Committee Opinion #606, “Options for Prevention and Management of Heavy Menstrual Bleeding in Adolescent Patients Undergoing Cancer Treatment,” and Committee Opinion #607, “Gynecologic Concerns in Children and Adolescents With Cancer,” are published in the August issue of Obstetrics & Gynecology.

Other recommendations issued in this month’s Obstetrics & Gynecology:

Practice Bulletin #146 “Management of Late-Term and Postterm Pregnancies” (NEW!)

ABSTRACT: Postterm pregnancy refers to a pregnancy that has reached or extended beyond 42 0/7 weeks of gestation from the last menstrual period (LMP), whereas a late-term pregnancy is defined as one that has reached between 41 0/7 weeks and 41 6/7 weeks of gestation (1). In 2011, the overall incidence of postterm pregnancy in the United States was 5.5% (2). The incidence of postterm pregnancies may vary by population, in part as a result of differences in regional management practices for pregnancies that go beyond the estimated date of delivery. Accurate determination of gestational age is essential to accurate diagnosis and appropriate management of late-term and postterm pregnancies. Antepartum fetal surveillance and induction of labor have been evaluated as strategies to decrease the risks of perinatal morbidity and mortality associated with late-term and postterm pregnancies. However, in uncomplicated pregnancies, the use of these interventions needs to be balanced with policies that support expectant management until the postterm period. The purpose of this document is to review the current understanding of late-term and postterm pregnancies and provide guidelines for management that have been validated by appropriately conducted outcome-based research when available. Additional guidelines on the basis of consensus and expert opinion also are presented.

The American College of Obstetricians and Gynecologists (The College), a 501(c)(3) organization, is the nation’s leading group of physicians providing health care for women. As a private, voluntary, nonprofit membership organization of more than 58,000 members, The College strongly advocates for quality health care for women, maintains the highest standards of clinical practice and continuing education of its members, promotes patient education, and increases awareness among its members and the public of the changing issues facing women’s health care. The American Congress of Obstetricians and Gynecologists (ACOG), a 501(c)(6) organization, is its companion organization. www.acog.org