Colposcopy Standards: Guidelines for Endocervical Curettage at Colposcopy.

OBJECTIVE: The most recent guidelines for colposcopy practice in the United States, the 2017 Colposcopy Standards Consensus Guidelines, did not include recommendations for endocervical curettage (ECC). This document provides updated guidelines for use of ECC among patients referred for colposcopy. METHODS: Consensus guidelines for the use of ECC were developed in 2012. To update these guidelines in concordance with the 2017 Colposcopy Standards process, an expert workgroup was convened in 2021. Literature had been previously reviewed through 2011, before the 2012 guideline. Literature from the years 2012-2021 and data from the NCI Biopsy study were reviewed, focusing on the additional yield of ECC. RESULTS: Endocervical curettage is recommended for patients with high-grade cytology, human papillomavirus 16/18 infection, positive results on dual staining for p16/Ki67, for those previously treated for known or suspected cervical precancer or considering observation of cervical intraepithelial neoplasia grade 2, and when the squamocolumnar junction is not fully visualized at colposcopy. Endocervical curettage is preferred for all patients aged older than 40 years. Endocervical curettage is acceptable for all nonpregnant patients undergoing colposcopy but may be omitted when a subsequent excisional procedure is planned, the endocervical canal does not admit a sampling device, or in nulliparous patients aged younger than 30 years, with cytology reported as atypical squamous cells of undetermined significance or low-grade squamous intraepithelial lesion regardless of whether the squamocolumnar junction is fully visualized. Endocervical curettage is unacceptable in pregnancy. CONCLUSIONS: These guidelines for ECC add to the 2017 consensus recommendations for colposcopy practice in the United States.

Neonatal outcomes of births in freestanding birth centers and hospitals in the United States, 2016-2019.

BACKGROUND: Births in freestanding birth centers have more than doubled between 2007 and 2019. Although birthing centers, which are defined by the American College of Obstetricians and Gynecologists as ". . . freestanding facilities that are not hospitals," are being promoted as offering women fewer interventions than hospitals, there are limited recent data available on neonatal outcomes in these settings. OBJECTIVE: To compare several important measures of neonatal safety between 2 United States birth settings and birth attendants: deliveries in freestanding birth centers and hospital deliveries by midwives and physicians. STUDY DESIGN: This is a retrospective cohort study using the United States Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Health Statistics, and Division of Vital Statistics natality online database for the years 2016 to 2019. All term, singleton, low-risk births were eligible for inclusion. The study outcomes were several neonatal outcomes including neonatal death, neonatal seizures, 5-minute Apgar scores of <4 and <7, and neonatal death in nulliparous and in multiparous women. Outcomes were compared between the following 3 groups: births in freestanding birth centers, in-hospital births by a physician, and in-hospital births by a midwife. The prevalence of each neonatal outcome among the different groups was compared using Pearson chi-squared test, with the in-hospital midwife births being the reference group. Multivariate logistic regression models were performed to account for several potential confounding factors such as maternal prepregnancy body mass index, maternal weight gain, parity, gestational weeks, and neonatal birthweight and calculated as adjusted odds ratio. RESULTS: The study population consisted of 9,894,978 births; 8,689,467 births (87.82%) were in-hospital births by MDs and DOs, 1,131,398 (11.43%) were in-hospital births by midwives, and 74,113 (0.75%) were births in freestanding birth centers. Freestanding birth center deliveries were less likely to be to non-Hispanic Black or Hispanic, less likely to women with public insurance, less likely to be women with their first pregnancy, and more likely to be women with advanced education and to have pregnancies at ≥40 weeks' gestation. Births in freestanding birth center had a 4-fold increase in neonatal deaths (3.64 vs 0.95 per 10,000 births: adjusted odds ratio, 4.00; 95% confidence interval, 2.62-6.1), a more than 7-fold increase in neonatal deaths for nulliparous patients (6.8 vs 0.92 per 10,000 births: adjusted odds ratio, 7.7; 95% confidence interval, 4.42-13.76), a more than 2-fold increase in neonatal seizures (3.91 vs 1.94 per 10,000 births: adjusted odds ratio, 2.19; 95% confidence interval, 1.48-3.22), and a more than 7-fold increase of a 5-minute Apgar score of <4 (194.84 vs 28.5 per 10,000 births: adjusted odds ratio, 7.46; 95% confidence interval, 7-7.95). Compared with hospital midwife deliveries, hospital physician deliveries had significantly higher adverse neonatal outcomes (P<0.001). CONCLUSION: Births in United States freestanding birth centers are associated with an increased risk of adverse neonatal outcomes such as neonatal deaths, seizures, and low 5-minute Apgar scores. Therefore, when counseling women about the location of birth, it should be conveyed that births in freestanding birth centers are not among the safest birth settings for neonates compared with hospital births attended by either midwives or physicians.

The care of pregnant women during the COVID-19 pandemic - response of a large health system in metropolitan New York.

The rapid progression of the coronavirus disease 2019 (COVID-19) outbreak presented extraordinary challenges to the US health care system, particularly straining resources in hard hit areas such as the New York metropolitan region. As a result, major changes in the delivery of obstetrical care were urgently needed, while maintaining patient safety on our maternity units. As the largest health system in the region, with 10 hospitals providing obstetrical services, and delivering over 30,000 babies annually, we needed to respond to this crisis in an organized, deliberate fashion. Our hospital footprint for Obstetrics was dramatically reduced to make room for the rapidly increasing numbers of COVID-19 patients, and established guidelines were quickly modified to reduce potential staff and patient exposures. New communication strategies were developed to facilitate maternity care across our hospitals, with significantly limited resources in personnel, equipment, and space. The lessons learned from these unexpected challenges offered an opportunity to reassess the delivery of obstetrical care without compromising quality and safety. These lessons may well prove valuable after the peak of the crisis has passed.

Obesity and STING1 genotype associate with 23-valent pneumococcal vaccination efficacy.

BACKGROUNDObesity has been associated with attenuated vaccine responses and an increased risk of contracting pneumococcal pneumonia, but no study to our knowledge has assessed the impact of obesity and genetics on 23-valent pneumococcal vaccine (PPSV23) efficacy. We assessed the relationship of obesity (primary analysis) and stimulator of interferon genes (STING1) genotype (secondary analysis) on PPSV23 efficacy.METHODSNonobese (BMI 22-25 kg/m2) and obese participants (BMI ≥30 kg/m2) were given a single dose of PPSV23. Blood was drawn immediately prior to and 4-6 weeks after vaccination. Serum samples were used to assess PPSV23-specific antibodies. STING1 genotypes were identified using PCR on DNA extracted from peripheral blood samples.RESULTSForty-six participants were categorized as nonobese (n = 23; 56.5% women; mean BMI 23.3 kg/m2) or obese (n = 23; 65.2% women; mean BMI 36.3 kg/m2). Obese participants had an elevated fold change in vaccine-specific responses compared with nonobese participants (P < 0.0001). The WT STING1 group (R232/R232) had a significantly higher PPSV23 response than individuals with a single copy of HAQ-STING1 regardless of BMI (P = 0.0025). When WT was assessed alone, obese participants had a higher fold serotype-specific response compared with nonobese participants (P < 0.0001), but no difference was observed between obese and nonobese individuals with 1 HAQ allele (P = 0.693).CONCLUSIONSThese observations demonstrate a positive association between obesity and PPSV23 efficacy specifically in participants with the WT STING1 genotype.TRIAL REGISTRATIONClinicalTrials.gov NCT02471014.FUNDINGThis research was supported by the NIH and the University of Florida MD-PhD Training Program.

Mommy Meltdown: Understanding Racial Differences Between Black and White Women in Attitudes About Postpartum Depression and Treatment Modalities.

BACKGROUND: Postpartum depression is a major public health problem, but limited information is available about risk factors and attitudes of minority women about postpartum depression. The objective of this study is to determine attitudes of minority women toward postpartum depression and treatment. METHODS: In this prospective study at an academic resident and faculty clinic, 39 women (19 black and 20 white) at the 6-week postpartum visit completed a survey that was developed for this study to assess personal and family attitudes about postpartum depression in addition to the routinely distributed Edinburgh postnatal depression scale. The primary outcome variable was the presence of postpartum depression amongst minority women compared to other races. The secondary outcome looked at descriptors of attitudes about depression and treatment. Data were analyzed with Chi-square test for categorical data and Student's t-test for continuous data. RESULTS: Black and white participants were comparable in age, distribution of gestational age at birth, delivery type and pregnancy complications. The diagnosis of postpartum depression was not different in either population (two black and three white women; P = 0.667). Black participants were referred less frequently to counseling as treatment (5% vs. 30%; P = 0.052) but both black and white study participants viewed counseling as helpful (84% vs. 80%; P = 0.345). Black participants had a lower frequency of family history of depression (11% vs. 40%; P = 0.052) but both study groups were comfortable discussing the topic with their families, felt that their families were not ashamed of any social stigma about depression, and would be supportive of either counseling or medications as a treatment modality. CONCLUSIONS: Postpartum depression was common among our patients regardless of race. Most black and white women were willing to discuss depression with their families and accept treatment. Despite previous evidence to the contrary, black women stated that they were open to counseling as treatment for depression.

Guidelines for Cervical Cancer Screening in Immunosuppressed Women Without HIV Infection.

EXECUTIVE SUMMARY: The risk of cervical cancer (CC) among women immunosuppressed for a variety of reasons is well documented in the literature. Although there is improved organ function, quality of life and life expectancy gained through use of immunosuppressant therapy, there may be increased long-term risk of cervical neoplasia and cancer and the need for more intense screening, surveillance, and management. Although guidance for CC screening among HIV-infected women (see Table 1) has been supported by evidence from retrospective and prospective studies, recommendations for CC screening among non-HIV immunosuppressed women remains limited because quality evidence is lacking. Moreover, CC screening guidelines for HIV-infected women have changed because better treatments evolved and resulted in longer life expectancy.The objective of this report was to summarize current knowledge of CC, squamous intraepithelial lesions, and human papillomavirus (HPV) infection in non-HIV immunocompromised women to determine best practices for CC surveillance in this population and provide recommendations for screening. We evaluated those with solid organ transplant, hematopoietic stem cell transplant, and a number of autoimmune diseases.A panel of health care professionals involved in CC research and care was assembled to review and discuss existing literature on the subject and come to conclusions about screening based on available evidence and expert opinion. Literature searches were performed using key words such as CC, cervical dysplasia/squamous intraepithelial lesion, HPV, and type of immunosuppression resulting in an initial group of 346 articles. Additional publications were identified from review of citations in these articles. All generated abstracts were reviewed to identify relevant articles. Articles published within 10 years were considered priority for review. Reviews of the literature were summarized with relevant statistical comparisons. Recommendations for screening generated from each group were largely based on expert opinion. Adherence to screening, health benefits and risks, and available clinical expertise were all considered in formulating the recommendations to the degree that information was available. RESULTS: Solid Organ Transplant: Evidence specific for renal, heart/lung, liver, and pancreas transplants show a consistent increase in risk of cervical neoplasia and invasive CC, demonstrating the importance of long-term surveillance and treatment. Reports demonstrate continued risk long after transplantation, emphasizing the need for screening throughout a woman's lifetime.Hematopoietic Stem Cell Transplant: Although there is some evidence for an increase in CC in large cohort studies of these patients, conflicting results may reflect that many patients did not survive long enough to evaluate the incidence of slow-growing or delayed-onset cancers. Furthermore, history of cervical screening or previous hysterectomy was not included in registry study analysis, possibly leading to underestimation of CC incidence rates.Genital or chronic graft versus host disease is associated with an increase in high-grade cervical neoplasia and posttransplant HPV positivity.Inflammatory Bowel Disease: There is no strong evidence to support that inflammatory bowel disease alone increases cervical neoplasia or cancer risk. In contrast, immunosuppressant therapy does seem to increase the risk, although results of observational studies are conflicting regarding which type of immunosuppressant medication increases risk. Moreover, misclassification of cases may underestimate CC risk in this population. Recently published preventive care guidelines for women with inflammatory bowel disease taking immunosuppressive therapy recommend a need for continued long-term CC screening.Systemic Lupus Erythematosus and Rheumatoid Arthritis: The risk of cervical high-grade neoplasia and cancer was higher among women with systemic lupus erythematosus than those with rheumatoid arthritis (RA), although studies were limited by size, inclusion of women with low-grade neoplasia in main outcomes, and variability of disease severity or exposure to immunosuppressants. In studies designed to look specifically at immunosuppressant use, however, there did seem to be an increase in risk, identified mostly in women with RA. Although the strength of the evidence is limited, the increase in risk is consistent across studies.Type 1 DM: There is a paucity of evidence-based reports associating type 1 DM with an increased risk of cervical neoplasia and cancer. RECOMMENDATIONS: The panel proposed that CC screening guidelines for non-HIV immunocompromised women follow either the (1) guidelines for the general population or (2) current center for disease control guidelines for HIV-infected women. The following are the summaries for each group reviewed, and more details are noted in accompanying table:Solid Organ Transplant: The transplant population reflects a greater risk of CC than the general population and guidelines for HIV-infected women are a reasonable approach for screening and surveillance.Hematopoietic Stem Cell Transplant: These women have a greater risk of CC than the general population and guidelines for HIV-infected women are a reasonable approach for screening. A new diagnosis of genital or chronic graft versus host disease in a woman post-stem cell transplant results in a greater risk of CC than in the general population and should result in more intensive screening and surveillance.Inflammatory Bowel Disease: Women with inflammatory bowel disease being treated with immunosuppressive drugs are at greater risk of cervical neoplasia and cancer than the general population and guidelines for HIV-infected women are a reasonable approach for screening and surveillance. Those women with inflammatory bowel disease not on immunosuppressive therapy are not at an increased risk and should follow screening guidelines for the general population.Systemic Lupus Erythematosus and Rheumatoid Arthritis: All women with systemic lupus erythematosus, whether on immunosuppressant therapy or not and those women with RA on immunosuppressant therapy have a greater risk of cervical neoplasia and cancer than the general population and should follow CC screening guidelines for HIV-infected women. Women with RA not on immunosuppressant therapy should follow CC screening guidelines for the general population.Type 1 Diabetes Mellitus: Because of a lack of evidence of increased risk of cervical neoplasia and cancer among women with type 1 DM, these women should follow the screening guidelines for the general population.

The Neonatal Microbiome and Its Partial Role in Mediating the Association between Birth by Cesarean Section and Adverse Pediatric Outcomes.

BACKGROUND: Cesarean sections (CS) are among the most commonly performed surgical procedures in the world. Epidemiologic data has associated delivery by CS with an increased risk of certain adverse health outcomes in children, such as asthma and obesity. OBJECTIVE: To explore what is known about the effect of mode of delivery on the development of the infant microbiome and discuss the potentially mediating role of CS-related microbial dysbiosis in the development of adverse pediatric health outcomes. Recommendations for future inquiry are also provided. METHODS: This study provides a narrative overview of the literature synthesizing the findings of literature retrieved from searches of PubMed and other computerized databases and authoritative texts. RESULTS: Emerging evidence suggests that mode of delivery is involved in the development of the neonatal microbiome and may partially explain pediatric health outcomes associated with birth by CS. Specifically, the gut microbiome of vaginally delivered infants more closely resembles their mothers' vaginal microbiome and thus more commonly consists of potentially beneficial microbiota such as Lactobacillus, Bifidobacterium, and Bacteroides. Conversely, the microbiome of infants born via CS shows an increased prevalence of either skin flora or potentially pathogenic microbial communities such as Klebsiella, Enterococcus, and Clostridium. CONCLUSIONS: Mode of delivery plays an important role in the development of the postnatal microbiome but likely tells only part of the story. More comprehensive investigations into all the pre- and perinatal factors that have the potential to contribute to the neonatal microbiome are warranted.

What Are Optimal Cesarean Section Rates in the U.S. and How Do We Get There? A Review of Evidence-Based Recommendations and Interventions.

Cesarean sections (CSs) are the most commonly performed surgical procedures in the world today. Global epidemiological studies from the last decade suggest that the optimal CS rates in developed countries exist somewhere between 15% and 19%. Despite these findings, CS rates in the United States have remained stable at slightly over 32% over the past 10 years. Using primary and secondary literature published from 2010 to 2015, this review discusses how optimal CS rates were developed. In addition, we define a category of potentially avoidable CS (i.e., those conducted on nulliparous low-risk women who present with vertex infants at term) and explore how CS in this population appear to be one of the main drivers of high CS rates overall. The institutional, provider, and patient-related factors, which may be related to higher-than-recommended rates of CS, particularly those conducted in low-risk women, will be discussed. This review will then delve into clinician and patient-oriented interventions that have been shown to effectively reduce the rate of potentially avoidable CS. Our analysis showed that large-scale, multifaceted interventions that include audit and feedback cycles as well as peer review strategies were the most effective in decreasing rates of potentially avoidable CS. This review concludes with an agenda for future research into interventions that aim to achieve optimal CS rates.

Clinical Utility of Molecular Biomarkers in Cervical Squamous Intraepithelial Lesions in a Young Adult Population.

OBJECTIVE: Although human papillomavirus (HPV) infection is necessary for cervical squamous intraepithelial lesion (SIL/CIN) and cancer to develop, exposure to HPV is not predictive of which women will develop SIL/CIN and cancer. This study examines mRNA expression of several potential biomarkers in exfoliated cervical cells collected from college-aged women. MATERIALS AND METHODS: Freshman female students were recruited into the Carolina Women's Care Study, which was designed to prospectively evaluate factors that contribute to persistent HPV infections. One component of this study was to extract mRNA from exfoliated cervical cells. In this study, mRNA expression of Frizzled (FZD), growth differentiating factor 15, interleukin 1 beta (IL1ß), and N-cadherin was assessed through real-time polymerase chain reaction. Statistical analysis was performed with a Student t test; all results were standardized with glyceraldehyde 3-phosphate dehydrogenase. RESULTS: Fifty samples were selected that reflected the demographics of the Carolina Women's Care Study participants. IL1ß mRNA expression was 9.4-fold higher in cervical cells from women with abnormal Pap tests (p = .0018); low-grade squamous intraepithelial lesion had 12.7-fold higher expression than negatives (p = .0011). The FZD mRNA expression was 5.7-fold higher in CIN 2 as compared with CIN 1 (p = .0041) and 8.5-fold higher compared with cytology/pathology negative (p = .0014). Other differences in mRNA expression showed trends but not reaching statistical significance for each condition. CONCLUSIONS: It seems that several biomarkers involved in the cytokine/inflammatory pathway (IL1ß), cell adhesion pathway (N-cadherin), growth factor (growth differentiating factor 15), and Wingless (WNT) signaling pathway (FZD) may be potential biomarkers in conjunction with the Pap test and HPV that help predict which women are at highest risk for developing CIN 3 and cervical cancer.

Disparity in the persistence of high-risk human papillomavirus genotypes between African American and European American women of college age.

BACKGROUND: Cervical cancer incidence and mortality rates are higher in African Americans than in European Americans (white, non-Hispanic of European ancestry). The reasons for this disparity are not known. METHODS: We recruited a population-based longitudinal cohort of 326 European American and 113 African American female college freshmen in Columbia, South Carolina, to compare clearance of high-risk human papillomavirus (HR-HPV) infection between ethnicities. HPV testing and typing from samples obtained for Papanicolaou testing occurred every 6 months. RESULTS: African American participants had an increased risk of testing positive for HR-HPV, compared with European American participants, but the frequency of incident HPV infection was the same in African American and European American women. Thus, exposure to HPV could not explain the higher rate of HPV positivity among African American women. The time required for 50% of participants to clear HR-HPV infection was 601 days for African American women (n = 63) and 316 days for European American women (n = 178; odds ratio [OR], 1.61; 95% confidence interval [CI], 1.08-2.53). African American women were more likely than European American women to have an abnormal result of a Papanicolaou test (OR, 1.58; 95% CI, 1.05-2.39). CONCLUSIONS: We propose that the longer time to clearance of HR-HPV among African American women leads to increased rates of abnormal results of Papanicolaou tests and contributes to the increased rates of cervical cancer observed in African American women.

Selection of contraceptive therapy for patients with thrombophilia: a review of the evidence.

BACKGROUND: Awareness of the contributions of thrombophilia to thrombosis-related morbidity and mortality has been growing in the last few decades. Thrombophilia is especially concerning in females seeking contraception because some types of hormonal contraception have been associated with venous thromboembolism (VTE). Clinicians face a growing need for awareness of evidence-based contraception selection for this population. METHODS: PubMed literature searches were conducted to provide a review of the literature describing contraceptive use in patients with thrombophilia. This review also describes contraceptive selection and counseling for this population. RESULTS: Studies of combined hormonal contraceptive (CHC) use demonstrate a 2- to 50-fold increase in VTE in individuals with thrombophilia, depending on the type of thrombophilia and the reference group identified. Two small studies describing VTE incidence in progesterone-only contraceptive (POC) users with thrombophilia were identified but they did not provide conclusive information regarding VTE risk in this population. CONCLUSIONS: POC may be recommended for contraception in patients with most thrombophilias, but studies should be undertaken to further define the safety of POC use in this population.

Delaying Pap test screening in the adolescent population: an evidence-based approach.

Cervical cancer screening guidelines have evolved significantly over the past ten years in the adolescent population. The objective of this article is to review the cervical screening guidelines in the adolescent population as well as examine the evidence and studies that support delaying screening until 21 years old. Delaying HPV and Papanicolaou testing until 21 years old is safe and will not increase cervical cancer rates in the adolescent population.

HPV prevalence at enrollment and baseline results from the Carolina Women's Care Study, a longitudinal study of HPV persistence in women of college age.

BACKGROUND: Cervical cancer, a rare outcome of high-risk human papillomavirus (HPV) infection, disproportionately affects African American women, who are about twice more likely than European American women to die of the disease. Most cervical HPV infections clear in about one year. However, in some women HPV persists, posing a greater risk for cervical dysplasia and cancer. The Carolina Women's Care Study (CWCS) was conducted to explore the biological, genetic, and lifestyle determinants of persistent HPV infection in college-aged European American and African American women. This paper presents the initial results of the CWCS, based upon data obtained at enrollment. METHODS: Freshman female students attending the University of South Carolina were enrolled in the CWCS and followed until graduation with biannual visits, including two Papanicolaou tests, cervical mucus collection, and a questionnaire assessing lifestyle factors. We recruited 467 women, 293 of whom completed four or more visits for a total of 2274 visits. RESULTS AND CONCLUSION: CWCS participants were 70% European American, 24% African American, 3% Latina/Hispanic, and 3% Asian. At enrollment, 32% tested positive for any HPV. HPV16 infection was the most common (18% of infections). Together, HPV16, 66, 51, 52, and 18 accounted for 58% of all HPV infections. Sixty-four percent of all HPV-positive samples contained more than one HPV type, with an average of 2.2 HPV types per HPV-positive participant. We found differences between African American and European American women in the prevalence of HPV infection (38.1% African American, 30.7% European American) and abnormal Papanicolaou test results (9.8% African-American, 5.8% European American). While these differences did not reach statistical significance at enrollment, as the longitudinal data of this cohort are analyzed, the sample size will allow us to confirm these results and compare the natural history of HPV infection in college-aged African American and European American women.

Keratinizing squamous dysplasia pap test: a case for colposcopy.

OBJECTIVE: This study characterized women with Pap tests showing keratinizing squamous dysplasia (KSD) and helped develop management strategies in these patients. METHODS: This is a retrospective chart review of women presenting to Palmetto Health Women's Center with KSD on a Pap test from 1999 to 2009. Data analysis was performed with standard statistical computer programming; null hypothesis was rejected for p values .05 or less. RESULTS: A total of 65 Pap tests with KSD were identified. We found that women with KSD were statistically older (35 vs 26.8 y) and were more likely African American and less likely Hispanic than the general clinic population at Palmetto Health Women's Center. There were no statistical differences in body mass index or history of teen pregnancy. Interestingly, 41% of the women with KSD were immunosuppressed (e.g., human immunodeficiency virus infection, end-stage renal disease, long-term steroid use). All women with KSD were referred for colposcopy; 24% of patients failed to follow-up. Pathology distribution on cervical biopsies were similar to what is found after high-grade squamous intraepithelial lesion findings in Pap tests, with 58% cervical intraepithelial neoplasia (CIN) 2/3 or cancer, 32% CIN 1, and 10% negative biopsies. Of the women who had CIN 1 on cervical biopsy, 80% had persistent dysplasia or abnormal Pap test. Also, 60% had CIN 1 and 20% progressed to CIN 2/3 or carcinoma in situ. CONCLUSIONS: Our data suggest that women with KSD on Pap test should be managed aggressively with immediate colposcopy and cervical biopsies and not with expectant management.

HPV high risk and protective behaviors: the effects of religious affiliation.

The majority of Americans identify themselves as belonging to some religious group. There is a mixed body of literature on whether or not religious affiliation has an influence on engaging in risky behaviors among young adults attending college. This study examined associations between religious affiliation, risky sexual practices, substance use, and family structure among a sample of predominantly white college females attending a southeastern university. Given the high risk of acquiring genital human papillomavirus infection as a result of high risk sexual practices, gaining a better understanding of how religious affiliation can be used to promote healthy sexual behaviors is warranted.

Graft-versus-host disease of the vulva and/or vagina: diagnosis and treatment.

We describe a series of women after allogeneic stem cell transplantation with vaginal graft-versus-host disease (GVHD) who were treated with topical cyclosporine, surgery, or both. We reviewed the medical charts of 11 women who presented with vaginal pain, discomfort, and vaginal scarring (inability to perform a Papanicolaou test or have vaginal intercourse because of pain). Vaginal symptoms develop an average of 10 months from bone marrow transplantation. Symptoms and physical findings include excoriated and ulcerated mucosa, thickened mucosa, narrowed introitus, and obliterated introitus from dense scar tissue that does not resolve with systemic or topical estrogens. The severity of symptoms and the physical findings in our study population did not correlate with age, type of leukemia, type of transplant, or severity or acute or chronic GVHD. Excoriated mucosa and moderately thickened mucosa were successfully treated with topical cyclosporine. Extensive synechiae and complete obliteration of the vaginal canal required surgical lysis with postoperative topical cyclosporine. Vaginal GVHD can successfully be treated with topical cyclosporine when mild to moderate disease is present. Surgical lysis with topical cyclosporine is required when more severe disease ensues.

Direct binding of AP-1 (Fos/Jun) proteins to a SMAD binding element facilitates both gonadotropin-releasing hormone (GnRH)- and activin-mediated transcriptional activation of the mouse GnRH receptor gene.

The response of pituitary gonadotropes to gonadotropin-releasing hormone (GnRH) correlates directly with the concentration of GnRH receptors (GnRHR) on the cell surface, which is mediated in part at the level of gene expression. Several factors are known to affect expression of the mouse GnRHR (mGnRHR) gene, including GnRH and activin. We have previously shown that activin augments GnRH-mediated transcriptional activation of mGnRHR gene, and that region -387/-308 appears to be necessary to mediate this effect. This region contains two overlapping cis-regulatory elements of interest: GnRHR activating sequence (GRAS) and a putative SMAD-binding element (SBE). This study investigates the role of these elements and their cognate transcription factors in transactivation of the mGnRHR gene. Transfection studies confirm the presence of GnRH- and activin-response elements within -387/-308 of mGnRHR gene promoter. Competition electrophoretic mobility shift assay experiments using -335/-312 as probe and alphaT3-1 nuclear extract or SMAD, Jun, and Fos proteins demonstrate direct binding of AP-1 (Fos/Jun) protein complexes to -327/-322 and SMAD proteins to -329/-328. Further transfection studies using mutant constructs of these cis-regulatory elements confirm that both are functionally important. These data define a novel cis-regulatory element comprised of an overlapping SBE and newly characterized non-consensus AP-1 binding sequence that integrates the stimulatory transcriptional effects of both GnRH and activin on the mGnRHR gene.