Hormonal contraceptive choices in a clinic-based series of transgender adolescents and young adults.

Aims: To describe the use of hormonal contraceptives for menstrual management and/or pregnancy prevention in a clinic-based series of transgender adolescents and young adults who were assigned female at birth (transmasculine identity). Methods: We performed a chart review of post-menarchal transgender assigned-female-at-birth (AFAB) patients, age 10-25 years, seen at CCHMC Transgender Health Clinic for at least 2 visits between July 1, 2013 and September 17, 2016, and who were not on a puberty suppression method. We collected data including choice of hormonal contraceptive and indication (menstrual suppression, pregnancy prevention, or both), duration of use, initiation of sexual activity, reported sexual partners, and use of gender-affirming hormone therapy (i.e., testosterone). We present simple descriptive statistics. Results: A total of 231 patients met inclusion criteria, with ages from 11 to 25 years. Of those, 135 (59%) were using a hormonal contraceptive method. Most patients (67%) used hormonal contraception for the indication of menstrual suppression. Most commonly used method was depot medroxyprogesterone (DMPA) (49 patients), followed by combined oral contraceptives (COC) and norethindrone (progestin-only pill, POP) (34 patients each). Thirteen patients used 52 mg levonorgestrel IUD (LNG-IUD). Of the total sample (n = 231), 82 (36%) reported sexual activity, 35 of whom (43% of sexually active patients) reported sexual intercourse with assigned-male-at-birth (AMAB) partners and/or penile-vaginal intercourse. Among 35 patients at risk for pregnancy, only 21 (60%) were using hormonal contraception. Over half (54%) of sexually active patients taking testosterone discontinued their hormonal contraceptive method once they stopped having menses. Discussion: Within a sample of transgender AFAB adolescents, half of whom were taking testosterone, a variety of contraceptives were used, including depot medroxyprogesterone, combined oral contraceptives, and levonorgestrel IUD. Among those taking testosterone, many patients discontinued contraception once they stopped having menses.

Comparison of Parental and Adolescent Views on the Confidential Interview and Adolescent Health Risk Behaviors within the Gynecologic Setting.

STUDY OBJECTIVE: To explore parental and adolescent views on the confidential interview in the gynecologic setting and compare adolescent reported risk-taking behaviors with parental perception. DESIGN: Anonymous surveys were administered separately to parents/guardians and adolescents between the ages of 11 and 17 years. Information pertaining to the patient's Tanner stage and reason for visit was obtained from the provider. This first phase served as the usual care group. In the second phase of the study, surveys were again distributed after a brief educational intervention. Linear regression analysis, Wilcoxon rank sum test, and Fisher exact test were used where appropriate. SETTING AND PARTICIPANTS: Pediatric and adolescent gynecology clinics in 2 tertiary hospitals. INTERVENTIONS: Brief educational handout on key concepts of the confidential interview. MAIN OUTCOME MEASURES: Parental perception of the confidential interview and adolescent risk-taking behaviors. RESULTS: A total of 248 surveys were included in the final analysis, which accounts for 62 adolescent and parent/guardian pairs in each group. Most parents and adolescents reported perceived benefit to the confidential interview. However, parents were less likely to rate benefits of private time specifically for their own adolescent and less than half of the parents believed that adolescents should have access to private time in the gynecologic setting. Parents/guardians as well as adolescents feared that the confidential interview would limit the parent's ability to take part in decision-making. The low support for confidential time for their adolescent was not different in the usual care group compared with the intervention group, although there was a trend toward parental acceptance with increased adolescent age. Adolescents were consistently more likely to report more risk-taking behaviors than their parents perceived. CONCLUSION: There is a discord between parental perception and adolescent reports of risk-taking behaviors. This is coupled with a lack of understanding or comfort regarding the benefits of the confidential interview among parents and adolescents who present for gynecologic care. A short educational intervention had only a modest effect on parental perceptions regarding the confidential interview.

Rate of Oophorectomy for Benign Indications in a Children's Hospital: Influence of a Gynecologist.

STUDY OBJECTIVE: To compare the rates of oophorectomy performed by pediatric surgeons for benign indications before and after the addition of a gynecologist to the surgical staff of a children's hospital. DESIGN, SETTING, PARTICIPANTS, INTERVENTIONS, AND MAIN OUTCOME MEASURES: We used a retrospective chart review of patients ages 5-21 years who underwent surgical management by pediatric surgeons for benign adnexal indications at a tertiary care children's hospital. Patient characteristics and clinical outcomes were recorded. Rates of oophorectomy for patients managed before the addition of a gynecologist (1998-2004) were compared with those managed after a gynecologist joined the surgical staff (2005-2013). Logistic regression analysis was conducted to compare the likelihood of oophorectomy before and after the addition of a gynecologist to the surgical staff. RESULTS: One hundred sixty-five cases were included in the final analysis. Pediatric surgeons were 8 times more likely to perform an oophorectomy for benign indications before the addition of a gynecologist to the surgical staff (odds ratio, 8.3; 95% confidence interval, 3.76-18.16). Oophorectomy was performed in 45% (25/56) of cases from 1998 to 2004 compared with 11% (12/109) of cases from 2005 to 2013. Younger age (P = .009), ischemic-appearing adnexa (P < .0001), presence of torsion (P = .017), and mature teratoma (P = .041) were associated with higher likelihood of oophorectomy. CONCLUSION: There was a higher rate of ovarian preservation for benign indications performed by pediatric surgeons after the addition of a gynecologist to the surgical staff. Younger patients, those with a mature teratoma, and ovarian torsion continue to be at higher risk for oophorectomy.

Delayed puberty in the female patient.

PURPOSE OF REVIEW: The purpose is to review current recommendations for the evaluation and management of delayed puberty in the female patient. RECENT FINDINGS: Kisspeptin activation has emerged as an important factor for initiation of pubertal development. Causes of delayed puberty can be considered in four main categories: constitutional delay of growth and puberty, hypergonadotropic hypogonadism, permanent hypogonadotropic hypogonadism, and transient/functional hypogonadism. The most common cause of delayed puberty is constitutional delay of growth and puberty; however, consistent differentiation from idiopathic hypogonadotropic hypogonadism remains challenging. Initial assessment with broad spectrum testing in an otherwise healthy adolescent is often of low clinical value. Treatment is aimed at the underlying cause of delayed puberty whenever possible and individualized to the patient. SUMMARY: Understanding the factors that contribute to delayed puberty and a thoughtful evaluation, structured to the patient, is important to identify the cause of delayed puberty and prevent unnecessary and often expensive investigations. Insuring appropriate pubertal progression, optimizing height and bone health, as well as preservation of psychosocial well-being are the ultimate goals of management of delayed puberty.

Late endocrine effects of childhood cancer.

The cure rate for paediatric malignancies is increasing, and most patients who have cancer during childhood survive and enter adulthood. Surveillance for late endocrine effects after childhood cancer is required to ensure early diagnosis and treatment and to optimize physical, cognitive and psychosocial health. The degree of risk of endocrine deficiency is related to the child's sex and their age at the time the tumour is diagnosed, as well as to tumour location and characteristics and the therapies used (surgery, chemotherapy or radiation therapy). Potential endocrine problems can include growth hormone deficiency, hypothyroidism (primary or central), adrenocorticotropin deficiency, hyperprolactinaemia, precocious puberty, hypogonadism (primary or central), altered fertility and/or sexual function, low BMD, the metabolic syndrome and hypothalamic obesity. Optimal endocrine care for survivors of childhood cancer should be delivered in a multidisciplinary setting, providing continuity from acute cancer treatment to long-term follow-up of late endocrine effects throughout the lifespan. Endocrine therapies are important to improve long-term quality of life for survivors of childhood cancer.

Acute Sexual Assault in the Pediatric and Adolescent Population.

Children and adolescents are at high risk for sexual assault. Early medical and mental health evaluation by professionals with advanced training in sexual victimization is imperative to assure appropriate assessment, forensic evidence collection, and follow-up. Moreover, continued research and outreach programs are needed for the development of preventative strategies that focus on this vulnerable population. In this review we highlight key concepts for assessment and include a discussion of risk factors, disclosure, sequelae, follow-up, and prevention.

Non-surgical management of the auto-amputated adnexa in the neonate: a report on two cases.

BACKGROUND: Prenatal ovarian torsion is a rare but significant gynecologic abnormality. Current literature has yet to establish standard management in the case of auto-amputated adnexa secondary to ovarian torsion in the neonate. CASES: We report 2 cases of abdominal masses that were diagnosed in the antenatal period and were clinically consistent with auto-amputated adnexa followed with serial ultrasonography until resolution. SUMMARY AND CONCLUSION: To our knowledge this is the first report in the literature to document resolution of 2 pelvic masses due to auto-amputated adnexa with expectant management. This suggests expectant management is an appropriate alternative to surgical management in carefully selected cases.