Progesterone Hypersensitivity: The Utility of a Janus Kinase Inhibitor for Recurrent Erythema Multiforme.

BACKGROUND: Progestogen hypersensitivity (PH) is a rare phenomenon reported in women with an immunologic response to rising progesterone levels in the luteal phase. This disease's rarity and clinical spectrum make it challenging to diagnose. CASE: In this case report, we will discuss a 14-year-old female with monthly oral mucositis and palmar lesions consistent with erythema multiforme. Over 2 years, she underwent an extensive multidisciplinary workup and was trialed on many different medical therapies. SUMMARY AND CONCLUSION: The prevalence of PH has grown in the literature over the past decade. Due to progesterone's role in many biochemical pathways, the pathophysiology is complex. Although many modalities are efficacious for treating PH's cyclical eruptions, we propose treatment with a Janus kinase inhibitor when hormonal management alone is insufficient.

Long-Acting Reversible Contraception for Adolescents: A Review of Practices to Support Better Communication, Counseling, and Adherence.

Long-acting reversible contraception (LARC) methods, including levonorgestrel and copper intrauterine devices (IUDs) and the subdermal contraceptive implant, are the most effective reversible forms of contraception and thus are an important aspect of adolescent pregnancy prevention. While LARC efficacy, safety, and appropriateness are supported by major medical organizations and usage rates are increasing, overall LARC uptake among United States (US) adolescents remains lower than uptake of short-acting contraceptive methods. A better understanding of the barriers affecting adolescent LARC uptake and reasons for discontinuation could help facilitate effective communication. For example, learning how to improve adolescent-centered communication, shared decision-making, and motivational counseling strategies may be the first step to improving utilization rates. This narrative review includes three sections. First, this review will describe the history, mechanisms of action, and epidemiology of adolescent LARC use in the US and globally. Next, this review will describe key factors influencing adolescent LARC uptake, reasons for discontinuation, and multilevel barriers specific to adolescent LARC use. Finally, this review will characterize communication techniques and LARC counseling strategies for adolescents in the context of a reproductive justice approach set in the health belief model framework. The distinction between moving away from a presumptive counseling approach towards an adolescent-centered, shared decision-making approach to encourage parent-adolescent sexual health communication to lay the foundation of empowering adolescent reproductive autonomy should be the underpinning of all effective reproductive communication strategies.

Sperm Cryopreservation Outcomes in Transgender Adolescents Compared with Adolescents Receiving Gonadotoxic Therapy.

Purpose: The target population for fertility preservation recently has been expanded from adolescents with cancer undergoing gonadotoxic chemotherapy to include transgender youth before initiating gender-affirming hormone therapy. Patients and providers may have knowledge deficits regarding options for fertility preservation, accessibility, and feasibility of its techniques, and impact of treatment on future fertility. This study describes outcomes of sperm cryopreservation in transgender male-to-female (affirmed female) youth and compares semen parameters with adolescents diagnosed with cancer. Methods: Medical records of transgender-affirmed female adolescents and adolescent males diagnosed with cancer who underwent sperm cryopreservation at the Fertility and Advanced Reproductive Medicine clinic of the University of Texas (UT) Southwestern Medical Center between March 2015 and March 2020 were reviewed. Demographic data were recorded and values for sperm parameters (volume, count, total count, motility (%), total motile) were collected. When available, hormone levels (luteinizing hormone, follicle-stimulating hormone, testosterone, and estradiol) and Tanner stages were also assessed. The two populations were compared using chi-square analysis and two-sample student's t-test. Data are presented as mean±standard deviation. Results: While semen quality parameters trended lower in transgender youth compared with adolescents with cancer, there was no statistically significant difference between groups. While four out of 18 patients in the transgender group had azoospermia, mean semen quality parameters fell within normal adult reference ranges for both groups. Conclusion: Sperm cryopreservation for transgender youth and adolescents with cancer is feasible, inexpensive, and does not result in significant treatment delays. This information can improve counseling and access to these procedures, particularly in the transgender population.

Benign, Borderline, and Malignant Pediatric Adnexal Masses: A 10-Year Review.

STUDY OBJECTIVE: To investigate the incidence, clinical features, tumor markers, radiologic findings, types of surgeries, and histologies for adnexal masses in female pediatric and adolescent patients. DESIGN: Retrospective chart review. SETTING: Children's Health in Dallas and Plano, Texas from 2009 to 2018. PARTICIPANTS: Female patients younger than 19 years old who underwent surgical management of an adnexal mass. INTERVENTIONS: None. MAIN OUTCOME MEASURES: Imaging characteristics, tumor markers, surgical procedures, and histopathology. RESULTS: In total, 752 patients (mean age, 13.7 years) underwent 756 surgical procedures for 781 adnexal masses. Of these, 732/781 (93.7%) were benign, 7/781 (0.9%) were borderline, and 42/781 (5.4%) were malignant. Of all 781 masses, 520/781 (66.6%) were ovarian and 261/781 (33.4%) were paratubal or tubal. Benign masses were associated with Hispanic race, pain, simple or cystic characteristics on imaging, and negative tumor markers. Borderline and malignant masses were associated with white race, pain, mass or distension, larger size, and heterogeneous appearance on imaging. Borderline masses were associated with negative tumor markers. Malignant masses were associated with elevated alpha fetoprotein, beta human chorionic gonadotropin, cancer antigen 125, and lactate dehydrogenase. CONCLUSION: Most adnexal masses in the pediatric and adolescent population are benign. Benign masses were significantly smaller, more likely to have negative tumor markers, and appear simple or cystic. There is little standardization with respect to preoperative tumor markers for adnexal masses. High-yield tumor markers for malignancy include alpha fetoprotein, beta human chorionic gonadotropin, cancer antigen 125, and lactate dehydrogenase. Low-yield tumor markers include inhibin A and B. Gynecologists performed more fertility-preserving surgeries including mini-laparotomies and fewer laparotomies for benign masses than pediatric surgeons.

Squamous Carcinoma of the Cervix in a 15-Year-Old with Congenital HIV: A Case Report.

BACKGROUND: Human papillomavirus (HPV) is the most prevalent sexually transmitted infection (STI) worldwide. Immunocompetent hosts have intact defense mechanisms to prevent HPV infection, but immunocompromised patients are at higher risk for complications, including HPV-related cancers. Most of these cancers originate from high-risk HPV strains in sexually active patients. CASE: Here we present a case of an immunocompromised adolescent who developed cervical cancer despite no prior sexual activity and only ever having had low-risk type HPV on biopsy. SUMMARY AND CONCLUSIONS: To our knowledge, this is the first case report of a cervical cancer arising from a low-risk HPV strain in an immunocompromised, non-sexually active adolescent. This case highlights the importance of preventive and screening mechanisms in immunocompromised populations, as they are have a higher probability of HPV-related complications, even in the absence of traditional risk factors.

The Ob/Gyn and the transgender patient.

PURPOSE OF REVIEW: Over the last few years, awareness and visibility of transgender individuals have exponentially grown. With this growth comes the need for medical providers who understand the unique needs of this population. The present review serves to help obstetrician-gynecologists recognize their important role in the care of these patients. RECENT FINDINGS: Although long-term data are still lacking in the medical care of individuals with gender dysphoria, standards of care for the medical treatment of transgender patients and long-term screening recommendations in the primary care setting were discussed. SUMMARY: Given their surgical expertise and experience with hormone management, obstetrician-gynecologists are in a unique position to provide quality healthcare in this population.

Therapy for anogenital verrucae in preadolescent children with topical and systemic treatment.

BACKGROUND/OBJECTIVES: Anogenital verrucae (AV) are benign, human papillomavirus (HPV)-induced tumors of the anogenital skin and mucosa. Medical therapy for AV in preadolescents has not been well studied. We explore the efficacy and safety profile of sinecatechins 15% ointment and imiquimod 5% cream in the treatment of AV, alone and in combination therapy with other commonly used medications. METHODS: A single-institution, retrospective review of children under 12 years of age with AV treated with imiquimod 5% cream and sinecatechins 15% ointment was performed. Demographic data, side effects, and outcomes of therapy were recorded for each patient, and overall efficacy was determined. RESULTS: A total of 37 patients met inclusion criteria. Responses were seen in 8 out of 9 patients treated with sinecatechins 15% ointment (5 full, 3 partial, and 1 no response) and 9 out of 17 patients treated with imiquimod 5% cream (4 full, 5 partial, and 8 no response). Combination therapy with one or more of the following treatments (podophyllin, cimetidine, candida antigen injection, and HPV vaccine) were evaluated, but no combination was objectively superior to the others. No significant difference was found in overall efficacy between sinecatechins and imiquimod. Side effects were mild and limited to irritation and erythema. CONCLUSIONS: Both imiquimod 5% cream and sinecatechins 15% ointment are moderately effective in the treatment of AV in preadolescent children, with a trend toward greater effectiveness of sinecatechins. Combination therapy with other treatments did not significantly increase the effectiveness of topical therapies. Each modality has a tolerable side effect profile with a low risk of serious complications.

Successful treatment of giant condyloma in a pediatric heart transplant recipient with topical cidofovir.

We report a case of giant condyloma that developed in a pediatric heart transplant recipient. This infection progressed for several months despite reduction in immunosuppression, topical treatment, and oral cimetidine therapy. Complete resolution was observed following 7 months of topical cidofovir, without evidence of systemic toxicity or rejection.

Immune biomarkers and anti-HIV activity in the reproductive tract of sexually active and sexually inactive adolescent girls.

PROBLEM: Adolescent girls are disproportionately affected by the HIV/AIDS pandemic, accounting for 22% of all new HIV infections globally. Yet little is known regarding the immune microenvironment of the adolescent female reproductive tract, especially regarding differences among sexually active and inactive girls, a critical parameter to evaluate HIV susceptibility associated with young age and sexual debut. METHODS: Cervico-vaginal lavage (CVL) was collected from sexually active (10) and inactive (8) girls aged 11-19 years and analyzed by ELISA for inflammation-associated biomarkers IL-6, IL-8, TNF-α, MIP-3α, IL-1α, IL-1ß, matrix metalloproteinases (MMP) 1, 2, 7, 8, and 9, as well as anti-HIV mediators, Elafin, SLPI, human beta-defensin 2, and tissue inhibitor of matrix metalloproteinases (TIMP) 1 and 2. Cervical ectopy was analyzed using Volocity. Anti-HIV activity was determined by TZM-bl assay. Statistical analyses were performed using GraphPad Prism and R. RESULTS: Sexually inactive girls had significantly higher levels of TNF-α (P = .029) in CVL compared to sexually active girls. In contrast, sexually active girls showed a trend toward higher levels of IL-1α (P = .051) compared to the sexually inactive girls. Heat-map correlations between cervical ectopy and immune biomarkers were also distinct between the 2 populations with significant positive associations between % ectopy and inflammation-associated biomarkers IL-6, IL-1ß, IL-8, MIP-3α, MMP-8, and MMP-9 observed in the sexually inactive but not sexually active group. CONCLUSION: Higher pro-inflammatory biomarker TNF-α, as well as a distinct inflammation-associated immune clustering in sexually inactive girls, can potentially increase risk for infections including HIV upon sexual debut. Future studies with larger sample sizes are needed to characterize the immune parameters associated with sexual activity.

Transgender Youth Fertility Attitudes Questionnaire: Measure Development in Nonautistic and Autistic Transgender Youth and Their Parents.

PURPOSE: The objective of this study was to assess transgender youth and parent attitudes regarding (1) the potential impact of gender-affirming hormone therapy on fertility and (2) fertility preservation (FP) options. METHODS: The Transgender Youth Fertility Attitudes Questionnaire was developed through a multistage participatory process with gender specialists and key stakeholders (transgender youth and their parents, N = 35). As up to 25% of youth gender referrals have co-occurring autism, measure development included a well-characterized supplementary sample of autistic transgender youth to maximize the applicability of the questionnaire. Following its development and refinement, the Transgender Youth Fertility Attitudes Questionnaire was pilot tested with transgender youth (nonautistic and autistic) and their parents (N = 51). RESULTS: The participatory process produced parallel child and parent questionnaires addressing fertility and FP knowledge and attitudes. In the pilot trial, youth and parents expressed generally similar attitudes about fertility and FP. Most youth (92%) reported learning about gender-affirming hormone therapy-related fertility issues online. Although many transgender youth endorsed a wish to parent children at some point, few (24%) expressed desire to have their own biological child. However, many youth wondered, or did not know, if their feelings about having a biological child might change in the future. CONCLUSIONS: This study presents a novel procedure for developing instruments for use with transgender youth. Although a majority of transgender youth in this study were uninterested in using FP, extending exploration of this topic with young people may be useful given findings of their openness to the idea that fertility attitudes may change in adulthood.

Cross-Sex Hormones and Metabolic Parameters in Adolescents With Gender Dysphoria.

BACKGROUND AND OBJECTIVES: The Endocrine Society states that adolescents with gender dysphoria may start cross-sex hormones. The goal of this study was to identify patterns in metabolic parameters in transgender adolescents receiving cross-sex hormones. METHODS: Data from adolescents aged 14 to 25 years seen in 1 of 4 clinical sites between 2008 and 2014 were retrospectively analyzed. Subjects were divided into affirmed male (female-to-male) patients taking testosterone and affirmed female (male-to-female) patients taking estrogen. Previously recorded measurements of blood pressure, BMI, testosterone, estradiol, prolactin, lipids, electrolytes, liver function tests, hemoglobin/hematocrit, and hemoglobin A1c were reviewed. These values were obtained from before the start of therapy, at 1 to 3 months after initiation, at 4 to 6 months, and at 6 months and beyond. Repeated measures analysis of variance models were used to evaluate changes over time. RESULTS: One hunderd and sixteen adolescents were included (72 female-to-male subjects and 44 male-to-female subjects). Of the 72 subjects taking testosterone, a significant increase in hemoglobin/hematocrit levels and BMI, as well as a decrease in high-density lipoprotein level, was recorded at each visit. No significant changes in any other parameter tested were found. Of the 44 subjects taking estrogen, no statistically significant changes were noted in the measured metabolic parameters. CONCLUSIONS: Testosterone use was associated with increased hemoglobin and hematocrit, increased BMI, and lowered high-density lipoprotein levels; estrogen was associated with lower testosterone and alanine aminotransferase levels. Otherwise, cross-sex hormone administration in adolescents was not associated with significant differences in the selected metabolic parameters over time.