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For the 300,000 youth in the US who identify as transgender or non-binary, medications that suppress endogenous puberty ("puberty blockers") prevent irreversible, undesired physical changes and allow time to explore gender identity. The histrelin subdermal implant is FDA-approved for treatment of precocious puberty for 1 year. These implants are used off-label in transgender youth, and the effective duration of treatment has not been studied. We sought to evaluate the duration and effectiveness of histrelin implants for puberty suppression among transgender youth at our institution. Retrospective review of all transgender patients who received histrelin implants for puberty suppression at an academic pediatric hospital from 2013 to 2022. Data collected included demographics, duration of implant, bone age X-ray, serum gonadotropins, initiation of gender-affirming hormonal treatment (GAHT). The effectiveness of histrelin was deemed "concluded" upon initiation of GAHT to avoid confounding effects. T-tests and Pearson correlation coefficients were performed using MS Excel. IRB approval was obtained through the institution of study. Charts of 48 patients were reviewed. Twenty patients were assigned female at birth (AFAB); 28 patients were assigned male at birth (AMAB). Mean age at histrelin insertion was 11.8 years (range 9.4 – 13.9). Five patients received a second implant, and one received a third prior to initiation of GAHT. Mean duration of the implant was 641 days (range 264-1310, standard deviation of 251). Duration of the implant was not statistically different among AMAB and AFAB patients (p = 0.07). The Pearson correlation coefficient for the age at initiation of implant compared to the duration of implant was -0.38 with a p-value of 0.003, indicating a statistically significant, moderately strong correlation: younger patients correlated with longer duration of implant use. All patients had FSH values < 2 +/-1 mIU/mL following implant insertion, indicating suppression. Clinical documentation also indicated that the degree of puberty suppression after the first year of implant use was satisfactory to patients and families. This review demonstrates that the histrelin implant provides effective puberty suppression for transgender youth, with a mean duration of effectiveness of 641 days. Although prospective studies are necessary, our data suggests that histrelin implants may be exchanged less frequently than the FDA-approved 1-year mark, providing convenience to patients and reducing costs. Given the barriers to healthcare access faced by many transgender youth, the use of puberty blockers with a longer effective duration may be a highly favorable option. [ABSTRACT FROM AUTHOR]

Granulosa cell tumors are rare, accounting for approximately 1-2% of all ovarian tumors across age groups and 10-20% of ovarian tumors in the pediatric population. Both juvenile- and adult-type granulosa cell tumors typically induce a hyperestrogenic state that may present as precocious puberty in the prepubertal female or as abnormal uterine bleeding in the postpubertal female. These tumors also often secrete elevated levels of inhibin B, which can be used to aid in diagnosis and in following clinical response to treatment. Here, we report an unusual presentation of adult-type granulosa cell tumor in a 14-year-old female with hyperandrogenism and a mild but persistent elevation in alpha-fetoprotein (AFP). The objective is to review an atypical presentation of a granulosa cell tumor in an adolescent. A 14-year-old Caucasian female with a history of obesity, clinical hyperandrogenism, and secondary amenorrhea, presented with severe abdominal pain. She was found to have a 16 × 13 × 8 cm right ovarian mass that was largely cystic but had subtle nodularity on imaging. Laboratory evaluation (Table 1) revealed a mild elevation of AFP (16 ng/mL) and marked elevations in free and total testosterone (33.6 pg/mL and 102.4 ng/dL, respectively). Inhibin B and estradiol levels were normal (61 pg/mL and 29.9 pg/mL, respectively). After multidisciplinary review by pediatric subspecialists including Gynecology, Oncology, Surgery and Radiology, as well as with shared decision making with the family, the patient underwent a diagnostic laparoscopy and exploratory laparotomy with right adnexal detorsion and right oophorectomy. Pelvic washings were negative for malignancy, and pathology evaluation of the ovary revealed an adult-type granulosa cell tumor. Review of intraoperative findings, pathology, and imaging resulted in a diagnosis of FIGO stage IA disease. Based on the diagnosis and disease stage, surveillance imaging alone is planned. Despite negative classic tumor markers, the index of suspicion for malignancy should be high for any large ovarian mass >10 cm, even in an adolescent. Granulosa cells tumors often result in elevated estrogen levels; however, this case demonstrates that elevated androgen levels should not eliminate concern for a granulosa cell tumor. Similarly, tumor markers can be used to aid in diagnosis but should not be used to rule out malignancy, which can only be definitively diagnosed with histopathologic examination. These factors should be taken into account when planning surgical intervention. Supporting Figures or Tables https://www.abstractscorecard.com/uploads/Tasks/upload/19245/RGXGDRUQ-1377107-1-ANY.docx ▪ [ABSTRACT FROM AUTHOR]