Characteristics of systemic testosterone therapy for female hypoactive sexual desire disorder-a claims database analysis.

BACKGROUND: Testosterone therapy (TTh) is recommended for postmenopausal women with hypoactive sexual desire disorder (HSDD); however, there remain insufficient data to support use of TTh in premenopausal women with sexual dysfunction. AIM: In this study, we used a large national database to evaluate prescribing trends of TTh for women with HSDD. METHODS: We conducted a cohort analysis of information from electronic health records acquired from the data network TriNetX Diamond. The study cohort consisted of women 18-70 years of age with a diagnosis of HSDD. We analyzed trends of testosterone prescriptions, routes of testosterone administration, and coadministration of testosterone with estrogen. OUTCOMES: Despite an increase in rates of testosterone prescriptions for HSDD, there remains a high degree of variability in the duration of treatment, route of administration, and coadministration of estrogen with significant underprescription of testosterone. RESULTS: Our query of the TriNetX database led to the identification of 33 418 women diagnosed with HSDD at a mean age of 44.2 ± 10.8 years, among whom 850 (2.54%) women received a testosterone prescription. The testosterone prescriptions were highly variable with regard to duration and route of administration and coadministration with estrogen. For all patients until 2015, the prevalence of testosterone prescriptions for HSDD showed a positive quadratic relation was observed. Since 2015 a linear increase in prevalence was observed, with the highest rate of increase for patients aged 41-55 years. CLINICAL IMPLICATIONS: The findings of this study reveal a significant need for further research investigating the optimal use of TTh to enhance the sexual health of women with HSDD, and further studies on the long-term effects of testosterone use must be undertaken to ensure that patients have access to safe and effective treatment. STRENGTHS AND LIMITATIONS: Limitations to this study include patient de-identification and lack of availability of testosterone dosage data. However, this study also has many strengths, including being the first, to our knowledge, to characterize the prescribing trends of testosterone for women with HSDD. CONCLUSION: Testosterone therapy should be considered as a potential therapy for premenopausal female patients with HSDD. Further studies on the long-term effects of testosterone use must be undertaken to address disparities in the management of HSDD and to ensure patients can access treatment.

Testosterone therapy in females is not associated with increased cardiovascular or breast cancer risk: a claims database analysis.

BACKGROUND: Testosterone therapy (TTh) has been shown to improve libido in women with sexual dysfunction, but its utilization has been limited due to concern for cardiovascular events and past studies reporting highly variable results. AIM: To assess the association of TTh in women with major adverse cardiac events (MACEs), including heart attack, stroke, or death, using a large database. METHODS: The TriNetX Diamond Network was queried from 2009 to 2022. Our study cohort included adult females with ≥3 systemic testosterone prescriptions within a year. Our control cohort excluded females with any testosterone prescriptions, polycystic ovary syndrome, or androgen excess. Both cohorts excluded females with prior heart failure, unstable angina, intersex surgery (female to male), personal history of sex reassignment, or gender identity disorders. Propensity matching between the cohorts was performed. A subanalysis by age was conducted (18-55 and >55 years). OUTCOMES: We evaluated the association of TTh to the following: MACE, upper or lower emboli or deep vein thrombosis (DVT), pulmonary embolism (PE), breast neoplasm, and hirsutism within 3 years of TTh. RESULTS: When compared with propensity-matched controls, adult females with TTh had a lower risk of MACE (risk ratio [RR], 0.64; 95% CI, 0.51-0.81), DVT (RR, 0.61; 95% CI, 0.42-0.90), PE (RR, 0.48; 95% CI, 0.28-0.82), and malignant breast neoplasm (RR, 0.48; 95% CI, 0.37-0.62). Similarly, females aged 18 to 55 years with TTh had a lower risk of MACE (RR, 0.49; 95% CI, 0.28-0.85) and DVT (RR, 0.48; 95% CI, 0.25-0.93) and a similar risk of malignant breast neoplasm (RR, 0.62; 95% CI, 0.34-1.12). Females aged ≥56 years with TTh had a similar risk of MACE (RR, 0.84; 95% CI, 0.64-1.10), DVT (RR, 0.82; 95% CI, 0.50-1.36), and PE (RR, 0.52; 95% CI, 0.26-1.05) and a significantly lower risk of malignant breast neoplasm (RR, 0.51; 95% CI, 0.38-0.68). Risk of hirsutism was consistently higher in those with TTh as compared with propensity-matched controls. CLINICAL IMPLICATIONS: Our results contribute to safety data on TTh, a therapy for sexual dysfunction in women. STRENGTHS AND LIMITATIONS: The TriNetX Diamond Network allows for significant generalizability but has insufficient information for some factors. CONCLUSIONS: We found a decreased risk of MACE among women with TTh as compared with matched controls and a similar risk of MACE in postmenopausal women while demonstrating a similar or significantly lower risk of breast cancer on age-based subanalysis.

Laparoscopic administration of bupivacaine at the uterosacral ligaments during benign laparoscopic and robotic hysterectomy: a randomized controlled trial.

BACKGROUND: Postoperative pain continues to be an undermanaged part of the surgical experience. Multimodal analgesia has been adopted in response to the opioid epidemic, but opioid prescribing practices remain high after minimally invasive hysterectomy. Novel adjuvant opioid-sparing analgesia to optimize acute postoperative pain control is crucial in preventing chronic pain and minimizing opioid usage. OBJECTIVE: This study aimed to determine the effect of direct laparoscopic uterosacral bupivacaine administration on opioid usage and postoperative pain in patients undergoing benign minimally invasive (laparoscopic and robotic) hysterectomy. STUDY DESIGN: This was a single-blinded, triple-arm, randomized controlled trial at an academic medical center between March 15, 2021, and April 8, 2022. The inclusion criteria were patients aged >18 years undergoing benign laparoscopic or robotic hysterectomy. The exclusion criteria were non-English-speaking patients, patients with an allergy to bupivacaine or actively using opioid medications, patients undergoing transversus abdominis plane block, and patients undergoing supracervical hysterectomy or combination cases with other surgical services. Patients were randomized in a 1:1:1 fashion to the following uterosacral administration before colpotomy: no administration, 20 mL of normal saline, or 20 mL of 0.25% bupivacaine. All patients received incisional infiltration with 10 mL of 0.25% bupivacaine. The primary outcome was 24-hour oral morphine equivalent usage (postoperative day 0 and postoperative day 1). The secondary outcomes were total oral morphine equivalent usage in 7 days, last day of oral morphine equivalent usage, numeric pain scores from the universal pain assessment tool, and return of bowel function. Patients reported postoperative pain scores, total opioid consumption, and return of bowel function via Qualtrics surveys. Patient and surgical characteristics and primary and secondary outcomes were compared using chi-square analysis and 1-way analysis of variance. Multiple linear regression was used to identify predictors of opioid use in the first 24 hours after surgery and total opioid use in the 7 days after surgery. RESULTS: Of 518 hysterectomies screened, 410 (79%) were eligible, 215 (52%) agreed to participate, and 180 were ultimately included in the final analysis after accounting for dropout. Most hysterectomies (70%) were performed laparoscopically, and the remainder were performed robotically. Most hysterectomies (94%) were outpatient. Patients randomized to bupivacaine had higher rates of former and current tobacco use, and patients randomized to the no-administration group had higher rates of previous surgery. There was no difference in first 24-hour oral morphine equivalent use among the groups (P=.10). Moreover, there was no difference in numeric pain scores (although a trend toward significance in discharge pain scores in the bupivacaine group), total 7-day oral morphine equivalent use, day of last opioid use, or return of bowel function among the groups (P>.05 for all). The predictors of increased 24-hour opioid usage among all patients included only increased postanesthesia care unit oral morphine equivalent usage. The predictors of 7-day opioid usage among all patients included concurrent tobacco use and mood disorder, history of previous laparoscopy, estimated blood loss of >200 mL, and increased oral morphine equivalent usage in the postanesthesia care unit. CONCLUSION: Laparoscopic uterosacral administration of bupivacaine at the time of minimally invasive hysterectomy did not result in decreased opioid usage or change in numeric pain scores.

Safety of Vaginal Estrogen Therapy for Genitourinary Syndrome of Menopause in Women With a History of Breast Cancer.

OBJECTIVE: To assess the risk of recurrence of breast cancer associated with vaginal estrogen therapy in women diagnosed with genitourinary syndrome of menopause with a history of breast cancer using a large U.S. claims database. METHODS: A U.S. health research network (TriNetX Diamond Network) was queried from January 2009 to June 2022. Our cohort consisted of women diagnosed with breast cancer within 5 years before the initial genitourinary syndrome of menopause diagnosis. Patients with active disease , defined as those undergoing mastectomy, radiation treatment, or chemotherapy within 3 months before diagnosis of genitourinary syndrome of menopause, were excluded. Recurrence was defined as mastectomy, radiation, chemotherapy, or secondary malignancy within 3 months to 5 years after the initiation of vaginal estrogen therapy for genitourinary syndrome of menopause. The study cohort included those with three or more vaginal estrogen prescriptions. The control cohort included women with breast cancer without any vaginal estrogen prescriptions after genitourinary syndrome of menopause diagnosis. Propensity matching was performed. A subanalysis by positive estrogen receptor status, when available, was performed. RESULTS: We identified 42,113 women with a diagnosis of genitourinary syndrome of menopause after breast cancer diagnosis with any estrogen receptor status, 5.0% of whom received vaginal estrogen. Of the initial cohort, 10,584 patients had a history of positive estrogen receptor breast cancer, and 3.9% of this group received vaginal estrogen. Risk of breast cancer recurrence was comparable between those who received vaginal estrogen and those who did not in both the any estrogen receptor (risk ratio 1.03, 95% CI 0.91-1.18) and positive estrogen receptor (risk ratio 0.94, 95% CI 0.77-1.15) status analyses. CONCLUSION: In a large, claims-based analysis, we did not find an increased risk of breast cancer recurrence within 5 years in women with a personal history of breast cancer who were using vaginal estrogen for genitourinary syndrome of menopause.

The relationship between COVID-19 vaccination status in pregnancy and birthweight.

BACKGROUND: Despite findings that maternal COVID-19 infection in pregnancy is associated with low birthweight (weight of ≤2500 g), previous studies demonstrate no difference in low birthweight risk between COVID-19 vaccinated and unvaccinated pregnant persons. Few studies, however, have examined the association between unvaccinated, incomplete vaccination, and complete vaccination on low birthweight, and they have been limited by small sample sizes and lack of adjustment for covariates. OBJECTIVE: We sought to address key limitations of prior work and evaluate this association between unvaccinated, incomplete, and complete COVID-19 vaccination status in pregnancy and low birthweight. We predicted a protective association of vaccination on low birthweight that varies by number of doses received. STUDY DESIGN: We performed a population-based retrospective study using the Vizient clinical database, which included data from 192 hospitals in the United States. Our sample included pregnant persons who delivered between January 2021 and April 2022 at hospitals that reported maternal vaccination data and birthweight at delivery. Pregnant persons were categorized into 3 groups as follows: unvaccinated; incompletely vaccinated (1 dose of Pfizer or Moderna); or completely vaccinated (1 dose of Johnson & Johnson or ≥2 doses of Moderna or Pfizer). Demographics and outcomes were analyzed using standard statistical tests. We performed multivariable logistic regression to account for potential confounders between vaccination status and low birthweight in the original cohort. Propensity score matching was used to reduce bias related to the likelihood of vaccination, and the multivariable logistic regression model was then applied to the propensity score-matched cohort. Stratification analysis was performed for gestational age and race and ethnicity. RESULTS: Of the 377,995 participants, 31,155 (8.2%) had low birthweight, and these participants were more likely to be unvaccinated than those without low birthweight (98.8% vs 98.5%, P<.001). Incompletely vaccinated pregnant persons were 13% less likely to have low birthweight neonates compared to unvaccinated persons (odds ratio, 0.87; 95% confidence interval, 0.73-1.04), and completely vaccinated persons were 21% less likely to have low birthweight neonates (odds ratio, 0.79; 95% confidence interval, 0.79-0.89). After controlling for maternal age, race or ethnicity, hypertension, pregestational diabetes, lupus, tobacco use, multifetal gestation, obesity, use of assisted reproductive technology, and maternal or neonatal COVID-19 infections in the original cohort, these associations remained significant for only complete vaccination (adjusted odds ratio, 0.80; 95% confidence interval, 0.70-0.91) and not incomplete vaccination (adjusted odds ratio, 0.87; 95% confidence interval, 0.71-1.04). In the propensity score-matched cohort, pregnant persons who were completely vaccinated against COVID-19 were 22% less likely to have low birthweight neonates compared to unvaccinated and incompletely vaccinated individuals (adjusted odds ratio, 0.78; 95% confidence interval, 0.76-0.79). CONCLUSION: Pregnant persons who were completely vaccinated against COVID-19 were less likely to have low birthweight neonates compared to unvaccinated and incompletely vaccinated individuals. This novel association was observed among a large population after adjusting for confounders of low birthweight and factors influencing the likelihood of receiving the COVID-19 vaccine.

Perioperative Pain Management With Opioid Analgesics in Colpopexy Increases Risk of New Persistent Opioid Usage.

IMPORTANCE: Although the use of perioperative pain medications is highly investigated, limited studies have examined the usage of pain medication for post hysterectomy prolapse repair and the few that have have been restricted to smaller sample sizes. OBJECTIVE: Our objective was to assess the association of perioperative opioid usage after posthysterectomy prolapse repairs with development of new persistent opioid usage. STUDY DESIGN: The TriNetX Diamond Research Network was queried to create our cohorts of opioid-naive adult women with vaginal repair or laparoscopic sacrocolpopexy. The primary study outcomes were (1) the rate of perioperative opioid usage and (2) development of new persistent opioid usage. All cohorts were matched on age, race, ethnicity, chronic kidney disease, hypertensive diseases, ischemic heart disease, diseases of the liver, obstructive sleep apnea, affective mood disorders, pelvic and perineal pain, obesity, tobacco use, and utilization of office/outpatient, inpatient, or emergency department services. RESULTS: We identified 10,414 opioid-naive women who underwent laparoscopic sacrocolpopexy and 13,305 opioid-naive women who underwent vaginal reconstruction. Rates of perioperative opioid usage were higher after laparoscopic sacrocolpopexy. Rates of developing new opioid usage were higher in both surgical-approach populations that received perioperative opioids compared with those that did not. Rates of new and persistent opioid usage did not differ by surgical approach when stratified by perioperative opioid usage. CONCLUSIONS: We identified that opioid dependence may occur after surgery if patients are given opioids within 7 days of either approach, associating opioid dependence with perioperative opioid usage rather than the approach taken.

Perioperative opioid prescribing after male fertility procedures is associated with new persistent opioid use: retrospective analysis of a large claims database.

OBJECTIVE: To assess the risk of new persistent opioid use in opioid-naïve men who underwent male fertility procedures. DESIGN: Retrospective cohort study using a claims database. SETTING: A database linking electronic medical record data and claims-assessing men who underwent fertility procedures between 2010 and 2021. PATIENT(S): Opioid-naïve men who underwent fertility procedures (open or laparoscopic varicocelectomy, spermatocele excision, and testicular excisional or incisional biopsy) without further surgical intervention requiring anesthesia in the 2 years after the index procedure. Those with and without perioperative opioid prescriptions were propensity score matched on age, race/ethnicity, smoking status, mental health diagnoses, and preoperative pain diagnoses. INTERVENTION(S): Perioperative opioid prescription. MAIN OUTCOME MEASURE(S): The primary outcome was the incidence of new persistent opioid use (opioid prescription 3-9 months after the index fertility procedure). The secondary outcome was prolonged opioid use (opioid prescription 9-24 months after the index fertility procedure). RESULT(S): A total of 387,565 men who underwent fertility procedures were identified, of whom 25.1% received an opioid prescription. After propensity score matching, 97,215 men were included; 4.7% of men who received a perioperative opioid prescription developed new persistent opioid use compared with 2.2% of those without a perioperative opioid prescription (risk ratio, 2.16; 95% confidence interval, 2.05-2.27; number needed to harm, 39). When assessing each unique fertility procedure independently, men who received perioperative opioids had statistically higher odds of developing new persistent opioid use for all procedure types. Men with new persistent opioid use were much more likely to go on and develop prolonged opioid use than men without new persistent opioid use. CONCLUSION(S): Opioid prescription after male fertility procedures is associated with a significant risk of new persistent opioid use, emphasizing the importance of judicious opioid prescribing for male fertility procedures.

Cost drivers for benign hysterectomy within a health care system: Influence of patient, perioperative, and hospital factors.

OBJECTIVE: To identify patient, perioperative, and hospital factors that drive total hospital charges for benign hysterectomy. METHODS: The authors conducted a retrospective cohort study between July 2014 and February 2019 at five academic and community hospitals within an integrated healthcare system in the state of Maryland with a Global Budget Revenue methodology for hospital charges. Predictor variables included patient, perioperative and hospital characteristics. One-way analysis of variance was used to compare charges among approaches. A multiple linear regression model was built to account for the interaction between covariates. RESULTS: A total of 2592 patients underwent hysterectomy via laparoscopic (61%), abdominal (16%), robotic (14%), or vaginal (9%) approaches. Before adjusting for covariates, laparoscopic and vaginal approaches had similar charges ($11 637 and $12 229, respectively), while robotic and open approaches had higher charges ($17 535 and $19 099, respectively). After adjusting, charges for open, laparoscopic, and robotic approaches were higher than the vaginal approach ($692, $712, and $1279, respectively). Each operating room minute resulted in an increased cost of $46. Length of stay >23 h was associated with an increase of $865. Year, uterine size, body mass index, additional procedures, and transfusion influenced charges. CONCLUSION: Perioperative and hospital characteristics significantly influence hospital charges for benign hysterectomy, more so than nonmodifiable patient characteristics. This provides opportunities to reduce healthcare expenditures, such as improving operating room efficiency and reducing length of stay.

Polypharmacy and Multimorbidity in the Urogynecology Population and Their Effect on Pelvic Floor Symptoms.

IMPORTANCE: Polypharmacy and multimorbidity are common in older adults but has not been well studied in the urogynecologic patient population. OBJECTIVES: The objective of this study was to determine the prevalence of polypharmacy and multimorbidity in a diverse outpatient urogynecologic population and to examine whether polypharmacy and/or multimorbidity were associated with lower urinary tract symptoms, pelvic organ prolapse, defecatory distress, and/or female sexual dysfunction. STUDY DESIGN: This is a secondary analysis of a dual-center cross-sectional study of new patients presenting for evaluation of pelvic floor disorders at 2 urban academic outpatient urogynecology clinics. Baseline demographics and clinical characteristics were obtained from the electronic medical record. Validated surveys were administered to determine severity of lower urinary tract symptoms (Overactive Bladder Validated 8-Question Screener, Urogenital Distress Inventory-6), pelvic floor dysfunction (Pelvic Organ Prolapse Distress Inventory-6, Colorectal-Anal Distress Inventory-8), and sexual dysfunction (6-item Female Sexual Function Index). Standard statistical techniques were used. RESULTS: One hundred ninety-seven women with mean age 58.8 years (SD, 13.4 years) were included, and most were of minority race/ethnicity (Black, 34.0%; Hispanic, 21.8%). The majority of participants met criteria for polypharmacy (58.4%) and multimorbidity (85.8%), with a mean prescription number of 6.5 (SD, ± 4.9) and mean number of medical comorbidities of 4.9 (SD, ± 3.3). Polypharmacy and multimorbidity were significantly associated with higher CRADI-8 scores. Specifically, polypharmacy was associated with straining with bowel movements and painful stools, whereas multimorbidity was associated with incomplete emptying and fecal urgency. There was no significant association between polypharmacy and multimorbidity with urinary symptoms, prolapse, or sexual dysfunction. CONCLUSIONS: Polypharmacy and multimorbidity are common in the urogynecologic population. There is a relationship between greater defecatory distress and polypharmacy and multimorbidity.

Sleep Disorders Are Associated with Female Sexual Desire and Genital Response - A U.S. Claims Database Analysis.

OBJECTIVE: To assess the association of common sleep disorders with female sexual dysfunction. MATERIALS AND METHODS: We conducted a cross-sectional analysis using the TriNetX Diamond Network. Adult women diagnosed with insomnia, obstructive sleep apnea, or circadian rhythm sleep disorder were assessed to determine the association with female sexual dysfunction, hypoactive sexual desire disorder, female orgasmic disorder, and female sexual arousal disorder. A propensity-score matched control cohort for age, race, ethnicity, tobacco use, outpatient service utilization, obesity, hyperlipidemia, diabetes mellitus, hypertensive disease, ischemic heart disease, and surgical procedures on the female genital system was generated, excluding those with any sleep disorders, sleep deprivation, or morbid obesity with alveolar hypoventilation. All cohorts excluded those with any antidepressant or antipsychotic prescriptions. RESULTS: Our query yielded 1,317,491 women diagnosed with sleep apnea, 1,538,567 with insomnia, and 58,902 with circadian rhythm sleep disorder. Women with sleep apnea and insomnia had higher odds of hypoactive sexual desire disorder, female sexual arousal disorder, and female orgasmic disorder compared to matched controls. Women with sleep apnea, insomnia, or circadian rhythm sleep disorder all had a significantly higher odds of female sexual dysfunction compared to matched controls. CONCLUSION: In this large cross-sectional analysis, sleep disorders were strongly associated with female sexual dysfunction. It is thus crucial for providers to screen for poor sleep when conducting a thorough evaluation for sexual dysfunction in women to diagnose highly prevalent sleep disorders and improve overall health.

Risk Factors for Postoperative Narcotic Use in Benign, Minimally-Invasive Gynecologic Surgery.

Background and Objectives: To evaluate postoperative opioid use after benign minimally-invasive gynecologic surgery and assess the impact of a patient educational intervention regarding proper opioid use/disposal. Methods: Educational pamphlets were provided preoperatively. Patients underwent hysterectomy, myomectomy, or other laparoscopic procedures. Opioid prescriptions were standardized with 25 tablets oxycodone 5mg for hysterectomy/myomectomy, 10 tablets oxycodone 5mg for LSC (oral morphine equivalents were maintained for alternatives). Pill diaries were reviewed and patient surveys completed during postoperative visits. Results: Of 106 consented patients, 65 (61%) completed their pill diaries. Median opioid use was 35 OME for hysterectomy (∼5 oxycodone tablets; IQR 11.25-102.5), 30 OME for myomectomy (∼4 tablets; IQR 15-75), and 18.75 OME for laparoscopy (∼3 tablets; IQR 7.5-48.75). Median last post-operative day (d) of use was 3d for hysterectomy (IQR 2, 8), 4d for myomectomy (IQR 1, 7), and 2d for laparoscopy (IQR 0.5-3.5). One patient (myomectomy) required a refill of 5mg oxycodone. No difference was found between total opioid use and presence of pelvic pain, chronic pain disorders, or psychiatric co-morbidities. Overall satisfaction with pain control (>4 on a 5-point Likert scale) was 91% for hysterectomy, 100% for myomectomy, 83% for laparoscopy. Of the 33 patients who read the pamphlet, 32(97%) felt it increased their awareness. Conclusion: Most patients required <10 oxycodone 5mg tablets, regardless of procedure with excellent patient satisfaction. A patient education pamphlet is a simple method to increase knowledge regarding the opioid epidemic and facilitate proper medication disposal.

Impact of Obesity on Clinical and Financial Outcomes of Minimally Invasive Hysterectomy for Benign Conditions.

OBJECTIVE: To evaluate the effect of obesity on clinical and financial outcomes of minimally invasive hysterectomy METHODS: This was a retrospective cohort study of 5 affiliated hospitals. We obtained demographic, operative, and financial characteristics to analyze the effects of obesity on outcomes, including operating room (OR) time, estimated blood loss (EBL), length of stay (LOS), adverse perioperative events, and hospital charges. Obesity was stratified by the following classes: no obesity (BMI <30 kg/m2), class I (BMI 30-34 kg/m2), class II (BMI 35-39 kg/m2), and class III (BMI >40 kg/m2). Descriptive statistics and multivariate logistic and linear regressions were performed. RESULTS: A total of 2483 women underwent benign, minimally invasive hysterectomy. Laparoscopic was the most common approach (79.8%), followed by robotic (12.2%), and vaginal (8.0%). Mean BMI was 30.13 ± 6.99 kg/m2, and total charges were US $13 928 ± $5954. Each additional minute in the OR increased costs by US $47.89 (P < 0.001). Compared with patients without obesity, OR time and EBL were significantly higher among patients with class I or II obesity and highest among patients with class III obesity (P < 0.001). Obesity did not affect LOS or occurrence of adverse perioperative events. Although obesity appeared to be a significant predictor of hysterectomy charges, after adjusting for covariates, charges for laparoscopic and robotic hysterectomy did not differ significantly by BMI. CONCLUSION: Obesity appears to have a significant effect on clinical outcomes of benign hysterectomy that is approach-dependent and most notable among patients with class III obesity. BMI was not, however, a predictor of financial outcomes.

The Effect of Social Determinants of Health on Overactive Bladder Symptom Severity.

PURPOSE: Social determinants of health may significantly impact overall health and drive health disparities. We evaluated the association between social determinants of health and overactive bladder severity. MATERIALS AND METHODS: We conducted a multicenter, cross-sectional study of patients presenting to outpatient female pelvic medicine and reconstructive surgery clinics at Montefiore Medical Center (Bronx, New York) and Johns Hopkins Bayview Medical Center (Baltimore, Maryland) from November 2018 to November 2019. Surveys were administered to screen for overactive bladder (Overactive Bladder-Validated 8-Question Screener) and to evaluate social determinants of health. Ordinal logistic regression models were used to examine the association between overactive bladder symptom level and social determinants of health items, while adjusting for age, race, body mass index, parity, history of pelvic surgery and clinical site. RESULTS: A total of 256 patients with a mean±SD age of 58.6±14.2 years and body mass index of 30.4±7.5 kg/m2 were recruited over a 12-month period. Our sample was 33.6% White, 32% Black and 29.3% Hispanic, with 5.1% categorized as other. A higher overactive bladder symptom level was associated with food insecurity (OR 2.51, 95% CI 1.03-6.11), financial strain (OR 1.94, 95% CI 1.06-3.53), difficulty finding or keeping employment (OR 3.14, 95% CI 1.01-9.72) and difficulty concentrating (OR 2.48, 95% CI 1.25-4.95), after adjusting for site, age, race, body mass index, parity and previous pelvic surgery. CONCLUSIONS: In this cross-sectional study, certain social determinants of health were associated with greater overactive bladder severity. Unmet social needs may impact the success of overactive bladder treatment. Urologists should consider collaborating with social work and mental health specialists to better serve patients with overactive bladder and social determinants of health needs.

Fertility-sparing Surgery for Patients with Cervical, Endometrial, and Ovarian Cancers.

OBJECTIVE: Nearly 10% of the 1.3 million women living with a gynecologic cancer are aged <50 years. For these women, although their cancer treatment can be lifesaving, it's also life-altering because traditional surgical procedures can cause infertility and, in many cases, induce surgical menopause. For appropriately selected patients, fertility-sparing options can reduce the reproductive impact of lifesaving cancer treatments. This review will highlight existing recommendations as well as innovative research for fertility-sparing treatment in the 3 major gynecologic cancers. TABULATION, INTEGRATION, AND RESULTS: For early-stage cervical cancers, fertility-sparing surgeries include cold knife conization, simple hysterectomy with ovarian preservation, or radical trachelectomy with placement of a permanent cerclage. In locally advanced cervical cancer, ovarian transposition before radiation therapy can help preserve ovarian function. For endometrial cancers, fertility-sparing treatment includes progestin therapy with endometrial sampling every 3 to 6 months. After cancer regression, progestin therapy can be halted to allow attempts to conceive. Hysterectomy with ovarian preservation can also be considered, allowing for fertility using assisted reproductive technology and a gestational carrier. For ovarian cancers, fertility-sparing surgery includes unilateral salpingo-oophorectomy or bilateral salpingo-oophorectomy (with lymphadenectomy and staging depending on tumor histology). With higher-risk histology or higher early-stage disease, adjuvant chemotherapy is recommended-however, this carries a 3% to 10% risk of ovarian failure. Use of oocyte or embryo cryopreservation in patients with early-stage ovarian malignancy remains an area of ongoing research. CONCLUSION: Overall, fertility-sparing management of gynecologic cancers is associated with acceptable rates of progression-free survival and overall survival and is less life-altering than more radical surgical approaches.

Skin cancer risk and tanning in pageant contestants.

Since tanned skin may be perceived as a marker of beauty in American pageant culture, we evaluated pageant contestants regarding motivations for tanning, skin care behaviors, and possible tanning addiction. Responses were analyzed via summary statistics and compared across Fitzpatrick skin types. Statistically significant differences were found between skin types regarding tanning frequency, feelings of attractiveness after tanning, and perceptions of elevated mood after tanning. Contestants also demonstrated limited skin care behaviors; nearly 70% of respondents examined their skin for moles less than monthly. Of all respondents, 34% met tanning-modified Cut-Annoyed-Guilty-Eye-opener (CAGE) criteria, suggesting possible tanning addiction. This study raises several considerations regarding the possible addictive nature of tanning and the importance of skin safety in the pageant population.

Evaluation of Reported Fertility Preservation Counseling Before Chemotherapy Using the Quality Oncology Practice Initiative Survey.

Importance: The opportunity to discuss fertility preservation is essential for patients of reproductive age with newly diagnosed cancer before the initiation of treatment. Objective: To identify factors associated with fertility preservation counseling among patients of reproductive age before initiating chemotherapy. Design, Setting, and Participants: This cross-sectional study used data obtained from the American Society of Clinical Oncology (ASCO) Quality Oncology Practice Initiative, an oncologist-led quality assessment program that surveys approximately 400 oncology practices biannually, from January, 2015, to June, 2019. Main Outcomes and Measures: The primary outcome was whether reproductive risks were discussed before initiation of chemotherapy. Multivariate logistic regression was performed to identify factors associated with fertility preservation counseling, controlling for age, sex, race/ethnicity, cancer type, year of study, region, clinic type (academic vs private), annual clinic volume, and rates of insurance coverage. Results: Among the 6976 patients of reproductive age (3571 men [51%]; mean (SD) age, 42.5 [7.1] years), with reproductive age ranging from 18 to 40 years for 3405 women and from 18 to 50 years for 3571 men, clinics reported that 3036 of 6976 patients (44%) received counseling regarding the risk of infertility associated with chemotherapy. Women were more likely to be informed (1912 of 3405 [56%]) compared with men (1126 of 3571 [32%]) (P < .001). Factors associated with reduced likelihood of fertility risk discussion included male sex (odds ratio [OR], 0.73; 95% CI, 0.60-0.90), increasing age (OR, 0.93; 95% CI, 0.92-0.94), private practice setting (OR, 0.70; 95% CI, 0.53-0.93), and lack of multidisciplinary team planning (OR, 0.54; 95% CI, 0.41-0.70). Factors associated with increased likelihood of fertility risk discussion included having breast cancer (OR, 1.39; 95% CI, 1.12-1.73) and lymphatic or hematopoietic cancers (OR, 1.79; 95% CI, 1.33-2.40), participating in each subsequent study year (OR, 1.16; 95% CI, 1.08-1.24), receiving care in an academic clinic (OR, 1.45; 95% CI, 1.05-2.01), and being a practice offering clinical trial enrollment (OR, 1.60; 95% CI, 1.13-2.29). States with legislatively mandated coverage of fertility preservation had significantly higher rates of fertility risk discussion compared with states without legislation (48.6% vs 39.6%, P < .001). Conclusions and Relevance: The findings suggest that clinicians are more likely to counsel younger patients and female patients about reproductive risks before initiation of chemotherapy. State laws mandating fertility preservation coverage may be associated with improved frequency of fertility counseling before chemotherapy. Further awareness and implementation of ASCO guidelines appear to be needed to improve rates of fertility risk discussion and referrals to fertility specialists before chemotherapy.

Varicocele Repair Prior to Assisted Reproductive Technology: Patient Selection and Special Considerations.

Clinical varicoceles are one of the most commonly identified physical exam abnormalities in men presenting with infertility. Clinical varicoceles can cause impaired spermatogenesis and surgical correction can improve semen parameters in select men. Increasingly, andrologists are performing varicocele repairs prior to intrauterine insemination (IUI), in vitro fertilization (IVF), and intracytoplasmic sperm injection (ICSI) to boost male fertility potential. In this review, we evaluated the available literature 1) to determine if varicocelectomy prior to IUI or assisted reproductive technologies proved to improve sperm production or pregnancy outcomes; and 2) to identify who may be the ideal candidate for pre-IUI/ART varicocelectomy. Overall, few studies have explored this topic and little can be concluded about the impact of varicocelectomy prior to IUI. The evidence, however, does support that correcting a clinical varicocele can increase pregnancy outcomes in couples who plan to pursue IVF or ICSI. When selecting patients for varicocelectomy prior to IUI or ART, clinicians should evaluate female age as improvement in semen parameters can take 6 months after varicocelectomy and this duration of time may be deleterious in cases of advanced maternal age when each cycle becomes increasingly important. Overall, the currently limited literature regarding clinical varicoceles correction demonstrates that pregnancy rates can be increased when comparing patients who have undergone varicocelectomy prior to ART with those who had clinical varicocele but did not undergo surgery.

Short-term Outcomes of Non-robotic Single-incision Laparoscopic Sacrocolpopexy: A Surgical Technique.

STUDY OBJECTIVE: Our main purpose was to describe the surgical technique and short-term outcomes of single-incision laparoscopic sacrocolpopexy (S-LSC) for the treatment of pelvic organ prolapse (POP). DESIGN: This study consisted of a retrospective analysis of 49 consecutive cases. SETTING: This study was set at the Third Affiliated Hospital of Guangzhou Medical University from October 2016 to November 2017. PATIENTS: The population for this study consisted of women with stage II to IV POP who met eligibility criteria for laparoscopic surgery. INTERVENTIONS: S-LSC included the use of V-loc barbed suture and retroperitoneal tunneling, in addition to standard single-incision laparoscopic surgery techniques. All 49 cases were successfully completed. All cases included concomitant procedures; 42 (85.7%) had removal of the uterus and adnexa. The main measured outcomes include patient characteristics, perioperative outcomes, and change in pelvic floor support (Pelvic Organ Prolapse Quantification System), and quality of life (Pelvic Floor Impact Questionnaire). MEASUREMENTS AND MAIN RESULTS: All patients were parous, and 42.9% had a history of previous abdominal surgery. The mean operative duration from skin to skin was 201.20 ± 46.53 minutes. The mean estimated blood loss was 27.0 ± 16.6 mL. The mean pre- and post-operative Pelvic Organ Prolapse Quantification System scores were 2.2 ± 1.1 cm versus -2.6 ± 0.5 cm for the Aa point and 3.2 ± 2.8 cm versus -4.6 ± 0.8 cm for the C point (p <.05 for both). The mean pre- and post-operative Pelvic Floor Impact Questionnaire scores were 106.4 ± 18.9 versus 8.9 ± 4.26 (p <.05), suggesting that S-LSC significantly improved physical prolapse and quality of life. Four patients suffered from postoperative complications (3 mesh exposure and 1 lumbosacral pain). Six patients complained of new onset of stress urinary incontinence. CONCLUSIONS: Single-incision laparoscopic sacrocolpopexy is a feasible method to manage POP. However, the long-term effects and complications need to be further investigated.

The Prevalence of Y-chromosome Microdeletions in Oligozoospermic Men: A Systematic Review and Meta-analysis of European and North American Studies.

CONTEXT: European and North American guidelines recommend Y-chromosome microdeletion (YCM) screening in azoospermic and oligozoospermic men with sperm concentrations of <5 million sperm/ml; however, numerous studies have suggested that YCMs are rare when sperm concentrations are >1 million sperm/ml. OBJECTIVE: We systematically reviewed and meta-analyzed European and North American studies to determine the prevalence of a complete YCM in oligozoospermic men with sperm concentrations of >0-1, >1-5, and >5-20 million sperm/ml, and to determine whether 1 or 5 million sperm/ml is the most appropriate sperm concentration threshold for YCM screening. EVIDENCE ACQUISITION: A systematic review of MEDLINE, EMBASE, Cochrane Library, and ClinicalTrials.gov was performed for studies assessing the prevalence of a complete YCM in oligozoospermic men in European and North American studies. EVIDENCE SYNTHESIS: Thirty-seven studies were identified during a systematic review (n = 12 492 oligozoospermic men). All complete YCMs in oligozoospermic men were AZFc microdeletions. Eighteen studies contained data conducive to meta-analysis (n = 10 866 men). Comparing the pooled estimated prevalence by sperm concentration, complete YCMs were significantly more common in men with sperm concentrations of >0-1 million sperm/ml (5.0% [95% confidence interval {CI}: 3.6-6.8%]) versus >1-5 million sperm/ml (0.8% [95% CI: 0.5-1.3%], p < 0.001). YCMs were similar in men with sperm concentrations of >1-5 and >5-20 million sperm/ml (0.8% [95% CI: 0.5-1.3%] vs 0.5% [95% CI: 0.2-0.9%], p = 0.14). CONCLUSIONS: In Europe and North America, the majority of YCMs occur in men with sperm concentrations of ≤1 million sperm/ml, with <1% identified in men with >1 million sperm/ml. Male infertility guidelines for North America and Europe should reconsider the sperm concentration screening thresholds to recommend testing for YCMs only for men with sperm concentrations of <1 million sperm/ml. PATIENT SUMMARY: Complete Y-chromosome microdeletions (YCMs) are rare in men with >1 million sperm/ml. Routine screening for YCMs should occur only if sperm concentration is ≤1 million sperm/ml.