Estrogen-containing Contraceptives Research Articles

Contraceptive Care in the Rheumatic Diseases: A Review.

Contraception can help individuals with rheumatic and musculoskeletal diseases (RMDs) to avoid undesired pregnancies and improve reproductive outcomes. Despite the importance of contraception in the care of females with RMDs, evidence suggests that many of these individuals do not receive consistent or disease-specific counseling regarding contraceptive options. This includes female patients receiving teratogenic prescriptions as part of the management of their RMDs, or who have severe disease activity that might culminate in adverse pregnancy and perinatal outcomes. Contraceptive counseling can help females with RMDs who wish to prevent pregnancy to select a contraceptive method that is best for them.We conducted a narrative review of the primary literature addressing reversible, prescription-based contraception for females with RMDs, framed by published guidelines on contraceptive safety. Many safe and effective contraceptive options are available for females with RMDs. Special considerations must be given to individuals with systemic lupus erythematosus, whose disease activity may be exacerbated by exogenous estrogen. Females with positive antiphospholipid antibodies should avoid estrogen-containing contraception due to an unacceptable risk of thrombosis and should conditionally avoid depot medroxyprogesterone acetate, which appears to have a prothrombotic signature. Limited contraceptive options are available to male patients. Contraceptive care for adolescents with RMDs can be extrapolated from guidelines written for adult patients, with the additional consideration of barrier protection for individuals at risk for sexually transmitted infections. Future research is needed to assess the effects of contraception use on rheumatic disease activity and side effects.

Hepatocellular adenoma update: diagnosis, molecular classification, and clinical course.

Hepatocellular adenomas (HCA) are acquired focal liver lesions, that occur mainly in young-to-middle-aged women who are on long-term estrogen-containing contraceptives or young men after prolonged use of anabolic steroids. Furthermore, distinct underlying diseases, such as obesity, metabolic dysfunction-associated steatotic liver disease, glycogen storage disease, etc. are considered risk factors. The 2017 Bordeaux classification, in particular Nault et al, divided HCAs into eight subtypes according to their pheno- and genotypic characteristics. This includes HCAs with hepatocyte-nuclear-factor (HNF1-alpha mutation), HCAs with β-catenin mutation, and HCAs without either of these genetic mutations, which are further subdivided into HCAs with and without inflammatory cells. HCAs should no longer be classified as purely benign without histologic workup since three of the eight subtypes are considered high-risk lesions, requiring adequate management: malignant transformation of the pure (ßex3-HCA) and mixed inflammatory/β-catenin exon 3 (ßex3-IHCA) adenomas, as well as potential bleeding of the sonic hedgehog HCA and pure (ßex7/8-HCA) and mixed inflammatory/β-catenin exon 7/8 (ßex7/8-IHCA). Elective surgery is recommended for any HCA in a male, or for any HCA exceeding 5 cm. Although MRI can classify up to 80% of adenomas, if findings are equivocal, biopsy remains the reference standard for adenoma subtype.

Hepatocellular adenomas with severe intra-abdominal bleeding, related to an underlying coagulation disorder: a case report

BackgroundHepatocellular adenoma is a rare benign liver tumor. Typically, hepatocellular adenomas are solitary and are found in young women who use estrogen-containing contraceptives. The occurrence of multiple hepatocellular adenoma has been linked to higher body mass index, and as the prevalence of overweight increases, multiple hepatocellular adenomas are seen more often. An hepatocellular adenoma does not always necessitate treatment, as they can regress under conservative strategies. In incidental cases, an adenoma presents owing to bleeding, which is mostly self-limiting. If it is not, embolization of hepatic involved vessels is indicated.Case presentationIn this case report, we discuss a 42-year old Caucasian woman with multiple hepatocellular bleeds, treated by multiple endovascular procedures. After the first embolization of an adenoma in the right liver lobe, a second bleed occurred in the left lobe, necessitating additional endovascular intervention. During admittance, treatment was complicated by pulmonary embolism and a pneumonia. During follow-up, our patient was diagnosed with antiphospholipid syndrome.ConclusionHepatocellular adenoma is a rare diagnosis that requires centralized expertise. This particular case illustrates the complexity of treatment strategies for associated intra-abdominal bleeding and possible complications. Although liver adenoma is often an incidental finding, it can also result in significant morbidity. Centralization of treatment leads to expertise in managing complex treatment strategies.

An Retrospective Study of Commonly Prescribed Antiepileptic Drugs and it’s Interaction with Other Drugs which are Already in use Respect to Other Disease

Antiepileptic drugs (AED) are increasingly used in the treatment of some non-epileptic neurological diseases and psychiatric diseases. Most of the available data on the use of these agents in clinical conditions other than epilepsy are from case series, uncontrolled studies, or small randomized clinical trials, and their apparent efficacy requires confirmation in well-designed large phase III trials. Interactions between antiepileptic drugs or between antiepileptic drugs and other drugs can be pharmacokinetic or pharmacodynamic. Pharmacokinetic interactions include changes in absorption, distribution ,or eliminate , while pharmacodynamic interactions include synergism and antagonism at the site ,of action. Most clinically significant antiepileptic drug interactions are due to induction or inhibition of drug metabolism. Carbamazepine, phenytoin, phenobarbital and primidone are strong inducers of cytochrome P450 and glucuronide enzymes (as well as P-glycoprotein) and may reduce the effectiveness of concomitantly administered drugs such as oral anticoagulants, calcium antagonists, antimicrobial steroids. Mechanism Oxcarbazepine, eslicarbazepine acetate, felbamate, rufinamide, topiramate (at doses ≥ 200 mg/day) and perampanel (at doses ≥ 8 mg/day) have weaker inducing properties and less tendency to produce interactions mediated by enzyme induction. In contrast to enzyme induction, enzyme inhibition results in decreased metabolic clearance of the affected drug, which can increase serum concentrations leading to toxic effects. Examples of important interactions mediated by enzyme inhibition include valproic-induced increases in serum concentrations of phenobarbital and lamotrigine. There are also interactions where other drugs induce or inhibit the metabolism of antiepileptic drugs. Examples include an increase in serum carbamazepine concentration due to erythromycin and a decrease in serum lamotrigine concentration due to estrogen-containing contraceptives. Pharmacodynamic interactions between antiepileptic drugs may also be clinically important. These interactions can have potentially beneficial effects, such as the combined therapeutic synergy of valproic acid and lamotrigine, or adverse effects, such as the mutual potentiation of neurotoxicity in patients treated with a combination of sodium channel blocking antiepileptic drugs. AEDs are also used to treat psychiatric conditions, particularly bipolar disorder. To date, the AEDs most commonly used to treat this disorder have been carbamazepine and valproic acid, which have shown manic efficacy and likely long-term mood-stabilizing effects in many bipolar patients, including those who are lithium-intolerant. . The availability of new generation AEDs has expanded treatment options for bipolar disorder. Lamotrigine, oxcarbazepine, gabapentin, and topiramate appear to show promise in the treatment of bipolar disorder, both as monotherapy and in combination with traditional mood stabilizers. In addition, newer AEDs appear to have a more favorable tolerability and drug interaction profile than older compounds, thus improving compliance

Estrogen-Containing Contraceptive Use and Blood Lead Concentrations in a Cohort of Young Women [ID 2683459

INTRODUCTION: Toxic metal lead is stored in the skeleton and, with increased bone turnover, is mobilized to systemic circulation. Given the bone-conserving properties of estrogens, we hypothesized that current users of estrogen-containing contraception would have lower blood lead concentrations. METHODS: We conducted a cross-sectional analysis using baseline data from the Study of Environment, Lifestyle & Fibroids (SELF). During 2010–2012 (baseline), 1,693 self-identified Black women, ages 23–35, enrolled. Data on contraceptive use were ascertained by interview. We quantified lead concentrations in whole blood using inductively coupled plasma mass spectrometry (ICP-MS). Among 1,555 participants, we estimated the percent difference in blood lead concentrations and 95% CIs between current users and nonusers of estrogen-containing contraception using multivariable linear regression, adjusting for potential confounders. RESULTS: The geometric mean blood lead concentrations for estrogen-containing contraceptive users and nonusers were 0.41 micrograms/dL (95% CI: 0.39, 0.43) and 0.51 micrograms/dL (95% CI: 0.50, 0.52), respectively. After adjustment, current use of estrogen-containing contraception was associated with 10% lower blood lead concentrations (95% CI: −15%, −4%). Considering estrogen-containing contraceptive type, compared to nonusers, combined oral contraceptive users (n=187) had 9% lower blood lead concentrations (95% CI: −15%, −2%) and vaginal ring/transdermal patch users (n=33) had 17% lower blood lead concentrations (95% CI: −29%, −4%). CONCLUSION: As hypothesized, we observed lower blood lead concentrations with current use of estrogen-containing contraception. Further research is warranted to confirm the results and to understand the relationship between lead exposure, hormonal contraception, and bone health to limit systemic lead exposure.

Lower levels of the neuroprotective tryptophan metabolite, kynurenic acid, in users of estrogen contraceptives

Changes in kynurenine metabolites are reported in users of estrogen containing contraception. We have assessed kynurenines, vitamin B6, vitamin B2 and the inflammation markers, C-reactive protein (CRP) and neopterin, in healthy, never-pregnant women between 18 and 40 years (n = 123) and related this to their use of hormonal contraception. The population included 58 women, who did not use hormonal contraceptives (non-users), 51 users of estrogen-containing contraceptives (EC-users), and 14 users of progestin only contraceptives (PC-users). EC-users had significantly lower plasma kynurenic acid (KA) and higher xanthurenic acid (XA) levels compared to non-users. Serum CRP was significantly higher and negatively associated with both vitamin B6 and B2 status in EC-user compared to non-users. No significant differences in any parameters were seen between PC-users and non-users (p > 0.1). The low KA and high XA concentration in users of estrogen containing contraception resemble the biochemical profile observed in vitamin B6 deficiency. The hormonal effect may result from interference with the coenzyme function of vitamin B6 and B2 for particular enzymes in the kynurenine metabolism. KA has been suggested to be neuroprotective and the significantly reduced concentration in EC-users may be of importance in the observed increased risk of mood disorders among users of oral contraceptives.

Influence of progestin-only hormonal use on hepatocellular adenomas: A retrospective cohort study

ObjectivesExogenous estrogen is associated with growth of hepatocellular adenomas (HCAs), although the influence of progestin-only agents is unknown. We therefore evaluated the association of progestin-only agents on HCA progression compared to no hormone exposure and compared to estrogen exposure in female patients. Study designIn this single-center, retrospective cohort study of reproductive-aged female patients (ages 16−45) with diagnosed HCAs between 2003 and 2021, we evaluated radiographic HCA growth during discrete periods of well-defined exogenous hormone exposures. ResultsA total of 34 patients were included. Nineteen (55.9%) had follow-up scans during periods without hormone exposure, 7 (20.6%) during estrogen exposure, and 8 (23.5%) during progestin-only exposure. Over a median follow-up of 11 months, percent change in sum of adenoma diameters from baseline to last available scan was -15.0% with progestin-only agents versus 29.4% with estrogen exposure (p = 0.04), and -7.4% with no hormonal exposure (p = 0.52 compared to progestin-only). Greater than 10% growth was observed in two individuals (25.0%) with progestin-only agent use (one patient on high-dose progestin for menorrhagia) versus five individuals (71.4%) with estrogen use (p = 0.13), and 7 (36.8%) with no exogenous hormone use (p = 0.68 vs progestin-only). ConclusionsDuring discrete periods of progestin-only use, HCA growth overall declined, similar to declining growth during periods without exogenous hormonal exposure. This differed from discrete periods of exogenous estrogen exposure, during which time HCAs demonstrated overall increased growth. Though larger studies are needed, these findings support recent guidance supporting progestin-only agents for female patients with HCAs seeking non-estrogen alternatives for contraception. ImplicationsIn this small retrospective study, we observed overall decrease in HCA size during discrete periods of progestin-only contraception use, similar to that observed during periods without exogenous hormone exposure, supporting their use as a safe alternative to estrogen-containing contraceptives in this patient population.

Pulmonary Embolism and Chronic Obstructive Pulmonary Disease.

Chronic obstructive pulmonary disease (COPD) is a frequent and devastating chronic respiratory disease. COPD is ranked among the top five causes of death worldwide. Patients with COPD suffer from persistent dyspnea, with periods of acute worsening, called exacerbations. Such exacerbations may be severe. In fact, one-third of COPD patients will be hospitalized because of an exacerbation. Hospitalization due to respiratory failure has been identified as a powerful predisposing risk factor for venous thromboembolism (VTE) for many years. Therefore, COPD is recognized as a moderate risk factor for VTE, with an odds ratio between 2 and 9, similar to other risk factors such as estrogen-containing contraceptives or (any) cancer. However, unlike other risk factors such as contraception, the presence of COPD can modify the initial presentation of VTE and worsen the short-term prognosis of patients who have acute pulmonary embolism (PE), particularly during a COPD exacerbation. It is not only that both stable COPD and acute exacerbations of COPD might increase the risk of VTE, but PE itself may mimic the symptoms of a COPD exacerbation. Hence, some authors have evaluated the prevalence of PE among COPD patients with acute worsening. This clinical review (1) gives an update on epidemiological data, clinical presentation, and prognosis of PE associated with COPD; (2) presents the results of the Prevalence de l'Embolie Pulmonaire chez les patients admis pour exacerbation de BPCO study, which aimed at determining the frequency of PE in COPD patients hospitalized for an acute exacerbation; (3) discusses the results of the Significance of Pulmonary Embolism in COPD Exacerbations study, the first randomized trial having compared the efficacy of a systematic search for PE versus routine care on admission for a COPD exacerbation; and (4) provides a selection of remaining unmet needs on the association between COPD and PE.

Clinical progress note: Noncardiac complications in adults with congenital heart disease.

Clinical progress note: Noncardiac complications in adults with congenital heart disease.

Contraception Use and Counseling at a Student-Run Free Clinic

Background: In the United States, about half of all pregnancies are unplanned. Unplanned pregnancy carries increased risks to patient and fetus and is increased independently by both poverty and being a racial or ethnic minority. The purpose of this study was to examine the percentage and types of contraceptives used by patients at the student-run Building Relationships and Initiatives Dedicated to Gaining Equality (BRIDGE) Healthcare Clinic and determine if clinic staff provided appropriate annual contraceptive counseling.
 Methods: A retrospective chart review was performed for all active BRIDGE patients that were female and aged 18-60 between 2015 and 2020. Information collected included demographics, obstetric history, tobacco use, medical history of deep vein thrombosis (DVT) or hypertension, and contraception use. 
 Results: Of 145 patients reviewed, 77.2% used contraception at some point during the study period. Surgical contraception was the most common form used. No patients with a documented history of DVT or tobacco use used estrogen-containing contraception during the study period. One patient out of the twenty with documented hypertension used an estrogen-containing form of contraception for one year.
 Conclusions: Overall, our clinic counseled the majority of patients of child-bearing age on contraception use. Contraception use in our population is above the national average and is appropriately prescribed.

Case report: cerebral sinus vein thrombosis in two patients with AstraZeneca SARS-CoV-2 vaccination

SARS-CoV-2 infection is associated with an increased rate of thromboembolic events and mortality. Different vaccines are globally used to limit the pandemic. In this report, we present the case of two young female patients with newly diagnosed cerebral sinus vein thrombosis occurring after injection of the vector-based ChAdOx1 vaccine. Both patients presented with unusual headache only. The two of them used an estrogen-containing contraception, had had a history of deep venous thrombosis, and both had MTHFR mutations. Both patients developed SARS-CoV-2 specific humoral and cellular immunity including both CD4 and CD8 T cells. This rare, but serious complication needs to be considered after vaccination of young females, even if there is no evidence of heparin-induced thrombocytopenia.

Estrogens in polycystic liver disease: A target for future therapies?

Background and AimsPatients suffering from polycystic liver disease (PLD) can develop large liver volumes, leading to physical and psychological complaints, reducing quality of life. There is an unmet need for new therapies in these patients. Estrogen seems to be a promising target for new therapies. In this review, we summarize the available experimental and epidemiological evidence to unravel the role of estrogens and other female hormones in PLD, to answer clinical questions and identify new targets for therapy.MethodsWe identified all experimental and epidemiologial studies concerning estrogens or other female hormones and PLD, to answer pre‐defined clinial questions.ResultsFemale sex is the most important risk factor for the presence and severity of disease; estrogen supplementation enhances liver growth and after menopause, liver growth decreases. Experimental studies show the presence of the estrogen receptors alfa and beta on cystic cholangiocytes, and increased in vitro growth after administration of estrogen.ConclusionsBased on the available evidence, female PLD patients should be discouraged from taking estrogen‐containing contraceptives or hormone replacement therapy. Since liver growth rates decline after menopause, treatment decisions should be based on measured liver growth in postmenopausal women. Finally, blockage of estrogen receptors or estrogen production is a promising target for new therapies.

Migraine diagnosis and treatment: A knowledge and needs assessment of women's healthcare providers.

Studies suggest that migraine is often underdiagnosed and inadequately treated in the primary care setting, despite many patients relying on their primary care provider (PCP) to manage their migraine. Many women consider their women's healthcare provider to be their PCP, yet very little is known about migraine knowledge and practice patterns in the women's healthcare setting. The objective of this study was to assess women's healthcare providers' knowledge and needs regarding migraine diagnosis and treatment. The comprehensive survey assessing migraine knowledge originally developed for PCPs was used in this study, with the addition of a section regarding the use of hormonal medications in patients impacted by migraine. Surveys were distributed online, and primarily descriptive analyses were performed. The online survey was completed by 115 women's healthcare providers (response rate 28.6%; 115/402), who estimated that they serve as PCPs for approximately one-third of their patients. Results suggest that women's healthcare providers generally recognize the prevalence of migraine, but experience some knowledge gaps regarding migraine management. Despite 82.6% (95/115) of survey respondents feeling very comfortable or somewhat comfortable with diagnosing migraine, only 57.9% (66/114) reported routinely asking patients about headaches during annual visits. Very few were familiar with the American Academy of Neurology guidelines on preventative treatment (6.3%; 7/111) and the Choosing Wisely Campaign recommendations on migraine treatment (17.3%; 19/110), and many prescribed medications known to contribute to medication overuse headache. In addition, only 24.3% (28/115) would order imaging for a new type of headache, 35.7% (41/115) for worsening headache, and 47.8% (55/115) for headache with neurologic symptoms; respondents cited greater tendency with sending patients to an emergency department for the same symptoms. Respondents had limited knowledge of evidence-based, non-pharmacological treatments for migraine (i.e., biofeedback or cognitive behavioral therapy), with nearly none placing referrals for these services. Most providers were comfortable prescribing hormonal contraception (mainly progesterone only) to women with migraine without aura (80.9%; 89/110) and with aura (72.5%; 79/109), and followed American College of Obstetricians and Gynecologists (ACOG) guidelines to limit combination hormonal contraception for patients with aura. When queried, 6.3% or less (5/79) of providers would prescribe estrogen-containing contraception for women with migraine with aura. Only 37.3% (41/110) of respondents reported having headache/migraine education. Providers indicated interest in education pertaining to migraine prevention and treatment (96.3%; 105/109), migraine-associated disability (74.3%; 81/109), and diagnostic testing (59.6%; 65/109). Women's healthcare providers appear to have several knowledge gaps regarding the management of migraine in their patients. These providers would likely benefit from access to a headache-specific educational curriculum to improve provider performance and patient outcomes.

A Major Knowledge Gap in Women's Health: The Combined Effect of Antifibrinolytics and Estrogen on Risk of Thromboembolism - a Scoping Review

Background:Up to 30% of women of reproductive age will seek medical attention for heavy menstrual bleeding (HMB), which negatively affects health-related quality of life. Both estrogen-containing oral contraceptives and antifibrinolytic agents are essential first-line treatments for HMB. Anecdotally, these agents appear synergistically effective when used in combination. Despite the strong evidence for the independent efficacy and safety of these agents for HMB as well as the use of antifibrinolytics in other high-estrogen states such as the post-partum state, prescribers are frequently uncomfortable prescribing them in combination due to the theoretical increased risk of thrombosis. Objective:To systematically evaluate the literature that explores the combined effect of pharmacologic or high physiologic estrogen and antifibrinolytic agents on risk of thromboembolism in women of reproductive age when used for heavy menstrual or post-partum bleeding. Methods:A literature search was performed on Medline, EMBASE, CINAHL, and Scopus from inception to July 2020. References of included articles were screened and a grey literature search was conducted to identify additional sources. Studies written in English that explored the risk of thromboembolism in women of reproductive age prescribed antifibrinolytic agents alongside estrogen-containing contraceptives or with a physiologic high-estrogen state were included. A thromboembolic event was defined as formation of a blood clot/thrombus in any arterial or venous structure with or without travel to a site distal to its point of origin, confirmed by appropriate diagnostic imaging/testing (including but not limited to deep vein thrombosis, superficial vein thrombosis, pulmonary embolism, ischemic stroke, myocardial infarction, mesenteric ischemia, ischemic colitis, kidney/spleen/liver infarct, or critical limb ischemia). Screening and data abstraction were performed by two independent reviewers (DM, DL) and conflicts were adjudicated by a third reviewer (MS). Results:A total of 2389 title and abstracts were identified from the literature. Of those, a total of 33 studies with 27933 participants were extracted for full text review. Of these studies, 31 investigatedantifibrinolytic use for post-partum bleeding: 22 randomized controlled trials (RCT), 3 retrospective cohort studies, 1 combined prospective-retrospective cohort study, 2 case series, and 3 case reports. Almost all (29/31) of these studies found no increased rate/risk of thromboembolism. However, only 4 of these studies were powered to make this assessment, all of which were RCTs. The 2 studies that described thromboembolism with antifibrinolytic use in the postpartum period were a case report and case series (N=18), respectively. We found only 2 case reports published describing thromboembolism withconcomitant estrogen-containing contraceptives and antifibrinolytic use, both of which reported thromboembolism in women using both agents for less than 3 months. Conclusions:We found no clear evidence that intermittent use of antifibrinolytics in either high physiologic or pharmacologic estrogenic states results in higher rates of thromboembolism. Prospective studies are warranted, particularly in the area of combined estrogen-containing contraceptive and antifibrinolytic use, to provide an accurate assessment of risk and properly inform prescribing practices. Disclosures James: Shire/Takeda:Research Funding;Bayer:Research Funding;CSL Behring:Research Funding.Sholzberg:Amgen:Honoraria, Other: Scientific Advisory Board, Research Funding;Octapharma:Honoraria, Other: Scientific Advisory Board, Research Funding;Takeda:Honoraria, Other: Scientific Advisory Board, Research Funding;Novartis:Honoraria, Other: Scientific Advisory Board;NovoNordisk:Honoraria, Other: Scientific Advisory Board.

Thrombosis Risk in Transgender Adolescents Receiving Gender-Affirming Hormone Therapy

An estimated 2-3% of US youth identify as transgender or gender non-conforming (hereafter transgender). Transgender youth may suffer from gender dysphoria, a condition associated with many health risks, including high risk of suicide. Transgender individuals have a 40% greater risk of attempting suicide than cis-gender individuals. Gender-affirming hormone therapy (GAHT) is associated with improvement of gender dysphoria and amelioration of the risk of suicide. GAHT consists of either estrogen [for transgender women (TGW)] or testosterone [for transgender men (TGM)]. However, GAHT may be associated with other risks, most notably thrombosis. Numerous studies documented increased thrombosis risk in cis-gender women using exogenous estrogen for contraception or hormone replacement therapy. Studies of GAHT suggest a risk of thrombosis with estrogen use; however, this data is not uniform. Studies of testosterone replacement in cis-gender show conflicting results with respect to thrombosis risk. All previous studies examining the risk of thrombosis with GAHT have included adults exclusively. Therefore we sought to determine the risk of thrombosis in a cohort of transgender youth receiving standardized GAHT regimens. Transgender youth have potential for a much longer exposure to GAHT, thus having different life-time risk of thrombosis than patients that start GAHT at an older age. Of all 1406 patients seen at the Cincinnati Children's Medical Center Transgender Health Clinic since its inception, 611 subjects started GAHT and were eligible for inclusion in the cohort. Of these, 176 (28.8%) identified as female, 416 (68.1%) as male, and 19 (3.1%) as non-binary. Thrombosis risks were common among the cohort: 34.5% had obesity, 15.4% used tobacco, 4.6% had migraine with aura, and 8.0% had a family history of thrombosis. Three subjects had a prior history of thrombosis: 2 with venous thromboembolism (VTE) and one with a stroke. 53.7% of the cohort had previously used hormones, most commonly for menstrual suppression. Of those with prior hormone use, the vast majority had used progesterone-only methods (5.7% previously used estrogen-containing contraceptives). All patients initiating GAHT were treated according to current guidelines with monitoring of estrogen and testosterone levels and titration of GAHT doses accordingly. Overall, 29.8% initiated estrogen therapy and 70.2% started testosterone therapy. Among the cohort, 17 individuals were referred to Hematology for evaluation for thrombosis risk prior to starting GAHT. The most common laboratory abnormality for these individuals was elevated factor VIII, elevated plasminogen-activator inhibitor 1 (PAI-1), and the PAI-1 polymorphism. Two TGW and one TGM started thromboprophylaxis prior to initiating GAHT due to thrombotic risk factors. Despite the presence of preexisting risk factors, no individual in the cohort developed a thrombosis (VTE or stroke) during GAHT. This is the first study to examine thrombosis risk of GAHT in an exclusively adolescent and young adult population. While there were no incidents of thrombosis in our cohort, we found individuals at risk for thrombosis. Careful history and counseling regarding risks are needed when discussing initiation of GAHT for transgender individuals. Additionally, further studies looking at long-term risk are needed. Disclosures Mullins: Takeda, Bayer: Other: Advisory Board.

Contraception and preconception counseling in women with autoimmune disease.

Appropriate contraception and preconception counseling are critical for women of reproductive age with systemic autoimmune diseases (AIDs) because clinical diagnosis, rheumatology medications, and disease activity may impact the safety or efficacy of certain contraceptives as well as the risk of adverse pregnancy outcomes. The presence of antiphospholipid (aPL) antibodies (anticardiolipin, anti-β2 glycoprotein I, and lupus anticoagulant) is the most important determinant of contraception choice, as women with these antibodies should not receive estrogen-containing contraceptives because of the increased risk of thrombosis. Prepregnancy counseling generally includes the assessment of preexisting disease-related organ damage, current disease activity, aPL antibodies, anti-Ro/SS-A and anti-La/SS-B antibodies, and medication safety in pregnancy. Quiescent AID for six months on pregnancy-compatible medications optimizes maternal and fetal/neonatal outcomes for most patients.

Contraception after pregnancy

Whatever the outcome, pregnancy provides the opportunity to offer effective contraception to couples motivated to avoid another pregnancy. This narrative review summarizes the evidence for health providers, drawing attention to current guidelines on which contraceptive methods can be used, and when they should be started after pregnancy, whatever its outcome. Fertility returns within 1month of the end of pregnancy unless breastfeeding occurs. Breastfeeding, which itself suppresses fertility after childbirth, influences both when contraception should start and what methods can be used. Without breastfeeding, effective contraception should be started as soon as possible if another pregnancy is to be avoided. Interpregnancy intervals of at least 6months after miscarriage and 1-2years after childbirth have long been recommended by the World Health Organization in order to reduce the chance of adverse pregnancy outcome. Recent research suggests that this may not be necessary, at least for healthy women <35years old. Most contraceptive methods can be used after pregnancy regardless of the outcome. Because of an increased risk of venous thromboembolism associated with estrogen-containing contraceptives, initiation of these methods should be delayed until 6weeks after childbirth. More research is required to settle the questions over the use of combined hormonal contraception during breastfeeding, the use of injectable progestin-only contraceptives before 6weeks after childbirth, and the use of both hormonal and intrauterine contraception after gestational trophoblastic disease. The potential impact on the risk of ectopic pregnancy of certain contraceptive methods often confuses healthcare providers. The challenges involved in providing effective, seamless service provision of contraception after pregnancy are numerous, even in industrialized countries. Nevertheless, the clear benefits demonstrate that it is worth the effort.

Does Extended Exposure to Estrogen Raise Risk for Clot

Estrogen-containing contraception raises risk for thromboembolic disease but is still considered safe for most women of reproductive age. To examine

Venous Thromboembolism in Female Adolescents: Patient Characteristics.

Our goal was to describe the period prevalence of venous thromboembolism (VTE) and characterize adolescent female patients diagnosed with VTE by describing their age, race, and number of comorbidities. Female adolescents with estrogen exposure were of particular interest because estrogen-containing contraceptives increase the risk of VTE. We queried the Pediatric Health Information System database for International Classification of Diseases, Ninth/Tenth Revision, Clinical Modification codes to identify female patients aged 12-18years diagnosed with a VTE or pulmonary embolism from April 2006 to March 2016 in the United States. Patient demographic characteristics and comorbidities were also analyzed. We divided our study population into two five-year groups and calculated the change in period prevalence of VTE between those groups. Primary diagnosis of VTE in the extremities, or pulmonary embolism. The period prevalence of VTE increased from 2.3 female adolescents per 10,000 hospitalized children (group 1) to 3.3 per 10,000 (group 2), representing a statistically significant increase of 0.010% (P<.001). Caucasian and black individuals were most commonly affected. The number of girls affected increased steadily from ages 12 to 16years and a large percentage (59.6%) had four or more comorbidities. In patients (n=32) with estrogen exposure, more than 96% had one or more comorbidity in addition to estrogen exposure. Pediatric health care providers should be aware that the period prevalence of VTEs in female adolescents is increasing. Those with a history of estrogen exposure rarely develop VTEs from estrogen alone and they typically have multiple comorbidities.

Can Screening and Confirmatory Testing in the Management of Patients with Primary Aldosteronism be Improved?

Widespread application of the plasma aldosterone/renin ratio (ARR) as a screening test has led to the recognition that primary aldosteronism (PA) is the most common specifically treatable and potentially curable form of hypertension, accounting for 5-10% of patients. Maximal detection requires accurate diagnostic approaches and awareness and control of factors that confound results, including most antihypertensives, posture, time of day, dietary salt, and plasma potassium. Recent studies have revealed potential for false positives in patients on beta-adrenoceptor blockers, and, when direct renin concentration (but not plasma renin activity) is used to measure renin, in women during the luteal phase of the menstrual cycle or receiving estrogen-containing contraceptives or hormonal replacement therapy. In addition to verapamil slow release, hydralazine and prazosin, moxonidine has minimal effects on the ARR and can be used to control hypertension during work-up. Fludrocortisone suppression testing, while probably the most reliable means of definitively confirming or excluding PA, is time consuming and expensive, requiring a five day inpatient stay. A novel approach, upright (seated) saline infusion suppression testing (SST), has shown excellent reliability with much greater sensitivity than conventional recumbent SST in a recent pilot study, and requires only a day visit. Accurate measurement of aldosterone is essential for each step of PA workup: introduction of new, highly reliable high-throughput mass spectrometric methods into clinical practice has represented a major advance. In response to concerns raised about accuracy of renin assays, new mass spectrometric methods for measuring angiotensin II are currently being assessed in the clinical setting.