Leuprolide, OCPs Manage Abnormal Uterine Bleeding in Stem Cell Transplant

There are interventions that can help curb abnormal uterine bleeding in patients undergoing a stem cell transplant, explained Amanda Brink, DNP, APRN, FNP-BC, AOCNP.

For patients with hematologic malignancies undergoing treatments such as stem cell transplantation, blood transfusions are often essential due to complications like anemia and thrombocytopenia, with the benefits typically outweighing the risks. However, transfusions are not without risk, as serious reactions can occur, including iron overload and acute or delayed transfusion reactions. Additionally, anemia significantly impacts a patient’s quality of life, increasing symptom burden and potentially leading to prolonged hospital stays.

One common cause of increased transfusion requirements in premenopausal patients is abnormal uterine bleeding (AUB), which occurs frequently in those undergoing allogeneic hematopoietic stem-cell transplantation (HSCT) due to prolonged pancytopenia. To address this, a multidisciplinary team at one institution implemented an algorithm using leuprolide, a gonadotropin-releasing hormone (GnRH) agonist, with or without continuous oral contraceptive pills (OCPs), to prevent and manage AUB.¹ Lupron works by suppressing the production of estrogen and progesterone, effectively inducing a temporary menopausal state that reduces the frequency and severity of menstruation.² This approach aimed to reduce bleeding and, consequently, the need for red blood cell (RBC) and platelet transfusions.

Hormonal Intervention to Reduce Bleeding in Stem Cell Transplant Patients

The study included premenopausal patients with hematologic malignancies undergoing their first HSCT. The study aimed to assess whether leuprolide, with or without OCPs as part of an algorithm to manage AUB, could reduce RBC and platelet transfusions. The algorithm, developed by a multidisciplinary team, focused on preventing AUB through therapeutic amenorrhea.

Data on transfusion requirements and venous thromboembolism (VTE) events were collected, with the primary outcome being the total number of RBC and platelet transfusions within 90 days post-HSCT.

VTE events were monitored through diagnostic imaging. Monitoring VTE rates in patients receiving leuprolide and OCPs is crucial due to the association between hormone therapies and an increased risk of thrombosis.³ Women undergoing HSCT are already at an elevated risk for thrombotic events because of factors such as reduced mobility during hospitalization.

Treatment groups were categorized into no medication, leuprolide with or without OCP, and OCP only.

The study analyzed 214 premenopausal women with hematologic malignancies who underwent HSCT between June 2016 and January 2022.

AUB occurred in 58.4% of the patients during the observation period. The results showed that patients who received leuprolide with or without OCPs as part of the AUB management algorithm were significantly less likely to require platelet and RBC transfusions. Specifically, these patients received 1.2 times fewer platelet transfusions (OR, 0.84 [95% CI, 0.79 to 0.91]) and 1.1 times fewer RBC transfusions (OR, 0.91 [95% CI, 0.85 to 0.98]) compared to those who received no medication.

The study also assessed VTE occurrence, which was observed in 8.9% of patients, with no significant relationship between VTE risk and age or treatment group. These findings suggest that the use of the AUB management algorithm, particularly with leuprolide, effectively reduced the need for transfusions without increasing the risk of VTE.

Nursing Considerations

Oncology nurses should be aware that AUB is a common issue among premenopausal women undergoing HSCT. Patients accustomed to regular menstrual cycles may not always think to report AUB to their providers, so nurses should proactively assess for this symptom by regularly inquiring about it. Nurses can advocate for the use of leuprolide with or without OCPs as part of a preventive strategy for AUB. Proactive intervention is essential, as the AUB management algorithm used in this study, along with previous research, recommends initiating leuprolide treatment at least one month before HSCT to prevent withdrawal bleeding during the conditioning phase.

Nurses should also provide patient education on the rationale behind using leuprolide and OCPs for AUB prevention. While this study showed no significant increase in VTE events, nurses must remain vigilant about the risk of thrombosis in HSCT patients, particularly those receiving hormonal therapy. Regular monitoring for signs of VTE, such as edema, should be a key part of both nurses' and providers' assessments.

In conclusion, the management of AUB in premenopausal women undergoing HSCT is essential to reducing the need for blood transfusions and improving patient outcomes. The use of leuprolide with or without OCPs as part of a multidisciplinary algorithm effectively reduces transfusion requirements without increasing the risk of VTE. Oncology nurses play a crucial role in identifying AUB, advocating for preventive interventions, and educating patients on the rationale behind treatment strategies.

References

1. Nebgen DR, Cheng L, Alousi AM, Ferrajoli A. Decreased Transfusions in Premenopausal Patients Undergoing Allogeneic Hematopoietic Stem-Cell Transplantation Given Leuprolide According to an Abnormal Uterine Bleeding Algorithm. JCO Oncol Pract. Published online September 16, 2024. doi:10.1200/OP.24.00169

2. Leuprolide acetate. National Cancer Institute. Accessed October 14, 2024. https://www.cancer.gov/publications/dictionaries/cancer-terms/def/leuprolide-acetate.

3. LaVasseur C, Neukam S, Kartika T, Samuelson Bannow B, Shatzel J, DeLoughery TG. Hormonal therapies and venous thrombosis: Considerations for prevention and management. Res Pract Thromb Haemost. 2022;6(6):e12763. Published 2022 Aug 23. doi:10.1002/rth2.12763