Desire for Gender-Affirming Surgery in a Sample of Transgender and Gender Diverse Individuals in Late Adolescence Assigned Female at Birth.

OBJECTIVE: To describe choices of transgender and gender diverse (TGD) late adolescents assigned female at birth regarding gender-affirming surgery (GAS). METHODS: Participants aged 18-21 completed an online survey that included demographic characteristics, surgical history, desire for GAS, and barriers to care. RESULTS: Two hundred and sixty surveys were completed. Forty-three (16.7%) respondents had undergone GAS. Of those who had not, 178 (83%) planned to do so in the future, and 15 (7%) reported no desire to undergo GAS. One hundred and sixteen (54%) had not due to financial reasons, 54 (25%) due to insurance difficulties, and 28 (13%) because they were unable to find a surgeon. CONCLUSION: TGD late adolescents assigned female at birth have varying desires for future GAS that align with their gender expression. They also face many barriers to care. It is important for health care providers to be aware of the unique desires of TGD adolescents, not assume any particular surgical path for gender affirmation, and acknowledge the barriers experienced.

Success in Accessing Fertility Preservation Appointments for Egg-Producing Transgender and Gender-Diverse Patients: A Mystery Caller Study.

Purpose: This study aimed to evaluate access to fertility preservation appointments for egg-producing transgender and gender-diverse patients. Methods: Fertility clinics nationwide were identified through the 2018 National Assisted Reproductive Technology Surveillance System dataset of the Centers for Disease Control and Prevention. Using a mystery caller approach with a standardized, community-developed script, three researchers called 456 clinics between July and December 2020 identifying themselves as a transgender man seeking oocyte cryopreservation. Information was collected regarding access to fertility preservation for the caller. Univariate and multivariable logistic regression analysis were used to compare call outcomes by geographic region and clinic demographics. Results: Of 369 clinics included in the final analysis, 90.2% of clinics offered an initial appointment. A clinic that offered an appointment was four times more likely to be located on the West Coast (95% confidence interval [CI] 1.33-12.7; p = 0.014). Notably, endorsement of prior experience caring for transgender patients was most strongly associated with an appointment being offered (odds ratio = 7.31; 95% CI: 3.44-15.5; p < 0.001). Themes across some calls included a lack of knowledge about transgender identities and care models (e.g., requiring a letter of support) leading to additional steps (e.g., having to explain anatomy or being transferred to another staff member) before accessing an appointment. Conclusion: The majority of clinics offered an initial appointment to a caller identifying as a transgender man seeking oocyte cryopreservation, suggesting access to an initial appointment is not a major barrier.

Prevalence of Vulvar Pain and Dyspareunia in Trans Masculine Individuals.

Purpose: The prevalence of vulvar pain and dyspareunia has not been studied in trans masculine individuals. The aim of this study was to determine the prevalence of self-reported vulvar pain symptoms and dyspareunia in this population and investigate its relationship to gender-affirming hormone therapy with testosterone. Methods: Trans masculine individuals of ages 18-64 years participated in a voluntary online survey including questions about demographics, hormone therapy, and whether they experienced vulvar pain symptoms. The study was conducted between May 2017 and October 2018. Descriptive statistics were used to analyze the data. Results: A total of 782 trans masculine individuals completed the survey. The mean age was 27 years (standard deviation 8.6). The majority was White (661/778, 85.0%) and had private health insurance (517/781, 66.2%). Testosterone use was reported by 468 of 782 (59.8%) individuals, and 566 of 672 (84.2%) individuals had been sexually active in their lifetime. Unintentional pain with sexual intercourse was experienced by 372 of 605 (61.5%) participants. A total of 236 of 399 (59.1%) individuals utilized testosterone compared with 136 of 206 (66.0%) individuals who did not (p = 0.11). Of survey respondents, 68 of 710 (9.6%) individuals reported vulvar pain symptoms, and 42 of 452 (9.3%) individuals were on testosterone compared with 26 of 258 (10.1%) individuals not on testosterone (p = 0.79). Of all participants experiencing vulvar pain symptoms, 42 of 68 (61.8%) individuals were on testosterone. Conclusion: In this study, trans masculine individuals had a higher prevalence of dyspareunia than the general population, whereas the prevalence of vulvar pain was similar to that reported in cisgender women. The use of testosterone did not appear to increase the risk of developing unintentional pain with intercourse or vulvar pain symptoms.

The Intrauterine Device Experience Among Transgender and Gender-Diverse Individuals Assigned Female at Birth.

INTRODUCTION: The intrauterine device (IUD) is a long-acting and highly efficacious form of contraception that can also be used for menstrual suppression. Although IUD use is increasing, the type chosen, appeal, and satisfaction among individuals who are transgender and gender diverse and assigned female at birth (TGD-AFAB) is unknown. The purpose of this study is to evaluate IUD usage among TGD-AFAB individuals. METHODS: TGD-AFAB individuals who had an IUD for a minimum of 6 months at the time of completing the survey or had one in the past completed an anonymous online survey. Descriptive statistics were used to analyze the data. RESULTS: One hundred and five TGD-AFAB individuals completed the survey. Among participants who were sexually active, 88% reported they were in a relationship in which it was possible to get pregnant. There were 85 individuals who currently had an IUD: 62 (73%) chose a 52-mg levonorgestrel (LNG) IUD, 5 (6%) chose a lower-dose LNG IUD, 17 (20%) chose the copper IUD, and one chose an IUD unavailable in the United States. Menstrual suppression was the primary reason for choosing a 52-mg LNG IUD (58%). Most individuals who opted for a copper IUD did so to avoid hormonal contraception (71%). Participants reported experiencing IUD side effects; however, few desired removal. Among the 36 respondents who had an IUD in the past, the most frequent reasons for removal were expiration of the device (LNG IUDs) and undesired side effects (copper IUD). Approximately half of participants who had an IUD removed had it replaced with another IUD. DISCUSSION: Pregnancy can occur among TGD-AFAB individuals even if they are on testosterone and amenorrheic. IUDs are well tolerated in this population, with few current users desiring removal for unwanted side effects. Clinicians should counsel TGD-AFAB individuals about the contraceptive and noncontraceptive benefits of IUDs and expected side effects.

Medical First-Trimester Termination of Pregnancy with Massive Fibroid Uterus.

First-trimester termination of pregnancy by medical or surgical route is highly effective with a low complication rate. Uterine abnormalities can complicate a procedure due to distortion of normal anatomy. In this case presentation, medical termination of pregnancy is performed using fetal intracardiac potassium chloride injection and intramuscular methotrexate.

Women Living with HIV over Age of 65: Cervical Cancer Screening in a Unique and Growing Population.

OBJECTIVE: Women living with HIV are at increased risk of human papillomavirus (HPV) infection, which can lead to cervical cancer. New guidelines recommend indefinite screening. The objective of this study is to describe cervical cancer screening practices and colposcopy results in a cohort of women living with HIV over age of 65 who were followed before the new guidelines. Comorbidities, sexually transmitted infections (STIs), and other risk factors were evaluated. METHODS: We conducted a retrospective chart review on 75 women aged 65 or older living with HIV with at least one Pap smear. RESULTS: The mean age of the cohort was 66.5 and at HIV diagnosis was 56. The majority of women were immunocompetent. 80% had serial Pap smears. Of these, 86% of 238 were negative or ASCUS. No women progressed to HSIL. 92% of colposcopies had negative or CIN I results. Three women were treated successfully for high-grade dysplasia. More than half of women had other STIs. 72% were screened for HPV; 50% were positive. CONCLUSION: The majority of women had negative and low-grade Pap smears. Questions remain regarding the utility of continued Pap screening and the added value of HPV testing in this unique population of older women living with HIV.

Knowledge and Acceptability of Anal Cytology Screening Among Women.

OBJECTIVE: Medical providers have initiated anal cytology screening among women to detect anal neoplasia early. Lack of knowledge of the human papillomavirus (HPV) and anticipated screening discomfort may limit patient acceptance. This study investigates attitudes toward anal cytology screening among women. MATERIALS AND METHODS: Women seen for gynecologic care at an urban university medical center were invited to complete an anonymous survey assessing their understanding of HPV and interest in anal cytology screening. Subjects reported the level of pain, discomfort, and embarrassment they expected from screening on a 100-mm visual analog scale. RESULTS: Four hundred four women with mean (SD) age 36 (13) years met criteria for participation. Three hundred thirty-five women reported their race: 52% were white and 36% were African American. Three hundred forty-eight women reported their ethnicities: 76% were Hispanic and 12% were Haitian. Twenty-two percent had never heard of HPV, 57% were not familiar with anal cytology screening, 67% acknowledged that screening was very helpful in detecting anal neoplasia early, and 28% were very interested in undergoing screening. Mean (SD) level of anticipated pain, discomfort, and embarrassment during screening was 62 (32), 68 (30), and 58 (34) mm, respectively. Level of familiarity with anal cytology screening (p < .001), belief in its utility in detecting anal neoplasia (p < .001), and level of anticipated pain (p = .004) were significant predictors of acceptability. CONCLUSIONS: Medical providers should improve counseling about anal cytology screening among at-risk women to familiarize them with the procedure, describe its role in detecting anal neoplasia, and address expectations surrounding pain to increase its acceptability.

Reproductive Health Abstracts (2004-2010) What Gets Published?.

OBJECTIVE: To determine the manuscript publication rate and associated predictors of publication for abstracts submitted to the Reproductive Health Conference from 2004-2010. STUDY DESIGN: We re- viewed all abstracts and determined publication. We identified and analyzed as- sociated factors potentially related to publication. RESULTS: We reviewed 577 abstracts: 142 oral presenta- tions (25%) and 435 poster presentations (75%). The majority were published (58%). Abstracts that were published had a higher average number of abstract authors: published abstracts mean=4.26, standard deviation (SD)=1.7, vs. unpub- lished abstracts mean=3.78, SD=1.9 (p=0.001). Multivariable analysis found oral presentation (odds ratio [OR) =2.1, 95% confidence interval [CII 1.4-3.2), high- volume authorship (defined as an author who was listed on >6 abstracts) (OR=1.6, 95% CI 1.1-2.3), and pro- spective study design (OR=1.4, 95% CI 1.0-2.0) to be independent predictors of publication. CONCLUSION: A high percentage of the abstracts selected by the Reproductive Health abstract selection committees are likely to be published, and thus it is an important venue for the dissemination of cutting-edge research.

IUDs at 1 year: predictors of early discontinuation.

OBJECTIVE: To assess baseline dysmenorrhea and insertion-related pain as predictors of intrauterine device (IUD) removal within 1 year following insertion. STUDY DESIGN: System-wide medical record abstraction 1 year after IUD insertion to identify removals and comparison of baseline characteristics (dysmenorrhea, insertion pain) among women with a removal versus women who continued IUD use was used. Baseline data came from a randomized trial of pain control during insertion. RESULTS: Among 199 insertions, we identified 21 removals and 7 expulsions, a continuation rate of 85.9%. Women with IUD removal had higher median dysmenorrhea scores before insertion than those who continued (42 vs. 25.5, p=.03). Insertion pain and other characteristics were not associated with removal. CONCLUSIONS: Preexisting dysmenorrhea may predict IUD removal within 1 year.

Accuracy of providers' assessment of pain during intrauterine device insertion.

BACKGROUND: Providers often underestimate patient pain. This study investigated if providers accurately assess pain during intrauterine device (IUD) insertion. STUDY DESIGN: This is a secondary analysis of a randomized trial. Participants rated pain on a 100-mm visual analogue scale (VAS). Providers marked a similar VAS for maximum level and timing of participant pain. RESULTS: The mean patient maximum pain was 64.8 mm (SD, 27) compared to 35.3 mm (SD, 26) rated by the provider (p<.001). Patient and provider agreement on most painful time point of procedure was weak (kappa statistic, 0.16). CONCLUSIONS: Providers underestimate pain during IUD insertion. IMPLICATIONS: To our knowledge, this is the first paper to compare provider and patient perceptions of pain during IUD insertion. Understanding this relationship will help guide further research about IUD insertion pain and techniques and could improve patient counseling.

Intracervical lidocaine gel for intrauterine device insertion: a randomized controlled trial.

BACKGROUND: Pain during intrauterine device (IUD) insertion can be a barrier to initiation. Clinical trials have found misoprostol and nonsteroidal drugs to be ineffective (Am J Obstet Gynecol 2006;195:1272-1277, Hum Reprod 2011;26:323-329, Hum Reprod 2007;22:2647-2652). One study suggested that 2% lidocaine gel decreased pain; however, study design problems limit its validity (Brit J Fam Plann 1996;22:177-180). We tested whether intracervical 2% lidocaine gel decreased insertion pain compared to placebo. STUDY DESIGN: We planned a randomized, double-blinded clinical trial of 200 women. We placed 2% lidocaine gel or placebo in the cervix prior to uterine sounding. Participants rated pain by marking a 100-mm visual analogue scale at four time points. RESULTS: We randomized 200 participants and placed 197 IUDs. Pain was greatest at uterine sounding and similar between groups: placebo group mean 51.6 mm (SD 25), lidocaine group mean 55.5 mm (SD 30, p=.33). Stratified analyses accounting for parity showed no treatment effect. Multivariable analyses identified longer time since last pregnancy, lower parity and higher anticipated pain as predictors of pain during sounding, and dysmenorrhea and the levonorgestrel IUD as additional predictors during IUD insertion. CONCLUSIONS: Intracervical 2% lidocaine gel does not decrease IUD insertion pain. Understanding predictors of increased pain may help providers with preprocedure counseling.

Perceptions of family planning and abortion education at a faith-based medical school.

BACKGROUND: Because of religious beliefs against contraception and abortion, family planning education is limited at faith-based institutions. The purpose of this study was to assess medical students' satisfaction with family planning education at a faith-based medical school. STUDY DESIGN: A self-administered anonymous questionnaire was designed and distributed to all second- and fourth-year students (n=273) at a faith-based medical school during the 2008-2009 academic year. The questionnaire included items on adequacy of and preference for amount and content of family planning preclinical education and clinical training. RESULTS: A total of 220 students completed the questionnaire for a response rate of 80.6%. The majority of respondents described the preclinical education as inadequate and preferred increased content on contraception (73.9%), sterilization (68.6%) and abortion (65.2%). The majority of fourth-year students reported appropriate contraceptive clinical training (69.0%), but inadequate sterilization training (54.8%) and abortion training (71.4%) during their third-year OB/GYN clerkship. Approximately half of fourth-year students (51.8%) desired clinical abortion training. CONCLUSION: The majority of students enrolled at a faith-based medical school rated their current family planning education as inadequate and desired additional opportunities.

The state of hormonal contraception today: established and emerging noncontraceptive health benefits.

In the 50 years since the advent of combined oral contraceptives the amount of estrogen in oral contraceptives dropped from over 100 mcg to less than 30 mcg. Many noncontraceptive health benefits have emerged that decrease mortality and improve quality of life. Some of the immediate benefits include improvement of menorrhagia and dysmenorrhea, reduction in premenstrual dysphoric disorder symptoms, and decreased acne. As an effective birth control method oral contraceptives also decrease pregnancy-related deaths by preventing pregnancy. After the reproductive years, previous use of oral contraceptives continues to be beneficial, reducing the risk of death from ovarian and endometrial cancer. All these benefits have held up over time whereas cardiovascular risks have lessened because of the decrease in oral contraceptive pill dosage. Decreased ovarian cyst formation is an example of benefit with higher-dose oral contraceptive formulations that no longer holds true with low-dose pills.