Lee Ann E. Conard

Emergency contraceptive pills: a review of the recent literature

Purpose of review The purpose of this review is to inform the reader of new information published since early 2003 about emergency contraception, with a particular focus on issues of access. Recent findings Research continues to document low but increasing levels of knowledge about emergency contraception, increasing use, and more positive attitudes towards emergency contraception by both patients and healthcare providers. Additional information is available about efficacy and mechanisms of action. More reports of side-effects have been published, as have studies relating to the impact of emergency contraception on sexual and contracepting behaviors. Advance provision, provision by pharmacists, and over-the-counter status have been studied as ways to improve access to emergency contraception. Summary Knowledge about the efficacy, safety, types and use of emergency contraception continues to increase. Although patients have greater awareness of and more access to emergency contraception, there are still numerous barriers to its use even in countries where it is available over the counter. Healthcare providers must continue to educate themselves and their patients about emergency contraception even when it becomes available over the counter. In countries where emergency contraception is only available by prescription, providers should offer an advance prescription or supply (where available), and use newer dosing regimens for levonorgestrel-only emergency contraception to increase adherence and efficacy. Developing collaborative practice agreements with pharmacists to increase access is also recommended. Patients should be counseled to seek follow-up if no menses occurs within 3 weeks of taking emergency contraception or if symptoms such as lower abdominal pain occur after the use of emergency contraception.

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

This study retrospectively identifies patterns in metabolic and cardiovascular parameters in transgender adolescents receiving cross-sex hormone treatment. 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.

Screening for Spiritual Struggle in an Adolescent Transgender Clinic: Feasibility and Acceptability

Spiritual struggles are associated with poorer health outcomes, including depression, which has higher prevalence among transgender individuals than the general population. This study’s objective was to improve the quality of care in an outpatient transgender clinic by screening patients and caregivers for spiritual struggle and future intervention. The quality improvement questions addressed were whether screening for spiritual struggle was feasible and acceptable; and whether the sensitivity and specificity of the Rush Protocol were acceptable. Revision of the screening was based on cognitive interviews with the 115 adolescents and caregivers who were screened. Prevalence of spiritual struggle was 38–47%. Compared to the Negative R-COPE, the Rush Protocol screener had sensitivities of 44–80% and specificities of 60–74%. The Rush Protocol was acceptable to adolescents seen in a transgender clinic, caregivers, and clinic staff; was feasible to deliver during outpatient clinic visits, and offers a straightforward means of identifying transgender persons and caregivers experiencing spiritual struggle.

Caring for Transgender and Gender-Nonconforming Youth

Purpose of ReviewWe reviewed recently published literature around the care of transgender and gender-nonconforming youth. In this nascent area of medicine, there are few randomized controlled trials, but there are treatment guidelines that include expert opinion and best practices for a more standardized approach to care.Recent FindingsThe most significant article published the past year is the updated standards of care—“Endocrine Treatment of Gender-Dysphoric/Gender-Incongruent Persons: An Endocrine Society Clinical Practice Guideline”—which establishes a care framework with special emphasis on the importance of interdisciplinary care. However, there are several other important articles that review health-care utilization and outcomes after treatment in the transgender population.SummaryAs gender dysphoria and nonconformity become more visible and prevalent, health-care providers will deliver care for these patients and will need to understand common health concerns and treatment options. The ability to provide culturally competent and appropriate care can improve psychosocial outcomes for these patients.

Health Concerns of Transgender and Gender Nonconforming Youth and Their Parents Upon Presentation to a Transgender Clinic

PURPOSE The purpose of the study was to determine the frequency of specific health concerns identified by transgender and gender nonconforming patients and their parents at initial clinic visit. METHODS Checklists were developed in an iterative process and distributed to both patients and parents at their initial visit to a transgender clinic. Retrospective chart review and secondary data analyses were performed to determine the number of items endorsed, frequency with which each item was endorsed, and provider domain of each item endorsed: physician, social work, or both physician and social work. RESULTS Checklists were collected from 118 patients and 103 parents. Patients endorsed a mean of 8.4 concerns (range 0-22) and parents 7.9 concerns (range 0-20). The most commonly endorsed patient concerns included use of gender-affirming hormones, steps for transition, gender-affirming surgery, restroom/dressing room use, and legal issues. Common parent concerns included general resources, child safety at school, acute mental health concerns, restroom/dressing room use, and steps for transition. Of the concerns endorsed by patients, 44% were in the social work domain, 37% in the physician domain, and 19% in both the social work and physician domain. Of the concerns endorsed by parents, 40% were in the social work domain, 31% in the physician domain, and 29% in the social work and physician domain. CONCLUSIONS Although patients and parents had similar numbers of concerns, they primarily focused on different topics. Youth were more interested in hormones and transition, while parents were more interested with transition and acceptance. Many concerns for both patients and parents fell within the social work domain.