REVIEW Clinical guidelines for gynecologic care after hematopoietic SCT. Report from the international consensus project on clinical practice in chronic GVHD B Frey Tirri 1 , P Häusermann 2 , H Bertz 3 , H Greinix 4 , A Lawitschka 5 , C-P Schwarze 6 , D Wolff 7 , JP Halter 8 , D Dörfler 9 and R Moffat 10,11 Despite similarities relevant age- and gender-specific issues exist in the care of patients after allogeneic hematopoietic SCT (HSCT). Female genital chronic GVHD (cGVHD) has been markedly underreported in the past but has a significant impact on the patients’ health and quality of life. Data on prevention and treatment of this complication are still limited. Here we present a comprehensive review summarizing the current knowledge, which was discussed during several meetings of the German, Austrian and Swiss Consensus Project on clinical practice in cGVHD. In this report, we provide recommendations for post-transplant gynecological care of cGVHD manifestations agreed upon by all participants. This includes guidelines for diagnosis, prevention, and therapeutic options and topical treatments in female patients with genital cGVHD and hormonal replacement treatment of premature ovarian failure for adult and pediatric patients and underlines the necessity for regular gynecological care and screening programs for women after HSCT. Bone Marrow Transplantation (2015) 50, 3–9; doi:10.1038/bmt.2014.242; published online 27 October 2014 INTRODUCTION Complications after allogeneic hematopoietic SCT (HSCT) are mainly due to adverse effects of cytotoxic treatment, acute and chronic GVHD (cGVHD), drug adverse effects or long-lasting immunodeficiency leading to prolonged susceptibility for opportunistic infections. 1 To prevent permanent dysfunctions long-term follow-up programs for post-transplant patients have been developed which address age- and gender-specific characteristics. 2 Despite many similarities, there are differences in clinical symptoms, prophylaxis and treatment of post-transplant complications between female and male patients. For example, hypogonadism due to premature gonadal failure is highly prevalent after intensive chemotherapy and TBI for conditioning in men and women. However, in women gonadal dysfunction is more pronounced and occurs more often and earlier after HSCT, and the recovery of gonadal function is less likely. 3 This report focuses on some post-transplant issues, which are important to consider in female patients after allogeneic HSCT including cGVHD. Data on this consensus process have been presented at the German, Austrian and Swiss Consensus Conference on clinical practice in cGVHD held in Regensburg in 2009 and have been updated in a workshop held in Wiesbaden 2013. Updates were discussed during the cGvHD consortia meetings in 2011 and 2013. The consensus summarizes the currently available evidence for first-line, second-line and topical therapies in cGVHD and provides practical guidelines for the use of supportive treatment modalities 4,5 (summarized in Table 1). The evaluation of evidence and the subsequent recommenda- tions were classified according to the rating system for ancillary therapy and supportive care published by Couriel in 2008 (ref. 27; Table 2). On the basis of the National Institutes of Health (NIH) Consensus recommendations for clinical research in cGVHD, the focus of this report was to provide updated and more detailed guidelines for the prevention and treatment of gender-specific problems associated with cGVHD in female patients in daily clinical routine. Strength of recommendation and evidence levels (Table 3) were based on a PubMed-based literature search with subsequent rating by an expert panel approval of the recom- mendations by all participants of the consensus process. Only English literature was considered. Abstracts from the Bone Marrow Transplantation Tandem meetings, the European Bone Marrow Transplantation meetings and the American Society of Hematol- ogy meetings were cited but not included in the evidence rating. Reference lists from the articles retrieved were also evaluated for relevant information. INCIDENCE AND RISK FACTORS FOR FEMALE GENITAL CGVHD The first report on female genital involvement of cGVHD was published in 1982. 28 It took another 20 years until this problem became more widely recognized and discussed in the literature. 29,30 Women rarely report genital symptoms to 1 Women’s Hospital, Cantonal Hospital Baselland, Bruderholz, Switzerland; 2 Department of Dermatology, University Hospital Basel, Basel, Switzerland; 3 Department of Hematology and Oncology, Albert Ludwigs-University Medical Center, Freiburg, Germany; 4 Department of Internal Medicine I, Medical University of Vienna, Vienna, Austria; 5 St Anna Children’s Hospital, Medical University of Vienna, Vienna, Austria; 6 University Children’s Hospital Tuebingen, Tuebingen, Germany; 7 Department of Medicine III, University of Regensburg, Regensburg, Germany; 8 Department of Hematology, University Hospital Basel, Basel, Switzerland; 9 Department of General Gynecology and Gynecological Oncology, Medical University of Vienna, Vienna, Austria; 10 Clinic for Gynecological Endocrinology and Reproductive Medicine, University Hospital Basel, Basel, Switzerland and 11 Fertisuisse, Center for Reproductive Medicine, Olten, Switzerland. Correspondence: Dr B Frey Tirri, Women’s Hospital, Cantonal Hospital Baselland, CH-4101 Bruderholz, Switzerland or Dr R Moffat, Clinic for Gynecological Endocrinology and Reproductive Medicine, University Hospital Basel, CH-4031 Basel, Switzerland. E-mail: brigitte.frey@ksbl.ch or rebecca.moffat@usb.ch Received 30 December 2013; revised 5 September 2014; accepted 17 September 2014; published online 27 October 2014 Bone Marrow Transplantation (2015) 50, 3 – 9 © 2015 Macmillan Publishers Limited All rights reserved 0268-3369/15 www.nature.com/bmt