Fertility and Sexuality Concerns for (Cis) Girls and Women After Pelvic Radiation for Childhood Cancers

Risks of Pelvic Radiation for Childhood Cancer

Radiation to your pelvis or abdomen (belly) can cause changes to the vagina, uterus, and ovaries. The ovaries make eggs and female hormones that help with growth, puberty, and menstruation (a period).

What are the risks to fertility?

A female baby has all the eggs in her ovaries that she will have for her lifetime. When the ovaries are exposed to radiation (at any age), the eggs (oocytes) can be affected. This means that a woman/girl who has had pelvic radiation may have a hard time getting pregnant later in life. The higher the dose of radiation to the ovaries, the higher the risk of fertility problems.

What are the risks that affect puberty?

Ovaries make hormones. If a girl has radiation to her ovaries and she has not gone through puberty yet, she is at risk for having puberty happen later than expected (late-onset puberty), or for not going through normal puberty at all. Young women who have gone through puberty and have started menstruating before radiation treatment are at risk for early menopause (early-onset ovarian failure).

What should I do to check for these risks?

If you have had pelvic radiation, you should be checked by your healthcare provider. This check should include:

• Measuring growth and finding out where you are in the stages of puberty each year.
• Asking about when puberty started, your menstruation history, sexual function, and any symptoms of menopause.
• Having a bone density test (Dexa scan) done each year if you have low levels of ovarian hormones. This test checks your bones for osteoporosis (weakening).
• You should be seen by an endocrinologist if you:
  • Do not have signs of puberty by age 13.
  • Start puberty that does not progress (continue).
  • Have abnormal menstruation patterns.
  • Have any symptoms of menopause.

What are the risks with pregnancy?

If you had radiation to the uterus (womb), it can lead to a decrease in the size of the uterus. It can also lead to a decrease in elasticity (stretch) and scarring. These changes in the uterine muscle can put you at risk for miscarriage, preterm labor, and having a baby born at a low birth weight.   An ultrasound of the uterus and other reproductive organs may be helpful. Women who become pregnant after pelvic radiation should receive high-risk obstetrical (OB) care.

If you would like to get pregnant, you should see a high-risk pregnancy specialist. If you are having trouble getting pregnant, you should see a reproductive endocrinologist. These providers can talk to you about parenting options.

If you are sexually active and you do not want to get pregnant, you should use reliable birth control. While your provider does their best to predict if you will be able to get pregnant, this is not a guarantee.

What are the risks to my vaginal and groin area?

You may have vaginal dryness and some other symptoms that are often part of menopause – these can include atrophy (a decrease in the size of your vagina) and vaginal pain. Some tips for helping these issues are:

• Personal lubricants that can make intercourse more comfortable.
• Regular use of vitamin E on and around the vaginal tissue may help to strengthen the tissue and reduce friction to sensitive tissue.

Scarring may cause the size of the vagina to get smaller or narrower. You should be taught how to use a vaginal dilator. These are put in the vagina for short periods of time to help prevent scar tissue, increase blood flow to the area, and keep the vagina open. Keeping the vaginal space open lets menstrual blood drain out of the uterus and helps make intercourse or vaginal exams more comfortable.

• If dilator or tampon insertion is hard, referral to a gynecologist or pelvic floor physical therapist may be helpful.
• If you are having chronic pain (continuous or on and off) in the vulva, which can be a sign of a vulvar pain syndrome, tell your healthcare provider. Medicines such as amitriptyline (tricyclic antidepressants) and psychological consultation may help vulvar pain.

Radiation to the groin can cause swelling (lymphedema) in the groin or legs. Tell your healthcare provider about any swelling. Starting physical therapy at the first sign of swelling can improve lymphedema.

You may have questions and concerns about fertility and sexuality after having radiation to the pelvic and abdominal areas for childhood cancers. Talking about your concerns with your healthcare team will help you know what to expect and how to handle these risks.