Graft-versus-host disease (GVHD) can affect women and girls in different ways throughout life. From childhood to postmenopause, GVHD can impact hormone production — including estrogen and testosterone — which plays a key role in development, sexual health, and overall well-being.

GVHD is a common complication after an allogeneic bone marrow transplant, which uses donor cells. This type of transplant is often used to treat leukemia or lymphoma, which are two types of blood cancer. GVHD is common among people who’ve had an allogeneic stem cell transplant. Among these transplant recipients, incidence rates range from 11 percent to 48 percent.

Symptoms of GVHD vary widely depending on which organs are affected and how severe the condition is. Some symptoms involve the genitals or reproductive system, while others increase the risk of certain chronic conditions. GVHD-related changes can influence puberty, menstrual cycles, fertility, sexual function, and the aging process.

Here are six key ways that GVHD can affect female health.

1. Sexual and Urinary Problems

Many people with graft-versus-host disease experience pain during sex, which may be the result of GVHD symptoms like vaginal dryness, vulvar pain, or scarring in the genital area. GVHD can also lead to bleeding after sex. In some cases, topical estrogen therapy (medication applied directly to vaginal tissue) may help relieve these symptoms.

More severe effects of GVHD include vaginal stenosis (narrowing of the vaginal opening) and labial fusion (when the lips of the vulva stick together). Vaginal stenosis can make sex painful or, left untreated, prevent intercourse altogether. In severe cases, labial fusion can completely block the vaginal opening and even interfere with urination.

A gynecological exam can help identify these issues, and a biopsy (a small tissue sample taken for testing) usually isn’t required. Early diagnosis and treatment can help slow GVHD progression and prevent more serious complications.

2. Problems With Puberty

Female children who undergo a bone marrow transplant before puberty may experience delayed or incomplete sexual development, depending on the cancer treatments used, according to the National Cancer Institute. In some cases, puberty may not occur at all.

Some treatments for GVHD-related genital issues are not recommended until after puberty. Communicate openly with your child’s pediatrician and specialists if you have concerns about puberty, growth, or development.

3. Fertility Challenges

GVHD may lead to ovarian insufficiency (also called ovarian failure) — when ovaries don’t produce enough hormones — or early menopause (the permanent end of menstrual periods). Donor immune cells from bone marrow transplants can cause shifts in hormones that affect how the ovaries function, which are even more significant in chronic graft-versus-host disease.

GVHD may not be the only factor affecting fertility. Cancer treatments such as chemotherapy and radiotherapy can also cause ovarian insufficiency. Symptoms can resemble those of menopause, such as:

• Difficulty getting pregnant
• Hot flashes
• Low sex drive
• Missed periods

Ideally, fertility preservation should be discussed before starting cancer treatment or undergoing a transplant. If you have GVHD and want to get pregnant, talk with your healthcare team. They can help assess your risks, fertility options, and the safest time for pregnancy. You may be advised to wait until GVHD is well managed before trying to conceive.

In some cases of ovarian insufficiency, fertility treatments or in vitro fertilization may offer a path to pregnancy.

4. Urinary Tract and Yeast Infections

GVHD occurs when the immune system overreacts to transplanted cells. Because of this, treatment focuses on calming the immune response, usually with steroids and other immunosuppressant medications. However, these medications can make the body more vulnerable to harmful bacteria, viruses, and fungi. As a result, GVHD can lead to a high risk of infections, including urinary tract infections (UTIs) and vaginal yeast infections.

Many over-the-counter treatments are available for these common infections, but it’s important to check with your healthcare provider before self-treating. Even if you’ve successfully managed a UTI or yeast infection at home before, immunosuppressant medications may make infections harder to treat now. Take all signs of infection seriously, and follow your doctor’s guidance to ensure the safest and most effective treatment.

5. Osteoporosis

Osteoporosis causes bones to become thin, weak, and more likely to fracture — sometimes from simple movements like bending or coughing. Being female is a risk factor for osteoporosis, especially after menopause, according to the journal Clinical Hematology International. Chronic graft-versus-host-disease leads to an even higher risk.

GVHD-related factors that contribute to osteoporosis include:

• Early menopause
• A weakened immune system
• Ovarian insufficiency
• Reduced physical activity
• Use of steroids and chemotherapy
• Weight loss

Bone loss typically happens fastest within the first six to 12 months after a transplant. Healthcare providers often advise taking vitamin D and calcium supplements to help protect bone health. Estrogen therapy may also be an option, because this hormone helps maintain strong bones. A bone density test can check for signs of osteoporosis and help your healthcare team determine the next steps to support your bone health.

6. Heart Disease

Cardiovascular disease is the leading cause of death for women in the U.S., according to the Centers for Disease Control and Prevention (CDC), and GVHD further raises that risk. This is partly because GVHD increases the likelihood of early menopause and diabetes, two major risk factors for heart disease. Diabetes can also develop as a side effect of steroid treatments used to manage GVHD.

The most common type of heart disease is coronary artery disease, which occurs when plaque builds up in the artery walls, narrowing blood vessels and restricting blood flow. This raises blood pressure and increases the risk of serious complications like heart attack and stroke. Hormonal changes after menopause can further increase the risk of coronary artery disease. Unfortunately, just 23 percent of women with high blood pressure have this condition under control, according to the CDC.

Lifestyle choices play a key role in heart health. Staying active, eating a nutritious diet, avoiding smoking, and managing stress can all help protect the heart. However, sometimes medication is also needed to manage blood pressure or cholesterol. If you have GVHD, be sure to monitor your blood pressure regularly, and talk with your healthcare team about ways to prevent or manage cardiovascular (heart and blood vessel) disease.

Speak Up About Your Symptoms and Concerns

Sensitive topics like sexual and reproductive health aren’t always easy to talk about, even with a doctor. However, being open about your symptoms allows your healthcare provider to connect you with the right specialists and find the best treatment options for you. Early treatment and support can ease stress and may help prevent GVHD from causing lasting damage.

In addition, connecting with others who understand your experience can make a difference. Finding a community of people who share your journey can provide reassurance, encouragement, and a sense of belonging.

Talk With Others Who Understand

On myGVHDteam, the site for people and their loved ones living with graft-versus-host disease, people come together to ask questions, give advice, and share their stories with others who understand what it’s like to live with GVHD.

Have you used hormone replacement therapy to manage premature menopause or other issues related to GVHD? Share your insights in the comments below.