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Lindsay Mart F, Gutmark-Little I, Streich-Tilles T, Trout AT, Khoury J, Bowers K, Casnellie L, Backeljauw P. Current Recommended Estrogen Dosing for Pubertal Induction in Turner Syndrome Results in Normal Uterine Growth. J Clin Endocrinol Metab 2024; 109:e1040-e1047. [PMID: 37933636 DOI: 10.1210/clinem/dgad649] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2023] [Revised: 10/27/2023] [Accepted: 10/30/2023] [Indexed: 11/08/2023]
Abstract
CONTEXT Most individuals with Turner syndrome (TS) require estrogen for pubertal induction. Current estrogen dosing guidelines are based on expert consensus opinion. OBJECTIVE Evaluate whether current international guidelines for estrogen dosing during pubertal induction of individuals with TS result in normal uterine growth. We hypothesized that uterine size in individuals with TS who reached adult estrogen dosing is smaller than in mature females without TS. METHODS Cross-sectional study of patients with TS at the Cincinnati Center for Pediatric and Adult Turner Syndrome Care. Twenty-nine individuals (age 15-26 years) with primary ovarian insufficiency who reached adult estrogen dosing (100 µg of transdermal or 2 mg of oral 17β-estradiol) were included. Comparison of uterine measurements with a published sample of 292 age-appropriate (age 15-20 years) controls without TS. Uterine length, volume, and fundal-cervical ratio (FCR) were measured. Clinical information (karyotype, Tanner staging for breast development, laboratory data) was extracted from an existing institutional patient registry. RESULTS There was no evidence of compromise of the uterine size/configuration in the TS cohort compared with the controls; in fact, uterine length, mean 7.7 cm (±1.3) vs 7.2 cm (±1.0) (P = .03), and volume, mean 60.6 cm3 (±26.6) vs 50.5 cm3 (±20.5) (P = .02), were both larger in individuals with TS. CONCLUSION Current international guidelines for hormone replacement using 17β-estradiol in individuals with TS appear adequate to allow for normal uterine growth by the end of pubertal induction.
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Affiliation(s)
- Faith Lindsay Mart
- Division of Endocrinology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH 45229-3026, USA
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH 45267, USA
| | - Iris Gutmark-Little
- Division of Endocrinology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH 45229-3026, USA
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH 45267, USA
| | - Tara Streich-Tilles
- Division of Pediatric and Adolescent Gynecology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH 45229-3026, USA
- Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, OH 45267, USA
| | - Andrew T Trout
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH 45267, USA
- Department of Radiology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH 45229-3026, USA
| | - Jane Khoury
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH 45267, USA
- Division of Biostatistics and Epidemiology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH 45229-3026, USA
| | - Katherine Bowers
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH 45267, USA
- Division of Biostatistics and Epidemiology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH 45229-3026, USA
| | - Lori Casnellie
- Division of Endocrinology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH 45229-3026, USA
| | - Philippe Backeljauw
- Division of Endocrinology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH 45229-3026, USA
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH 45267, USA
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Hollond CS, Ganti A, Streich-Tilles T, Debiec K, Galloway A, Inneh O, Cizek S. Adolescent and Young Adult Patients with Vaginal Graft-vs-Host Disease and Hematocolpos Managed with Vaginal Stents: A Case Series. J Pediatr Adolesc Gynecol 2024; 37:78-86. [PMID: 37797789 DOI: 10.1016/j.jpag.2023.09.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2023] [Revised: 09/20/2023] [Accepted: 09/28/2023] [Indexed: 10/07/2023]
Abstract
STUDY OBJECTIVE Vaginal stenosis can be acquired as a result of vaginal graft-vs-host disease (GVHD) in patients who have undergone hematopoietic stem cell transplant (HSCT). Little data exist to guide the management of vaginal GVHD, particularly in adolescent and young adult patients. The objective of this study was to detail the management of vaginal stenosis with lysis of adhesions and vaginal stent placement in 3 young patients with vaginal GVHD. METHODS A retrospective chart review was done for 3 patients with vaginal GVHD causing vaginal stenosis with hematometrocolpos. All 3 were treated using vaginal stent placement. Additionally, a literature review was conducted through PubMed and Google Scholar to identify 21 case reports (with a total of 35 patients) of menstrual obstruction due to GVHD. RESULTS Obstructive vaginal stenosis secondary to vaginal GVHD occurred in our patients at ages 15, 16, and 24 years. Resolution of hematocolpos was obtained with lysis of vaginal adhesions with vaginal stent placement in all patients, with varying regimens of systemic and topical hormones, topical corticosteroids, and dilator therapy. DISCUSSION Vaginal stenosis secondary to vaginal GVHD should be considered in patients with a history of allogeneic HSCT presenting with amenorrhea, especially those with a diagnosis of primary ovarian insufficiency. The use of vaginal stents, along with postoperative medical and dilator management as appropriate, may prevent re-stenosis, although more information is needed regarding the efficacy of treatments.
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Affiliation(s)
| | - Amitha Ganti
- Department of OB/GYN, Division of Pediatric and Adolescent Gynecology, Stanford University School of Medicine, Stanford, California
| | - Tara Streich-Tilles
- Department of Surgery, Division of Pediatric and Adolescent Gynecology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Kate Debiec
- Department of Obstetrics and Gynecology, Division of Pediatric and Adolescent Gynecology, University of Washington and Seattle Children's, Seattle, Washington
| | | | - Oyenmwen Inneh
- Department of Obstetrics and Gynecology, University of Washington School of Medicine, Seattle, Washington
| | - Stephanie Cizek
- Department of OB/GYN, Division of Pediatric and Adolescent Gynecology, Stanford University School of Medicine, Stanford, California.
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Morrison A, Pressey JG, VandenHeuvel K, Streich-Tilles T. Atypical Presentation of Granulosa Cell Tumor in an Adolescent: A Case Report. J Pediatr Adolesc Gynecol 2023; 36:553-555. [PMID: 37354988 DOI: 10.1016/j.jpag.2023.06.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2023] [Revised: 06/13/2023] [Accepted: 06/16/2023] [Indexed: 06/26/2023]
Abstract
BACKGROUND Granulosa cell tumors (GCTs) frequently present with elevated levels of estrogen and inhibin. Most diagnoses in the pediatric and adolescent population are juvenile-type GCTs; adult-type GCTs in this population are rare. CASE We describe a 14-year-old female who presented with a large adnexal mass and clinical hyperandrogenism. Laboratory evaluation revealed elevated levels of free and total testosterone, low-normal estradiol, and mildly elevated alpha-fetoprotein (AFP). Other tumor markers, including inhibin, were within normal limits. Intraoperative assessment with unilateral oophorectomy, pathology, and imaging resulted in a diagnosis of a stage IA adult-type GCT. SUMMARY AND CONCLUSION GCTs often result in elevated estrogen and inhibin B levels; however, this case demonstrates that non-classic elevations in testosterone and normal inhibin levels should not eliminate concern for a GCT, particularly in the setting of a large ovarian mass.
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Affiliation(s)
- Aimee Morrison
- Department of Surgery, Division of Pediatric and Adolescent Gynecology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio.
| | - Joseph G Pressey
- Division of Oncology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Katherine VandenHeuvel
- Division of Pathology and Laboratory Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Tara Streich-Tilles
- Department of Surgery, Division of Pediatric and Adolescent Gynecology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
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Yu LX, McGowan M, Bendle K, Mullins C, Streich-Tilles T, Breech LL. Sexual and Reproductive Health Concerns in Adults With Cloacal Anomalies: A Qualitative Study. J Pediatr Surg 2023; 58:2300-2307. [PMID: 37690871 DOI: 10.1016/j.jpedsurg.2023.08.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2023] [Revised: 07/15/2023] [Accepted: 08/13/2023] [Indexed: 09/12/2023]
Abstract
STUDY OBJECTIVE Long-term gynecologic data are lacking to inform the care of patients with cloacal malformations. We seek to examine perceived sexual and reproductive health challenges of patients born with cloacal anomalies and characterize the experiences of patients as adults. DESIGN AND SETTING Virtual semi-structured focus groups and single-participant interviews were conducted using an online video platform. Retrospective chart review was performed to abstract available demographics and surgical history. PARTICIPANTS Adult patients were contacted from a database of 143 patients born with cloaca who had been seen at or referred to a tertiary care pediatric colorectal center. Participants were recruited until data collection reached thematic saturation. Twenty patients aged 18-53 years participated in 5 focus groups and 3 single-participant interviews. The hospital IRB determined the research activities to be exempt from IRB review and oversight. INTERVENTIONS AND MAIN OUTCOME MEASURES Interviews and focus groups were transcribed and analyzed using the constant comparative method to identify themes regarding sexual and reproductive health and compared with medical and surgical history abstracted from chart review. RESULTS Participants reported many perceived barriers to intercourse and intimacy including bowel and bladder continence management. All participants reported discussion of pregnancy and fertility with healthcare providers as important. Other common themes included concerns about independence and transitioning from pediatric to adult providers. CONCLUSION Anorectal malformations are associated with sexual and reproductive health concerns. Patients seek guidance on family building, intimacy, and transition to adult care. Future quantitative study of these topics is needed to develop best practices for counseling and clinical management of these patients. LEVEL OF EVIDENCE Level VI. TYPE OF STUDY Prognosis Study.
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Affiliation(s)
- Lissa X Yu
- Division of Pediatric and Adolescent Gynecology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA.
| | - Michelle McGowan
- Biomedical Ethics Research Program, Department of Quantitative Health Sciences, Mayo Clinic, Rochester, MN, USA; Department of Women's, Gender, and Sexuality Studies, University of Cincinnati, Cincinnati, OH, USA
| | - Kara Bendle
- Division of Pediatric and Adolescent Gynecology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | | | - Tara Streich-Tilles
- Division of Pediatric and Adolescent Gynecology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Lesley L Breech
- Division of Pediatric and Adolescent Gynecology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
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Shim S, Streich-Tilles T, Gutmark-Little I, Yao M, Shafer J, Breech L, Casnellie L, Backeljauw P. Abnormal Uterine Bleeding during Pubertal Induction with Transdermal Estrogen in Turner Syndrome Individuals. J Pediatr Adolesc Gynecol 2023:S1083-3188(23)00314-5. [PMID: 36934801 DOI: 10.1016/j.jpag.2023.03.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2022] [Revised: 01/13/2023] [Accepted: 03/10/2023] [Indexed: 03/21/2023]
Abstract
STUDY OBJECTIVES Incidence of abnormal uterine bleeding (AUB) during pubertal induction among individuals with Turner syndrome (TS) has not been described previously. We estimated the incidence and characterize factors associated with AUB among TS individuals. A secondary objective was to evaluate the management of AUB among this patient population. DESIGN, SETTING, PARTICIPANTS, AND INTERVENTION We conducted a retrospective chart review to evaluate TS individuals undergoing hormone replacement therapy (HRT) for pubertal induction with transdermal estrogen (TDE). A total of 45 participants were identified between January 2007 and June 2019. RESULTS Of the 45 TS individuals included, 16 (35%) experienced AUB. Individuals with AUB most commonly experienced prolonged (44%), prolonged and heavy (25%), and intermenstrual (19%) bleeding. Individuals who experienced AUB were more likely to experience spontaneous bleeding (69% vs. 28%) and a duration of unopposed estrogen greater than 18 months (63% vs. 41%), undergo progestin cycling less often than monthly (69% vs. 0%), use a micronized progestin dose of less than 200 mg (25% vs. 14%), and be noncompliant with HRT (19% vs. 0%) compared to those who did not experience AUB. CONCLUSIONS There is a relatively high incidence of AUB among TS individuals undergoing pubertal induction with TDE. Care providers should consider the clinical factors examined to guide monitoring and management of TS individuals on HRT.
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Affiliation(s)
- Sarah Shim
- Division of Endocrinology, Cincinnati Children's Hospital Medical Center, 3333 Burnet Ave, Room T5.272, Cincinnati, OH 45229.
| | - Tara Streich-Tilles
- Division of Pediatric and Adolescent Gynecology, Cincinnati Children's Hospital Medical Center, 3333 Burnet Ave, Room T5.272, Cincinnati, OH 45229
| | - Iris Gutmark-Little
- Division of Endocrinology, Cincinnati Children's Hospital Medical Center, 3333 Burnet Ave, Room T5.272, Cincinnati, OH 45229
| | - Michael Yao
- Division of Endocrinology, Cincinnati Children's Hospital Medical Center, 3333 Burnet Ave, Room T5.272, Cincinnati, OH 45229
| | - Jessica Shafer
- Division of Endocrinology, Cincinnati Children's Hospital Medical Center, 3333 Burnet Ave, Room T5.272, Cincinnati, OH 45229
| | - Lesley Breech
- Division of Pediatric and Adolescent Gynecology, Cincinnati Children's Hospital Medical Center, 3333 Burnet Ave, Room T5.272, Cincinnati, OH 45229
| | - Lori Casnellie
- Division of Endocrinology, Cincinnati Children's Hospital Medical Center, 3333 Burnet Ave, Room T5.272, Cincinnati, OH 45229
| | - Philippe Backeljauw
- Division of Endocrinology, Cincinnati Children's Hospital Medical Center, 3333 Burnet Ave, Room T5.272, Cincinnati, OH 45229
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Bird L, Streich-Tilles T, Kanj R, Yu L. 7986 Laparoscopic Left Adnexal Cystectomy in a Pediatric Patient with Infected Ohvira. J Minim Invasive Gynecol 2022. [DOI: 10.1016/j.jmig.2022.09.358] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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McCauley HL, Falb KL, Streich-Tilles T, Kpebo D, Gupta J. Mental health impacts of reproductive coercion among women in Côte d'Ivoire. Int J Gynaecol Obstet 2014; 127:55-9. [PMID: 24952817 DOI: 10.1016/j.ijgo.2014.04.011] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2013] [Revised: 04/05/2014] [Accepted: 05/28/2014] [Indexed: 11/30/2022]
Abstract
OBJECTIVE To assess the independent associations of partner-perpetrated reproductive coercion, intimate partner violence (IPV), in-law reproductive coercion, and in-law abuse with recent probable post-traumatic stress disorder (PTSD), and to test their relationship with PTSD symptoms when controlling for the other types of abuse among partnered women in rural Côte d'Ivoire. METHODS Cross-sectional analyses were conducted using logistic generalized estimating equations, which accounted for village-level clustering. Data were drawn from baseline data from a randomized controlled trial among 24 villages in rural Côte d'Ivoire (n=953 partnered women). Three adjusted models were used to test associations of reproductive coercion and abuse with probable PTSD. RESULTS Partner-perpetrated reproductive coercion was experienced by 176 (18.5%) women. In model 3, which accounted for the co-occurrence of abuses, partner-perpetrated reproductive coercion (odds ratio [OR] 2.3; 95% confidence interval [CI], 1.4-3.9) and partner-perpetrated IPV (OR 1.7; 95% CI, 1.1-2.7) were the most significant predictors of past-week probable PTSD (P<0.05). CONCLUSION Reproductive coercion may be a significant contributor to poor mental health. The mental health impacts of reproductive coercion and IPV should be considered within psychosocial programming for rural Ivorian communities to address the full range of traumatic experiences that may have been experienced by women.
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Affiliation(s)
- Heather L McCauley
- University of Pittsburgh School of Medicine, Division of Adolescent Medicine, Children's Hospital of Pittsburgh of UPMC, Pittsburgh, USA.
| | - Kathryn L Falb
- Department of Chronic Disease Epidemiology, Yale University School of Public Health, New Haven, USA; Center for Interdisciplinary Research on AIDS, Yale University, New Haven, USA
| | | | - Denise Kpebo
- Innovations for Poverty Action, Abidjan, Côte d'Ivoire
| | - Jhumka Gupta
- Department of Chronic Disease Epidemiology, Yale University School of Public Health, New Haven, USA; Center for Interdisciplinary Research on AIDS, Yale University, New Haven, USA
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