Serum estradiol in women ingesting combination oral contraceptive steroids

Age and Menopausal Status in Idiopathic Subglottic Stenosis

OBJECTIVE

To evaluate the impact of age on disease recurrence in idiopathic subglottic stenosis (iSGS) patients.

METHODS

This was a retrospective chart review of iSGS patients treated with laser wedge excision. Patients did not have prior surgery. Survival rates free of recurrence were estimated using the Kaplan-Meier methods, and associations were evaluated using Cox Proportional Hazards models.

RESULTS

Eighty-five female patients were included in the study. Most patients (68%) were postmenopausal, had first period at or before 13 years of age, had at least one full-term pregnancy (82%), were not undergoing hormone replacement therapy (93%), were not using hormonal birth control (88%), and were either partially or completely compliant with triple therapy regime (80%). There was a statistically significant average reduction in risk of recurrence of 5% for every additional year of age (p < 0.0001). When compared to patients older than 65 years of age, patients less than 35 were nearly 10 times more likely to recur (p = 0.002), and patients 55-65 and 45-55 years of age were 8 and 5 times more likely to recur, respectively (p = 0.003 and 0.009). Additionally, females on birth control showed decreased risk of recurrence of 74% compared with their counterparts (p = 0.04).

CONCLUSION

This is the first study to demonstrate an inverse relationship between age and disease recurrence in patients with iSGS following surgery. Using age as a surrogate for menopausal status, these results suggest that increased age and/or birth control provide a protective effect through decreased recurrence rates, possibly mediated by decreased estrogen levels.

LEVEL OF EVIDENCE

4 Laryngoscope, 135:198-205, 2025.

Further evidence that peritraumatic 17β-estradiol levels influence chronic posttraumatic pain outcomes in women, data from both humans and animals

ABSTRACT

Chronic posttraumatic pain (CPTP) is common after traumatic stress exposure (TSE) and disproportionately burdens women. We previously showed across 3 independent longitudinal cohort studies that, in women, increased peritraumatic 17β-estradiol (E2) levels were associated with substantially lower CPTP over 1 year. Here, we assessed this relationship in a fourth longitudinal cohort and also assessed the relationship between E2 and CPTP at additional time points post-TSE. Furthermore, we used a well-validated animal model of TSE to determine whether exogenous E2 administration protects against mechanical hypersensitivity. Using nested samples and data from the Advancing Understanding of RecOvery afteR traumA study (n = 543 samples, 389 participants), an emergency department-based prospective study of TSE survivors, we assessed the relationship between circulating E2 levels and CPTP in women and men using multivariate repeated-measures mixed modeling. Male and ovariectomized female Sprague Dawley rats were exposed to TSE and administered E2 either immediately after or 3 days post-TSE. Consistent with previous results, we observed an inverse relationship between peritraumatic E2 and longitudinal CPTP in women only (β = -0.137, P = 0.033). In animals, E2 protected against mechanical hypersensitivity in female ovariectomized rats only if administered immediately post-TSE. In conclusion, peritraumatic E2 levels, but not those at post-TSE time points, predict CPTP in women TSE survivors. Administration of E2 immediately post TSE protects against mechanical hypersensitivity in female rats. Together with previous findings, these data indicate that increased peritraumatic E2 levels in women have protective effects against CPTP development and suggest that immediate post-TSE E2 administration in women could be a promising therapeutic strategy for reducing risk of CPTP.

Longitudinal changes in sexual desire and attraction among women who started using the Natural Cycles app

Many women experience sexual side effects, such as decreased libido, when taking hormonal contraceptives (HCs). However, little is known about the extent to which libido recovers after discontinuing HCs, nor about the timeframe in which recovery is expected to occur. Given that HCs suppress the activities of multiple endogenous hormones that regulate both the ovulatory cycle and women's sexual function, resumption of cycles should predict libido recovery. Here, using a combination of repeated and retrospective measures, we examined changes in sexual desire and partner attraction (among partnered women) across a three-month period in a sample of Natural Cycles users (Survey 1: n = 1596; Survey 2: n = 550) who recently discontinued HCs. We also tested whether changes in these outcomes coincided with resumption of the ovulatory cycle and whether they were associated with additional factors related to HC use (e.g., duration of HC use) or relationship characteristics (e.g., relationship length). Results revealed that both sexual desire and partner attraction, on average, increased across three months after beginning to use Natural Cycles. While the prediction that changes in sexual desire would co-occur with cycle resumption was supported, there was also evidence that libido continued to increase even after cycles resumed. Together, these results offer new insights into relationships between HC discontinuation and women's sexual psychology and lay the groundwork for future research exploring the mechanisms underlying these effects.

Hormonal Contraception Use and Sexual Frequency across Young Women's Intimate Relationships

We examined whether hormonal contraception (HC) use predicts sexual frequency throughout and across young women's intimate relationships. From 2008-2012, the Relationships Dynamics and Social Life Study collected weekly surveys over 2.5 years, and included 893 women (aged 18-19 at baseline) who reported 2,547 intimate relationships across 32,736 weeks. Three-level logistic multilevel models assessed the weekly probability of sexual intercourse based on 1) weekly HC use (vs. nonuse) and 2) duration of HC use, both accounting for several relational and individual characteristics, including relationship duration. Women had more frequent sexual intercourse when they were using HC than when they were not (predicted probabilities .65 vs .41). The weekly probability of sexual intercourse increased sharply within the first month of HC initiation (by about 27 percentage points), remained high for several months, then began to slowly decline (yet remained above that of nonuse). When separated by method type, similar trajectories were found for the pill, ring, and IUD/implant; following the initial increase, steeper declines in intercourse frequency were found for the contraceptive injectable, eventually dropping below pre-initiation levels. Findings signify the immediate influence of reduced pregnancy fears in facilitating sexual intercourse among young women, which may decline as HC use continues long-term.

Sexual Health Behaviors by Age 17 and Lower Urinary Tract Symptoms at Age 19: PLUS Research Consortium Analysis of ALSPAC Data

PURPOSE

We examined how antecedent sexual health factors affect lower urinary tract symptoms (LUTS) in adolescent women.

METHODS

We analyzed 1,941 adolescent women from the Avon Longitudinal Study of Parents and Children at age 19. At ages 15 and 17, participants reported use of oral contraceptives (OCs), history of sexual intercourse, number of sexual partners, and condom use. At age 19, The Bristol Female Lower Urinary Tract Symptoms questionnaire quantified the frequency over the past month: stress incontinence, any incontinence, urgency, sensation of incomplete emptying, bladder pain, and urinary tract infection. Multivariable regression models examined associations between sexual health behaviors reported at ages 15 and 17 and six LUTS reported at age 19, after controlling for covariates.

RESULTS

Commonly reported LUTS at age 19 were past-month stress incontinence (26.8%), bladder pain (26.3%), any urine leakage (22.1%), and urinary tract infection (15.4%). OC use by age 17 was associated with urgency (odds ratio [OR] = 1.62, 95% confidence interval [CI] 1.19-2.20), incomplete emptying (OR = 1.62, 95% CI = 1.17-2.26), bladder pain (OR = 1.45, 95% CI = 1.15-1.83), and urinary tract infections (OR = 1.68, 95% CI = 1.28-2.21) at age 19 after adjustment for covariates. However, associations were attenuated after adjustment for condom use and number of sexual partners. Sexual intercourse by age 17 was associated with 1.53-2.65 increased odds of LUTs categories except incontinence, with lower confidence interval boundaries > 1.0. Associations were stronger among women with ≥ 3 sexual partners (vs. 0) by age 17.

DISCUSSION

We found longitudinally assessed associations between OC use, sexual intercourse, and number of sexual partners during adolescence and LUTS at age 19.

Breastfeeding history and adenomyosis risk using a novel case-control study design

OBJECTIVE

To evaluate the association between breastfeeding history, including lifetime exclusive breastfeeding, and risk of adenomyosis.

DESIGN

We used data from a case-control study designed with 2 control groups to address the challenge of selecting noncases for a valid epidemiologic study when cases are identified by hysterectomy. The case-control study was conducted among premenopausal and postmenopausal enrollees aged 18-59 years in a large, integrated health care system in western Washington state.

PATIENT(S)

Cases were enrollees with incident, pathology-confirmed adenomyosis diagnosed during 2001-2006 (n = 386). The 2 control groups were as follows: (1) randomly selected age-matched enrollees with intact uteri ("population controls," n = 323) and (2) hysterectomy controls (n = 233).

INTERVENTION(S)

Data on breastfeeding history were collected by in-person interviews. For each reported live birth, participants were asked whether they breastfed, along with infant age at supplemental feeding introduction and breastfeeding discontinuation.

MAIN OUTCOME MEASURE(S)

Among participants with at least 1 live birth (330 cases, 246 population controls, and 198 hysterectomy controls), we used unconditional logistic regression to estimate adjusted odds ratios and 95% confidence intervals (CIs) for the associations between the following: (1) ever breastfeeding, (2) ever breastfeeding for ≥8 weeks, (3) lifetime breastfeeding, and (4) lifetime exclusive breastfeeding and risk of adenomyosis. Analyses were adjusted for age, reference year, smoking, education, and parity.

RESULT(S)

In analyses comparing cases with population controls, we observed a 40% decreased odds of adenomyosis with a history of ever breastfeeding (adjusted odds ratio, 0.6; 95% CI, 0.3-1.0) and breastfeeding for ≥8 weeks (adjusted odds ratio, 0.6; 95% CI, 0.4-0.8). The strongest associations, 60%-70% decreased odds of adenomyosis, were observed with ≥12 months of lifetime breastfeeding (vs. <3 months) (adjusted odds ratio, 0.4; 95% CI, 0.2-0.6) and 9 to <12 months of lifetime exclusive breastfeeding (vs. <3 months) (adjusted odds ratio, 0.3; 95% CI, 0.2-0.6), comparing cases to population controls. In analyses using hysterectomy controls, we observed similar patterns of associations slightly attenuated in magnitude.

CONCLUSION(S)

Breastfeeding history was associated with a 40% decreased odds of adenomyosis, a condition that can confer substantial morbidity and requires hysterectomy for definitive treatment. The consistency of our findings with that of a previous study lends support that breastfeeding may modify risk of adenomyosis.

A prospective observational study of the effects of sugammadex on peri-operative oestrogen and progesterone levels in women who take hormonal contraception

Pharmacokinetic modelling suggests that sugammadex may interact with endogenous progesterone and reduce levels by 34% in patients taking hormonal contraception. Due to this potential interaction that may be equivalent to missing one dose of an oral contraceptive pill, both the manufacturer and professional anaesthesia organisations recommend counselling patients to use additional non-hormonal contraception after administration of sugammadex. We performed a prospective observational study examining the changes in serum oestrogen and progesterone concentrations in premenopausal adult women undergoing an operative procedure. Sixty participants who were on hormonal contraception received sugammadex. Two additional control groups were recruited, consisting of 30 participants who were not on hormonal contraception and did not receive sugammadex, and 32 who were not on hormonal contraception and did receive sugammadex. Three blood samples were taken: before sugammadex; 15 min post-sugammadex; and 240 min post-sugammadex or end of operating theatre time. Median oestrogen levels decreased from baseline by around 40% at 240 min in all three groups (p ≤ 0.001). Progesterone levels rose significantly at 15 min (p = 0.002) in patients on contraception then decreased non-significantly to 20% below baseline at 240 min. The decrease in oestrogen and the rise in progesterone could both act to minimise the risk of ovulation and thus protect contraception in this population. We found no evidence of a change in hormone levels that might threaten contraceptive efficacy in women on hormonal contraception receiving sugammadex.

Steady-state estradiol triggers a unique innate immune response to allergen resulting in increased airway resistance

RATIONALE

Asthma is a chronic airway condition that occurs more often in women than men during reproductive years. Population studies have collectively shown that long-term use of oral contraceptives decreased the onset of asthma in women of reproductive age. In the current study, we hypothesized that steady-state levels of estrogen would reduce airway inflammation and airway hyperresponsiveness to methacholine challenge.

METHODS

Ovariectomized BALB/c mice (Ovx) were implanted with subcutaneous hormone pellets (estrogen, OVX-E2) that deliver consistent levels of estrogen [68 ± 2 pg/mL], or placebo pellets (OVX-Placebo), followed by ovalbumin sensitization and challenge. In conjunction with methacholine challenge, immune phenotyping was performed to correlate inflammatory proteins and immune populations with better or worse pulmonary outcomes measured by invasive pulmonary mechanics techniques.

RESULTS

Histologic analysis showed an increase in total cell infiltration and mucus staining around the airways leading to an increased inflammatory score in ovarectomized (OVX) animals with steady-state estrogen pellets (OVX-E2-OVA) as compared to other groups including female-sham operated (F-INTACT-OVA) and OVX implanted with a placebo pellet (OVX-Pl-OVA). Airway resistance (Rrs) and lung elastance (Ers) were increased in OVX-E2-OVA in comparison to F-INTACT-OVA following aerosolized intratracheal methacholine challenges. Immune phenotyping revealed that steady-state estrogen reduced CD3+ T cells, CD19+ B cells, ILC2 and eosinophils in the BAL across all experiments. While these commonly described allergic cells were reduced in the BAL, or airways, we found no changes in neutrophils, CD3+ T cells or CD19+ B cells in the remaining lung tissue. Similarly, inflammatory cytokines (IL-5 and IL-13) were also decreased in OVX-E2-OVA-treated animals in comparison to Female-INTACT-OVA mice in the BAL, but in the lung tissue IL-5, IL-13 and IL-33 were comparable in OVX-E2-OVA and F-INTACT OVA mice. ILC2 were sorted from the lungs and stimulated with exogenous IL-33. These ILC2 had reduced cytokine and chemokine expression when they were isolated from OVX-E2-OVA animals, indicating that steady-state estrogen suppresses IL-33-mediated activation of ILC2.

CONCLUSIONS

Therapeutically targeting estrogen receptors may have a limiting effect on eosinophils, ILC2 and potentially other immune populations that may improve asthma symptoms in those females that experience perimenstrual worsening of asthma, with the caveat, that long-term use of estrogens or hormone receptor modulators may be detrimental to the lung microenvironment over time.

Regulatory T Cell Proportion and Phenotype Are Altered in Women Using Oral Contraception

Regulatory T (Treg) cells are a specialized CD4+ T cell subpopulation that are essential for immune homeostasis, immune tolerance, and protection against autoimmunity. There is evidence that sex-steroid hormones estrogen and progesterone modulate Treg cell abundance and phenotype in women. Since natural oscillations in these hormones are modified by hormonal contraceptives, we examined whether oral contraception (OC) use impacts Treg cells and related T cell populations. T cells were analyzed by multiparameter flow cytometry in peripheral blood collected across the menstrual cycle from healthy women either using OC or without hormonal contraception and from age-matched men. Compared to naturally cycling women, women using OC had fewer Treg cells and an altered Treg cell phenotype. Notably, Treg cells exhibiting a strongly suppressive phenotype, defined by high FOXP3, CD25, Helios, HLADR, CTLA4, and Ki67, comprised a lower proportion of total Treg cells, particularly in the early- and mid-cycle phases. The changes were moderate compared to more substantial differences in Treg cells between women and men, wherein women had fewer Treg cells-especially of the effector memory Treg cell subset-associated with more T helper type 1 (Th1) cells and CD8+ T cells and lower Treg:Th1 cell and Treg:CD8+ T cell ratios than men. These findings imply that OC can modulate the number and phenotype of peripheral blood Treg cells and raise the possibility that Treg cells contribute to the physiological changes and altered disease susceptibility linked with OC use.

Sex and gender differences in mild traumatic brain injury/concussion

The high incidence of concussions/mild traumatic brain injury and the significant number of people with persisting concussion symptoms as well as the concern for delayed, neurodegenerative effects of concussions makes them a major public health concern. There is much to learn on concussions with respect to pathophysiology as well as vulnerability and resiliency factors. The heterogeneity in outcome after a concussion warrants a more personalized approach to better understand the biological and psychosocial factors that may affect outcome. In this chapter we address biological sex and gender as they impact different aspects of concussion including incidence, risk factors and outcome. As well, this chapter will provide a more fulsome overview of intimate partner violence, an often-overlooked cause of concussion in women. Applying the sex and gender lens to concussion/mild traumatic brain injury is imperative for discovery of its pathophysiology and moving closer to treatments.

Discontinuation of hormonal contraception due to changes in mood and decreases in sexual desire: the role of adverse childhood experiences

PURPOSE

To evaluate if adverse childhood experiences are associated with hormonal contraception discontinuation due to mood and sexual side effects.

MATERIALS AND METHODS

Women, ages 18-40 (N = 826), with current and/or previous hormonal contraceptive use completed surveys on demographics, contraceptive history, and the Adverse Childhood Experiences Questionnaire. We characterised women into high (≥2 adverse experiences) and low (0 or 1) adverse childhood experience groups. We calculated risk ratios for associations between adverse childhood experiences and outcomes of interest using log binomial generalised linear models, and adjusted for relevant demographic variables.

RESULTS

Women in the high adverse childhood experiences group (n = 355) were more likely to report having discontinued hormonal contraception due to decreases in sexual desire (adjusted risk ratio 1.44, 1.03-2.00, p = .030). Covariates included age, current hormonal contraception use, and various demographic variables associated with discontinuation. Adverse childhood experiences were not associated with mood or sexual side effects among current (n = 541) hormonal contraceptive users.

CONCLUSIONS

Self-reported adverse childhood experiences were associated with greater likelihood of discontinuing hormonal contraception due to behavioural side effects, particularly decreases in sexual desire. Identification of risk factors for behavioural side effects can assist patients and clinicians in making informed choices on contraception that minimise risk of early discontinuation.

Lifetime caffeine intake and the risk of epithelial ovarian cancer

BACKGROUND

Caffeine intake has been inconsistently associated with the risk of ovarian cancer in previous studies. The measure of caffeine in these studies has not always distinguished between caffeinated and decaffeinated sources, and the time for which intake was assessed was often for late adulthood and thus may have excluded the etiologic window. We investigated lifetime caffeine intake from caffeinated coffee, black tea, green tea and cola sodas in relation to ovarian cancer risk.

METHODS

Among 497 cases and 904 controls in a population-based case-control study in Montreal, Canada, lifetime intake of caffeinated coffee, black tea, green tea and cola sodas was assessed and used to calculate lifetime total intake of caffeine. Unconditional multivariable logistic regression was used to estimate odds ratios (ORs) with 95% confidence intervals (CIs) for the association between caffeine intake and ovarian cancer risk overall, as well as by menopausal status. Multivariable polytomous logistic regression was used to estimate the associations for invasive and borderline ovarian cancers separately.

RESULTS

Almost all participants (98.4% of cases and 97.5% of controls) had consumed caffeine in their lifetime. The mean (standard deviation) daily consumption of caffeine over the lifetime was of 117 (89) mg/day among cases and 120 (118) mg/day among controls. The OR (95% CI) of ovarian cancer for the highest versus lowest quartile of lifetime caffeine intake was 1.17 (0.83-1.64). According to menopausal status, the OR (95% CI) was 1.56 (0.85-2.86) for premenopausal women and 0.94 (0.66-1.34) for postmenopausal women, comparing the highest to lowest tertiles of intake. Associations for invasive and borderline ovarian cancers separately were similar to that observed for ovarian cancer overall.

CONCLUSION

Lifetime caffeine intake was not strongly associated with ovarian cancer risk. A difference in relationship by menopausal status is possible.

Breakthrough Bleeding in Transgender and Gender Diverse Adolescents and Young Adults on Long-Term Testosterone

STUDY OBJECTIVE

Amenorrhea is a goal of many transgender and gender diverse adolescent and young adult (TGD AYA) patients on testosterone gender-affirming hormone therapy (T-GAHT). Breakthrough bleeding can contribute to worsening gender dysphoria. Our objective was to evaluate breakthrough bleeding in TGD AYA on T-GAHT.

DESIGN

Institutional review board-approved retrospective cohort.

SETTING

Tertiary-care children's hospital.

PARTICIPANTS

TGD AYA on T-GAHT >1 year.

INTERVENTIONS

None; observational.

MAIN OUTCOME MEASURES

Presence of, and risk factors for, breakthrough bleeding.

RESULTS

Of the 232 patients who met inclusion criteria, one-fourth (n = 58) had 1 or more episodes of breakthrough bleeding, defined as bleeding after more than 1 year on T-GAHT. In comparing patients with breakthrough bleeding to those without, there were no significant differences between age of initiation, body mass index (BMI), race/ethnicity, testosterone type used, use of additional menstrual suppression, serum testosterone, or estradiol levels. Patients with breakthrough bleeding patients were on T-GAHT longer (37.3 ± 17.0 vs 28.5 ± 14.6 months, P < .001) and were more likely to have endometriosis (P = .049). Breakthrough bleeding began at a mean of 24.3 ± 17.2 months after T-GAHT initiation. Of those with breakthrough bleeding, 46 (79.3%) had no known cause, 10 (17.2%) bled only with missed T-GAHT doses, and 2 (3.4%) bled only when withdrawing from concomitant menstrual suppression. No breakthrough bleeding management method was found to be superior.

CONCLUSION

Breakthrough bleeding is relatively common (25%) on T-GAHT despite early amenorrhea. Most cases do not have an identifiable cause. Our data did not show superiority of any 1 method for managing breakthrough bleeding on T-GAHT.

Do oral contraceptives affect young women's memory? Dopamine-dependent working memory is influenced by COMT genotype, but not time of pill ingestion

Background

Despite the widespread use of oral contraceptives (OCs), and the well-documented influence of estrogens, notably 17β-estradiol (E2), on cognition, research relating OCs to working memory is limited and mixed. Two factors may contribute to these mixed findings: 1) pharmacokinetics of oral contraceptives, which drive fluctuations in synthetic hormone levels; and 2) genetic polymorphisms related to dopamine degradation and working memory, which interact with E2. This research investigated whether the pharmacokinetics of oral contraceptives, in concert with the single nucleotide polymorphism (Val¹⁵⁸Met; rs4680) of the catechol-o-methyltransferase gene (COMT), influence working memory performance.

Methods

University-age women taking and not taking OCs were tested for working memory and genotyped for COMT. If they were not taking OCs (n = 62), sessions occurred in the early follicular (low E2) and late follicular (high E2) phase. If they were taking OCs (n = 52), sessions occurred 1–2 hours after (high ethinyl estradiol, EE) and ~24 hours after (low EE) pill ingestion. Working memory was tested using the N-back, AX-CPT, Digit Span, and Digit Ordering Tasks. Data were analyzed using multilevel models with estrogen condition, COMT, and group as predictors, controlling for mood and practice effects.

Results

For women taking OCs, time of pill ingestion did not influence performance. However, the subgroup with COMT val/val (low dopamine) were less accurate on 2-back lure trials than those with COMT met/met (high dopamine). For women not taking OCs, cycle phase moderated COMT’s influence on lure accuracy. When compared, women taking OCs had higher AX-CPT proactive control indices than those not taking OCs.

Conclusion

These findings suggest that oral contraceptives are not detrimental for young women’s working memory and that they may increase proactive control. The more pronounced effects of COMT in women taking OCs suggests that, in women taking OCs, suppressed endogenous E2–not fluctuating EE levels–may be more relevant for working memory. Future studies are needed to differentiate effects of endogenous versus synthetic estrogens on working memory.

COVID-19 in Africa: an ovarian victory?

Coronavirus disease 2019 (COVID-19) caused by Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) mainly attacks the respiratory system and is characterized by pneumonia, cytokine storm, coagulation disorders and severe immune downregulation. Although public health experts predicted worst outcomes in Africa, the incidence, hospitalization and mortality rates have been lower in Africa compared to other continents. Interestingly, lower incidence and mortality rates have been observed in women from Africa compared to their cohorts from other continents. Also, in the US non-Hispanic Black females have lower COVID-19 and death rates compared to their white counterparts. It's unclear why this significant difference exists; however, the ovarian function, genetics and immunological statuses could play a major role. Women of African descent have elevated levels of estrogen compared with Caucasians hence we anticipate that estrogen might offer some protection against the SARS-CoV-2 infections. The racial differences in lifestyle, age and inaccessibility to contraceptive usage might also play a role. Here, we provide insight on how the high levels of estrogen in African women might contribute to the lower cases and fatalities in Africa. Specifically, estrogen might offer protection against COVID-19 by suppressing hyper-production of cytokines, promoting anti-inflammatory cytokines, stimulating antibody production and suppressing endoplasmic reticulum (ER) stress. This will as well provide useful information on how future pandemics could be managed using Africa as a case study.

Reproductive Considerations for the LGBTQ+ Community

When working with LGBTQ+ patients who want to build families, primary care providers play a key role in increasing access to reproductive health care. There is growing demand for assisted reproductive services among LGBTQ+ individuals who do not already have their own children or do not wish to adopt. Fertility-preservation options are available for transgender patients; however, many of these treatments are inaccessible to patients because of lack of insurance coverage and high cost. Legal options for LGBTQ+ patients' reproduction vary by state. Knowledge of the laws and regulations in your own state of practice is necessary to manage expectations.

Oral contraceptive use is associated with smaller hypothalamic and pituitary gland volumes in healthy women: A structural MRI study

The effects of hormonal contraceptives on structural features of the hypothalamus and pituitary are incompletely understood. One prior study reported microstructural changes in the hypothalamus with oral contraceptive pill (OCP) use. However, effects on hypothalamic volume have not been reported. One prior study reported volumetric changes in the pituitary. However, this study was limited by including participants evaluated for neurological symptoms. We sought to determine if OCP use is associated with alteration of hypothalamic or pituitary volume. High-resolution 3T MRI was performed for a prospective cohort of 50 healthy women from 2016 to 2018, which comprised 21 OCP users (age, 19-29) and 29 naturally cycling women (age, 18-36). Participants were excluded if they were pregnant or had significant medical conditions including neurological, psychiatric, and endocrine disorders. After confirming reliability of the image analysis techniques, 5 raters independently performed manual segmentation of the hypothalamus and semi-automated intensity threshold-based segmentation of the pituitary using ITK-SNAP. Total intracranial volume was estimated using FreeSurfer. A general linear model tested the association of OCP use with hypothalamic and pituitary volumes. Hypothalamic (B = -81.2 ± 24.9, p = 0.002) and pituitary (B = -81.2 ± 38.7, p = 0.04) volumes in OCP users were smaller than in naturally cycling women. These findings may be related to interference with known trophic effects of sex hormones and suggest a structural correlate of central OCP effects.

Targeting progesterone signaling prevents metastatic ovarian cancer

Effective cancer prevention requires the discovery and intervention of a factor critical to cancer development. Here we show that ovarian progesterone is a crucial endogenous factor inducing the development of primary tumors progressing to metastatic ovarian cancer in a mouse model of high-grade serous carcinoma (HGSC), the most common and deadliest ovarian cancer type. Blocking progesterone signaling by the pharmacologic inhibitor mifepristone or by genetic deletion of the progesterone receptor (PR) effectively suppressed HGSC development and its peritoneal metastases. Strikingly, mifepristone treatment profoundly improved mouse survival (∼18 human years). Hence, targeting progesterone/PR signaling could offer an effective chemopreventive strategy, particularly in high-risk populations of women carrying a deleterious mutation in the BRCA gene.

Offspring sex and risk of epithelial ovarian cancer: a multinational pooled analysis of 12 case-control studies

While childbearing protects against risk of epithelial ovarian cancer (EOC), few studies have explored the impact on maternal EOC risk of sex of offspring, which may affect the maternal environment during pregnancy. We performed a pooled analysis among parous participants from 12 case-controls studies comprising 6872 EOC patients and 9101 controls. Odds ratios (ORs) and 95% confidence intervals (CIs) were calculated using multivariable logistic regression for case-control associations and polytomous logistic regression for histotype-specific associations, all adjusted for potential confounders. In general, no associations were found between offspring sex and EOC risk. However, compared to bearing only female offspring, bearing one or more male offspring was associated with increased risk of mucinous EOC (OR = 1.45; 95% CI = 1.01-2.07), which appeared to be limited to women reporting menarche before age 13 compared to later menarche (OR = 1.71 vs 0.99; P-interaction = 0.02). Bearing increasing numbers of male offspring was associated with greater risks of mucinous tumors (OR = 1.31, 1.84, 2.31, for 1, 2 and 3 or more male offspring, respectively; trend-p = 0.005). Stratifying by hormonally-associated conditions suggested that compared to bearing all female offspring, bearing a male offspring was associated with lower risk of endometrioid cancer among women with a history of adult acne, hirsutism, or polycystic ovary syndrome (OR = 0.49, 95% CI = 0.28-0.83) but with higher risk among women without any of those conditions (OR = 1.64 95% CI = 1.14-2.34; P-interaction = 0.003). Offspring sex influences the childbearing-EOC risk relationship for specific histotypes and conditions. These findings support the differing etiologic origins of EOC histotypes and highlight the importance of EOC histotype-specific epidemiologic studies. These findings also suggest the need to better understand how pregnancy affects EOC risk.

Dysmenorrhea and Endometriosis in Transgender Adolescents

STUDY OBJECTIVE

To study the presentation of dysmenorrhea and endometriosis in transmasculine adolescents and review their treatment outcomes.

DESIGN

A retrospective review.

SETTING

Boston Children's Hospital.

PARTICIPANTS

Transmasculine persons younger than 26 years old who were diagnosed with dysmenorrhea and treated between January 1, 2000 and March 1, 2020.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

An electronic medical record review of the clinical characteristics, transition-related care, and treatment outcomes.

RESULTS

Dysmenorrhea was diagnosed in 35 transmasculine persons. Mean age was 14.9 years ± 1.9 years. Twenty-nine (82.9%) were diagnosed after social transition. Twenty-three of 35 (65.7%) were first treated with combined oral contraceptives, but 14/23 (61%) discontinued or transitioned to alternative therapy. Twelve patients with dysmenorrhea alone initiated testosterone treatment, and 4/12 (33.3%) experienced persistent symptoms. Seven of 35 patients with dysmenorrhea (20.0%) were laparoscopically evaluated for endometriosis, and it was confirmed in all seven. Six had stage I disease, and one had stage II. Three of the 7 (42.9%) were diagnosed after social transition, with one diagnosed 20 months after initiating testosterone treatment. Their endometriosis was treated with combined oral contraceptives, danazol, or progestins; four experienced suboptimal response during treatment with these therapies alone. Two of those with suboptimal response subsequently resolved their dysmenorrhea when using testosterone. Five patients with endometriosis initiated testosterone treatment, and of the 5 (40%) experienced persistent symptomatology with combined testosterone and progestin therapies.

CONCLUSION

To our knowledge, this is the first study to characterize endometriosis in transmasculine persons. Evaluation for endometriosis was underutilized in transmasculine persons with dysmenorrhea, despite those who underwent laparoscopic evaluation and had disease confirmation. Although testosterone treatment can resolve symptoms in some, others might require additional suppression. Endometriosis should be considered in transmasculine persons with symptoms even when they are using testosterone.

Transgender Men and the Gynecologist

Recently, greater attention has been paid to the care of gender dysphoric and gender incongruent individuals. Gynecologists may be called upon to care for individuals who were assigned female at birth throughout or following social, medical, or surgical gender transition. Thus, gynecologists need to be aware of language regarding sex and gender, treatment typically used for the care of gender dysphoric or incongruent individuals, and aspects of well gynecologic care necessary for these individuals. This review highlights these aspects of care for transgender males to aid the general gynecologist in the care and treatment of these individuals.

Do Transgender and Gender Diverse Individuals Receive Adequate Gynecologic Care? An Analysis of a Rural Academic Center

Purpose: The transgender population faces disparities accessing gynecologic health care services, especially in rural settings. There is limited knowledge among medical providers regarding transgender-specific gynecologic care. Methods: A retrospective chart review of 255 transgender and gender diverse patients at a rural, academic center and associated ambulatory clinics was performed. Demographics, insurance status, and utilization rates of screening services, including cervical cancer, breast cancer, human papillomavirus (HPV) vaccination status, and contraceptive status, were analyzed using descriptive statistics. These rates were compared with national rates of cisgender individuals. Chi-square tests were performed to assess the association of insurance status with receipt of services. Results: Prevalence of HPV vaccination was lowest among transgender men (20%) compared with transgender women (60%) and gender nonbinary/nonconfirming and gender diverse individuals (60%), p<0.001. Our cohort was significantly less likely to receive Papanicolaou smears (51% vs. 81%, p<0.05) and contraception (48% vs. 65%, p<0.05) than cisgender individuals. Around 18% of transgender women had a documented pelvic examination in the past year. There was no significant difference in utilization rates based on insurance status. Conclusion: In our rural setting, there is lower utilization of gynecologic services among transgender and gender diverse individuals. Although participants in our study had high rates of access to insurance and health care providers, they still had lower rates of gynecologic screening and prevention services. To address these disparities, we advocate for developing transgender-specific gynecologic health maintenance guidelines, robust provider education, and an inclusive electronic medical record to ensure appropriate gynecologic health screening.

The Role of Hormonal and Reproductive Status in the Treatment of Anxiety Disorders in Women

Exposure therapy, a key treatment for anxiety disorders, can be modelled in the laboratory using Pavlovian fear extinction. Understanding the hormonal and neurobiological mechanisms underlying fear extinction in females, who are twice more likely than males to present with anxiety disorders, may aid in optimising exposure therapy outcomes in this population. This chapter will begin by discussing the role of the sex hormones, estradiol and progesterone, in fear extinction in females. We will also propose potential mechanisms by which these hormones may modulate fear extinction. The second half of this chapter will discuss the long-term hormonal, neurological and behavioural changes that arise from pregnancy and motherhood and how these changes may alter the features of fear extinction in females. Finally, we will discuss implications of this research for the treatment of anxiety disorders in women with and without prior reproductive experience.

Contraception across the transmasculine spectrum

The field of transgender health continues to expand rapidly, including research in the area of family planning. While much attention has been given to fertility preservation and the parenting intentions of transgender individuals, far less has been paid to pregnancy prevention and contraceptive needs of people along the transmasculine gender spectrum (transgender men and gender-nonbinary persons who were assigned female at birth). Existing research illustrates that many clinicians and transmasculine individuals falsely believe that there is no risk of pregnancy while amenorrheic. These studies also show inconsistent counseling practices provided to transmasculine persons surrounding contraception and pregnancy while falling short of providing robust clinical guidance for improvement. Clinicians report a lack of adequate training in transgender reproductive health, and consequently, many do not feel comfortable treating transgender patients. The aim of this publication is to consolidate the findings of these prior studies and build upon them to offer comprehensive clinical guidance for managing contraception in transmasculine patients. To do so, it reviews the physiologic effects of testosterone on the sex steroid axis and current understanding of why ovulation and pregnancy may still occur while amenorrheic. Gender-inclusive terminology and a suggested script for eliciting a gender-affirming sexual history are offered. Common concerns (such as the effects on gender dysphoria and gender affirmation) and side effects of available contraceptive methods are subsequently addressed and how these may have a unique impact on transmasculine persons as compared with cisgender women. Lastly, a model is provided for approaching contraceptive counseling in the transmasculine population to assist clinicians and patients in determining the need for and selection of the type of contraception. To center transmasculine voices, the development of this publication's guidelines have been led by reproductive care clinicians of transgender experience.

Hypothalamic Structural and Functional Imbalances in Anorexia Nervosa

The hypothalamus contains integrative systems that support life, including physiological processes such as food intake, energy expenditure, and reproduction. Here, we show that anorexia nervosa (AN) patients, contrary to normal weight and constitutionally lean individuals, respond with a paradoxical reduction in hypothalamic levels of glutamate/glutamine (Glx) upon feeding. This reversal of the Glx response is associated with decreased wiring in the arcuate nucleus and increased connectivity in the lateral hypothalamic area, which are involved in the regulation on a variety of physiological and behavioral functions including the control of food intake and energy balance. The identification of distinct hypothalamic neurochemical dysfunctions and associated structural variations in AN paves the way for the development of new diagnostic and treatment strategies in conditions associated with abnormal body mass index and a maladaptive response to negative energy balance.

The Number of X Chromosomes Influences Inflammatory Cytokine Production Following Toll-Like Receptor Stimulation

Sex differences are observed in the evolution of numerous inflammatory conditions. Women exhibit better clinical courses compared to men in acute inflammatory processes, yet worse prognosis in several chronic inflammatory diseases. Inflammatory markers are significantly different between prepubertal boys and girls, whose sex steroid levels are very low, suggesting genetics play a role. To evaluate the potential influence of the X chromosome, we studied cytokine production and protein phosphorylation following Toll-like receptor (TLR) activation in whole blood and purified neutrophils and monocytes of healthy adults of both sexes as well as subjects with Klinefelter syndrome. We recorded higher levels of inflammatory cytokines in men compared to both women and patients with Klinefelter syndrome following whole blood stimulation. In purified monocytes, production of inflammatory cytokines was also higher in men compared to women, while Klinefelter subjects expressed the same pattern of cytokine production as males, in contrast with whole blood analyses. These differences remained after adjusting for sex steroid levels. Our study revealed higher cytokine inflammatory responses in men than women, yet also compared to subjects with Klinefelter syndrome, who carry two copies of the X chromosome, like women, and thus potentially benefit from the cellular mosaicism of X-linked genes.

Fertility treatment is associated with multiple meningiomas and younger age at diagnosis

PURPOSE

Meningiomas are more common in females and 70-80% express the progesterone receptor, raising the possibility that high-dose exogenous estrogen/progesterone exposure, such as occurs during fertility treatments, may increase the risk of developing a meningioma. The goal of this study was to report the incidence of prior fertility treatment in a consecutive series of female meningioma patients.

METHODS

A retrospective review (2015-2018) was performed of female patients with meningioma, and those with prior fertility treatment were compared to those without fertility treatment using standard statistical methods.

RESULTS

Of 206 female patients with meningioma, 26 (12.6%) had a history of fertility treatments. Patients underwent various forms of assisted reproductive technology including: in vitro fertilization (50.0%), clomiphene with or without intrauterine insemination (34.6%), and unspecified (19.2%). Median follow up was 1.8 years. Tumors were WHO grade I (78.6%) or grade II (21.4%). Patients who underwent fertility treatments presented at significantly younger mean age compared to those who had not (51.8 vs. 57.3 years, p = 0.0135, 2-tailed T-test), and on multivariate analysis were more likely to have multiple meningiomas (OR 4.97, 95% CI 1.4-18.1, p = 0.0154) and convexity/falx meningiomas (OR 4.45, 95% CI 1.7-11.5, p = 0.0021).

CONCLUSIONS

Patients in this cohort with a history of fertility treatment were more likely to present at a younger age and have multiple and convexity/falx meningiomas, emphasizing the importance of taking estrogen/progesterone exposure history when evaluating patients with meningioma. Future clinical studies at other centers in larger populations and laboratory investigations are needed to determine the role of fertility treatment in meningioma development.

Effect of Estrogen on Musculoskeletal Performance and Injury Risk

Estrogen has a dramatic effect on musculoskeletal function. Beyond the known relationship between estrogen and bone, it directly affects the structure and function of other musculoskeletal tissues such as muscle, tendon, and ligament. In these other musculoskeletal tissues, estrogen improves muscle mass and strength, and increases the collagen content of connective tissues. However, unlike bone and muscle where estrogen improves function, in tendons and ligaments estrogen decreases stiffness, and this directly affects performance and injury rates. High estrogen levels can decrease power and performance and make women more prone for catastrophic ligament injury. The goal of the current work is to review the research that forms the basis of our understanding how estrogen affects muscle, tendon, and ligament and how hormonal manipulation can be used to optimize performance and promote female participation in an active lifestyle at any age.

Comparisons of Blood Parameters, Red Blood Cell Deformability and Circulating Nitric Oxide Between Males and Females Considering Hormonal Contraception: A Longitudinal Gender Study

Red blood cell (RBC) deformability is an important determinant of the microcirculation. It is influenced by various hematological parameters but also by nitric oxide (NO) which is produced in RBC from L-arginine by RBC-NO synthase. Longitudinal studies on blood profile, deformability at rest and NO levels but also differences between males and females (±hormonal contraception; HC) are less known so far. The study thus aimed to investigate RBC deformability, RBC NO species (nitrite, RxNO), RBC L-arginine concentration and basal blood parameters in males and females (±HC) as a function of time. RBC deformability was measured at rest once per week and the remaining parameters were measured once per month, respectively. A second experiment aimed to daily measure RBC deformability and 17β-estradiol in Female ± HC during a whole menstruation cycle to investigate a possible relation of the two parameters. Measured parameters showed low week-to-week variation and remained constant during study period. However, RBC deformability increased in Female + HC during study period possibly because of increasing training volume of the participants. Overall, results indicate gender differences in hematological parameters with higher RBC parameters (RBC count, hematocrit, hemoglobin concentration) in males compared to females. Differences were also observed between the female groups with Females - HC showing lower number of RBC but higher MCV and hematocrit compared to Females + HC. RBC deformability was highest in Females - HC which might be related to permanent higher estradiol levels and/or higher RBC NO levels because RBC nitrite and RBC RxNO concentrations were also highest in Females-HC. Results of the second experiment also suggest higher RBC deformability in Female - HC because of higher estradiol concentrations. L-arginine levels known to be related to RBC NO production were comparable in all groups. In conclusion, hematological, hemorheological and NO related parameters show gender differences. In particular, RBC deformability is affected by training volume and RBC estradiol concentrations. The results add new information on the complex regulation of RBC function which might help to better understand the role of RBC in the microcirculation.

Sex difference in brain CB1 receptor availability in man

The endocannabinoid system (ECS) has a widespread neuromodulatory function in the central nervous system and is involved in important aspects of brain function including brain development, cortical rhythms, plasticity, reward, and stress sensitivity. Many of these effects are mediated via the cannabinoid CB1 receptor (CB1R) subtype. Animal studies convincingly show an interaction between the ECS and sex hormones, as well as a sex difference of higher brain CB1R in males. Human in vivo studies of sex difference have yielded discrepant findings. Gender differences in CB1R availability were investigated in vivo in 11 male and 11 female healthy volunteers using a specific CB1R tracer [¹⁸F]FMPEP-d2 and positron emission tomography (PET). Regional [¹⁸F]FMPEP-d2 distribution volume was used as a proxy for CB1R availability. In addition, we explored whether CB1R availability is linked to neuropsychological functioning. Relative to females, CB1R availability was on average 41% higher in males (p = 0.002) with a regionally specific effect larger in the posterior cingulate and retrosplenial cortices (p = 0.001). Inter-subject variability in CB1R availability was similar in both groups. Voxel-based analyses revealed an inverse association between CB1R availability and visuospatial working memory task performance in both groups (p < 0.001). A CB1R sex difference with a large effect size was observed and should be considered in the design of CB1R-related studies on neuropsychiatric disorders. The behavioural correlates and clinical significance of this difference remain to be further elucidated, but our studies suggest an association between CB1R availability and working memory.

The Effects of Sex Differences and Hormonal Contraception on Outcomes after Collegiate Sports-Related Concussion

There is conflicting evidence regarding whether females are more adversely affected after concussion than males. Further, recent research suggests that hormonal contraceptive (HC) use may affect symptom severity and duration post-concussion. The objective of this study was to examine the effects of sex and HC use on outcomes following concussion among collegiate varsity athletes. We hypothesized that females would have longer length of recovery (LOR), and that peak symptom severity would be associated with longer LOR in both males and females. Among females, we hypothesized that non-HC users would have longer LOR and higher peak symptom severity than HC users. Ninety collegiate student-athletes were included in this study (40 males, 50 females; 24 HC users, 25 non-HC users). Demographic, injury, and recovery information was abstracted via retrospective record review. LOR was defined as days between injury and clearance for full return to play by team physician. Peak symptom severity score (Sport Concussion Assessment Tool [SCAT] 2 or 3) was used in analyses. Study results revealed that males had shorter LOR than females (F[1, 86] = 5.021, p < 0.05, d = 0.49), but had comparable symptom severity scores. Symptom severity was strongly related to LOR for males (r = 0.513, p < 0.01) but not females (r = -0.003, p > 0.05). Among females, non-HC users demonstrated higher symptom severity than HC users (F[1,47] = 5.142, p < 0.05, d = 0.70). No significant differences between female HC users and non-HC users on LOR were observed. This study provides evidence for differential concussion outcomes between male and female collegiate athletes and between HC users and nonusers among females.

The possible effect of human menopausal gonadotropin on the audio-vestibular system

OBJECTIVE

Human menopausal gonadotropin (HMG) is one of the commonest drugs used for ovarian stimulation with no reports on the audio-vestibular system. This study aims to examine HMG on the hearing profile of patients planning intracytoplasmic sperm injection (ICSI).

METHODS

This prospective study was conducted from June 2016 to June 2017 in a tertiary referral hospital. The audio-vestibular system of a total of 30 patients was evaluated using pure tone audiometry, distortion product otoacoustic emissions (DPOAEs in the form of a DP-gram) and Vestibular-evoked myogenic potential (VEMP) immediately before therapy and at the day 10 after therapy. Audio-vestibular adverse effects including hearing loss, tinnitus, vertigo, and otalgia were also considered.

RESULTS

Significant elevations in hearing thresholds were found on comparing thresholds at the day 10 at the onset of the study. The elevations were mostly at frequencies (1000, 2000 and 8000Hz) and did not affect speech perception. For DPOAE, significant differences were observed at all F2 frequencies on comparing both amplitudes and signal to noise ratios. Otologic complaints were significant for tinnitus and hearing loss.

CONCLUSION

Significant auditory and vestibular adverse effects may result from HMG therapy, indicating the importance of prompt monitoring of auditory functions in these patients.

17-β-Estradiol induces spreading depression and pain behavior in alert female rats

AIMS

Test the putative contribution of 17-β-estradiol in the development of spreading depression (SD) events and head pain in awake, non-restrained rats.

MAIN METHODS

Female, Sprague-Dawley rats were intact or underwent ovariectomy followed one week later by surgery to place electrodes onto the dura to detect epidural electroencephalographic activity (dEEG). dEEG activity was recorded two days later for 12 hours after systemic administration of 17-β-estradiol (180 μg/kg, i.p.). A separate set of rats were observed for changes in exploratory, ambulatory, fine, and rearing behaviors; periorbital allodynia was also assessed.

KEY FINDINGS

A bolus of 17-β-estradiol significantly elevated serum estrogen levels, increased SD episodes over a 12-hour recording period and decreased rearing behaviors in ovariectomized rats. Pre-administration of ICI 182,780, an estrogen receptor antagonist, blocked 17-β-estradiol-evoked SD events and pain behaviors; similar results were observed when the antimigraine therapeutic sumatriptan was used.

SIGNIFICANCE

These data indicate that an estrogen receptor-mediated mechanism contributes to SD events in ovariectomized rats and pain behaviors in both ovariectomized -and intact- rats. This suggests that estrogen plays a different role in each phenomenon of migraine where intense fluctuations in concentration may influence SD susceptibility. This is the first study to relate estrogen peaks to SD development and pain behaviors in awake, freely moving female rats, establishing a framework for future preclinical migraine studies.

Oral contraceptive use and fracture risk around the menopausal transition

OBJECTIVE

The effect of oral contraceptive (OC) use on risk of fracture remains unclear, and use during later reproductive life may be increasing. To determine the association between OC use during later reproductive life and risk of fracture across the menopausal transition, we conducted a population-based case-control study in a Pacific Northwest HMO, Group Health Cooperative.

METHODS

For the January 2008 to March 2013 interval, 1,204 case women aged 45 to 59 years with incident fractures, and 2,275 control women were enrolled. Potential cases with fracture codes in automated data were adjudicated by electronic health record review. Potential control women without fracture codes were selected concurrently, sampling based on age. Participants received a structured study interview. Using logistic regression, associations between OC use and fracture risk were calculated as odds ratios (ORs) and 95% confidence intervals (CIs).

RESULTS

Participation was 69% for cases and 64% for controls. The study sample was 82% white; mean age was 54 years. The most common fracture site for cases was the wrist/forearm (32%). Adjusted fracture risk did not differ between cases versus controls for OC use in the 10 years before menopause (OR 0.90, 95% CI 0.74, 1.11); for OC use after age 38 (OR 0.94, 95% CI 0.78, 1.14); for duration of use, or for other OC exposures.

CONCLUSIONS

The current study does not show an association between fractures near the menopausal transition and OC use in the decade before menopause or after age 38. For women considering OC use at these times, fracture risk does not seem to be either reduced or-reassuringly-increased.

Anorexia nervosa as a motivated behavior: Relevance of anxiety, stress, fear and learning

The high comorbidity between anorexia nervosa (AN) and anxiety disorders is well recognized. AN is a motivated behavioral disorder in which habit formation is likely to contribute to the persistence of abnormal eating and exercise behaviors. Secondary alterations in brain circuitry underlying the reward value of food and exercise, along with disturbances in neuroendocrine hunger and satiety signaling arising from starvation and excessive exercise, are likely contributors to the maintenance of anorectic behaviors in genetically vulnerable individuals. The potential role of fear conditioning in facilitating onset of AN, or of impaired fear extinction in contributing to the high relapse rates observed following weight restoration, is of interest. Evidence from animal models of anxiety and human laboratory studies indicate that low estrogen impairs fear extinction. Low estradiol levels in AN may therefore play a role in perpetuating fear of food and fat in recently weight restored patients. Translational models including the activity based anorexia (ABA) rodent model of AN, and neuroimaging studies of fear extinction and conditioning, could help clarify the underlying molecular mechanisms and neurocircuitry involved in food avoidance behaviors in AN. Moreover, the adaptation of novel treatment interventions with efficacy in anxiety disorders may contribute to the development of new treatments for this impairing disorder.

Follicle-stimulating hormone (FSH), current suicidal ideation and attempt in female patients with major depressive disorder

Current suicidal ideation and attempts are more commonly found in female patients with major depressive disorder (MDD) than in males. However, little is known about the relationship between activity of female reproductive hormones and suicide. The study population consisted of 490 female MDD patients of age ≥18. They were assessed by the Mini-International Neuropsychiatric Interview. At the same visit, we measured blood Follicle-Stimulating Hormone (FSH), Luteinizing Hormone (LH), estradiol, progesterone, Adrenocorticotropic Hormone (ACTH), cortisol, thyroid hormones, and prolactin. Blood FSH showed a significant difference among female MDD patients with suicide attempt, those with ideation, and those without within the previous month. Post-hoc analysis also showed that FSH was significantly lower in MDD patients with suicide attempt and ideation than those without, whereas other hormones showed no differences between those with and without attempt. FSH was negatively associated with current suicidality scores after adjustment for age and education years in all age groups. FSH was significantly lower in those with current suicide ideation or attempt than those without in age 45 years or under, but not in other age groups. In conclusion, blood FSH is significantly lower in female MDD patients with current suicide attempt or ideation than those without, especially in age 45 years or under.

Oral contraceptive use and bone density in adolescent and young adult women

BACKGROUND

Most of the millions of oral contraceptive (OC) users are under 30 years of age and in the critical period for bone mass accrual.

STUDY DESIGN

This cross-sectional study of 606 women aged 14-30 years examined both OC duration and estrogen dose and their association with bone mineral density (BMD) at the hip, spine, and whole body (dual-energy X-ray absorptiometry).

RESULTS

Of 389 OC users and 217 nonusers enrolled, 50% were adolescents (14-18 years). Of OC users, 38% used "low-dose" OCs [<30 mcg ethinyl estradiol (EE)]. In adolescents, mean BMD differed by neither OC duration nor EE dose. However, 19- to 30-year-old women's mean BMD was lower with longer OC use for spine and whole body (p=.004 and p=.02, respectively) and lowest for >12 months of low-dose OCs for the hip, spine and whole body (p=.02, .003 and .002, respectively).

CONCLUSIONS

Prolonged use of today's OCs, particularly <30 mcg EE, may adversely impact young adult women's bone density while using these agents.

Determining the subjective and physiological effects of BZP on human females

BACKGROUND

"Party pills" containing benzylpiperazine (BZP) used to be widely and legally available as recreational drugs in New Zealand. There are only two published trials on human subjects (1973), which suggested that 100 mg of BZP produced subjective and physiological effects similar to 10 mg of dexamphetamine. The purpose of this study is to further investigate the subjective and physiological responses to BZP in females.

METHODS/STUDY DESIGN

In a randomised, double blind, placebo-controlled study, the subjective and physiological effects of BZP were investigated in 27 healthy, right-handed non-smoking females (mean age 22 +/- 3 years). Two groups were tested before and approximately 120 minutes after administration of a single oral dose of either 200 mg BZP (n = 14) or placebo (n = 13). Participants were required to comment on the subjective effects of BZP using three rating scales-the Addiction Centre for Research Inventory, the Profile of Mood States and the Visual Analogue Scale. Participants' blood pressure, heart rate and temperature were also measured.

RESULTS/FINDINGS

Statistical analysis using a split-plot analysis of variance and t tests revealed that BZP significantly increases blood pressure and heart rate (p < 0.05) Likewise, the subjective reports revealed that BZP has significant stimulant effects, increases euphoria and dysphoria and increases sociability and drug liking (p < 0.05).

DISCUSSION/INTERPRETATION

Physiological and subjective data reflected a clear similarity between the effects of BZP and those of other commonly known stimulants such as amphetamine and 3,4-methylenedioxymethamphetamine.

Effects of menstrual cycle phase and oral contraceptive use on verbal memory

Surgical or pharmacological suppression of ovarian hormones leads to declines in verbal memory, and estrogen treatment reverses these deficits. In the current study, we investigated the effects of menstrual cycle phase and oral contraceptives on verbal memory, as measured by the California Verbal Learning Test, in two groups of premenopausal women - 16 naturally cycling women and 20 current users of estrogen-based oral contraceptives (OCs). Naturally cycling women were assessed twice - once during the early follicular phase (Days 2-4) and once during the midluteal phase (Days 20-22) of the menstrual cycle. OC users were tested on the same cycle days, corresponding to inactive and active pill phases, respectively. We predicted that naturally cycling women would show improved verbal memory during the midluteal phase, when estradiol levels are high, compared with the follicular phase, when estradiol levels are low. We also predicted that OC users, who show no change in endogenous estradiol across the cycle, would show no change in verbal memory. Contrary to predictions, naturally cycling women showed no changes in verbal memory across the cycle, whereas OC users showed enhanced memory during the active pill phase (p<.05). None of the secondary cognitive outcome measures varied with cycle phase or OC use including measures of visuospatial memory, verbal fluency, visuospatial abilities, and attention. Overall, these results suggest that verbal memory performance in premenopausal women varies across the cycle with OC use, but does not vary systematically with changes in endogenous estradiol.

Reproductive hormone effects on strength of the rat anterior cruciate ligament

The material properties of the anterior cruciate ligament (ACL) in female rats with normal estrous cycles were compared to those regulated by oral contraceptive steroids. Forty female Sprague-Dawley rats were divided into two groups: an experimental group received daily ethinylestradiol and levonorgestrel in a dosing model designed to simulate a typical oral contraception regime in humans, while a control group received daily oral placebo. After eight cycles, six rats from each group underwent daily phlebotomy to measure serum estradiol and progesterone levels over the course of a single 5-day estrous cycle. Significant differences between groups were found for the area under the curve of blood progesterone levels versus time over the length of the estrous cycle (P=0.02). After 12 cycles, the rats were euthanized and one femur-ACL-tibia complex from each animal was dynamically loaded to failure. The ACLs from the rats in the experimental group had significantly decreased average and tangent stiffness, (P=0.002 and 0.0001, respectively), and significantly increased elongation (P=0.002) and total energy absorbed (P=0.03), or greater toughness than controls. In rats, it appears that the administration of reproductive hormones designed to simulate typical oral contraception in humans alters the mechanical properties of the rat ACL.

Oral contraceptives and neuroactive steroids

A deregulation in the peripheral and brain concentrations of neuroactive steroids has been found in certain pathological conditions characterized by emotional or affective disturbances, including major depression and anxiety disorders. In this article we summarize data pertaining to the modulatory effects of oral contraceptive treatment on neuroactive steroids in women and rats. Given that the neuroactive steroids concentrations are reduced by oral contraceptives, together with the evidence that a subset of women taking oral contraceptives experience negative mood symptoms, we propose the use of this pharmacological treatment as a putative model to study the role of neuroactive steroids in the etiopathology of mood disorders. Moreover, since neuroactive steroids are potent modulators of GABA(A) receptor function and plasticity, the treatment with oral contraceptives might also represent a useful experimental model to further investigate the physiological role of these steroids in the modulation of GABAergic transmission.

Progression of liver fibrosis in women infected with hepatitis C: long-term benefit of estrogen exposure

Female sex is a protective factor for the progression of fibrosis in patients with chronic hepatitis C virus (HCV) infection. Experimental data suggest that estrogens may have an antifibrotic effect. The objective of this study was to evaluate the influence of past pregnancies, oral contraceptives, menopause, and hormone replacement therapy (HRT) on liver fibrosis progression in HCV-infected women. Four hundred seventy-two HCV-infected women received a survey regarding prior pregnancies, menopause, and the use of oral contraceptives and HRT. The impact of these variables on liver fibrosis and its progression were evaluated using multivariate analyses considering all putative confounding factors. Two hundred one women completed the survey (43% response rate), 157 of whom had an estimated date of HCV infection (96 postmenopausal women, 96 women with previous pregnancies, and 105 women with past use of oral contraceptives). Through multivariate analyses, the estimated rate of fibrosis progression was higher in postmenopausal (P < .05) and nulliparous (P = .02) women and was associated with greater histological activity (P < .001). Prior use of oral contraceptives had no significant influence. Among postmenopausal women, the estimated rate of fibrosis progression (+/-SE) was lower in women who received HRT compared with untreated patients (0.099 +/- 0.016 vs. 0.133 +/- 0.006 METAVIR units/yr; P = .02) and was similar to that of premenopausal women (0.093 +/- 0.012 METAVIR units/yr; P value not significant). In conclusion, menopause appears to be associated with accelerated liver fibrosis progression in HCV-infected women, an effect that may be prevented by HRT. Pregnancies may have a beneficial impact on the long-term progression of liver fibrosis.

Oral Contraceptive Use and Breast Cancer Risk: Modification by NAD(P)H:Quinone Oxoreductase (NQO1) Genetic Polymorphisms

Despite intensive study, the relationship between oral contraception (OC) and breast cancer remains unclear. OCs contain a potent synthetic estrogen (ethinyl estradiol) but lower endogenous estradiol levels, and ethinyl estradiol is a weak progenitor of semiquinones, catechol estrogens capable of damaging DNA. NAD(P)H:quinone oxoreductase (NQO1) stabilizes semiquinones, thus potentially preventing genetic damage from catechol estrogens, and the NQO1 C609T polymorphism seems functionally relevant. Using data from the Shanghai Breast Cancer Study, a population-based case-control study, we investigated the relationships between OC use (20% ever using), breast cancer, and NQO1 (C/C 31% and C/T + T/T 69%) among 1,039 cases and 1,121 controls. Breast cancer was not significantly associated with NQO1 genotype. There was a significant protective association between OC after age 30 years and premenopausal breast cancer [odds ratio (OR) 0.51, 95% confidence interval (95% CI) 0.29-0.89] primarily with the NQO1 T allele (C/C OR 0.76, 95% CI 0.31-1.82; C/T + T/T OR 0.38, 95% CI 0.18-0.80; P for interaction = 0.19). The association between premenopausal breast cancer and OCs significantly differed with NQO1 genotype when using OCs for &gt;18 months (C/C OR 2.34, 95% CI 0.92-5.99; C/T + T/T OR 0.69, 95% CI 0.38-1.25; P for interaction = 0.02). Among women with the C/C genotype, postmenopausal breast cancer was significantly associated with ever-using OCs (C/C OR 2.01, 95% CI 1.08-3.74; C/T + T/T OR 0.72, 95% CI 0.49-1.05; P for interaction &lt; 0.01). This crossover was stronger with OC use prior to age 30 years (C/C OR 3.00, 95% CI 1.43-6.25; C/T or T/T OR 0.49, 95% CI 0.29-0.81; P for interaction &lt; 0.01). Our results require confirmation but suggest that the OC and breast cancer association depends on the ability to invoke protection from catechol estrogens.

Effects of oral contraceptive pill use on vaginal flora and vaginal epithelium

The objective of this study was to examine the effect of oral contraceptive (OC) use on vaginal discharge, epithelium, and flora. Thirty women who planned to use OC for contraception were evaluated before and 2 months after the start of OC use. At both visits, genital symptoms and exposures were assessed by questionnaire; vaginal signs were assessed by speculum examination and colposcopy; vaginal microflora was evaluated by quantitative culture; and a vaginal biopsy was obtained for histopathologic evaluation. Variables were compared between the initial visit and after 2 months of OC use. It was found that OC use did not change the gross, colposcopic, or histologic appearance of the vaginal epithelium or characteristics of vaginal or cervical discharge. Vaginal flora essentially remained unchanged after 2 months of OC use, except that a small decrease occurred in the number of subjects with > or =10(5) colony forming units/mL of H(2)O(2) producing Lactobacillus from 16 at baseline to 9 (p = 0.04) and in the total number of subjects with Ureaplasma urealyticum from 17 at baseline to 10 of 29 (p = 0.04). The results indicate minimal effect of OC use on the vaginal epithelium and vaginal and cervical discharge, and a small effect on vaginal flora.

Hormonal etiology of epithelial ovarian cancer, with a hypothesis concerning the role of androgens and progesterone

In the United States, ovarian cancer is the fourth most frequent cause of cancer death among women, following lung, breast, and colorectal cancers. Each year, approximately 26,000 women are diagnosed with ovarian cancer and 14,000 die of it. Germline mutations in BRCA1, BRCA2, or other genes have been implicated in a small fraction of cases. However, it has been suggested that, for the great majority of patients, the risk of epithelial ovarian cancer could be related to "incessant ovulation" (i.e., to the chronically repeated formation of stromal epithelial clefts and inclusion cysts following ovulation) or to some type of hormonal stimulation of ovarian epithelial cells, either on the surface of the ovary or within ovarian inclusion cysts, possibly mediated through excessive gonadotropin secretion. From the evidence to date, the relative importance of these two hypotheses--incessant ovulation and gonadotropin stimulation--cannot be distinguished. While either or both may play a role in the development of ovarian cancer, it appears that an additional major factor must also be involved. The purpose of this review is to evaluate evidence for and against the incessant ovulation and gonadotropin hypotheses, as well as to consider the possibility that risk of ovarian cancer may be increased by factors associated with excess androgenic stimulation of ovarian epithelial cells and may be decreased by factors related to greater progesterone stimulation. Many features of the evidence bearing on the pathophysiology of ovarian cancer appear to support a connection with androgens and progesterone.

Hormonal contraception, vitamin A deficiency, and other risk factors for shedding of HIV-1 infected cells from the cervix and vagina

BACKGROUND

Factors that influence shedding of HIV-1 infected cells in cervical and vaginal secretions may be important determinants of sexual and vertical transmission of the virus. We investigated whether hormonal contraceptive use, vitamin A deficiency, and other variables were risk factors for cervical and vaginal shedding of HIV-infected cells.

METHODS

Between December, 1994, and April, 1996, women who attended a municipal sexually transmitted diseases (STDs) clinic in Mombasa, Kenya, and had previously tested positive for HIV-1, were invited to take part in our cross-sectional study. Cervical and vaginal secretions from 318 women were evaluated for the presence of HIV-1 infected cells by PCR amplification of gag DNA sequences.

FINDINGS

HIV-1 infected cells were detected in 51% of endocervical and 14% of vaginal-swab specimens. Both cervical and vaginal shedding of HIV-1 infected cells were highly associated with CD4 lymphocyte depletion (p = 0.00001 and p = 0.003, respectively). After adjustment for CD4 count, cervical proviral shedding was significantly associated with use of depot medroxyprogesterone acetate (odds ratio 2.9, 95% CI 1.5-5.7), and with use of low-dose and high-dose oral contraceptive pills (3.8, 1.4-9.9 and 12.3, 1.5-101, respectively). Vitamin A deficiency was highly predictive of vaginal HIV-1 DNA shedding. After adjustment for CD4 count, severe vitamin A deficiency, moderate deficiency, and low normal vitamin A status were associated with 12.9, 8.0, and 4.9-fold increased odds of vaginal shedding, respectively. Gonococcal cervicitis (3.1, 1.1-9.8) and vaginal candidiasis (2.6, 1.2-5.4) were also correlated with significant increases in HIV-1 DNA detection, but Chlamydia trachomatis and Trichomonas vaginalis were not.

INTERPRETATION

Our study documents several novel correlates of HIV-1 shedding in cervical and vaginal secretions, most notably hormonal contraceptive use and vitamin A deficiency. These factors may be important determinants of sexual or vertical transmission of HIV-1 and are of public health importance because they are easily modified by simple interventions.

Ethinylestradiol from contraceptive formulations and the ovarian response: an estrogen dose-dependency on natural estradiol concentrations

To evaluate the competitive molecular phenomenon of ethinylestradiol from contraceptive formulations vs. endogenous 17 beta-estradiol in the intra- and extracellular compartments, a descriptive analysis was performed. Plasma and endometrial samples were simultaneously obtained on different days of the pseudomenstrual cycle from oral contraceptive users taking ethinylestradiol/norgestrel (30 micrograms/500 micrograms; n = 13) and ethinylestradiol/norethindrone (50 micrograms/1.0 mg; n = 14) in order to quantify the 17 beta-estradiol concentrations. From our results the chronic administration of these combined oral contraceptives demonstrated that the lower component ethinyl-estradiol (30 micrograms) does not compete substantially at the circulating level, permitting concentrations of natural estradiol such as those seen during follicular maturation in the ovulatory cycle. However, in the endometrium such a cyclicity is not seen, thus the possibility of a local infertility effect should be reconsidered to enable the investigation of a different approach in future methods of contraception.

The effect of previous oral contraceptive use on bone mineral density in perimenopausal women

The bone mineral density (BMD) of the lumbar vertebrae L2-4 and femoral neck was determined by dual-energy X-ray absorptiometry (DXA) in 3222 perimenopausal women-a random stratified sample of the population-based Kuopio Osteoporosis Study (OSTPRE). The mean age of the women was 53.4 years (range 47.9-59.6 years). Twenty-nine percent of the women were past users of oral contraceptives (OC) containing 50 micrograms or less of ethinyl estradiol and 7.4% (n = 250) of the women reported OC use for more than 6 years. There was a slight but statistically significant difference between OC users (n = 939) and non-users (n = 2283) in lumbar BMD (1.134 +/- 0.155 g/cm2 v 1.123 +/- 0.161 g/cm2, p = 0.014). A statistically significant difference was recorded also after adjustment for years since menopause, duration of hormonal replacement therapy (HRT) and present weight (p = 0.044). When the analysis was performed among women who had never used oestrogen replacement therapy (n = 1427) and among premenopausal women (n = 387), no differences in BMD were found between OC users and non-users. Similarly, femoral neck BMD did not differ between the groups. This population-based study demonstrated a slightly higher lumbar BMD among past OC users. However, OC users and non-users differed from each other in many behavioral characteristics. Thus, the differences in BMD may be accounted for more by other factors than by past OC use itself. The low-dosage estrogen OCs used today would not be expected to have any positive bone effects among future perimenopausal women.