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Breast cancer screening recommendations for transgender and gender nonconforming individuals are based on the sex assigned at birth, risk factors, and use of exogenous hormones. Insufficient evidence exists to determine whether transgender people undergoing hormone therapy have an overall lower, average, or higher risk of developing breast cancer compared to birth-sex controls. Furthermore, there are no longitudinal studies evaluating the efficacy of breast cancer screening in the transgender population. In the absence of definitive data, current evidence is based on data extrapolated from cisgender studies and a limited number of cohort studies and case reports published on the transgender community. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

OBJECTIVE To evaluate the effects of buffered lidocaine on pain scores during vulvar biopsy. METHODS We conducted a double-blind, randomized controlled trial, using prefilled, sequentially numbered, randomized syringes to infiltrate either 3 mL of buffered or nonbuffered lidocaine before vulvar biopsy. The primary outcome was a pain score marked on a 100-mm visual analog scale during infiltration. Secondary outcomes included pain scores after the procedure and change from baseline to infiltration. Participants were recruited to detect a clinically meaningful 15-mm difference in pain scores between groups. Sample size was calculated based on the null hypothesis that the mean pain score would be the same in women treated with buffered lidocaine as in those treated with nonbuffered placebo based on prior studies. Categorical data were compared by Fisher exact test, and continuous data were compared between groups by t-test or Wilcoxon rank sum test. RESULTS From July 2015 to April 2018, 129 participants were randomized to one of two groups: nonbuffered lidocaine or buffered lidocaine. One hundred twenty-five were analyzed (nonbuffered n=62, buffered n=63). Four patients were excluded. The majority of participants were non-Hispanic white women with a mean age of 59 years. There was no difference in the primary outcome of pain during infiltration with a mean pain score of 35.8 mm in the buffered lidocaine group compared with 42.2 in the nonbuffered lidocaine group (mean difference -6.4; 95% CI -18.4 to 5.6; P=.3 by Wilcoxon rank sum test). There was also no difference in secondary outcomes of pain over the entire procedure (mean difference -0.3, 95% CI -9.7 to 9.2; P=.7) or change in pain from baseline to infiltration (mean difference -6.9, 95% CI -18.4 to 4.7; P=.2). CONCLUSION There was no difference in pain scores during vulvar biopsy infiltration between the buffered and nonbuffered lidocaine groups. CLINICAL TRIAL REGISTRATION ClinicalTrials.gov, NCT02698527.

To compare the prevalence of abnormal anal cytology, high-risk anal HPV and biopsy proven anal dysplasia among women with a history of lower genital tract malignancy compared to those with dysplasia.A prospective cohort study was performed from December 2012 to February 2014 at outpatient clinics at an academic medical center. Women with a history of high-grade cervical, vulvar, or vaginal dysplasia, or malignancy were recruited. Anal cytology and HPV genotyping were performed. All women with abnormal anal cytology were referred for high-resolution anoscopy and biopsy.Sixty-seven women had a lower genital tract malignancy and 123 had a history of genital dysplasia. Average age in the malignancy group was 52.6years (range 27-86) versus 43.5years (range 21-81) in the dysplasia group (p0.0002). Similar rates of anal dysplasia were seen in both groups, 12.99% (10 cases) in the malignancy group, versus 12.20% (15) in the dysplasia group (p=1.0). Six women in the malignancy group had anal intraepithelial neoplasia (AIN2+) compared to 2 in the dysplasia group (p=0.03).We found high rates of abnormal anal cytology and HPV in women with lower genital tract dysplasia and malignancy. We also found high rates of anal dysplasia in both groups with a trend towards increased rate in those women with history of genital malignancy. Since precancerous anal lesions are detectable and treatable, anal cancer screening may be potentially useful in both of these higher risk groups.

BACKGROUND Postpartum myomectomy is typically discouraged as a result of the risk of hemorrhage and longer operative times. However, myomectomy at the time of cesarean delivery or after a vaginal delivery is feasible and is sometimes necessary. CASE A 38-year-old multiparous woman with a 9-cm pedunculated submucosal leiomyoma presented in labor and underwent a vacuum-assisted vaginal delivery with manual extraction of the placenta. In the immediate postpartum period she had bleeding and hemodynamic instability requiring blood transfusion. Examination under anesthesia demonstrated uterine atony and placental fragments adherent to the pedunculated leiomyoma. An abdominal myomectomy was performed, and the patient recovered normally. CONCLUSION Although it should not be recommended routinely, postpartum myomectomy is feasible and can be life-saving, even after a vaginal delivery.

Objectives Human papillomavirus is a multifocal infection that can involve the cervix, vagina, vulva, anus, and oropharynx. Our study aimed to determine whether standard sexual history questions regarding anal intercourse identify women participating in anal-related sexual practices. Materials and methods A cross-sectional survey was conducted at the dysplasia clinic of a large academic medical center. Women presenting with human papillomavirus-related cervical, vulvar, or vaginal abnormalities were eligible. Participants completed a self-administered sexual history questionnaire that included standard sexual history questions and more detailed questions about sexual practices. Additional demographic information was obtained from chart review. Results A total of 149 eligible women were approached, 125 (84%) consented and enrolled (ages = 21-65 years). Forty-seven (44%) reported participating in some type of anal-related sexual practice: anal fingering, oral-anal penetration, or anal intercourse. Of those participating in anal-related practices, 5 (11%) reported only anal fingering or oral-anal penetration. Thus, adding the new anal questions detected an additional 5% of women with high-risk anal behaviors that may have been missed by the standard question (p = .06). Seventy-nine women (63%) reported receiving oral penetration of the vagina, and 102 (82%) reported receiving vaginal fingering. Fifty-nine women (47%) used sex toys: 58 (98%) used sex toys vaginally, with 5 (8.5%) using them also anally. Conclusions Women are willing to report their participation in a range of sexual practices. Of those who participated in anal practices, 11% did not have anal intercourse. Adding additional sexual health questions to clinical intake forms may enable clinicians to better counsel their patients on risky sexual behaviors.

Introduction Ovarian cancer is the fifth leading cause of death in women. PLD has been effective in recurrent ovarian cancer, but the ideal treatment length is unknown. We hypothesized that patients with regression or stabilization of disease while receiving PLD, who continued with prolonged treatment, would have increased PFS. Patients and Methods A retrospective chart review was performed of women with recurrent ovarian, fallopian tube, primary peritoneal, or uterine papillary serous carcinoma, who received 6 or more cycles of PLD without evidence of progression. Evaluation for progression was based on carcinoma antigen 125, physical examination, and imaging studies. Results Of the 30 patients meeting criteria for inclusion, 13 patients (43%) stopped treatment at best response (median, 6 cycles) and 17 (57%) continued treatment until disease progression (median, 11 cycles). Patients treated to best response experienced a significantly shorter PFS compared with those who continued treatment until progression, median 10 versus 15 months ( P = .009). There was a trend toward improved OS in the prolonged therapy group of 42.5 months (range, 12-84) versus 23 months in the standard therapy group (range, 17-98; P = .56). Conclusion Our data suggest that prolonged PLD treatment to progression is associated with a PFS advantage compared with treatment to best response. In the absence of toxicity, this treatment paradigm should be considered.

Vaginal cuff dehiscence and evisceration are rare but serious complications of pelvic surgery, specifically hysterectomy. The data on risks of vaginal cuff dehiscence are variable, and there is no consensus on how to manage this complication. In our review, we present a summary of the risk factors, with symptoms, precipitating events, and treatment options for patients with vaginal cuff dehiscence after pelvic surgery. In addition, we provide a review of the current literature on this important surgical outcome and suggestions for future research on the incidence and prevention of vaginal cuff dehiscence.

Management of women with a pelvic mass is a very common scenario for gynecologists. Often these are benign masses that can either be observed or managed with straightforward laparoscopic surgery, but complex, potentially malignant masses require careful consideration and triaging for appropriate care. This article aims to outline the presentation, management, and triage guidelines for women presenting with an ovarian cyst or pelvic mass. We discuss data surrounding the use of triage guidelines, as well as the role of promising biomarkers that can assist in better predicting benign versus malignant pathology.

In the roundtable that follows, clinicians discuss a study published in this issue of the Journal in light of its methodology, relevance to practice, and implications for future research. Article discussed: van der Kooij SM, Hehenkamp WJK, Volkers NA, et al. Uterine artery embolization vs hysterectomy in the treatment of symptomatic uterine fibroids: 5-years outcome from the randomized EMMY trial. Am J Obstet Gynecol 2010;203:105.e1-13.

OBJECTIVE To compare the prevalence of abnormal anal cytology and high-risk human papillomavirus (HPV) among women with a history of HPV-related genital neoplasia with women without a history of HPV-related genital neoplasia. METHODS A cross-sectional cohort study was performed from December 2012 to February 2014. Women were recruited from outpatient clinics at an academic medical center. Women with a history of high-grade cervical, vulvar, or vaginal cytology, dysplasia, or cancer were considered the high-risk group. Women with no history of high-grade anogenital dysplasia or cancer were considered the low-risk group. Human immunodeficiency virus-positive women were excluded. Anal cytology and HPV genotyping were performed. Women with abnormal anal cytology were referred for high-resolution anoscopy. RESULTS There were 190 women in the high-risk group and 83 in the low-risk group. The high-risk group was slightly older: 57 years compared with 47 years (P=.045); 21.7% of low-risk women had abnormal anal cytology compared with 41.2% of high-risk women (P=.006). High-risk HPV was detected in the anal canal of 1.2% of the low-risk group compared with 20.8% of the high-risk group (P

In the study reported on here, the authors used computer-based video instruction (CBVI) to teach 3 high school students with moderate or severe intellectual disabilities how to order in fast-food restaurants by using an augmentative, alternative communication device. The study employed a multiple probe design to institute CBVI as the only intervention tool and measured generalization of skills to community restaurants. For 2 of the 3 students, the ability to order their meals dramatically increased immediately following CBVI; for the third student, the ability to perform this task increased during a second generalization condition. Performance was maintained for each student. The authors discuss their results as support for this approach, which would be one solution for providing instruction in a simulated environment when community-based instruction is limited.

Recent studies have suggested that mouse allergen exposure and sensitization are common in urban children with asthma. The effectiveness of environmental intervention in reducing mouse allergen exposure has not been established.To evaluate whether environmental intervention of mouse extermination and cleaning results in a reduction in mouse allergen levels.Eighteen homes of children with positive mouse allergen skin test results and at least mild persistent asthma in urban Boston, MA, with evidence of mouse infestation or exposure were randomized in a 2:1 ratio (12 intervention and 6 control homes). The intervention homes received an integrated pest management intervention, which consisted of filling holes with copper mesh, vacuuming and cleaning, and using low-toxicity pesticides and traps. Dust samples were collected and analyzed for major mouse allergen (Mus m 1) and cockroach allergen (Bla g 1) at baseline and 1, 3, and 5 months after the intervention was started and compared with control homes.Mouse allergen levels were significantly decreased compared with control homes by the end of the intervention period at month 5 in the kitchen and bedroom (kitchen intervention, 78.8% reduction; control, 319% increase; P = .02; bedroom intervention, 77.3% reduction; control, 358% increase; P.01; and living room intervention, 67.6% reduction; control, 32% reduction; P = .07).Mouse allergen levels were significantly reduced during a 5-month period using an integrated pest management intervention.

INTRODUCTION:The human papilloma virus (HPV) is a multifocal infection that can involve the cervix, vagina, vulva, anus, and oropharynx. The objective of our study was to determine if standard sexual history questions capture the sexual behaviors of women that put them at increased risk for HPV-rela

Age may affect the treatment choice and subsequent outcome in elderly patients with cervical cancer. Given the potential for cure with either surgery or chemoradiation in early stage disease, we aimed to determine whether a patient's age influenced treatment received and the ensuing outcome.We identified 303 patients with stages IB1-IIB cervical carcinoma treated at our institution between 2000 and 2010, who were divided into two groups based on age at time of diagnosis:65 and ≥ 65 years. Adjusted odd ratios were calculated to determine variables associated with treatment received. Single and multivariate Cox proportional hazards modeling were used to estimate hazard ratios (HRs) for variables associated with disease-specific survival.Patients were more commonly65 years at diagnosis (83% versus 17% ≥ 65 years). There was no difference between the two groups in terms of tumor histology, stage at presentation, and grade. Women ≥ 65 years of age were less likely to receive primary surgical management (p=0.03). Age did not influence disease-specific or all-cause mortality. However, women over 65 years who underwent primary surgery were at significantly increased risk of all-cause mortality compared to younger women (HR 6.53, 95% CI: 2.57-16.6).Age appears to influence treatment received by patients with stages IB1-IIB cervical cancer. Although there was no difference in cancer-specific mortality stratified by type of treatment received, surgery was associated with a 6.5-fold increased risk of all-cause mortality among women 65 years or over.

Background: Legislation on physician-assisted suicide (PAS) is being considered in a number of states since the passage of the Oregon Death With Dignity Act in 1994. Opinion assessment surveys have historically assessed particular subsets of physicians. Objective: To determine variables predictive of physicians’ opinions on PAS in a rural state, Vermont, USA. Design: Cross-sectional mailing survey. Participants: 1052 (48% response rate) physicians licensed by the state of Vermont. Results: Of the respondents, 38.2% believed PAS should be legalised, 16.0% believed it should be prohibited and 26.0% believed it should not be legislated. 15.7% were undecided. Males were more likely than females to favour legalisation (42% vs 34%). Physicians who did not care for patients through the end of life were significantly more likely to favour legalisation of PAS than physicians who do care for patients with terminal illness (48% vs 33%). 30% of the respondents had experienced a request for assistance with suicide. Conclusions: Vermont physicians’ opinions on the legalisation of PAS is sharply polarised. Patient autonomy was a factor strongly associated with opinions in favour of legalisation, whereas the sanctity of the doctor–patient relationship was strongly associated with opinions in favour of not legislating PAS. Those in favour of making PAS illegal overwhelmingly cited moral and ethical beliefs as factors in their opinion. Although opinions on legalisation appear to be based on firmly held beliefs, approximately half of Vermont physicians who responded to the survey agree that there is a need for more education in palliative care and pain management.

Background Because of potential toxicities of inhaled corticosteroid (ICS) use in pediatric asthma, alternative or steroid-sparing therapy is desirable. There are no previous studies evaluating montelukast's steroid-sparing effects in children with asthma. Objective To evaluate whether (1) montelukast as add-on therapy improves asthma symptom control and (2) montelukast provides steroid-sparing effects in children with asthma treated with low to moderate doses of ICS therapy. Methods In a double-blind, placebo-controlled trial, 36 children ages 6 to 14 years with symptomatic asthma maintained on a stable low to moderate dose of ICSs were randomly assigned to receive montelukast or matching placebo for 24 weeks after a run-in period of 2 weeks (period I). During the trial, subjects kept daily asthma diary cards and monthly spirometry was performed. After a 4 week add-on period (period II), the subjects completed a 20-week (period III) ICS tapering period based on a predetermined protocol. Results In period II, the difference in the number of rescue-free days was significantly higher in the montelukast group ( P = 0.0001), and the number of rescue-free days per week was also significantly higher in montelukast-treated subjects compared with placebo subjects ( P = 0.002). In period III, the percentage reduction in ICS dose was not significant between montelukast and placebo ( P = 0.10), but the montelukast group experienced an average 17% decrease in ICS dose and the control group experienced an average 64% increase in ICS dose. Conclusions Montelukast treatment significantly increased the number of rescue-free days in symptomatic children with asthma.

Objective To compare the prevalence of abnormal anal cytology and high-risk HPV among women with a recent history of HPV-related genital neoplasia to women without a history of HPV-related genital neoplasia. Methods: A cross-sectional pilot study was performed. Women with a history of high-grade cervical, vulvar, or vaginal dysplasia or cancer within the past 2 years were eligible for the exposed group. Women without a history of high-grade anogenital dysplasia or cancer were eligible for the control group. Anal cytology and HPV genotyping were performed after informed consent was obtained. Results: 127 women were enrolled in the exposed group and 45 in the control group. The control group was slightly older and less likely to be current smokers. There was no difference between groups in history of anal intercourse. Forty-four per cent of the exposed group had abnormal anal cytology compared with 21.6% of the control group (P = 0.03). High-risk HPV was detected in the anal canal of 6 in the exposed group compared with none in the control group (P = 0.2). Fourteen per cent of the anal cytology results were read as insufficient in both groups. HPV results were insufficient in 29.2% of exposed versus 43.5% of control (P = 0.2). Conclusions: Women with a history of lower genital tract dysplasia are more likely to have a positive anal cytology result compared with women without a history. Additional information is needed to determine the best method of anal cancer screening among women with a history of lower genital tract dysplasia.

5100 Background: Advanced age may affect the treatment choice and subsequent outcome in elderly patients with cervical cancer. Given the potential for cure with either surgery or chemoradiation in early stage disease, we aimed to determine whether a patient’s age influenced the treatment received and the outcome. Methods: Our retrospective cohort identified a total of 303 patients diagnosed with Stage IB1 through IIB cervical carcinoma who were treated at our institution between 2000 and 2010. The eligible patients were divided into two groups based on age at the time of diagnosis: 65 years. Adjusted odd ratios were calculated to determine variables associated with treatment received (chemoradiation or surgery). Single and multivariate Cox proportional hazards modeling were used to estimate hazard ratios for variables associated with disease specific survival. Results: Of the patients meeting inclusion criteria, 253 were 65 years. The distribution of tumor histology, stage and grade was not different between the two groups. After adjusting for histology, stage and a validated comorbidity score, the odds ratio of receiving chemoradiation vs. surgery for the cohort > 65 years was 1.69 (OR 95% CI: 0.68-4.17). There was no significant difference in the type of primary treatment received between the two groups (P = 0.16). Persistent disease was seen in 46 (18%) of the younger patients and in 19 (38%) of the older patients (P = 0.02). In the elderly cohort the treatment received did not influence disease-specific or all-cause mortality. However, compared to women under 65, older women treated surgically had increased disease specific (HR 3.18, 95% CI: 0.98-10.3) and all-cause mortality (HR 6.53, 95% CI: 2.57-16.6). Conclusions: Age does not appear to be a factor influencing the treatment received by patients with Stage IB1-IIB cervical cancer. The type of treatment received does not seem to affect disease-specific mortality among older versus younger women. However, surgery was associated with a 6.5-fold increased risk of all cause mortality among older women when compared to women under 65 years.