Feasibility and safety of two different surgical routes for the eradication of recto-vaginal endometriosis with vaginal mucosa infiltration (Endo-Vag-r study).

INTRODUCTION: Recto-vaginal endometriosis surgical management needing partial colpectomy is a surgically challenging condition and has been associated with a notable risk of major postoperative complications. In the present study we sought to compare feasibility and safety of total laparoscopic (TL) and vaginal-assisted (VA) routes in women affected by symptomatic recto-vaginal endometriosis with vaginal mucosa infiltration scheduled for minimally invasive surgery. MATERIAL AND METHODS: Multi-centric, retrospective cohort study on medical records of consecutive reproductive age women submitted to complete macroscopic eradication of symptomatic recto-vaginal endometriosis with vaginal mucosa infiltration between March 2013 and November 2017. The two groups were compared in terms of preoperative data and surgical outcomes. RESULTS: 84 women were included in the study (TL = 57 and VA = 27). The two groups were comparable in terms of preoperative, surgical and postoperative data. The major postoperative complications rate was 5.3% (3 of 57) in the TL group and 7.4% (2 of 27) in the VA group, without a significant difference. In the TL group we reported one case of bowel anastomosis dehiscence and two cases of pelvic abscess. In the VA group, one case of small bowel perforation after extensive adhesiolysis treated with ileal resection and one case of rectal sub-occlusion after segmental resection and mechanical anastomosis were noticed. CONCLUSIONS: In women affected by recto-vaginal endometriosis with vaginal mucosal infiltration, perioperative outcomes do not seem to be influenced by the surgical route adopted.

Chest Wall Masculinization in Female-to-Male Transsexuals: Our Treatment Algorithm and Life Satisfaction Questionnaire.

Esthetic masculinization of the chest wall is one of the first surgical steps in female-to-male transsexual (FTMTS) reassignment.This surgical procedure is not a simple mastectomy: it is required for removal of breast tissue with glandular resection and skin excess revision, to reduce and replace the nipple-areola complex in the right location, minimizing chest wall scars. The creation of an esthetically pleasing male chest allows the patient to live at ease in the male gender role.In this article, we present our series of 68 FTMTSs who underwent bilateral mastectomies for surgical sexual reassignment (a total of 136 mastectomies) according to our algorithm, in the period between January 2010 and December 2017. We selected 4 different operative procedures, classified as subcutaneous ("pull-through" and "concentric circular" techniques) and skin extended ("ultrathin vertical bipedicle" and free nipple graft).We achieved a total complication rate of 6.6%, less than that reported in the literature; additional procedures for esthetic improvements were performed in 14.7% of cases. The mean patient satisfaction was approximately 4.57% of a maximal value of 5 (excellent).To help surgeons in choosing the most appropriate FTMTS surgical technique and to reduce unfavorable results, we propose the use of our treatment algorithm in preoperative evaluation of the chest wall according to the breast volume, degree of glandular ptosis, and skin elasticity.

Testosterone undecanoate and testosterone enanthate injections are both effective and safe in transmen over 5 years of administration.

OBJECTIVE: To retrospectively evaluate and compare safety and efficacy of short and long-acting testosterone (T) parenteral formulations over 5 years in transmen. DESIGN AND METHODS: Fifty transmen between 21 and 42 years of age were enrolled. Twenty-five received T undecanoate 1000 mg IM (weeks 0 and 6 then every 12-16 weeks), and 25 received T enanthate 250 mg IM (every 3-4 weeks). Hormonal and biochemical parameters, anthropometric characteristics and blood pressure were assessed at baseline and then every 12 months. Body composition was evaluated at baseline and then after 1, 3 and 5 years of T treatment. Global satisfaction was assessed at baseline and after 1 and 5 years. RESULTS: Both T formulations led to amenorrhoea in all subjects within 1 year of T administration. Both T treatments led to a similar increase in haemoglobin and haematocrit which always remained within the physiological range. T administration was associated with an increase in total cholesterol, low-density lipoprotein cholesterol and triglycerides and a slight reduction in high-density lipoprotein cholesterol. Coagulative and glucidic profiles and blood pressure did not change significantly in either group. Body weight and BMI showed a slight but not significant increase in both groups, while lean mass rose significantly in both groups. Global satisfaction was increased at years 1 and 5 in both groups. CONCLUSIONS: Preliminary results from this pilot study suggest that administration of either TU or TE for 5 years in young transmen is both effective and safe. Our study presents the longest follow-up published so far reporting no adverse events and these data are consistent with previous reports with a shorter follow-up.

Effects of three different testosterone formulations in female-to-male transsexual persons.

INTRODUCTION: Gender dysphoria is characterized by a strong discomfort with the gender assigned at birth and the urge to live as a member of the opposite gender. The acquisition of phenotypic features of the desired gender requires the use of cross-sex hormones. Female-to-male (FtM) transsexual persons are treated with testosterone to induce virilization. AIM: The aim of the study was to assess the effects of three different testosterone formulations on body weight and composition and metabolic and bone parameters. METHODS: Forty-five FtM transsexuals were randomly assigned to receive testoviron depot (i.m.: 100 mg/10 days; n = 15), testosterone gel (50 mg/die; n = 15), and testosterone undecanoate (i.m.: 1,000 mg every 6 weeks for the first 6 weeks and then every 12 weeks, n = 15). FtM individuals were studied before, at week 30, and at week 54 of testosterone treatment. MAIN OUTCOME MEASURES: Anthropometric, metabolic, bone, hematological, and biochemical parameters were evaluated at baseline and after 12 months of treatment. RESULTS: Lean body mass significantly increased and fat mass decreased in all groups. No modifications were reported in fasting insulin and insulin sensitivity index. High-density plasma lipoprotein levels declined significantly and low-density lipoprotein concentrations increased significantly in the three groups. The activated partial thromboplastin time and factor I did not change while prothrombin time significantly increased in all groups. At week 54, all subjects were amenorrheic and time to amenorrhea did not differ between the three groups. Current general life satisfaction was increased in all subjects after 1 year of treatment. CONCLUSIONS: One-year testosterone administration in FtM transsexuals appears to be very safe with no differences among the testosterone formulations used. Our study is preliminary, and the detection of subtle or long-term differences in the effects of the three formulations may require further larger and longer term studies in this and other populations.

Sociodemographic and clinical features of gender identity disorder: an Italian multicentric evaluation.

INTRODUCTION: Male to female (MtFs) and female to male (FtMs) subjects with gender identity disorder (GID) seem to differ with regard to some sociodemographic and clinical features. Currently, no descriptive studies focusing on MtFs and FtMs attending an Italian clinic are available. AIM: To describe the sociodemographic characteristics of a GID population seeking assistance for gender transition and to assess possible differences in those features between MtFs and FtMs. METHODS: A consecutive series of 198 patients was evaluated for gender dysphoria from July 2008 to May 2011 in four dedicated centers. A total of 140 subjects (mean age 32.6 ± 9.0 years old) meeting the criteria for GID, with their informed consent and without genital reassignment surgery having already been performed, were considered (92 MtFs and 48 FtMs). Diagnosis was based on formal psychiatric classification criteria. MAIN OUTCOME MEASURES: Medical history and sociodemographic characteristics were investigated. Subjects were asked to complete the Body Uneasiness Test (a self-rating scale exploring different areas of body-related psychopathology), Symptom Checklist-90 Revised (a self-rating scale to measure psychological state), and the Bem Sex Role Inventory (a self-rating scale to evaluate gender role). The presence of psychiatric comorbidities was evaluated using the Structured Clinical Interviews for Diagnostic and Statistical Manual of Mental Disorders, 4th Edition, Text Revision (DSM-IV-TR) (SCID I and SCID II). RESULTS: Several significant differences were found between MtFs and FtMs regarding lifestyle and sociodemographic factors and in psychometric test scores. No differences were found in terms of psychiatric comorbidity. CONCLUSIONS: This is the first large study reporting the sociodemographic characteristics of a GID sample referring to Italian clinics, and it provides different profiles for MtFs and FtMs. In particular, FtMs display significantly better social functioning.

Dimensional profiles of male to female gender identity disorder: an exploratory research.

INTRODUCTION: Male-to-Female Gender Identity Disorder (MtF GID) is a complex phenomenon that could be better evaluated by using a dimensional approach. AIM: To explore the aggregation of clinical manifestations of MtF GID in order to identify meaningful variables describing the heterogeneity of the disorder. METHODS: A consecutive series of 80 MtF GID subjects (mean age 37 +/- 10.3 years), referred to the Interdepartmental Center for Assistance Gender Identity Disorder of Florence and to other Italian centers from July 2008 to June 2009, was studied. Diagnosis was based on formal psychiatric classification criteria. Factor analysis was performed. MAIN OUTCOME MEASURES: Several socio-demographic and clinical parameters were investigated. Patients were asked to complete the Bem Sex Role Inventory (BSRI, a self-rating scale to evaluate gender role) and Symptom Checklist-90 Revised (SCL-90-R, a self-rating scale to measure psychological state). RESULTS: Factor analysis identified two dimensional factors: Factor 1 was associated with sexual orientation, and Factor 2 related to behavioral and psychological correlates of early GID development. No correlation was observed between the two factors. A positive correlation between Factor 2 and feminine BSRI score was found, along with a negative correlation between Factor 2 and undifferentiated BSRI score. Moreover, a significant association between SCL-90-R Phobic subscale score and Factor 2 was observed. A variety of other socio-demographic parameters and clinical features were associated with both factors. CONCLUSIONS: Behavioral and psychological correlates of Factor 1 (sexual orientation) and Factor 2 (gender identity) do not constitute the framework of two separate clinical entities, but instead represent two dimensions of the complex MtF GID structure, which can be variably intertwined in the same subject. By using factor analysis, we offer a new approach capable of delineating a psychopathological and clinical profile of MtF GID patients.

Diagnostic accuracy of 18F-FDG PET/CT in characterizing ovarian lesions and staging ovarian cancer: correlation with transvaginal ultrasonography, computed tomography, and histology.

AIMS: To (a) assess the accuracy of 18F-FDG PET/CT in distinguishing malignant from benign pelvic lesions, compared to transvaginal ultrasonography (TVUS) and (b) to establish the role of whole-body 18F-FDG PET/CT, compared to contrast enhanced computed tomography (CT), in staging patients with ovarian cancer. PATIENTS: Fifty consecutive patients with a pelvic lesion, already scheduled for surgery on the basis of physical examination, TVUS, and serum Ca125 levels, were enrolled in the study. Patients' age ranged between 23 and 89 years (mean 64). All patients underwent TVUS including a colour Doppler study followed by a thorax and abdominal CT scan, and whole-body 18F-FDG PET/CT within 2 weeks prior to surgery. Histological findings obtained at surgery were taken as the 'gold standard' to compare 18F-FDG PET/CT and TVUS, and 18F-FDG PET/CT vs. CT. When tissue analysis showed ovarian cancer, the accuracy of 18F-FDG PET/CT and CT were compared for the purpose of obtaining a precise staging. RESULTS: At surgery, the ovarian lesions were malignant in 32/50 patients (64%) and benign in the remaining 18/50 patients (36%). The sensitivity, specificity, NPV, PPV and accuracy of 18F-FDG PET/CT were 87%, 100%, 81%, 100% and 92%, respectively, compared with 90%, 61%, 78%, 80% and 80%, respectively, for TVUS. In staging ovarian cancer, 18F-FDG PET/CT results were concordant with final pathological staging in 22/32 (69%) patients while CT results were concordant in 17/32 (53%) patients. CT incorrectly down-staged four out of six stage IV patients by missing distant metastasis in the liver, pleura, mediastinum, and in left supraclavicular lymph nodes, which were correctly detected by 18F-FDG PET/CT. CONCLUSION: PET/CT with 18F-FDG provides additional value to TVUS for the differential diagnosis of benign from malignant pelvic lesions, and to CT for the staging of ovarian cancer patients.

Bone Mineral Density in Women Living with Complete Androgen Insensitivity Syndrome and Intact Testes or Removed Gonads.

Complete androgen insensitivity syndrome (CAIS) is due to complete androgen resistance in androgen-dependent tissues. Since androgens are involved in growth, development, and mass maintenance of the skeleton, bone health may be a relevant clinical issue for improving quality of life of women living with CAIS. Bone mineral density (BMD) in women with CAIS and intact gonads has been reported in a normal range, although exceptions are known showing a low BMD mainly at the lumbar level. In women with CAIS and removed gonads, BMD is usually reduced at both the lumbar spine and femoral neck. However, the fracture risk remains largely unknown. In women with CAIS, hormonal replacement therapy may improve BMD, but it does not normalize it. Several factors may be operative (e.g., loss of AR signaling at the bone level, gonadal removal, and age at surgery [before or after attainment of the peak bone mass], inadequate sex steroid replacement therapy, poor compliance with hormonal treatment, high serum FSH levels, lack of testicular protein hormones after gonadal removal), but they are poorly evaluated. In conclusion, the maintenance of testes may represent a strategy to improve bone health in women with CAIS, but a strict follow-up to monitor the cancer risk is mandatory mainly from their 20s onwards. Optimal sex steroid substitutive therapy in adolescence and adulthood is a key factor to improve BMD status in women with CAIS and removed gonads, but conclusive data on optimal management are lacking.

Hot issues in female and male hormonal contraception.

In recent years a number of significant developments in the field of female hormonal contraception have been made which have produced new formulations and delivery systems providing high efficacy, safety and important non-contraceptive benefits. In particular long-acting reversible contraception (LARC) formulations have been demonstrated to ensure extremely high efficacy in typical use, minimal contraindications, optimal safety in all women thereby representing the best option for most women of all ages. Their effectiveness is not reliant upon user adherence and their ability to reduce unintended pregnancies and abortions has been proven. Unfortunately the same considerations cannot be made for male hormonal contraception. Although a large number of men are interested and would welcome the opportunity to use male contraceptive methods, no safe, effective and reversible methods are available on the market. Current methods available for men are limited to condoms and vasectomy. Highly effective prototype regimens have been developed but the pharmaceutical industry is unwilling to pursue further development and market these products. Of all new approaches to male contraception, hormonal methods are the closest to clinical application. These are based on the reversible suppression of luteinizing hormone and follicle stimulating hormone with subsequent reversible inhibition of spermatogenesis and consequent replacement to maintain androgen dependent physiological functions. Most approaches tested combination regimens such as testosterone and a progestin or testosterone and a GnRH analog.