title: Genital manifestation of graft-vs.-host disease: a series of case reports.
abstract: BACKGROUND
  After hematopoietic stem cell transplantation (HSCT), many patients present genital graft-vs.-host disease (GVHD) that can culminate with sexual problems, which are poorly dimensioned.
  
  
  OBJECTIVE
  We hope to draw attention to the need to perform genital biopsy to diagnose genital GVHD, and thus to call attention to the need to incorporate careful attention to sexual health in the treatment of these patients.
  
  
  METHODS
  Five allogeneic stem cell transplant recipients complaining of coital pain after HSCT were clinically diagnosed for genital GVHD. Genital biopsies were given for histological analysis, and microphotographs of the corresponding marked field in the slide were taken. Specimens were evaluated by the site pathologist and then sent to a reference pathologist, each blinded to the histological findings. A literature search was performed in PubMed/MEDLINE (1966-2009) for cross-sectional and cohort studies or trials related to genital GVHD. Expert opinions peer reviews and case reports were also considered.
  
  
  METHODS
  HSCT, genital GVHD, genital biopsy.
  
  
  RESULTS
  The biopsy showed evidence of dilated apoptotic cells in the basal layer and detachment of the epithelial lining of the mucosa, hyalinization and thickening of collagen fibers, capillary ectasia, and mononuclear inflammatory infiltrate of the submucosa. Three patients presented vulval lesion such as leucoplasia and ulcer on the large lip. Histological analyses showed evidence of epithelial hyperplasia and influx of inflammatory cells to the epithelial surface, intercellular edema and spongiosis, apoptotic bodies on the basal layer of the epithelium, spongiosis, and nuclear vacuolization. A common treatment based on corticotherapy resulted in complete remission of coetaneous or mucous genital lesions in all five patients.
  
  
  CONCLUSIONS
  Genital biopsy is important to differentially diagnose GVHD and secondary symptoms due to hypoestrogenism. Prevention is the most important step in controlling the evolution GVHD in the vagina to prevent vaginal obstruction and sexual dysfunction.
authors.affiliation: Sexual Medicine Service of Human Reproduction Sector, Department of Gynaecology and Obstetrics, Faculty of Medicine of Ribeirão Preto, São Paulo University, Ribeirão Preto, SP, Brazil. luciaalvess@yahoo.com.br
authors.forename: Lúcia Alves da Silva
authors.initials: LA
authors.lastname: Lara
authors.forename: Jurandyr Moreira
authors.initials: JM
authors.lastname: De Andrade
authors.forename: Lenira Maria Queiroz
authors.initials: LM
authors.lastname: Mauad
authors.forename: Sany Rose
authors.initials: SR
authors.lastname: Ferrarese
authors.forename: Heitor Ricardo Cosiski
authors.initials: HR
authors.lastname: Marana
authors.forename: Daniel Guimarães
authors.initials: DG
authors.lastname: Tiezzi
authors.forename: Ana Carolina Japur
authors.initials: AC
authors.lastname: De Sá Rosa e Silva
mesh_terms: D000328:Adult; D017209:Apoptosis; D001706:Biopsy; D004414:Dyspareunia / Q000209:etiology; D004848:Epithelium / Q000473:pathology; D005260:Female; D006086:Graft vs Host Disease / Q000175:diagnosis*; D006801:Humans; D006965:Hyperplasia / Q000276:immunology; D033581:Stem Cell Transplantation; D014184:Transplantation, Homologous; D014617:Vacuoles / Q000473:pathology; D014623:Vaginal Diseases / Q000276:immunology* / Q000473:pathology; D014845:Vulvar Diseases / Q000276:immunology* / Q000473:pathology