Hypertension, Cardiovascular Risk Factors, and Uterine Fibroid Diagnosis in Midlife.

Importance: Fibroids are benign neoplasms associated with severe gynecologic morbidity. There are no strategies to prevent fibroid development. Objective: To examine associations of hypertension, antihypertensive treatment, anthropometry, and blood biomarkers with incidence of reported fibroid diagnosis in midlife. Design, Setting, and Participants: The Study of Women's Health Across the Nation is a prospective, multisite cohort study in the US. Participants were followed-up from enrollment (1996-1997) through 13 semiannual visits (1998-2013). Participants had a menstrual period in the last 3 months, were not pregnant or lactating, were aged 42 to 52 years, were not using hormones, and had a uterus and at least 1 ovary. Participants with prior fibroid diagnoses were excluded. Data analysis was performed from November 2022 to February 2024. Exposures: Blood pressure, anthropometry, biomarkers (cholesterol, triglycerides, and C-reactive protein), and self-reported antihypertensive treatment at baseline and follow-up visits were measured. Hypertension status (new-onset, preexisting, or never [reference]) and hypertension treatment (untreated, treated, or no hypertension [reference]) were categorized. Main Outcomes and Measures: Participants reported fibroid diagnosis at each visit. Discrete-time survival models estimated hazard ratios (HRs) and 95% CIs for associations of time-varying hypertension status, antihypertensive treatment, anthropometry, and biomarkers with incident reported fibroid diagnoses. Results: Among 2570 participants without a history of diagnosed fibroids (median [IQR] age at screening, 45 [43-48] years; 1079 [42.1%] college educated), 526 (20%) reported a new fibroid diagnosis during follow-up. Risk varied by category of hypertension treatment: compared with those with no hypertension, participants with untreated hypertension had a 19% greater risk of newly diagnosed fibroids (HR, 1.19; 95% CI, 0.91-1.57), whereas those with treated hypertension had a 20% lower risk (HR, 0.80; 95% CI, 0.56-1.15). Among eligible participants with hypertension, those taking antihypertensive treatment had a 37% lower risk of newly diagnosed fibroids (HR, 0.63; 95% CI, 0.38-1.05). Risk also varied by hypertension status: compared with never-hypertensive participants, participants with new-onset hypertension had 45% greater risk of newly diagnosed fibroids (HR, 1.45; 95% CI, 0.96-2.20). Anthropometric factors and blood biomarkers were not associated with fibroid risk. Conclusions and Relevance: Participants with untreated and new-onset hypertension had increased risk of newly diagnosed fibroids, whereas those taking antihypertensive treatment had lower risk, suggesting that blood pressure control may provide new strategies for fibroid prevention.

Long-Term Risk of Reintervention After Surgical Leiomyoma Treatment in an Integrated Health Care System.

OBJECTIVE: To compare long-term risk of reintervention across four uterus-preserving surgical treatments for leiomyomas and to assess effect modification by sociodemographic factors in a prospective cohort study in an integrated health care delivery system. METHODS: We studied a cohort of 10,324 patients aged 18-50 (19.9% Asian, 21.2% Black, 21.3% Hispanic, 32.5% White, 5.2% additional races and ethnicities) who had a first uterus-preserving procedure (abdominal, laparoscopic, or vaginal myomectomy [referred to as myomectomy]; hysteroscopic myomectomy; endometrial ablation; uterine artery embolization) after leiomyoma diagnosis in the 2009-2021 electronic health records of Kaiser Permanente Northern California. We followed up patients until reintervention (second uterus-preserving procedure or hysterectomy) or censoring. We used a Kaplan-Meier estimator to calculate the cumulative incidence of reintervention and Cox regression models to estimate hazard ratios and 95% CIs comparing rates of reintervention across procedures, adjusting for age, parity, race and ethnicity, body mass index (BMI), Neighborhood Deprivation Index, and year. We also assessed effect modification by demographic characteristics. RESULTS: Median follow-up was 3.8 years (interquartile range 1.8-7.4 years). Index procedures were 18.0% (1,857) hysteroscopic myomectomies, 16.2% (1,669) uterine artery embolizations, 21.4% (2,211) endometrial ablations, and 44.4% (4,587) myomectomies. Accounting for censoring, the 7-year reintervention risk was 20.6% for myomectomy, 26.0% for uterine artery embolization, 35.5% for endometrial ablation, and 37.0% for hysteroscopic myomectomy; 63.2% of reinterventions were hysterectomies. Within each procedure type, reintervention rates did not vary by BMI, race and ethnicity, or Neighborhood Deprivation Index. However, rates of reintervention after uterine artery embolization, endometrial ablation, and hysteroscopic myomectomy decreased with age, and reintervention rates for hysteroscopic myomectomy were higher for parous than nulliparous patients. CONCLUSION: Long-term reintervention risks for uterine artery embolization, endometrial ablation, and hysteroscopic myomectomy are greater than for myomectomy, with potential variation by patient age and parity but not BMI, race and ethnicity, or Neighborhood Deprivation Index.

Neighborhood Disadvantage, Race and Ethnicity, and Postpartum Depression.

Importance: Postpartum depression (PPD) is a debilitating condition with higher rates among Black individuals. Increasingly, neighborhood disadvantage is being recognized as a contributor to poor health and may be associated with adverse postpartum mental health; however, associations between neighborhood disadvantage, race and ethnicity, and PPD have not been examined. Objective: To investigate the association between neighborhood disadvantage and PPD and evaluate the extent to which these associations may differ by race and ethnicity. Design, Setting, and Participants: This population-based cross-sectional study included 122 995 postpartum Kaiser Permanente Northern California members 15 years or older with a live birth between October 7, 2012, and May 31, 2017, and an address in the electronic health record. Analyses were conducted from June 1, 2022, through June 30, 2023. Exposures: Neighborhood disadvantage defined using quartiles of the Neighborhood Deprivation Index (NDI), a validated census-based socioeconomic status measure; self-reported race and ethnicity ascertained from Kaiser Permanente Northern California electronic health records. Main Outcomes and Measures: Multivariable Poisson regression was conducted to assess associations between neighborhood disadvantage, race and ethnicity, and a diagnosis of PPD. Results: Of 122 995 included postpartum individuals, 17 554 (14.3%) were younger than 25 years, 29 933 (24.3%) were Asian, 8125 (6.6%) were Black, 31 968 (26.0%) were Hispanic, 47 527 (38.6%) were White, 5442 (4.4%) were of other race and ethnicity, and 15 436 (12.6%) had PPD. Higher neighborhood disadvantage and race and ethnicity were associated with PPD after covariate adjustment. Compared with White individuals, Black individuals were more likely to have PPD (adjusted relative risk [ARR], 1.30; 95% CI, 1.24-1.37), whereas Asian (ARR, 0.48; 95% CI, 0.46-0.50), and Hispanic (ARR, 0.92; 95% CI, 0.89-0.96) individuals and those identified as having other race and ethnicity (ARR, 95% CI, 0.90; 0.85-0.98) were less likely to have PPD. Associations between NDI and PPD differed by race and ethnicity (likelihood ratio test for interaction, χ212 = 41.36; P < .001). Among Black individuals, the risk of PPD was the greatest overall and increased with neighborhood disadvantage in a dose-response manner (quartile [Q] 2 ARR, 1.39 [95% CI, 1.13-1.71]; Q3 ARR, 1.50 [95% CI, 1.23-1.83]; Q4 ARR, 1.60 [95% CI, 1.32-1.93]; Cochrane-Armitage test for trend, P < .001). Neighborhood disadvantage was associated with PPD among Asian (Q2 ARR, 1.17 [95% CI, 1.04-1.31]; Q3 ARR, 1.20 [95% CI, 1.06-1.35]) and White (Q3 ARR, 1.14 [95% CI, 1.07-1.21]; Q4 ARR, 1.17 [95% CI, 1.09-1.26]) individuals and those of other race and ethnicity (Q3 ARR, 1.34 [95% CI, 1.09-1.63]; Q4 ARR, 1.28 [95% CI, 1.03-1.58]), but the magnitude of risk was lower. Neighborhood disadvantage was not associated with PPD among Hispanic individuals (eg, Q2 ARR, 1.04 [95% CI, 0.94-1.14]; Q3 ARR, 1.00 [95% CI, 0.91-1.10]; Q4 ARR, 0.98 [95% CI, 0.90-1.08]). Conclusions and Relevance: In this cross-sectional study of postpartum individuals, residing in more disadvantaged neighborhoods was associated with PPD, except among Hispanic individuals. Neighborhood disadvantage may be associated with racial and ethnic differences in postpartum mental health. Geographic targeting of mental health interventions may decrease postpartum mental health inequities.

Urinary Tract Infections Among Gender Diverse People Assigned Female at Birth on Testosterone.

IMPORTANCE: The current literature lacks evidence to support the relationship between gender-affirming testosterone use and urinary tract infections (UTIs). OBJECTIVES: The aims of the study are to compare UTI rates among gender diverse people assigned female at birth on testosterone (GDT) to cisgender women (CW) and to identify factors associated with UTI. STUDY DESIGN: This is a retrospective cohort study of GDT and age-matched CW over a 5-year period. The primary outcome was based on the International Classification of Diseases, Ninth/Tenth Revisions, Clinical Modification, UTI diagnosis codes with a filled pharmacy order for antibiotics within 7 days of the diagnosis. RESULTS: The study included 2,401 GDT who were then age matched to 2,401 CW. The mean rates of UTI among GDT and CW were not significantly different at 0.09 and 0.10 UTIs per year, respectively. During the study period, 6.9% of GDT and 7.5% of CW had at least 1 UTI. Diabetes mellitus type 1 or 2 was significantly associated with UTI frequency among CW (P = 0.04) but not GDT (P = 0.96). CONCLUSIONS: The rate of UTIs among our young cohort of GDT and CW was similarly low. Diabetes mellitus type 1 or 2 was significantly associated with UTIs among CW but not GDT. These findings suggest that testosterone-induced vaginal atrophy may not be associated with a higher a UTI risk. A deeper understanding of the pathogenesis of UTI in people assigned female at birth and more data on the relationship between testosterone and UTIs are needed before recommending vaginal estrogen to all GDT with recurrent UTI.

Hereditary Breast and Ovarian Cancer Genetic Risk: Screening and Treatment Among Transgender and Gender Diverse Patients.

IntroductionTransgender and gender diverse (TGD) populations with hereditary cancer syndromes face unique barriers to care and thus may not be accessing appropriate cancer screening or risk-reducing procedures. Our objective was to evaluate health care utilization of TGD patients with hereditary cancer syndromes. This includes counseling received, cancer screenings conducted, and risk-reducing procedures performed. MethodsA case series of TGD patients (N = 11) with hereditary breast and ovarian cancer (n = 9) or Lynch syndrome (n = 2) who received care within Kaiser Permanente Northern California between 2009 and 2019. ResultsAll patients received counseling and prophylactic options. Three patients (27%) completed all recommended screening, 6 (54%) had partial screening, 1 (9%) received no screening, and 1 (9%) did not require any screening. Six (55%) underwent a risk-reducing procedure. DiscussionThis case series highlights that despite all the study participants being appropriately counseled by practitioners about their risk of cancer, screening, and prophylactic options, in many cases, the screening received was partial or absent. Relatively few completed all the recommended screenings based on their clinical risk factors. ConclusionMany of the TGD patients with hereditary cancer syndromes in this cohort did not complete all the recommended cancer screening. This can be an area of focus in order to improve the quality of care provided to this vulnerable population.

Impact of COVID-19 on the Incidence and Severity of Obstetric and Gynecologic Emergency Department Visits in an Integrated Health Care System.

OBJECTIVE: COVID-19 has had an unprecedented impact on medical care use and delivery, including stark reductions in emergency department (ED) volume. The aim of this study was to assess changes in incidence of OB/GYN ED visits and disease severity at time of presentation during the COVID-19 pandemic. STUDY DESIGN: We conducted a multicenter retrospective study of OB/GYN-related ED visits before and during the COVID-19 pandemic. Incidence rates (IRs) and severity measures were compared across time periods and years. RESULTS: A total of 18,668 OB/GYN ED encounters occurred between January 1 and December 31, 2020, compared to 21,014 encounters between January 1 and December 31, 2019. During shelter-in-place, visits decreased by 41% compared to the pre-pandemic period in 2020 before returning to typical rates (incidence rate ratio (IRR) = 0.98 in fall/winter). We found a similar proportion of patients with hemoglobin < 7 g/dL for diagnoses associated with bleeding and patients with white blood cell count > 12,000 per µL in the setting of infection comparing corresponding time periods in 2019 and 2020. There were fewer formal OB/GYN consults, hospital admissions at time of presentation, and urgent surgical procedures performed across all periods in 2020; however, hospitalization within 7 days substantially increased in the first half of 2020. CONCLUSION: The incidence of OB/GYN ED visits declined substantially between March and August 2020 but then returned to pre-pandemic levels by fall/winter 2020. The decreased incidence was not accompanied by an increase in severity of presentation.

Minimally invasive myomectomy: practice trends and differences between Black and non-Black women within a large integrated healthcare system.

BACKGROUND: Although multiple professional organizations encourage minimally invasive surgical approaches whenever feasible, nationally, fewer than half of myomectomies are performed via minimally invasive routes. Black women are less likely than their non-Black counterparts to have minimally invasive surgery. OBJECTIVE: This study aimed to assess the trends in surgical approach among women who underwent minimally invasive myomectomies for uterine leiomyomas within a large integrated healthcare system as initiatives were implemented to encourage minimally invasive surgery, particularly evaluating differences in the proportion of minimally invasive surgery performed in Black vs non-Black women. STUDY DESIGN: We conducted a retrospective cohort study of women, aged ≥18 years, who underwent a myomectomy for a uterine leiomyoma within Kaiser Permanente Northern California between 2009 and 2019. Generalized estimating equations and Cochran-Armitage testing were used to assess myomectomy incidence and linear trend in the proportions of myomectomy by surgical route-abdominal myomectomy and minimally invasive myomectomy. Multivariable logistic regression analyses were used to assess the associations between surgical route and (1) race and ethnicity and (2) complications, controlling for patient demographic, clinical, and surgical characteristics. RESULTS: A total of 4033 adult women underwent a myomectomy during the study period. Myomectomy incidence doubled from 0.12 (95% confidence interval, 0.12-0.13) per 1000 women in 2009 to 0.25 (95% confidence interval, 0.24-0.25) per 1000 women in 2019 (P<.001). During the 11-year study period, the proportion of minimally invasive myomectomy increased from 6.0% to 89.5% (a 15-fold increase). The proportion of minimally invasive myomectomy in Black women remained lower than in non-Black women (54.5% vs 64.7%; P<.001). Black women undergoing myomectomy were younger (36.4±5.6 vs 37.4±5.8 years; P<.001), had a higher mean fibroid weight (436.0±505.0 vs 324.7±346.1 g; P<.001), and had a higher mean body mass index (30.8±7.3 vs 26.6±5.9 kg/m2; P<.001) than their non-Black counterparts. In addition to patient race, surgery performed between 2016 and 2019 compared with surgery performed between 2009 and 2012 and higher surgeon volume compared with low surgeon volume were associated with an increased proportion of minimally invasive myomectomy (adjusted relative risks, 12.58 [95% confidence interval, 9.96-15.90] and 6.63 [95% confidence interval, 5.35-8.21], respectively). Black race and fibroid weight of >500 g each independently conferred lower rates of minimally invasive myomectomy. In addition, there was an interaction between race and fibroid weight such that Black women with a fibroid weight of ≤500 g or >500 g were both less likely to have minimally invasive myomectomy than non-Black women with a fibroid weight of ≤500 g (adjusted relative risks, 0.74 [95% confidence interval, 0.58-0.95] and 0.26 [95% confidence interval, 0.18-0.36], respectively). Operative, perioperative, and medical complications were low during the 11-year study period. In regression analyses, after controlling for race, age, fibroid weight, parity, low-income residence, body mass index, surgeon volume, and year of myomectomy, the risk of complications was not markedly different comparing abdominal myomectomy with minimally invasive myomectomy. Similar results were found comparing laparoscopic minimally invasive myomectomy with robotic-assisted minimally invasive myomectomy except for women who underwent laparoscopic minimally invasive myomectomy had a lower risk of experiencing any medical complications than those who underwent robotic-assisted minimally invasive myomectomy (adjusted relative risk, 0.27; 95% confidence interval, 0.09-0.83; P=.02). CONCLUSION: Within an integrated healthcare delivery system, although initiatives to encourage minimally invasive surgery were associated with a marked increase in the proportion of minimally invasive myomectomy, Black women continued to be less likely to undergo minimally invasive myomectomy than their non-Black counterparts. Race and fibroid weight alone did not explain the disparities in minimally invasive myomectomy.

Intrauterine device, subdermal contraceptive, and depot medroxyprogesterone use among transmasculine and cisgender patients over a 10-year period.

OBJECTIVE: To describe use of three types of longer-acting contraception-intrauterine devices, subdermal contraceptives, and depot medroxyprogesterone-among transmasculine and cisgender women patients. STUDY DESIGN: A repeated cross-sectional study using electronic medical records of patients, age 18 to 45, receiving care within Kaiser Permanente Northern California between 2009 and 2019. Variations in demographics, clinical characteristics and contraception method uptake were assessed using t tests for continuous variables and chi-square tests for categorical variables for patients enrolled in 2019. A linear trend test for each group was used to assess the age-adjusted uptake of contraception methods by study year. RESULTS: The transmasculine group was younger, with a mean age of 27.3 years (±7.2) vs 32.5 years (±7.8) years, respectively p < 0.001. The transmasculine group used more tobacco, alcohol, and illicit drugs. The uptake of these contraception methods increased from 2009 to 2019 for both groups (transmasculine: 0.7% to 4.1%; cisgender: 5.6% to 6.7%) with a positive linear trend for both groups (p = 0.003 and p < 0.001, respectively). The change in uptake of any intrauterine device from 2009 to 2019 was greater for the transmasculine group (0.3% to 2.3% vs 3.3% to 3.5%). Etonogestrel implant uptake had a positive linear trend from 2009 to 2019 for both groups (transmasculine: 0% to 0.5%, p = 0.02, and cisgender 0.1% to 1.2%, p < 0.001). CONCLUSION: Annual uptake of these contraception methods increased significantly for both transmasculine and cisgender groups, and this increase was greater for the transmasculine patients. Uptake of these contraception methods was higher in the cisgender population. IMPLICATIONS: These findings suggest an improvement in use of long-term contraception and menstrual suppression medications for the transmasculine population. Further research is needed to understand these differences and identify a possible unmet need for intrauterine and subdermal contraceptives and depot medroxyprogesterone use among this often-marginalized population.

Prophylactic transdermal scopolamine for the reduction of postoperative length of stay after uterine aspiration at Kaiser Permanente Northern California from 2017-2018.

OBJECTIVE: To determine if transdermal scopolamine is associated with decreased postoperative nausea and vomiting and shorter length of stay in the postoperative care unit among patients undergoing uterine aspiration for abortion or early pregnancy loss. STUDY DESIGN: We conducted a retrospective cohort study at an integrated medical center that initiated a protocol to prescribe transdermal scopolamine to patients undergoing uterine aspiration under moderate sedation. We compared outcomes among patients who underwent uterine aspiration in 2017, before the institution enacted the protocol, with their counterparts in 2018, immediately after the institution instated the protocol. We reviewed patient charts for data on the postoperative length of stay, use of additional antiemetics, and a standardized clinician designated postoperative nausea and vomiting score. We analyzed outcomes by relevant demographic and clinical characteristics using chi-square or Fisher's exact tests for categorical variables and t tests for continuous variables. RESULTS: The final sample included 386 patients; 228 who did not receive scopolamine and 158 who did. The cohorts were comparable in terms of demographic and clinical characteristics. The cohort that received transdermal scopolamine had a similar mean postoperative length of stay (75.4 ± 54.1 vs 71.1 ± 50.8 minutes; p = 0.43). There were no differences in the proportions of patients who were provided additional antiemetics (26 ± 11.4 vs 17 ± 10.8; p = 0.84) or had transient vomiting and retching (3 ± 1.9 vs 3 ± 1.3; p = 0.69) between the cohorts. CONCLUSION: We found no evidence that prophylactic transdermal scopolamine reduces postoperative nausea, vomiting, or length of stay among patients undergoing uterine aspiration. IMPLICATIONS: Among patients who underwent uterine aspiration under moderate sedation, use of prophylactic transdermal scopolamine was not associated with shorter postoperative length of stay or lesser use of antiemetics. Prophylactic transdermal scopolamine is not likely to be useful for patients undergoing uterine aspiration and could be an unnecessary cost.

Active versus Passive Voiding Protocols after Same-day Minimally Invasive Hysterectomy.

STUDY OBJECTIVE: To determine the proportion of patients discharged with a urinary catheter after a same-day benign gynecologic minimally invasive hysterectomy (MIH) according to active vs passive voiding protocols. The secondary objectives included assessing postanesthesia care unit (PACU) duration and postoperative urinary retention (POUR) rate ≤2 weeks of discharge. DESIGN: Retrospective, observational cohort study. SETTING: Large integrated healthcare system serving approximately 40% of the Northern California population. PATIENTS: Patients aged 18 years or older undergoing same-day MIH without urogynecology procedures from 2015 to 2018 were categorized into active or passive voiding trial groups. Active voiding trials were defined as patients arriving in the PACU with a catheter, retrograde filling of the bladder with 300 mL saline then allowing for voiding ≥50% within 30 minutes. If the patients were unable to void this volume, they were discharged with a catheter to be removed within 24 hours. A passive voiding trial involved filling or not filling the bladder before PACU arrival without a catheter, then allowing for voiding or performing a straight catheterization if the patients were unable to void. INTERVENTIONS: Retrospective cohort study. MEASUREMENTS AND MAIN RESULTS: A total of 1644 (83.2%) patients underwent passive voiding trials, and 333 (16.8%) underwent active voiding trials. The proportion of patients discharged with a catheter was lower in the passive voiding group than in the active voiding group (5.4% vs 10.5%; p = .001). The passive group had a shorter mean PACU time than the active group (218 ± 86 vs 240 ± 93 minutes; p <.001). The crude POUR rates for the passive and active voiding groups were 1.8% and 3.0%, respectively (p = .16). CONCLUSION: Within an integrated healthcare system, patients who underwent passive voiding trials compared with those who underwent active voiding trials were discharged home from the PACU after a shorter duration. In addition, a larger proportion of the patients who underwent passive voiding trials were discharged home without a urinary catheter. There were no differences in the POUR rates. Our findings suggest that passive voiding trials can be safely used after a benign MIH to reduce hospital duration, optimize healthcare resources, and improve patient experience.

Variation in Vaginal Hysterectomy Rates in an Integrated Healthcare System.

STUDY OBJECTIVE: To describe trends in minimally invasive hysterectomy (MIH) and assess patient, surgical, and provider characteristics associated with differences in vaginal versus laparoscopic rates within an integrated healthcare system. DESIGN: A retrospective cohort study. SETTING: Kaiser Permanente Northern California from 2008 to 2018. PATIENTS: Patients who underwent MIH for benign conditions excluding uterine prolapse and incontinence surgeries. INTERVENTIONS: Hysterectomies. MEASUREMENTS AND MAIN RESULTS: A total of 27518 hysterectomies were performed for benign indications. Of these, the proportion of MIH increased from 29.1% (2008) to 96.7% (2018) (p <.001). The proportion of vaginal hysterectomies (VHs) of all hysterectomies did not change significantly over the study period (p = .07); however, the proportion of VH among MIH cases decreased from a high of 50.6% in 2008 to 13.2% in 2018 (p <.001). VH rates were lower in obese and morbidly obese patients (p <.001 and p = .02, respectively) and in women with uterine weights >250 g (p <.001). The differences persisted after controlling for patient demographic, clinical, and surgery characteristics. Low surgical volume was inversely associated with VH (adjusted relative risk, 7.19; 95% confidence interval, 6.62-7.81; p <.001). VH rates ranged from 11.5% to 27.8% across service areas (hospitals). Service area remained a significant predictor of VH after controlling for patient (including body mass index and uterine weight) and surgery-related characteristics. Postoperative hospital stay decreased from 33.8 ± 16.4 hours (2008) to 6.1 ± 12.2 (2018) for VH. Operative time was shorter for VH than laparoscopic hysterectomies (LHs) (1.7 vs 2.5 hours; p <.001). Overall operative/perioperative complications were low and not significantly different (VH vs LH). CONCLUSION: As the proportion of MIH increased, LH became the preferred route despite similar rates of postoperative stay and intraoperative complications and shorter operative time for VH compared with LH. Service area and provider volume were independent predictors of MIH route, suggesting that training and evidence-based guidelines for route selection may help preserve VH rates.

Training the Next Generation of Obstetrics and Gynecology Leaders, A Multi-Institutional Needs Assessment.

OBJECTIVE: To assess resident and faculty interest in, as well as content and preferred format for, a leadership curriculum during obstetrics and gynecology residency DESIGN: From June to July 2019, a needs assessment survey on leadership training was distributed to residents and academic faculty at 3 United States obstetrics and gynecology residency programs. Descriptive and bivariate analyses were performed. Open ended questions were analyzed for themes. SETTING: Three ob/gyn residency programs across the United States: Kaiser Permanente East Bay in Oakland, California, Baylor College of Medicine in Houston, Texas, and Weill Cornell Medicine in New York, New York. PARTICIPANTS: Surveys were distributed to all residents (n = 111) and affiliated academic faculty (n = 124) at each of the 3 participating sites. RESULTS: Resident response rate was 71% (79/111) and faculty rate was 63% (78/124). Postgraduate year (PGY) 1 residents were more likely to believe there was sufficient leadership training during residency (17/23, 74%) compared to PGY 2-4s (16/56, 29%) and faculty (20/76, 26%; p < 0.01). Most residents (66/79, 84%) and faculty (74/78, 82%) expressed that residents would benefit from a leadership curriculum. Both deemed small group exercises and leadership case studies taught by physicians were the preferred format for this curriculum. Residents and faculty agreed on 3 of the top 4 topics for a leadership curriculum - effective communication, team management, and time management - while residents chose self-awareness and faculty chose professionalism as the fourth of their top domains. Open-ended survey questions revealed that leadership demands in obstetrics and gynecology are similar to other specialties but differ in emphasis on crisis management, situational awareness, and advocacy training. CONCLUSIONS: Given unique aspects of leadership within the specialty, obstetrics and gynecology residents and faculty see benefit for specialty-specific formalized leadership training.

An Evaluation of the SCORE Program: A Novel Research and Mentoring Program for Medical Students in Obstetrics/Gynecology and Otolaryngology.

BACKGROUND: There has been a steady decrease in the number of physician-scientists and a lack of diversity and inclusion of underrepresented minorities (URMs) in medicine. OBJECTIVE: To assess the research productivity, interest, and experience of medical students, including URMs, and resident and faculty mentors of the Kaiser Permanente Oakland Medical Center's 8-week, intensive, mentored Summer Clinical Otolaryngology and Obstetrics/Gynecology Research (SCORE) Program for second-year medical students. METHODS: A database of SCORE Program research projects was generated from 2016, when the program was launched, through 2018. SCORE Program students and faculty completed a brief, mixed-methods, anonymous exit survey that captured respondents' experiences, perceived program strengths, and opportunities for improvement. The number of peer-reviewed manuscripts produced were counted. RESULTS: A total of 16 SCORE Program students (50% female and 38% URMs) between 2016 and 2018 and 8 residents and 8 faculty members in 2018 completed a brief, mixed-methods, anonymous exit survey that captured respondents' experiences, perceived program strengths, and opportunities for improvement. The medical students coauthored 12 published peer-reviewed articles, 25 abstracts or national posters, and 1 opinion editorial. According to the program's annual exit survey, 87% of students reported an increased interest in pursuing research, 93% had an increased interest in their respective specialties, and 93% believed they had positive mentorship experiences. Similarly, faculty and residents enjoyed mentoring students, thought that students positively contributed to their projects, and would support the SCORE Program in the future. CONCLUSION: Structured research and mentoring experiences, such as the SCORE Program, may encourage students, including URMs, to pursue research throughout their careers in addition to adding research to their curriculum vitae to strengthen their residency applications.

Prediction of Occult Uterine Sarcoma before Hysterectomy for Women with Leiomyoma or Abnormal Bleeding.

STUDY OBJECTIVE: To develop a risk prediction model for occult uterine sarcoma using preoperative clinical characteristics in women undergoing hysterectomy for presumed uterine leiomyomata. DESIGN: Cases of uterine sarcoma were identified from the electronic medical records. Age/race-matched controls were selected at a 2:1 ratio (controls:cases) from a cohort of 45 188 women who underwent hysterectomy for uterine leiomyomata or abnormal bleeding during the same time interval. Unadjusted conditional logistic regression was performed to identify risk factors for occult uterine sarcomas, defined as no preoperative suspicion for malignancy. A risk prediction model was developed using a weighted logistic regression model, and the performance of the model was assessed using the receiver operator characteristic curve and corresponding area under the curve. SETTING: A large integrated health care system in California PATIENTS: Women 18 years of age and older who underwent a hysterectomy and were diagnosed with a uterine sarcoma and matched controls from 2006 to 2013. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: There were 117 cases of occult uterine sarcomas that met inclusion criteria during the study period. The final risk prediction model included age, race/ethnicity, number of myomas, uterine weight, uterine size increase, degree of pelvic pain, and recent history of blood transfusion. The risk prediction model showed high accuracy based on the receiver operating characteristic curve method (area under the curve = 0.83; 95% confidence interval, 0.77-0.90); however, the positive predictive values were low (0.048 or less) at all risk thresholds. CONCLUSION: Multiple clinical features are associated with the presence of a uterine sarcoma, but when incorporated into a prediction model, they fail to provide significantly more information about women who may have an unrecognized sarcoma and only marginally improve the certainty about women who are not likely to have sarcoma.

Trends in Referrals to a Pediatric Transgender Clinic.

OBJECTIVES: We characterized referral trends over time at a transgender clinic within an integrated health system in Northern California. We identified the transition-related requests of pediatric transgender and gender-nonconforming patients and evaluated differences in referrals by age group. METHODS: Medical records were analyzed for all patients <18 years of age in the Kaiser Permanente Northern California health system who were referred to a specialty transgender clinic between February 2015 and June 2018. Trends in treatment demand, demographic data, service requests, and surgical history were abstracted from medical charts and analyzed by using descriptive statistics. RESULTS: We identified 417 unique transgender and gender-nonconforming pediatric patients. The median age at time of referral was 15 years (range 3-17). Most (62%) identified on the masculine spectrum. Of the 203 patients with available ethnicity data, 68% were non-Hispanic. During the study period, the clinic received a total of 506 referrals with a significant increase over time (P < .001). Most referrals were for requests to start cross-sex hormones and/or blockers (34%), gender-affirming surgery (32%), and mental health (27%). Transition-related requests varied by age group: younger patients sought more mental health services, and older patients sought hormonal and surgical services. Eighty-nine patients underwent gender-affirming surgeries, mostly before age 18 and most frequently mastectomies (77%). CONCLUSIONS: The increase in referrals supports the need for expanded and accessible health care services for this population. The transition-related care of patients in this large sample varied by age group, underscoring the need for an individualized approach to gender-affirming care.

Effectiveness of a Gender Affirming Surgery Class for Transgender and non-binary Patients and their Caregivers in an Integrated Healthcare Setting.

Background: Gender affirming surgeries are increasingly accessible to transgender and non-binary individuals due to changes in health care coverage policies and rising numbers of trained providers. Improved access to care has led to an increase in the number of individuals pursuing gender affirming surgeries. Little is known about how to optimally prepare patients for these surgeries. Aims: This evaluation examined attendees' assessment of a four-hour single-session class developed to prepare transgender and non-binary patients and their caregivers for gender affirming surgeries in a multi-disciplinary transgender clinic within an integrated health care system. Methods: A multi-disciplinary group of providers within a health maintenance organization in Northern California designed and facilitated two separate curricula, one for patients preparing for metoidioplasty/phalloplasty and the other preparing for vaginoplasty. Between November 2015 and June 2017, 214 patients and caregivers took one of the two versions of the class and completed the post-class survey evaluating perceived favorability of the class and preparedness regarding surgery options, complications and postoperative care. Descriptive statistics were used to summarize the Likert scale questions, with 1 showing the least improvement and 5 showing the most. Results: Of the 214 patients and caregivers that completed the survey, the majority reported that they were better informed about their surgical options (mean: 4.4, SD: 0.7), more prepared for surgery (mean: 4.5, SD: 0.6), better informed about possible complications (mean: 4.5, SD: 0.7), and better understood their postoperative care needs (mean: 4.6, SD: 0.6). Of the respondents, 204 (95%) reported they would recommend the course to a friend preparing for gender affirming surgery. Discussion: Our findings demonstrate that a single-session class is a favorable method for preparing transgender and non-binary patients to make informed decisions regarding the perioperative gender affirming surgical process, from preoperative preparedness, to surgical complications, and postoperative care.

Alternative Treatment Utilization Before Hysterectomy for Benign Gynecologic Conditions at a Large Integrated Health System.

STUDY OBJECTIVE: To investigate rates of utilization of alternative treatments before hysterectomy for benign gynecologic indications within a large integrated health care system. DESIGN: Retrospective cohort study of patients who underwent hysterectomies for benign gynecologic conditions between 2012 and 2014 (Canadian Task Force classification II-2). SETTING: Kaiser Permanente Northern California, a community-based integrated health system. PATIENTS: Women who underwent hysterectomy for a benign gynecologic condition between 2012 and 2014. INTERVENTIONS: From an eligible cohort of 6892 patients who underwent hysterectomy, a stratified random sample of 1050 patients were selected for chart review. Stratification was based on the proportion of indications for hysterectomy. MEASUREMENTS AND MAIN RESULTS: The primary outcome was the use of alternative treatments before hysterectomy. Alternative treatments included oral hormone treatment, leuprolide, medroxyprogesterone intramuscular injections, a levonorgestrel intrauterine device, hormonal subdermal implants, endometrial ablation, uterine artery embolization, hysteroscopy, and myomectomy. Of the 1050 charts reviewed, 979 (93.2%) met the criteria for inclusion in this study. The predominant indication for hysterectomy was symptomatic myomas (54.4%), followed by abnormal uterine bleeding (29.0%), endometriosis (5.8%), pelvic pain (3.1%), dysmenorrhea (3.4%), and other (4.3%). The major routes of hysterectomy were laparoscopy (68.7%) and vaginal hysterectomy (13.4%). Before hysterectomy, 81.2% of patients tried at least 1 type of alternative treatment (33.8% with 1 treatment and 47.4% with at least 2 treatments), and 99.3% of patients were counseled regarding alternative treatments. Compared with younger women age <40 years, women age 45 to 49 years were less likely to use alternative treatments before hysterectomy (adjusted odds ratio, 0.41; 95% confidence interval, 0.21-0.76). There were no variations in treatment rates by socioeconomic status or between major racial and ethnic groups. The final pathological analysis identified myomas as the most common pathology (n = 637; 65.1%); 96 patients (9.8%) had normal uterine pathology. CONCLUSION: More than 80% of patients received alternative treatments before undergoing hysterectomy for a benign gynecologic condition. Additional investigation is warranted to assess alternative treatment use as it relates to preventing unnecessary hysterectomies.