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Female Reproductive System Problems in Childhood Cancer Survivors

Some female childhood cancer survivors may have problems with their reproductive health — menstrual periods, pregnancy, and childbearing — because of certain treatments they received.

The effect, if any, depends on the:

  • Tissues and organs involved in the cancer
  • Type, dosage, and combination of treatments
  • Age at the time of therapy

Treatments are available for many conditions that affect the reproductive system.

This illustration shows a teen with her uterus, fallopian tubes, ovaries, cervix, and vagina labeled. To the right of the main image, the endocrine system organs are also shown against the silhouette of the young woman’s body: pineal gland, hypothalamus, pituitary gland, thyroid and parathyroid, thymus, adrenal gland, and pancreas.

The organs of the female reproductive system work together so a woman can get pregnant, carry a developing human until time for delivery, and give birth.

Cancer treatments that can affect female health

  1. Chemotherapy

    Alkylating Drugs
    		 Heavy Metal Drugs
    Non-classical alkylators

  2. Radiation

    Radiation therapy that affects a patient’s pelvic area, reproductive organs, and pituitary gland in the brain may affect a patient’s fertility. The treatment may decrease the number of eggs or affect the quality of the eggs.

    Abdomen/ pelvic/ total body radiation

    Radiation directly to or near the ovaries can cause them to stop working. Radiation therapy to the abdomen, pelvis, and lower spine can affect the uterus and increase the risk of miscarriage, premature labor, low birth weight, and problems during labor.

    Brain/ hypothalamus/ pituitary gland

    Brain radiation can damage the pituitary gland in the brain. The pituitary gland produces two hormones needed for the ovaries to function correctly – FSH (follicle-stimulating hormone) and LH (luteinizing hormone.) FSH stimulates the ovarian follicles to produce eggs. LH signals the follicles to release eggs. High levels of radiation to this area of the brain can lead to low levels of these hormones.

    Pelvic radiation and alkylating agent combination

    The combination of pelvic radiation and high doses of alkylating agents causes the highest risk of damage to reproductive function.

  3. Surgery

    Tumors and/or surgery that result in damage to the pituitary gland can cause the ovaries to stop working due to deficiency in LH and FSH. This condition is called central hypogonadism.

    Surgery that removes both ovaries before the normal age of menopause causes premature ovarian failure.

    Removal of one ovary before the normal age of menopause may cause menopause to happen a few years earlier than normal.

Other factors that may increase the risk of female health problems

Age

In general, females who are adolescents and young adults at the time of treatment are at higher risk for problems than younger girls.

Problems that may occur

  1. Failure to enter or progress through puberty

    Damage to ovaries can cause puberty to be delayed (no signs of breast development after age 13 years) or to stall (no progress in signs of puberty, no onset of periods past the age of 16 years). Affected girls will need hormone treatment prescribed by a doctor to experience puberty and have a menstrual period.

  2. Temporary stopping of menstrual periods

    Many females will temporarily stop having their period during treatment, but it may return later. That timing is unpredictable. It could take several years. It is important that women take birth control if they are sexually active and don’t want to become pregnant.

  3. Premature menopause

    Cancer treatment can cause women to stop menstruating earlier than expected (before the age of 40.) Heath care professionals recommend that women at risk for early menopause not put off trying to have children beyond the early 30s if they are able.

  4. Lack of female hormones

    Women with ovarian failure don’t produce enough estrogen, which is needed for healthy bones, a healthy heart, and overall well-being. Girls at risk for this problem may need to consult an endocrinologist and/or gynecologist.

    Lack of female hormones represents a problem with the endocrine system.

    Lack of female hormones represents a problem with the endocrine system.

  5. Infertility

    Infertility is defined as not being able to get pregnant and have a biologic child after 1 year of unprotected sexual intercourse. Women at risk for infertility may want to see a fertility specialist.

  6. Pregnancy risks

    Women who had radiation to the pelvis, lower spine or total body (TBI) may be at increased risk for miscarriage, premature delivery, low birthweight infants, or problems during labor. Survivors who received these treatments and who are planning to become pregnant or are already pregnant should ask to see an obstetrician/ gynecologist (OB/GYN) who specializes in high-risk pregnancies.

    Women who had chemotherapy with anthracyclines could have heart problems during pregnancy and labor. Survivors are encouraged to talk to their OB/GYN about the possible need to have a heart muscle function evaluation.

What survivors can do

Know your risks and monitor your health

Survivors should have annual physical examinations that include:

  • Checking of the progress of puberty
  • Asking about menstrual cycle and pregnancy history
  • Discussing sexual function
  • Having blood tests for FSH, LH and estradiol.

If the health care provider sees problems in these areas, he or she may refer the survivor to an endocrinologist or other specialists.

Treatments are available for many conditions that affect hormones and fertility.

For women with ovarian failure, a bone density test to check for thinning of the bones may also be recommended.

For more information, read the Children’s Oncology Group’s Female Health Issues after Cancer Treatment.

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Together does not endorse any branded product mentioned in this article.

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Reviewed: June 2020

Protecting Fertility in Female Patients

Some childhood cancer treatments can affect a female’s ability to have children. Families should ask about the impact on fertility before therapy starts.

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Endocrine Late Effects

Some childhood cancers and treatments can affect the development and functioning of the endocrine system.

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Male Reproductive Health Issues

Childhood cancer therapy may sometimes affect male reproductive functions later in life. It is important that boys who are at risk for reproductive health problems have a yearly check-up for related concerns.

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