The Use of Injectable Estradiol in Transgender and Gender Diverse Adults: A Scoping Review of Dose and Serum Estradiol Levels.

Feminizing gender-affirming hormone therapy (GAHT) is the mainstay of treatment for many transgender and gender diverse (TGD) people. Injectable estradiol preparations are recommended by the World Professional Association for Transgender Health Standards of Care 8 and the Endocrine Society guidelines. Many patients prefer this route of administration, but few studies have rigorously assessed optimal dosing or route. We performed a scoping review of the available data on estradiol levels achieved with various dosages of estradiol injections in TGD adults on feminizing GAHT. We also report on testosterone suppression, route (i.e., subcutaneous vs. intramuscular), and type of injectable estradiol ester as well as timing of blood draw relative to the most recent dose, where available. The data we reviewed suggests that the current guidelines, which recommend starting doses 2-10 mg weekly or 5-30 mg every two weeks of estradiol cypionate or valerate, are too high and likely lead to patients having supraphysiologic levels across much of their injection cycle. The optimal starting dose for injectable estradiol remains unclear and whether it should differ for cypionate and valerate. Based on the data available, we suggest that clinicians start injectable estradiol valerate via subcutaneous or intramuscular injections at a dose ≤ 5 mg weekly and then titrate accordingly to keep levels within guideline recommended range. Future studies should assess timing of injections and subsequent levels more precisely across the injection cycle and between esters.

Novel Lactation Induction Protocol for a Transgender Woman Wishing to Breastfeed: A Case Report.

Background: Lactation induction in transgender women is a clinical and research priority in the field of breastfeeding medicine. To date, there are four case reports detailing successful induced lactation in transgender patients who wished to breastfeed. The Academy of Breast Feeding Medicine does not formally recommend a specific medication regimen for transgender patients due to lack of high-quality research. Case Presentation: A 50-year-old transgender woman with a hypercoagulable disorder who was able to lactate and breastfeed with novel hormone regimen management at a gender care clinic. Her baseline hormone treatment was an estradiol 0.3 mg transdermal patch every 72 hours and micronized progesterone 200 mg daily. Results: Within four weeks of initiating a modified hormone regimen (estradiol 0.4 mg patch every 72 hours, progesterone 300 mg daily, metoclopramide 10 mg three times daily), the patient was lactating spontaneously. On multiple occasions, she breastfed and expressed up to 30 mL of milk through pumping. Conclusion: This report offers a new effective hormone regimen for transgender patients who wish to lactate and cannot access domperidone-the galactagogue used in previous case reports. It also provides a review of previously published case reports on this subject. Future research in this field should prioritize cohort studies of transgender patients who desire lactation to further assess patient attitudes, experiences, and outcomes.

Role of Thyroid RFA in the Treatment of Autonomously Functioning Thyroid Nodules.

Autonomously functioning thyroid nodules (AFTN) are a common cause of hyperthyroid symptoms. While hemithyroidectomy or radioactive iodine ablation have historically been used to treat AFTNs, percutaneous thyroid radiofrequency ablation (RFA) is emerging as a promising option for outpatient therapy. The technique is compared to medical therapy, radioactive iodine therapy, and surgery, with an emphasis on technical differences in the ablation procedure for AFTN vs other benign thyroid nodules.

Functionalized carbon nanotube microfibers for chronic neural implants.

BACKGROUND: Much progress has been made at the interface between neural tissue and electrodes for neurophysiology. However, there continues to be a need for novel materials that integrate well with the nervous system and facilitate neural recordings with longer-term sustainability and stability. Such materials have the potential to improve clinical approaches and provide important tools for basic neuroscience research. NEW METHOD: In this paper, we explore the use of dry-spun untreated or functionalized carbon nanotube fibers as implantable electrodes for neural recordings from insects over extended time periods. RESULTS: Measurements of fly eyes responding to light flashes illustrate the suitability of these materials for recording both the low- and high-frequency components of neural signals. Repeated recordings show good sustainability, especially with functionalized carbon nanotube fibers. In particular, recordings from the optic lobes of Madagascar hissing cockroaches last for at least 8 weeks. COMPARISON WITH EXISTING METHOD(S): Electrophysiological research continues to rely heavily on metal electrodes that are good for short-lived preparations but less suitable for longer-term recordings, as scar tissue formation and cytotoxicity tend to cause a gradual reduction in signals. CONCLUSIONS: Functionalized carbon nanotubes are a promising novel material that can be used to obtain long-term or repeated stable recordings, which are necessary for longitudinal studies, or to maintain other neural tissue interfaces such as those in insect-machine hybrid robots. The introduced insect preparation can also be used for the relatively rapid and cost-efficient testing of novel electrode materials.

Diabetes Mellitus: ACOG Clinical Updates in Women's Health Care Primary and Preventive Care Review.

Diabetes mellitus is a chronic illness with increased morbidity and mortality. The prevalence of diabetes mellitus is increasing among women of all ages. This monograph provides an overview of the pathophysiology, evaluation, and management of diabetes mellitus and comorbidities in women. Management approaches in pediatric, adolescent, reproductive-aged, perimenopausal, and postmenopausal patients are addressed.

Assessing electronic health record phenotypes against gold-standard diagnostic criteria for diabetes mellitus.

OBJECTIVE: We assessed the sensitivity and specificity of 8 electronic health record (EHR)-based phenotypes for diabetes mellitus against gold-standard American Diabetes Association (ADA) diagnostic criteria via chart review by clinical experts. MATERIALS AND METHODS: We identified EHR-based diabetes phenotype definitions that were developed for various purposes by a variety of users, including academic medical centers, Medicare, the New York City Health Department, and pharmacy benefit managers. We applied these definitions to a sample of 173 503 patients with records in the Duke Health System Enterprise Data Warehouse and at least 1 visit over a 5-year period (2007-2011). Of these patients, 22 679 (13%) met the criteria of 1 or more of the selected diabetes phenotype definitions. A statistically balanced sample of these patients was selected for chart review by clinical experts to determine the presence or absence of type 2 diabetes in the sample. RESULTS: The sensitivity (62-94%) and specificity (95-99%) of EHR-based type 2 diabetes phenotypes (compared with the gold standard ADA criteria via chart review) varied depending on the component criteria and timing of observations and measurements. DISCUSSION AND CONCLUSIONS: Researchers using EHR-based phenotype definitions should clearly specify the characteristics that comprise the definition, variations of ADA criteria, and how different phenotype definitions and components impact the patient populations retrieved and the intended application. Careful attention to phenotype definitions is critical if the promise of leveraging EHR data to improve individual and population health is to be fulfilled.

Statin intolerance in a referral lipid clinic.

BACKGROUND: Statins effectively prevent atherosclerotic cardiovascular disease, but rates of statin discontinuation after adverse events are high. OBJECTIVE: Describe the range and relative frequencies of adverse events potentially attributable to statins in lipid referral practice and assess statin rechallenge outcomes. METHODS: Retrospective cohort study of 642 patients with statin-associated adverse events evaluated in a referral lipid clinic between January 1, 2004 and January 27, 2011. RESULTS: Patients experiencing adverse events by organ system included 92% with musculoskeletal, 8% central nervous system, 10% liver, 8% gastrointestinal, 5% peripheral nervous system, 5% skin, and 3% other events. Overlap of organ system involvement occurred in 22.5%. At least 1 follow-up visit was made by 557 patients, among whom overall median follow-up was 25 months. Among patients treated with a statin in the clinic, 71% remained on a statin at the last follow-up visit. Patients with hepatic transaminase increases by history were numerically more likely than the overall group to resume or remain on statin treatment, whereas those reporting central nervous system or gastrointestinal symptoms trended lower for statin maintenance. Among patients who experienced an adverse event after statin rechallenge, the majority (64%) were being treated with intermittent, nondaily dosing at the time of the adverse event. CONCLUSION: Although musculoskeletal symptoms are reported by 90% of patients with statin intolerance, symptoms involving other organ systems may be more frequent than previously supposed. Understanding the range of symptoms, time course, and impact on daily activities informs counseling in patient-centered practice, but assessment of causation by statins remains challenging.

Review of nonalcoholic fatty liver disease in women with polycystic ovary syndrome.

Polycystic ovary syndrome (PCOS) is the most common endocrine disorder in reproductive-aged women. Women with PCOS frequently have metabolic complications including insulin resistance (IR), early diabetes, hypertension and dyslipidemia. Recent studies have demonstrated an association between PCOS and another metabolic complication: nonalcoholic fatty liver disease (NAFLD). NAFLD occurs as a result of abnormal lipid handling by the liver, which sensitizes the liver to injury and inflammation. It can progress to nonalcoholic steatohepatitis (NASH), which is characterized by hepatocyte injury and apoptosis. With time and further inflammation, NASH can progress to cirrhosis. Thus, given the young age at which NAFLD may occur in PCOS, these women may be at significant risk for progressive hepatic injury over the course of their lives. Many potential links between PCOS and NAFLD have been proposed, most notably IR and hyperandrogenemia. Further studies are needed to clarify the association between PCOS and NAFLD. In the interim, clinicians should be aware of this connection and consider screening for NAFLD in PCOS patients who have other metabolic risk factors. The optimal method of screening is unknown. However, measuring alanine aminotransferase and/or obtaining ultrasound on high-risk patients can be considered. First line treatment consists of lifestyle interventions and weight loss, with possible pharmacologic interventions in some cases.

Screening for glucose intolerance in polycystic ovary syndrome: hemoglobin A1C, fasting blood glucose or oral glucose tolerance test?

Polycystic ovary syndrome (PCOS) is a chronic condition with many reproductive, metabolic and psychological manifestations. Insulin resistance puts women with PCOS at an increased risk for developing impaired glucose tolerance (IGT) and diabetes (T2D). An oral glucose tolerance test is the preferred IGT/T2D screening test, since it is most sensitive for detecting early glucose abnormalities. The goals in detecting IGT in these women are to avoid progression to T2D, modify cardiovascular risk and prevent gestational diabetes. Periodic IGT/T2D rescreening is necessary, given their propensity for more rapid deterioration in glucose tolerance. Lifestyle intervention is first-line therapy for PCOS women with IGT. Metformin is an option if lifestyle intervention fails to have an impact, while bariatric surgery is reserved for a select set of morbidly obese patients.