In recent years, there has been an increase in the number of transgender youth presenting for care. For transgender children and adolescents, their gender identity is incongruent with the gender they were assigned at birth, which often leads to significant dysphoria. Transgender youth face significant health and social burdens, with alarmingly high risks of victimization, risk-taking behaviors, sexually transmitted infections, self-harm, and suicidality. Providers are charged with providing a safe and welcoming environment for patients, giving appropriate referrals, and aiding in social and/or medical transition as needed. There are well-established guidelines available to aid practitioners in caring for this vulnerable population. The clinician providing for adolescents has an essential role in providing care for transgender youth, including preventive health care, management of menses and other acute or chronic gynecologic concerns, as well as fertility preservation counseling. In addition, the adolescent gynecologist may also provide hormonal or surgical management. This chapter reviews the historical and recent literature on transgender care for adolescents, including terminology, diagnosis, and treatment guidelines, with a focus on important considerations for the gynecologist.
Vulvovaginal graft-versus-host disease (GVHD) is an underdiagnosed and poorly recognized complication of hematopoietic stem cell transplantation (HSCT). Previous studies have reported findings restricted to predominantly adult populations. We report a case series of pediatric and young adult vulvovaginal GVHD, which was identified in 19 patients (median age, 11.8 years; range, 2.4 to 21.9 years) out of a total 302 female patients who underwent transplantation over an 8-year period at a pediatric HSCT center. The majority of patients had concomitant nongenital GVHD; only 1 patient had isolated vulvovaginal GVHD. The median time from bone marrow transplantation to diagnosis of vulvovaginal GVHD was 30 months (range, 2.3 to 97.5 months). A high percentage of the patients in our series were without vulvar or vaginal symptoms (n = 8; 42%), even though 17 patients (89%) presented with grade 3 disease based on current adult grading scales. Vulvar examination findings most frequently included interlabial and clitoral hood adhesions (89%), loss of architecture of the labia minora or clitoral hood (42%), and skin erosions or fissures (37%). Only 5 patients underwent a speculum exam, none of whom had vaginal GVHD. Examination findings of primary ovarian insufficiency (POI) can overlap with those of GVHD, and 6 patients (32%) in our cohort were diagnosed with POI. Only 1 patient was on systemic hormone replacement therapy at the time of vulvovaginal GVHD diagnosis. The majority of patients (n = 16) were treated with topical steroid therapy, with a median time to response of 43 days. Five patients (26%) had a complete response to therapy, and 10 patients (53%) had a partial response. This case series provides valuable insight into pediatric and young adult vulvovaginal GVHD and highlights the need for increased screening for vulvar disease in this population.
INTRODUCTION: Rapid repeat pregnancy (within 2 years) among young women poses serious health consequences. Long-acting reversible contraception (LARC) is safe and effective, and available to women immediately postpartum at our institution. Our primary aim was to compare the rapid repeat pregnancy rate for young women (aged 13-24 years) initiating LARC immediately postpartum versus initiating LARC within 8 weeks of delivery, and LARC versus other contraceptive methods. METHODS: A retrospective cohort study was conducted of 592 young women with a live birth from 2011-2013 within our healthcare system. Logistic regression models were used to determine the odds of rapid repeat pregnancy. RESULTS: Women using short-acting or no contraception had higher adjusted odds of rapid repeat pregnancy compared to those using LARC (aOR 2.9, 95% CI 1.5-6.0; and OR 3.2, 95% CI 1.6-7.0). Immediate postpartum LARC initiation had higher odds of rapid repeat pregnancy versus LARC initiation within 8 weeks (aOR 2.2, 95% CI 1.0-5.0). The LARC removal/expulsion rate within 2 years was 46% with immediate postpartum placement and 36% with 8 week placement. Women receiving immediate postpartum LARC were more likely to be under 18 years old, had higher gravidity, and received primarily subdermal implants. CONCLUSION: Overall, postpartum LARC use among young women resulted in decreased risk of rapid repeat pregnancy compared to short-acting or no contraception. However, because of early LARC removal and switching to short-acting or no method, young women initiating LARC immediately postpartum were more likely to experience a rapid repeat pregnancy than those initiating LARC around 6-8 weeks postpartum.
Background: Hysterectomy and mastectomy surgery for gender affirmation have traditionally been performed as separate surgeries. Our institution offers these surgeries as a single combined procedure, typically with same-day discharge. Decreasing the number of times patients need to have surgery may reduce barriers to care by limiting surgical and hospital stay events. Our primary objective was to describe the perioperative experience of transgender patients who underwent combined hysterectomy and mastectomy surgery.Methods: This retrospective case series assessed patients who underwent combined hysterectomy and mastectomy surgery between 2013 and 2015 in an integrated health care setting in the United States. Chart reviews were performed for outcomes of interest, which included operative and postoperative complications.Results: We identified 25 patients who underwent a combined hysterectomy and mastectomy for the indication of gender transition. Preoperative patient characteristics included a median age of 31, with a median BMI of 25. Ninety-two percent of the patients were on testosterone therapy at the time of surgery. A total of 76% and 24% of patients had laparoscopic and vaginal hysterectomies, respectively. Intraoperatively, the average blood loss was 104 mL, and there were no complications. Eighty percent of patients were discharged on the same day. Postoperatively, 92% of patients experienced no major complications. One patient received a uterine artery embolization and blood transfusion for postoperative intraabdominal bleeding, and one patient presented 9 weeks after surgery with partial vaginal cuff dehiscence requiring a cuff revision. There were no re-admissions within six months of surgery. There were no major mastectomy-related complications.Conclusions: Combined surgeries are feasible and reduce the number of surgical events and hospital stays. There were no complications that could be attributed to undergoing two procedures as a single incident.
Low physiologic concentrations of H2O2 stimulate vascular cell proliferation and play an important role in the proliferative phases of human vascular diseases. The biochemical mechanisms whereby human vascular cells sense and respond to these low levels of H2O2 remain poorly understood. Low concentrations of H2O2 have been shown to stimulate the rapid hyperphosphorylation of the nuclear pre-mRNA binding protein hnRNP-C by protein kinase CK1α. Here it is shown that application of low concentrations of H2O2 to endothelial cells increases the isoelectric point of protein kinase CK1αLS, the nuclear splice form of CK1α. An identical change is accomplished by treating nuclear extracts with alkaline phosphatase in vitro, indicating that H2O2 is stimulating the dephosphorylation of the kinase. This dephosphorylation is maximal with 5 μM H2O2, and occurs prior to hnRNP-C hyperphosphorylation. Treatment of endothelial cells with H2O2 stimulates the association of CK1αLS with hnRNP-C. Likewise, treating CK1αLS with alkaline phosphatase in vitro also stimulates the association of the kinase with hnRNP-C, indicating that association of the kinase with its substrate is facilitated by dephosphorylation.
The current article explores some of the more complex subtopics concerning adolescents and long-acting reversible contraceptives (LARC).Recent research has highlighted ways in which LARC provision can be optimized in adolescents and has identified gaps in adolescent LARC access and utilization.Contraceptive counseling for adolescents should be patient-centered, not necessarily LARC-first, to avoid coercion. There are increasing applications for the noncontraceptive benefits of LARC for several unique patient populations and medical conditions.
