Anti-Androgenic Effects Comparison Between Cyproterone Acetate and Spironolactone in Transgender Women: A Randomized Controlled Trial

Effects of gender affirming hormone treatment in transgender individuals - a retrospective cohort study

PURPOSE

Gender affirming hormone treatment (GAHT) results in measurable changes to anthropomorphic, biochemical and hormonal variables that are important to patients and their health care professionals to guide treatment. This study sought to quantify changes which occur in response to initiation of GAHT.

METHODS

We performed a retrospective cohort study of outcomes in transgender and gender diverse (TGD) patients starting GAHT. The primary outcome was proportion of patients and time required to achieve optimal hormone levels after commencement of GAHT. Additional analyses were performed to assess whether clinical and biochemical factors were associated with likelihood of achieving target hormone levels.

RESULTS

345 patients were included. Among 154 transmasculine individuals, 116 (75%) achieved a testosterone level >10 nmol/L during follow-up at a median of 4-months (IQR 4-9). No clinical or biochemical factors were significantly associated with likelihood of reaching therapeutic testosterone concentrations in transmen. Among 191 transfeminine individuals, 131 (72%) achieved a testosterone level <2.0 nmol/L during follow-up at a median of 4-months (IQR 3-9). Factors associated with increased likelihood of testosterone suppression were use of subdermal estradiol implants as well as cyproterone acetate as an androgen antagonist. Changes in differing directions were observed during repeated measures of lipids, liver function, and blood count between transmasculine and transfeminine individuals, reflecting the important effects of testosterone and estradiol on biochemical tests ordered as part of routine clinical care.

CONCLUSION

Most TGD patients achieve target testosterone levels within 9 months of GAHT initiation. Adverse effects of GAHT are rare, and are usually mild.

Priorities for efficacy trials of gender-affirming hormone therapy with estrogen: collaborative design and results of a community survey

PURPOSE

Treatment guidelines for gender-affirming hormone therapy with estrogen (GAHT-E) recommend specific dosing regimens based on limited data. Well-controlled efficacy trials are essential to tailoring treatment to patient goals as the guidelines recommend. The goal of this study was to take a foundational step toward designing community-centered effectiveness trials for gender-diverse individuals seeking GAHT-E.

METHODS

Our team developed a cross-sectional survey based on broad clinical experience and consultation with our community advisory board. The survey included 60 items covering demographics, transition history, goals and priorities for treatment, indicators of treatment success, sexual function goals, and future research priorities. The survey was distributed during the summer of 2021, primarily through social networks designed for gender-expansive individuals seeking treatment with estrogen.

RESULTS

A total of 1270 individuals completed the survey. Overall treatment goals most frequently rated "extremely important" or "very important" were the following: (1) improved satisfaction with life (81%), (2) appearing more feminine (80%), (3) appearing less masculine (77%), (4) improved mental health (76%), and (5) being seen as your true gender by others (75%). The three body characteristics most frequently rated "highest priority" or "high priority" among changes were the following: (1) facial hair (85%), (2) breast shape or size (84%), and (3) body shape (80%). The highest-rated research priority was comparing feminization with different routes of estrogen administration.

CONCLUSION

The goals and experiences of individuals seeking GAHT-E are diverse. Future clinical trials of GAHT-E should be grounded in the needs and priorities of community stakeholders.

Risk assessment of transgender people: implementation of a demasculinizing-feminizing rodent model including the evaluation of thyroid homeostasis

BACKGROUND

Individuals whose gender identity differs from the biological sex and the social norms are defined as transgender. Sometimes transgender undergo gender affirming hormone therapy, which lasts for the entire life making essential to evaluate its potential long-term effects. Moreover, transgender can represent a susceptible sub-group of population and specific attention is needed in risk assessment, including the development of targeted animal models. Aim of the study is the implementation of a rodent demasculinizing-feminizing model through the setting of appropriate dose of hormone therapy and the selection of specific biomarkers to evaluate the sex transition. Specific attention is paid to thyroid homeostasis due to the close link with reproductive functions. Four male adult rats/group were subcutaneously exposed to three doses plus control of β-estradiol valerate plus cyproterone acetate at: 0.045 + 0.2 (low), 0.09 + 0.2 (medium) and 0.18 + 0.2 (high) mg/dose, five times/week. The doses were selected considering the most recent recommendations for transgender woman. Sperm count, histopathological analysis (testis, liver, thyroid), testosterone, estradiol, triiodothyronine and thyroid-stimulating hormone serum levels and gene expression of sex dimorphic CYP450 were evaluated.

RESULTS

The doses induced feminizing-demasculinizing effects: decreased testosterone serum levels at the corresponding cisgender, increased estradiol, impairment of male reproductive function and reversal of sex-specific CYP liver expression. However, the medium and high doses induced marked liver toxicity and the low dose is considered the best choice, also for long-term studies in risk assessment. The alterations of thyroid indicated follicular cell hypertrophy supported by increased thyroid-stimulating hormone serum levels at the higher doses.

CONCLUSIONS

The implementation of animal models that mimic the effects of gender affirming hormone therapy is essential for supporting clinical studies in transgender people and filling data gap in order to ensure an appropriate risk assessment and a more accurate, personalized care for transgender people.

Insights Into the Cardiomodulatory Effects of Sex Hormones: Implications in Transgender Care

Transgender individuals that undergo gender-affirming hormone therapy may experience discrimination in the health care setting with a lack of access to medical personnel competent in transgender medicine. Recent evidence suggests that gender-affirming hormone therapy is associated with an increased risk of cardiovascular diseases and cardiovascular risk factors. A recent statement from the American Heart Association reinforces the importance of cardiovascular-focused clinical management and the necessity for more research into the impact of gender-affirming hormone therapy. With this in mind, this review will highlight the known cardiovascular risk factors associated with gender-affirming hormone therapy and identify potential molecular mechanisms determined from the limited animal studies that explore the role of cross-sex steroids on cardiovascular risk. The lack of data in this understudied population requires future clinical and basic research studies to inform and educate clinicians and their transgender patient population to promote precision medicine for their care to improve their quality of life.

Low-dose spironolactone combats dyslipidemia and hepatic inflammation by modulating PCSK9 in rat model of polycystic ovarian syndrome

Polycystic ovarian syndrome (PCOS) is the most common endocrine disorder among women and it is associated with overt metabolic derangement. Circulating lipids are regulated by proprotein convertase subtilisin/kexin type 9 (PCSK9) which blocks low density lipoprotein (LDL) receptors especially in the liver. The liver is highly vulnerable in dyslipidemia as lipid accumulation leads to progression of non-alcoholic fatty liver disease (NAFLD). An array of scientific endeavours hold that low-dose spironolactone (LDS) is beneficial as intervention for PCOS traits, but this claim is yet to be fully elucidated. The aim of this study was to investigate the effect of LDS on dyslipidemia and hepatic inflammation in rats with letrozole (LET)-induced PCOS and to assess the possible involvement of PCSK9 in these effects. Eighteen female Wistar rats were randomly assigned into 3 groups. The control group received vehicle (distilled water; p.o.), LET-treated group received letrozole (1 mg/kg; p.o.), LET+LDS-treated group received LET plus LDS (0.25 mg/kg, p.o.) for 21 days. Exposure to LET increased body and hepatic weights, plasma and hepatic total cholesterol (TC), TC/HDL, LDL, interleukin-6, MDA, PCSK9, ovarian degenerated follicles and hepatic NLRP3 intensity, reduced GSH and normal ovarian follicles. Interestingly, LDS averted dyslipidemia, NLRP3-dependent hepatic inflammation and ovarian PCOS traits. It is evident herein that LDS ameliorates PCOS traits and combats dyslipidemia and hepatic inflammation in PCOS by a PCSK9-dependent mechanism.

Sex Differences in Athletic Performance: Perspectives on Transgender Athletes

Sex hormone concentrations, particularly testosterone, are primary determinants of sex-based differences in athletic and sports performance, and this relationship may inform fair competition and participation for athletes. This article describes the sex-based dichotomy in testosterone and the implications for sex-based differences in individual sports performance, including factors that relate to athletic performance for transgender individuals, and areas of future investigation.

Incidence of hypertension in young transgender people after a 5-year follow-up: association with gender-affirming hormonal therapy

In order to assess the risk of hypertension development, we performed a retrospective analysis of the clinical records of consecutive transgender patients who began gender-affirming hormonal therapy in our Outpatient Gender Identity Clinic with <30 years of age and had a follow-up >5 years. 149 transgender women treated with estradiol and 153 transgender men treated with testosterone were included; 129 of the transgender women received also androgen blockers (54 spironolactone, 49 cyproterone acetate and 26 LHRH agonists). The annual incidence of hypertension in young transgender men (1.18%) seemed comparable to that of the general population. In young transgender women, it seemed higher (2.14%); we found that the choice of androgen blocker had a remarkable effect, with a highly significant increase in patients treated with cyproterone acetate (4.90%) vs. the rest (0.80%); the adjusted hazard-ratio was 0.227 (p = 0.001). Correlation, logistic regression and mediation analyses were performed for the associations of the available clinical variables with the increase in systolic blood pressure and the onset of hypertension, but besides the use of cyproterone acetate, only the ponderal gain was found significant (Spearman's r: 0.361, p < 0.001); with a 36.7% mediation effect (31.2-42.3%). Cyproterone acetate has additional known risks, such as meningioma; although we cannot conclusively prove that it has a role in the development of hypertension, we conclude that the use of cyproterone acetate for this indication should be reconsidered.

Effects of Hormones on Breast Development and Breast Cancer Risk in Transgender Women

Transgender women experience gender dysphoria due to a gender assignment at birth that is incongruent with their gender identity. Transgender people undergo different surgical procedures and receive sex steroids hormones to reduce psychological distress and to induce and maintain desired physical changes. These persons on feminizing hormones represent a unique population to study the hormonal effects on breast development, to evaluate the risk of breast cancer and perhaps to better understand the precise role played by different hormonal components. In MTF (male to female) patients, hormonal treatment usually consists of antiandrogens and estrogens. Exogenous hormones induce breast development with the formation of ducts and lobules and an increase in the deposition of fat. A search of the existing literature dedicated to hormone regimens for MTF patients, their impact on breast tissue (incidence and type of breast lesions) and breast cancer risk provided the available information for this review. The evaluation of breast cancer risk is currently complicated by the heterogeneity of administered treatments and a lack of long-term follow-up in the great majority of studies. Large studies with longer follow-up are required to better evaluate the breast cancer risk and to understand the precise mechanisms on breast development of each exogenous hormone.

A Review of Gender-Affirming Hormone Therapy for Transgender and Gender Diverse Adults in South Korea

Recently, gender-affirming hormone therapy for gender incongruence has become an issue in various countries and organizations with various guidelines. In South Korea, several clinical treatments are also used with many possible options. These treatments include masculinizing (female-to-male [FTM]) or feminizing (male-to-female [MTF]) hormone therapies, with regimens usually driven by standards of hormonal replacement therapy for hypogonadism (i.e., hypogonadal natal men and postmenopausal women). This cross-sex hormone therapy can change patients' physical appearance to better match their gender identity and expression. Regarding masculinizing therapy, injection and transdermal gel types of testosterone are used according to international guidelines. Progesterone is utilized in the form of oral pills, injections, or intrauterine devices to suppress menstruation and avoid pregnancy. Essentially, feminizing therapy uses androgen blockers along with estrogen. This is because estrogen alone cannot exert sufficient androgen-suppressing effects. In South Korea, the most commonly used androgen blockers are spironolactone and cyproterone acetate. Gonadotropin-releasing hormone (GnRH) agonist is also available. Regarding estrogen, oral pills, injections, and transdermal gels are utilized. This review introduces these gender-affirming hormone therapies in South Korea and discusses the side effects of each regimen.

Hormonothérapies de transition chez les personnes transgenres

Aujourd’hui encore, la prise en charge médicale des personnes transgenres pâtit d’une insuffisance d’offre de soins et de formation des soignants. La mise en œuvre d’une hormonothérapie est souvent souhaitée par les personnes transgenres et il est nécessaire qu’un médecin sache l’instaurer et la suivre tout au long de la transition. Nous abordons dans cette revue le traitement hormonal féminisant (THF) chez les femmes transgenres adultes, et le traitement hormonal masculinisant (THM) chez les hommes transgenres adultes.

Hormone Concentrations in Transgender Women Who Self-Prescribe Gender Affirming Hormone Therapy: A Retrospective Study

BACKGROUND

Self-prescribed gender-affirming hormone therapy (GAHT) is common practice among transgender women, especially in resource-limited countries, yet the effectiveness of each GAHT regimen to achieve female range sex hormone concentrations is not known.

AIM

To describe the use and sex hormone concentrations of various GAHT regimens among transgender women who self prescribe in Thailand.

METHODS

This was a retrospective study in a community-based setting. Five hundred and 27 records of transgender women taking GAHT who were receiving care at a community health center between January 1, 2018, and December 31, 2020 were included for the analysis.

MAIN OUTCOME MEASURES

Blood total testosterone and estradiol concentration after at least a 6-month period of GAHT.

RESULTS

Multiple GAHT regimens were identified including oral estradiol valerate (EV), transdermal 17β-estradiol gel, injectable EV with hydroxyprogesterone caproate, injectable estradiol benzoate with progesterone, oral EV with cyproterone acetate (CPA), and oral contraceptive pills (OCPs). The most common GAHT regimen used by 49.1% of the participants was OCPs that contained 0.035 mg of ethinyl estradiol and 2 mg of CPA. Only 25.2% of this group had female range testosterone concentrations (<50 ng/dL). Oral EV and CPA were used by 23.1% of the participants. Most of them used 12.5 mg of CPA and 47.7% of this group had female range testosterone concentrations. There was no statistical significance between mean testosterone concentrations in CPA 12.5 and 25 mg groups, (P = .086).

CLINICAL IMPLICATIONS

The inadequate sex hormone levels found in these commonly self-prescribed GAHT regimens provide information regarding the efficacy and safety of GAHT regimens for health care providers working with transgender women in a community-based setting.

STRENGTHS AND LIMITATIONS

This study reflected a real-world situation and provided hormonal profiles among transgender women taking self-prescribed GAHT. However, issues in recall, medical literacy, and adherence to the medication may limit the results.

CONCLUSION

Combined hormonal contraceptive pill was a commonly used GAHT regimen in Thai transgender women who self prescribe GAHT. However, this regimen was not effective to decrease testosterone concentrations to the recommended range of less than 50 ng/dL. Overall, self-prescription of GAHT does not appear to be effective in reaching target sex hormone concentrations. Including health care providers in the prescription and monitoring of GAHT may be a more effective approach in the delivery of GAHT. Salakphet T, Mattawanon N, Manojai N, et al. Hormone Concentrations in Transgender Women Who Self-Prescribe Gender Affirming Hormone Therapy: A Retrospective Study. J Sex Med 2022;19:864-871.

Gender affirming hormonal treatment in Danish transgender persons. A nationwide register-based study

BACKGROUND

Gender affirming hormonal treatment (GAHT) is a cornerstone in transgender care. National data are sparse regarding use of hormonal treatment by transgender persons.

AIM

To assess use of GAHT in transgender persons.

DESIGN

National register-based cohort study in Danish transgender persons followed from 2000 until 2018. The main outcome measure was prescription and purchase of GAHT. Persons with ICD-10 diagnosis code of "gender identity disorder" (CGI-cohort) and persons with legal sex change but without diagnosis (CPR-cohort) were included. In the CGI-cohort, transgender women were defined by prescription of estrogen and/or cyproterone acetate and/or testosterone-5-alpha reductase inhibitors and transgender men were defined by prescription of testosterone after study inclusion. Discontinuation of GAHT was defined as no purchase of GAHT ≥ 13 months or shift from feminizing to masculinizing hormone treatment, or vice versa.

RESULTS

The cohort included 2789 transgender persons (n = 1717, CGI-cohort and n = 1072, CPR-cohort). The median age (interquartile range) at study inclusion was 26.1 (17.7) years for persons assigned male at birth (n = 1447) and 22.5 (10.5) years for persons assigned female at birth (n = 1342). In the CGI-cohort, the event rate for GAHT in transgender women increased from 4.0 (95% CI: [3.1; 5.2]) events per 100 person in year 2000-2005 to 20.6 [17.8; 23.7] between 2014 -2018. In transgender men, the event rate of GAHT increased from 4.2 [2.8; 6.2] to 18.8 [16.4; 21.6]. The rate of discontinuation of GAHT was 0.06 (95% CI 0.049; 0.071) per person year.

CONCLUSIONS

The event rate of GAHT increased during 2000-2018. Our data suggested high adherence to GAHT. This article is protected by copyright. All rights reserved.

Bone health in transgender people: a narrative review

Bone health in transmen and transwomen is an important issue that needs to be evaluated by clinicians. Prior to gender-affirming hormone treatment (GAHT), transwomen have lower bone mineral density (BMD) and a higher prevalence of osteopenia than cismen probably related to external factors, such as hypovitaminosis D and less physical activities. Gonadotropin-releasing hormone (GnRH) analogues in transgender youth may cause bone loss; however, the addition of GAHT restores or at least improves BMD in both transboys and transgirls. The maintenance or increase in BMD shown in short-term longitudinal studies emphasizes that GAHT does not have a negative effect on BMD in adult transwomen and transmen. Gonadectomy is not a risk factor if GAHT is taken correctly. The prevalence of fractures in the transgender population seems to be the same as in the general population but more studies are required on this aspect. To evaluate the risk of osteoporosis, it is mandatory to define the most appropriate reference group not only taking into consideration the medical aspects but also in respect of the selected gender identity of each person.