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Grimstad FW, Boskey ER, Clark RS, Ferrando CA. Incidence of breakthrough bleeding in transgender and gender-diverse individuals on long-term testosterone. Am J Obstet Gynecol 2024; 230:434.e1-434.e10. [PMID: 38181830 DOI: 10.1016/j.ajog.2023.12.036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2023] [Revised: 11/28/2023] [Accepted: 12/22/2023] [Indexed: 01/07/2024]
Abstract
BACKGROUND Little is known about the maintenance of amenorrhea among transgender and gender-diverse individuals with uteri who are using long-term testosterone gender-affirming hormone therapy. Emerging data describe breakthrough bleeding among adolescents on long-term testosterone therapy and among adults who are seeking a gender-affirming hysterectomy. More studies are needed to better understand breakthrough bleeding patterns among transgender and gender-diverse individuals with uteri who are using testosterone, including the frequency, timing, and etiology of bleeding and how these patterns may differ between adults and younger populations. OBJECTIVE The primary aim of this study was to characterize the incidence and patterns of breakthrough bleeding in a cohort of transgender and gender-diverse individuals who had been on testosterone for longer than 12 months and who had uteri in situ. Secondary aims included identifying the time to first bleed for those who experienced breakthrough bleeding and the risk factors associated with breakthrough bleeding while on testosterone therapy. STUDY DESIGN This was an institutional review board-approved, single tertiary center, retrospective chart review of transgender and gender diverse individuals who had been on testosterone for at least 1 year. A primary survival analysis that evaluated the incidence of bleeding was combined with descriptive analyses and an evaluation of the factors associated with bleeding. RESULTS Of the 279 patients included in the analysis, the median age of testosterone initiation was 22 years (interquartile range, 19-41), and the median follow-up time was 34 months (range, 12-278). The absolute proportion of individuals who ever experienced breakthrough bleeding on testosterone was 34% (n=96; 95% confidence interval, 29-40). Patients who experienced breakthrough bleeding initiated testosterone at a younger age (20.5 vs 22.0 years; P=.04), had lower mean serum testosterone levels (389.14 vs 512.7 ng/dL; P=.001), were more likely to have a mean testosterone level <320 ng/dL (52% vs 48%; P=.001), and had higher mean estradiol levels (62% vs 49%; P=.003). Survival analyses estimated a breakthrough bleeding incidence rate of 0.09 per year (95% confidence interval, 0.07-1.0). Although 58 people underwent a hysterectomy during the follow-up period, 64% of the cohort who maintained a uterus eventually experienced breakthrough bleeding. The median time to the initial bleeding episode was 22 months (interquartile range, 12-201) after testosterone initiation. CONCLUSION These results suggest that a substantial fraction of transgender and gender-diverse individuals who are using testosterone will experience at least 1 episode of breakthrough bleeding even after their initial year of testosterone use. We recommend that clinicians inform all patients that breakthrough bleeding is a common occurrence even after the first year on testosterone therapy.
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Affiliation(s)
- Frances W Grimstad
- Division of Gynecology, Department of Surgery, Boston Children's Hospital, Boston, MA; Department of Obstetrics, Gynecology, and Reproductive Biology, Harvard Medical School, Boston, MA; Center for Urogynecology & Pelvic Reconstructive Surgery, Women's Health Institute, Cleveland Clinic, Cleveland, OH.
| | - Elizabeth R Boskey
- Division of Gynecology, Department of Surgery, Boston Children's Hospital, Boston, MA; Department of Surgery, Harvard Medical School, Boston, MA; Department of Social and Behavioral Sciences, Harvard T.H. Chan School of Public Health, Boston, MA
| | - Rachael S Clark
- Case Western University School of Medicine, Cleveland, OH; Department of Obstetrics & Gynecology, University of Massachusetts, Worcester, MA
| | - Cecile A Ferrando
- Center for Urogynecology & Pelvic Reconstructive Surgery, Women's Health Institute, Cleveland Clinic, Cleveland, OH; Case Western University School of Medicine, Cleveland, OH
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2
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Asseler JD, Del Valle JS, Chuva de Sousa Lopes SM, Verhoeven MO, Goddijn M, Huirne JAF, van Mello NM. One-third of amenorrheic transmasculine people on testosterone ovulate. Cell Rep Med 2024; 5:101440. [PMID: 38402622 PMCID: PMC10982961 DOI: 10.1016/j.xcrm.2024.101440] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2023] [Revised: 09/27/2023] [Accepted: 01/31/2024] [Indexed: 02/27/2024]
Abstract
Transmasculine people usually reach amenorrhea within 6 months of adequate testosterone treatment. It is often assumed that no ovulation occurs during amenorrhea. However, in this study, we report recent ovulatory activity in amenorrheic transmasculine people on testosterone therapy at gender-affirming oophorectomy. Histological signs of recent ovulatory activity, including the presence of ovulatory follicles, corpus luteum, and corpus albicans, are observed in 17 of 52 individuals (33%). This is not significantly correlated to the duration, testosterone serum levels, or type of testosterone used. These results suggest that amenorrhea does not equal anovulation in transmasculine people on adequate testosterone therapy, emphasizing the importance of contraception for people who engage in sexual activity that can result in pregnancy.
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Affiliation(s)
- Joyce D Asseler
- Amsterdam UMC, Location Vrije Universiteit Amsterdam, Department of Obstetrics and Gynaecology, Amsterdam, the Netherlands; Amsterdam UMC, Centre of Expertise on Gender Dysphoria, Amsterdam, the Netherlands; Amsterdam Reproduction and Development Research Institute, Amsterdam, the Netherlands.
| | - Julieta S Del Valle
- Leiden University Medical Center, Department of Anatomy and Embryology, Leiden, the Netherlands
| | - Susana M Chuva de Sousa Lopes
- Leiden University Medical Center, Department of Anatomy and Embryology, Leiden, the Netherlands; Ghent University Hospital, Department of Reproductive Medicine: Ghent-Fertility and Stem Cell Team (G-FAST), Ghent, Belgium
| | - Marieke O Verhoeven
- Amsterdam UMC, Location Vrije Universiteit Amsterdam, Department of Obstetrics and Gynaecology, Amsterdam, the Netherlands; Amsterdam Reproduction and Development Research Institute, Amsterdam, the Netherlands
| | - Mariette Goddijn
- Amsterdam Reproduction and Development Research Institute, Amsterdam, the Netherlands; Amsterdam UMC Location University of Amsterdam, Center for Reproductive Medicine, Department of Obstetrics and Gynaecology, Amsterdam, the Netherlands
| | - Judith A F Huirne
- Amsterdam UMC, Location Vrije Universiteit Amsterdam, Department of Obstetrics and Gynaecology, Amsterdam, the Netherlands; Amsterdam Reproduction and Development Research Institute, Amsterdam, the Netherlands
| | - Norah M van Mello
- Amsterdam UMC, Location Vrije Universiteit Amsterdam, Department of Obstetrics and Gynaecology, Amsterdam, the Netherlands; Amsterdam UMC, Centre of Expertise on Gender Dysphoria, Amsterdam, the Netherlands; Amsterdam Reproduction and Development Research Institute, Amsterdam, the Netherlands.
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3
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Ferrando CA. Gynecologic Care of Transgender and Gender-Diverse People. Obstet Gynecol 2024; 143:243-255. [PMID: 37963404 DOI: 10.1097/aog.0000000000005440] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2023] [Accepted: 09/14/2023] [Indexed: 11/16/2023]
Abstract
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.
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Affiliation(s)
- Cecile A Ferrando
- Center for Urogynecology & Pelvic Reconstructive Surgery, Obstetrics & Gynecology Institute, Cleveland Clinic, Cleveland, Ohio
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4
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da Silva ED, Spritzer PM, Fighera TM. Persistent vaginal bleeding during gender-affirming hormone therapy in transgender men. J Endocrinol Invest 2024:10.1007/s40618-023-02296-w. [PMID: 38300501 DOI: 10.1007/s40618-023-02296-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2023] [Accepted: 12/28/2023] [Indexed: 02/02/2024]
Abstract
PURPOSE While it is common for menstrual cycles to cease within the initial 6 months of treatment, there are instances where some transgender men may not experience this cessation. We analyzed transgender men undergoing gender-affirming hormone therapy (GAHT) with testosterone who experienced breakthrough bleeding in order to identify the factors associated with this condition. METHODS In this case-control study, 24 transgender men in the case group and 48 in the control group were assessed for clinical, sociodemographic, hormonal, and body composition variables using dual-energy X-ray absorptiometry. All participants had been on GATH for at least 6 months. RESULTS A few transgender men experienced persistent breakthrough bleeding, which was associated with decreased testosterone levels and free androgen index (FAI) compared with controls (p = 0.002 and p = 0.008, respectively). Among individuals with breakthrough bleeding, 50% had testosterone levels below the lowest tertile calculated for the sample, compared with 18.8% on controls (p = 0.007). After therapy adjustment, testosterone levels increased compared with the values obtained in the initial bleeding episode (p = 0.031). Eight transgender men required the addition of an oral progestogen to achieve amenorrhea, and these individuals had higher BMI than those in whom the adjustment of the parenteral testosterone dose was adequate (p = 0.026). A univariate prevalence ratio analysis revealed a negative association of persistent bleeding with testosterone levels (p = 0.028) and FAI levels (p = 0.019). CONCLUSION Higher BMI and lower levels of testosterone and FAI were the main factors associated with breakthrough bleeding in transgender men.
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Affiliation(s)
- E D da Silva
- Gynecological Endocrinology Unit, Division of Endocrinology, Hospital de Clínicas de Porto Alegre, Rua Ramiro Barcelos 2350, Porto Alegre, RS, CEP 90035 003, Brazil
- Postgraduate Program in Endocrinology, Medicine School, Universidade Federal do Rio Grande do Sul, Porto Alegre, RS, Brazil
- Transdisciplinary Gender Identity Program, Hospital de Clínicas de Porto Alegre, Porto Alegre, RS, Brazil
| | - P M Spritzer
- Gynecological Endocrinology Unit, Division of Endocrinology, Hospital de Clínicas de Porto Alegre, Rua Ramiro Barcelos 2350, Porto Alegre, RS, CEP 90035 003, Brazil.
- Postgraduate Program in Endocrinology, Medicine School, Universidade Federal do Rio Grande do Sul, Porto Alegre, RS, Brazil.
- Transdisciplinary Gender Identity Program, Hospital de Clínicas de Porto Alegre, Porto Alegre, RS, Brazil.
- Department of Physiology and Postgraduate Program in Physiology, Universidade Federal do Rio Grande do Sul, Porto Alegre, RS, Brazil.
| | - T M Fighera
- Gynecological Endocrinology Unit, Division of Endocrinology, Hospital de Clínicas de Porto Alegre, Rua Ramiro Barcelos 2350, Porto Alegre, RS, CEP 90035 003, Brazil
- Postgraduate Program in Endocrinology, Medicine School, Universidade Federal do Rio Grande do Sul, Porto Alegre, RS, Brazil
- Transdisciplinary Gender Identity Program, Hospital de Clínicas de Porto Alegre, Porto Alegre, RS, Brazil
- Department of Internal Medicine, Universidade Federal do Rio Grande do Sul, Porto Alegre, RS, Brazil
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Kinnear HM, Moravek MB. Reproductive capacity after gender-affirming testosterone therapy. Hum Reprod 2023; 38:1872-1880. [PMID: 37573140 PMCID: PMC10546082 DOI: 10.1093/humrep/dead158] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2023] [Revised: 07/11/2023] [Indexed: 08/14/2023] Open
Abstract
Transgender and nonbinary people with female birth sex may utilize testosterone therapy for masculinization. Individuals interested in reproduction using their own gametes should be offered fertility preservation prior to starting testosterone. However, logistical and practical barriers prevent many from accessing fertility preservation options prior to starting testosterone. Some of these transmasculine and nonbinary individuals may later become interested in carrying a pregnancy or using their oocytes for reproduction after being on testosterone. Many questions remain about the reproductive impact of long-term masculinizing testosterone therapy. Emerging literature has documented pregnancies and successful assisted reproduction for some people after taking testosterone, but it is not known whether individuals can expect these successful outcomes. Testosterone appears to impact the reproductive tract, including the ovaries, uterus, and fallopian tubes, but the reversibility and functional impact of these changes also remain unclear. A greater understanding of the impact of masculinizing testosterone on reproductive capacity remains a priority area for future research.
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Affiliation(s)
- Hadrian M Kinnear
- Program in Cellular and Molecular Biology, University of Michigan, Ann Arbor, MI, USA
- Medical Scientist Training Program, University of Michigan, Ann Arbor, MI, USA
| | - Molly B Moravek
- Division of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, MI, USA
- Department of Urology, University of Michigan, Ann Arbor, MI, USA
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6
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Barrero JA, Mockus I. Preservation of Fertility in Transgender Men on Long-Term Testosterone Therapy: A Systematic Review of Oocyte Retrieval Outcomes During and After Exogenous Androgen Exposure. Transgend Health 2023; 8:408-419. [PMID: 37810944 PMCID: PMC10551752 DOI: 10.1089/trgh.2022.0023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Testosterone therapy prompts the development of male secondary sexual characteristics coupled with numerous physiological changes; however, the effect of prolonged androgen exposure on transgender men's fertility remains to be fully elucidated. Multiple clinical consensuses advise assisted reproduction before hormone treatment and state that fertility preservation following androgen therapy entails the suspension of testosterone administration. Although the desire for reproduction among transgender men is prevalent, the discontinuation of gender-affirming hormone therapy poses a major challenge due to the anxiety, unease, and gender dysphoria that follow androgen withdrawal. The present investigation aimed to explore the feasibility and outcomes of oocyte retrieval in adult transgender men undergoing testosterone administration before or during fertility preservation. Seven case reports, four cohort studies, and two cross-sectional studies were identified following a systematic literature search on the PubMed/Ovid MEDLINE, Scopus, and ScienceDirect databases. The findings gathered in this review disclose the viability of oocyte retrieval after prolonged androgen exposure and suggest the absence of a direct relationship between the duration of testosterone suspension and fertility preservation outcomes. Although the reports are limited, recent evidence shows that continuous testosterone administration and the use of aromatase inhibitors during ovarian stimulation could potentially reduce the distressing effects of hormonal ovulation induction. New approaches to fertility preservation in transgender men must be further explored to ensure interventions aligned both with the reproductive desire and avoidance of gender dysphoria exacerbation that follow hormone therapy suspension.
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Affiliation(s)
- Jorge A. Barrero
- Lipids and Diabetes Division, Department of Physiological Sciences, Faculty of Medicine, Universidad Nacional de Colombia, Bogotá, Colombia
| | - Ismena Mockus
- Lipids and Diabetes Division, Department of Physiological Sciences, Faculty of Medicine, Universidad Nacional de Colombia, Bogotá, Colombia
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Schwartz AR, Xu M, Henderson NC, Dela Cruz C, Pfau D, Padmanabhan V, Shikanov A, Moravek MB. Impaired in vitro fertilization outcomes following testosterone treatment improve with washout in a mouse model of gender-affirming hormone treatment. Am J Obstet Gynecol 2023; 229:419.e1-419.e10. [PMID: 37453652 PMCID: PMC10654792 DOI: 10.1016/j.ajog.2023.07.013] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2023] [Revised: 06/22/2023] [Accepted: 07/09/2023] [Indexed: 07/18/2023]
Abstract
BACKGROUND The impact of gender-affirming testosterone on fertility is poorly understood, with ovarian histopathologic studies showing variable results, some with a detrimental effect on reproductive capacity and uncertain reversibility. Assisted reproductive outcome data are restricted to small case series that lack the ability to inform clinical practice guidelines and limit fertility preservation counseling for transgender and nonbinary individuals. OBJECTIVE This study aimed to determine the impact of current testosterone and testosterone washout on in vitro fertilization outcomes in a mouse model for gender-affirming hormone treatment. We hypothesized that current or previous testosterone treatment would not affect in vitro fertilization outcomes. STUDY DESIGN C57BL/6N female mice (n=120) were assigned to 4 treatment groups: (1) current control, (2) current testosterone, (3) control washout, and (4) testosterone washout. Testosterone implants remained in situ for 6 or 12 weeks, representing the short- and long-term treatment arms, respectively. Current treatment groups underwent ovarian stimulation with implants in place, and washout treatment groups were explanted and had ovarian stimulation after 2 weeks. Oocytes were collected, fertilized, and cultured in vitro, with one arm continuing to the blastocyst stage and the other having transfer of cleavage-stage embryos. Statistical analysis was performed using GraphPad Prism, version 9.0 and R statistical software, version 4.1.2, with statistical significance defined by P<.05. RESULTS Current long-term testosterone treatment impaired in vitro fertilization outcomes, with fewer mature oocytes retrieved (13.7±5.1 [standard deviation] vs 28.6±7.8 [standard deviation]; P<.0001) leading to fewer cleavage-stage embryos (12.1±5.1 vs 26.5±8.2; P<.0001) and blastocysts (10.0±3.2 vs 25.0±6.5; P<.0001). There was recovery of in vitro fertilization outcomes following washout in the short-term treatment cohort, with incomplete reversibility in the long-term cohort. Testosterone did not negatively affect maturity, fertilization, or blastulation rates. CONCLUSION In a mouse model of gender-affirming hormone treatment, testosterone negatively affected oocyte yield without affecting oocyte quality. Our findings suggest that testosterone reversibility is duration-dependent. These results demonstrate the feasibility of in vitro fertilization without testosterone discontinuation while supporting a washout period for optimization of mature oocyte yield.
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Affiliation(s)
- Amanda R Schwartz
- Division of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, MI.
| | - Min Xu
- Division of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, MI
| | - Nicholas C Henderson
- Department of Biostatistics, University of Michigan School of Public Health, Ann Arbor, MI
| | - Cynthia Dela Cruz
- Department of Biomedical Engineering, University of Michigan, Ann Arbor, MI
| | - Daniel Pfau
- Department of Biomedical Engineering, University of Michigan, Ann Arbor, MI
| | | | - Ariella Shikanov
- Department of Biomedical Engineering, University of Michigan, Ann Arbor, MI
| | - Molly B Moravek
- Division of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, MI
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Pallotti F, Senofonte G, Conflitti AC, Giancotti A, Anzuini A, Delli Paoli E, Di Chiano S, Faja F, Gatta V, Mondo A, Mosconi M, Rizzo F, Spiniello L, Lombardo F, Paoli D. Safety of gender affirming treatment in assigned female at birth transgender people and association of androgen and estrogen β receptor polymorphisms with clinical outcomes. Endocrine 2023; 81:621-630. [PMID: 37326767 DOI: 10.1007/s12020-023-03421-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2023] [Accepted: 06/06/2023] [Indexed: 06/17/2023]
Abstract
PURPOSE Gender affirming hormone treatment (GAHT) with androgens in assigned female at birth (AFAB) people with Gender Incongruence (GI) can induce and maintain variable phenotypical changes, but individual response may be genetically determined. To clarify the role of AR and ERβ polymorphisms we prospectively evaluated AFAB subjects undergoing virilizing GAHT. METHODS Fifty-two AFAB people with confirmed GI were evaluated before (T0) and after 6 (T6) and 12 months (T12) of testosterone enanthate 250 mg i.m. every 28 days. Hormone profile (testosterone, estradiol), biochemical (blood count, glyco-metabolic profile) and clinical parameters (Ferriman-Gallwey score, pelvic organs) were evaluated at each time-point, as well as number of CAG and CA repeats for AR and ERβ, respectively. RESULTS All subjects have successfully achieved testosterone levels within normal male ranges and improved their degree of virilization, in absence of significant side effects. Hemoglobin, hematocrit and red blood cells were significantly increased after treatment, but within normal ranges. Ultrasound monitoring of pelvic organs showed their significant reduction already after 6 months of GATH, in absence of remarkable abnormalities. Furthermore, a lower number of CAG repeats was associated with a higher Ferriman-Gallwey score post treatment and a higher number of CA repeats was associated with uterine volume reduction. CONCLUSION We confirmed safety and efficacy of testosterone treatment on all measured parameters. This preliminary data hints a future role of genetic polymorphisms to tailor GAHT in GI people, but evaluation on a larger cohort is necessary as the reduced sample size could limit data generalization at this stage.
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Affiliation(s)
- Francesco Pallotti
- Laboratory of Seminology - Sperm Bank "Loredana Gandini", Department of Experimental Medicine, "Sapienza" University of Rome, 00161, Rome, Italy.
- Faculty of Medicine and Surgery, University of Enna "Kore", 94100, Enna, Italy.
| | - Giulia Senofonte
- Laboratory of Seminology - Sperm Bank "Loredana Gandini", Department of Experimental Medicine, "Sapienza" University of Rome, 00161, Rome, Italy
| | - Anna Chiara Conflitti
- Laboratory of Seminology - Sperm Bank "Loredana Gandini", Department of Experimental Medicine, "Sapienza" University of Rome, 00161, Rome, Italy
| | - Antonella Giancotti
- Prenatal Diagnosis Centre, Department of Obstetrics, Gynaecology and Urologic Science, "Sapienza" University of Rome, 00161, Rome, Italy
| | - Antonella Anzuini
- Laboratory of Seminology - Sperm Bank "Loredana Gandini", Department of Experimental Medicine, "Sapienza" University of Rome, 00161, Rome, Italy
| | - Enrico Delli Paoli
- Laboratory of Seminology - Sperm Bank "Loredana Gandini", Department of Experimental Medicine, "Sapienza" University of Rome, 00161, Rome, Italy
| | - Silvia Di Chiano
- Laboratory of Seminology - Sperm Bank "Loredana Gandini", Department of Experimental Medicine, "Sapienza" University of Rome, 00161, Rome, Italy
| | - Fabiana Faja
- Laboratory of Seminology - Sperm Bank "Loredana Gandini", Department of Experimental Medicine, "Sapienza" University of Rome, 00161, Rome, Italy
| | - Valentina Gatta
- Department of Psychological Health and Territorial Sciences, School of Medicine and Health Sciences, "G. d'Annunzio" University of Chieti-Pescara, 66100, Chieti, Italy
- Unit of Molecular Genetics, Center for Advanced Studies and Technology (CAST), "G. d'Annunzio" University of Chieti-Pescara, 66100, Chieti, Italy
| | - Alessandro Mondo
- Prenatal Diagnosis Centre, Department of Obstetrics, Gynaecology and Urologic Science, "Sapienza" University of Rome, 00161, Rome, Italy
| | - Maddalena Mosconi
- Gender Identity Development Service, Hospital S. Camillo-Forlanini, 00152, Rome, Italy
| | - Flavio Rizzo
- Section of Medical Pathophysiology and Endocrinology, Department of Experimental Medicine, Sapienza University of Rome, 00161, Rome, Italy
| | - Lorenzo Spiniello
- Prenatal Diagnosis Centre, Department of Obstetrics, Gynaecology and Urologic Science, "Sapienza" University of Rome, 00161, Rome, Italy
| | - Francesco Lombardo
- Laboratory of Seminology - Sperm Bank "Loredana Gandini", Department of Experimental Medicine, "Sapienza" University of Rome, 00161, Rome, Italy
| | - Donatella Paoli
- Laboratory of Seminology - Sperm Bank "Loredana Gandini", Department of Experimental Medicine, "Sapienza" University of Rome, 00161, Rome, Italy
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D'Amato A, Cascardi E, Etrusco A, Laganà AS, Schonauer LM, Cazzato G, Vimercati A, Malvasi A, Damiani GR, Di Naro E, Trojano G, Cicinelli E, Vitagliano A, Dellino M. "Lights and Shades" of Fertility Preservation in Transgender Men Patients: A Clinical and Pathological Review. Life (Basel) 2023; 13:1312. [PMID: 37374095 DOI: 10.3390/life13061312] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2023] [Revised: 05/25/2023] [Accepted: 05/30/2023] [Indexed: 06/29/2023] Open
Abstract
Fertility preservation (FP) is becoming a critical issue in transgender men who desire biological offspring in the future. The prevalence of transgender individuals in the United States is increasing, and as a result, the demand for gender-affirming surgeries (GAS) and associated FP techniques is rising. Despite the growing demand, there is currently no personalized approach to FP for transgender men, and the available techniques have limitations that require further investigation. In the present review we carefully examine the existing literature on this topic to highlight the shortcomings of current methods and areas where additional research is needed to advance the field. Hormonal therapy (HT), which is an integral part of gender transition in transgender men, can have a significant impact on fertility and may increase the risk of various diseases. Moreover, GAS usually leads to permanent sterility in these patients. Therefore, it is essential to provide patients with accurate information about the benefits and potential risks of different FP techniques, taking into account the patient's reproductive goals. This review underscores the complex and multifaceted nature of FP in transgender men and emphasizes the need for further research to develop more effective and personalized approaches to FP for this population.
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Affiliation(s)
- Antonio D'Amato
- Obstetrics and Gynaecology Unit, Department of Biomedical Sciences and Human Oncology, University of Bari "Aldo Moro", Piazza Giulio Cesare 11, 70124 Bari, Italy
| | - Eliano Cascardi
- Department of Medical Sciences, University of Turin, 10124 Turin, Italy
- Pathology Unit, FPO-IRCCS Candiolo Cancer Institute, 10060 Candiolo, Italy
| | - Andrea Etrusco
- Unit of Gynecologic Oncology, ARNAS "Civico-Di Cristina-Benfratelli", Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties (PROMISE), University of Palermo, 90127 Palermo, Italy
| | - Antonio Simone Laganà
- Unit of Gynecologic Oncology, ARNAS "Civico-Di Cristina-Benfratelli", Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties (PROMISE), University of Palermo, 90127 Palermo, Italy
| | - Luca Maria Schonauer
- Obstetrics and Gynaecology Unit, Department of Biomedical Sciences and Human Oncology, University of Bari "Aldo Moro", Piazza Giulio Cesare 11, 70124 Bari, Italy
| | - Gerardo Cazzato
- Department of Emergency and Organ Transplantation, Pathology Section, University of Bari "Aldo Moro", Piazza Giulio Cesare 11, 70124 Bari, Italy
| | - Antonella Vimercati
- Obstetrics and Gynaecology Unit, Department of Biomedical Sciences and Human Oncology, University of Bari "Aldo Moro", Piazza Giulio Cesare 11, 70124 Bari, Italy
| | - Antonio Malvasi
- Obstetrics and Gynaecology Unit, Department of Biomedical Sciences and Human Oncology, University of Bari "Aldo Moro", Piazza Giulio Cesare 11, 70124 Bari, Italy
| | - Gianluca Raffaello Damiani
- Obstetrics and Gynaecology Unit, Department of Biomedical Sciences and Human Oncology, University of Bari "Aldo Moro", Piazza Giulio Cesare 11, 70124 Bari, Italy
| | - Edoardo Di Naro
- Obstetrics and Gynaecology Unit, Department of Biomedical Sciences and Human Oncology, University of Bari "Aldo Moro", Piazza Giulio Cesare 11, 70124 Bari, Italy
| | - Giuseppe Trojano
- Obstetrics and Gynaecology Unit, Department of Biomedical Sciences and Human Oncology, University of Bari "Aldo Moro", Piazza Giulio Cesare 11, 70124 Bari, Italy
| | - Ettore Cicinelli
- Obstetrics and Gynaecology Unit, Department of Biomedical Sciences and Human Oncology, University of Bari "Aldo Moro", Piazza Giulio Cesare 11, 70124 Bari, Italy
| | - Amerigo Vitagliano
- Obstetrics and Gynaecology Unit, Department of Biomedical Sciences and Human Oncology, University of Bari "Aldo Moro", Piazza Giulio Cesare 11, 70124 Bari, Italy
| | - Miriam Dellino
- Obstetrics and Gynaecology Unit, Department of Biomedical Sciences and Human Oncology, University of Bari "Aldo Moro", Piazza Giulio Cesare 11, 70124 Bari, Italy
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10
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Lissaman AC, Girling JE, Cree LM, Campbell RE, Ponnampalam AP. Androgen signalling in the ovaries and endometrium. Mol Hum Reprod 2023; 29:gaad017. [PMID: 37171897 PMCID: PMC10663053 DOI: 10.1093/molehr/gaad017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2022] [Revised: 04/27/2023] [Indexed: 05/14/2023] Open
Abstract
Currently, our understanding of hormonal regulation within the female reproductive system is largely based on our knowledge of estrogen and progesterone signalling. However, while the important functions of androgens in male physiology are well known, it is also recognized that androgens play critical roles in the female reproductive system. Further, androgen signalling is altered in a variety of gynaecological conditions, including endometriosis and polycystic ovary syndrome, indicative of regulatory roles in endometrial and ovarian function. Co-regulatory mechanisms exist between different androgens, estrogens, and progesterone, resulting in a complex network of steroid hormone interactions. Evidence from animal knockout studies, in vitro experiments, and human data indicate that androgen receptor expression is cell-specific and menstrual cycle stage-dependent, with important regulatory roles in the menstrual cycle, endometrial biology, and follicular development in the ovaries. This review will discuss the expression and co-regulatory interactions of androgen receptors, highlighting the complexity of the androgen signalling pathway in the endometrium and ovaries, and the synthesis of androgens from additional alternative pathways previously disregarded as male-specific. Moreover, it will illustrate the challenges faced when studying androgens in female biology, and the need for a more in-depth, integrative view of androgen metabolism and signalling in the female reproductive system.
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Affiliation(s)
- Abbey C Lissaman
- Department of Physiology, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand
| | - Jane E Girling
- Department of Anatomy, School of Biomedical Sciences, University of Otago, Dunedin, New Zealand
| | - Lynsey M Cree
- Department of Obstetrics and Gynaecology, University of Auckland, Auckland, New Zealand
| | - Rebecca E Campbell
- Department of Physiology and Centre for Neuroendocrinology, University of Otago, Dunedin, New Zealand
| | - Anna P Ponnampalam
- Department of Physiology, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand
- Pūtahi Manawa-Healthy Hearts for Aotearoa New Zealand, Centre of Research Excellence, New Zealand
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11
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Yoshida H, Uno M, Ogimoto K, Kobayashi-Kato M, Tanase Y, Ishikawa M, Kato T. Endometrioid Endometrial Carcinoma With NKX3.1 Expression in a Transgender Man: A Case Report. Int J Gynecol Pathol 2023; 42:308-314. [PMID: 36811847 DOI: 10.1097/pgp.0000000000000869] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/24/2023]
Abstract
Endometrial cancer in transgender men is rare, and its histopathologic features remain unknown. A 30-yr-old transgender man with an intrauterine tumor, an ovarian mass, and a 2-yr history of testosterone use was referred to us for treatment. The presence of the tumors was confirmed via imaging, and the intrauterine tumor was identified as an endometrial endometrioid carcinoma via endometrial biopsy. The patient underwent hysterectomy, bilateral salpingo-oophorectomy, omentectomy, and lymph node dissection. Pathologic examination revealed grade 3 endometrioid endometrial carcinoma, and the synchronous endometrial and ovarian tumors were collectively characterized as primary endometrial carcinoma. Metastatic carcinomas were discovered in both ovaries and the omentum, pelvic peritoneum, and a para-aortic lymph node. On immunohistochemistry, the tumor cells diffusely expressed p53, retained expression of PTEN, ARID1A, PMS2, and MSH6, and focally expressed estrogen receptors, androgen receptors, and NKX3.1. NKX3.1 was also expressed in glandular structures within the exocervical squamous epithelium. Prostate-specific antigen and prostatic acid phosphatase were focally positive. In conclusion, we describe a transgender man with NKX3.1-expressing endometrioid endometrial carcinoma who provides valuable suggestions regarding the effects of testosterone on endometrial cancer and appropriate gynecological care for transgender men.
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12
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Moravek MB, Dixon M, Pena SM, Obedin-Maliver J. Management of testosterone around ovarian stimulation in transmasculine patients: challenging common practices to meet patient needs-2 case reports. Hum Reprod 2023; 38:482-488. [PMID: 36644915 PMCID: PMC9977120 DOI: 10.1093/humrep/dead003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2022] [Revised: 12/05/2022] [Indexed: 01/17/2023] Open
Abstract
Approximately 50% of transmasculine people use testosterone for gender affirmation, yet very little is known about the effects of testosterone on future reproductive capacity. Moreover, there are no data to guide fertility specialists on how to manage testosterone leading up to or during ovarian stimulation. Most clinics require cessation of testosterone prior to ovarian stimulation in this setting of no data; however, the current literature does suggest a potential increase in dysphoria with cessation of testosterone and during stimulation. This divergence begs the question of whether clinicians may be doing more harm than good by enacting this requirement. Here, we present two cases of transmasculine individuals who were on testosterone prior to stimulation and maintained their testosterone dosage throughout stimulation as proof of concept, followed by a discussion of current clinical practice and providing some rationale to support continuation of testosterone throughout stimulation.
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Affiliation(s)
- Molly B Moravek
- Division of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, MI, USA
| | - Marjorie Dixon
- Anova Fertility and Reproductive Health, North York, Ontario, Canada
| | - Samantha M Pena
- Anova Fertility and Reproductive Health, North York, Ontario, Canada
| | - Juno Obedin-Maliver
- Department of Obstetrics and Gynecology, Stanford University School of Medicine, Palo Alto, CA, USA
- Department of Epidemiology and Population Health, Stanford University School of Medicine, Palo Alto, CA, USA
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13
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Federico A, Patel M, Cummings K. Cystic Teratoma Resection With Ovarian Preservation in a Pediatric Transgender Male: A Case Report. Cureus 2022; 14:e29161. [PMID: 36259003 PMCID: PMC9564695 DOI: 10.7759/cureus.29161] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/14/2022] [Indexed: 12/04/2022] Open
Abstract
Ovarian teratomas are germ cell-derived tumors that are classically reported in the literature to occur in cisgender female patients. While this is statistically the most common patient population that they are diagnosed in, they can also occur in transgender men with ovaries who have not undergone a previous oophorectomy. Because of the lack of research and literature regarding this unique patient population, decisions regarding the treatment of these neoplasms are controversial. Here, we report the case of a pediatric transgender male who developed an ovarian teratoma and discuss specific considerations for treating ovarian neoplasms in the transgender population.
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14
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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. Sex Med Rev 2022; 10:636-647. [PMID: 37051961 DOI: 10.1016/j.sxmr.2022.03.003] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2021] [Revised: 03/20/2022] [Accepted: 03/23/2022] [Indexed: 11/22/2022]
Abstract
INTRODUCTION The transmasculine and gender diverse (TMGD) spectrum includes transgender men and non-binary individuals whose sex was assigned female at birth. Many TMGD patients pursue treatment with exogenous testosterone to acquire masculine characteristics. Some may choose to undergo gynecological gender-affirming surgery for total hysterectomy with bilateral salpingectomy and/or bilateral oophorectomy (TH/BSO). The decision to retain or remove the ovaries in the setting of chronic testosterone therapy has implications on reproductive health, oncologic risk, endocrine management, cardiovascular health, bone density and neurocognitive status. However, there is limited evidence on the long-term outcomes from this intervention. OBJECTIVE Here we review health-related outcomes of oophorectomy in TMGD population treated with chronic testosterone therapy in order to guide clinicians and patients in the decision to retain or remove their ovaries. METHOD We conducted a systematic literature review following PRISMA guidelines. MEDLINE, EMBASE, ClinicalTrials.gov, and Cochrane Library databases were searched for peer-reviewed studies published prior to October 26, 2021 that: (i) included transgender men/TMGD individuals in the study populations; (ii) were full-text randomized controlled studies, case reports, case series, retrospective cohort studies, prospective cohort studies, qualitative studies, and cross-sectional studies; and (iii) specifically discussed ovaries, hysterectomy, oophorectomy, ovariectomy, or gonadectomy. RESULTS We identified 469 studies, of which 39 met our inclusion criteria for this review. Three studies discussed fertility outcomes, 11 assessed histopathological changes to the ovaries, 6 discussed ovarian oncological outcomes, 8 addressed endocrine considerations, 3 discussed cardiovascular health outcomes, and 8 discussed bone density. No studies were found that examined surgical outcomes or neurocognitive changes. CONCLUSION There is little information to guide TMGD individuals who are considering TH/BSO versus TH/BS with ovarian retention. Our review suggests that there is limited evidence to suggest that fertility preservation is successful after TH/BS with ovarian retention. Current evidence does not support regular reduction in testosterone dosing following oophorectomy. Estradiol levels are likely higher in individuals that choose ovarian retention, but this has not been clearly demonstrated. Although bone mineral density decreases following oophorectomy, data demonstrating an increased fracture risk are lacking. No studies have described the specific impact on neurocognitive function, or changes in operative complications. Further research evaluating long-term health outcomes of oophorectomy for TMGD individuals treated with chronic testosterone therapy is warranted to provide comprehensive, evidence-based healthcare to this patient population. Sahil Kumar, Smita Mukherjee, Cormac O'Dwyer, et al. 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. Sex Med Rev 2022;XX:XXX-XXX.
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15
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Mehra G, Boskey ER, Peters CJ, Njubigbo C, Charlton BM, Ganor O. Assessing Fertility Intentions in Patients Presenting for Gender-Affirming Surgery. LGBT Health 2022; 9:325-332. [PMID: 35749209 DOI: 10.1089/lgbt.2021.0148] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Purpose: For some transgender and gender-diverse (TGD) individuals, gender-affirming surgery may represent the last opportunity to engage in gamete banking (GB) and other forms of fertility preservation (FP). Previous research has assessed fertility intentions among TGD people initiating hormone therapy. The objective of this study was to describe the fertility intentions of patients seeking gender-affirming surgery. Methods: A retrospective chart review was conducted for 233 patients seeking chest or genital surgery between 2017 and 2019. Data abstracted included interest in having children (biological or non-biological) and GB, and barriers to FP. Associations between fertility intentions, sex assigned at birth, and surgical procedure sought were assessed. Results: Of the 233 records reviewed, 162 (70%) documented information about fertility intentions for patients without a history of sterilizing surgery. At initial consultation, 94% were receiving hormone therapy. Among the 60 patients seeking genital surgery, 30% expressed interest in GB and 38% were not interested in biological children. Among the 102 patients seeking chest surgery, 11% expressed interest in GB and 47% were not interested in biological children. Patients assigned male at birth were more likely to have already completed GB (p < 0.001). Among the patients interested in FP, 41% reported barriers to access. Conclusion: Many TGD people in our study expressed no interest in biological parenthood; however, 30% of patients seeking genital surgery expressed interest in GB. This suggests that some who defer FP when starting hormones may wish to pursue it later in life. Ongoing assessment of fertility intentions and reducing barriers to FP are integral to caring for TGD people.
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Affiliation(s)
| | - Elizabeth R Boskey
- Center for Gender Surgery, Boston Children's Hospital, Boston, Massachusetts, USA.,Department of Plastic and Oral Surgery, Boston Children's Hospital, Boston Massachusetts, USA
| | - Carson J Peters
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA
| | - Chinelo Njubigbo
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA
| | - Brittany M Charlton
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA.,Division of Adolescent Medicine, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Oren Ganor
- Center for Gender Surgery, Boston Children's Hospital, Boston, Massachusetts, USA.,Department of Plastic and Oral Surgery, Boston Children's Hospital, Boston Massachusetts, USA
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16
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Endometrial thickness assessed by transvaginal ultrasound in trans masculine persons on testosterone, compared to cis gender women. Reprod Biomed Online 2022; 45:1033-1038. [DOI: 10.1016/j.rbmo.2022.06.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2022] [Revised: 05/24/2022] [Accepted: 06/16/2022] [Indexed: 11/20/2022]
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17
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Kelley JT, McMullen-Tabry ER, Skala SL. Reproductive Organ Pathology of Individuals Undergoing Gender-Affirming Surgery. Surg Pathol Clin 2022; 15:421-434. [PMID: 35715169 DOI: 10.1016/j.path.2022.02.013] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
As gender-affirming surgeries become more routine, it is increasingly important for pathologists to recognize the expected histologic changes seen in various tissues secondary to gender-affirming hormone therapy. For example, exogenous testosterone-related squamous atrophy or transitional cell metaplasia of the cervix may be confused for high-grade squamous intraepithelial lesion. In addition to distinguishing between benign and dysplastic/malignant features, pathologists should be mindful of the phrasing of their reports and aim to use objective, nongendered language.
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Affiliation(s)
- Justin T Kelley
- Department of Pathology, University of Michigan, Ann Arbor, MI, USA
| | - Emily R McMullen-Tabry
- Department of Pathology, Grand Traverse Pathology, PLLC, 1105 6th Street, Traverse City, MI 49684, USA
| | - Stephanie L Skala
- Department of Pathology, University of Michigan, Ann Arbor, MI, USA.
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18
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Israeli T, Preisler L, Kalma Y, Samara N, Levi S, Groutz A, Azem F, Amir H. Similar fertilization rates and preimplantation embryo development among testosterone-treated transgender men and cisgender women. Reprod Biomed Online 2022; 45:448-456. [DOI: 10.1016/j.rbmo.2022.04.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2022] [Revised: 04/13/2022] [Accepted: 04/26/2022] [Indexed: 11/25/2022]
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19
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Borrás A, Manau D, Fabregues F, Peralta S, Calafell JM, Casals G, Saco A, Agustí I, Carmona F. Comparison between slow freezing and vitrification of ovarian tissue cryopreservation in assigned female at birth transgender people receiving testosterone therapy: data on histological and viability parameters. J Assist Reprod Genet 2022; 39:527-541. [PMID: 35098405 PMCID: PMC8956766 DOI: 10.1007/s10815-021-02386-9] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2021] [Accepted: 12/20/2021] [Indexed: 02/03/2023] Open
Abstract
PURPOSE The use of fertility preservation (FP) techniques has significantly increased in recent years in the assigned female at birth (AFAB) transgender population. Oocyte cryopreservation is the established method for FP, but ovarian tissue cryopreservation may be considered an alternative option, especially during gender-affirming surgery (GAS). The slow freezing (SF) cryopreservation technique is the standard method for human ovarian tissue, but recently, several studies have shown good results with the vitrification (VT) technique. The objective of this study was to compare the effectiveness of VT and SF techniques in ovarian tissue from AFAB transgender people. METHODS This was a prospective study including 18 AFAB transgender people after GAS. Ovarian tissue pieces from each ovary were cryopreserved by SF and VT and compared with fresh tissue. Study by light microscopy (LM) assessed follicular morphology and density. The percentage of surviving and degenerated follicles was studied with the tissue viability test. Oocytes, granulosa cells and stroma were analysed separately by transmission electron microscopy. RESULTS The VT technique preserves follicle and stromal tissue as well as the SF method, but with some differences. Evaluation by LM showed better follicle preservation with VT, but the ultrastructural study showed the presence of minor damage with both techniques compared to fresh tissue. CONCLUSION Both cryopreservation techniques are accurate for maintaining the follicular population and stromal tissue. Further studies are needed to determine the impact of VT on ovarian tissue and the subsequent follicular activation mechanisms in AFAB ovarian tissue.
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Affiliation(s)
- Aina Borrás
- Assisted Reproduction Unit, Clinical Institute of Gynecology, Obstetrics, and Neonatology, Hospital Clínic de Barcelona, Carrer de Villarroel N° 170, 08036 Barcelona, Spain
| | - Dolors Manau
- Assisted Reproduction Unit, Clinical Institute of Gynecology, Obstetrics, and Neonatology, Hospital Clínic de Barcelona, Carrer de Villarroel N° 170, 08036 Barcelona, Spain ,Institut d’Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
| | - Francesc Fabregues
- Assisted Reproduction Unit, Clinical Institute of Gynecology, Obstetrics, and Neonatology, Hospital Clínic de Barcelona, Carrer de Villarroel N° 170, 08036 Barcelona, Spain ,Institut d’Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
| | - Sara Peralta
- Assisted Reproduction Unit, Clinical Institute of Gynecology, Obstetrics, and Neonatology, Hospital Clínic de Barcelona, Carrer de Villarroel N° 170, 08036 Barcelona, Spain
| | - Josep Maria Calafell
- Assisted Reproduction Unit, Clinical Institute of Gynecology, Obstetrics, and Neonatology, Hospital Clínic de Barcelona, Carrer de Villarroel N° 170, 08036 Barcelona, Spain
| | - Gemma Casals
- Assisted Reproduction Unit, Clinical Institute of Gynecology, Obstetrics, and Neonatology, Hospital Clínic de Barcelona, Carrer de Villarroel N° 170, 08036 Barcelona, Spain ,Institut d’Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
| | - Adela Saco
- Department of Pathology, Hospital Clinic, University of Barcelona, Barcelona, Spain ,Institut d’Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
| | - Inés Agustí
- Assisted Reproduction Unit, Clinical Institute of Gynecology, Obstetrics, and Neonatology, Hospital Clínic de Barcelona, Carrer de Villarroel N° 170, 08036 Barcelona, Spain
| | - Francisco Carmona
- Assisted Reproduction Unit, Clinical Institute of Gynecology, Obstetrics, and Neonatology, Hospital Clínic de Barcelona, Carrer de Villarroel N° 170, 08036 Barcelona, Spain ,Institut d’Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
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20
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Wilde M, Huguelet P, Alaniz VI. Transgender Medicine and Hormone Therapy: What the Gynecologist Needs to Know. Clin Obstet Gynecol 2021; 64:739-756. [PMID: 34292172 DOI: 10.1097/grf.0000000000000646] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
The transgender community comprises individuals with diverse identities in both gender and sexual orientation. Unfortunately, many face discrimination and harassment within our society-including within the medical system. There is an overall lack of provider training in transgender specific health which has led to health disparities and inequities within this population. This chapter aims to elucidate the medical needs unique to transgender and gender nonconforming individuals and thus enable medical providers to meet those needs with competency and compassion.
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Affiliation(s)
- Melyssa Wilde
- Department of Obstetrics and Gynecology, University of Colorado School of Medicine, Aurora, Colorado
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21
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Secchi C, Belli M, Harrison TNH, Swift J, Ko C, Duleba AJ, Stupack D, Chang RJ, Shimasaki S. Effect of the spatial-temporal specific theca cell Cyp17 overexpression on the reproductive phenotype of the novel TC17 mouse. J Transl Med 2021; 19:428. [PMID: 34654452 PMCID: PMC8520195 DOI: 10.1186/s12967-021-03103-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2021] [Accepted: 10/01/2021] [Indexed: 12/15/2022] Open
Abstract
Background In the ovarian follicle, the Theca Cells (TCs) have two main functions: preserving morphological integrity and, importantly, secreting steroid androgen hormones. TCs express the essential enzyme 17α-hydroxylase/17,20-desmolase (CYP17), which permits the conversion of pregnenolone and progesterone into androgens. Dysregulation of CYP17 enzyme activity due to an intrinsic ovarian defect is hypothesized to be a cause of hyperandrogenism in women. Androgen excess is observed in women with polycystic ovary syndrome (PCOS) resulting from excess endogenous androgen production, and in transgender males undergoing exogenous testosterone therapy after female sex assignment at birth. However, the molecular and morphological effects of Cyp17 overexpression and androgen excess on folliculogenesis is unknown. Methods In this work, seeking a comprehensive profiling of the local outcomes of the androgen excess in the ovary, we generated a transgenic mouse model (TC17) with doxycycline (Dox)-induced Cyp17 overexpression in a local and temporal manner. TC17 mice were obtained by a combination of the Tet-dependent expression system and the Cre/LoxP gene control system. Results Ovaries of Dox-treated TC17 mice overexpressed Cyp17 specifically in TCs, inducing high testosterone levels. Surprisingly, TC17 ovarian morphology resembled the human ovarian features of testosterone-treated transgender men (partially impaired folliculogenesis, hypertrophic or luteinized stromal cells, atretic follicles, and collapsed clusters). We additionally assessed TC17 fertility denoting a perturbation of the normal reproductive functions (e.g., low pregnancy rate and numbers of pups per litter). Finally, RNAseq analysis permitted us to identify dysregulated genes (Lhcgr, Fshr, Runx1) and pathways (Extra Cellular Matrix and Steroid Synthesis). Conclusions Our novel mouse model is a versatile tool to provide innovative insights into study the effects of Cyp17 overexpression and hyperandrogenism in the ovary. Supplementary Information The online version contains supplementary material available at 10.1186/s12967-021-03103-x.
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Affiliation(s)
- Christian Secchi
- Department of Obstetrics, Gynecology and Reproductive Sciences, School of Medicine, University of California San Diego, La Jolla, CA, USA.
| | - Martina Belli
- Department of Obstetrics, Gynecology and Reproductive Sciences, School of Medicine, University of California San Diego, La Jolla, CA, USA
| | - Tracy N H Harrison
- Department of Obstetrics, Gynecology and Reproductive Sciences, School of Medicine, University of California San Diego, La Jolla, CA, USA
| | - Joseph Swift
- The Salk Institute for Biological Studies, La Jolla, CA, USA
| | - CheMyong Ko
- Department of Comparative Biosciences, College of Veterinary Medicine, University of Illinois at Urbana-Champaign, Urbana, IL, USA
| | - Antoni J Duleba
- Department of Obstetrics, Gynecology and Reproductive Sciences, School of Medicine, University of California San Diego, La Jolla, CA, USA
| | - Dwayne Stupack
- Department of Obstetrics, Gynecology and Reproductive Sciences, School of Medicine, University of California San Diego, La Jolla, CA, USA
| | - R Jeffrey Chang
- Department of Obstetrics, Gynecology and Reproductive Sciences, School of Medicine, University of California San Diego, La Jolla, CA, USA
| | - Shunichi Shimasaki
- Department of Obstetrics, Gynecology and Reproductive Sciences, School of Medicine, University of California San Diego, La Jolla, CA, USA
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22
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Lunde CE, Spigel R, Gordon CM, Sieberg CB. Beyond the Binary: Sexual and Reproductive Health Considerations for Transgender and Gender Expansive Adolescents. FRONTIERS IN REPRODUCTIVE HEALTH 2021; 3:670919. [PMID: 36304055 PMCID: PMC9580725 DOI: 10.3389/frph.2021.670919] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2021] [Accepted: 08/31/2021] [Indexed: 01/10/2023] Open
Abstract
Awareness and visibility of transgender individuals have grown exponentially. However, conceptualizing sexual and reproductive health (SRH) as “women's” or “men's” health services further marginalizes transgender and gender-expansive (TGE) youth. Multiple reviews and commentaries have been published on the topic of SRH care for adults under the umbrella term of sexual and gender minorities, all with a call to action for more inclusive care and the need for more clinical research involving TGE individuals, and notably, TGE youth. Results from adult TGE studies are often translated to describe adolescent models. However, models specific to adolescent TGE populations are needed to understand their unique SRH needs. This review will describe the current literature relating to SRH needs of TGE youth and adults, highlighting key areas with significant disparities in need of further research. This comprehensive summary will also provide recommendations for clinicians and researchers with the goal of improving SRH care and obtaining wider representation in both clinical settings and research directed toward TGE youth.
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Affiliation(s)
- Claire E. Lunde
- Biobehavioral Pediatric Pain Lab, Department of Psychiatry and Behavioral Sciences, Boston Children's Hospital, Boston, MA, United States
- Pain & Affective Neuroscience Center, Department of Anesthesiology, Critical Care, and Pain Medicine, Boston Children's Hospital, Boston, MA, United States
- Nuffield Department of Women's and Reproductive Health, Medical Sciences Division, University of Oxford, Oxford, United Kingdom
| | - Rebecca Spigel
- Division of Adolescent/Young Adult Medicine, Boston Children's Hospital, Boston, MA, United States
| | - Catherine M. Gordon
- Division of Adolescent/Young Adult Medicine, Boston Children's Hospital, Boston, MA, United States
- Harvard Medical School, Boston, MA, United States
| | - Christine B. Sieberg
- Biobehavioral Pediatric Pain Lab, Department of Psychiatry and Behavioral Sciences, Boston Children's Hospital, Boston, MA, United States
- Pain & Affective Neuroscience Center, Department of Anesthesiology, Critical Care, and Pain Medicine, Boston Children's Hospital, Boston, MA, United States
- Department of Psychiatry, Harvard Medical School, Boston, MA, United States
- *Correspondence: Christine B. Sieberg
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23
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Salzer EAJ. Fecundity in transgender men. JAAPA 2021; 34:51-53. [PMID: 34582387 DOI: 10.1097/01.jaa.0000750996.25261.ce] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
ABSTRACT Premenopausal transgender men who retain internal female reproductive organs, who use exogenous testosterone, and who are sexually active with cisgender men are often capable of conception. This article discusses the potential for fecundity in transgender men, as well as appropriate reproductive care depending on whether the patient prefers to avoid conception or to become pregnant.
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Affiliation(s)
- Elizabeth A J Salzer
- Elizabeth A.J. Salzer is a clinical associate professor in the PA program at the Pace University-Lenox Hill Hospital in New York, N.Y., and practices at Mount Sinai Medical Center and in a private practice in the Bronx. The author has disclosed no potential conflicts of interest, financial or otherwise
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24
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Lin LH, Hernandez A, Marcus A, Deng FM, Adler E. Histologic Findings in Gynecologic Tissue From Transmasculine Individuals Undergoing Gender-Affirming Surgery. Arch Pathol Lab Med 2021; 146:742-748. [PMID: 34591101 DOI: 10.5858/arpa.2021-0199-oa] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/20/2021] [Indexed: 11/06/2022]
Abstract
CONTEXT.— Gender-affirming surgery is part of a multidisciplinary approach in gender transitioning. Deeper histologic examination may strengthen care for transmasculine individuals and increase the understanding of the influence of hormonal therapy in specific organs. OBJECTIVE.— To evaluate and catalogue histologic findings of tissue obtained from gender-affirming gynecologic surgery and cervical cytology specimens. DESIGN.— This is an institutional review board-approved retrospective study that included transmasculine individuals who underwent gender-affirming gynecologic surgery from January 2015 to June 2020. All surgical gynecologic pathology and cervical cytology slides were reviewed by 2 pathologists. RESULTS.— Fifty-five patients were included, which represented 40 uteri, 35 bilateral ovaries, 15 vaginectomy specimens, and 24 cervical cytology results. The median age was 27 years (range, 18-56) and 94% (50 of 53) of patients were receiving testosterone for at least 1 year. Seventy-five percent (30 of 40) of endometria were inactive, while 25% (10 of 40) showed evidence of cycling. Transitional cell metaplasia was the most common finding in the cervix (17 of 40) and vagina (15 of 15), reflecting a high percentage (4 of 24) of unsatisfactory or ASC-US (atypical squamous cells of undetermined significance) cervical cytologies. Prostatic-type glands were identified in 20% (8 of 40) of cervices and 67% (10 of 15) of vaginectomy specimens. Multiple bilateral cystic follicles and evidence of follicular maturation were present in 57% (20 of 35) of cases. Four cases showed paratubal epididymis-like mesonephric remnant hypertrophy. CONCLUSIONS.— A comprehensive evaluation of tissue from gender-affirming surgery increases knowledge of the changes following androgen therapy in transmasculine individuals and may contribute to optimal patient care by raising awareness of normal histologic variations in this population.
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Affiliation(s)
- Lawrence Hsu Lin
- From the Department of Pathology, NYU Langone Medical Center, New York, New York (Lin, Marcus, Deng, Adler)
| | - Andrea Hernandez
- the Department of Pathology, NYU Long Island School of Medicine, Mineola, New York (Hernandez)
| | - Alan Marcus
- From the Department of Pathology, NYU Langone Medical Center, New York, New York (Lin, Marcus, Deng, Adler)
| | - Fang-Ming Deng
- From the Department of Pathology, NYU Langone Medical Center, New York, New York (Lin, Marcus, Deng, Adler)
| | - Esther Adler
- From the Department of Pathology, NYU Langone Medical Center, New York, New York (Lin, Marcus, Deng, Adler)
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Andrews AR, Kakadekar A, Greene DN, Khalifa MA, Santiago V, Schmidt RL. Histologic Findings in Surgical Pathology Specimens From Individuals Taking Masculinizing Hormone Therapy for the Purpose of Gender Transition: A Systematic Scoping Review. Arch Pathol Lab Med 2021; 146:766-779. [PMID: 34559874 DOI: 10.5858/arpa.2020-0774-ra] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/24/2021] [Indexed: 11/06/2022]
Abstract
CONTEXT.— Transgender men and transmasculine persons experience a discordance between the female sex they were assigned at birth and their gender. They may choose to take hormone therapy and/or undergo surgery to masculinize the body. Understanding the common (and less common) histologic changes present in patients taking masculinizing hormones will empower pathologists to better serve this unique patient population. OBJECTIVE.— To summarize histologic findings in surgical pathology specimens from persons taking masculinizing hormones as a part of gender transition. DATA SOURCES.— A systematic review of the OVID Medline and PubMed databases was performed to identify all studies describing histologic findings in surgical pathology specimens from transgender men from January 1946 to January 2021. CONCLUSIONS.— Publication in this area has markedly increased in the last 2 decades. However, most of the studies identified were descriptive and case reports describing changes seen in specimens removed as a part of masculinizing surgical procedures. Benign histologic findings include stromal hyalinization and epithelial atrophy in the breast, polycystic ovarian syndrome-like changes in the ovary, and transitional cell metaplasia in the cervix. The most commonly reported neoplastic finding was adenocarcinoma of the breast, with rare cases of ovarian, endometrial, cervical, vaginal, pituitary, pancreatic, and cardiovascular neoplasia also reported. Ongoing research in this area is needed to better characterize the histologic findings in persons taking masculinizing hormones to provide a deeper understanding of the effect of these treatments on different tissues and facilitate better patient management.
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Affiliation(s)
- Alicia R Andrews
- From the Department of Pathology and Laboratory Medicine, University of Saskatchewan, Saskatoon, SK Canada (Andrews, Kakadekar)
| | - Archan Kakadekar
- From the Department of Pathology and Laboratory Medicine, University of Saskatchewan, Saskatoon, SK Canada (Andrews, Kakadekar)
| | - Dina N Greene
- Kaiser Permanente Washington Laboratories, Seattle, Washington (Greene)
| | - Mahmoud A Khalifa
- Department of Laboratory Medicine and Pathology, University of Minnesota, Minneapolis (Khalifa, Santiago)
| | - Victor Santiago
- Department of Laboratory Medicine and Pathology, University of Minnesota, Minneapolis (Khalifa, Santiago)
| | - Robert L Schmidt
- Department of Pathology, University of Utah, Salt Lake City (Schmidt)
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Schwartz AR, Moravek MB. Reproductive potential and fertility preservation in transgender and nonbinary individuals. Curr Opin Obstet Gynecol 2021; 33:327-334. [PMID: 34173770 DOI: 10.1097/gco.0000000000000729] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
PURPOSE OF REVIEW To synthesize recent literature to better understand parenting desires and challenges of transgender individuals as well as the impact of gender-affirming care on reproductive potential. RECENT FINDINGS Survey studies of transgender and nonbinary individuals demonstrate significant parenting interest, yet uptake in fertility preservation services remains low with potential for decisional regret. Masculinizing hormones have demonstrated variable effects on folliculogenesis and follicle distribution in the human ovary. In the mouse model, testosterone administration has demonstrated an increase in atretic late antral follicles without a reduction in primordial or total antral follicle counts and a preserved ability to respond to gonadotropin stimulation. Case series of transgender individuals undergoing oocyte or embryo cryopreservation are promising with outcomes similar to cisgender controls. Feminizing hormones have shown detrimental effects on sperm parameters at time of cryopreservation and spermatogenesis in orchiectomy samples with uncertainty regarding the reversibility of these changes. SUMMARY Current evidence demonstrates variable effects of gender-affirming hormones on ovarian and testicular function with potential for detrimental impact on an individual's reproductive potential. As many individuals initiate gender-affirming care prior to or during their reproductive years it is imperative that they receive thorough fertility preservation counseling and improved access to reproductive care services.
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Affiliation(s)
- Amanda R Schwartz
- Division of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, Michigan, USA
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Clinical Characteristics and Histologic Features of Hysterectomy Specimens From Transmasculine Individuals. Obstet Gynecol 2021; 138:51-57. [PMID: 34259463 DOI: 10.1097/aog.0000000000004421] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2021] [Accepted: 03/25/2021] [Indexed: 11/27/2022]
Abstract
OBJECTIVE To describe the clinical characteristics of transmasculine individuals who underwent hysterectomy and characterize surgical pathology findings. METHODS Under an institutional review board-approved protocol, transmasculine individuals who were undergoing hysterectomy and bilateral salpingectomy or bilateral salpingo-oophorectomy were retrospectively identified from a single institution. Past medical, surgical, obstetric, and gynecologic history were collected, including prior testosterone use, cervical cancer screening status, and preoperative pelvic imaging. Surgical pathologic findings of the endometrium, ovaries, and cervix were collected. RESULTS A total of 72 individuals were included. The median age was 30 years (range 19-51). The majority of patients had private insurance (n=53, 74%) and were on testosterone at time of the preoperative visit (n=63, 88%). Forty-two patients (58%) reported anxiety, depression, or bipolar disorder, and 34 patients (47%) were taking an antidepressant or mood stabilizer. Of the 68 patients eligible for cervical cancer screening, 33 (49%) were up to date before their surgical consultation visits. Pelvic pain was the leading indication for surgery (n=65, 90%), and 29 patients (40%) had multiple listed indications for surgery. Surgical pathology results included cervical intraepithelial neoplasia 2-3 in three patients (4%), endometrial or cervical atrophy in 13 patients (18%), and ovarian or paratubal cysts in 16 patients (22%). CONCLUSION This study describes the distinct clinical characteristics and surgical pathology findings that health care professionals should consider when caring for this unique patient population, including a relatively high rate of mental health conditions, pelvic pain as the leading indication for surgery, and the presence of endometrial or cervical atrophy and ovarian or paratubal cysts on surgical pathology.
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Hawkins M, Deutsch MB, Obedin-Maliver J, Stark B, Grubman J, Jacoby A, Jacoby VL. Endometrial findings among transgender and gender nonbinary people using testosterone at the time of gender-affirming hysterectomy. Fertil Steril 2021; 115:1312-1317. [PMID: 33583596 DOI: 10.1016/j.fertnstert.2020.11.008] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2020] [Revised: 11/03/2020] [Accepted: 11/04/2020] [Indexed: 01/08/2023]
Abstract
OBJECTIVE To describe clinical characteristics and associated endometrial findings of transgender and gender nonbinary people using gender-affirming testosterone. DESIGN Retrospective case series. SETTING Academic medical center and public safety net hospital. PATIENT(S) Eighty-one patients using gender-affirming testosterone therapy undergoing hysterectomy for the indication of gender affirmation from 2000 to 2018. INTERVENTION(S) None. MAIN OUTCOME MEASURE(S) Preoperative clinical characteristics and endometrium surgical pathology diagnoses. RESULT(S) Median age was 31 years (interquartile range [IQR] 27-40), and median body mass index 27 kg/m2 (IQR 24-30). Six patients (7%) were parous and 60 (74%) had amenorrhea. Thirty-three patients (40%) had proliferative and 40 (50%) atrophic endometrium. Endometrial polyps were found in nine patients (11%) of the sample. Endometrial findings were similar in the subgroup of 60 patients with preoperative amenorrhea. There were no cases of endometrial hyperplasia or malignancy. In bivariate analysis, those with proliferative endometrium were found to be, on average, 5.6 years younger than those with atrophic endometrium. There were no clinical factors associated with having proliferative versus atrophic endometrium in multivariable models. CONCLUSION(S) People using gender-affirming testosterone may have either proliferative or atrophic endometrium, including people who present with amenorrhea. Further study is needed to develop evidence-based guidelines for appropriate screening for endometrial hyperplasia or cancer in this population.
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Affiliation(s)
- Mitzi Hawkins
- San Francisco Veteran Affairs Medical Center, San Francisco, California; Department of Obstetrics, Gynecology, and Reproductive Sciences, University of California, San Francisco, California.
| | - Madeline B Deutsch
- Department of Family and Community Medicine, University of California, San Francisco, California
| | - Juno Obedin-Maliver
- Department of Obstetrics and Gynecology, Stanford University, Palo Alto, California
| | - Brett Stark
- Department of Obstetrics, Gynecology, and Reproductive Sciences, University of California, San Francisco, California
| | - Jessica Grubman
- Department of Obstetrics, Gynecology, and Reproductive Sciences, University of California, San Francisco, California
| | - Alison Jacoby
- Department of Obstetrics, Gynecology, and Reproductive Sciences, University of California, San Francisco, California
| | - Vanessa L Jacoby
- Department of Obstetrics, Gynecology, and Reproductive Sciences, University of California, San Francisco, California
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Contraception across transgender. Int J Impot Res 2021; 33:710-719. [PMID: 33558672 DOI: 10.1038/s41443-021-00412-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2020] [Revised: 01/19/2021] [Accepted: 01/21/2021] [Indexed: 11/09/2022]
Abstract
Sexual and reproductive issues are essential elements of well-being in cisgenders as well as for the transgender population. Gender-affirming hormonal treatments (GAHTs) aim to induce phenotypical changes congruent with the desired gender and subsequent reduction of gender dysphoria. While genital surgical procedures including hysterectomy and/or adenectomy cause permanent loss of ability to conceive, GAHT may induce a varying degree of reversible loss of fertility. For these reasons, transgender men and women need to be counseled concerning contraceptive options and potential effects of treatment on reproductive function before initiating GAHT. The literature reports that sexual activity with genital involvement is performed by less than half of transgender persons who have been sexually active with a partner in the past. Testosterone (T) is the most commonly used compound in transmen and usually leads to amenorrhea within 1-12 months from first administration, however cessation of menses does not mean anovulation. Some studies report cases of unintended pregnancies among transgender men under masculinizing therapy, therefore T treatment cannot be considered a contraceptive option. Currently available contraceptive options have pros and cons in transmen and scarce literature exists on their use. The effects of GAHT on fertility in transwomen are even less well known. Prolonged estrogen exposure induces sperm suppression and morphological changes of the spermatozoa, however the degree of resulting pregnancy protection is unclear. Further research to inform the contraceptive counseling in this population is mandatory.
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A serous borderline ovarian tumour in a transgender male adolescent. Br J Cancer 2020; 124:567-569. [PMID: 33106582 PMCID: PMC7851115 DOI: 10.1038/s41416-020-01129-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2020] [Revised: 09/25/2020] [Accepted: 10/07/2020] [Indexed: 02/07/2023] Open
Abstract
Here we present a transgender male adolescent with an androgen receptor-positive serous borderline ovarian tumour in the setting of testosterone treatment for medical gender transition. To our knowledge, this is the second report of borderline tumour in a transgender individual and the first in an adolescent, an age group in which borderline tumours are extremely rare. We discuss the specific considerations of treating ovarian tumours in the transgender male population, the incompletely understood role of androgens in the genesis of ovarian epithelial neoplasia, and an emphasis on assessing cancer risk in transgender patients based on patient anatomy.
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Mayhew AC, Gomez-Lobo V. Fertility Options for the Transgender and Gender Nonbinary Patient. J Clin Endocrinol Metab 2020; 105:5892794. [PMID: 32797184 PMCID: PMC7455280 DOI: 10.1210/clinem/dgaa529] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2020] [Accepted: 08/10/2020] [Indexed: 12/14/2022]
Abstract
Comprehensive care for transgender and gender nonbinary patients has been a priority established by the World Professional Association for Transgender Health. Because pubertal suppression, gender-affirming hormone therapy, and antiandrogen therapy used alone or in combination during medical transition can affect gonadal function, understanding the effects these treatments have on fertility potential is important for practitioners caring for transgender and gender nonbinary patients. In this review, we outline the impacts of gender-affirming treatments on fertility potential and discuss the counseling and the treatment approach for fertility preservation and/or family building in transgender and gender nonbinary individuals.
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Affiliation(s)
- Allison C Mayhew
- Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, Maryland
- Children’s National Medical Center, Washington, DC
| | - Veronica Gomez-Lobo
- Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, Maryland
- Children’s National Medical Center, Washington, DC
- Correspondence and Reprint Requests: Veronica Gomez-Lobo, MD, National Institute of Child Health and Human Development, Children’s National Medical Center, Division of Pediatric and Adolescent Gynecology, 10 Central Dr, Bldg 10, Rm 8N248, Bethesda, MD 20892, USA. E-mail:
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Stenzel AE, Moysich KB, Ferrando CA, Starbuck KD. Clinical needs for transgender men in the gynecologic oncology setting. Gynecol Oncol 2020; 159:899-905. [PMID: 33004214 DOI: 10.1016/j.ygyno.2020.09.038] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2020] [Accepted: 09/21/2020] [Indexed: 01/15/2023]
Abstract
Transgender men remain at risk for gynecologic malignancies, but are an underserved population. Members of the transgender community experience discrimination and have experiences that contribute to health disparities, including in gynecology and oncology. While efforts have been made within the United States to reduce inequalities experienced by members of this community, many needs in the clinical setting remain. Increased education and training among providers and healthcare professionals, and general improvements towards understanding barriers to health screening and health resource uptake may reduce some disparities. Additional research towards screening and cancer surveillance among this community will be necessary to understand any potential additional risks and survival disparities experienced by transgender men. This review focuses on barriers and clinical needs for transgender men in the gynecologic oncology setting, and suggestions for moving forward to improve care for this patient population.
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Affiliation(s)
- Ashley E Stenzel
- Program in Health Disparities Research, Department of Family Medicine & Community Health, University of Minnesota Medical School, Minneapolis, MN, USA.
| | - Kirsten B Moysich
- Department of Cancer Prevention & Control, Roswell Park Comprehensive Cancer Center, Buffalo, NY, USA
| | - Cecile A Ferrando
- Center for Urogynecology & Pelvic Reconstructive Surgery, Center for LGBT Care, Subspecialty Care for Women's Health, Cleveland Clinic, Cleveland, OH, USA
| | - Kristen D Starbuck
- Department of Gynecologic Oncology, Roswell Park Comprehensive Cancer Center, Buffalo, NY, USA
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33
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Kinnear HM, Constance ES, David A, Marsh EE, Padmanabhan V, Shikanov A, Moravek MB. A mouse model to investigate the impact of testosterone therapy on reproduction in transgender men. Hum Reprod 2020; 34:2009-2017. [PMID: 31585007 DOI: 10.1093/humrep/dez177] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2019] [Revised: 07/22/2019] [Indexed: 11/14/2022] Open
Abstract
STUDY QUESTION Can mice serve as a translational model to investigate the reproductive effects of testosterone (T) therapy commonly used by transgender men? SUMMARY ANSWER T enanthate subcutaneous injections at 0.45 mg twice weekly can be used in the postpubertal C57BL/6N female mouse to investigate the reproductive effects of T therapy given to transgender men. WHAT IS KNOWN ALREADY Most models of T treatment in female mice involve prenatal or prepubertal administration, which are not applicable to transgender men who often begin T therapy after puberty. Studies that have looked at the impact of postpubertal T treatment in female mice have generally not investigated reproductive outcomes. STUDY DESIGN, SIZE, DURATION A total of 20 C57BL/6N female mice were used for this study. Study groups (n = 5 mice per group) included sesame oil vehicle controls and three doses of T enanthate (0.225, 0.45 and 0.90 mg). Mice were injected subcutaneously twice weekly for 6 weeks. PARTICIPANTS/MATERIALS, SETTING, METHODS Daily vaginal cytology was performed prior to initiation of treatment to confirm that all mice were cycling. At 8-9 weeks of age, therapy with subcutaneous T enanthate (0.225, 0.45 or 0.90 mg) or the vehicle control was begun. T therapy continued for 6 weeks, at which point mice were sacrificed and compared to control mice sacrificed during diestrus/metestrus. Data collected included daily vaginal cytology, weekly and terminal reproductive hormone levels, terminal body/organ weights/measurements, ovarian follicular distribution/morphology and corpora lutea counts. MAIN RESULTS AND THE ROLE OF CHANCE Of the mice treated with 0.90 mg T enanthate, two of five mice experienced vaginal prolapse, so this group was excluded from further analysis. T enanthate administration twice weekly at 0.225 or 0.45 mg resulted in cessation of cyclicity and persistent diestrus. One of five mice at the 0.225-mg dose resumed cycling after 2.5 weeks of T therapy. As compared to controls, T-treated mice had sustained elevated T levels and luteinizing hormone (LH) suppression in the terminal blood sample. T-treated mice demonstrated increases in clitoral area and atretic cyst-like late antral follicles (0.45 mg only) as compared to controls. No reduction in primordial, primary, secondary or total antral follicle counts was detected in T-treated mice as compared to controls, and T-treated mice demonstrated an absence of corpora lutea. LIMITATIONS, REASONS FOR CAUTION Mouse models can provide us with relevant key findings for further exploration but may not perfectly mirror human reproductive physiology. WIDER IMPLICATIONS OF THE FINDINGS To our knowledge, this report describes the first mouse model mimicking T therapy given to transgender men that facilitates analysis of reproductive changes. This model allows for future studies comparing duration and reversibility of T-induced changes, on the reproductive and other systems. It supports a role for T therapy in suppressing the hypothalamic-pituitary-gonadal axis in adult female mice as evidenced by LH suppression, persistent diestrus and absence of corpora lutea. The increase in atretic cyst-like late antral follicles aligns with the increased prevalence of polycystic ovary morphology seen in case series of transgender men treated with T therapy. The results also suggest that T therapy does not deplete the ovarian reserve. STUDY FUNDING/COMPETING INTEREST(S) This work was supported by the American Society for Reproductive Medicine/Society of Reproductive Endocrinology and Infertility Grant and NIH R01-HD098233 to M.B.M. and University of Michigan Office of Research funding (U058227). H.M.K. was supported by the Career Training in Reproductive Biology and Medical Scientist Training Program T32 NIH Training Grants (T32-HD079342, T32-GM07863) as well as the Cellular and Molecular Biology Program. The University of Virginia Center for Research in Reproduction Ligand Assay and Analysis Core is supported by the Eunice Kennedy Shriver NICHD/NIH (NCTRI) Grant P50-HD28934. E.E.M. consults for Allergan. No other authors have competing interests.
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Affiliation(s)
- H M Kinnear
- Program in Cellular and Molecular Biology, University of Michigan, Ann Arbor, MI, USA.,Medical Scientist Training Program, University of Michigan, Ann Arbor, MI, USA
| | - E S Constance
- Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, MI, USA.,Division of Reproductive Endocrinology and Infertility, University of Michigan, Ann Arbor, MI, USA
| | - A David
- Department of Biomedical Engineering, University of Michigan, Ann Arbor, MI, USA
| | - E E Marsh
- Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, MI, USA.,Division of Reproductive Endocrinology and Infertility, University of Michigan, Ann Arbor, MI, USA
| | - V Padmanabhan
- Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, MI, USA.,Department of Pediatrics and Communicable Diseases, University of Michigan, Ann Arbor, MI, USA
| | - A Shikanov
- Program in Cellular and Molecular Biology, University of Michigan, Ann Arbor, MI, USA.,Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, MI, USA.,Department of Biomedical Engineering, University of Michigan, Ann Arbor, MI, USA
| | - M B Moravek
- Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, MI, USA.,Division of Reproductive Endocrinology and Infertility, University of Michigan, Ann Arbor, MI, USA.,Department of Urology, University of Michigan, Ann Arbor, MI, USA
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Fertility preservation options for transgender and gender-nonconforming individuals. Curr Opin Obstet Gynecol 2020; 31:170-176. [PMID: 30870185 DOI: 10.1097/gco.0000000000000537] [Citation(s) in RCA: 32] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW To provide an overview of the current state of knowledge of fertility risks of gender-affirming therapy, review fertility preservation options for transgender individuals and ways to minimize gender dysphoria during fertility treatment, and identify gaps in knowledge. RECENT FINDINGS Recent studies have corroborated older data that gender-affirming hormone therapy creates histopathological changes in the gonads; however, the newer data suggests that some function of the gametes may be preserved. One study in transgender men reported successful in-vitro maturation of testosterone-exposed oocytes with normal spindle structures, and recent studies in transgender women reveal early spermatogenesis in estradiol-exposed testes and some recovery of semen parameters following cessation of hormones. Particular attention has recently been given to fertility preservation in transgender adolescents, revealing unmet informational needs in this population and very few are actually pursuing fertility preservation, even with counseling. SUMMARY There is currently a paucity of data on the fertility effects of gender-affirming hormones, necessitating fertility preservation counseling prior to initiation of therapy. Several modifications can be made to fertility preservation protocols and procedures to decrease gender dysphoria or distress in transgender individuals, but outcome data is still lacking. Achieving high-quality data collection will likely require cooperation across multiple institutions.
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Abstract
Recently, greater attention has been paid to the care of gender dysphoric and gender incongruent individuals. Gynecologists may be called upon to care for individuals who were assigned female at birth throughout or following social, medical, or surgical gender transition. Thus, gynecologists need to be aware of language regarding sex and gender, treatment typically used for the care of gender dysphoric or incongruent individuals, and aspects of well gynecologic care necessary for these individuals. This review highlights these aspects of care for transgender males to aid the general gynecologist in the care and treatment of these individuals.
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Affiliation(s)
- Allison C. Mayhew
- Children’s National Medical Center, Division of Pediatric and Adolescent Gynecology
- Eunice Kennedy Shriver National Institute of Child Health and Human Development
| | | | - Veronica Gomez-Lobo
- Children’s National Medical Center, Division of Pediatric and Adolescent Gynecology
- Eunice Kennedy Shriver National Institute of Child Health and Human Development
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Ovarian stimulation outcomes among transgender men compared with fertile cisgender women. J Assist Reprod Genet 2020; 37:2463-2472. [PMID: 32719977 DOI: 10.1007/s10815-020-01902-7] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2020] [Accepted: 07/23/2020] [Indexed: 12/30/2022] Open
Abstract
PURPOSE To compare assisted reproductive technology (ART) outcomes among transgender men with those of fertile cisgender women. METHODS This retrospective cohort study included 12 transgender men, six with no testosterone exposure and six after testosterone treatment, and 12 cisgender women (oocyte donors) who underwent ART in our institution between June 2017 and December 2019. Statistical analyses compared ART data and outcomes between three groups: cisgender women, transgender men without testosterone exposure, and transgender men after testosterone exposure. Comparisons were also made between transgender men with and without testosterone exposure. RESULTS The transgender men with no testosterone exposure (23.3 ± 4 years) were significantly younger than the transgender men who had undergone testosterone treatment (30.3 ± 3.8 years; P = 0.012) and the cisgender women (29.1 ± 3.1 years; P = 0.004). The amount of FSH used for ovulation induction (1999 ± 683 mIU/mL) was significantly lower among transgender men without prior testosterone exposure compared with that among cisgender women (3150 ± 487 mIU/mL; P = 0.007). There were no differences in the peak estradiol levels, the number of oocytes retrieved, the number of MII oocytes, and the oocyte maturity rates between the three groups. Five out of six testosterone-treated transgender men underwent embryo cryopreservation, and they all achieved good-quality embryos. CONCLUSIONS Transgender men have an excellent response to ovulation stimulation even after long-term exposure to testosterone. Oocyte/embryo cryopreservation is, therefore, a feasible and effective way for them to preserve their fertility for future biological parenting.
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Grimstad FW, Fowler KG, New EP, Ferrando CA, Pollard RR, Chapman G, Gray M, Gomez Lobo V. Ovarian Histopathology in Transmasculine Persons on Testosterone: A Multicenter Case Series. J Sex Med 2020; 17:1807-1818. [PMID: 32703706 DOI: 10.1016/j.jsxm.2020.05.029] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2020] [Revised: 04/15/2020] [Accepted: 05/27/2020] [Indexed: 12/19/2022]
Abstract
BACKGROUND As transmasculine persons utilize androgen gender affirming hormone therapy as a part of transition, guidance has been lacking on the effects of the therapy on the ovaries, especially for those who may desire retention. AIM To describe the ovarian histopathology of transmasculine persons on testosterone therapy following oophorectomy at the time of hysterectomy performed for gender affirmation. METHODS This was a multicenter case series study of transmasculine patients on testosterone therapy who underwent hysterectomy with oophorectomy for gender affirmation between January 2015 and December 2017 at 5 tertiary care referral centers. Patients were identified by their current procedural and International Classification of Diseases codes. OUTCOMES Pre-, perioperative, and pathologic data were obtained from the electronic medical records and ovarian tissue descriptions from pathology reports were grouped into the following classifications: (i) simple/follicular cysts; (ii) polycystic ovaries; (iii) complex cysts; (iv) endometriomas; (v) other masses; (vi) atrophy; and (vii) normal. RESULTS 85 patients were included in the study. At the time of oophorectomy, the mean age and body mass index of the cohort were 30.4 ± 8.4 years and 30.2 ± 7.3 kg/m2, respectively, and the average interval from the initiation of testosterone to oophorectomy was 36 0.3 ± 37.9 months. On examination of ovarian histopathology, 49.4% (42) of specimens were found to have follicular/simple cysts, 5.9% (5) were polycystic, and 38.8% (33) had normal pathology. For those specimens with volume documented (n = 41), the median volume was 9.6 (range 1.5-82.5) cm3. There was no association between the duration of testosterone therapy or body mass index and the presence of cysts in the ovaries. CLINICAL IMPLICATIONS The results of this study reported benign histopathology in ovaries of a large cohort of transmasculine persons on testosterone which should be included when counseling patients on ovarian retention, as transmasculine patients may choose to retain their ovaries while on testosterone for a variety of reasons (including no desire to undergo surgery, desire for backup sex steroids, and potential use for future fertility). STRENGTHS & LIMITATIONS This is a large multicenter study seeking to address the uncertainty in present counseling surrounding ovarian conservation in transmasculine persons on testosterone therapy. Its limitations included its retrospective nature and inability to address ovarian function after testosterone discontinuance. CONCLUSION In this cohort of transmasculine patients on testosterone therapy undergoing hysterectomy with oophorectomy for gender affirmation, ovarian histopathology was benign in all the specimens. Grimstad FW, Fowler KG, New EP, et al. Ovarian Histopathology in Transmasculine Persons on Testosterone: A Multicenter Case Series. J Sex Med 2020;17:1807-1818.
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Affiliation(s)
- Frances W Grimstad
- Division of Gynecology, Department of Surgery, Boston Children's Hospital, Boston, MA, USA.
| | - Kylie G Fowler
- Department of Pediatric and Adolescent Gynecology, Children's Hospitals and Clinics of Minnesota, Minneapolis, MN, USA
| | - Erika P New
- Department of Obstetrics and Gynecology, University of South Florida Morsani College of Medicine, Tampa, FL, USA
| | - Cecile A Ferrando
- Center for Urogynecology and Pelvic Reconstructive Surgery, Center for LGBT Care, Cleveland Clinic, Cleveland, OH, USA
| | - Robert R Pollard
- Department of Obstetrics and Gynecology, University Hospitals Cleveland Medical Center/MetroHealth Medical Center, Cleveland, OH, USA
| | - Graham Chapman
- Department of Obstetrics and Gynecology, University Hospitals Cleveland Medical Center/MetroHealth Medical Center, Cleveland, OH, USA
| | - Meredith Gray
- Department of Obstetrics and Gynecology, University of Kansas Medical Center, Kansas City, KS, USA
| | - Veronica Gomez Lobo
- Department of Pediatric and Adolescent Gynecology, National Institute for Child Health and Human Development, Bethesda, MA, USA
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Grimstad FW, Boskey E, Grey M. New-Onset Abdominopelvic Pain After Initiation of Testosterone Therapy Among Trans-Masculine Persons: A Community-Based Exploratory Survey. LGBT Health 2020; 7:248-253. [DOI: 10.1089/lgbt.2019.0258] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Frances W. Grimstad
- Division of Gynecology, Department of Surgery, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Elizabeth Boskey
- Department of Plastic and Oral Surgery, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Meredith Grey
- Department of Obstetrics and Gynecology, University of Kansas Medical Center, Kansas City, Kansas, USA
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Moulder JK, Carrillo J, Carey ET. Pelvic Pain in the Transgender Man. CURRENT OBSTETRICS AND GYNECOLOGY REPORTS 2020. [DOI: 10.1007/s13669-020-00293-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
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Moravek MB, Kinnear HM, George J, Batchelor J, Shikanov A, Padmanabhan V, Randolph JF. Impact of Exogenous Testosterone on Reproduction in Transgender Men. Endocrinology 2020; 161:5762628. [PMID: 32105330 PMCID: PMC7046016 DOI: 10.1210/endocr/bqaa014] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/01/2019] [Accepted: 02/25/2020] [Indexed: 12/11/2022]
Abstract
Studies show that a subset of transgender men desire children; however, there is a paucity of literature on the effect of gender-affirming testosterone therapy on reproductive function. In this manuscript, we will review the process of gender-affirming hormone therapy for transgender men and what is known about ovarian and uterine consequences of testosterone exposure in transgender men; draw parallels with existing animal models of androgen exposure; summarize the existing literature on parenting experiences and desires in transgender people; discuss considerations for assisted reproductive technologies and fertility preservation; and identify gaps in the literature and opportunities for further research.
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Affiliation(s)
- Molly B Moravek
- Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, Michigan
- Department of Urology, University of Michigan, Ann Arbor, Michigan
- Correspondence: Molly B. Moravek, MD, MPH, Department of Obstetrics and Gynecology, Center for Reproductive Medicine, 475 Market Place, Building 1, Suite B, Ann Arbor, MI 48108. E-mail
| | - Hadrian M Kinnear
- Cellular and Molecular Biology Program, University of Michigan, Ann Arbor, Michigan
- Medical Scientist Training Program, University of Michigan, Ann Arbor, Michigan
| | - Jenny George
- Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, Michigan
| | | | - Ariella Shikanov
- Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, Michigan
- Cellular and Molecular Biology Program, University of Michigan, Ann Arbor, Michigan
- Department of Biomedical Engineering, University of Michigan, Ann Arbor, Michigan
| | - Vasantha Padmanabhan
- Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, Michigan
- Department of Pediatrics and Communicable Diseases, University of Michigan, Ann Arbor, Michigan
| | - John F Randolph
- Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, Michigan
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Fertility Preservation in the Transgender Population. CURRENT SEXUAL HEALTH REPORTS 2020. [DOI: 10.1007/s11930-020-00238-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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Defreyne J, Aers XP, Collet SM, Wiepjes CM, Fisher AD, Schreiner T, Den Heijer M, Kaufman JM, T'Sjoen GG. Lower Serum Estradiol Levels in Assigned Female at Birth Transgender People with Initiation of Testosterone Therapy: Results from the European Network for the Investigation of Gender Incongruence. LGBT Health 2020; 7:71-81. [DOI: 10.1089/lgbt.2019.0260] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Affiliation(s)
- Justine Defreyne
- Department of Endocrinology, Ghent University Hospital, Ghent, Belgium
| | | | - Sarah M. Collet
- Department of Endocrinology, Ghent University Hospital, Ghent, Belgium
| | - Chantal M. Wiepjes
- Department of Endocrinology and Center of Expertise on Gender Dysphoria, Amsterdam University Medical Center, VUmc, Amsterdam, the Netherlands
| | - Alessandra D. Fisher
- Andrology, Women's Endocrinology and Gender Incongruence Unit, Department of Experimental, Clinical and Biomedical Sciences, University of Florence, Florence, Italy
| | - Thomas Schreiner
- Department of Endocrinology, Oslo University Hospital, Oslo, Norway
| | - Martin Den Heijer
- Department of Endocrinology and Center of Expertise on Gender Dysphoria, Amsterdam University Medical Center, VUmc, Amsterdam, the Netherlands
| | - Jean-Marc Kaufman
- Department of Endocrinology, Ghent University Hospital, Ghent, Belgium
| | - Guy G.R. T'Sjoen
- Department of Endocrinology and Center for Sexology and Gender, Ghent University Hospital, Ghent, Belgium
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García-Acosta JM, San Juan-Valdivia RM, Fernández-Martínez AD, Lorenzo-Rocha ND, Castro-Peraza ME. Trans* Pregnancy and Lactation: A Literature Review from a Nursing Perspective. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2019; 17:ijerph17010044. [PMID: 31861638 PMCID: PMC6981677 DOI: 10.3390/ijerph17010044] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/18/2019] [Revised: 12/13/2019] [Accepted: 12/14/2019] [Indexed: 11/16/2022]
Abstract
Pregnancy and lactation involve two aspects that are socially and culturally associated with women. However, there are a few biological differences between male and female breast tissue. Lactation and pregnancy are viable processes that do not depend on sex. Even for the latter, it is only necessary to have an organ capable of gestation. Ways to favor mammogenesis and lactogenesis in trans* women have been established. There are protocols to promote lactation in trans* women, usually used for adoptive mothers or those whose children have been born through gestational surrogacy. Chestfeeding a baby could be the cause of feelings as diverse as gender dysphoria in the case of trans* men, and euphoria and affirmation of femininity in trans* women. This study involves a review of the available scientific literature addressing medical aspects related to pregnancy and lactation in trans* individuals, giving special attention to nursing care during perinatal care. There are scarce studies addressing care and specifically nursing care in trans* pregnancy and lactation. Our study indicates the factors that can be modified and the recommendations for optimizing the care provided to these individuals in order to promote and maintain the lactation period in search of improvement and satisfaction with the whole process.
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Affiliation(s)
- Jesús Manuel García-Acosta
- Faculty of Nursing, University of La Laguna, Canary Islands Public Health Service, 38010 Tenerife, Canary Islands, Spain
- Correspondence: ; Tel.: +34-6-8700-7510
| | | | - Alfredo David Fernández-Martínez
- Department of Education Counseling Universities, Culture and Sports, Government of the Canary Islands, 38010 Tenerife, Canary Islands, Spain;
| | - Nieves Doria Lorenzo-Rocha
- The Faculty of Nursing Nª Sª de La Candelaria, University of La Laguna, Canary Islands Public Health Service, 38010 Tenerife, Canary Islands, Spain; (N.D.L.-R.); (M.E.C.-P.)
| | - Maria Elisa Castro-Peraza
- The Faculty of Nursing Nª Sª de La Candelaria, University of La Laguna, Canary Islands Public Health Service, 38010 Tenerife, Canary Islands, Spain; (N.D.L.-R.); (M.E.C.-P.)
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Histologic Features of Hysterectomy Specimens From Female-Male Transgender Individuals. Int J Gynecol Pathol 2019; 38:520-527. [DOI: 10.1097/pgp.0000000000000548] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Baram S, Myers SA, Yee S, Librach CL. Fertility preservation for transgender adolescents and young adults: a systematic review. Hum Reprod Update 2019; 25:694-716. [DOI: 10.1093/humupd/dmz026] [Citation(s) in RCA: 41] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2019] [Revised: 06/21/2019] [Accepted: 07/14/2019] [Indexed: 12/17/2022] Open
Abstract
Abstract
BACKGROUND
Many transgender individuals choose to undergo gender-affirming hormone treatment (GAHT) and/or sex reassignment surgery (SRS) to alleviate the distress that is associated with gender dysphoria. Although these treatment options often succeed in alleviating such symptoms, they can also negatively impact future reproductive potential.
OBJECTIVE AND RATIONALE
The purpose of this systematic review was to synthesize the available psychosocial and medical literature on fertility preservation (FP) for transgender adolescents and young adults (TAYAs), to identify gaps in the current research and provide suggestions for future research directions.
SEARCH METHODS
A systematic review of English peer-reviewed papers published from 2001 onwards, using the preferred reporting items for systematic reviews and meta-analyses protocols (PRISMA-P) guidelines, was conducted. Four journal databases (Ovid MEDLINE, PubMed Medline, Ovid Embase and Ovid PsychINFO) were used to identify all relevant studies exploring psychosocial or medical aspects of FP in TAYAs. The search strategy used a combination of subject headings and generic terms related to the study topic and population. Bibliographies of the selected articles were also hand searched and cross-checked to ensure comprehensive coverage. All selected papers were independently reviewed by the co-authors. Characteristics of the studies, objectives and key findings were extracted, and a systematic review was conducted.
OUTCOMES
Included in the study were 19 psychosocial-based research papers and 21 medical-based research papers that explore fertility-related aspects specific for this population. Key psychosocial themes included the desire to have children for TAYAs; FP discussions, counselling and referrals provided by healthcare providers (HCPs); FP utilization; the attitudes, knowledge and beliefs of TAYAs, HCPs and the parents/guardians of TAYAs; and barriers to accessing FP. Key medical themes included fertility-related effects of GAHT, FP options and outcomes. From a synthesis of the literature, we conclude that there are many barriers preventing TAYAs from pursuing FP, including a lack of awareness of FP options, high costs, invasiveness of the available procedures and the potential psychological impact of the FP process. The available medical data on the reproductive effects of GAHT are diverse, and while detrimental effects are anticipated, the extent to which these effects are reversible is unknown.
WIDER IMPLICATIONS
FP counselling should begin as early as possible as a standard of care before GAHT to allow time for informed decisions. The current lack of high-quality medical data specific to FP counselling practice for this population means there is a reliance on expert opinion and extrapolation from studies in the cisgender population. Future research should include large-scale cohort studies (preferably multi-centered), longitudinal studies of TAYAs across the FP process, qualitative studies of the parents/guardians of TAYAs and studies evaluating the effectiveness of different strategies to improve the attitudes, knowledge and beliefs of HCPs.
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Affiliation(s)
- Shira Baram
- Create Fertility Centre, 790 Bay Street, Suite 1100, Toronto, Ontario M5G 1N8, Canada
- Department of Obstetrics and Gynecology, University of Toronto, 27 King’s College Circle, Toronto, Ontario M5S, Canada
| | - Samantha A Myers
- Create Fertility Centre, 790 Bay Street, Suite 1100, Toronto, Ontario M5G 1N8, Canada
- McMaster University, 1280 Main St W, Hamilton, Ontario L8S 4L8, Canada
| | - Samantha Yee
- Create Fertility Centre, 790 Bay Street, Suite 1100, Toronto, Ontario M5G 1N8, Canada
| | - Clifford L Librach
- Create Fertility Centre, 790 Bay Street, Suite 1100, Toronto, Ontario M5G 1N8, Canada
- Department of Obstetrics and Gynecology, University of Toronto, 27 King’s College Circle, Toronto, Ontario M5S, Canada
- Department of Physiology, University of Toronto, 27 King’s College Circle, Toronto, Ontario M5S, Canada
- Institute of Medical Science, University of Toronto, 27 King’s College Circle, Toronto, Ontario M5S, Canada
- Department of Obstetrics and Reproductive Endocrinology, Sunnybrook Health Sciences Centre; 2075 Bayview Ave, Toronto, Ontario M4N 3M5, Canada
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Feigerlová E, Pascal V, Ganne-Devonec MO, Klein M, Guerci B. Fertility desires and reproductive needs of transgender people: Challenges and considerations for clinical practice. Clin Endocrinol (Oxf) 2019; 91:10-21. [PMID: 30943314 DOI: 10.1111/cen.13982] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2019] [Revised: 03/31/2019] [Accepted: 03/31/2019] [Indexed: 12/20/2022]
Abstract
The majority of transgender and gender nonconforming persons seeking medical care are of reproductive age. Hormonal treatment and sex reassignment surgery, which are used in the management of gender dysphoria, compromise fertility potential. Children and adolescents with gender dysphoria have specific treatment regimens starting with puberty-blocking medications. According to international guidelines, fertility preservation should be discussed before any hormonal treatment, although our knowledge on the reproductive needs of transgender and gender nonconforming persons is limited. Recently, some data have emerged on fertility management in some centres for the adult population with gender dysphoria. The goal of this review was to summarize the available evidence on the fertility desires and parental roles of transgender and gender nonconforming people. In light of newly emerging societal challenges, we aim to provide some considerations for clinical practice and suggest further areas of research.
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Affiliation(s)
- Eva Feigerlová
- Department of Endocrinology, Diabetology and Nutrition, University Hospital Centre Nancy, Vandoeuvre-lès-Nancy, France
- Faculty of Medicine, University of Lorraine, Vandoeuvre-lès-Nancy, France
| | - Véronique Pascal
- Department of Endocrinology, Diabetology and Nutrition, University Hospital Centre Nancy, Vandoeuvre-lès-Nancy, France
| | - Marie-Odile Ganne-Devonec
- Department of Endocrinology, Diabetology and Nutrition, University Hospital Centre Nancy, Vandoeuvre-lès-Nancy, France
| | - Marc Klein
- Department of Endocrinology, Diabetology and Nutrition, University Hospital Centre Nancy, Vandoeuvre-lès-Nancy, France
- Faculty of Medicine, University of Lorraine, Vandoeuvre-lès-Nancy, France
| | - Bruno Guerci
- Department of Endocrinology, Diabetology and Nutrition, University Hospital Centre Nancy, Vandoeuvre-lès-Nancy, France
- Faculty of Medicine, University of Lorraine, Vandoeuvre-lès-Nancy, France
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Approaches to Vaginal Bleeding and Contraceptive Counseling in Transgender and Gender Nonbinary Patients. Obstet Gynecol 2019; 134:81-90. [DOI: 10.1097/aog.0000000000003308] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
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Abstract
Hormonal therapy and gender-affirming surgeries in transgender people have known deleterious impacts on future fertility using one's own gametes. This review focuses on fertility preservation, including the effects of medical hormone treatment on fertility, available and experimental options of fertility preservation in transgender adults, including sperm cryopreservation for transwomen and oocyte cryopreservation for transmen, and options for prepubertal transgender adolescents, including testicular and ovarian tissue cryopreservation. Transgender patients continue to face barriers and receive infrequent counseling regarding fertility preservation. Physicians should ideally counsel and discuss fertility preservation options before transgender patients undergo hormone therapy of gender-affirmation surgery.
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Affiliation(s)
- Michael F Neblett
- Department of Gynecology and Obstetrics, Emory University, Emory University School of Medicine, Glenn Building, 4th Floor-412 B, 69 Jesse Hill Jr. Drive Southeast, Atlanta, GA 30303, USA
| | - Heather S Hipp
- Division of Reproductive Endocrinology and Infertility, Department of Gynecology and Obstetrics, Emory University School of Medicine, 550 Peachtree Street, Suite 1800, Atlanta, GA 30308, USA.
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Abstract
There are an estimated 1.4 million transgender adults in the United States, and lack of providers knowledgeable in transgender care is a barrier to health care. Obstetricians and Gynecologists can help increase access in part by becoming competent in gender-affirming hormone therapy. For transgender men, testosterone protocols can be extrapolated from those used for hypogonadal cisgender men. Unfortunately, there are not any high-quality, long-term prospective studies on the effectiveness and safety of different testosterone regimens specifically in transgender men, but the available data suggest that gender-affirming testosterone therapy is safe and effective with proper screening and monitoring.
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de Castro-Peraza ME, García-Acosta JM, Delgado-Rodriguez N, Sosa-Alvarez MI, Llabrés-Solé R, Cardona-Llabrés C, Lorenzo-Rocha ND. Biological, Psychological, Social, and Legal Aspects of Trans Parenthood Based on a Real Case-A Literature Review. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2019; 16:ijerph16060925. [PMID: 30875835 PMCID: PMC6466010 DOI: 10.3390/ijerph16060925] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/20/2019] [Revised: 03/11/2019] [Accepted: 03/11/2019] [Indexed: 01/01/2023]
Abstract
Trans men are people who, based on their genitals, were assigned the status of female at birth. However, their identity and their way of living gender do not correspond to the socially established norms. In this paper, we discuss the different perspectives in relation to transgender people and their desire for parenthood. This review, and the basis of this paper, is inspired by the case of a trans man who desired gestation with his own genetic material. He began the cycle of assisted reproduction when he was a legally recognized woman, but that attempt ended with a miscarriage. From that assisted reproduction cycle, four embryos remained frozen. After the failed experience of gestation, the person completed his transition. Now legally a man, he attempted to gestate using his reproductive organs. This literature review aimed to identify relevant studies describing the relationship between transgender person and biological parenthood. This study comprehensively addresses important aspects one should know when considering a transgender pregnancy. These factors include biological, psychological, social, and legal issues. After reviewing the state-of-the-art information on trans parenthood, the main conclusion is that ‘the desire to have a child is not a male or female desire but a human desire’.
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Affiliation(s)
| | | | | | | | - Rosa Llabrés-Solé
- Faculty of Nursing N. S. Candelaria, University of La Laguna, 38010, Tenerife, Canary Islands, Spain.
| | - Carla Cardona-Llabrés
- Faculty of Nursing N. S. Candelaria, University of La Laguna, 38010, Tenerife, Canary Islands, Spain.
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