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ABSTRACT: To describe the experience of hormone treatment of gender identity disorder (GID) in children and adolescents within a specialist clinic.
Cohort study by medical record review of children aged 0-17 years referred during 2003-2011 for management at the GID clinic in a tertiary paediatric referral centre - the Royal Children's Hospital, Melbourne, Victoria.
Clinical characteristics of the patient population, hormone treatment provided, frequency of referrals with time.
Thirty-nine children and adolescents were referred for gender dysphoria. Seventeen individuals were pubertal with persistent GID, and were considered eligible for hormone treatment. Seven patients, comprising three biological males and four biological females, had legally endorsed hormone treatment. In this group, gender dysphoria was first noted at 3-6 years of age. Hormone treatment with GnRH analogue to suppress pubertal progression (phase 1) was given at 10-16 years of age. Treatment with cross-sex hormones (phase 2) was given at 15.6-16 years. One patient purchased cross-sex hormone treatment overseas. One patient received oestrogen and progesterone for menstrual suppression before phase 1. The annual frequency of new referrals increased continuously over the study period.
Hormone treatment for pubertal suppression and subsequent gender transition needs to be individualised within stringent protocols in multidisciplinary specialist units.
The Medical journal of Australia 05/2012; 196(9):578-81. · 2.81 Impact Factor
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ABSTRACT: Knowledge regarding the natural history of human papillomavirus (HPV) infection and its clinical sequelae in adolescents has increased significantly over the last decade; as a result, there have been world-wide recommendations for less aggressive Pap screening and management of cervical dysplasias in young women. It is important that adolescent health providers understand these issues, as knowledge of HPV and its sequelae in the Australian community is limited, despite the introduction of a national immunisation programme. Parents and young women have expressed a desire for further information to make informed choices. This paper reviews the natural history of HPV infection in adolescents and the evidence behind new conservative guidelines for cervical screening, plus prophylactic vaccination in young women.
Journal of Paediatrics and Child Health 09/2011; · 1.28 Impact Factor
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Sonia R Grover
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ABSTRACT: Menstruation and contraception is a concern for families who have a daughter with a significant disability, either physical or developmental. Accessing information regarding options may be difficult. Maternal experiences of menses further impact on the anxiety. The onset of menses is a reminder that their daughter is at risk of sexual abuse and pregnancy. It may highlight the fact that they are at their limits of coping - without the addition of yet another problem, of managing menses. Parental and carer concern is about the practicalities of how the adolescent will manage menstruation - both the hygiene aspects of menses and also the potential pain. Additionally, information is required about the possible need for contraception and the role and importance of reproductive hormones for preventing cardiac disease and osteoporosis. Recognition that a number of other medical problems may be related to reproductive hormones - such as cyclic seizure, behavioural difficulties and osteoporosis - is important as this gives an alternative avenue for intervention. The focus of this paper will be on the gynaecological aspects of young women with significant disabilities, rather than those with mild disabilities.
Journal of Paediatrics and Child Health 09/2011; 47(9):610-3. · 1.28 Impact Factor
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ABSTRACT: The aim of this study was to review a consecutive cohort of adolescent females on warfarin to determine the effect of warfarin on menstruation, management options and their perceived efficacy.
All female patients on warfarin, over the age of 10 years, as of 31 August 2006, were identified using the Department of Haematology (Royal Children's Hospital) warfarin database. The presence of menorrhagia was defined by clinical indicators.
Of 81 adolescent females on warfarin, 24 (30%) were referred to gynaecology due to a concern about heavy periods and one for anticipatory guidance, on the basis of impending menarche. In 18 cases (22% of the cohort), menorrhagia could be substantiated on the basis of clinical indicators. Nineteen patients required treatment for menorrhagia with the options for treatment being the combined oral contraceptive pill, subdermal hormone administrations, tranexamic acid and the progesterone-only contraceptive pill. Significant adolescent psychosocial stresses were identified in those adolescents taking warfarin.
Adolescent females on warfarin commonly suffer from menorrhagia. Adolescent review of all teenage girls receiving warfarin therapy is indicated.
Journal of Paediatrics and Child Health 06/2011; 47(12):893-7. · 1.28 Impact Factor
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ABSTRACT: To assess long-term quality of life and sexual satisfaction outcomes of women treated for vaginal agenesis.
An audit project using questionnaires to assess quality of life (World Health Organization Quality of Life Bref [WHOQoL-Bref]) and sexual satisfaction (Golombok Rust Inventory of Sexual Satisfaction [GRISS]).
Gynecology Department of Royal Children's Hospital.
Women with vaginal agenesis.
Medical data were extracted from notes. Women were contacted at their review consultation or were offered the opportunity for review and participation in the audit.
WHOQoL-Bref and GRISS were measured. Correlation with medical details and treatment method was undertaken.
Age range was 16-71 years (median, 23 years). WHOQoL-Bref (n=28) scores (mean±SD, 4.2±0.8), were similar to the mean Australian population score. The GRISS questionnaire (n=20) revealed that 75% of women had overall satisfactory scores. WHOQoL scores had a high correlation with GRISS scores. Time since diagnosis correlated to GRISS scores with 12 of 13 diagnosed>5 years earlier having satisfactory results. Women without a hymen had more problems with vaginismus.
General outcomes are good for these women, although vaginismus was an issue. There was a correlation between lower health satisfaction scores, feeling less feminine and feeling down, but not GRISS.
Fertility and sterility 01/2011; 95(1):238-41. · 3.97 Impact Factor
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Craig Munns,
Margaret R Zacharin,
Christine P Rodda,
Jennifer A Batch,
Ruth Morley,
Noel E Cranswick,
Maria E Craig,
Wayne S Cutfield,
Paul L Hofman,
Barry J Taylor, Sonia R Grover,
Julie A Pasco,
David Burgner,
Christopher T Cowell
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ABSTRACT: Vitamin D deficiency has re-emerged as a significant paediatric health issue, with complications including hypocalcaemic seizures, rickets, limb pain and fracture. A major risk factor for infants is maternal vitamin D deficiency. For older infants and children, risk factors include dark skin colour, cultural practices, prolonged breastfeeding, restricted sun exposure and certain medical conditions. To prevent vitamin D deficiency in infants, pregnant women, especially those who are dark-skinned or veiled, should be screened and treated for vitamin D deficiency, and breastfed infants of dark-skinned or veiled women should be supplemented with vitamin D for the first 12 months of life. Regular sunlight exposure can prevent vitamin D deficiency, but the safe exposure time for children is unknown. To prevent vitamin D deficiency, at-risk children should receive 400 IU vitamin D daily; if compliance is poor, an annual dose of 150,000 IU may be considered. Treatment of vitamin D deficiency involves giving ergocalciferol or cholecalciferol for 3 months (1000 IU/day if < 1 month of age; 3000 IU/day if 1-12 months of age; 5000 IU/day if > 12 months of age). High-dose bolus therapy (300,000-500,000 IU) should be considered for children over 12 months of age if compliance or absorption issues are suspected.
The Medical journal of Australia 09/2006; 185(5):268-72. · 2.81 Impact Factor
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ABSTRACT: To assess obstetricians' antenatal screening practice for blood-borne viruses (HIV, hepatitis B and C viruses [HBV and HCV]) and knowledge about management during labour and risk of transmission via breastfeeding for infected women after an educational intervention, Australia.
Cohort study, with surveys before and after an educational intervention.
Survey 1 was mailed in 2002-2003 to all 767 Fellows registered with the Royal Australian and New Zealand College of Obstetricians and Gynaecologists (RANZCOG), and Survey 2 was mailed in 2004 to the 743 of these Fellows who were still practising.
Multifaceted intervention with mail-out of survey results and a summary of recommended management, publication of two review articles in the RANZCOG journal, and an oral presentation at the RANZCOG annual scientific meeting.
Self-reported frequency of antenatal screening for blood-borne viruses, change in practice based on a woman's infection status, and advice given about risk of virus transmission via breastfeeding in Survey 2, compared with Survey 1.
Survey 2 (response rate, 68%) found increases from the previous survey in the proportion of respondents reporting they always offered antenatal screening for HIV, from 51% to 59%, and for HCV, from 60% to 69% (P = 0.001 for both). For women with HIV infection, the proportion of respondents always recommending elective caesarean section increased from 37% to 49% (P = 0.001) and always avoiding rupture of membranes increased from 33% to 49% (P < 0.001). The proportion who reported advising (incorrectly) that breastfeeding is associated with increased risk of transmission to the infant decreased from 34% to 25% for HBV (P = 0.01) and from 47% to 39% for HCV (P = 0.03).
The frequency of antenatal testing for HIV and HCV is increasing in Australia. Knowledge about interventions to reduce mother-to-child transmission of HIV and knowledge of the risk of HBV and HCV transmission via breastfeeding improved after a relatively simple educational intervention.
The Medical journal of Australia 05/2006; 184(8):389-92. · 2.81 Impact Factor
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ABSTRACT: Reports on anatomic and cosmetic outcomes after genital surgery for children with ambiguous genitalia are mixed, with recent reports using standardized assessments suggesting poor outcomes and that multiple operations may be required.
All children with ambiguous genitalia and who had feminizing surgery at the Royal Children's Hospital in Melbourne, Australia, were identified. Standardized genital assessment was undertaken at their clinical review after informed consent. Underlying diagnosis, number and type of procedures performed, and the expertise of the surgeon were recorded from their medical notes.
Of 32 patients examined aged 13 to 33 years, 47% had congenital adrenal hyperplasia. Ten patients had initial surgery performed elsewhere. Overall, there were good anatomic and cosmetic outcomes for those initially treated at our institute by a specialized surgeon, although some required additional intervention in adolescence or adulthood. Initial surgery before or after 2 years of age did not significantly affect outcomes. Those patients who had only 1 operation (by a surgeon with special interest in intersex) had better cosmetic and anatomic outcomes than those patients who had multiple operations.
Cosmetic and anatomic outcomes of surgery for ambiguous genitalia were generally good when undertaken by pediatric surgeons with specific expertise in intersex surgery.
Journal of Pediatric Surgery 01/2006; 40(12):1856-60. · 1.45 Impact Factor
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ABSTRACT: To determine the postnatal vitamin D status and bone health of women identified as vitamin D-deficient in pregnancy, and of their infants.
Retrospective audit conducted between 27 August and 5 November 2003. The study included women delivering between August and October 2002 at the Royal Women's Hospital, Melbourne, who had had a 25-hydroxyvitamin D (25-[OH]D) level < 30 nmol/L in pregnancy, and their infants at age 4-10 months.
The outpatient clinic at the Royal Children's Hospital, Melbourne.
Maternal and infant serum levels of vitamin D, total alkaline phosphatase (tALP), parathyroid hormone (PTH), calcium and phosphorus; x-ray results in children with clinical or laboratory findings suggestive of rickets.
Of 69 mother-infant pairs invited to participate, 47 (68%) attended. All 47 women had 25-(OH)D levels < 50 nmol/L, and 39 (83%) had levels < 30 nmol/L. Vitamin D supplements had been prescribed in pregnancy for 35 women (74%), and 19/35 reported having taken them as prescribed. None had continued to take supplements postnatally, but one had recently started taking them again. Among 45 infants from whom blood samples were successfully obtained, 18 (40%) had 25-(OH)D levels < 50 nmol/L, and 14 (31%) had levels < 30 nmol/L. Twelve of 16 breastfed infants had 25-(OH)D levels < 30 nmol/L, compared with 2/29 fed formula milk (P = 0.001).
Most mothers who had been vitamin D-deficient in pregnancy were also deficient postnatally, indicating that treatment offered, counselling and/or treatment compliance were inadequate. Their infants, especially if breastfed, were at high risk of vitamin D deficiency and increased bone formation. Breastfed infants of mothers at high risk of vitamin D deficiency should receive vitamin D supplements.
The Medical journal of Australia 12/2004; 181(9):486-8. · 2.81 Impact Factor
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ABSTRACT: It is estimated there are over 19 million women worldwide living with HIV infection. In Australia the total number of notified cases of HIV in women has been gradually increasing (the estimated number of women newly diagnosed with HIV infection was 78 in 2000 and 94 in 2001). Management of women in pregnancy and strategies to reduce perinatal transmission is critical, but differ significantly according to resource availability. The current review examines the best available scientific evidence and current guidelines for optimal management of HIV-infected women contemplating pregnancy in Australia.
Australian and New Zealand Journal of Obstetrics and Gynaecology 07/2004; 44(3):197-204. · 1.24 Impact Factor
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ABSTRACT: To assess obstetricians' current antenatal screening practices for blood-borne viruses (hepatitis B, hepatitis C and HIV) and how they manage pregnant women infected with a blood-borne virus.
National cross-sectional survey conducted between September 2002 and January 2003. All obstetricians (n = 767) registered with the Royal Australian and New Zealand College of Obstetricians and Gynaecologists (RANZCOG) were mailed a questionnaire assessing their antenatal screening practices and knowledge of management of women potentially infected with a blood-borne virus.
Concordance of clinical practice with RANZCOG recommendations and current evidence-based guidelines.
523 obstetricians (68% response rate) completed the questionnaire. Fifty-one per cent of respondents said they would always offer HIV screening and 60% would always offer HCV screening. For HIV-infected women, 36% of obstetricians would always recommend elective caesarean section and 33% would always avoid rupture of membranes. Despite a lack of evidence, 34% of obstetricians advise patients that the risk of HBV transmission is increased with breastfeeding, and 47% give the same advice about HCV transmission.
There is some discordance between the RANZCOG antenatal screening recommendations for HCV and HIV and current practice. Knowledge about the management of HIV-infected women could be improved, and more obstetricians need to be aware that current evidence suggests there is no increased risk of transmission of HBV or HCV with breastfeeding.
The Medical journal of Australia 05/2004; 180(7):328-32. · 2.81 Impact Factor
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ABSTRACT: Healthy risk-taking is a normal part of adolescence. Young people who participate in multiple risk-taking increase the chance of damaging their health. There appears to be a growing range and prevalence of health-risk behaviours among young women, notably in their use of alcohol and marijuana. Research suggests that such health-risk behaviours may be related to psychological factors such as stress and depression. General practitioners have a central role in identifying and preventing health-risk behaviours and associated mental health problems in young people. Comprehensive assessment includes a series of screening questions about home, education (or employment), activities, drugs, sexuality and suicide for young people, known as the HEADSS technique.
The Medical journal of Australia 07/2003; 178(12):601-4. · 2.81 Impact Factor
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Sonia R Grover
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ABSTRACT: To review the clinical management of young women with intellectual disabilities with menstrual and contraceptive concerns.
Prospective cohort study of all girls and young women with a significant intellectual disability and moderate to high support needs who presented at my gynaecology clinic for management of menstrual and contraception-related issues in the period 1990-1999.
Gynaecology clinic at the Centre for Adolescent Health, Royal Children's Hospital, Melbourne, and my private consulting rooms.
The clinical management options considered most appropriate for these women, including advice, reassurance, medication (oral contraceptive pill, non-steroidal anti-inflammatory drugs, depomedroxyprogesterone acetate, hormone replacement therapy) and surgical options.
For 2 of 107 young women, surgical approaches were required to manage their menstrual problems or contraception-related issues. For the remainder of the women, information, advice or medical management were sufficient.
Management of the menstrual and contraceptive needs of young women with an intellectual disability is similar in most cases to the management of non-disabled women. Surgical management is required infrequently.
The Medical journal of Australia 03/2002; 176(3):108-10. · 2.81 Impact Factor
