Reproductive health and endocrine disruption in women with breast cancer: a pilot study.

PURPOSE: The purpose of this study was to assess whether incorporation of an original reproductive health assessment and algorithm into breast cancer care helps providers appropriately manage patient reproductive health goals and to follow laboratory markers for fertility and correlate these with menstruation. METHODS: This prospective observational pilot study was set in an urban, public hospital. Newly diagnosed premenopausal breast cancer patients between 18 and 49 years old were recruited for this study prior to chemotherapy initiation. As the intervention, these patients received a reproductive health assessment and care per the study algorithm at 3-month intervals for 24 months. Blood samples were also collected at the same time intervals. The main outcome measures were to assess if the reproductive health management was consistent with patient goals and to track any follicle-stimulating hormone (FSH) and thyroid-stimulating hormone (TSH) level changes throughout treatment and post-treatment period. RESULTS: Two patients were pregnant at study initiation. They received obstetric consultations, opted to continue pregnancies, and postpone treatment; both delivered at term without complications. One woman desired future childbearing and received fertility preservation counseling. All women received family planning consultations and received/continued effective contraceptive methods. Seventy-three percent used long-term contraception, 18 % remained abstinent, and 9 % used condoms. During chemotherapy, FSH rose to menopausal levels in 82 % of patients and TSH rose significantly in 9 %. While 82 % of women experienced amenorrhea, 44 % of these women resumed menstruation after chemotherapy. CONCLUSIONS: The assessment and algorithm were useful in managing patients' reproductive health needs. Chemotherapy-induced endocrine disruption impacted reproductive health.

Cervical intraepithelial neoplasia and cancer in women 35 years and older.

OBJECTIVE: To evaluate the distribution of abnormal cytohistopathology among low-income women 35 years and older compared with women younger than 35 years. MATERIALS AND METHODS: This was a retrospective analysis of the 896 women who presented to the dysplasia clinic at an urban, public, tertiary care hospital with abnormal cervical cytology from September 23, 2008, to September 23, 2010. Statistical comparisons were made using t, χ(2), and Wilcoxon rank sum tests. RESULTS: Of the 896 patients, 460 (51%) were aged 35 years or older. Among the women 35 years and older, 56% had negative/benign histologic findings compared with 45% in women younger than 35 years. Conversely, women 35 years and older had lower rates of cervical intraepithelial neoplasia 1 (14%) than women younger than 35 years (30%). However, the prevalence of cancer diagnosis, per colposcopy, increased significantly with age, affecting 6% of women aged 50 years or older, 2% of women aged 35 to 49 years, and 1% of women younger than 35 years (p = .0008). CONCLUSIONS: Women older than 35 years with abnormal cytology demonstrated increased severity of cervical intraepithelial neoplasia on histology compared with younger women. Although women younger than 35 years were more likely to have transient human papillomavirus infections, a very high prevalence of severe cervical intraepithelial neoplasia and cancer was identified among women aged 35 years and older. Careful evaluation and follow-up must be performed for this group of women who may have previously been considered by some clinicians to be low risk on the basis of their age.

Detection of gynecologic cancers in indigent women in an urban inner-city hospital.

OBJECTIVE: Access to care is a major concern for impoverished urban communities in the United States, whereas early detection of gynecologic malignancies significantly influences ultimate survival. Our goal was to compare the stage at detection of common gynecologic cancers at an urban county hospital with national estimates, and to describe the demographic and socioeconomic characteristics of this population. METHODS: All new patients presenting to the John H. Stroger, Jr. Hospital of Cook County gynecologic oncology clinic from January 1, 2008, to December 31, 2009, were reviewed under an institutional review board-approved protocol. Patients receiving primary treatment at the institution during these dates were included for analysis. We used χ tests to compare the institution's stage distributions to national estimates. RESULTS: Two hundred nineteen patients met inclusion criteria over the 2-year study period. Racial and ethnic minorities represented 72.5% of the population. Of the 219 patients, 56.1% (123/219) were uninsured and 37.9% (83/219) were covered by Medicaid or Medicare. We identified 97 (43.9%) cervical, 95 (43%) uterine, and 29 (13.1%) ovarian cancers, including 2 synchronous primaries. Compared to the National Cancer Data Base, women with uterine cancer at our institution were significantly more likely to present with later-stage disease (P < 0.05), whereas cervical cancer and ovarian cancer stage distributions did not differ significantly. CONCLUSIONS: Compared to national trends, women with uterine cancer presenting to an urban tertiary care public hospital have significantly more advanced disease, whereas those with cervical cancer do not. Nationally funded cervical cancer screening is successful but does not address all barriers to accessing gynecologic cancer care. Promotion of public education of endometrial cancer symptoms may be a vital need to impoverished communities with limited access to care.

Prostate cancer presentation, treatment selection, and outcomes among men with HIV/AIDS: A clinical stage, race, and age-matched contemporary analysis.

PURPOSE: To compare the clinical presentation, treatment receipt, and oncologic outcomes between human immunodeficiency virus-seropositive (HIV+) and seronegative (HIV-) men with prostate cancer (CaP) matched by age, clinical stage, and race. MATERIALS AND METHODS: A retrospective review of 3,135 men treated for CaP from 2000 to 2016 was performed. HIV+ patients (N = 46) were matched 1:2 to 3 to HIV- men (N = 137) by age, race, and clinical stage. Clinicopathologic features and primary treatment received were compared between cohorts. Associations between HIV status and progression-free, cancer-specific, and overall survival were compared by HIV status using the Kaplan-Meier method and Cox proportional hazards analysis. RESULTS: After matching, men with and without HIV were similar with respect initial prostate-specific antigen, Gleason Sum, and Eastern Cooperative Oncology Group (ECOG) performance status. Among HIV+ men, 67.4% had a history of acquired immune deficiency syndrome, and 91.3% were on highly active antiretroviral therapy at CaP diagnosis. Among men with localized disease, HIV+ men were more likely to receive radiation (59.5% vs. 44.8%) or no therapy (13.5% vs. 4.3%) and less likely to receive surgery (16.2% vs. 30.2%), or to initiate active surveillance (10.8% vs. 16.4%; P = 0.04 overall). There were no differences in rates of clinical progression, development of castration resistance, or CaP death by HIV status. However, HIV+ status was associated with inferior overall survival (hazard ratio 2.89, P = 0.04). CONCLUSIONS: While most HIV+ patients had a history of acquired immune deficiency syndrome; HIV was well controlled in the majority of patients at the time of CaP diagnosis. While oncologic outcomes were similar between HIV+ and HIV- men, significant differences in treatment selection were observed. Further research is necessary to understand differences in treatment election by HIV status and to define optimal CaP treatment selection in men with HIV.

Gender Based Differences in Discriminatory Questions Asked of Urology Applicants during Residency Interviews.

INTRODUCTION: Interviews are essential to the residency application process. Questions regarding marital status, childbearing, ethnicity and religion violate employment law if asked by the interviewer. In this study we determined rates of discriminatory questions asked during urology residency interviews and assessed for differences by applicant gender. METHODS: A 22-question anonymous survey was distributed to 340 urology residency applicants. Questions were asked in a 2-part, stepwise fashion. If candidates replied "no" to whether they introduced a restricted topic, they were subsequently asked how often interviewers introduced the topic. RESULTS: Overall 35% of respondents believed they were asked an inappropriate question. However, for the 7 restricted topics assessed in this survey 54.5% of respondents reported being asked at least 1 unprompted illegal question. Of note, 85% of female respondents vs 44.9% of male respondents reported being asked about 1 of the restricted topics from the survey (p <0.0001). Women were statistically more likely to be asked about age (33.3% vs 12.4%, p=0.0064), parental status (59.1% vs 31.1%, p=0.0172) and intent for children (41.9% vs 12.5%, p=0.0003). Men were more frequently asked about their opinions and rankings of other residency programs (51.6% vs 18.8%, p=0.0296). CONCLUSIONS: An alarming percentage of urology applicants are asked interview questions that violate employment law. Female applicants are disproportionately questioned about age, parental status and intent for children. Education of interviewers regarding legally restricted questions is warranted.

Prevalence of Chlamydia trachomatis and Neisseria gonorrhoeae in an urban public hospital pregnancy termination clinic.

This study is a follow-up observational study to assess the prevalence of chlamydia (CT) and gonorrhea (GC) among women who undergo a first-trimester surgical termination in a large public, urban hospital-based termination clinic, and to compare the rates to previously published data. We conducted a retrospective chart review on 4197 patients who underwent CT and GC testing before an elective, first-trimester surgical termination between 1 June 2014 and 31 May 2015. The prevalence rates were calculated and compared by chi square tests to previously published data from 1 January 2006 to 30 June 2006 from the same publicly-funded pregnancy termination clinic. Our study population comprised mostly of African Americans (86.8%), and more than half were aged less than 25 years. The overall prevalence of CT in our population was 9.6%, which was significantly different to the prevalence of 11.4% in 2006 ( p value = 0.03). The overall prevalence of GC in our population was 1.9%, which was not significantly different to the prevalence of 2.6% in 2006. To conclude, this study demonstrates the high prevalence rate of CT-positive and GC-positive patients in our publicly-funded pregnancy termination clinic. The prevalence of infection with CT and GC in our study is higher than in other family planning clinics. Regular screening of all patients who undergo induced termination in pregnancy termination clinics can provide a valuable opportunity for physicians to counsel patients about sexually transmitted infection prevention and treatment prior to the procedure or distribution of medications.

Effect of previous induced abortions on postabortion contraception selection.

OBJECTIVE: The objective was to compare contraceptive method selection in women undergoing their first pregnancy termination versus women undergoing repeat pregnancy termination in an urban abortion clinic. We hypothesized that women undergoing repeat abortions will select highly effective contraceptives (intrauterine device, subdermal implant, tubal ligation) more often than patients undergoing their first abortion. STUDY DESIGN: We conducted a retrospective analysis of all women undergoing first-trimester surgical abortion at John H. Stroger, Jr., Hospital of Cook County from October 1, 2009, to October 31, 2011. We compared contraceptive method selection in the postabortion period after receipt of contraceptive counseling for 7466 women, stratifying women by history of no prior abortion versus one or more abortions. RESULTS: Of the 7466 women, 48.6% (3625) had no history of previous abortion. After controlling for age, race and number of living children, women with a history of abortion were more likely to select a highly effective method [odds ratio (OR) 1.19, 95% confidence interval (CI) 1.06-1.33]. Most significantly, having living children was the strongest predictor of a highly effective method with an OR of 3.17 (95% CI 2.69-3.75). CONCLUSIONS: In women having a first-trimester abortion, the factors most predictive of selecting a highly effective method for postabortion contraception include history of previous abortion and having living children. The latter holds true independent of abortion history. IMPLICATIONS: This paper is unique in its ability to demonstrate the high interest in highly effective contraceptive selection in high-risk, low-income women with prior abortion history. Efforts to integrate provision of highly effective methods of contraception for postabortion care are essential for the reduction of future unintended pregnancies.

Reproductive health counseling and practices: a cross-sectional survey of bariatric surgeons.

BACKGROUND: Nearly 50% of bariatric surgery patients are women of reproductive age. Both obstetric and gynecology and surgery professional guidelines recommend a delay of fertility 1-2 years postbariatric surgery. METHODS: We sought to assess bariatric surgeons' perioperative reproductive counseling and contraceptive provision for women of reproductive age. We conducted a cross-sectional, national 32-question mail survey of bariatric surgeons. Survey topics included demographic factors, contraceptive counseling and provision, and method preference. Descriptive statistics were reported and Χ2 tests compared results among respondent demographic characteristics. RESULTS: A total of 574 of 1,935 physicians returned surveys (30%). After excluding 41 surveys due to missing data, we analyzed 533 (27%) surveys. Mean respondent age was 48.1 years. Most respondents were male (89%), white (78%), and completed residency training ≥10 years ago (72%). The majority of respondents' bariatric surgery patients were female (77%), 63% of which were of reproductive age. Most respondents recommended that their female patients delay pregnancy 12-24 months (87%). Whereas 70% of respondents did not require preoperative contraception, 52% always required postoperative contraceptive use. Although the majority of respondents (64%) referred patients to an obstetrician-gynecologist or primary care physician to obtain contraception, 35% did not know how their female patients obtained contraception. Female respondents were more likely than male respondents to always require a medicine consultation and preoperative contraception, P<.05. CONCLUSION: Despite consistently recommending a delay in pregnancy, bariatric surgeons inconsistently address perioperative contraceptive needs of women of reproductive age. These findings highlight the need for greater collaboration between bariatric surgeons and women's healthcare providers to address the reproductive health needs of women having bariatric surgery.

Get Yourself Tested 2011-2012: findings and prevalence of Chlamydia trachomatis and Neisseria gonorrhoeae at an urban public health system.

During April 2011 and April 2012 the Get Yourself Tested campaign was launched throughout the Cook County Health and Hospitals System to promote testing of Chlamydia trachomatis (CT) and Neisseria gonorrhoeae (GC) among 15-25-year-olds in a high-prevalence urban community. Retrospective data were collected and analysed. Demographic differences by CT and GC positivity were evaluated along with factors associated with CT and GC status. A total of 2853 tests were conducted among individuals aged 15-25 years. A total of 2060 (72%) females and 793 (28%) males were tested. Of those tested, 488 (17%) individuals tested positive for either CT or GC or both; 400 (14%) were positive for CT, 139 (5%) were positive for GC. The prevalence for GC was 8.8% (n = 70) in males compared to 3.3% (n = 69) in females (p < 0.001) and the prevalence of CT was 16% (n = 127) for males compared to 13.3% (n = 273) for females (p = 0.057). Women in a high-risk population are more likely to get tested for sexually transmitted infections; however, men are more likely to test positive for CT and GC. Get Yourself Tested is an important campaign to encourage wider spread testing among populations at risk in Cook County.

Misoprostol 1 to 3 h preprocedure vs. overnight osmotic dilators prior to early second-trimester surgical abortion.

OBJECTIVES: We sought to compare the effectiveness of at least 1 h of 400 mcg of buccal misoprostol to overnight osmotic dilators for early second-trimester surgical abortion cervical preparation. DESIGN: We conducted a retrospective cohort study, reviewing 145 consecutive charts to compare procedure duration for women who received 400 mcg of buccal misoprostol at least 1 h preprocedure vs. overnight osmotic dilators before dilation and evacuation between 14 weeks, 0 days and 15 weeks, 6 days' gestation. Primary outcome was procedure duration and secondary outcomes included maximum mechanical dilator size, estimated blood loss and side effects. RESULTS: Sixty-four women (44.1%) received buccal misoprostol (mean 1.6 h), and 81 women (55.9%) received overnight osmotic dilators. Groups did not differ regarding mean gestational age or gynecologic history. All procedures in both groups were completed. Procedure duration was not significantly different between the misoprostol and osmotic dilator groups (median 11.0 min vs. 10.0 min, p=.22), even after multivariable linear regression (p=.17). The mean total cervical preparation duration was 1.6 h for women in the misoprostol group compared to 20.3 h in the osmotic dilator group (p<.001). Secondary outcomes did not differ between groups. CONCLUSIONS: We found that at least 1 h of preprocedure misoprostol decreased the duration of cervical preparation for early second-trimester procedures performed by an experienced surgeon. IMPLICATIONS: In this small, retrospective review, at least 1 h of preprocedure buccal misoprostol decreased the duration from cervical preparation initiation to procedure completion in early second-trimester procedures performed by an experienced surgeon. These results should be considered as a pilot evaluation, and further prospective study is needed to further clarify whether this short interval could be applied in general practice.

Staying on track: a cluster randomized controlled trial of automated reminders aimed at increasing human papillomavirus vaccine completion.

OBJECTIVES: To evaluate whether automated reminders increase on-time completion of the three-dose human papillomavirus (HPV) vaccine series. METHODS: Ten reproductive health centers enrolled 365 women aged 19-26 to receive dose one of the HPV vaccine. Health centers were matched and randomized so that participants received either routine follow-up (control) or automated reminder messages for vaccine doses two and three (intervention). Intervention participants selected their preferred method of reminders - text, e-mail, phone, private Facebook message, or standard mail. We compared vaccine completion rates between groups over a period of 32 weeks. RESULTS: The reminder system did not increase completion rates, which overall were low at 17.2% in the intervention group and 18.9% in the control group (p=0.881). Exploratory analyses revealed that participants who completed the series on-time were more likely to be older (OR=1.15, 95% CI 1.01-1.31), report having completed a four-year college degree or more (age-adjusted OR=2.51, 95% CI 1.29-4.90), and report three or more lifetime sexual partners (age-adjusted OR=3.45, 95% CI 1.20-9.92). CONCLUSIONS: The study intervention did not increase HPV vaccine series completion. Despite great public health interest in HPV vaccine completion and reminder technologies, completion rates remain low.

Assessing the extent of provision of comprehensive medical care management for female sexual assault patients in US hospital emergency departments.

OBJECTIVE: To describe medical services provided to sexual assault patients in US emergency departments and to identify the percentage of hospitals always providing the 10 elements of comprehensive medical care management (CMCM). METHODS: A cross-sectional study was conducted in a national sample of US hospitals. A 26-item telephone survey assessed provision of services to sexual assault survivors in accordance with CMCM. Management included acute medical care comprising history and physical examination; acute and long-term rape crisis counseling; STI testing and prophylaxis; emergency contraception counseling and provision; and HIV testing and prophylaxis. The primary outcome was extent of provision of these elements. RESULTS: Overall, 582 emergency departments responded to the survey. The following components of CMCM were provided: acute medical care (582 [100.0%]); rape crisis counseling (234 [40.2%]); STI management (448 [77.0%]); emergency contraception (351 [60.3%]); and HIV management (380 [65.3%]). Only 101 (17.4%) hospitals provided all 10 elements of CMCM. CONCLUSION: Less than one-fifth of US hospitals provide comprehensive services to sexual assault patients. A national program incorporating clinical guidelines, checklists, and funding for sexual assault forensic/nurse examiner programs could improve the standard of care provided in emergency departments-the primary point of contact for acute care of sexual assault survivors.