Novel Approaches to Patients with Differences of Sex Development.

Patients with differences of sex development (DSDs) have complex anatomy and surgical needs related to both Mullerian and non-Mullerian structures. Approaches to vaginal reconstruction for these conditions are guided by individual anatomy, with the goal of establishing unobstructed outflow for the reproductive, urinary, and gastrointestinal tracts. Patients may have anatomy requiring vaginoplasty for either outflow tract obstruction or chosen sexual function. In this article, the authors focus on management of differences in vaginal anatomy with delayed vaginoplasty for the newborn with DSD.

Bleeding Patterns among Adolescents Using the Levonorgestrel Intrauterine Device: A Single Institution Review.

STUDY OBJECTIVE: To describe the bleeding patterns associated with the use of the levonorgestrel intrauterine device (IUD) in adolescents. DESIGN, SETTING, AND PARTICIPANTS: A retrospective chart review of postmenarchal adolescent patients ages 8-19 years who had the levonorgestrel IUD inserted at Phoenix Children's Hospital from 2012 to 2018. INTERVENTIONS: Insertion of the 52-mg and 13.5-mg levonorgestrel IUD. MAIN OUTCOME MEASURES: The rate of amenorrhea and other bleeding patterns after insertion of the levonorgestrel IUD and the factors that might predict those bleeding patterns. RESULTS: A total of 260 charts were identified with 221/260 (85.0%) patients choosing the 52-mg IUD and 39/260 (15.0%) patients choosing the 13.5-mg IUD to be inserted. Follow-up data were available for 166 patients. The overall rate of amenorrhea among IUD users was 39.8% (n = 66) with no difference between 52-mg and 13.5-mg IUD users (P = .656). Regularity and flow of menstrual cycle, history of bleeding disorder, history of developmental delay, and current treatment with testosterone for gender dysphoria before IUD insertion did not appear to have a significant effect on the rate of amenorrhea or bleeding patterns post-IUD insertion. CONCLUSION: The levonorgestrel IUD can be successfully used to control abnormal uterine bleeding and suppress menses in adolescents. Menstrual cycle characteristics pre-IUD insertion did not result in predictable post-IUD bleeding patterns.

Trends in the Management of Nonviable Pregnancies of Unknown Location in the United States.

BACKGROUND: When managing a nonviable pregnancy of unknown location (PUL), a debate has emerged in the literature whether to perform uterine curettage for definitive diagnosis of pregnancy location or administer methotrexate for a presumed ectopic pregnancy. The purpose of this study is to describe the treatment patterns when managing a PUL. METHODS: A prospective, anonymous Internet based-electronic survey of PUL case scenarios was administered to a random sample of physicians across the United States. RESULTS: A total of 214 physicians responded. When presented with a PUL by ultrasound and a ßhCG measurement of 3,270 mIU/mL, which is above the discriminatory level, 88.3% (188) would choose an additional ßhCG measurement before recommending any intervention. When presented with a PUL by ultrasound and serial ßhCG measurements demonstrating an inappropriate trend for a viable gestation, 36.5% would offer uterine curettage and 31.3% would offer methotrexate. Resident and private clinicians had a fourfold lower adjusted odds of choosing uterine curettage compared to academic physicians. CONCLUSIONS: Based on our findings, there does not appear to be a consensus regarding the management of a PUL.