Health Outcomes Associated With Having an Oophorectomy Versus Retaining One's Ovaries for Transmasculine and Gender Diverse Individuals Treated With Testosterone Therapy: A Systematic Review

A review of menopause in transgender and gender diverse individuals

PURPOSE OF REVIEW

This review aims to provide a comprehensive overview of the specific challenges, health considerations, and healthcare needs of transgender and gender diverse (TGD) people navigating menopause, highlighting the intersection of gender identity, hormone treatment, and age-related changes.

RECENT FINDINGS

Research on menopause in TGD individuals is lacking, without guidelines to support clinical management. This is the first review of its type to summarize the described impact of the menopausal transition on TGD individuals, the potential long-term risks associated with both gender-affirming hormone therapy and the intersectionality with aging, and how these risks may impact hormone management and overall comprehensive care.

SUMMARY

By drawing on the shared principles of cisgender menopausal hormone therapy and gender-affirming hormone therapy, providers are well positioned to apply their expertise to support the TGD population during menopause. We recommend using shared decision-making, culturally competent care, and a strong understanding of the biological, personal, and social experiences of TGD people that do not necessarily conform to stereotypically ciswoman experiences.

Reproductive mechanisms, pathologies, and health inclusivity: insights from the 2023 Annual Meeting of the Society for Reproductive Biology

In 2023, the Society for Reproductive Biology met in Brisbane to deliver its largest scientific program to date. Herein, we detail key areas of notable discovery across the reproductive biology and fertility landscapes, as well as pressing areas that require further research. Specifically, we focus on five key themes: the cellular basis of reproduction; environmental impacts on reproduction; inclusivity in reproductive health; reproductive cancers; and evolution of reproduction mechanisms. Highlights included the utility of organism models, such as using fruit flies to model human genetic disease, and the development of new blastocyst models; the impact of elevated temperature and endocrine-disrupting chemicals on the germline, sex organ development, and fertility in mammals; how we can improve the inclusivity of transgender and Pacific Rainbow+ people in reproductive health; novel insights in reproductive cancer pathogenesis and inhibitor treatments; and the evolution of the sex chromosomes and sex determination across animals. The breadth of topics covered underscores the far-reaching impacts of reproduction and its related processes across life, health, and wellbeing, as well as for food production and the economy.

Histological ovarian features and hormonal determinations in assigned females at birth transgender individuals according to different testosterone preparations

Introduction

Distinct androgen formulations have been used as gender-affirming hormone treatment, but little is known about the specific changes that may occur in the ovary depending on the testosterone preparation used. The study aims to evaluate the histological modifications of the ovarian tissue and the hormonal changes after gender-affirming surgery based on the testosterone preparation employed, such as testosterone cypionate or undecanoate.

Design

Unicenter transversal cohort study.

Materials and methods

Sixty transmasculine persons before and after gender-affirming surgery. A histological examination of the ovaries was conducted, including the follicular population and the characterization of the ovarian stroma. Hormonal status (testosterone, estradiol, FSH, and LH) were also assessed before and after the procedure.

Results

The median age of participants was similar between the two groups (27.9 vs. 26.7 years, p = 0.27). There were no differences in all hormonal determinations before gender-affirming surgery between the groups. After surgery, FSH levels increased significantly, especially in the testosterone undecanoate group compared to the cypionate group (72.3 vs. 38.3 U/L, p = 0.02), consistent with LH determinations (43.0 vs. 23.4 U/L, p = 0.02). However, no regimen modification was required for any individual. No statistical differences were observed in any parameter concerning the follicular population, nor were there any variances in the thickness of the tunica albuginea (p = 0.85) or the proportion of luteinized stromal cells. Nevertheless, there was a tendency toward increased luteinization in the testosterone cypionate group (88.2% vs. 76.9%, p > 0.05).

Conclusions

In a cohort of transmasculine individuals using different androgen preparations, histological analysis of ovarian tissue revealed comparable findings. Both groups exhibited similar follicular populations and comparable modifications in stromal tissue. However, significant differences were observed in hormonal profiles, although no modification in testosterone dosage was needed.

Bone health in transgender assigned female at birth people: effects of gender-affirming hormone therapy and gonadectomy

Introduction

Gender-affirming hormone therapy (GAHT) and gender-affirming surgery (GAS) may be desired by transgender and gender-diverse (TGD) individuals who want to affirm their gender identity. Testosterone is the basis of GAHT for transgender individuals assigned female at birth (AFAB), whereas GAS can involve hysterectomy, bilateral salpingectomy, bilateral oophorectomy (BO), thorax masculinization, and phalloplasty. Our study aimed to evaluate the effects of GAHT on the bone health of TGD AFAB individuals who have undergone or not undergone BO.

Methods

This was a single-center, longitudinal study with retrospectively collected data. TGD AFAB GAHT-naïve individuals were enrolled and underwent dual-energy X-ray absorptiometry scans and laboratory tests (hormonal and bone metabolism parameters) at baseline and after 5 and 10 years of GAHT.

Results

Two hundred and forty-three TGD AFAB people were included in this study. Seventy-five subjects had completed data for 5 years and 19 subjects for 10 years of GAHT. At baseline, low bone density (Z-score < -2.0) was found in 2.5% (6/243) of subjects for lumbar spine (LS), whereas total hip (TH) and femoral neck (FN) Z-scores and laboratory tests were within the normal female range. After stratifying by physical activity, the physically active group showed significantly higher LS BMD and Z-scores (p ≤ 0.05). Five years after the start of GAHT, a significant reduction in LS (p ≤ 0.05), TH (p ≤ 0.001), and FN (p ≤ 0.01) Z-scores was detected. A significant reduction in the Z-scores of all three bone sites was observed only in the subgroup that had undergone BO. After 5 years of GAHT, estradiol levels were significantly decreased compared to those in baseline (p ≤ 0.001). Significantly higher estradiol levels were detected in the 5-year no-BO subgroup compared to those in the 5-year BO subgroup (p ≤ 0.001). A significant reduction in LS and TH Z-scores were observed after 10 years of GAHT. At this time, estradiol levels were significantly decreased compared to those in baseline (p ≤ 0.01).

Conclusion

Bone density in TGD AFAB individuals is comparable to that in their peers prior to GAHT and BO, but those subjects who underwent BO had a reduced Z-score at LS, FN, and TH after 5 years and at LS after 10 years of GAHT.

Gender-affirming surgeries for transgender and gender diverse individuals and associated health outcomes

Gender-affirming care is treatment that recognizes and affirms the gender identity of transgender and gender-diverse (TGD) individuals. Though not all TGD people choose to surgically transition, gender-affirming surgeries (GAS) are an important part of many TGD people's transition. GAS can include a wide array of procedures aimed at aligning an individual's physical characteristics and gender identity. This review describes the most common procedures considered to be GAS, detailing important relevant considerations for each procedure. These include transfeminine procedures (i.e., breast augmentation, penile inversion vaginoplasty, orchiectomy, tracheal shave, and facial feminization); transmasculine procedures (i.e., chest masculinization, hysterectomy, phalloplasty, and metoidioplasty); and other procedures (i.e., fertility preservation and hair removal). Patient outcomes and the legal landscape for GAS are also discussed to contextualize these procedures within largest discourses surrounding gender-affirming care.

Transgender and Nonbinary Individuals' Perceptions Regarding Gender-Affirming Hormone Therapy and Cardiovascular Health: A Qualitative Study

BACKGROUND

Transgender and nonbinary individuals face substantial cardiovascular health uncertainties. The use of gender-affirming hormone therapy can be used to achieve one's gender-affirming goals. As self-rated health is an important predictor of health outcomes, an understanding of how this association is perceived by transgender and nonbinary individuals using gender-affirming hormone therapy is required. The objective of this research was to explore transgender and nonbinary individuals' perceptions of cardiovascular health in the context of using gender-affirming hormone therapy.

METHODS

In this qualitative study, English-speaking transgender and nonbinary adults using gender-affirming hormone therapy for 3 months or more were recruited from across Canada using purposive and snowball sampling methods. Semistructured interviews were conducted through videoconference to explore transgender and nonbinary individuals' perceptions of the association between gender-affirming hormone therapy and cardiovascular health between May and August 2023. Data were transcribed verbatim, and transcripts were analyzed independently by 3 reviewers using thematic analysis.

RESULTS

Twenty-one participants were interviewed (8 transgender women, 9 transgender men, and 3 nonbinary individuals; median [range] age, 27 [20-69] years; 80% White participants). Three main themes were identified: cardiovascular health was not a primary concern in the decision-making process with regard to gender-affirming hormone therapy, the improved well-being associated with gender-affirming hormone therapy was felt to contribute to improved cardiovascular health, and health care provider knowledge and attitude facilitate the transition process.

CONCLUSIONS

Gender-affirming hormone therapy in transgender and nonbinary individuals is perceived to improve cardiovascular health. Given the positive associations between care aligned with patient priorities, self-rated health, and health outcomes, these findings should be considered as part of shared decision-making and person-centered care.

Gender affirming care for the minimally invasive gynecologic surgeon

PURPOSE OF REVIEW

Given the current political climate and the release of an updated version of the World Professional Association for Transgender Health's guidelines, this review assesses recent updates in the care of transgender and gender diverse (TGD) patients, specifically related to care provided by gynecologists.

RECENT FINDINGS

The number of people identifying as TGD and pursuing gender affirming care is increasing. Contraception for these patients is underdiscussed and high rates of pelvic pain and irregular bleeding were identified. Rates of regret are low following gender affirming surgeries, and studies have repeatedly shown their benefits for gender dysphoria. A minimally invasive approach is recommended for gender affirming hysterectomy, and the decision to proceed with bilateral salpingo-oophorectomy should be based on shared decision making. Surgical techniques include ensuring an adequate margin when taking the infundibulopelvic ligament, and consideration for two-layer vaginal cuff closure.

SUMMARY

Gynecologists play a key role in the care of TGD patients. Recent reviews have found extensive gaps in our knowledge, including a lack of guidelines for cancer prevention, effects of testosterone on benign conditions, and the long-term effects of bilateral salpingo-oophorectomy on health outcomes for patients on testosterone.

Gynecologic Care for Sexual and Gender Minority Patients

Sexual and gender minority (SGM) people, including lesbian, gay, bisexual, transgender, and queer individuals, are a diverse population with a wide spectrum of gynecologic needs. Institutionalized cisheteronormativity, stigmatization, lack of provider training, and fear of discrimination contribute to health disparities in this patient population. In this article, we review key topics in the gynecologic care of SGM patients and provide strategies to enable gynecologists to provide SGM people with equitable and inclusive full spectrum reproductive health care.

Gynecologic Care of Transgender and Gender-Diverse People

The visibility and care of transgender and gender-diverse (TGD) people is an important component of gynecology. Transmasculine individuals require routine gynecologic and preventative care. Guidelines can be extrapolated from the cisgender female population, and using affirming language, acknowledging the challenges patients face with pelvic examination, and discussing individual gynecologic needs are important components of care. Transmasculine patients may seek hysterectomy for gender affirmation from gynecologists. Unique nuances exist in the considerations needed when preparing for hysterectomy, and patients should be thoroughly counseled with regard to concurrent vaginectomy or oophorectomy or both. Transfeminine patients often seek gynecologic care after gender-affirming surgery, and, unlike transmasculine patients, the gynecology visit is often very affirming and welcomed by patients. Becoming familiar with the perioperative and delayed postoperative care needs of transfeminine patients undergoing vaginoplasty can help improve the care provided by gynecologists. In general, prospective data on the outcomes of gender-affirming care in large cohorts of TGD patients are limited, but the body of literature is growing. Gynecologists remain central to the care of TGD patients, the academic advancement of the field of transgender health, and the advocacy needed to support this vulnerable patient population.

Retrospective review of changes in testosterone dosing and physiologic parameters in transgender and gender-diverse individuals following hysterectomy with and without oophorectomy

BACKGROUND

As more transgender and gender-diverse patients undergo hysterectomy, gaps in knowledge remain about how testosterone dosing or other physiologic parameters change following surgery and how these are influenced by concomitant oophorectomy.

AIM

The aims of this study were to determine the incidence of testosterone dosing change after gender-affirming hysterectomy and to compare this incidence between patients who underwent oophorectomy and ovarian preservation.

METHODS

This multicenter retrospective cohort study consisted of transmasculine patients who underwent hysterectomy for gender affirmation.

OUTCOMES

Outcome measures included testosterone dosing changes at least 3 months following hysterectomy, as identified by clinical documentation, as well as clinical and laboratory parameters assessed for a change after hysterectomy: free and total testosterone, estradiol, hemoglobin, hematocrit, total cholesterol, weight, and blood pressure.

RESULTS

Of the 50 patients, 32 (64%) underwent bilateral oophorectomy, 10 (20%) unilateral oophorectomy, and 8 (16%) maintained both ovaries. Eight percent (n = 4) changed testosterone dosing following hysterectomy. Those who underwent bilateral oophorectomy were no more likely to change their testosterone dose than those who did not (P = .09). Those who also used menstrual suppression were 1.31 times more likely to change doses of testosterone after hysterectomy (95% CI, 1.09-1.82; P = .003). For those who had pre- and posthysterectomy laboratory and clinical values, the majority saw no clinically significant change. However, among patients who underwent bilateral oophorectomy, the calculated free testosterone increased by 90.1 ± 288.4 ng/dL (mean ± SD), and estradiol dropped by 20.2 ± 29.0 pg/mL.

CLINICAL IMPLICATIONS

In a field where access to care can be a significant barrier, there is unlikely to be a need for routine reassessment of testosterone dose or laboratory parameters following hysterectomy, whether or not a bilateral oophorectomy occurs.

STRENGTHS AND LIMITATIONS

Limitations of the study include its retrospective nature and the lack of consistent clinical laboratory testing, which resulted in limited data about any given hormonal change. The heterogeneity of our population limited the number of patients undergoing or not undergoing oophorectomy; however, it allowed our study to more truly reflect a clinical environment.

CONCLUSION

In a multisite cohort of individuals who underwent hysterectomy for gender affirmation, few patients changed testosterone dosing after surgery. In addition, dosing change was not associated with the presence or absence of bilateral oophorectomy, and most measured laboratory values remained consistent following hysterectomy.