Requests for vulvoplasty as gender-affirming surgery: a cross-sectional study in Denmark.

BACKGROUND: Vulvoplasty, described as a promising procedure for transgender and gender diverse (TGD) persons who were assigned male at birth and who, for example, do not need a vagina or who have contraindications to vaginoplasty, is a procedure that in accordance with current guidelines is not offered as genital gender-affirming surgery in Denmark. AIM: In this study we sought to quantify the need for offering vulvoplasty in Denmark. MATERIALS AND METHODS: An online questionnaire was developed. The target group included TGD persons who were assigned male at birth and a minimum of 18 years old. Prior to data collection, the questionnaire was tested with stakeholders from the target group and was subsequently distributed exclusively in closed groups and online fora for TGD persons. Data collection took place from September 1 to October 31, 2022. OUTCOMES: Primary outcomes were type of bottom surgery respondents preferred, when vulvoplasty was chosen, the reason(s) for choosing it. RESULTS: A total of 152 responses were included for data analysis, and 134 records were complete responses. Out of 134 respondents, 35 (26.1%) preferred vulvoplasty. The reasons for preferring vulvoplasty were the belief that there is less risk with the procedure (71%), followed by not wanting to dilate (54%), no need for a vagina (48%), and no need for vaginal penetration (40%). Health issues or other reasons were infrequent (5%). Out of 122 respondents who had not had prior bottom surgery, 106 (86.9%) wanted it in the future. CLINICAL IMPLICATIONS: Some TGD individuals in Denmark could benefit from vulvoplasty and would choose it if offered. STRENGTHS AND LIMITATIONS: Strengths of this study were that the questionnaire was thoroughly tested prior to application and that the survey could only be accessed via closed fora and groups for TDG persons. Limitations were that the sample size was small, and that the response rate could not be estimated. CONCLUSION: The results of this study imply that there is an unmet need for vulvoplasty, and bottom surgery in general, in Denmark.

The influence of lichen sclerosus on women's sexual health from a biopsychosocial perspective: a mixed methods study.

BACKGROUND: Women with lichen sclerosus (LS) may suffer sexually because of dyspareunia, fissures, and introital narrowing. However, the literature remains limited on the biopsychosocial aspects of LS and its impact on sexual health. AIM: To examine the biopsychosocial aspects and impact of LS on the sexual health of Danish women with vulvar LS. METHODS: The study was conducted with a mixed methods approach, including women with LS from a Danish patient association. The quantitative sample consisted of 172 women who completed a cross-sectional online survey that included 2 validated questionnaires: the Female Sexual Function Index (FSFI) and the Female Sexual Distress Scale (FSDS). The qualitative sample consisted of 5 women with LS who volunteered for audiotaped, individual, semistructured interviews. OUTCOMES: This mixed methods study combined data from 2 quantitative questionnaires (FSFI and FSDS) with qualitative interviews to achieve a comprehensive insight into the biopsychosocial aspects of sexual health in women living with LS. RESULTS: The sexual function of women with LS was considerably affected, with FSFI scores below the cutoff value of 26.55, indicating a risk of sexual dysfunction. On average, 75% of the women were sexually distressed, with a total FSDS score of 25.47. Furthermore, 68% of the sexually active women were considerably affected in terms of sexual function and sexual distress, thus meeting international criteria for sexual dysfunction. However, a negative impact on sexual function was not always related to sexual distress and vice versa. The qualitative analysis identified 4 overarching themes: (1) decrease in or loss of sexual activity, (2) interference with relationship dynamics, (3) importance of sex and intimacy - loss and restoration, and (4) worries about sexual insufficiency. CLINICAL IMPLICATIONS: Insight into the influence of LS on sexual health is important for health care professionals, including doctors, nurses, sex therapists, and physiotherapists, to provide the best guidance, support, and management for women with LS. STRENGTHS AND LIMITATIONS: The strengths of the study are its use of a mixed methods design and the inclusion of sexual function and sexual distress. A limitation is related to the properties of the FSFI regarding women with no sexual activity. CONCLUSIONS: LS has a considerable influence on women's sexual health in terms of sexual function and sexual distress, as supported by quantitative and qualitative measures. Our understanding of the complex interactions among sexual activity, intimate relations, and causes of psychological distress has been enriched.

Gender incongruence and timing of puberty: a population-based cohort study.

OBJECTIVE: To study whether the timing of puberty in adolescents who reported gender incongruence (incongruence between birth-assigned sex and self-identified gender) was different from those adolescents who reported gender congruence. DESIGN: Population-based cohort study using data from the Danish National Birth Cohort. SETTING: Not applicable. PATIENT(S): Birth-assigned boys and girls born between 2000 and 2003, who self-reported gender incongruence at 11 years (N = 10,046) and their pubertal developmental stages from age 11 years to every 6 months throughout puberty were included. INTERVENTION(S): Not applicable. MAIN OUTCOME MEASURE: Mean age differences in months at reaching Tanner stages 2-5 for breast or genital development and pubic hair, voice break, first ejaculation, menarche, axillary hair, acne, and the average difference at attaining all pubertal milestones (primary outcome). RESULT(S): In total, 549 (5.5% ) adolescents reported part or full gender incongruence at 11 years. Tendencies toward earlier timing of puberty were observed in adolescents who reported part gender incongruence (average difference, birth-assigned boys: -3.2 months [95% confidence interval {CI}: -6.7; 0.3]; birth-assigned girls: -2.0 months [95% CI: -3.9; -0.1]). Tendencies toward earlier timing of puberty were observed in adolescents who reported full gender incongruence (average difference, birth-assigned boys: -2.4 months [95% CI: -5.0; 0.4]; birth-assigned girls: -1.9 months [95% CI: -5.1; 1.2]). CONCLUSIONS: The results from this study indicated that birth-assigned boys and girls who reported either part or full gender incongruence tended to reach puberty slightly earlier than those adolescents who reported gender congruence at 11 years of age. Knowledge on the timing of puberty among adolescents who experience gender incongruence is essential to inform mutual decision-making in clinical settings.

Biochemical Changes During the First Year of Feminizing Hormone Therapy in Transfeminine Individuals.

BACKGROUND: Persons with assigned male sex at birth (AMAB) might wish to obtain feminization and/or demasculinization according to the person's gender identity and are therefore treated with estradiol and/or antiandrogens. AIM: The aim was to evaluate biochemical changes and side effects in AMAB individuals treated with guideline-based feminizing hormone treatment (FHT). METHODS: Medical charts of 99 AMAB individuals ≥ 18 years referred to the Center for Gender Identity; Aalborg University hospital, Denmark, between January 2017 and July 2019 were reviewed to identify adverse side effects. Furthermore, data from the laboratory information system (Labka II) were retrieved to obtain biochemical parameters. Biochemical plasma concentrations after initiation of FHT were compared to concentrations prior to FHT and to existing guidelines. OUTCOMES: After 11-19 months, 29% of the trans feminine individuals had plasma estradiol concentrations within the treatment target. RESULTS: The plasma concentration of estradiol varies greatly during FHT. Plasma levels of estrogen were within the treatment target after 11-19 months of treatment, whereas 100% had concentrations within the reference range for premenopausal cis-women. Furthermore, plasma concentrations of lipids and hematological parameters approached female reference ranges after 11 months of FHT. CLINICAL IMPLICATIONS: The target levels of plasma estradiol concentrations during FHT could be expanded, making the wanted physiological changes easier to obtain. STRENGTHS & LIMITATION: This cohort study included 99 AMAB individuals and biochemical evaluation was possible in 67 individuals. Only one individual was lost during follow-up. However, the follow-up period was limited making evaluation of long-term side effects impossible. CONCLUSION: Plasma concentration of estradiol varies greatly during guideline based FHT, making plasma estradiol levels within the target level difficult to attain. JA Hojbjerg, AD Højgaard, A-M Hvas. Biochemical Changes During the First Year of Feminizing Hormone Therapy in Transfeminine Individuals. Sex Med 2021;10:100472.

Current Treatment Regimens for Transfeminine Individuals in the Nordic Countries.

BACKGROUND: The demand for gender-affirming hormone therapy is increasing worldwide prompting a growing requirement for solid evidence for efficacy and safety. AIM: We aimed to report on the organization of transgender care and the current clinical practice of feminizing hormone therapy in specialized clinics in the Nordic countries. METHODS: This study was a cross-sectional study performed as a questionnaire survey. A quantitative questionnaire was sent to 15 specialized clinics prescribing feminizing hormone therapy in the Nordic countries. OUTCOMES: Twelve clinics responded to the inquiry. RESULTS: The answers showed great variance in both number of clinics in each country as well as number of doctors responsible for prescribing gender-affirming hormone therapy. There was great difference in the width of the target ranges for estrogen plasma concentrations and in preferred route of administration for estrogens. Likewise, the risk assessment and monitoring of side effects were diverse. CLINICAL IMPLICATIONS: To gather solid data on efficacy and safety of feminizing hormone therapy, the treatment regimens and the recording of side effects need to be consistent across the clinics responsible for the treatment of transfeminine patients. Strenghts & Limitations: This is to our knowledge the first report on treatment regimens for feminizing hormone treatment in the Nordic countries. The response rate was 80%; however, the included clinics only cover approximately 30% of the expected numbers of transfeminine individuals. CONCLUSION: Despite the great diversity across clinics as regard to organization of clinics and to treatment regimens, the vast majority of clinics operated within the guidelines defined by The Endocrine Society. Hojbjerg JA, Saini SL, Hvas A-M, et al. Current Treatment Regimens for Transfeminine Individuals in the Nordic Countries. J Sex Med 2021;18:656-663.

The majority of Danish breast cancer survivors on adjuvant endocrine therapy have clinically relevant sexual dysfunction: a cross-sectional study.

BACKGROUND: Impairments in sexual function are common among breast cancer survivors (BCSs), particularly in BCSs receiving adjuvant endocrine therapy (AET). Whether these impairments cause distress, thus qualifying for a more clinically relevant diagnosis of sexual dysfunction (SD), is inadequately described among BCSs and represents an important research gap. Hence, the primary aim of this study was to estimate the prevalence of clinically relevant SD, in this context: impairments with associated distress, and to identify factors associated with SD among BCSs on AET. Secondly, to explore the extent of distress caused by specific impairments in sexual function. MATERIALS AND METHODS: In this cross-sectional study of BCSs on adjuvant treatment with endocrine therapy for at least three months, participants completed an online survey comprising standardized measures of sexual and psychosocial function. Female Sexual Function Index (FSFI) and Sexual Complaint Screener - Women (SCS-W) were used to asses clinically relevant SD. Multiple regression analyses were performed to identify factors significantly associated with SD. RESULTS: In total, 333 BCSs with a mean age of 58.7 years were included in the study, of whom 227 were sexually active. Among sexually active BCSs, 134 (59%) met the criteria for having clinically relevant SD, of whom 78 (58%) perceived cancer treatment as the primary reason for their sexual problems. Factors associated with SD included vaginal dryness (adjusted OR= 2.25, 95% CI: 1.52-3.34, p < .01) and psychological well-being (adjusted OR= 1.11, 95% CI: 1.03-1.18, p < .01). Age was not related to neither prevalence of SD nor the level of distress caused by any impairment, with exception of low sexual desire. Pain in relation to intercourse was the most distressing impairment. CONCLUSION: SD was highly prevalent among sexually active BCSs on AET. Sexual health is important to address independent of the woman's age.

Neonatal male circumcision is associated with altered adult socio-affective processing.

BACKGROUND: Neonatal male circumcision is a painful skin-breaking procedure that may affect infant physiological and behavioral stress responses as well as mother-infant interaction. Due to the plasticity of the developing nociceptive system, neonatal pain might carry long-term consequences on adult behavior. In this study, we examined whether infant male circumcision is associated with long-term psychological effects on adult socio-affective processing. METHODS: We recruited 408 men circumcised within the first month of life and 211 non-circumcised men and measured socio-affective behaviors and stress via a battery of validated psychometric scales. RESULTS: Early-circumcised men reported lower attachment security and lower emotional stability while no differences in empathy or trust were found. Early circumcision was also associated with stronger sexual drive and less restricted socio-sexuality along with higher perceived stress and sensation seeking. LIMITATIONS: This is a cross-sectional study relying on self-reported measures from a US population. CONCLUSIONS: Our findings resonate with the existing literature suggesting links between altered emotional processing in circumcised men and neonatal stress. Consistent with longitudinal studies on infant attachment, early circumcision might have an impact on adult socio-affective traits or behavior.

Informing patients about the negative effect of nephrectomy on sexual function.

OBJECTIVE: The quality-of-life concept has increasingly gained attention, but an important aspect has been neglected, which is the sexual function of patients with kidney cancer after surgery. The aim of this study was to explore the impact of nephrectomy on sexual function in patients with kidney cancer and the information patients received with this regard. MATERIAL AND METHODS: We conducted a retrospective study of patients who underwent nephrectomy or nephro-ureterectomy within a 5-year period at the Department of Urology, Odense University Hospital, Denmark. Among 310 patients having undergone surgery, 226 were still alive and eligible for participation. Their records were reviewed, and a validated questionnaire concerning their sex life was mailed to them. All participants were invited to take part in a semi-structured interview in person or by phone. RESULTS: Of 154 former patients who replied, 95 were men (mean age, 66 years, range 37-89), 59 were women (mean age 63 years, range 26-87). A significant difference was observed regarding problems with sexual relationships prior to operation compared after (P<0.0001). Seven patients (5%) had been informed about potential effects and changes in their sex life following operation. Both male and female participants were worried about their sex life (61.4%). Among sexually active male responders, 54.7% reported having some degree of erectile dysfunction. CONCLUSION: Patients experience significantly more problems in their sexual relationships after surgery. Very few were informed about this, showing the need to offer sex counselling before surgery. More research is required to fully comprehend the magnitude of the problem.

Development of a Sexual Dysfunction Scale for Women With Inflammatory Bowel Disease.

Background: Women with inflammatory bowel disease (IBD) may have decreased sexual function. To understand how common this condition is in our female patients, we developed a new IBD-specific Female Sexual Dysfunction Scale (the IBD-FSDS). Methods: We performed a prospective cross-sectional study of 454 female IBD patients ≥18 years of age attending 1 of 3 IBD clinics in the United States or Denmark. We gathered information on sexual function via a de novo 23-item scale. General sexual functioning was measured with the Female Sexual Function Index (FSFI) and the Female Sexual Distress Scale-Revised (FSDS-R). Depressive symptoms were measured with the Patient Health Questionnaire-9 (PHQ-9). Medical history and sociodemographic data were collected via chart review. Exploratory factor analyses (EFAs) of the English language version of IBD-FSDS assessed unidimensionality, factor structure, reliability, criterion validity, and construct validity. Results: EFAs suggested retaining 15-items creating a unidimensional scale with strong internal consistency reliability (α = 0.93). Validity of the English language IBD-FSDS was measured using Spearman's coefficient, demonstrating significant criterion validity with the FSDS-R (P < 0.05) and the FSFI (P < 0.05) and significant construct validity with the composite for cases of active IBD (P < 0.05) and PHQ-9 (P < 0.05). Sexual dysfunction in women with IBD was significantly associated with depression (P = 0.042), active IBD (P = 0.002), and no history of surgery (P = 0.044). Conclusions: We have developed and validated an IBD-specific scale to assess the psychosexual impact of IBD in women. This novel screening questionnaire may help health care providers recognize factors contributing to impaired sexual function in their female patients.

Reproductive patterns and fertility wishes among HIV-infected patients: survey from six outpatient clinics in Denmark.

OBJECTIVES: Reproductive patterns among HIV patients in Denmark have not previously been described. We aimed to uncover the fertility wishes among Danish HIV-infected persons. METHODS: A cross-sectional questionnaire survey was done at six outpatient HIV clinics in Denmark. A total of 409 (56%) HIV patients returned the questionnaire; 323 had completed the questionnaire, although they had not all responded to all of the questions. RESULTS: Among HIV-infected individuals, 49% (137/280) had their own biological children. Fifteen percent (43/280) desired (additional) children and 15% (43/280) were undecided. Female gender, birth outside Europe, young age, completed high school education, heterosexuality, present partner, and non-disclosure were associated with a desire for children in the univariate analysis. In the multivariate analysis only young age, heterosexual orientation, and non-disclosure were significant. Thirty-seven percent (93/250) felt that HIV infection was a hindrance to having more children. The most common reasons indicated were fear of HIV transmission to the child (24%, 59/244) and to the partner (16%, 40/244). CONCLUSIONS: Many HIV-infected patients have children and a substantial proportion of HIV-infected patients desire (additional) children, although there is a high degree of fear of HIV transmission to their partner or child. This highlights the need for care providers to improve the services provided to HIV-infected patients who desire to have children.

Predictive value of serum human chorionic gonadotropin ratio, progesterone and inhibin A for expectant management of early pregnancies of unknown location.

OBJECTIVE: To evaluate serum human chorionic gonadotropin (hCG) ratio, progesterone and inhibin A as single parameters and in combination for the prediction of spontaneous resolution of pregnancies of unknown location (PUL). STUDY DESIGN: Prospective observational study of 105 consecutive patients with a diagnosis of PUL. Serum levels of hCG, progesterone and inhibin A were determined at the first visit and after 2 days. Patients were followed clinically until a final diagnosis of spontaneously resolving PUL, viable or non-viable intrauterine pregnancy, or ectopic pregnancy with need of laparoscopic intervention had been reached. Different combinations of hCG ratio (hCG at 48 h/hCG at 0 h), s-progesterone and s-inhibin A were investigated to find the best predictor for successful expectant management. RESULTS: The final pregnancy outcomes were: 52 spontaneously resolving PUL (49.5%), 37 viable intrauterine pregnancies (35.2%), 8 non-viable intrauterine pregnancies (7.6%), 7 ectopic pregnancies (6.7%), and one molar pregnancy (1.0%). An hCG ratio<0.80 predicted spontaneously resolving PUL with positive and negative predictive values (PPV and NPV), sensitivity, and specificity of 0.98, 0.78, 0.72, and 0.99, respectively. In patients with hCG ratio ≥ 0.80, a combination of s-progesterone < 20 nmol/l and s-inhibin A < 30 pg/ml predicted spontaneously resolving PUL with PPV, NPV, sensitivity and specificity of 0.92, 0.96, 0.85, and 0.98 respectively. CONCLUSION: Our results suggest that patients with PUL and hCG ratio < 0.80 display a high probability of spontaneously resolving PUL with minimum need of follow-up. In cases of hCG ratio ≥ 0.80, a combination of s-progesterone < 20 nmol/l and s-inhibin A < 30 pg/ml, may be a reliable predictor of spontaneously resolving PUL. The safety of this approach should be tested in large prospective studies.

[Extrauterine pregnancy with gestagen-releasing intrauterine device in situ]. / Ekstrauterin graviditet med gestagenspiral in situ.

The levonorgestrel-releasing intrauterine device (IUD) (Mirena) is a frequently used and effective method of contraception, with a Pearl index of 0.1. The ectopic pregnancy rate is 0.02 per 100 woman-years. Special attention is needed in situations where pregnancy is detected with a levonorgestrel-releasing IUD in situ, because almost two thirds of these pregnancies are ectopic. We describe one of these rare cases of ectopic pregnancy in a woman aged 37 years, who was admitted to hospital with abdominal pain and vaginal bleeding.

[Double cardiac arrest caused by amniotic fluid embolism during caesarean section]. / Dobbelt hjertestop ved amnionvaeskeemboli opstået under kejsersnit.

Amniotic fluid embolism is a rare unpredictable complication of pregnancy with high maternal morbidity and mortality rates because of the risk of cardio-respiratory collapse and/or disseminated intravascular coagulation (DIC). We here report a case of a patient who survived without any sequelae after two cardiac arrests and subsequent DIC due to amniotic fluid embolism during a caesarean section. Early consideration of the diagnosis after prompt resuscitation is needed to reduce morbidity and mortality.

Patient attitudes towards twin pregnancies and single embryo transfer - a questionnaire study.

BACKGROUND: The present trend towards selective single embryo transfer (SET) calls for evaluation of patient attitudes towards twins and how the patients balance advantages and disadvantages of one or two embryos in IVF/ICSI treatment. METHODS: The study was conducted in a Danish public fertility clinic, where the common practice was double embryo transfer (DET), and the number of reimbursed treatments was limited to three. Referred patients were given oral and written information about the IVF/ICSI treatment including twin probability following DET and the risk of preterm delivery and neonatal complications associated with twins. In order to evaluate patients and partners attitudes towards twins and SET, an anonymous survey was conducted, and 588 couples were invited to participate. RESULTS: Four hundred and fourteen women (70.4%) and 404 men (68.7%) answered the questionnaire adequately for analysis. About 58.7% preferred having twins to having one child at a time (37.9%). Primary reasons for preferring twins were desire for siblings (23.3%), a positive attitude towards twins (22.5%), and a wish to minimize physical and psychological stress through having as few IVF treatments as possible (19.3%). Economic considerations were not important. CONCLUSIONS: Obligatory single embryo policy would be in conflict with patient interests and wishes. More carefully prepared information seems to be needed. The challenge consists in balancing clinical considerations with unbiased information on twin pregnancy, respecting patient autonomy and enabling informed decision-making.

[Health economic consequences of the choice of follicle stimulating hormone alternatives in IVF treatment]. / Sundhedsøkonomiske konsekvenser af valg af follikelstimulerende hormonpraeparat ved in vitro-fertilisationsbehandlinger.

INTRODUCTION: There is a choice between two types of hormones for stimulation of the follicles in IVF treatment - recombinant FSH and the urine-derived menotrophin. A literature review by NICE (2004) in the United Kingdom documented that the two types of hormones were equally effective and safe, which is why it was recommended to use the cheaper urine-derived hormone. Based on the EISG study (European and Israeli Study Group), the aim was to analyse the health economic consequences of the choice between the two types of hormone in IVF treatment in Denmark. MATERIALS AND METHODS: In a prospective cost-effectiveness analysis (health care sector perspective), menotrophin and recombinant FSH (Gonal-F) were compared. Differences in costs were compared with differences in effects of the two alternatives. RESULTS: The total costs for the average patient are lower when using menotrophin compared with recombinant FSH. Furthermore, the cost per clinical pregnancy was lower with menotrophin compared with recombinant FSH hormone. Menotrophin is therefore less expensive both for the patient as well as for the health care sector. The use of menotrophin instead of recombinant FSH can result in savings of up to DKK 16 million on the drug budget--savings that could finance 1,400 additional IVF cycles. CONCLUSION: The analysis shows that urine-derived menotrophin is a cost-effective alternative to recombinant FSH with a potential for considerable savings for patients as well as the public drug budget.