Gynecologic complication of chronic graft-versus-host disease: Vaginal obstruction
A 43-year-old, gravida 4, para 2 woman came to the gynecology clinic for counseling about premature menopause. She had been diagnosed with acute myeloid leukemia 2 years earlier and treated with induction and consolidation chemotherapy using idarubicin and cytosine arabinoside. After developing complete remission, physician recommended patient to have gynecological examination. At the gynecology clinic office, gynecologist conducted pelvic examination with Papanicolaou (Pap) test. The uterine cervix revealed cooper intrauterine device (IUD) tail string which got stuck into exocervix, but otherwise non-specific finding (). Of course the IUD was immediately removed. The result of Pap test was reactive cellular changes. Eleven days after gynecologic consultation, patient underwent Allo-PBSCT and the donor was her younger brother. There was no evidence of residual disease on a bone marrow biopsy performed 10 months after transplantation.\nTwenty-six months after Allo-PBSCT, she revisited our gynecology clinic and it was found that her follicle-stimulating hormone level was greater than 100 IU/mL and estradiol was 4.14 pg/mL. By reviewing the patient medical record and taking a medical history, it was found that when she started chemotherapy, her menstrual cycle completely disappeared. About one year after chemotherapy, the patient tried coitus with husband, but vaginal dryness and dyspareunia were very severe, so could not have sexual intercourse. However, patient had no other menopausal symptoms like hot flush, sleep disturbance, mood swing and so on. To introduce sequential hormone replacement therapy (HRT), we performed clinical examination. The clinical examination revealed extensive vulvar atrophy with flattening but otherwise non-specific appearance including uterine cervix. After that, the patient started sequential HRT.\nFourteen months after initiation of HRT, it was discovered that her upper vaginal canal was completely obstructed (). The lower vagina had a normal appearance. The human papillomavirus (HPV) deoxyribonucleic acid (DNA) chip test and Pap test were conducted in vagina not in uterine cervix because of obstruction of upper vaginal canal. The HPV DNA chip test was positive for HPV (other type) in the vagina. The Pap test was negative. Trans-rectal ultrasonographic findings were hematocolpos and atrophic uterus (). We explained the results to the patient and provided reassurance. The patient is currently being treated with tibolone and we recommended non-hormonal moisturizing vaginal gel and vaginal dryness and dyspareunia were much improved.\nHere, we present the case of a woman who after Allo-PBSCT, showed obstruction of the upper vagina as a chronic complication of GvHD.