Estrogen and Androgen Receptor Status in Uterosacral Ligaments of Women with Pelvic Organ Prolapse Stratified by the Pelvic Organ Prolapse Histology Quantification System.

Menopause is a significant risk factor for pelvic organ prolapse (POP), suggesting that ovarian sex steroids play a major role in the etiology of the condition. POP results from failure of the uterine-cervix-vagina support structures, including the uterosacral ligament (USL). We previously identified consistent degenerative USL phenotypes that occur in POP and used their characteristics to develop a standardized POP Histologic Quantification System (POP-HQ). In this study, POP and matched control USL tissue was first segregated into the unique POP-HQ phenotypes, and specimens were then compared for estrogen receptor (ER) alpha (ERα), ERbeta (ERß), the G-protein estrogen receptor (GPER), and androgen receptor (AR) content via immunohistochemical staining. ER and AR expression levels in the control USL tissues were indistinguishable from those observed in the POP-A phenotype, and partially overlapped with those of the POP-I phenotype. However, control-USL steroid receptor expression was statistically distinct from the POP-V phenotype. This difference was driven mainly by the increased expression of GPER and AR in smooth muscle, connective tissue, and endothelial cells, and increased expression of ERα in connective tissue. These findings support a multifactorial etiology for POP involving steroid signaling that contributes to altered smooth muscle, vasculature, and connective tissue content in the USL. Furthermore, these data support the concept that there are consistent and distinct degenerative processes that lead to POP and suggest that personalized approaches are needed that target specific cell and tissues in the pelvic floor to treat or prevent this complex condition.

Gender-inclusive research instructions in author submission guidelines: results of a cross-sectional study of obstetrics and gynecology journals.

BACKGROUND: People with marginalized gender identities, including people with transgender and gender-expansive identities, have been historically excluded from research. Professional societies recommend the use of inclusive language in research, but it is uncertain how many obstetrics and gynecology journals mandate the use of gender-inclusive research practices in their author guidelines. OBJECTIVE: This study aimed to evaluate the proportion of "inclusive" journals with specific instructions about gender-inclusive research practices in their author submission guidelines; to compare these journals with "noninclusive" journals based on publisher, country of origin, and several metrics of research influence; and to qualitatively evaluate the components of inclusive research in author submission guidelines. STUDY DESIGN: A cross-sectional study of all obstetrics and gynecology journals in the Journal Citation Reports, a scientometric resource, was conducted in April 2022. Of note, One journal was indexed twice (due to a name change), and only the journal with the 2020 Journal Impact Factor was included. Author submission guidelines were reviewed by 2 independent reviewers to identify inclusive vs noninclusive journals based on whether journals had gender-inclusive research instructions. Journal characteristics, including publisher, country of origin, impact metrics (eg, Journal Impact Factor), normalized metrics (eg, Journal Citation Indicator), and source metrics (eg, number of citable items), were evaluated for all journals. The median (interquartile range) and median difference between inclusive and noninclusive journals with bootstrapped 95% confidence interval were calculated for journals with 2020 Journal Impact Factors. In addition, inclusive research instructions were thematically compared to identify trends. RESULTS: Author submission guidelines were reviewed for all 121 active obstetrics and gynecology journals indexed in the Journal Citation Reports. Overall, 41 journals (33.9%) were inclusive, and 34 journals (41.0%) with 2020 Journal Impact Factors were inclusive. Most inclusive journals were English-language publications and originated in the United States and Europe. In an analysis of journals with 2020 Journal Impact Factors, inclusive journals had a higher median Journal Impact Factor (3.4 [interquartile range, 2.2-4.3] vs 2.5 [interquartile range, 1.9-3.0]; median difference, 0.9; 95% confidence interval, 0.2-1.7) and median 5-year Journal Impact Factor (3.6 [interquartile range, 2.8-4.3] vs 2.6 [interquartile range, 2.1-3.2; median difference, 0.9; 95% confidence interval, 0.3-1.6) than noninclusive journals. Inclusive journals had higher normalized metrics, including a median 2020 Journal Citation Indicator (1.1 [interquartile range, 0.7-1.3] vs 0.8 [interquartile range, 0.6-1.0]; median difference, 0.3; 95% confidence interval, 0.1-0.5) and median normalized Eigenfactor (1.4 [interquartile range, 0.7-2.2] vs 0.7 [interquartile range, 0.4-1.5]; median difference, 0.8; 95% confidence interval, 0.2-1.5) than noninclusive journals. Moreover, inclusive journals had higher source metrics, including more citable items, total items, and Open Access Gold subscriptions, than noninclusive journals. The qualitative analysis of gender-inclusive research instructions revealed that most inclusive journals recommend that researchers use gender-neutral language and provide specific examples of inclusive language. CONCLUSION: Fewer than half of obstetrics and gynecology journals with 2020 Journal Impact Factors have gender-inclusive research practices in their author submission guidelines. This study underscores the urgent need for most obstetrics and gynecology journals to update their author submission guidelines to include specific instructions about gender-inclusive research practices.

Resident Burnout Trends During COVID-19: A Retrospective Observational Study.

OBJECTIVE: This study was designed to assess the effects of the coronavirus disease pandemic on job satisfaction (JS) and burnout among surgical sub-specialty residents. DESIGN: This is a retrospective, observational, survey-based study. We administered a web-based questionnaire to surgical sub-specialty residents, and results were compared to a prior study in 2016. The questionnaire included elements on demographics, JS, burnout, and self-care habits. Basic statistical analyses were used to compare data from 2020 and 2016. SETTING: This study takes place at Robert Wood Johnson University Hospital, a single mid-sized New Jersey-based academic institution. PARTICIPANTS: This survey was sent to all obstetrics and gynecology and general surgery residents from every postgraduate year based out of our institution. The survey was sent to a total of 50 residents across the 2 programs. Forty total residents responded to the survey, with a response rate of 80%. RESULTS: JS was significantly higher in 2020 than 2016 (p < 0.001). There were no differences between postgraduate years for 2020 or 2016 in emotional exhaustion (p = 0.29, p = 0.75), personal accomplishment (p = 0.88, p = 0.26), or depersonalization (p = 0.14, p = 0.59) burnout scores. A total of 0% of residents in 2020 worked fewer than 61 hours per week. Residents in 2020 exercised more (40.0% vs 21.6%), had similar alcohol usage (60%), and had similar diets to residents in 2016. Residents in 2020 were less likely to regret their specialty (7.5% vs 21.6%), consider changing residencies (30.0% vs 37.8%), or consider a career change (15.0% vs 45.9%). CONCLUSIONS: JS scores were significantly higher during the coronavirus disease pandemic. The cancellation of elective surgeries led to a lighter workload for surgical residents. Residents were uncertain of their role during the pandemic, however, new stressors encouraged residents to seek alternative methods for personal wellness.

Prenatal care and pregnancy outcome among incarcerated pregnant individuals in the United States: a systematic review and meta-analysis.

This systematic review and meta-analysis assessed the risk of inadequate prenatal care and pregnancy outcome among incarcerated pregnant individuals in the United States. PubMed/MedLine, Embase, ClinicalTrials.gov and Web of Science were searched from inception up to March 30th, 2022. Studies were included if they reported the risk of inadequate prenatal care and/or pregnancy outcomes among incarcerated pregnant individuals in the United States jails or prisons. Adequacy of prenatal care was quantified by Kessner index. The random-effects model was used to pool the mean differences or odds ratios (OR) and the corresponding 95% confidence intervals (CIs) using RevMan software. Nine studies were included in the final review. A total of 11,534 pregnant individuals, of whom 2,544 were incarcerated while pregnant, and 8,990 who were matched non-incarcerated pregnant individuals serving as control group, were utilized. Compared to non-incarcerated pregnancies, incarcerated pregnant individuals were at higher risk of inadequate prenatal care (OR 2.99 [95% CI: 1.60, 5.61], p<0.001) and were more likely to have newborns with low birthweight (OR 1.66 [95% CI: 1.19, 2.32], p=0.003). There was no significant difference between incarcerated and matched control pregnancies in the rates of preterm birth and stillbirth. The findings of the current systematic review and meta-analysis suggest that incarcerated pregnant individuals have an increased risk of inadequate prenatal care. Considering the limited number of current studies, further research is indicated to both assess whether the risk of inadequate prenatal care has negative impact on prenatal outcomes for this population and to determine the steps that can be taken to enhance prenatal care for all pregnant individuals incarcerated in the United States prisons.

New Jersey maternal mortality dashboard: an interactive social-determinants-of-health tool.

OBJECTIVES: The United States maternal mortality (MM) rate is the highest amid developed/industrialized nations, and New Jersey's rate is among the highest. Healthcare professionals, public health officials, and policy makers are working to understand drivers of MM. An interactive data visualization tool for MM and health-related information (New Jersey Maternal Mortality Dashboard [NJMMD]) was recently developed. METHODS: NJMMD is an open-source application that uses data from publicly available state/federal government sources to provide a cross-sectional, high-level depiction of potential relationships between MM and demographic, social, and public health factors. RESULTS: MM rates or ratios (maternal deaths/1,000 women aged 15-49 years or 100,000 live births, respectively) are available by year (2005-2017), age (5-year [15-49] periods), and race/ethnicity (non-Hispanic White, Black, or Asian; Hispanic; or other), and by contextual social determinants of health (percent insured; percent covered by Medicaid; difference in nulliparous, term, singleton, vertex Cesarian birth rate from New Jersey goal; number of obstetrician/gynecologists or midwives per capita; and poverty rate). Bar graphs also can be produced with these variables. CONCLUSIONS: NJMMD is the first publicly available, interactive, state-focused MM tool that takes into account the intersection of social and demographic determinants of health, which play important roles in health outcomes. Trends and patterns in variables associated with MM and health can be identified for New Jersey and each of its 11 counties, and inform areas of focus for further analysis. Outputs may enable researchers, policy makers, and others to develop appropriate interventions and be better positioned to set benchmarks, allocate resources, and evaluate outcomes.

Structural racism and the impact on incarcerated midlife women.

High recidivism rates indicate that current forms of imprisonment may be an ineffective response to problems that mainly burden those ensconced in poverty and marginalization. Homelessness, unemployment, racial disparities, drug use, and mental illness, disappear from public view when the afflicted individuals are relegated to a life behind bars. Women are the fastest growing prison population and most incarcerated women are from Black and Latinx groups. Structural racism encompasses the many ways in which society fosters racial discrimination through mutually reinforcing unfair systems of housing, education, employment, earnings, benefits, credit, media, health care, and criminal justice. In turn, this behavior reinforces discriminatory beliefs, values, and distribution of resources. Structural racism pervades every aspect of society, including the carceral system, from policing to prosecutorial decisions, pretrial release processes, sentencing, correctional discipline, and even reentry. Women constitute a minority within the carceral system, and as a result, their unique health care needs, especially during the midlife period, are inadequately addressed and often overlooked. There is also a general lack of gender sensitivity and special considerations in existing jail and prison policies and practices. This commentary highlights the impact of structural racism on the arrests and incarceration of women, and discusses their special health and wellness needs, with emphasis on midlife women. It also illuminates the need to address structural racism and its ripple effects within the carceral system.

Fertility preservation in transgender men and the need for uniform, comprehensive counseling.

Objective: To review the literature to assess best practices for counseling transgender men who desire gender-affirming surgery on fertility preservation options. Design: A scoping review of articles published through July 2021. Setting: None. Patients: Articles published in Cochrane, Web of Science, PubMed, Science Direct, SCOPUS, and Psychinfo. Interventions: None. Main Outcome Measures: Papers discussing transgender men, fertility preservation (FP), and FP counseling. Results: The primary search yielded 1,067 publications. After assessing eligibility and evaluating with a quality assessment tool, 25 articles remained, including 8 reviews, 5 surveys, 4 consensus studies, 3 retrospective studies, 3 committee opinions, and 2 guidelines. Publications highlighted the importance of including the following topics during counseling: (1) FP and family building options; (2) FP outcomes; (3) effects of testosterone therapy on fertility; (4) contraception counseling; (5) attitudes toward family building; (6) consequences of transgender parenting; and (7) barriers to success. Conclusions: Currently, there is a lack of standardization for comprehensive counseling about FP for transgender men. Standardized approaches can facilitate conversation between physicians and transgender men and ensure patients are making informed decisions regarding pelvic surgery and future family building plans.

Symptomatic menopause: Additional challenges for incarcerated women.

Menopause is an age-associated physiological transition in women, usually occurring between the ages of 40 and 58 years, with an average of 51 years. As the age of women residing in the prison system is increasing globally, it becomes increasingly important for older female inmates to be assessed for menopausal symptoms and offered effective, personalized management. Middle-aged and older women, regardless of their living situation, are at increased risk of experiencing vasomotor symptoms and developing pelvic floor problems, bladder dysfunction and osteoporosis. However, all of these menopausal sequelae are typically exacerbated by prison conditions and by a lack of health support. Therefore, it is critical to implement prison programs and to create gender-specific training to aid in the health care needs of aging female inmates. Addressing this growing population of incarcerated women and attending to their menopausal needs require advocacy and active monitoring of prison-specific templates of care to ensure quality care. One such initiative legislated to address the health care needs of incarcerated women was commenced in New Jersey, USA. This entity, the NJ Commission on Women's Reentry, is addressing the unique health care needs of women, including menopausal ones, while incarcerated and then upon reentry into their community.

Pregnancy in incarcerated women: need for national legislation to standardize care.

OBJECTIVES: This review examined prenatal care provided to incarcerated women to identify areas where improvement is needed, and examined current legislative gaps such that they can be addressed to ensure uniform templates of care be instituted at women's prisons. METHODS: Data were compiled from 2000-2021 citations in PubMed and Google Scholar using the keywords: prison AND prenatal care AND pregnancy. RESULTS: Although the right to health care of inmates is protected under the Eight Amendment to the United States Constitution, the literature suggests that prenatal care of incarcerated individuals is variable and would benefit from uniform federal standards. Inconsistency in reporting requirements has created a scarcity of data for this population, making standardization of care difficult. Although incarceration may result in improved access to care that women may not have had in their community, issues of shackling, inadequate prenatal diet, lack of access to comprehensive mental health management, and poor availability of opioid use disorder (OUD) management such as Medication Assisted Therapy (MAT) amd Opioid Treatment Programs (OTP), history of post-traumatic stress disorder (PTSD) are just a few areas that must be focused on in prenatal care. After birth, mother-baby units (MBU) to enhance maternal-fetal bonding also should be a prison standard. CONCLUSIONS: In addition to implementing templates of care specifically directed to this subgroup of women, standardized state and federal legislation are recommended to ensure that uniform standards of prenatal care are enforced and also to encourage the reporting of data regarding pregnancy and neonatal outcomes in correctional facilities.

Using the novel pelvic organ prolapse histologic quantification system to identify phenotypes in uterosacral ligaments in women with pelvic organ prolapse.

BACKGROUND: Pelvic organ prolapse is common, but the underlying etiologies are poorly understood, which limits our current prevention and treatment options. OBJECTIVE: Our primary objective was to compare the uterosacral ligament histologic features in women with and without prolapse using the novel pelvic organ prolapse histologic quantification system. Our secondary aim was to determine whether composite histologic findings in uterosacral ligaments are associated with prolapse risk factors. STUDY DESIGN: This was a prospective cohort study in which paracervical uterosacral ligament biopsies were performed at the time of hysterectomy for primary prolapse or other benign gynecologic indications and processed for histologic evaluation. The pelvic organ prolapse quantification system was used to determine the prolapse stage. In this study, 9 prominent histologic features were semiquantitatively scored using the pelvic organ prolapse histologic quantification system in a blinded fashion and compared between prolapse and control groups. Unbiased principal component analysis of these scores was independently performed to identify potential relationships between histologic measures and prolapse risk factors. RESULTS: The histologic scores of 81 prolapse and 33 control ligaments were analyzed. Compared with the control group, women in the prolapse group were significantly older and more likely to be in the menopausal phase. There was no difference in the number of vaginal deliveries, body mass index, hormone use, or smoking status between the groups. To control for baseline differences, patients were also stratified by age over 40 years and menopausal status. Compared with the control group, the prolapse ligaments in the premenopausal group had significantly more loss of smooth muscle fibers within the fascicles (P<.001), increased inflammatory infiltrates of neutrophils within the tissue and perineural inflammatory cells (P<.01 and P=.04, respectively), and reduced neointimal hyperplasia (P=.02). Prolapse ligaments in the postmenopausal group exhibited elevated adipose content compared with that of the control group (P=.05). Amount of fibrillar collagen, total nonvascular smooth muscle, and muscle fiber vesicles of prolapse ligaments did not differ in either the premenopausal or postmenopausal group compared with that of the control group. Unbiased principal component analysis of the histologic scores separated the prolapse ligaments into 3 phenotypes: (1) increased adipose accumulation, (2) increased inflammation, and (3) abnormal vasculature, with variable overlap with controls. Posthoc analysis of these subgroups demonstrated a positive correlation between increasing number of vaginal deliveries and body mass index with increasing adipose content in the adipocyte accumulation and inflammatory phenotype and increasing neointimal hyperplasia in the vascular phenotype. However, only the relationship between vaginal delivery and adipocytes was significant in the adipose phenotype (R2=0.13; P=.04). CONCLUSION: Histologic phenotypes exist in pelvic support ligaments that can be distinguished using the pelvic organ prolapse histologic quantification system and principle component analysis. Vaginal delivery is associated with aberrant adipose accumulation in uterosacral ligaments. Our findings support a multifactorial etiology for pelvic organ prolapse contributing to altered smooth muscle, vasculature, and connective tissue content in crucial pelvic support structures. To confirm these associations and evaluate the biomechanical properties of histologic phenotypes of prolapse, larger studies are warranted. Closing this gap in knowledge will help optimize personalized medicine and help identify targets for prevention and treatment of this complex condition.

Delayed Diagnosis of Vesicouterine Fistula After Treatment for Mixed Urinary Incontinence: Menstrual Cup Management and Diagnosis.

INTRODUCTION: A vesicouterine fistula is a rare form of urogenital fistula, yet there is increasing prevalence in the United States because of the rising rate of cesarean deliveries. Vesicouterine fistulas have various presentations including menouria, hematuria, or urinary incontinence. CASE PRESENTATION: A 39-year-old multiparous woman presented with urine leakage after her third cesarean delivery. She had been treated for mixed urinary incontinence with overactive bladder medications and a midurethral sling with continued complaints of urine leakage. The patient noticed her symptoms of urine leakage improved during menses when she used a menstrual cup. After confirmation of vesicouterine fistula, the patient underwent robotic-assisted surgery and her symptoms of insensible urine leakage resolved. CONCLUSIONS: When evaluating women with urinary incontinence and a history of cesarean deliveries, use of menstrual cup may aid in the diagnosis of vesicouterine fistula. Robotic-assisted laparoscopic repair with tissue interposition flap is an efficacious minimally invasive method for treatment of vesicouterine fistula.

Genitourinary syndrome of menopause and the use of laser therapy.

Genitourinary syndrome of menopause is a common condition that left untreated can progress and negatively affect quality of life and sexual function. Laser therapy has a therapeutic role for several gynecologic conditions and most recently has gained interest as a non-hormonal treatment for genitourinary syndrome of menopause (GSM). The laser is well tolerated and may increase thickness of the squamous epithelium and improve vascularity of the vagina. These morphological changes presumably alleviate symptoms of dryness, dyspareunia, and irritation. However, the duration of therapeutic effects and safety of repeated applications at this point is not clear. Further research is needed in the form of controlled studies of the laser and other non-hormonal GSM therapies. The objective of this paper is to review the existing literature describing laser therapy for GSM.