Today, more and more girls are living healthy lives after having cancer. As a cancer survivor, you may have some special concerns about your menstrual periods, fertility, and sexual relationships. This guide was created to help answer your questions about: hormones and ovaries, premature ovarian insufficiency (POI, formerly called premature ovarian failure, or POF), fertility and pregnancy, fertility treatments, other fertility issues, and sexual relationships after cancer.

What is “normal” ovarian function?

Your ovaries are a part of your reproductive system and their normal function is to release eggs and make hormones. Hormones are chemical messengers in the body that are needed for healthy growth and development in girls and women. Estrogen and progesterone are two important hormones released by the ovaries. They are the hormones responsible for healthy bones, breast growth, and regular menstruation (periods).

What is “normal” menstruation?

Menstruation, or your period, happens about once a month for most women. A typical menstrual cycle is about 28 days. This means that there should be about 28 days from the first day of your period to the first day of your next period. 28 days is an average number, but anywhere between 21 and 35 days is normal. Your period will usually last between 2-7 days. During the first year of menstruation it is common for your period to be irregular. Stress, intense physical activity, not eating well, pregnancy, and cancer treatments can all cause you to skip your period.

Will my ovaries work after receiving chemotherapy?

Both the type and amount of chemotherapy that you had could affect how well your ovaries will work. Many types have no effect on the ovaries.

During your chemotherapy, or for up to a year after your chemotherapy has ended, it is possible that your ovaries will temporarily stop working and then begin to work again.

Certain types of chemotherapy can also cause some women to go through menopause early and to cause periods to stop permanently. Ask your doctor if your chemotherapy will have any effect on your ovaries. This means, instead of going through menopause at the average age of 52 years old, it’s possible that you may begin menopause early (premature ovarian insufficiency, where periods stop permanently) in your 20s, 30s or 40s. This is important for you to consider when planning to have a family.

Will my ovaries work after having had radiation?

It depends on what part of your body was treated and the dose of radiation you were given. If you received radiation to a part(s) of your body other than your pelvis (the lower part of your abdomen, beneath the belly button), it is unlikely that your ovaries were severely affected. If your ovaries were exposed to the radiation that was used to treat your cancer, they may have been damaged.

How will I know if chemotherapy or radiation affected my ovaries?

Your oncologist or gynecologist should be able to tell you if your ovaries were affected by your cancer treatment(s). Your ovaries are part of your reproductive system. They make hormones and release eggs. Generally, if the chemotherapy and/or radiation you received affected your ovaries severely, your ovaries will stop making hormones and eggs and you will not have a menstrual period. The menstrual periods may stop temporarily during and after cancer treatments; it can take up to a year to know whether your ovaries have recovered somewhat from treatment and whether your period will come back.

In some cases, ovaries may continue to partially work. Some young woman may ovulate occasionally and have light or infrequent periods because their ovaries are releasing small amounts of hormones and some eggs. We expect that if this occurs, premature menopause is likely to occur as well.

If I’m planning to receive chemotherapy or radiation therapy, is there anything that I can do to increase my chances of being able to get pregnant in the future?

Possibly. The goal of treatment is to cure your cancer and hope that at the same time your ovaries can be protected from the side effects of chemotherapy and/or radiation. Although there are limited scientific studies, a surgical procedure to move the ovaries out of the field of radiation, or medicine that temporarily turns the ovaries off and may keep the eggs safer, could be helpful in increasing the chances of becoming pregnant later. Everybody is different and factors such as your age at treatment, kind of cancer you had, and the type of treatment you received, will determine what treatment option your gynecologist or reproductive endocrinologist recommends for you.

Freezing of ovarian tissue: Some fertility centers are able to freeze ovarian tissue. This requires surgery to remove an ovary. Talk to your doctor to see if this is a possible option for you.

Freezing eggs: This requires at least two weeks of medication injections, a procedure to remove eggs from your ovaries, and then freezing the eggs. The medical term for this is “oocyte” (egg) “cryopreservation” (freezing) of a human egg.

Oophoropexy (oo·​pho·​rec·​to·​my): This is a surgical procedure that is done to move one or both of the ovaries away from where the radiation is pointed. A procedure called a laparoscopic oophoropexy may be recommended.

GnRH agonists: This is a man-made hormone treatment that works by temporarily shutting off the ovaries, and which causes symptoms similar to menopause. This medicine is available in a nasal spray or injection. GnRH agonists work by stopping the eggs in the ovaries from being stimulated, and therefore also lowers the estrogen levels. Most women will not have periods while taking this therapy, however, some side effects of treatment may include hot flashes, irregular vaginal bleeding, depression, headaches and/or insomnia. Usually a woman will start to ovulate again and get her period about 6 weeks after stopping this medicine. A few studies have shown that women who receive GnRH agonists while on chemotherapy have a better chance of preserving their ovarian function, but others show no effect.

Oral Contraceptive Pills (OCPs): Most health care providers feel that OCPs may have a protective effect on fertility. This is based on a small research study that compared the amount of “follicles” or young “eggs” a woman has before and after chemotherapy. Early findings suggest those women, who were taking OCP’s during chemotherapy, had the same amount of follicles (young eggs) before and after treatment.

If I had chemotherapy or radiation, will I be able to get pregnant?

If chemotherapy or radiation has not affected your ovaries or uterus, then you should be able to get pregnant. If chemotherapy or radiation has affected your uterus and ovaries then you will need to talk about your options with a fertility specialist.

Other Fertility Issues

If I get pregnant with my own eggs after cancer treatment, will my baby be normal?

Yes! Your chance of having a normal baby is the same as other women your age.

Should I expect any problems with my pregnancy or breast-feeding since I had cancer?

In most cases, women who become pregnant after cancer treatment have normal and healthy pregnancies. In some studies, women who had high amounts of radiation to their pelvis had higher rates of miscarriages (the pregnancy doesn’t keep growing and fails) or early births. Every woman’s pregnancy is different and should be followed closely by her doctors regardless of whether or not she has received cancer treatment.

Your ability to breastfeed your child after your pregnancy will not be affected unless you have received radiation treatment to your breast area or head during your cancer treatment. Although the breast that received radiation will most likely produce little or no milk, you will still be able to feed your baby with the other breast if it was not exposed to radiation.

Is there a chance that my children will get cancer too?

While some cancers run in families, most cases of cancer are caused by something random and do not increase the risk of cancer for other family members. Only 5-15% of all cancer cases are related to a gene that you inherited. Most cancer survivors have healthy children. If you have concerns, you should talk to your health care provider or a genetics counselor.

Who can I talk to about fertility issues?

The first person you should talk to about fertility issues is your oncologist, gynecologist or a reproductive endocrinology specialist. They will be able to figure out if your cancer treatment had any effect on your ovaries and/or uterus. If needed, your oncologist can refer you to a fertility specialist who can help you with your options.

What are the chances that my cancer treatment caused my infertility?

Infertility is a common problem that affects millions of couples around the world. It may be difficult for your doctor to tell whether your infertility is a result of your cancer treatment or a condition that existed before your cancer.

The chances that you are infertile because of cancer treatment depend on a few factors:

• Your age at treatment: Girls who are treated in childhood usually have fewer reproductive problems than those who are treated in their teen or adult years. Also, older women are more likely to be infertile and have Premature Ovarian Insufficiency (POI). This is because girls are born with all the eggs that they will ever have. The older you are and the more menstrual cycles you’ve had, the fewer eggs you have left. Younger girls have a larger supply of eggs and may be able to finish cancer treatment with some eggs still remaining in their ovaries.
• The kind of cancer you had: Some cancers need treatments that are more harmful to your reproductive organs than others. An example of this would be a cancer that requires either surgery on your pelvic organs or direct radiation to your pelvis.
• The kind of treatment you received: Low amounts of radiation to areas of your body not near your reproductive organs are less likely to cause infertility. Some cancer treatments cause higher rates of infertility.

Sexual Relationships After Cancer

Will I be able to have a normal sex life?

Most likely the answer is yes. Having a sexual relationship often involves thinking a lot about your inner feelings, therefore, it can be very helpful to talk to your partner about how having cancer has impacted you emotionally. Treatment for cancer may have left you with scars from operations, loss of hair,  loss of body weight, loss of parts of your body (such as a breast, arm, or leg), or other physical changes. You may experience sadness about these changes and you may also have fears and anxieties about sharing your body with a partner. You may also be concerned about what your partner’s response might be. Talking with your partner and telling them about your fears may help you to better understand each other.

Is it normal for it to take a long time before feeling comfortable in a relationship?

Yes. Some cancer survivors worry about being “different” in their social and sexual development because of the struggles they’ve been through. Because of this, you might have a hard time getting comfortable in your relationships, or you could find it difficult to tell your partner what you want in a relationship. It is important to remember that lots of girls/women who have not had cancer feel better moving at a slower pace for many different reasons. There is no reason to rush your relationship, and you should take as much time as you need to feel comfortable with your partner. There is nothing wrong with taking your time!

What physical problems might I have with intercourse?

Some cancer survivors may have sexual problems because of their cancer treatment. These include a lowered sexual response, pain, vaginal dryness, and less interest in having sex. Surgery that has changed the size or shape of your vagina may cause difficulty with intercourse. In addition, if you have POI, you might have vaginal dryness and less of an interest in sex because of low hormone levels. Vaginal dryness can cause pain with intercourse, but vaginal lubricants such as K-Y Jelly™ or AstroGlide™ often help with this problem. If you take HRT (hormone replacement therapy) it is likely that most of these symptoms will go away completely.

Should I tell my partner about my cancer?

Sharing information about your cancer with a romantic partner is a very personal decision. It is a difficult one to make because it’s hard to know when the time is right to bring it up. Some girls worry that their partner will find them less attractive if they find out about their cancer or that the news will “scare them away.”

You should talk about your cancer when you feel ready and comfortable with sharing it. Your partner will not be able to tell from having intercourse with you that you have had cancer. However, if you have had surgery on your vagina you might have physical changes that your partner could have questions about, and you may want to prepare some answers.

In-vitro Fertilization (IVF) with your own eggs: 

This type of IVF involves fertilizing your eggs with your partner’s or a donor’s sperm in a laboratory environment after you received injections of fertility medicine. These fertilized eggs or embryos, are then put back into your uterus. Otherwise, they are frozen and kept in the lab until you are ready to become pregnant. At that time, one of the frozen embryos (fertilized eggs) is thawed and then put into your uterus where it has the potential of developing into a baby.

Human eggs can be frozen and fertilized later; however, an egg that is first frozen, and fertilized later, appears to have a somewhat lower chance of resulting in a baby than an egg that was fertilized before it was frozen. Most girls or women choose to freeze eggs before cancer treatment so that they can have them fertilized with their partner’s sperm in the future.

IVF – with donor eggs: This is done by removing another woman’s eggs from her ovaries, fertilizing the egg with your partner’s or donor’s sperm, and putting a fertilized egg into your uterus. You would then carry and give birth to the baby. This type of fertility treatment is offered to those who have POI (premature ovarian insufficiency) and do not have quality eggs. Your uterus (womb) will be able to carry a baby even if you have POI, unless you received high doses of radiation directly to your uterus.

Gestational Carriers: If, as a result of your cancer treatment, your ovaries are still healthy but your uterus is not, it is possible to have another woman (called a gestational carrier) carry a baby that comes from one of your eggs. In this case, eggs would be removed from your ovaries and fertilized by your partner’s or donor’s sperm in a lab. A fertilized egg would then be placed into the gestational carrier’s uterus, and she would carry the baby until birth. Before this process, you would work with a lawyer and sign a contract with the gestational carrier. If both your ovaries and uterus are damaged, you can also use a gestational carrier with donor eggs and your partner’s or donor’s sperm.

Adoption: This is another important option for young women who have premature ovarian insufficiency (POI). There are many children who need a home and are adopted by both couples and single women who are unable to have their own children.

What is POI?

If your doctor has told you that you have POI, your ovaries are no longer able to release hormones or eggs and you will not get your period. This condition is called premature ovarian insufficiency. Premature means, “before it is supposed to happen.” Ovarian insufficiency means that the ovaries are not working as they should be.

What are the symptoms of premature ovarian insufficiency (POI)?

POI symptoms may include:

• Lack of development during puberty
• Amenorrhea (no menstrual periods)
• Decrease in breast size
• Hot flashes
• Vaginal dryness
• Mood swings
• Decreased interest in sex
• Insomnia (not being able to sleep)

The two most common symptoms that adolescents with POI report are lack of breast development and/or a lack of menstrual periods.

How is POI diagnosed?

Your doctor can find out if your ovaries are working by doing a simple blood test to check the hormones FSH and estrogen. Sometimes it’s necessary to repeat the blood test to figure out the average number or level. High levels of FSH and low levels of estrogen in a blood test usually mean that you have at least partial ovarian insufficiency. Another blood test called AMH (Anti-Mullerian Hormone) is often done to try to assess the size of a woman’s egg supply. Women with higher levels of AMH have a better response to IVF medications (In vitro fertilization.)

Why are the hormones FSH and Estrogen so important?

In menstruating women, the pituitary gland in the brain can sense if the ovaries are making the right amounts of estrogen. If a woman is not getting her period and there is no estrogen being made, the pituitary gland in the brain will release a hormone called the follicle-stimulating hormone (FSH). This hormone sends a signal to the ovaries telling them to start making estrogen.

Your ovaries should respond to this signal and begin to release estrogen. When the estrogen is released, the pituitary gland then stops sending out FSH and the level of FSH in your blood stream lowers. However, if you have POI, your ovaries can’t make estrogen so the amount of FSH in your blood stays very high.

Is POI permanent?

POI can be unpredictable. After treatment for cancer, you may or may not get back regular menstrual cycles and ovarian function. It is possible to have POI after cancer treatment but later have your ovaries return to making hormones and possibly eggs. Unfortunately, there is no available test at this time for health care providers to tell for sure if POI will be permanent.

How is POI treated?

There is no treatment for POI. However, it is important to replace the hormones your body is no longer making. The name for this type of treatment is called hormone replacement therapy, or HRT. The hormones that need to be replaced are estrogen, progesterone or both. These hormones are necessary for breast development, menstrual periods, and healthy bones.

How do you take HRT?

There are different types of HRT. HRT is available as a pill, skin patch, vaginal cream or tablets, a vaginal hormonal ring, or shot. Pills are usually the easiest type of HRT for young women to take. Providers may recommend a hormonal patch (that contains estradiol) that’s applied to the skin once or twice a week because the level of hormones are more similar to the hormones made by the ovaries. A vaginal hormonal ring is another option. Birth control pills may also be used as HRT because they contain estrogen and progestin.

Although HRT may help to replace the hormones that your ovaries don’t make anymore, there is no way to replace your eggs if they no longer exist due to cancer treatment.

What are the effects of Hormone Replacement Therapy (HRT)?

Your breasts may increase in size if they have not finished growing. You may start having menstrual periods if your uterus is healthy. You may get PMS, menstrual cramps, irregular menstrual periods, or mood swings, just like you would if your body was making the progesterone and/or estrogen on its own.

If you are having any side effects from the HRT such as breast soreness, headaches, mood swings, etc., it’s important to discuss them with your doctor. There are many different types of HRT, and your provider can work with you to find the one that is best for you.