Female-to-male transgender patient with idiopathic intracranial hypertention

Idiopathic Intracranial Hypertension in Female-to-Male Transgender Patients on Exogenous Testosterone Therapy

PURPOSE

To present four female-to-male (FTM) transgender patients on testosterone therapy diagnosed with idiopathic intracranial hypertension (IIH).

METHODS

The authors report 4 consecutive FTM transgender patients on exogenous testosterone diagnosed with IIH at a single institution.

RESULTS

Patient 1 presented with progressive blurred vision and a central scotoma 10 weeks after starting testosterone cypionate injections for hormonal gender transition. Bilateral grade 5 papilledema was present; the patient underwent bilateral optic nerve sheath fenestration with improved vision and resolution of edema. Patient 2 presented with transient vision loss, pulsatile tinnitus, and blurred vision 13 months after starting testosterone cypionate injections. The patient had grade 4 and 3 disc edema of the right and left eyes, respectively. Patient 3 presented with headaches and pulsatile tinnitus and was on testosterone injections at an unknown dose. The examination revealed grade 1 and 2 disc edema of the right and left eyes, respectively. Patient 4 presented with decreased vision, transient visual obscurations, and daily migraines while using topical testosterone gel every other day. Color vision was reduced, and lumbar puncture revealed elevated intracranial pressure. All patients had neuroimaging findings consistent with increased intracranial pressure.

CONCLUSIONS

Testosterone therapy plays an essential role in FTM hormonal transitioning and may play a role in IIH. Patients undergoing testosterone therapy for gender transition should be informed of the possibility of developing IIH while on treatment, with obesity possibly increasing this risk. Comprehensive eye examinations should be considered in these patients before initiating hormone therapy.

Intracranial Hypertension Associated With Testosterone Therapy In Female-To-Male Transgender Patients: A Case Report And Literature Review

We highlight a case of intracranial hypertension secondary to exogenous testosterone in a female-to-male transgender patient and present a systematic review of similar cases. Our review identified 19 female-to-male transgender individuals with intracranial hypertension. The mean age was 24.2 years and most common presenting symptom was headache (78.9% of patients). The most frequently associated ocular symptoms were transient visual obscurations (42.1%) and blurred vision (21.1%). Onset of symptoms occurred concurrently with exogenous testosterone therapy in 89.5% of the patients. The most common treatments were acetazolamide (89.5%), topiramate (31.6%), and alteration in hormone regimen (21.1%); four cases required surgery. These findings aid clinicians treating intracranial hypertension in patients undergoing gender affirmation therapy in a conscientious, patient-centered manner.

[Idiopathic intracranial hypertension: From physiopathological mechanisms to therapeutic decision]

Clinical features include visual disturbances, headaches, and pulsatile tinnitus that can be associated with reduced quality of life, and a risk of irreversible visual impairment in some cases. Obese women of childbearing age represent the main at-risk population, and the incidence of the disease is increasing because of rising prevalence of obesity worldwide. In addition, an imbalance in sex hormones is reported as a contributing risk factor. The pathophysiology of idiopathic intracranial hypertension involves a disturbance of the evacuation pathway of intracranial fluids caused by the increase in intracranial venous pressure. Brain imaging is useful for diagnosis with several signs including bilateral stenosis of the transverse sinuses that plays a major role in the pathogenesis of the disease by creating a positive feedback loop that increases intracranial venous hypertension and contributes to clinical manifestations. Treatment aims to relieve symptoms and prevent permanent visual impairment. Drug therapies including acetazolamide and topiramate have moderate effectiveness. Among invasive treatments, transverse sinus stenting seems to be the most interesting option to consider in drug-resistant patients. Weight loss remains essential to achieve a sustainable improvement by reducing central venous pressure. Future randomized trials are expected to reach a consensus on this treatment.