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I. Zapotek, MD
Associate Professor, University of North Carolina School of Medicine
Cessation of menses is driven by a combination of testosterone induced ovulation suppression encore erectile dysfunction pump safe kamagra super 160mg, which may be incomplete erectile dysfunction after radiation treatment for rectal cancer cheap kamagra super 160mg without prescription, and endometrial atrophy erectile dysfunction prevention buy kamagra super 160mg free shipping. This includes ruling out pregnancy in transmen who are sexually active with partners who produce sperm erectile dysfunction treatment success rate 160 mg kamagra super with visa. Both structural and non-structural causes should be investigated in consultation with a gynecologist. Noninvasive diagnostic approaches such as watchful waiting for induction of amenorrhea 6 months after initiation of testosterone, observing for a withdrawal bleed after a progestin challenge, or use of a transabdominal approach to ultrasonography should all be considered. Persistent menses despite testosterone may also be related to body habitus; those with higher June 17, 2016 64 Guidelines for the Primary and Gender-Affirming Care of Transgender and Gender Nonbinary People levels of body adipose tissue have higher endogenous estrogen levels and increased conversion of testosterone to estradiol through the peripheral aromatization process. For example, one study of transgender men presenting for initiation of crosssex hormones found that 84% of those completing the study were amenorrheic at 6 months. This was despite many only 58% achieving physiologic male total testosterone levels and 68% achieving physiologic male free testosterone levels. Endometrial ablation can be considered [31] for those transgender men who do not desire future fertility and who also either decline hysterectomy or have surgical complications. Weight loss plays a critical role in all cases for health promotion as well as resulting in amenorrhea through reduction of adipose containing aromatase. When treating the pain is not enough: a multidisciplinary approach for chronic pelvic pain. Pathogenesis, consequences, and control of peritoneal adhesions in gynecologic surgery: a committee opinion. Sex and gender diversity among transgender persons in Ontario, Canada: results from a respondent-driven sampling survey. Histological changes in the genital tract in transsexual women following androgen therapy. Hysterectomy and oophorectomy experiences of femaleto-male transgender individuals. June 17, 2016 67 Guidelines for the Primary and Gender-Affirming Care of Transgender and Gender Nonbinary People 25. Effects of three different testosterone formulations in female-to-male transsexual persons. Sexual health of trans men who are gay, bisexual, or who have sex with men: results from Ontario, Canada. Use of aromatase inhibitors to treat endometriosis-related pain symptoms: a systematic review. Nonbinary gender terms evolve and change rapidly; spelling and hyphenation vary widely. As with all transgender people, identifying and using the chosen name and pronoun are central to appropriate patient care. On occasion, masculine spectrum clients might choose continuous combined oral contraceptives for cessation of menses as well as for contraception. Surgical options for cessation of menses may include uterine ablation or hysterectomy. It is important to remember to address reproductive and fertility considerations as part of informed consent for medical and surgical approaches, discussed in greater detail in other sections of this protocol. A feminine spectrum nonbinary person may choose to have vaginoplasty but not desire breast development and not pursue hormonal transition; in these cases hormone replacement will be necessary after gonadectomy to maintain bone health, and surgery should only be pursued after an appropriate evaluation by an experienced and qualified mental health provider. Other considerations: Challenges for the gender nonbinary person include the lack of nonbinary gender markers for documentation in medical records and in legal identification, such as passports and drivers licenses. A more substantial discussion of gender nonbinary experiences can be found in blogs and websites. June 17, 2016 71 Guidelines for the Primary and Gender-Affirming Care of Transgender and Gender Nonbinary People 11. A 2010 Cochrane analysis found no interaction between menopausal hormone therapy and all-cause mortality, cardiovascularrelated mortality, non-fatal myocardial infarction or angina, or the need for bypass surgery or coronary angioplasty. Larger studies have been retrospective and did not adjust for numerous coexisting risk factors. Any analysis of the possible negative effects of hormone therapy on cardiovascular disease and stroke should take into consideration the significant benefits of hormone therapy on quality of life and psychosocial functioning. Some studies have found increased morbidity and mortality from myocardial infarction and stroke compared with nontransgender men, however these studies did not adjust for a number of risk factors including tobacco use, obesity, and diabetes. Currently there is no guidance on whether to use risk calculators based on natal sex or affirmed gender.
An Evaulation of the Effectiveness of Targeted Social Marketing To Promote Adolescents and Young Adult Reproductive Health in Cameroon erectile dysfunction treatment supplements order 160mg kamagra super visa. Empowering married young women and improving their sexual and reproductive health:Effects of the First-time Parents Project erectile dysfunction education purchase 160 mg kamagra super overnight delivery. Undie effective erectile dysfunction drugs cheap kamagra super 160 mg on-line, Chi- Chi erectile dysfunction doctor type buy cheap kamagra super 160mg, Birungi, Harriet, Obare, Francis, Ochieng, Ben, Liambila, Wilson, Oweya, Erick, & Askew, Ian. Exposure to media content and sexual health behaviour among adolescents in Lagos metropolis, Nigeria. In building the search, we combined a list of terms that describe young people with a list of terms that describe the number of children during young adulthood including parity, and repeat pregnancy. This initial search produced 1,595 hits about limiting the number of children, which were stored using EndNote reference manager software. This title screening reduced the original list of 1,592 hits down to 32 articles that seemed relevant. Of the 32, 6 published articles included interventions to decrease the number of children during young adulthood, and were included for abstraction. Results We abstracted 11 articles that related to interventions designed to prevent repeat pregnancies and births (5 grey literature and 6 published peer-reviewed articles). The articles contained interventions that focused primarily in Asia (n=7), Latin America (n=3) and just one from Africa. Intervention Characteristics the articles represented a relatively even mix between rural interventions (n=4), urban interventions (n=3), or both rural and urban (n=3). The majority of interventions were community based (n=7) and the remaining (n=4) were based in facilities-clinics or hospitals. Some interventions targeted preventing repeat pregnancies and/or abortions (n=2), most considered contraceptive uptake or use following a birth or abortion (n= 5), contraceptive uptake for those with a child (n=2) and contraceptive uptake in couples (n=2). Interventions that scores in the low range (n=2) failed to explain how intervention was better than the standard of care or provided very limited detail on the intervention. A majority of the interventions fell in the moderate quality group (n=5), based on receiving a score of 3. The limitations of these interventions included potential contamination in the control group, poor monitoring of the intervention implementation, and too many components to sort out "effective". Interventions receiving a score of 4 (n=3) had significant positive aspects that outweighed the limitations. Among noted positive aspects were community engagement in the intervention design, thorough training of providers, and a good control group. Limitations included not accounting for or describing existing services in the intervention area, being resource intensive, and sorting out the impact of multicomponent interventions. This intervention had no major deficiencies and benefitted from being rigorously designed. Most of the evaluations were a pre/post design (n=6), three were post-only, and the remaining (n=2) were evaluations that included pre, mid and post. Nearly all quantitative evaluations included some sort of survey data, and were analyzed with a range of techniques from simple percentages (with and without significance testing) (n=7), multivariable regression analysis (n=3) and other more advanced techniques including difference in- difference models (n=1). The lowest scoring evaluations (n=5) had few to no strengths, and serious flaws including poorly done statistical analyses, no clear measure of exposure to the intervention, and serious limitations with the control group. Two of the evaluations scored in the moderate range (score=3), based on have some strengths but significant limitations. Two scored in the high quality group, with strengths including strong design (prospect cohort data), large sample size, and multiple data points. Weaknesses included lack of sufficient detail and concerns about blinding of the interviews to the assignment of participants. These studies had strong evaluation designs that were able that followed the same individuals over time and used rigorous statistical methods. Overall Assessment the majority of the studies (n=8) found a positive impact of the intervention on some component of preventing repeat pregnancies including uptake of contraception, and avoiding repeat pregnancies. A final group of interventions had no results reported on avoiding having multiple children during adolescence from which to draw conclusions (n=1). Among the studies with positive results, only two had interventions and evaluations that scored a four or above on both the quality of the intervention and the quality of the evaluation. Below we describe the intervention, evaluation and results from these two studies that represent high quality interventions and evaluations and had a positive impact on limiting the number of children. Table 4 summarizes the high scoring interventions with a positive impact on limiting the number of children.
This should occur during the vaccine development and allocation decision-making processes erectile dysfunction late 20s purchase 160mg kamagra super amex, so that stakeholders are assured that the vaccines are safe and know that decision makers are responsive to their concerns erectile dysfunction doctor manila buy cheap kamagra super 160mg on-line. After a vaccine is available there should be ongoing erectile dysfunction pills supplements order kamagra super 160mg amex, transparent how to cure erectile dysfunction at young age discount kamagra super 160mg overnight delivery, active monitoring for vaccine safety so that people can base their level of confidence on actual data. Appropriate expectations also must be communicated so that people know what to expect with regards to safety. First, if we are to respectfully resolve moral disagreements, it is important that the ethical reasoning involved is transparent to those affected. Given the stakes, people are entitled to know how and why allocation decisions were made. Second, transparency at each stage in the decision-making process will ideally prevent or mitigate distrust of government. Culturally Competent Policy A third consideration for the process by which a vaccine allocation strategy is developed is the coexistence of different cultural beliefs in a pluralistic form. When their input is elicited in connection with limited vaccine doses, communities that come from different cultural traditions can offer unanticipated insights that expand, or possibly contract, the ethical terms that govern vaccine allocation. Moreover, by facilitating feedback from communities on allocation strategies, vaccination planners can learn what communities ultimately value, and when they share the rationale for an allocation policy, they can communicate why vaccines were allocated the way they were with genuine empathy, and in terms that are clear to and relevant for those communities. Also, by learning any cultural or social beliefs that are prevalent in a community, decision makers can also communicate in culturally meaningful ways about why an allocation framework is necessary and important in the first place. On the receiving end of vaccination efforts, the broader community can help innovate the vaccination program and identify circumstances that would prevent them from accessing vaccines as members of specific target groups. Combining and Balancing Ethical Values and Principles in an Allocation Plan Once the relevant ethical values and principles are identified, an allocation plan should combine and balance them in some way. In other cases, there may be trade-offs between ethical values and principles, and hard choices will have to be made. Adapting to Changing Conditions and Evolving Evidence Changing conditions, therefore, could lead to changing priorities. For example, an aim of preventing the most illness could be justified initially and for a mild pandemic. In the event of a severe pandemic, however, maintaining social order was considered increasingly important. In that case, priority populations for vaccine access would change as the aims for the vaccination program changed, and those aims would change mostly in response to the perceived severity of the outbreak. Changing conditions and evolving evidence should also be taken into account when determining which groups should be prioritized. For example, if the elderly are first identified as a priority group because of their higher risk of severe illness, but evidence emerges that the elderly do not mount a strong immune response to the vaccines that are available for us, it may be appropriate to remove them as a priority group for vaccine and find other ways of providing them with protection. Two preventative options might be stepping up efforts to reduce obstacles to and harms and burdens of sheltering for the elderly and vaccinating younger family members to enable them to provide assistance to and social connection for older relatives. Ideally, a vaccine allocation plan would be developed and assessed as part of an overall pandemic response plan. Whether a group should be prioritized for vaccination should depend in part on whether there are other means of protecting them. For example, can some groups of essential workers be adequately protected from workplace transmission by modifications to the workplace and provision of effective personal protective equipment, and can policies incentivize providing these protections? Any good allocation scheme should incorporate, as a core feature, the ability to manage the high level of uncertainty about the vaccines that will be developed and about public willingness to get vaccinated. A good allocation plan should be adaptable to changing conditions and evolving evidence and engineered to quickly adapt to lessons learned as we gain knowledge and experience. In conjunction, we need a robust and nimble communications effort for letting the public know about the plan and how allocation decisions were made. Linking Ethical Values and Principles with Policy Goals and Objectives Table 1 summarizes the ethical values and principles discussed, as well as the policy goals that follow these principles. There are 3 broad ethical values: promote the common good; treat people fairly and promote equity; promote legitimacy, trust, and sense of ownership in a pluralistic society. For example, the goal "Enable children to return to school and childcare settings" supports the objective "Provide vaccination to enable safer and more rapid return to in-building school and childcare. For example, prioritizing "Teachers and other school workers" would advance the objective of "Provide vaccination to enable safer and more rapid return to in-building school and childcare. These tables provide, in essence, a menu of options that policymakers, stakeholders, and the public can reference and choose from when they are deliberating about vaccine allocation. Based on these tables, our team identified candidate priority groups for vaccine allocation.
Modality of screening Screening mammography is the primary recommended modality for breast cancer screening in transgender women erectile dysfunction 18-25 discount 160 mg kamagra super otc. June 17 erectile dysfunction 42 quality 160mg kamagra super, 2016 105 Guidelines for the Primary and Gender-Affirming Care of Transgender and Gender Nonbinary People Special considerations As with non-transgender women does erectile dysfunction get worse with age effective 160mg kamagra super, clinicians may choose to reduce the age of onset of screening zantac causes erectile dysfunction cheap 160mg kamagra super free shipping, number of years of feminizing hormone exposure, or frequency of screening in patients with significant family risk factors. Canadian Task Force on Preventative Care: Screening for Breast Cancer (2011) [Internet]. American Cancer Society recommendations for early breast cancer detection in women without breast symptoms [Internet]. Adherence to mammography screening guidelines among transgender persons and sexual minority women. June 17, 2016 107 Guidelines for the Primary and Gender-Affirming Care of Transgender and Gender Nonbinary People 22. If a prostate exam is indicated, both rectal and neovaginal approaches may be considered. Transgender women who have undergone vaginoplasty have a prostate anterior to the vaginal wall, and a digital neovaginal exam examination may be more effective. June 17, 2016 108 Guidelines for the Primary and Gender-Affirming Care of Transgender and Gender Nonbinary People 2. Metastatic prostate cancer in transsexual diagnosed after three decades of estrogen therapy. The interpretation of serum prostate specific antigen in men receiving 5alpha-reductase inhibitors: a review and clinical recommendations. Inadequate screening for cervical cancer is linked to the barriers transgender individuals face in accessing culturally sensitive health care. In addition, the requisition should indicate any testosterone use as well June 17, 2016 111 Guidelines for the Primary and Gender-Affirming Care of Transgender and Gender Nonbinary People as the presence of amenorrhea, to allow the pathologist can accurately interpret cell morphology. A painful pap smear experience is correlated with nonadherence to future screening and colposcopy. A pediatric speculum may allow visualization of the cervix and can reduce discomfort with the exam; however it is important to avoid using a speculum so short that it requires excessive external pressure to visualize the cervix. If the examiner notes tension or anxiety, taking time to go through a verbal relaxation exercise can be helpful. American Cancer Society, American Society for Colposcopy and Cervical Pathology, and American Society for Clinical Pathology screening guidelines for the prevention and early detection of cervical cancer. Female-to-male patients have high prevalence of unsatisfactory Paps compared to non-transgender females: implications for cervical cancer screening. Comparison of self-collected vaginal, vulvar and urine samples with physician-collected cervical samples for human papillomavirus testing to detect high-grade squamous intraepithelial lesions. June 17, 2016 114 Guidelines for the Primary and Gender-Affirming Care of Transgender and Gender Nonbinary People 25. Despite this theoretical risk, only one case report of an endometrioid adenocarcinoma exists in the literature. This recommendation may also be unrealistic since transgender men report avoiding gynecologic care due to lack of cultural competency among providers. Hysterectomy for primary prevention of endometrial cancer is not currently recommended (Grading: X C M); consideration of hysterectomy for the purpose of eliminating the need for cervical cancer screening may be discussed on a case-by-case basis, in recognition of the role of hysterectomy in reducing gender dysphoria, and in consideration of surgical risks and irreversible infertility. Ovarian cancer While there have been several case reports of ovarian cancer among transgender men,[5,6] there is no evidence to suggest that trans men on testosterone are at increased risk. While a unilateral or bilateral oopherectomy may be performed in transgender men as part of the management of gender dysphoria or for a pathologic process, routine oopherectomy in for primary prevention of ovarian cancer is not recommended. Gynecologic malignancies in female-to-male transgender patients: the need of original gender surveillance. Ovarian cancer associated with testosterone supplementation in a female-to-male transsexual patient. Review of studies of androgen treatment of female-to-male transsexuals: effects and risks of administration of androgens to females. June 17, 2016 116 Guidelines for the Primary and Gender-Affirming Care of Transgender and Gender Nonbinary People 8.