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Fisher AD, Ristori J, Romani A, Cassioli E, Mazzoli F, Cocchetti C, Pierdominici M, Marconi M, Ricca V, Maggi M, Vignozzi L, Castellini G. Back to the Future: Is GnRHa Treatment in Transgender and Gender Diverse Adolescents Only an Extended Evaluation Phase? J Clin Endocrinol Metab 2024; 109:1565-1579. [PMID: 38099569 DOI: 10.1210/clinem/dgad729] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2023] [Indexed: 05/18/2024]
Abstract
CONTEXT The role of body modifications induced by gonadal suppression in transgender and gender diverse adolescents on psychological functioning has not yet been evaluated. OBJECTIVE The main aim of the present study was to explore several hormone, physical and psychological functioning changes during gonadotropin-releasing hormone analog (GnRHa) treatment in transgender and gender diverse adolescents (TGDAs). The potential relationship between the physical and hormone effects of GnRHa and psychological well-being, along with its magnitude, was assessed for the first time. METHODS This prospective multidisciplinary study included 36 TGDA (22 assigned female at birth, and 14 assigned male at birth) who received psychological assessment followed by triptorelin prescription after referring to the Florence Gender Clinic. This study consisted of 3 time points: first referral (T0), psychological assessment (T1); and treatment with intramuscular injections of triptorelin for 3 up to 12 months (T2). Psychometric questionnaires were administered at each time point, and clinical and biochemical evaluations were performed at T1 and T2. RESULTS The following results were found: (1) GnRHa showed efficacy in inhibiting puberty progression in TGDAs; (2) an increase in psychopathology was observed before starting GnRHa (T1) compared with baseline levels; (3) during GnRHa treatment (T2), a significant improvement in psychological functioning, as well as decrease in suicidality, body uneasiness, depression, and anxiety levels were observed; (4) hormone and physical changes (in terms of gonadotropin and sex steroid levels, height and body mass index percentiles, waist-hip ratio, and acne severity) observed during triptorelin treatment significantly correlated with a reduction in suicidal ideation, anxiety, and body image concerns. CONCLUSION Psychological improvement in TGDA on GnRHa seems to be related to the objective body changes induced by a GnRHa. Therefore, the rationale for treatment with a GnRHa may not only be considered an extension of the evaluation phase, but also the start of a medical (even if reversible) gender-affirming path, especially in TGDAs whose puberty has already progressed.
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Affiliation(s)
- Alessandra D Fisher
- Andrology, Women's Endocrinology and Gender Incongruence Unit, Florence University Hospital, Florence 50139, Italy
| | - Jiska Ristori
- Andrology, Women's Endocrinology and Gender Incongruence Unit, Florence University Hospital, Florence 50139, Italy
- Department of Experimental, Clinical, and Biomedical Sciences, University of Florence, Florence 50139, Italy
| | - Alessia Romani
- Andrology, Women's Endocrinology and Gender Incongruence Unit, Florence University Hospital, Florence 50139, Italy
- Department of Experimental, Clinical, and Biomedical Sciences, University of Florence, Florence 50139, Italy
| | - Emanuele Cassioli
- Psychiatry Unit, Department of Health Sciences, University of Florence, Florence 50100, Italy
| | - Francesca Mazzoli
- Andrology, Women's Endocrinology and Gender Incongruence Unit, Florence University Hospital, Florence 50139, Italy
- Department of Experimental, Clinical, and Biomedical Sciences, University of Florence, Florence 50139, Italy
| | - Carlotta Cocchetti
- Andrology, Women's Endocrinology and Gender Incongruence Unit, Florence University Hospital, Florence 50139, Italy
- Department of Experimental, Clinical, and Biomedical Sciences, University of Florence, Florence 50139, Italy
| | - Marina Pierdominici
- Reference Center for Gender Medicine, Italian National Institute of Health, Rome 00161, Italy
| | - Matteo Marconi
- Reference Center for Gender Medicine, Italian National Institute of Health, Rome 00161, Italy
| | - Valdo Ricca
- Psychiatry Unit, Department of Health Sciences, University of Florence, Florence 50100, Italy
| | - Mario Maggi
- Department of Experimental, Clinical, and Biomedical Sciences, University of Florence, Florence 50139, Italy
| | - Linda Vignozzi
- Andrology, Women's Endocrinology and Gender Incongruence Unit, Florence University Hospital, Florence 50139, Italy
- Department of Experimental, Clinical, and Biomedical Sciences, University of Florence, Florence 50139, Italy
| | - Giovanni Castellini
- Psychiatry Unit, Department of Health Sciences, University of Florence, Florence 50100, Italy
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Pei Q, Song Y, Huang Z, Yu H, Xu H, Ye X, Gao L, Gong J, Tian X. Effects of gender-affirming hormone therapy on body fat: a retrospective case‒control study in Chinese transwomen. Lipids Health Dis 2024; 23:146. [PMID: 38760846 PMCID: PMC11100057 DOI: 10.1186/s12944-024-02131-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2024] [Accepted: 05/06/2024] [Indexed: 05/19/2024] Open
Abstract
BACKGROUND There is insufficient research on how gender-affirming hormone therapy (GAHT) affects body fat modifications in transwomen from China. It is unclear whether hormone therapy affects the prevalence of obesity and blood lipid levels within this population. The current research aimed to assess how GAHT and treatment duration had an impact on the change in and redistribution of body fat in Chinese transwomen. METHODS This study included 40 transwomen who had not received GAHT and 59 who had. Body fat, blood lipid, and blood glucose levels were measured. GAHT is mainly a pharmacologic (estrogen and anti-androgen) treatment. The study also stratified participants based on the duration of GAHT to assess its impact on body fat distribution. The duration of GAHT was within one year, one to two years, two to three years, or more than three years. RESULTS After receiving GAHT, total body fat increased by 19.65%, and the percentage of body fat increased by 17.63%. The arm, corrected leg, and leg regions showed significant increases in fat content (+ 24.02%, + 50.69%, and + 41.47%, respectively) and percentage (+ 25.19%, + 34.90%, and + 30.39%, respectively). The total visceral fat content decreased (-37.49%). Based on the diagnostic standards for a body mass index ≥ 28 or total body fat percentage ≥ 25% or 30%, the chance of developing obesity did not change significantly. Blood glucose levels significantly increased (+ 12.31%). Total cholesterol levels (-10.45%) decreased significantly. Fat changes in those who received GAHT for one to two years were significantly different from those who did not receive GAHT. CONCLUSION After receiving GAHT, total body fat and regional fat increased in Chinese transwomen, and the body fat distribution changed from masculine to feminine, especially during the first two years. However, neither the increase in total body fat percentage nor the decrease in visceral fat content didn't bring about significant changes in the incidence of obesity, nor did triglycerides or low-density lipoprotein-cholesterol.
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Affiliation(s)
- Qin Pei
- School of Nursing, Jinan University, No. 601, West Huangpu Avenue, Guangzhou, Guangdong, 510632, China
- Department of Obstetrics and Gynecology, The First Affiliated Hospital of Jinan University, No. 613, West Huangpu Avenue, Guangzhou, Guangdong, 510630, China
| | - Yuwei Song
- Central Laboratory, The First Affiliated Hospital of Jinan University, Guangzhou, China
| | - Zhongwei Huang
- Department of Obstetrics and Gynaecology, National University Health Systems, Singapore, Singapore
| | - Hongkun Yu
- Department of Nuclear Medicine, The First Affiliated Hospital of Jinan University, No. 613, West Huangpu Avenue, Guangzhou, Guangdong, 510630, China
| | - Hao Xu
- Department of Nuclear Medicine, The First Affiliated Hospital of Jinan University, No. 613, West Huangpu Avenue, Guangzhou, Guangdong, 510630, China
| | - Xunda Ye
- Central Laboratory, The First Affiliated Hospital of Jinan University, Guangzhou, China
| | - Lvfen Gao
- Department of Obstetrics and Gynecology, The First Affiliated Hospital of Jinan University, No. 613, West Huangpu Avenue, Guangzhou, Guangdong, 510630, China.
| | - Jian Gong
- Department of Nuclear Medicine, The First Affiliated Hospital of Jinan University, No. 613, West Huangpu Avenue, Guangzhou, Guangdong, 510630, China.
| | - Xiaoying Tian
- School of Nursing, Jinan University, No. 601, West Huangpu Avenue, Guangzhou, Guangdong, 510632, China.
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Santi D, Spaggiari G, Marinelli L, Cacciani M, Scipio S, Bichiri A, Profeta A, Granata ARM, Simoni M, Lanfranco F, Manieri C, Ghigo E, Motta G. Gender-affirming hormone treatment: friend or foe? Long-term follow-up of 755 transgender people. J Endocrinol Invest 2024; 47:1091-1100. [PMID: 37889433 DOI: 10.1007/s40618-023-02220-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2023] [Accepted: 10/07/2023] [Indexed: 10/28/2023]
Abstract
PURPOSE Gender-affirming hormone treatment (GAHT) is one of the main demands of transgender and gender diverse (TGD) people, who are usually categorised as transgender assigned-male-at birth (AMAB) and assigned-female-at birth (AFAB). The aim of the study is to investigate the long-term therapeutic management of GAHT, considering hormonal targets, treatment adjustments and GAHT safety. METHODS A retrospective, longitudinal, observational, multicentre clinical study was carried out. Transgender people, both AMAB and AFAB, were recruited from two Endocrinology Units in Italy (Turin and Modena) between 2005 and 2022. Each subject was managed with specific and personalized follow-up depending on the clinical practice of the Centre. All clinical data routinely collected were extracted, including anthropometric and biochemical parameters, lifestyle habits, GAHT regime, and cardiovascular events. RESULTS Three-hundred and two transgender AFAB and 453 transgender AMAB were included. Similar follow-up duration (p = 0.974) and visits' number (p = 0.384) were detected between groups. The transgender AFAB group reached therapeutic goals in less time (p = 0.002), fewer visits (p = 0.006) and fewer adjustments of GAHT scheme (p = 0.024). Accordingly, transgender AFAB showed a higher adherence to medical prescriptions compared to transgender AMAB people (p < 0.001). No significantly increased rate of cardiovascular events was detected in both groups. CONCLUSION Our real-world clinical study shows that transgender AFAB achieve hormone target earlier and more frequently in comparison to transgender AMAB individuals. Therefore, transgender AMAB people may require more frequent check-ups in order to tailor feminizing GAHT and increase therapeutic adherence.
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Affiliation(s)
- D Santi
- Unit of Endocrinology, Department of Medical Specialties, Azienda Ospedaliero-Universitaria of Modena, Modena, Italy.
- Unit of Endocrinology, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Modena, Italy.
- Unit of Andrology and Sexual Medicine of the Unit of Endocrinology, Department of Medical Specialties, Azienda Ospedaliero-Universitaria of Modena, Modena, Italy.
| | - G Spaggiari
- Unit of Endocrinology, Department of Medical Specialties, Azienda Ospedaliero-Universitaria of Modena, Modena, Italy
- Unit of Andrology and Sexual Medicine of the Unit of Endocrinology, Department of Medical Specialties, Azienda Ospedaliero-Universitaria of Modena, Modena, Italy
| | - L Marinelli
- Division of Endocrinology, Diabetes and Metabolism, Department of Medical Sciences, University of Turin, Corso Dogliotti 14, 10126, Turin, Italy
| | - M Cacciani
- Unit of Endocrinology, Department of Medical Specialties, Azienda Ospedaliero-Universitaria of Modena, Modena, Italy
- Unit of Endocrinology, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Modena, Italy
| | - S Scipio
- Unit of Endocrinology, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Modena, Italy
| | - A Bichiri
- Division of Endocrinology, Diabetes and Metabolism, Department of Medical Sciences, University of Turin, Corso Dogliotti 14, 10126, Turin, Italy
| | - A Profeta
- Division of Endocrinology, Diabetes and Metabolism, Department of Medical Sciences, University of Turin, Corso Dogliotti 14, 10126, Turin, Italy
| | - A R M Granata
- Unit of Endocrinology, Department of Medical Specialties, Azienda Ospedaliero-Universitaria of Modena, Modena, Italy
- Unit of Andrology and Sexual Medicine of the Unit of Endocrinology, Department of Medical Specialties, Azienda Ospedaliero-Universitaria of Modena, Modena, Italy
| | - M Simoni
- Unit of Endocrinology, Department of Medical Specialties, Azienda Ospedaliero-Universitaria of Modena, Modena, Italy
- Unit of Endocrinology, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Modena, Italy
- Unit of Andrology and Sexual Medicine of the Unit of Endocrinology, Department of Medical Specialties, Azienda Ospedaliero-Universitaria of Modena, Modena, Italy
| | - F Lanfranco
- Division of Endocrinology, Andrology and Metabolism, Department of Medical Sciences, Humanitas Gradenigo, University of Turin, Turin, Italy
| | - C Manieri
- Division of Endocrinology, Diabetes and Metabolism, Department of Medical Sciences, University of Turin, Corso Dogliotti 14, 10126, Turin, Italy
| | - E Ghigo
- Division of Endocrinology, Diabetes and Metabolism, Department of Medical Sciences, University of Turin, Corso Dogliotti 14, 10126, Turin, Italy
| | - G Motta
- Division of Endocrinology, Diabetes and Metabolism, Department of Medical Sciences, University of Turin, Corso Dogliotti 14, 10126, Turin, Italy
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Millington K, Lee JY, Olson-Kennedy J, Garofalo R, Rosenthal SM, Chan YM. Laboratory Changes During Gender-Affirming Hormone Therapy in Transgender Adolescents. Pediatrics 2024; 153:e2023064380. [PMID: 38567424 PMCID: PMC11035161 DOI: 10.1542/peds.2023-064380] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/02/2024] [Indexed: 04/04/2024] Open
Abstract
OBJECTIVES Guidelines for monitoring of medications frequently used in the gender-affirming care of transgender and gender-diverse (TGD) adolescents are based on studies in adults or other medical conditions. In this study, we aimed to investigate commonly screened laboratory measurements in TGD adolescents receiving gender-affirming hormone therapy (GAHT). METHODS TGD adolescents were recruited from 4 study sites in the United States before beginning GAHT. Hemoglobin, hematocrit, hemoglobin A1c, alanine transaminase, aspartate aminotransferase, prolactin, and potassium were abstracted from the medical record at baseline and at 6, 12, and 24 months after starting GAHT. RESULTS Two-hundred and ninety-three participants (68% designated female at birth) with no previous history of gonadotropin-releasing hormone analog use were included in the analysis. Hemoglobin and hematocrit decreased in adolescents prescribed estradiol (-1.4 mg/dL and -3.6%, respectively) and increased in adolescents prescribed testosterone (+1.0 mg/dL and +3.9%) by 6 months after GAHT initiation. Thirteen (6.5%) participants prescribed testosterone had hematocrit > 50% during GAHT. There were no differences in hemoglobin A1c, alanine transaminase, or aspartate aminotransferase. There was a small increase in prolactin after 6 months of estradiol therapy in transfeminine adolescents. Hyperkalemia in transfeminine adolescents taking spironolactone was infrequent and transient if present. CONCLUSIONS Abnormal laboratory results are rare in TGD adolescents prescribed GAHT and, if present, occur within 6 months of GAHT initiation. Future guidelines may not require routine screening of these laboratory parameters beyond 6 months of GAHT in otherwise healthy TGD adolescents.
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Affiliation(s)
- Kate Millington
- Division of Pediatric Endocrinology and Adolescent Medicine, Hasbro Children’s Hospital, Providence, Rhode Island
- Department of Pediatrics, Warren Alpert Medical School of Brown University, Providence, Rhode Island
| | - Janet Y. Lee
- Division of Pediatric Endocrinology, Department of Pediatrics, University of California, San Francisco, San Francisco, California
- Division of Endocrinology & Metabolism, Department of Medicine, University of California, San Francisco, California
- Endocrine and Metabolism Section, San Francisco Veterans Affairs Health Care System, San Francisco, California
| | - Johanna Olson-Kennedy
- Division of Adolescent and Young Adult Medicine, Department of Pediatrics, Keck School of Medicine of University of Southern California, Los Angeles, California
| | - Robert Garofalo
- Division of Adolescent Medicine, Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Stephen M. Rosenthal
- Division of Pediatric Endocrinology, Department of Pediatrics, University of California, San Francisco, San Francisco, California
| | - Yee-Ming Chan
- Division of Endocrinology, Department of Pediatrics, Boston Children’s Hospital, Boston, Massachusetts
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Piñar-Gutiérrez A, Dueñas Disotuar S, de Lara-Rodríguez I, Amuedo-Domínguez S, González-Cejudo C, Tejero-Delgado J, Mangas-Cruz MÁ. Difficulties of gender affirming treatment in trans women with BRCA1+ mutation: A case report. ENDOCRINOL DIAB NUTR 2024; 71:144-148. [PMID: 38555112 DOI: 10.1016/j.endien.2023.12.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2023] [Accepted: 12/19/2023] [Indexed: 04/02/2024]
Abstract
Gender affirming treatment in transgender women is based on a combination of antiandrogens and estrogens, with the latter maintained over the long term. When prescribing these treatments, we must consider the possibility of developing estrogen-dependent breast cancer. In transgender women, a breast cancer incidence of 4.1 per 100,000 has been estimated, which would increase the risk by 46% in relation to cisgender men but decrease it by 70% in relation to cisgender women. It is known that certain gene mutations such as BRCA1 imply an increased risk of breast cancer, but at present the risk in transgender women with BRCA1 treated with estrogens is not well established. We present the case of a transgender woman with a family history of breast cancer and BRCA1 mutation and the therapeutic decisions made in a multidisciplinary team. Following this case, we review and discuss the published literature.
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Affiliation(s)
- Ana Piñar-Gutiérrez
- UGC Endocrinología y Nutrición, Hospital Universitario Virgen del Rocío, Sevilla, Spain.
| | - Suset Dueñas Disotuar
- UGC Endocrinología y Nutrición, Hospital Universitario Virgen del Rocío, Sevilla, Spain
| | - Irene de Lara-Rodríguez
- UGC Endocrinología y Nutrición, Hospital Universitario Virgen del Rocío, Sevilla, Spain; UGC de Ginecología, Oncología Ginecológica y Patología mamaria, Hospital Universitario Virgen del Rocío, Sevilla, Spain
| | | | - Carmen González-Cejudo
- UGC de Ginecología, Oncología Ginecológica y Patología mamaria, Hospital Universitario Virgen del Rocío, Sevilla, Spain
| | - José Tejero-Delgado
- UGC de Ginecología, Oncología Ginecológica y Patología mamaria, Hospital Universitario Virgen del Rocío, Sevilla, Spain
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Ristori J, Motta G, Meriggiola MC, Bettocchi C, Crespi C, Falcone M, Lombardo F, Maggi M, Morelli G, Colao AM, Isidori AM, Fisher AD. A comment from SIGIS, SIE and SIAMS: "Puberty blockers in transgender adolescents-a matter of growing evidence and not of ideology". J Endocrinol Invest 2024; 47:479-481. [PMID: 37695460 DOI: 10.1007/s40618-023-02173-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2023] [Accepted: 08/02/2023] [Indexed: 09/12/2023]
Affiliation(s)
- J Ristori
- Andrology, Women's Endocrinology and Gender Incongruence Unit, Florence University Hospital, Careggi University Hospital, University of Florence, Viale Pieraccini 6, 50139, Florence, Italy
| | - G Motta
- Endocrinology, Diabetology and Metabolism Unit, Department of Medical Sciences, University of Turin, Turin, Italy
| | - M C Meriggiola
- Division of Gynecology and Human Reproduction Physiopathology, IRCSS Azienda Ospedaliero Universitaria di Bologna, University of Bologna, Bologna, Italy
| | - C Bettocchi
- Department of Urology, University of Foggia, Foggia, Italy
| | - C Crespi
- Endocrinology, Diabetology and Metabolism Unit, Department of Medical Sciences, University of Turin, Turin, Italy
| | - M Falcone
- Department of Urology, A.O.U. Città della Salute e della Scienza di Torino, Molinette Hospital, Turin, Italy
| | - F Lombardo
- Department of Experimental Medicine, University of Rome "La Sapienza", Rome, Italy
| | - M Maggi
- Endocrinology Unit, "Mario Serio" Department of Experimental and Clinical Biomedical Sciences, University of Florence, Florence, Italy
| | - G Morelli
- Urology Department, University of Pisa, Pisa, Italy
| | - A M Colao
- Cattedra Unesco "Educazione alla Salute e allo Sviluppo Sostenibile", University "Federico II", Naples, Italy
- UNESCO Chair on Health Education and Sustainable Development, Federico II University, Naples, Italy
| | - A M Isidori
- Department of Experimental Medicine, University of Rome "La Sapienza", Rome, Italy
| | - A D Fisher
- Andrology, Women's Endocrinology and Gender Incongruence Unit, Florence University Hospital, Careggi University Hospital, University of Florence, Viale Pieraccini 6, 50139, Florence, Italy.
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Ceolin C, Scala A, Dall'Agnol M, Ziliotto C, Delbarba A, Facondo P, Citron A, Vescovi B, Pasqualini S, Giannini S, Camozzi V, Cappelli C, Bertocco A, De Rui M, Coin A, Sergi G, Ferlin A, Garolla A. Bone health and body composition in transgender adults before gender-affirming hormonal therapy: data from the COMET study. J Endocrinol Invest 2024; 47:401-410. [PMID: 37450195 PMCID: PMC10859333 DOI: 10.1007/s40618-023-02156-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2023] [Accepted: 07/05/2023] [Indexed: 07/18/2023]
Abstract
PURPOSE Preliminary data suggested that bone mineral density (BMD) in transgender adults before initiating gender-affirming hormone therapy (GAHT) is lower when compared to cisgender controls. In this study, we analyzed bone metabolism in a sample of transgender adults before GAHT, and its possible correlation with biochemical profile, body composition and lifestyle habits (i.e., tobacco smoke and physical activity). METHODS Medical data, smoking habits, phospho-calcic and hormonal blood tests and densitometric parameters were collected in a sample of 125 transgender adults, 78 Assigned Females At Birth (AFAB) and 47 Assigned Males At Birth (AMAB) before GAHT initiation and 146 cisgender controls (57 females and 89 males) matched by sex assigned at birth and age. 55 transgender and 46 cisgender controls also underwent a complete body composition evaluation and assessment of physical activity using the International Physical Activity Questionnaire (IPAQ). RESULTS 14.3% of transgender and 6.2% of cisgender sample, respectively, had z-score values < -2 (p = 0.04). We observed only lower vitamin D values in transgender sample regarding biochemical/hormonal profile. AFAB transgender people had more total fat mass, while AMAB transgender individuals had reduced total lean mass as compared to cisgender people (53.94 ± 7.74 vs 58.38 ± 6.91, p < 0.05). AFAB transgender adults were more likely to be active smokers and tend to spend more time indoor. Fat Mass Index (FMI) was correlated with lumbar and femur BMD both in transgender individuals, while no correlations were found between lean mass parameters and BMD in AMAB transgender people. CONCLUSIONS Body composition and lifestyle factors could contribute to low BMD in transgender adults before GAHT.
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Affiliation(s)
- C Ceolin
- Geriatrics Division, Department of Medicine (DIMED), University of Padua, Padua, Italy.
- Regional Reference Center for Gender Incongruence, Padua, Veneto Region, Italy.
| | - A Scala
- Unit of Andrology and Reproductive Medicine, Department of Medicine (DIMED), University of Padua, Padua, Italy
- Regional Reference Center for Gender Incongruence, Padua, Veneto Region, Italy
| | - M Dall'Agnol
- Geriatrics Division, Department of Medicine (DIMED), University of Padua, Padua, Italy
| | - C Ziliotto
- Geriatrics Division, Department of Medicine (DIMED), University of Padua, Padua, Italy
| | - A Delbarba
- Unit of Endocrinology and Metabolism, University of Brescia and ASST Spedali Civili, Brescia, Italy
| | - P Facondo
- Unit of Endocrinology and Metabolism, University of Brescia and ASST Spedali Civili, Brescia, Italy
| | - A Citron
- Geriatrics Division, Department of Medicine (DIMED), University of Padua, Padua, Italy
| | - B Vescovi
- Unit of Andrology and Reproductive Medicine, Department of Medicine (DIMED), University of Padua, Padua, Italy
| | - S Pasqualini
- Unit of Andrology and Reproductive Medicine, Department of Medicine (DIMED), University of Padua, Padua, Italy
| | - S Giannini
- Clinica Medica 1, Department of Medicine, University of Padua, Padua, Italy
- Regional Reference Center for Gender Incongruence, Padua, Veneto Region, Italy
| | - V Camozzi
- Endocrinology Unit, Department of Medicine (DIMED), University of Padua, Padua, Italy
- Regional Reference Center for Gender Incongruence, Padua, Veneto Region, Italy
| | - C Cappelli
- Unit of Endocrinology and Metabolism, University of Brescia and ASST Spedali Civili, Brescia, Italy
| | - A Bertocco
- Geriatrics Division, Department of Medicine (DIMED), University of Padua, Padua, Italy
| | - M De Rui
- Geriatrics Division, Department of Medicine (DIMED), University of Padua, Padua, Italy
| | - A Coin
- Geriatrics Division, Department of Medicine (DIMED), University of Padua, Padua, Italy
| | - G Sergi
- Geriatrics Division, Department of Medicine (DIMED), University of Padua, Padua, Italy
- Regional Reference Center for Gender Incongruence, Padua, Veneto Region, Italy
| | - A Ferlin
- Unit of Andrology and Reproductive Medicine, Department of Medicine (DIMED), University of Padua, Padua, Italy
- Regional Reference Center for Gender Incongruence, Padua, Veneto Region, Italy
| | - A Garolla
- Unit of Andrology and Reproductive Medicine, Department of Medicine (DIMED), University of Padua, Padua, Italy
- Regional Reference Center for Gender Incongruence, Padua, Veneto Region, Italy
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Cheung AS, Zwickl S, Miller K, Nolan BJ, Wong AFQ, Jones P, Eynon N. The Impact of Gender-Affirming Hormone Therapy on Physical Performance. J Clin Endocrinol Metab 2024; 109:e455-e465. [PMID: 37437247 PMCID: PMC10795902 DOI: 10.1210/clinem/dgad414] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2022] [Revised: 07/03/2023] [Accepted: 07/10/2023] [Indexed: 07/14/2023]
Abstract
CONTEXT The inclusion of transgender people in elite sport has been a topic of debate. This narrative review examines the impact of gender-affirming hormone therapy (GAHT) on physical performance, muscle strength, and markers of endurance. EVIDENCE ACQUISITION MEDLINE and Embase were searched using terms to define the population (transgender), intervention (GAHT), and physical performance outcomes. EVIDENCE SYNTHESIS Existing literature comprises cross-sectional or small uncontrolled longitudinal studies of short duration. In nonathletic trans men starting testosterone therapy, within 1 year, muscle mass and strength increased and, by 3 years, physical performance (push-ups, sit-ups, run time) improved to the level of cisgender men. In nonathletic trans women, feminizing hormone therapy increased fat mass by approximately 30% and decreased muscle mass by approximately 5% after 12 months, and steadily declined beyond 3 years. While absolute lean mass remains higher in trans women, relative percentage lean mass and fat mass (and muscle strength corrected for lean mass), hemoglobin, and VO2 peak corrected for weight was no different to cisgender women. After 2 years of GAHT, no advantage was observed for physical performance measured by running time or in trans women. By 4 years, there was no advantage in sit-ups. While push-up performance declined in trans women, a statistical advantage remained relative to cisgender women. CONCLUSION Limited evidence suggests that physical performance of nonathletic trans people who have undergone GAHT for at least 2 years approaches that of cisgender controls. Further controlled longitudinal research is needed in trans athletes and nonathletes.
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Affiliation(s)
- Ada S Cheung
- Trans Health Research Group, Department of Medicine (Austin Health), The University of Melbourne, Melbourne 3084, Australia
- Department of Endocrinology, Austin Health, Heidelberg 3084, Australia
| | - Sav Zwickl
- Trans Health Research Group, Department of Medicine (Austin Health), The University of Melbourne, Melbourne 3084, Australia
| | | | - Brendan J Nolan
- Trans Health Research Group, Department of Medicine (Austin Health), The University of Melbourne, Melbourne 3084, Australia
- Department of Endocrinology, Austin Health, Heidelberg 3084, Australia
| | - Alex Fang Qi Wong
- Trans Health Research Group, Department of Medicine (Austin Health), The University of Melbourne, Melbourne 3084, Australia
| | - Patrice Jones
- Institute for Health and Sport (IHeS), Victoria University, Footscray 3011, Australia
| | - Nir Eynon
- Institute for Health and Sport (IHeS), Victoria University, Footscray 3011, Australia
- Australian Regenerative Medicine Institute, Monash University, Clayton 3800, Australia
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9
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Karakılıç Özturan E, Öztürk AP, Baş F, Erdoğdu AB, Kaptan S, Kardelen Al AD, Poyrazoğlu Ş, Yıldız M, Direk N, Yüksel Ş, Darendeliler F. Endocrinological Approach to Adolescents with Gender Dysphoria: Experience of a Pediatric Endocrinology Department in a Tertiary Center in Turkey. J Clin Res Pediatr Endocrinol 2023; 15:276-284. [PMID: 36987788 PMCID: PMC10448553 DOI: 10.4274/jcrpe.galenos.2023.2023-1-13] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2023] [Accepted: 03/27/2023] [Indexed: 03/30/2023] Open
Abstract
Objective A significant rise in the number of trans adolescents seeking medical interventions has been reported in recent years. The aim of this study was to report the clinical features, treatment, and follow-up of adolescents with gender dysphoria (GD) with our increased experience. Methods Twenty-six male-to-female (MTF) and twenty-seven female-to-male (FTM) adolescents who were referred to the GD-outpatient clinic between 2016 and 2022 were reviewed. The clinical and laboratory findings of thirty transgender adolescents (15 FTM /15 MTF) who received medical intervention were evaluated retrospectively. Results Most individuals (60.4%) were admitted between 2020 and 2022, and the remaining (39.6%) were admitted between 2016 and 2019. At the time of referral, median age was 16.3 years [interquartile range (IQR) 1.53; range 13.2-19.4] in 26 MTF, and 16.4 years (IQR 1.74; range 11.7-21.6) in 27 FTM adolescents. The median age at pubertal blockage with gonadotropin-releasing hormone analog and androgen receptor blocker was 16.4 years (IQR 1.4; range 11.7-17.8) in 22 adolescents (9 MTF, 13 FTM), and 17.4 years (IQR 1.4; range 15.5-19.4) in 6 MTF individuals, respectively. Cross-sex hormone therapy was commenced in 21 adolescents (12 MTF, 9 FTM) at the median age of 17.7 years (IQR 0.61; range 16-19.5). Fifteen individuals (8 MTF, 7 FTM) have been transferred to the adult endocrinology department in transition clinics. Conclusion All treatments were generally well tolerated and effective, including bicalutamide, and no significant side effects were observed. Transition clinics played an important role in the better management of gender reassignment processes.
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Affiliation(s)
- Esin Karakılıç Özturan
- İstanbul University, İstanbul Faculty of Medicine, Department of Pediatrics, Division of Pediatric Endocrinology, İstanbul, Turkey
| | - Ayşe Pınar Öztürk
- İstanbul University, İstanbul Faculty of Medicine, Department of Pediatrics, Division of Pediatric Endocrinology, İstanbul, Turkey
| | - Firdevs Baş
- İstanbul University, İstanbul Faculty of Medicine, Department of Pediatrics, Division of Pediatric Endocrinology, İstanbul, Turkey
| | - Ayşe Burcu Erdoğdu
- Marmara University, Pendik Training and Research Hospital, Clinic of Child and Adolescent Psychiatry, İstanbul, Turkey
| | - Seven Kaptan
- Psychiatrists in Private Practice, İstanbul, Turkey
| | - Aslı Derya Kardelen Al
- İstanbul University, İstanbul Faculty of Medicine, Department of Pediatrics, Division of Pediatric Endocrinology, İstanbul, Turkey
| | - Şükran Poyrazoğlu
- İstanbul University, İstanbul Faculty of Medicine, Department of Pediatrics, Division of Pediatric Endocrinology, İstanbul, Turkey
| | - Melek Yıldız
- İstanbul University, İstanbul Faculty of Medicine, Department of Pediatrics, Division of Pediatric Endocrinology, İstanbul, Turkey
| | - Neşe Direk
- İstanbul University, İstanbul Faculty of Medicine, Department of Psychiatry, İstanbul, Turkey
| | - Şahika Yüksel
- İstanbul University, İstanbul Faculty of Medicine, Department of Psychiatry, Psychiatrist in Private Practice, Emeritus Professor, İstanbul, Turkey
| | - Feyza Darendeliler
- İstanbul University, İstanbul Faculty of Medicine, Department of Pediatrics, Division of Pediatric Endocrinology, İstanbul, Turkey
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Pérez López G. Gender identity: Current concepts and gender-affirming hormone therapy. ENDOCRINOL DIAB NUTR 2023; 70 Suppl 1:27-37. [PMID: 36543601 DOI: 10.1016/j.endien.2022.11.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/02/2022] [Accepted: 02/06/2022] [Indexed: 12/23/2022]
Abstract
In the past five years, healthcare organisation for trans people in Spain has changed as laws intended to protect sexual and gender diversity have been put in place. As a result, endocrinologists are not only on the front lines (understood as prescribing and following up gender-affirming hormone therapy) but also coordinating multidisciplinary healthcare for these individuals. Advances in transgender medicine, the complexity of diverse trans identities and the impact of hormone therapy on quality of life and risk of middle- and long-term complications call for in-depth examination of a personalised biopsychosocial approach to trans people that requires specific training in this field of knowledge as well as updates on the concepts, terminology and drug treatments used.
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Affiliation(s)
- Gilberto Pérez López
- Servicio de Endocrinología y Nutrición, Hospital General Universitario Gregorio Marañón, Madrid, Spain; Co-director del Curso Universitario Experto en Medicina Transgénero de la SEEN, Universidad de Barcelona, Editorial Panamericana, Spain.
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11
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Roberts CM, Klein DA, Adirim TA, Schvey NA, Hisle-Gorman E. Continuation of Gender-affirming Hormones Among Transgender Adolescents and Adults. J Clin Endocrinol Metab 2022; 107:e3937-e3943. [PMID: 35452119 DOI: 10.1210/clinem/dgac251] [Citation(s) in RCA: 26] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2021] [Indexed: 12/13/2022]
Abstract
INTRODUCTION Concerns about future regret and treatment discontinuation have led to restricted access to gender-affirming medical treatment for transgender and gender-diverse (TGD) minors in some jurisdictions. However, these concerns are merely speculative because few studies have examined gender-affirming hormone continuation rates among TGD individuals. METHODS We performed a secondary analysis of 2009 to 2018 medical and pharmacy records from the US Military Healthcare System. We identified TGD patients who were children and spouses of active-duty, retired, or deceased military members using International Classification of Diseases-9/10 codes. We assessed initiation and continuation of gender-affirming hormones using pharmacy records. Kaplan-Meier and Cox proportional hazard analyses estimated continuation rates. RESULTS The study sample included 627 transmasculine and 325 transfeminine individuals with an average age of 19.2 ± 5.3 years. The 4-year gender-affirming hormone continuation rate was 70.2% (95% CI, 63.9-76.5). Transfeminine individuals had a higher continuation rate than transmasculine individuals 81.0% (72.0%-90.0%) vs 64.4% (56.0%-72.8%). People who started hormones as minors had higher continuation rate than people who started as adults 74.4% (66.0%-82.8%) vs 64.4% (56.0%-72.8%). Continuation was not associated with household income or family member type. In Cox regression, both transmasculine gender identity (hazard ratio, 2.40; 95% CI, 1.50-3.86) and starting hormones as an adult (hazard ratio, 1.69; 95% CI, 1.14-2.52) were independently associated with increased discontinuation rates. DISCUSSION Our results suggest that >70% of TGD individuals who start gender-affirming hormones will continue use beyond 4 years, with higher continuation rates in transfeminine individuals. Patients who start hormones, with their parents' assistance, before age 18 years have higher continuation rates than adults.
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Affiliation(s)
- Christina M Roberts
- Division of Adolescent Medicine, Children's Mercy Kansas City, Kansas City, MO 64111, USA
- Department of Pediatrics, University of Missouri-Kansas City School of Medicine, Kansas City, MO 64111, USA
| | - David A Klein
- Department of Family Medicine, Uniformed Services University, Bethesda, MD 20814, USA
- Department of Pediatrics, Uniformed Services University, Bethesda, MD 20814, USA
- Department of Family Medicine, David Grant Medical Center, Travis Air Force Base, CA 94533, USA
| | - Terry A Adirim
- Department of Defense, Washington, DC 22042, USA
- Department of Preventive Medicine and Biostatistics, Uniformed Services University, Bethesda, MD 20814, USA
| | - Natasha A Schvey
- Department of Medical and Clinical Psychology, Uniformed Services University, Bethesda, MD 20814, USA
| | - Elizabeth Hisle-Gorman
- Department of Pediatrics, Uniformed Services University, Bethesda, MD 20814, USA
- Department of Preventive Medicine and Biostatistics, Uniformed Services University, Bethesda, MD 20814, USA
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12
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Kennis M, Duecker F, T'Sjoen G, Sack AT, Dewitte M. Gender Affirming Medical Treatment Desire and Treatment Motives in Binary and Non-Binary Transgender Individuals. J Sex Med 2022; 19:1173-1184. [PMID: 35418328 DOI: 10.1016/j.jsxm.2022.03.603] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2021] [Revised: 03/11/2022] [Accepted: 03/14/2022] [Indexed: 01/07/2023]
Abstract
BACKGROUND It is currently unknown whether there are differences in desire for gender affirming medical treatment (GAMT) between binary and non-binary transgender individuals, although the latter seek treatment less prevalently. AIM To investigate differences between binary and non-binary individuals on received GAMT, desire for GAMT, and motives for (not) wanting GAMT, and to explore the association between having an unfulfilled treatment desire and general and sexual well-being. METHODS We conducted an online questionnaire in a community sample of 125 transgender men, 72 transgender women, and 62 non-binary transgender individuals (age: M = 30.4, SD = 11.31, range 18-69). OUTCOME MEASURES Undergone GAMT, GAMT desire, motives for (not) wanting (further) GAMT, Utrecht Gender Dysphoria Scale, Satisfaction With Life Scale, Hospital Anxiety and Depression Scale, Global Measure of Sexual Satisfaction, transgender-specific body image worries, and sexual self-concept discrepancies. RESULTS Binary transgender participants reported having undergone more GAMT procedures than non-binary transgender participants (P < .001 for both gender affirming hormone treatment (GAHT) and gender affirming surgery (GAS)). While binary participants reported a stronger desire for GAHT compared to non-binary participants (X2(1, N = 93) = 32.63, P < .001), the groups did not differ in their desire for GAS (X2(1, N = 247) = 0.68, P = .411). Binary and non-binary participants reported similar reasons for wanting treatment, mostly related to body and/or gender incongruence and gender affirmation. In terms of not wanting treatment, the non-binary group reported their gender identity as the most important reason, while the binary group mostly mentioned possible medical complications. The majority of both groups had an unfulfilled treatment desire (69% of binary participants and 64.5% of non-binary participants), which was related to lower levels of general life satisfaction (P < .001) and sexual satisfaction (P = .005), more anxiety (P = .006) and transgender-specific body image worries (P < .001), and larger sexual self-concept discrepancies (P < .001 for actual and/or ideal, P < .001 for actual and/or ought). CLINICAL IMPLICATIONS Systemic barriers to GAMT (especially GAS) should be removed not only for binary but also for non-binary identifying transgender individuals to decrease the discrepancy between treatment desire and actually seeking treatment. STRENGTHS & LIMITATIONS This study was the first to systematically investigate differences in treatment desire motives between binary and non-binary transgender individuals, while also showing the possible negative consequences of an unfulfilled treatment desire. Given the online character of the study, results may not generalize to the broader transgender community. CONCLUSION Similarly to binary transgender individuals, many non-binary transgender individuals have a desire for GAMT, and not being able to receive GAMT has a negative effect on their mental and sexual health. Further efforts should be made to make GAMT accessible for all transgender individuals, regardless of gender identity. Kennis M, Duecker F, T'Sjoen G, et al. Gender Affirming Medical Treatment Desire and Treatment Motives in Binary and Non-Binary Transgender Individuals. J Sex Med 2022;19:1173-1184.
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Affiliation(s)
- Mathilde Kennis
- Maastricht University, Department of Clinical Psychological Science, Maastricht, The Netherlands; Maastricht University, Department of Cognitive Neuroscience, Maastricht, The Netherlands; Maastricht Brain Imaging Center, Maastricht, The Netherlands.
| | - Felix Duecker
- Maastricht University, Department of Cognitive Neuroscience, Maastricht, The Netherlands; Maastricht Brain Imaging Center, Maastricht, The Netherlands
| | - Guy T'Sjoen
- Ghent University Hospital, Department of Endocrinology, Ghent, Belgium; Ghent University Hospital, Center for Sexology and Gender, Ghent, Belgium
| | - Alexander T Sack
- Maastricht University, Department of Cognitive Neuroscience, Maastricht, The Netherlands; Maastricht Brain Imaging Center, Maastricht, The Netherlands; Maastricht University, Department of Psychiatry and Neuropsychology, Maastricht, The Netherlands; Maastricht University, Center for Integrative Neuroscience, Maastricht, The Netherlands
| | - Marieke Dewitte
- Maastricht University, Department of Clinical Psychological Science, Maastricht, The Netherlands
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13
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Goetsch MF, Ribbink PJA. Penetrative genital pain in transgender men using testosterone: a survey study. Am J Obstet Gynecol 2022; 226:264-270. [PMID: 34555318 DOI: 10.1016/j.ajog.2021.09.019] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2021] [Revised: 08/19/2021] [Accepted: 09/14/2021] [Indexed: 11/16/2022]
Affiliation(s)
- Martha F Goetsch
- Program in Vulvar Health, Department of Obstetrics and Gynecology, Oregon Health and Science University, UHN 50, 3181 SW, Sam Jackson Park Rd., Portland, OR 97239.
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14
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Jue JS, Alameddine M. Evaluation of Renal Function in Transgender Patients after Gender Affirming Hormone Therapy. Endocr Pract 2021; 28:449. [PMID: 34958944 DOI: 10.1016/j.eprac.2021.12.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2021] [Accepted: 12/21/2021] [Indexed: 11/18/2022]
Affiliation(s)
- Joshua S Jue
- Department of Urology, Lenox Hill Hospital, Northwell Health, Zucker School of Medicine at Hofstra/Northwell, New York, New York.
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15
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Millington K, Chan YM. Lipoprotein subtypes after testosterone therapy in transmasculine adolescents. J Clin Lipidol 2021; 15:840-844. [PMID: 34657833 PMCID: PMC8742606 DOI: 10.1016/j.jacl.2021.09.051] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2021] [Revised: 09/22/2021] [Accepted: 09/28/2021] [Indexed: 11/30/2022]
Abstract
Differences in lipoprotein-particle subclasses between men and women start in puberty and narrow after menopause, suggesting a role for sex steroids. In this cross-sectional cohort study, we examined lipoprotein subtype profiles in transmasculine adolescents treated with testosterone. Transmasculine adolescents (n = 17) had lipoprotein profiles that were similar to those of cisgender males (n = 33) and more atherogenic than those of cisgender females (n = 32), with higher concentrations of small low-density lipoprotein (LDL) particles (435 ± 222 nmol/L vs. 244 ± 163 nmol/L, p = 0.008) and lower concentrations of large high-density lipoprotein (HDL) particles (1.5 ± 1.3 μmol/L vs 2.7 ± 1.2 μmol/L, p = 0.003) when compared to cisgender females. Thus, testosterone appears to be a major contributor to differences in lipoprotein profiles, a surrogate for cardiovascular disease risk, between cisgender women and both transgender and cisgender men.
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Affiliation(s)
- Kate Millington
- Division of Endocrinology, Boston Children's Hospital, Boston, Massachusetts, United States; Department of Pediatrics, Harvard Medical School, Boston, Massachusetts, United States.
| | - Yee-Ming Chan
- Division of Endocrinology, Boston Children's Hospital, Boston, Massachusetts, United States; Department of Pediatrics, Harvard Medical School, Boston, Massachusetts, United States
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16
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Kuijpers SME, Wiepjes CM, Conemans EB, Fisher AD, T’Sjoen G, den Heijer M. Toward a Lowest Effective Dose of Cyproterone Acetate in Trans Women: Results From the ENIGI Study. J Clin Endocrinol Metab 2021; 106:e3936-e3945. [PMID: 34125226 PMCID: PMC8571811 DOI: 10.1210/clinem/dgab427] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2021] [Indexed: 02/08/2023]
Abstract
CONTEXT Cyproterone acetate (CPA) is a competitive inhibitor of the androgen receptor and exerts negative hypothalamic feedback. It is often used in combination with estrogens in trans women to achieve feminization. However, CPA has been associated with side effects such as changes in liver enzyme concentrations and increases in prolactin concentrations. The question is whether the testosterone-lowering effect, as well as these side effects, are dose dependent. OBJECTIVE To assess the lowest effective dose of CPA in trans women to prevent side effects. METHODS This longitudinal study, conducted at gender identity centers in Amsterdam, Ghent, and Florence, is part of the European Network for the Investigation of Gender Incongruence (ENIGI), a multicenter prospective cohort study. Participants were trans women (n = 882) using estrogens only or in combination with 10, 25, 50, or 100 mg CPA daily. The primary outcome measure was the concentration of testosterone at 3 and/or 12 months of hormone therapy. RESULTS Using estrogens only (without CPA) led to testosterone concentrations of 5.5 nmol/L (standard error of the mean [SEM] 0.3). All doses of CPA resulted in testosterone concentrations below the predefined threshold of suppression of 2 nmol/L (10 mg, 0.9 nmol/L, SEM 0.7; 25 mg, 0.9 nmol/L, SEM 0.1; 50mg, 1.1 nmol/L, SEM 0.1; 100 mg, 0.9 nmol/L, SEM 0.7). Higher prolactin and lower high-density lipoprotein concentrations were observed with increasing doses of CPA. No differences in liver enzyme concentrations were found between the doses. CONCLUSION Compared with higher doses of CPA, a daily dose of 10 mg is equally effective in lowering testosterone concentrations in trans women, while showing fewer side effects.
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Affiliation(s)
- Suzanne M E Kuijpers
- Department of Endocrinology and Center of Expertise on Gender Dysphoria, Amsterdam University Medical Center, location VUmc, 1007 MBAmsterdam, the Netherlands
| | - Chantal M Wiepjes
- Department of Endocrinology and Center of Expertise on Gender Dysphoria, Amsterdam University Medical Center, location VUmc, 1007 MBAmsterdam, the Netherlands
| | - Elfi B Conemans
- Department of Endocrinology and Center of Expertise on Gender Dysphoria, Amsterdam University Medical Center, location VUmc, 1007 MBAmsterdam, the Netherlands
| | - Alessandra D Fisher
- Sexual Medicine and Andrology Unit, Department of Experimental, Clinical and Biomedical Sciences, University of Florence, Florence, Italy
| | - Guy T’Sjoen
- Department of Endocrinology and Center for Sexology and Gender, Ghent University Hospital, Ghent, Belgium
| | - Martin den Heijer
- Department of Endocrinology and Center of Expertise on Gender Dysphoria, Amsterdam University Medical Center, location VUmc, 1007 MBAmsterdam, the Netherlands
- Correspondence: Prof. M. den Heijer, MD, PhD, Department of Internal Medicine, Section Endocrinology, Amsterdam University, location VUmc, PO Box 7057, 1007 MB Amsterdam, the Netherlands.
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Glintborg D, T'Sjoen G, Ravn P, Andersen MS. MANAGEMENT OF ENDOCRINE DISEASE: Optimal feminizing hormone treatment in transgender people. Eur J Endocrinol 2021; 185:R49-R63. [PMID: 34081614 DOI: 10.1530/eje-21-0059] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2021] [Accepted: 06/03/2021] [Indexed: 01/06/2023]
Abstract
Transgender women are assigned male at birth but identified as women. The incidence of gender dysphoria is estimated to be around 1% of the population. Gender dysphoria may be associated with depression and low quality of life, which in most cases improves during gender-affirming hormonal treatment (GAHT). Feminizing hormonal treatment for transgender women or gender non-binary people typically includes natural estrogen (estradiol). Additional testosterone-blocking treatment is often needed to ensure the suppression of the pituitary-gonadal axis and may include cyproterone acetate, a gonadotropin-releasing hormone agonist (GnRH-a), or spironolactone. The health risks of cyproterone acetate as anti-androgen treatment are debated and randomized protocols with other anti-androgen treatments are requested. Orchiectomy is performed in some transgender women after various duration of GAHT. Currently, natural progesterone is not recommended as part of GAHT due to limited knowledge on the balance between risks and benefits. In the present article, we discuss evidence regarding established and upcoming feminizing treatment for adult transgender women or gender non-binary people seeking feminization. Data on study populations with transgender women are put into a wider context of literature regarding the effects of sex steroid hormones in cisgender study populations. Relevant follow-up and monitoring during feminizing treatment is debated. The review has a special focus on the pharmacotherapy of feminizing hormonal therapy.
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Affiliation(s)
- Dorte Glintborg
- Department of Endocrinology, Odense University Hospital, Odense, Denmark
| | - Guy T'Sjoen
- Department of Endocrinology and Center for Sexology and Gender, Ghent University Hospital, Ghent, Belgium
| | - Pernille Ravn
- Department of Gynaecology and Obstetrics, Odense University Hospital, Odense, Denmark
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Madsen MC, van Dijk D, Wiepjes CM, Conemans EB, Thijs A, den Heijer M. Erythrocytosis in a Large Cohort of Trans Men Using Testosterone: A Long-Term Follow-Up Study on Prevalence, Determinants, and Exposure Years. J Clin Endocrinol Metab 2021; 106:1710-1717. [PMID: 33599731 PMCID: PMC8118580 DOI: 10.1210/clinem/dgab089] [Citation(s) in RCA: 30] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2020] [Indexed: 12/20/2022]
Abstract
CONTEXT Erythrocytosis is a known side effect of testosterone therapy that can increase the risk of thromboembolic events. OBJECTIVES To study the prevalence and determinants in the development of erythrocytosis in trans men using testosterone. METHODS A 20-year follow-up study in adult trans men who started testosterone therapy and had monitoring of hematocrit at our center (n = 1073). RESULTS Erythrocytosis occurred in 11% (hematocrit > 0.50 L/L), 3.7% (hematocrit > 0.52 L/L), and 0.5% (hematocrit > 0.54 L/L) of trans men. Tobacco use (odds ratio [OR] 2.2; 95% CI, 1.6-3.3), long-acting undecanoate injections (OR 2.9; 95% CI, 1.7-5.0), age at initiation of hormone therapy (OR 5.9; 95% CI, 2.8-12.3), body mass index (BMI) (OR 3.7; 95% CI, 2.2-6.2), and pulmonary conditions associated with erythrocytosis and polycythemia vera (OR 2.5; 95% CI, 1.4-4.4) were associated with hematocrit > 0.50 L/L. In the first year of testosterone therapy hematocrit increased most: 0.39 L/L at baseline to 0.45 L/L after 1 year. Although there was only a slight continuation of this increase in the following 20 years, the probability of developing erythrocytosis still increased (10% after 1 year, 38% after 10 years). CONCLUSION Erythrocytosis occurs in trans men using testosterone. The largest increase in hematocrit was seen in the first year, but also after the first years a substantial number of people present with hematocrit > 0.50 L/L. A reasonable first step in the care for trans men with erythrocytosis while on testosterone is to advise them to quit smoking, to switch to a transdermal administration route, and if BMI is high, to lose weight.
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Affiliation(s)
- Milou Cecilia Madsen
- Department of Endocrinology and Center of Expertise on Gender Dysphoria, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
- Department of Internal Medicine, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
- Correspondence: M. den Heijer, MD PhD, Amsterdam UMC, Vrije Universiteit, Department of Internal Medicine, section Endocrinology, PO Box 7057, 1007 MB Amsterdam, the Netherlands.
| | - Dennis van Dijk
- Department of Endocrinology and Center of Expertise on Gender Dysphoria, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
| | - Chantal Maria Wiepjes
- Department of Endocrinology and Center of Expertise on Gender Dysphoria, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
- Department of Internal Medicine, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
| | - Elfi Barbara Conemans
- Department of Endocrinology and Center of Expertise on Gender Dysphoria, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
- Department of Internal Medicine, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
| | - Abel Thijs
- Department of Internal Medicine, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
| | - Martin den Heijer
- Department of Endocrinology and Center of Expertise on Gender Dysphoria, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
- Department of Internal Medicine, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
- Correspondence: M. den Heijer, MD PhD, Amsterdam UMC, Vrije Universiteit, Department of Internal Medicine, section Endocrinology, PO Box 7057, 1007 MB Amsterdam, the Netherlands.
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Pappas II, Craig WY, Spratt LV, Spratt DI. Efficacy of Sex Steroid Therapy Without Progestin or GnRH Agonist for Gonadal Suppression in Adult Transgender Patients. J Clin Endocrinol Metab 2021; 106:e1290-e1300. [PMID: 33247919 DOI: 10.1210/clinem/dgaa884] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2020] [Indexed: 02/04/2023]
Abstract
CONTEXT Testosterone (T) or estradiol (E2) are administered to suppress gonadal function in female-to-male (FTM) and male-to-female (MTF) transgender patients. How often sex steroids cause adequate suppression without GnRH agonist (GnRHa) or progestin therapy has not been reported. OBJECTIVES (1) To determine how often T and E2 therapy alone can effectively suppress gonadal function in MTF and FTM transgender patients, and (2) to determine the frequency and range of serum E2 levels above the normal male range in FTM patients receiving T therapy. DESIGN Retrospective cohort study. SETTING Outpatient reproductive endocrinology clinic at an academic medical center. PATIENTS A total of 65 FTM and 33 MTF patients were included who were > 18 years of age and not receiving progestin or GnRHa therapy. INTERVENTION Female-to-male patients were receiving T through injections or gel. Male-to-female patients were receiving oral or subcutaneous E2. MAIN OUTCOME MEASUREMENTS In FTM patients the indicator of ovary suppression was amenorrhea. In MTF patients, the indicator of testes suppression was T levels <50 ng/dL. RESULTS Median serum total T level for FTM patients was 712 ng/dL (range, 370-1164 ng/dL). On T therapy alone, 90.8% of patients achieved amenorrhea and 49.2% of patients had serum E2 levels above the normal range for women. For MTF patients, the median serum E2 level was 129.2 pg/mL (range, 75-197 pg/mL). On E2 therapy alone, 84.8% of MTF patients had adequate suppression of testicular function. CONCLUSIONS Testosterone and E2 therapy are usually effective without progestin or GnRHa therapy to suppress gonadal function in transgender patients. Progestin and/or GnRHa therapy should only be initiated in those patients who do not have adequate gonadal suppression on optimized doses of T or E2 alone.
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Affiliation(s)
- India I Pappas
- The Department of Obstetrics and Gynecology, Division of Reproductive Endocrinology and Infertility Maine Medical Center, Portland, Maine, USA
| | - Wendy Y Craig
- Maine Medical Center Research Institute, Scarborough, Maine, USA
| | - Lindsey V Spratt
- The Department of Obstetrics and Gynecology, Division of Reproductive Endocrinology and Infertility Maine Medical Center, Portland, Maine, USA
| | - Daniel I Spratt
- The Department of Obstetrics and Gynecology, Division of Reproductive Endocrinology and Infertility Maine Medical Center, Portland, Maine, USA
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de Blok CJM, Dijkman BAM, Wiepjes CM, Staphorsius AS, Timmermans FW, Smit JM, Dreijerink KMA, den Heijer M. Sustained Breast Development and Breast Anthropometric Changes in 3 Years of Gender-Affirming Hormone Treatment. J Clin Endocrinol Metab 2021; 106:e782-e790. [PMID: 33206172 DOI: 10.1210/clinem/dgaa841] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2020] [Indexed: 12/19/2022]
Abstract
CONTEXT Breast development is important for most trans women. An important limitation of current breast development measurement methods is that these do not allow for 3D volume analyses. OBJECTIVES To examine breast development and change in anthropometry during the first 3 years of gender-affirming hormone treatment using 3D imaging. Associations with clinical or laboratory parameters and satisfaction with the gained breast development were also studied. DESIGN Prospective cohort study. SETTING Specialized tertiary gender identity clinic in Amsterdam, the Netherlands. PARTICIPANTS Participants were 69 adult trans women with a median age of 26 years (interquartile range, 21-38). INTERVENTIONS Gender-affirming hormone treatment. MAIN OUTCOME MEASURES Volumetric and anthropometric breast development and satisfaction. RESULTS Breast volume increased by 72 cc (95% confidence interval [CI], 48-97) to 100 cc (standard deviation 48). This resulted in a cup-size <A-cup in 71% of the participants. Although the change in breast-chest difference plateaued after approximately 9 months, sustained increase in breast volume was observed during the 3-year observation period. Sternal notch to nipple distance increased by 1.3 cm (95% CI, 0.9-1.7) and internipple distance increased by 1.0 cm (95% CI, 0.4-1.5). At least 58% of trans women were satisfied with the gained breast size. CONCLUSIONS Sustained breast growth and development during hormone treatment was observed during the full 3-year observation period. The breasts of trans women are positioned more laterally and caudally on the chest compared with cis women. Although modest breast volumes were observed, breast development was satisfactory to most trans women.
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Affiliation(s)
- Christel J M de Blok
- Department of Endocrinology, Amsterdam UMC, VU University Medical Center, HV, Amsterdam, the Netherlands
- Center of Expertise on Gender Dysphoria, Amsterdam UMC, VU University Medical Center, HV, Amsterdam, the Netherlands
| | - Benthe A M Dijkman
- Department of Endocrinology, Amsterdam UMC, VU University Medical Center, HV, Amsterdam, the Netherlands
- Center of Expertise on Gender Dysphoria, Amsterdam UMC, VU University Medical Center, HV, Amsterdam, the Netherlands
| | - Chantal M Wiepjes
- Department of Endocrinology, Amsterdam UMC, VU University Medical Center, HV, Amsterdam, the Netherlands
- Center of Expertise on Gender Dysphoria, Amsterdam UMC, VU University Medical Center, HV, Amsterdam, the Netherlands
| | - Annemieke S Staphorsius
- Department of Endocrinology, Amsterdam UMC, VU University Medical Center, HV, Amsterdam, the Netherlands
- Center of Expertise on Gender Dysphoria, Amsterdam UMC, VU University Medical Center, HV, Amsterdam, the Netherlands
| | - Floyd W Timmermans
- Center of Expertise on Gender Dysphoria, Amsterdam UMC, VU University Medical Center, HV, Amsterdam, the Netherlands
- Department of Plastic, Reconstructive, and Hand Surgery, Amsterdam UMC, VU University Medical Center, Amsterdam Movement Sciences, HV, Amsterdam, the Netherlands
| | - Jan Maerten Smit
- Center of Expertise on Gender Dysphoria, Amsterdam UMC, VU University Medical Center, HV, Amsterdam, the Netherlands
- Department of Plastic, Reconstructive, and Hand Surgery, Amsterdam UMC, VU University Medical Center, Amsterdam Movement Sciences, HV, Amsterdam, the Netherlands
| | - Koen M A Dreijerink
- Department of Endocrinology, Amsterdam UMC, VU University Medical Center, HV, Amsterdam, the Netherlands
- Center of Expertise on Gender Dysphoria, Amsterdam UMC, VU University Medical Center, HV, Amsterdam, the Netherlands
| | - Martin den Heijer
- Department of Endocrinology, Amsterdam UMC, VU University Medical Center, HV, Amsterdam, the Netherlands
- Center of Expertise on Gender Dysphoria, Amsterdam UMC, VU University Medical Center, HV, Amsterdam, the Netherlands
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21
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Schagen SEE, Wouters FM, Cohen-Kettenis PT, Gooren LJ, Hannema SE. Bone Development in Transgender Adolescents Treated With GnRH Analogues and Subsequent Gender-Affirming Hormones. J Clin Endocrinol Metab 2020; 105:5903559. [PMID: 32909025 PMCID: PMC7524308 DOI: 10.1210/clinem/dgaa604] [Citation(s) in RCA: 48] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2020] [Accepted: 09/08/2020] [Indexed: 12/30/2022]
Abstract
CONTEXT Hormonal interventions in adolescents with gender dysphoria may have adverse effects, such as reduced bone mineral accrual. OBJECTIVE To describe bone mass development in adolescents with gender dysphoria treated with gonadotropin-releasing hormone analogues (GnRHa), subsequently combined with gender-affirming hormones. DESIGN Observational prospective study. SUBJECTS 51 transgirls and 70 transboys receiving GnRHa and 36 transgirls and 42 transboys receiving GnRHa and gender-affirming hormones, subdivided into early- and late-pubertal groups. MAIN OUTCOME MEASURES Bone mineral apparent density (BMAD), age- and sex-specific BMAD z-scores, and serum bone markers. RESULTS At the start of GnRHa treatment, mean areal bone mineral density (aBMD) and BMAD values were within the normal range in all groups. In transgirls, the mean z-scores were well below the population mean. During 2 years of GnRHa treatment, BMAD stabilized or showed a small decrease, whereas z-scores decreased in all groups. During 3 years of combined administration of GnRHa and gender-affirming hormones, a significant increase of BMAD was found. Z-scores normalized in transboys but remained below zero in transgirls. In transgirls and early pubertal transboys, all bone markers decreased during GnRHa treatment. CONCLUSIONS BMAD z-scores decreased during GnRHa treatment and increased during gender-affirming hormone treatment. Transboys had normal z-scores at baseline and at the end of the study. However, transgirls had relatively low z-scores, both at baseline and after 3 years of estrogen treatment. It is currently unclear whether this results in adverse outcomes, such as increased fracture risk, in transgirls as they grow older.
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Affiliation(s)
- Sebastian E E Schagen
- Department of Pediatric Endocrinology, VU University Medical Center, 1081 HV Amsterdam, & Leiden University Medical Center, ZA Leiden, the Netherlands
| | - Femke M Wouters
- Department of Pediatric Endocrinology, VU University Medical Center, HV Amsterdam, the Netherlands
| | - Peggy T Cohen-Kettenis
- Department of Medical Psychology, Amsterdam UMC, VU University, HV Amsterdam, the Netherlands
| | - Louis J Gooren
- Department of Endocrinology, VU University Medical Center, HV Amsterdam, the Netherlands
| | - Sabine E Hannema
- Department of Pediatrics, Willem-Alexander Children Hospital, Leiden University Medical Center, ZA Leiden, the Netherlands
- Department of Pediatric Endocrinology, Sophia Children's Hospital, Erasmus Medical Centre, CN Rotterdam, Netherlands
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22
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Gava G, Mancini I, Alvisi S, Seracchioli R, Meriggiola MC. A comparison of 5-year administration of cyproterone acetate or leuprolide acetate in combination with estradiol in transwomen. Eur J Endocrinol 2020; 183:561-569. [PMID: 33055297 DOI: 10.1530/eje-20-0370] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2020] [Accepted: 09/10/2020] [Indexed: 11/08/2022]
Abstract
OBJECTIVE The impact of different combinations of long-term gender-affirming hormone therapy (GAHT) in transwomen (TW) is largely unknown. To assess the effects of 5-year administration of cyproterone acetate (CPA) or leuprolide acetate (Leu) plus transdermal or oral estradiol (E). DESIGN Cohort study based on prospectively collected data. Fifty TW received 50 mg CPA daily orally (n = 25; CPA+E group) or 3.75 mg Leu i.m. monthly (n = 25; Leu+E group) with 1 or 2 mg E daily for 5 years. Reproductive hormones, biochemical and anthropometric parameters, body composition and bone mineral density (BMD) were assessed. RESULTS LH, FSH and total testosterone levels were similarly and significantly suppressed in both groups. Prolactin increased only in the CPA+E group (P = 0.002). Fasting insulin resistance and glucose progressively increased in the CPA+E group only (treatment × time effect P = 0.002 and P = 0.043, respectively). Total cholesterol increased more in the Leu+E group than in the CPA+E group and HDL-cholesterol decreased in the CPA+E group (time × treatment interaction effect, P = 0.007). Lumbar and total body BMD increased in both groups after 3 years. No serious adverse events were recorded. CONCLUSIONS Both regimens were effective in suppression of T production. CPA+E worsened the metabolic profile with a slight increase in PRL levels. All subjects presented an increase in BMD regardless of treatment. These preliminary data could have clinical implications in the choice of GAHT, in particular for those TW not requiring gender-affirming surgery.
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Affiliation(s)
- Giulia Gava
- Gynecology and Physiopathology of Human Reproduction, Department of Medical and Surgical Sciences (DIMEC), S. Orsola-Malpighi Hospital, University of Bologna, Bologna, Italy
| | - Ilaria Mancini
- Gynecology and Physiopathology of Human Reproduction, Department of Medical and Surgical Sciences (DIMEC), S. Orsola-Malpighi Hospital, University of Bologna, Bologna, Italy
| | - Stefania Alvisi
- Gynecology and Physiopathology of Human Reproduction, Department of Medical and Surgical Sciences (DIMEC), S. Orsola-Malpighi Hospital, University of Bologna, Bologna, Italy
| | - Renato Seracchioli
- Gynecology and Physiopathology of Human Reproduction, Department of Medical and Surgical Sciences (DIMEC), S. Orsola-Malpighi Hospital, University of Bologna, Bologna, Italy
| | - Maria Cristina Meriggiola
- Gynecology and Physiopathology of Human Reproduction, Department of Medical and Surgical Sciences (DIMEC), S. Orsola-Malpighi Hospital, University of Bologna, Bologna, Italy
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de Nie I, de Blok CJM, van der Sluis TM, Barbé E, Pigot GLS, Wiepjes CM, Nota NM, van Mello NM, Valkenburg NE, Huirne J, Gooren LJG, van Moorselaar RJA, Dreijerink KMA, den Heijer M. Prostate Cancer Incidence under Androgen Deprivation: Nationwide Cohort Study in Trans Women Receiving Hormone Treatment. J Clin Endocrinol Metab 2020; 105:5864158. [PMID: 32594155 PMCID: PMC7379905 DOI: 10.1210/clinem/dgaa412] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2020] [Accepted: 06/23/2020] [Indexed: 12/28/2022]
Abstract
CONTEXT Trans women (male sex assigned at birth, female gender identity) mostly use antiandrogens combined with estrogens and can subsequently undergo vaginoplasty including orchiectomy. Because the prostate remains in situ after this procedure, trans women are still at risk for prostate cancer. OBJECTIVE To assess the incidence of prostate cancer in trans women using hormone treatment. The incidence of prostate cancer in trans women using hormone treatment. DESIGN In this nationwide retrospective cohort study, data of participants were linked to the Dutch national pathology database and to Statistics Netherlands to obtain data on prostate cancer diagnosis and mortality. SETTING Gender identity clinic. PARTICIPANTS Trans women who visited our clinic between 1972 and 2016 and received hormone treatment were included. MAIN OUTCOME MEASURES Standardized incidence ratios (SIRs) were calculated using the number of observed prostate cancer cases in our cohort and the number of expected cases based on age-specific incidence numbers from the Netherlands Comprehensive Cancer Organization. RESULTS The study population consisted of 2281 trans women with a median follow-up time of 14 years (interquartile range 7-24), and a total follow-up time of 37 117 years. Six prostate cancer cases were identified after a median 17 years of hormone treatment. This resulted in a lower prostate cancer risk in trans women than in Dutch reference males (SIR 0.20, 95% confidence interval 0.08-0.42). CONCLUSIONS Trans women receiving androgen deprivation therapy and estrogens have a substantially lower risk for prostate cancer than the general male population. Our results support the hypothesis that androgen deprivation has a preventive effect on the initiation and development of prostate cancer.
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Affiliation(s)
- Iris de Nie
- Department of Endocrinology, Amsterdam UMC, VU University Medical Centre, Amsterdam, the Netherlands
- Centre of Expertise on Gender Dysphoria, Amsterdam UMC, VU University Medical Centre, Amsterdam, the Netherlands
| | - Christel J M de Blok
- Department of Endocrinology, Amsterdam UMC, VU University Medical Centre, Amsterdam, the Netherlands
- Centre of Expertise on Gender Dysphoria, Amsterdam UMC, VU University Medical Centre, Amsterdam, the Netherlands
| | - Tim M van der Sluis
- Department of Urology, Amsterdam UMC, VU University Medical Centre, Amsterdam, the Netherlands
| | - Ellis Barbé
- Department of Pathology, Amsterdam UMC, VU University Medical Centre, Amsterdam, the Netherlands
| | - Garry L S Pigot
- Centre of Expertise on Gender Dysphoria, Amsterdam UMC, VU University Medical Centre, Amsterdam, the Netherlands
- Department of Urology, Amsterdam UMC, VU University Medical Centre, Amsterdam, the Netherlands
| | - Chantal M Wiepjes
- Department of Endocrinology, Amsterdam UMC, VU University Medical Centre, Amsterdam, the Netherlands
- Centre of Expertise on Gender Dysphoria, Amsterdam UMC, VU University Medical Centre, Amsterdam, the Netherlands
| | - Nienke M Nota
- Department of Endocrinology, Amsterdam UMC, VU University Medical Centre, Amsterdam, the Netherlands
- Centre of Expertise on Gender Dysphoria, Amsterdam UMC, VU University Medical Centre, Amsterdam, the Netherlands
| | - Norah M van Mello
- Centre of Expertise on Gender Dysphoria, Amsterdam UMC, VU University Medical Centre, Amsterdam, the Netherlands
- Department of Obstetrics and Gynecology, Amsterdam UMC, VU University Medical Centre, Amsterdam, the Netherlands
| | - Noelle E Valkenburg
- Department of Endocrinology, Amsterdam UMC, VU University Medical Centre, Amsterdam, the Netherlands
| | - Judith Huirne
- Department of Obstetrics and Gynecology, Amsterdam UMC, VU University Medical Centre, Amsterdam, the Netherlands
| | - Louis J G Gooren
- Department of Endocrinology, Amsterdam UMC, VU University Medical Centre, Amsterdam, the Netherlands
- Centre of Expertise on Gender Dysphoria, Amsterdam UMC, VU University Medical Centre, Amsterdam, the Netherlands
| | | | - Koen M A Dreijerink
- Department of Endocrinology, Amsterdam UMC, VU University Medical Centre, Amsterdam, the Netherlands
- Centre of Expertise on Gender Dysphoria, Amsterdam UMC, VU University Medical Centre, Amsterdam, the Netherlands
| | - Martin den Heijer
- Department of Endocrinology, Amsterdam UMC, VU University Medical Centre, Amsterdam, the Netherlands
- Centre of Expertise on Gender Dysphoria, Amsterdam UMC, VU University Medical Centre, Amsterdam, the Netherlands
- Correspondence and Reprint Requests: M. den Heijer, MD PhD, Department of Internal Medicine, Section Endocrinology, Amsterdam UMC, VU University Medical Centre, Amsterdam, the Netherlands, PO Box 7057, 1007 MB Amsterdam. E-mail:
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24
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de Blok CJM, Wiepjes CM, Nota NM, den Heijer M. [Hormone treatment of transgender people: Long-term health effects and safety]. Ned Tijdschr Geneeskd 2020; 164:D4481. [PMID: 32757514] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
•Transgender people experience incongruence between the sex assigned at birth and the gender with which they identify. •Transgender people can be treated with sex hormones and gender-affirming surgery to induce desired physical changes of the gender they identify with. •Treatment with sex hormones is effective; it induces the desired physical characteristics and improves self-image. •Transgender women have a higher risk of venous thromboembolism, stroke and meningioma compared to cisgender men and cisgender women. Compared to cisgender men, transgender women have a higher risk of breast cancer and transgender women > 50 years old have a higher risk of fractures. •Transgender men have a higher risk of myocardial infarction than cisgender women. Their risk of fracture is just as high as that of cisgender women and their risk of breast cancer is lower. •Although hormone treatment is generally considered safe for transgender people, the risk of cardiovascular disease should definitely be carefully monitored. Transgender people should also be advised to participate in population screening programmes based on the organs they have.
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Affiliation(s)
- Christel J M de Blok
- Amsterdam UMC, locatie VUmc, Amsterdam, afd. Endocrinologie (tevens Kennis- en Zorgcentrum voor Genderdysforie)
| | - Chantal M Wiepjes
- Amsterdam UMC, locatie VUmc, Amsterdam, afd. Endocrinologie (tevens Kennis- en Zorgcentrum voor Genderdysforie
| | - Nienke M Nota
- Amsterdam UMC, locatie VUmc, Amsterdam, afd. Endocrinologie (tevens Kennis- en Zorgcentrum voor Genderdysforie
| | - Martin den Heijer
- Amsterdam UMC, locatie VUmc, Amsterdam, afd. Endocrinologie (tevens Kennis- en Zorgcentrum voor Genderdysforie
- Contact: Martin den Heijer
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25
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Wiik A, Lundberg TR, Rullman E, Andersson DP, Holmberg M, Mandić M, Brismar TB, Dahlqvist Leinhard O, Chanpen S, Flanagan JN, Arver S, Gustafsson T. Muscle Strength, Size, and Composition Following 12 Months of Gender-affirming Treatment in Transgender Individuals. J Clin Endocrinol Metab 2020; 105:5651219. [PMID: 31794605 DOI: 10.1210/clinem/dgz247] [Citation(s) in RCA: 40] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2019] [Accepted: 12/03/2019] [Indexed: 02/04/2023]
Abstract
CONTEXT As many sports are divided in male/female categories, governing bodies have formed regulations on the eligibility for transgender individuals to compete in these categories. Yet, the magnitude of change in muscle mass and strength with gender-affirming treatment remains insufficiently explored. OBJECTIVE This study explored the effects of gender-affirming treatment on muscle function, size, and composition during 12 months of therapy. DESIGN, SETTINGS, PARTICIPANTS In this single-center observational cohort study, untrained transgender women (TW, n = 11) and transgender men (TM, n = 12), approved to start gender-affirming medical interventions, underwent assessments at baseline, 4 weeks after gonadal suppression of endogenous hormones but before hormone replacement, and 4 and 12 months after treatment initiation. MAIN OUTCOME MEASURES Knee extensor and flexor strength were assessed at all examination time points, and muscle size and radiological density (using magnetic resonance imaging and computed tomography) at baseline and 12 months after treatment initiation. RESULTS Thigh muscle volume increased (15%) in TM, which was paralleled by increased quadriceps cross-sectional area (CSA) (15%) and radiological density (6%). In TW, the corresponding parameters decreased by -5% (muscle volume) and -4% (CSA), while density remained unaltered. The TM increased strength over the assessment period, while the TW generally maintained their strength levels. CONCLUSIONS One year of gender-affirming treatment resulted in robust increases in muscle mass and strength in TM, but modest changes in TW. These findings add new knowledge on the magnitude of changes in muscle function, size, and composition with cross-hormone therapy, which could be relevant when evaluating the transgender eligibility rules for athletic competitions.
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Affiliation(s)
- Anna Wiik
- Department of Laboratory Medicine, Division of Clinical Physiology, Karolinska Institutet, and Unit of Clinical Physiology, Karolinska University Hospital, Stockholm, Sweden
| | - Tommy R Lundberg
- Department of Laboratory Medicine, Division of Clinical Physiology, Karolinska Institutet, and Unit of Clinical Physiology, Karolinska University Hospital, Stockholm, Sweden
| | - Eric Rullman
- Department of Laboratory Medicine, Division of Clinical Physiology, Karolinska Institutet, and Unit of Clinical Physiology, Karolinska University Hospital, Stockholm, Sweden
| | - Daniel P Andersson
- Department of Medicine, Karolinska Institutet, Karolinska University Hospital Huddinge, Stockholm, Sweden
| | - Mats Holmberg
- ANOVA, Andrology, Sexual Medicine and Transgender Medicine, Karolinska University Hospital, Stockholm, Sweden
| | - Mirko Mandić
- Department of Laboratory Medicine, Division of Clinical Physiology, Karolinska Institutet, and Unit of Clinical Physiology, Karolinska University Hospital, Stockholm, Sweden
| | - Torkel B Brismar
- Division of Radiology, Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - Olof Dahlqvist Leinhard
- AMRA Medical AB, Linköping, Sweden
- Department of Medical and Health Sciences, Linköping University, Linköping, Sweden
| | - Setareh Chanpen
- ANOVA, Andrology, Sexual Medicine and Transgender Medicine, Karolinska University Hospital, Stockholm, Sweden
| | - John N Flanagan
- Department of Medicine, Karolinska Institutet, Karolinska University Hospital Huddinge, Stockholm, Sweden
- ANOVA, Andrology, Sexual Medicine and Transgender Medicine, Karolinska University Hospital, Stockholm, Sweden
| | - Stefan Arver
- ANOVA, Andrology, Sexual Medicine and Transgender Medicine, Karolinska University Hospital, Stockholm, Sweden
| | - Thomas Gustafsson
- Department of Laboratory Medicine, Division of Clinical Physiology, Karolinska Institutet, and Unit of Clinical Physiology, Karolinska University Hospital, Stockholm, Sweden
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26
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Meyer G, Mayer M, Mondorf A, Flügel AK, Herrmann E, Bojunga J. Safety and rapid efficacy of guideline-based gender-affirming hormone therapy: an analysis of 388 individuals diagnosed with gender dysphoria. Eur J Endocrinol 2020; 182:149-156. [PMID: 31751300 DOI: 10.1530/eje-19-0463] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2019] [Accepted: 11/15/2019] [Indexed: 11/08/2022]
Abstract
OBJECTIVE Hormone treatment is an important part of gender reassignment therapy in gender dysphoria. Previous data about efficacy and safety are commonly based on small cohorts or they comprise former cohorts under meanwhile obsolete therapy regimes. Our objective was to investigate these topics in a large cohort of individuals under guideline-based treatment. DESIGN/METHODS Cohort study of medical files of n = 155 male-to-female (transwomen) and n = 233 female-to-male transgender persons (transmen) of an Endocrine outpatient clinic between 2009 and 2017. RESULTS Median time to reach amenorrhoea in transmen under testosterone monotherapy was 3 months, regardless of whether testosterone undecanoat or gel was used. Transmen with higher levels of hemoglobin 3-4 months after onset of GAHT had a greater chance to reach amenorrhea early, whereas testosterone levels showed no significant correlation (hemoglobin: HR: 1.639; 95% CI: 1.036-2.591, P = 0.035; testosterone: HR: 0.999; 95% CI: 0.998-1.001, P = 0.490). Estradiol levels (ρ -0.117; P = 0.316) had no significant influence on breast development in transwomen. Testosterone levels (ρ -0.398; P < 0.001) and FAI (ρ 0.346; P = 0.004) were significantly negatively correlated with reached Tanner stage. Liver values and blood lipids showed an alignment to reference range of the required sex in both groups. Relevant elevations of liver values were rare (2.44% in transmen, 4.23% in transwomen) and transient in most cases. Most relevant side effects were acne (44.8%), respectively erythrocytosis (up to 5.6%) in transmen and venous thrombembolism (1.9%) in transwomen. CONCLUSIONS Gender-affirming hormone therapy in accordance with current clinical practice guidelines is efficient and safe.
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Affiliation(s)
- Gesine Meyer
- Division of Endocrinology, Department of Internal Medicine 1, Goethe-University Hospital, Frankfurt, Germany
| | - Moritz Mayer
- Division of Endocrinology, Department of Internal Medicine 1, Goethe-University Hospital, Frankfurt, Germany
| | - Antonia Mondorf
- Division of Endocrinology, Department of Internal Medicine 1, Goethe-University Hospital, Frankfurt, Germany
| | - Anna Katharina Flügel
- Division of Endocrinology, Department of Internal Medicine 1, Goethe-University Hospital, Frankfurt, Germany
| | - Eva Herrmann
- Institut for Biostatistics and Mathematic Modelling, Goethe-University, Frankfurt, Germany
| | - Joerg Bojunga
- Division of Endocrinology, Department of Internal Medicine 1, Goethe-University Hospital, Frankfurt, Germany
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Gulanski BI, Flannery CA, Peter PR, Leone CA, Stachenfeld NS. Compromised endothelial function in transgender men taking testosterone. Clin Endocrinol (Oxf) 2020; 92:138-144. [PMID: 31765022 PMCID: PMC6957681 DOI: 10.1111/cen.14132] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2019] [Revised: 11/18/2019] [Accepted: 11/22/2019] [Indexed: 12/13/2022]
Abstract
CONTEXT Transgender men (TGM) are persons assigned female gender at birth with a male gender identity and are routinely treated with testosterone. Androgen excess is associated with endothelial dysfunction among cisgender females (CGF) and is an early sign of atherosclerosis and hypertension. OBJECTIVE To determine the effect of testosterone treatment on endothelial function in TGM. SETTING The John B. Pierce Laboratory and Yale School of Medicine. SUBJECTS Eleven TGM (age 27 ± 5 years; BMI 24.4 ± 3.7 kg/m2 ) receiving testosterone (T) and 20 CGF (28 ± 5 years; BMI 26.0 ± 5.1 kg/m2 ) during the early follicular phase of their menstrual cycle. DESIGN AND OUTCOME MEASURES We evaluated brachial vasodilatory responses following stimuli designed to elicit shear stress using 5-minute occlusion to determine endothelial function (flow-mediated vasodilation, FMD). RESULTS Total T was greater in the TGM compared to CGF (484.6 ± 122.5 vs 1.5 ± 0.7 ng/dL), as was free T (83.9 ± 32.4 vs 1.9 ± 0.8 pg/dL). FMD was markedly lower in the TGM (4.5 ± 2.7%) compared to the CGF (8.1 ± 2.9%, P = .002) indicating significantly diminished endothelial function in TGM. CONCLUSIONS We have shown for the first time that in TGM the androgen-dominant hormonal milieu was associated with impaired endothelial function. Endothelial dysfunction precedes clinically detectable atherosclerotic plaque in the coronary arteries, so is an important marker for clinical cardiovascular risk. Therefore, attention to cardiovascular risk factors should be integral to the care of transgender men.
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Affiliation(s)
- Barbara I. Gulanski
- Department of Medicine, Section of Endocrinology, Yale School of Medicine, New Haven, CT, 06520
| | - Clare A. Flannery
- Department of Obstetrics, Gynecology and Reproductive Sciences, New Haven, CT, 06520
- Department of Medicine, Section of Endocrinology, Yale School of Medicine, New Haven, CT, 06520
| | - Patricia R. Peter
- Department of Medicine, Section of Endocrinology, Yale School of Medicine, New Haven, CT, 06520
| | | | - Nina S. Stachenfeld
- The John B. Pierce Laboratory, New Haven, CT, 06519
- Department of Obstetrics, Gynecology and Reproductive Sciences, New Haven, CT, 06520
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Abstract
PURPOSE OF REVIEW Kidney transplantation and gender affirmation treatments are becoming increasingly more prevalent due to advances in technology. However, there is a paucity of data regarding kidney transplantation in transgender patients. Interesting considerations must be made in this patient population, since there are many hormonal interactions with kidney function and the transplantation process. RECENT FINDINGS The diagnosis of estimated glomerular filtration rate (eGFR), preoperative assessment/counseling, decreased testosterone levels in a transgender male to female patient, increased estrogen/progesterone in a female to male patient, and drug side effects all have important and unique implications for kidney transplant recipients. Kidney transplantation can be safely and effectively managed in transgender patients with special considerations in eGFR calculations, mental health/lifestyle counseling, and drug interactions.
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Affiliation(s)
- Joshua S Jue
- Department of Urology, Lenox Hill Hospital, Zucker School of Medicine at Hofstra/Northwell, New York, NY, 10075, USA.
| | - Mahmoud Alameddine
- Department of Surgery and Urology, Miami Transplant Institute, University of Miami Miller School of Medicine, Jackson Memorial Hospital, Miami, FL, 33136, USA
| | - Gaetano Ciancio
- Department of Surgery and Urology, Miami Transplant Institute, University of Miami Miller School of Medicine, Jackson Memorial Hospital, Miami, FL, 33136, USA
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Rydelius PA, Frisén L, Halldin-Stenlid M, Söder O, Dhejne C, Arver S. [Not Available]. Lakartidningen 2019; 116:FR6P. [PMID: 31613371] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Affiliation(s)
- Per-Anders Rydelius
- Karolinska Institutet - Institutionen för kvinnors och barns hälsa Stockholm, Sweden -
| | - Louise Frisén
- Karolinska Institutet - Institutionen för klinisk neurovetenskap Stockholm, Sweden - Department of Clinical Neuroscience Stockholm, Sweden
| | - Maria Halldin-Stenlid
- Karolinska Institutet - Womens' and Children's Health Stockholm, Sweden Karolinska Institutet - Womens' and Children's Health Stockholm, Sweden
| | - Olle Söder
- Karolinska Institutet - Institutionen för kvinnors och barns hälsa Stockholm, Sweden - Stockholm, Sweden
| | - Cecilia Dhejne
- Karolinska Universitetssjukhuset - ANOVA Stockholm, Sweden - , Sweden
| | - Stefan Arver
- Karolinska Universitetssjukhuset - ANOVA Stockholm, Sweden
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Abstract
Transgender women often seek hormone therapy to attain feminine physical features congruent with their gender identity. The aim of feminizing hormone therapy (FHT) is to provide suppression of endogenous testosterone and to maintain estradiol levels within the normal female range. Overall, FHT is safe if provided under supervision of an experienced health care provider and has been shown to improve quality of life. Data on care of transgender women are scarce and high-quality evidence-based recommendations are lacking. This article aims to review the published literature on FHT and provide guidance to clinicians caring for transgender women.
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Affiliation(s)
- Oksana Hamidi
- Division of Endocrinology and Metabolism, University of Texas Southwestern Medical Center, 2001 Inwood Road, Dallas, TX 75235, USA
| | - Caroline J Davidge-Pitts
- Division of Endocrinology, Diabetes, and Nutrition, Mayo Clinic, 200 First Street Southwest, Rochester, MN 55902, USA.
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31
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Abstract
Worldwide, transgender populations are disproportionately affected by human immunodeficiency virus (HIV). Pervasive stigma and discrimination impact social and economic determinants of health, which perpetuate HIV disparities among transgender individuals. This article reviews the prevalence of HIV infection among transgender populations and presents psychosocial, behavioral, and individual level factors that contribute to HIV acquisition. The authors provide practical recommendations regarding a patient-centered approach to HIV/sexually transmitted infection risk assessment. The role of preexposure prophylaxis utilization in preventing the transmission of HIV is discussed as well as the current data on HIV treatment outcomes for transgender people living with HIV.
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Affiliation(s)
- Cassie G Ackerley
- Division of Infectious Diseases, Department of Medicine, Emory University School of Medicine, Atlanta, GA, USA; The Hope Clinic of the Emory Vaccine Center, 500 Irvin Ct, Suite 200, Decatur, GA 30030, USA.
| | - Tonia Poteat
- Center for Health Equity Research, University of North Carolina School of Medicine, 333 South Columbia Street, 345B MacNider Hall, Chapel Hill, NC 27514, USA
| | - Colleen F Kelley
- Division of Infectious Diseases, Department of Medicine, Emory University School of Medicine, Atlanta, GA, USA; The Hope Clinic of the Emory Vaccine Center, 500 Irvin Ct, Suite 200, Decatur, GA 30030, USA; Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA, USA
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32
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Abstract
Prescribing gender-affirming hormonal therapy in transgender men (TM) not only induces desirable physical effects but also benefits mental health. In TM, testosterone therapy is aimed at achieving cisgender male serum testosterone to induce virilization. Testosterone therapy is safe on the short term and middle term if adequate endocrinological follow-up is provided. Transgender medicine is not a strong part of the medical curriculum, although a large number of transgender persons will search for some kind of gender-affirming care. Because hormonal therapy has beneficial effects, all endocrinologists or hormone-prescribing physicians should be able to provide gender-affirming hormonal care.
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Affiliation(s)
- Justine Defreyne
- Department of Endocrinology, Ghent University Hospital, Corneel Heymanslaan 10, Ghent 9000, Belgium.
| | - Guy T'Sjoen
- Department of Endocrinology, Center for Sexology and Gender, Ghent University Hospital, Corneel Heymanslaan 10, Ghent 9000, Belgium
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Abstract
Transgender persons receiving gender-affirming hormone therapy and procedures may face specific skin conditions. Skin diseases in transgender patients often are underdiagnosed and underrecognized despite their important impact on quality of life and mental health. This article discusses pathophysiology, diagnosis, and treatment of common skin diseases in the transgender populations. For transmasculine patients, conditions include acne vulgaris and male pattern hair loss. For transfeminine patients, conditions include hirsutism, pseudofolliculitis barbae, and melasma. Postprocedural keloids and other cutaneous complications are discussed. Unique aspects of skin health in transgender persons should be considered in the context of multidisciplinary gender-affirming care.
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Affiliation(s)
- Howa Yeung
- Department of Dermatology, Emory University School of Medicine, 1525 Clifton Road NE, Suite 100, Atlanta, GA 30322, USA; Regional Telehealth Services, Veterans Integrated Service Network 7, 250 N Arcadia Avenue, Decatur, GA 30030, USA.
| | - Benjamin Kahn
- Department of Dermatology, Emory University School of Medicine, 1525 Clifton Road NE, Suite 100, Atlanta, GA 30322, USA
| | - Bao Chau Ly
- Department of Dermatology, Emory University School of Medicine, 1525 Clifton Road NE, Suite 100, Atlanta, GA 30322, USA
| | - Vin Tangpricha
- Division of Endocrinology, Metabolism and Lipids, Department of Medicine, Emory University School of Medicine, 101 Woodruff Circle Northeast, WRMB 1301, Atlanta, GA 30322, USA; Atlanta VA Medical Center, 1670 Clairmont Road Northeast, Decatur, GA 30300, USA
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de Blok CJM, Wiepjes CM, Nota NM, van Engelen K, Adank MA, Dreijerink KMA, Barbé E, Konings IRHM, den Heijer M. Breast cancer risk in transgender people receiving hormone treatment: nationwide cohort study in the Netherlands. BMJ 2019; 365:l1652. [PMID: 31088823 PMCID: PMC6515308 DOI: 10.1136/bmj.l1652] [Citation(s) in RCA: 154] [Impact Index Per Article: 30.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
OBJECTIVE To investigate the incidence and characteristics of breast cancer in transgender people in the Netherlands compared with the general Dutch population. DESIGN Retrospective, nationwide cohort study. SETTING Specialised tertiary gender clinic in Amsterdam, the Netherlands. PARTICIPANTS 2260 adult trans women (male sex assigned at birth, female gender identity) and 1229 adult trans men (female sex assigned at birth, male gender identity) who received gender affirming hormone treatment. MAIN OUTCOME MEASURES Incidence and characteristics (eg, histology, hormone receptor status) of breast cancer in transgender people. RESULTS The total person time in this cohort was 33 991 years for trans women and 14 883 years for trans men. In the 2260 trans women in the cohort, 15 cases of invasive breast cancer were identified (median duration of hormone treatment 18 years, range 7-37 years). This was 46-fold higher than in cisgender men (standardised incidence ratio 46.7, 95% confidence interval 27.2 to 75.4) but lower than in cisgender women (0.3, 0.2 to 0.4). Most tumours were of ductal origin and oestrogen and progesterone receptor positive, and 8.3% were human epidermal growth factor 2 (HER2) positive. In 1229 trans men, four cases of invasive breast cancer were identified (median duration of hormone treatment 15 years, range 2-17 years). This was lower than expected compared with cisgender women (standardised incidence ratio 0.2, 95% confidence interval 0.1 to 0.5). CONCLUSIONS This study showed an increased risk of breast cancer in trans women compared with cisgender men, and a lower risk in trans men compared with cisgender women. In trans women, the risk of breast cancer increased during a relatively short duration of hormone treatment and the characteristics of the breast cancer resembled a more female pattern. These results suggest that breast cancer screening guidelines for cisgender people are sufficient for transgender people using hormone treatment.
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Affiliation(s)
- Christel J M de Blok
- Centre of Expertise on Gender Dysphoria, Amsterdam UMC, VU University Medical Centre, Amsterdam, Netherlands
- Department of Endocrinology, Amsterdam UMC, VU University Medical Centre, Amsterdam, Netherlands
| | - Chantal M Wiepjes
- Centre of Expertise on Gender Dysphoria, Amsterdam UMC, VU University Medical Centre, Amsterdam, Netherlands
- Department of Endocrinology, Amsterdam UMC, VU University Medical Centre, Amsterdam, Netherlands
| | - Nienke M Nota
- Centre of Expertise on Gender Dysphoria, Amsterdam UMC, VU University Medical Centre, Amsterdam, Netherlands
- Department of Endocrinology, Amsterdam UMC, VU University Medical Centre, Amsterdam, Netherlands
| | - Klaartje van Engelen
- Department of Clinical Genetics, Amsterdam UMC, VU University Medical Centre, Amsterdam, Netherlands
| | - Muriel A Adank
- Department of Clinical Genetics, Netherlands Cancer Institute, Amsterdam, Netherlands
| | - Koen M A Dreijerink
- Centre of Expertise on Gender Dysphoria, Amsterdam UMC, VU University Medical Centre, Amsterdam, Netherlands
- Department of Endocrinology, Amsterdam UMC, VU University Medical Centre, Amsterdam, Netherlands
| | - Ellis Barbé
- Department of Pathology, Amsterdam UMC, VU University Medical Centre, Amsterdam, Netherlands
| | - Inge R H M Konings
- Department of Oncology, Amsterdam UMC, VU University Medical Centre, Amsterdam, Netherlands
| | - Martin den Heijer
- Centre of Expertise on Gender Dysphoria, Amsterdam UMC, VU University Medical Centre, Amsterdam, Netherlands
- Department of Endocrinology, Amsterdam UMC, VU University Medical Centre, Amsterdam, Netherlands
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35
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Abstract
Understanding the user, the health system, and the environment is key to ensuring that self care interventions for sexual and reproductive health are not only available but safe and empowering for all, say Laura Ferguson and colleagues
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Affiliation(s)
- Laura Ferguson
- Keck School of Medicine of the University of Southern California, Institute on Inequalities in Global Health, Los Angeles, California, USA
| | - Susana Fried
- Yale Law School, Global Health Justice Partnership, New Haven, Connecticut, USA
| | - Thabo Matsaseng
- Reproductive Medicine Unit, Stellenbosch University, Stellenbosch, Western Cape, South Africa
| | - Sundari Ravindran
- Sree Chitra Tirunal Institute for Medical Sciences and Technology, Thiruvananthapuram, Kerala, India
| | - Sofia Gruskin
- Keck School of Medicine of the University of Southern California, Institute on Inequalities in Global Health, Los Angeles, California, USA
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36
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Nguyen HB, Loughead J, Lipner E, Hantsoo L, Kornfield SL, Epperson CN. What has sex got to do with it? The role of hormones in the transgender brain. Neuropsychopharmacology 2019; 44:22-37. [PMID: 30082887 PMCID: PMC6235900 DOI: 10.1038/s41386-018-0140-7] [Citation(s) in RCA: 36] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2018] [Revised: 05/23/2018] [Accepted: 06/21/2018] [Indexed: 01/04/2023]
Abstract
Sex differences and hormonal effects in presumed cisgender individuals have been well-studied and support the concept of a mosaic of both male and female "characteristics" in any given brain. Gonadal steroid increases and fluctuations during peri-puberty and across the reproductive lifespan influence the brain structure and function programmed by testosterone and estradiol exposures in utero. While it is becoming increasingly common for transgender and gender non-binary individuals to block their transition to puberty and/or use gender-affirming hormone therapy (GAHT) to obtain their desired gender phenotype, little is known about the impact of these manipulations on brain structure and function. Using sex differences and the effects of reproductive hormones in cisgender individuals as the backdrop, we summarize here the existing nascent neuroimaging and behavioral literature focusing on potential brain and cognitive differences in transgender individuals at baseline and after GAHT. Research in this area has the potential to inform our understanding of the developmental origins of gender identity and sex difference in response to gonadal steroid manipulations, but care is needed in our research questions and methods to not further stigmatize sex and gender minorities.
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Affiliation(s)
- Hillary B Nguyen
- School of Arts and Sciences, Philadelphia, PA, USA
- Penn PROMOTES Research on Sex and Gender in Health, University of Pennsylvania, Philadelphia, PA, USA
- Department of Psychiatry, Philadelphia, PA, USA
| | | | - Emily Lipner
- School of Arts and Sciences, Philadelphia, PA, USA
- Penn PROMOTES Research on Sex and Gender in Health, University of Pennsylvania, Philadelphia, PA, USA
| | | | | | - C Neill Epperson
- School of Arts and Sciences, Philadelphia, PA, USA.
- Penn PROMOTES Research on Sex and Gender in Health, University of Pennsylvania, Philadelphia, PA, USA.
- Department of Psychiatry, Philadelphia, PA, USA.
- Department of Obstetrics and Gynecology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA.
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37
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Abstract
RATIONALE Testosterone is important for the development of secondary sexual characteristics in female-to-male transsexuals. On the contrary, it can increase the risk of breast cancer. PATIENT CONCERNS We present a rare case of breast cancer in female-to-male transsexual patient after long-term hormonal therapy. DIAGNOSIS Breast cancer in female-to-male transsexual patient. INTERVENTIONS The patient underwent mastectomy and chemotherapy. OUTCOMES The patient had local recurrence of the disease and he underwent re-excision, radiotherapy and the tamoxifen treatment. After this treatment, the patient is in the remission from the disease. LESSONS Breast cancer in transsexuals appears to be rare. However, there is a potential risk that testosterone exposure can increase the risk of developing breast cancer by the stimulation of breast tissue. There is limited published literature on the risk of breast cancer in transsexual patients.
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Affiliation(s)
| | - Ondrej Hes
- Department of Pathology, University Hospital in Plzen, Charles University in Prague, Alej Svobody, Plzen, Czech Republic
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38
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Turan Ş, Aksoy Poyraz C, Usta Sağlam NG, Demirel ÖF, Haliloğlu Ö, Kadıoğlu P, Duran A. Alterations in Body Uneasiness, Eating Attitudes, and Psychopathology Before and After Cross-Sex Hormonal Treatment in Patients with Female-to-Male Gender Dysphoria. Arch Sex Behav 2018; 47:2349-2361. [PMID: 29594702 DOI: 10.1007/s10508-018-1189-4] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/29/2016] [Revised: 02/28/2018] [Accepted: 03/02/2018] [Indexed: 05/28/2023]
Abstract
Body dissatisfaction plays an important role in the development of psychiatric problems such as eating disorders as well as gender dysphoria (GD). Cross-sex hormonal treatment (CHT) alleviates the dissatisfaction by making various changes in the body. We examined the alteration of body uneasiness, eating attitudes and behaviors, and psychological symptoms longitudinally in Turkish participants with female-to-male gender dysphoria (FtM GD) after CHT. Thirty-seven participants with FtM GD and 40 female controls were asked to complete the Body Uneasiness Test to explore different areas of body-related psychopathology, the Eating Attitudes Test to assess eating disturbances, and the Symptom Checklist-90 Revised to measure psychological state, both before CHT and after 6 months of CHT administration. The baseline mean body weight, BMI scores, body uneasiness scores, and general psychopathological symptoms of participants with FtM GD were significantly higher than female controls, whereas baseline eating attitudes and behaviors were not significantly different. Over time, FtM GD participants' mean body weight and BMI scores increased, body uneasiness and general psychopathological symptoms decreased, and eating attitudes and behaviors had not changed at 24th weeks following CHT administration compared to baseline. CHT may have a positive impact on body uneasiness and general psychopathological symptoms in participants with FtM GD. However, CHT does not have an impact on eating attitudes and behaviors.
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Affiliation(s)
- Şenol Turan
- Department of Psychiatry, Cerrahpaşa School of Medicine, Istanbul University, 34303, Kocamustafapaşa-Fatih/Istanbul, Turkey.
| | - Cana Aksoy Poyraz
- Department of Psychiatry, Cerrahpaşa School of Medicine, Istanbul University, 34303, Kocamustafapaşa-Fatih/Istanbul, Turkey
| | - Nazife Gamze Usta Sağlam
- Department of Psychiatry, Cerrahpaşa School of Medicine, Istanbul University, 34303, Kocamustafapaşa-Fatih/Istanbul, Turkey
| | - Ömer Faruk Demirel
- Department of Psychiatry, Cerrahpaşa School of Medicine, Istanbul University, 34303, Kocamustafapaşa-Fatih/Istanbul, Turkey
| | - Özlem Haliloğlu
- Department of Endocrinology and Metabolism, Cerrahpaşa School of Medicine, Istanbul University, 34303, Kocamustafapaşa-Fatih/Istanbul, Turkey
| | - Pınar Kadıoğlu
- Department of Endocrinology and Metabolism, Cerrahpaşa School of Medicine, Istanbul University, 34303, Kocamustafapaşa-Fatih/Istanbul, Turkey
| | - Alaattin Duran
- Department of Psychiatry, Cerrahpaşa School of Medicine, Istanbul University, 34303, Kocamustafapaşa-Fatih/Istanbul, Turkey
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López Guzmán J, González Vázquez C. [Assessment of the suppression of puberty in children with gender identity problems]. Cuad Bioet 2018; 29:247-256. [PMID: 30380899] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Received: 02/16/2018] [Accepted: 09/11/2018] [Indexed: 06/08/2023]
Abstract
The objective of this article is to reflect on the opportunity and risk of the proposed treatments to address gender identity problems in that sector of the population. In most of the protocols for the care of minors with gender identity problems, the abolition of puberty is proposed as a method of choice. This technique consists in the administration of reversible agonists of GnRH to provoke a suppression of the hormonal expression of the minor and, thus, the development of the sexual characters of their gender. The opportunity or adequacy of the systematic use of reversible GnRH agonists may be questioned for several reasons. The first, because the diagnosis of transsexualism in minors carries a great complexity and difficulty, so there is a wide margin of error. The second, because the suppression of puberty has direct consequences in the development of the child. Thirdly, because the aforementioned treatments have some risks and side effects in minors, some of them not studied and unknown, which, without a doubt, should be weighted. Finally, because the drugs used are neither designed nor experienced, for the care of minors with gender identity problems. Therefore, they are used without being approved by the regulatory agencies of the medicinal product for that purpose. These issues need to be addressed and also transmitted in the information provided to the stakeholders.
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Affiliation(s)
- José López Guzmán
- Área de Humanidades Farmacéuticas. Departamento de Farmacología. Facultad de Farmacia. Universidad de Navarra.
| | - Carmen González Vázquez
- Área de Humanidades Farmacéuticas. Departamento de Farmacología. Facultad de Farmacia. Universidad de Navarra
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Tack LJW, Craen M, Lapauw B, Goemaere S, Toye K, Kaufman JM, Vandewalle S, T'Sjoen G, Zmierczak HG, Cools M. Proandrogenic and Antiandrogenic Progestins in Transgender Youth: Differential Effects on Body Composition and Bone Metabolism. J Clin Endocrinol Metab 2018; 103:2147-2156. [PMID: 29672753 DOI: 10.1210/jc.2017-02316] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2017] [Accepted: 04/11/2018] [Indexed: 02/13/2023]
Abstract
CONTEXT Progestins can be used to attenuate endogenous hormonal effects in late-pubertal transgender (trans) adolescents (Tanner stage B4/5 and G4/5). Currently, no data are available on the effects of progestins on the development of bone mass or body composition in trans youth. OBJECTIVE To study prospectively the evolution of body composition and bone mass in late-pubertal trans adolescents using the proandrogenic or antiandrogenic progestins lynestrenol (L) and cyproterone acetate (CA), respectively. DESIGN AND OUTCOME MEASUREMENTS Forty-four trans boys (Tanner B4/5) and 21 trans girls (Tanner G4/5) were treated with L or CA for 11.6 (4 to 40) and 10.6 (5 to 31) months, respectively. Anthropometry, grip strength, body composition, and bone mass, size, and density were determined by dual-energy X-ray absorptiometry and peripheral quantitative computed tomography before the start of progestin and before addition of cross-sex hormones. RESULTS Using L, lean mass [+3.2 kg (8.6%)] and grip strength [+3 kg (10.6%)] significantly increased, which coincided with a more masculine body shape in trans boys. Trans girls showed loss of lean mass [-2.2 kg (4.7%)], gain of fat mass [+1.5 kg (9.4%)], and decreased grip strength Z scores. CA limited normal bone expansion and impeded pubertal bone mass accrual, mostly at the lumbar spine [Z score: -0.765 to -1.145 (P = 0.002)]. L did not affect physiological bone development. CONCLUSION Proandrogenic and antiandrogenic progestins induce body composition changes in line with the desired appearance within 1 year of treatment. Bone health, especially at the lumbar spine, is of concern in trans girls, as bone mass accrual is severely affected by androgen suppressive therapy.
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Affiliation(s)
- Lloyd J W Tack
- Division of Pediatric Endocrinology, Department of Pediatrics, Ghent University Hospital, Ghent University, Ghent, Belgium
| | - Margarita Craen
- Division of Pediatric Endocrinology, Department of Pediatrics, Ghent University Hospital, Ghent University, Ghent, Belgium
| | - Bruno Lapauw
- Department of Endocrinology, Ghent University Hospital, Ghent University, Ghent, Belgium
- Unit for Osteoporosis and Metabolic Bone Diseases, Department of Internal Medicine, Ghent University Hospital, Ghent, Belgium
| | - Stefan Goemaere
- Department of Endocrinology, Ghent University Hospital, Ghent University, Ghent, Belgium
- Unit for Osteoporosis and Metabolic Bone Diseases, Department of Internal Medicine, Ghent University Hospital, Ghent, Belgium
| | - Kaatje Toye
- Department of Endocrinology, Ghent University Hospital, Ghent University, Ghent, Belgium
- Unit for Osteoporosis and Metabolic Bone Diseases, Department of Internal Medicine, Ghent University Hospital, Ghent, Belgium
| | - Jean-Marc Kaufman
- Department of Endocrinology, Ghent University Hospital, Ghent University, Ghent, Belgium
| | - Sara Vandewalle
- Department of Endocrinology, Ghent University Hospital, Ghent University, Ghent, Belgium
| | - Guy T'Sjoen
- Department of Endocrinology, Ghent University Hospital, Ghent University, Ghent, Belgium
| | - Hans-Georg Zmierczak
- Department of Endocrinology, Ghent University Hospital, Ghent University, Ghent, Belgium
- Unit for Osteoporosis and Metabolic Bone Diseases, Department of Internal Medicine, Ghent University Hospital, Ghent, Belgium
| | - Martine Cools
- Division of Pediatric Endocrinology, Department of Pediatrics, Ghent University Hospital, Ghent University, Ghent, Belgium
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41
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Savkovic S, Lim S, Jayadev V, Conway A, Turner L, Curtis D, Goebel C, Handelsman DJ. Urine and Serum Sex Steroid Profile in Testosterone-Treated Transgender and Hypogonadal and Healthy Control Men. J Clin Endocrinol Metab 2018; 103:2277-2283. [PMID: 29584875 DOI: 10.1210/jc.2018-00054] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2018] [Accepted: 03/19/2018] [Indexed: 11/19/2022]
Abstract
BACKGROUND The impact of testosterone (T) treatment on antidoping detection tests in female-to-male (F2M) transgender men is unknown. We investigated urine and serum sex steroid and luteinizing hormone (LH) profiles in T-treated F2M men to determine whether and, if so, how they differed from hypogonadal and healthy control men. METHOD Healthy transgender (n = 23) and hypogonadal (n = 24) men aged 18 to 50 years treated with 1000 mg injectable T undecanoate provided trough urine and blood samples and an additional earlier postinjection sample (n = 21). Healthy control men (n = 20) provided a single blood and urine sample. Steroids were measured by mass spectrometry-based methods in urine and serum, LH by immunoassay, and uridine 5'-diphospho-glucuronosyltransferase 2B17 genotype by polymerase chain reaction. RESULTS Urine LH, human chorionic gonadotropin, T, epitestosterone (EpiT), androsterone (A), etiocholanolone (Etio), A/Etio ratio, dehydroepiandrosterone (DHEA), dihydrotestosterone (DHT), and 5α,3α- and 5β,3α-androstanediols did not differ between groups or by time since last T injection. Urine T/EpiT ratio was <4 in all controls and 12/68 (18%) samples from T-treated men, but there was no difference between T-treated groups. Serum estradiol, estrone, and DHEA were higher in transgender men, and serum T and DHT were higher in earlier compared with trough blood samples, but serum LH, follicle-stimulating hormone, and 3α- and 3β,5α-diols did not differ between groups. CONCLUSION Urine antidoping detection tests in T-treated transgender men can be interpreted like those of T-treated hypogonadal men and are unaffected by time since last T dose. Serum steroids are more sensitive to detect exogenous T administration early but not later after the last T dose.
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Affiliation(s)
- Sasha Savkovic
- Andrology Department, Concord Hospital, ANZAC Research Institute, Sydney, New South Wales, Australia
| | - Sarina Lim
- Andrology Department, Concord Hospital, ANZAC Research Institute, Sydney, New South Wales, Australia
| | - Veena Jayadev
- Andrology Department, Concord Hospital, ANZAC Research Institute, Sydney, New South Wales, Australia
| | - Ann Conway
- Andrology Department, Concord Hospital, ANZAC Research Institute, Sydney, New South Wales, Australia
| | - Leo Turner
- Andrology Department, Concord Hospital, ANZAC Research Institute, Sydney, New South Wales, Australia
| | - Douglas Curtis
- Australian Sports Drug Testing Laboratory, National Measurement Institute, Sydney, New South Wales, Australia
| | - Catrin Goebel
- Australian Sports Drug Testing Laboratory, National Measurement Institute, Sydney, New South Wales, Australia
| | - David J Handelsman
- Andrology Department, Concord Hospital, ANZAC Research Institute, Sydney, New South Wales, Australia
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Fighera TM, da Silva E, Lindenau JDR, Spritzer PM. Impact of cross-sex hormone therapy on bone mineral density and body composition in transwomen. Clin Endocrinol (Oxf) 2018; 88:856-862. [PMID: 29630732 DOI: 10.1111/cen.13607] [Citation(s) in RCA: 40] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2018] [Revised: 03/25/2018] [Accepted: 03/26/2018] [Indexed: 12/11/2022]
Abstract
OBJECTIVE Cross-sex hormone therapy (CSHT) has been associated with changes in bone and lean/fat mass. This study assessed bone mineral density (BMD), appendicular lean mass (ALM), and total fat mass in transwomen undergoing CSHT. PATIENTS AND DESIGN We evaluated 142 transwomen (mean age: 33.7 ± 10.3 years; BMI: 25.4 ± 4.6; 86.6% with previous CSHT) during the first 3 months of regular oestrogen treatment (with or without anti-androgens). A reference group including 22 men and 17 cis women was also studied. MEASUREMENTS Clinical and hormonal evaluation and dual-energy X-ray absorptiometry (DXA). RESULTS Bone mineral density was similar in trans and reference women, and lower at all sites in transwomen vs men. Low bone mass for age was observed in 18% of transwomen at baseline vs none of the reference women or men. Appendicular lean mass and total fat mass were positively correlated with L1-L4 BMD, explaining 14.9% of the observed variation in lumbar spine BMD and 20.6% of the variation in total femur BMD. Appendicular lean mass was similar in trans and reference women, and lower in transwomen vs men. Total fat mass was lower in trans vs reference women. Densitometry was repeated after a mean of 31.3 ± 6.5 months in 46 transwomen. There was a significant increase in total fat mass and a significant decrease in ALM. Bone mineral density remained stable over time. CONCLUSIONS The fairly high prevalence of low bone mass in this sample of transwomen from southern Brazil seems to be related to lower ALM. Non-pharmacological lifestyle-related strategies for preventing bone loss could be beneficial for transgender women receiving long-term CSHT.
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Affiliation(s)
- Tayane Muniz Fighera
- Gynecological Endocrinology Unit, Division of Endocrinology, Hospital de Clínicas de Porto Alegre, Porto Alegre, Brazil
- Gender Identity Program, Hospital de Clínicas de Porto Alegre, Porto Alegre, Brazil
| | - Eliane da Silva
- Gynecological Endocrinology Unit, Division of Endocrinology, Hospital de Clínicas de Porto Alegre, Porto Alegre, Brazil
- Gender Identity Program, Hospital de Clínicas de Porto Alegre, Porto Alegre, Brazil
| | - Juliana Dal-Ri Lindenau
- Gynecological Endocrinology Unit, Division of Endocrinology, Hospital de Clínicas de Porto Alegre, Porto Alegre, Brazil
| | - Poli Mara Spritzer
- Gynecological Endocrinology Unit, Division of Endocrinology, Hospital de Clínicas de Porto Alegre, Porto Alegre, Brazil
- Gender Identity Program, Hospital de Clínicas de Porto Alegre, Porto Alegre, Brazil
- Department of Physiology, Federal University of Rio Grande do Sul, Porto Alegre, Brazil
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43
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Mancini I, Rotilio A, Coati I, Seracchioli R, Martelli V, Meriggiola MC. Presentation of a meningioma in a transwoman after nine years of cyproterone acetate and estradiol intake: case report and literature review. Gynecol Endocrinol 2018; 34:456-459. [PMID: 29105524 DOI: 10.1080/09513590.2017.1395839] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
Abstract
The administration of cyproterone acetate (CPA) and estradiol is a common regimen used by male-to-female transsexuals (transwoman) to adjust their body to their gender identity. Major adverse events are uncommon in these subjects in spite of long-term, high dose cross-sex steroid treatments. We describe the occurrence of a meningioma in a transwoman treated with estrogens and CPA over a period of nine years. The meningioma was revealed during a magnetic resonance imaging (MRI) scan performed as follow-up of a previous surgery for ganglioglioma. CPA intake was discontinued and tumor resection was performed. Histological diagnosis confirmed a strong progesterone receptor-positive and slight estrogen positive meningioma. After surgery, the patient continued her treatment with leuprorelina acetate and estradiol. At one-year follow-up, the MRI scan reveals no recurrence of the tumor. This is the ninth case in literature of a meningioma in a transwoman treated with estrogens and CPA, confirming a possible association between female sex steroids and meningioma. Although there is no still strong evidence of an association between meningioma and CPA, this report may suggest use of alternative treatment for transwomen. This report highlights the importance to record all the cases of meningiomas in high dose CPA-users, in order to improve data.
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Affiliation(s)
| | - Antonino Rotilio
- b Department of Surgery , Operative Unit of Neurosurgery, Hospital of Padua , Padua , Italy
| | - Irene Coati
- c Department of Medicine (DIMED) , Surgical Pathology Unit, University of Padua , Padua , Italy
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Hembree WC, Cohen-Kettenis PT, Gooren L, Hannema SE, Meyer WJ, Murad MH, Rosenthal SM, Safer JD, Tangpricha V, T'Sjoen GG. ENDOCRINE TREATMENT OF GENDER-DYSPHORIC/GENDER-INCONGRUENT PERSONS: AN ENDOCRINE SOCIETY CLINICAL PRACTICE GUIDELINE. Endocr Pract 2018; 23:1437. [PMID: 29320642 DOI: 10.4158/1934-2403-23.12.1437] [Citation(s) in RCA: 82] [Impact Index Per Article: 13.7] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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Abdala R, Nagelberg A, Silveira F, Otero P, Mormandi E. [Short-term safety profile of cross-hormonal therapy in trans-male subjects]. Medicina (B Aires) 2018; 78:399-402. [PMID: 30504106] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/09/2023] Open
Abstract
A trans-male (TM) is a biologically female person with male gender identity who wishes to acquire male sexual characteristics and fulfil a male social role. To achieve that purpose, both cross-hormonal therapy (CHT) and surgical phalloplasty can be used. We evaluated the short term (12 months) safety profile of CHT using different forms of testosterone available for prescription in Argentina. In this retrospective study, we analyzed the medical history of 30 trans-male patients fitting the inclusion criteria. The mean age of the population was 27 years. The mean basal serum level of testosterone was 0.43 ng/ml, which increased to 6.36 ng/ml (male hormonal levels). The hematocrit increased from a baseline of 40.0 to 45.2% (p < 0.01) and hemoglobin increased from 13.6 to 15.2 g/dl (p < 0.01). Total cholesterol remained stable with values of 175 and 185 mg/dl (p = 0.81). There were no significant changes in serum triglycerides: 88.3 and 102 mg/dl (p = 0.08). LDL increased in the first 6 to 12 months of CHT from 101.2 to 112.5 mg/dl (p = 0.17). At 12 months HDL levels increased from 50.1 to 52 mg/dl (p < 0.01). Hepatic enzymes remained stable. There is no available data regarding safety of testosterone use in TM in our country. In no case did we need to suspend the medication due to unwanted effects.
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Affiliation(s)
- Rubén Abdala
- Instituto de Diagnóstico e Investigaciones Metabólicas (IDIM), Buenos Aires, Argentina. E-mail:
| | - Alberto Nagelberg
- División Endocrinología, Hospital Carlos G. Durand, Buenos Aires, Argentina
| | - Fernando Silveira
- Instituto de Diagnóstico e Investigaciones Metabólicas (IDIM), Buenos Aires, Argentina
| | - Patricia Otero
- Laboratorio de Endocrinología Hospital Carlos G. Durand, Buenos Aires, Argentina
| | - Eduardo Mormandi
- Laboratorio de Endocrinología Hospital Carlos G. Durand, Buenos Aires, Argentina
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Kranz GS, Hahn A, Kaufmann U, Tik M, Ganger S, Seiger R, Hummer A, Windischberger C, Kasper S, Lanzenberger R. Effects of testosterone treatment on hypothalamic neuroplasticity in female-to-male transgender individuals. Brain Struct Funct 2018; 223:321-328. [PMID: 28819863 PMCID: PMC5772168 DOI: 10.1007/s00429-017-1494-z] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2017] [Accepted: 08/04/2017] [Indexed: 11/26/2022]
Abstract
Diffusion-weighted imaging (DWI) is used to measure gray matter tissue density and white matter fiber organization/directionality. Recent studies show that DWI also allows for assessing neuroplastic adaptations in the human hypothalamus. To this end, we investigated a potential influence of testosterone replacement therapy on hypothalamic microstructure in female-to-male (FtM) transgender individuals. 25 FtMs were measured at baseline, 4 weeks, and 4 months past treatment start and compared to 25 female and male controls. Our results show androgenization-related reductions in mean diffusivity in the lateral hypothalamus. Significant reductions were observed unilaterally after 1 month and bilaterally after 4 months of testosterone treatment. Moreover, treatment induced increases in free androgen index and bioavailable testosterone were significantly associated with the magnitude of reductions in mean diffusivity. These findings imply microstructural plasticity and potentially related changes in neural activity by testosterone in the adult human hypothalamus and suggest that testosterone replacement therapy in FtMs changes hypothalamic microstructure towards male proportions.
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Affiliation(s)
- Georg S Kranz
- Neuroimaging Labs (NIL) PET, MRI, EEG and Chemical Lab, Department of Psychiatry and Psychotherapy, Medical University of Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria
| | - Andreas Hahn
- Neuroimaging Labs (NIL) PET, MRI, EEG and Chemical Lab, Department of Psychiatry and Psychotherapy, Medical University of Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria
| | - Ulrike Kaufmann
- Department of Obstetrics and Gynecology, Medical University of Vienna, Vienna, Austria
| | - Martin Tik
- MR Centre of Excellence, Center for Medical Physics and Biomedical Engineering, Medical University of Vienna, Vienna, Austria
| | - Sebastian Ganger
- Neuroimaging Labs (NIL) PET, MRI, EEG and Chemical Lab, Department of Psychiatry and Psychotherapy, Medical University of Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria
| | - René Seiger
- Neuroimaging Labs (NIL) PET, MRI, EEG and Chemical Lab, Department of Psychiatry and Psychotherapy, Medical University of Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria
| | - Allan Hummer
- MR Centre of Excellence, Center for Medical Physics and Biomedical Engineering, Medical University of Vienna, Vienna, Austria
| | - Christian Windischberger
- MR Centre of Excellence, Center for Medical Physics and Biomedical Engineering, Medical University of Vienna, Vienna, Austria
| | - Siegfried Kasper
- Neuroimaging Labs (NIL) PET, MRI, EEG and Chemical Lab, Department of Psychiatry and Psychotherapy, Medical University of Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria
| | - Rupert Lanzenberger
- Neuroimaging Labs (NIL) PET, MRI, EEG and Chemical Lab, Department of Psychiatry and Psychotherapy, Medical University of Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria.
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47
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Singh-Ospina N, Maraka S, Rodriguez-Gutierrez R, Davidge-Pitts C, Nippoldt TB, Prokop LJ, Murad MH. Effect of Sex Steroids on the Bone Health of Transgender Individuals: A Systematic Review and Meta-Analysis. J Clin Endocrinol Metab 2017; 102:3904-3913. [PMID: 28945851 DOI: 10.1210/jc.2017-01642] [Citation(s) in RCA: 63] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/21/2017] [Accepted: 08/24/2017] [Indexed: 02/05/2023]
Abstract
BACKGROUND The impact of sex steroids on bone health in transgender individuals is unclear. METHODS A comprehensive search of several databases to 7 April 2015 was conducted for studies evaluating bone health in transgender individuals receiving sex steroids. Pairs of reviewers selected and appraised studies. A random effects model was used to pool weighted mean differences and 95% confidence intervals (CIs). RESULTS Thirteen studies evaluating 639 transgender individuals were identified [392 male-to-female (MTF), 247 female-to-male (FTM)]. In FTM individuals and compared with baseline values before initiation of masculinizing hormone therapy, there was no statistically significant difference in the lumbar spine, femoral neck, or total hip bone mineral density (BMD) when assessed at 12 and 24 months. In MTF individuals and compared with baseline values before initiation of feminizing hormone therapy, there was a statistically significant increase in lumbar spine BMD at 12 months (0.04 g/cm2; 95% CI, 0.03 to 0.06 g/cm2) and 24 months (0.06 g/cm2; 95% CI, 0.04 to 0.08 g/cm2). Fracture rates were evaluated in a single cohort of 53 MTF and 53 FTM individuals, with no events at 12 months. The body of evidence is derived mostly from observational studies at moderate risk of bias. CONCLUSION In FTM individuals, masculinizing hormone therapy was not associated with significant changes in BMD, whereas in MTF individuals feminizing hormone therapy was associated with an increase in BMD at the lumbar spine. The impact of these BMD changes on patient-important outcomes such as fracture risk is uncertain.
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Affiliation(s)
- Naykky Singh-Ospina
- Evidence-Based Practice Research Program, Mayo Clinic, Rochester, Minnesota 55905
- Division of Endocrinology, Diabetes and Metabolism, University of Florida, Gainesville, Florida 32610
| | - Spyridoula Maraka
- Evidence-Based Practice Research Program, Mayo Clinic, Rochester, Minnesota 55905
- Division of Endocrinology and Metabolism, University of Arkansas for Medical Sciences, Little Rock, Arkansas 72205
| | - Rene Rodriguez-Gutierrez
- Division of Endocrinology, Department of Internal Medicine, University Hospital "Dr. Jose E. Gonzalez," Autonomous University of Nuevo Leon, Monterrey, Mexico
| | - Caroline Davidge-Pitts
- Division of Endocrinology, Diabetes, Metabolism, and Nutrition, Mayo Clinic, Rochester, Minnesota 55905
| | - Todd B Nippoldt
- Division of Endocrinology, Diabetes, Metabolism, and Nutrition, Mayo Clinic, Rochester, Minnesota 55905
| | - Larry J Prokop
- Evidence-Based Practice Research Program, Mayo Clinic, Rochester, Minnesota 55905
- Mayo Clinic Libraries, Mayo Clinic, Rochester, Minnesota 55905
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48
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Maraka S, Singh Ospina N, Rodriguez-Gutierrez R, Davidge-Pitts CJ, Nippoldt TB, Prokop LJ, Murad MH. Sex Steroids and Cardiovascular Outcomes in Transgender Individuals: A Systematic Review and Meta-Analysis. J Clin Endocrinol Metab 2017; 102:3914-3923. [PMID: 28945852 DOI: 10.1210/jc.2017-01643] [Citation(s) in RCA: 149] [Impact Index Per Article: 21.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/21/2017] [Accepted: 08/24/2017] [Indexed: 11/19/2022]
Abstract
BACKGROUND Transgender individuals receive cross-sex hormonal therapy to induce desired secondary sexual characteristics despite limited data regarding its effects on cardiovascular health. METHODS A comprehensive search of several databases up to 7 April 2015 was conducted for studies evaluating the effect of sex steroid use on lipids, myocardial infarction, stroke, venous thromboembolism (VTE), and mortality in transgender individuals. Pairs of reviewers selected and appraised the studies. A random-effects model was used to pool weighted mean differences and 95% confidence intervals (CIs). RESULTS We found 29 eligible studies with moderate risk of bias. In female-to-male (FTM) individuals, sex steroid therapy was associated with statistically significant increases in serum triglyceride (TG) levels at 3 to 6 months and at ≥24 months (21.4 mg/dL; 95% CI: 0.14 to 42.6) and in low-density lipoprotein cholesterol (LDL-C) levels at 12 months and ≥24 months (17.8 mg/dL; 95% CI: 3.5 to 32.1). High-density lipoprotein cholesterol (HDL-C) levels decreased significantly across all follow-up periods (highest at ≥24 months, -8.5 mg/dL; 95% CI: -13.0 to -3.9). In male-to-female (MTF) individuals, serum TG levels were significantly higher at ≥24 months (31.9 mg/dL; 95% CI: 3.9 to 59.9) without any changes in other parameters. Few myocardial infarction, stroke, VTE, and death events were reported (more frequently in MTF individuals). CONCLUSIONS Low-quality evidence suggests that sex steroid therapy may increase LDL-C and TG levels and decrease HDL-C level in FTM individuals, whereas oral estrogens may increase TG levels in MTF individuals. Data about important patient outcomes remain sparse.
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Affiliation(s)
- Spyridoula Maraka
- Evidence-Based Practice Research Program, Mayo Clinic, Rochester, Minnesota 55905
- Division of Endocrinology and Metabolism, Center for Osteoporosis and Metabolic Bone Diseases, University of Arkansas for Medical Sciences, Little Rock, Arkansas 72205
- Central Arkansas Veterans Health Care System, Little Rock, Arkansas 72205
| | - Naykky Singh Ospina
- Evidence-Based Practice Research Program, Mayo Clinic, Rochester, Minnesota 55905
- Division of Endocrinology, Diabetes and Metabolism, University of Florida, Gainesville, Florida 32610
| | - Rene Rodriguez-Gutierrez
- Division of Endocrinology, Department of Internal Medicine, University Hospital "Dr. Jose E. Gonzalez," Autonomous University of Nuevo León, Monterrey, Mexico 64460
| | - Caroline J Davidge-Pitts
- Division of Endocrinology, Diabetes, Metabolism, and Nutrition, Mayo Clinic, Rochester, Minnesota 55905
| | - Todd B Nippoldt
- Division of Endocrinology, Diabetes, Metabolism, and Nutrition, Mayo Clinic, Rochester, Minnesota 55905
| | - Larry J Prokop
- Evidence-Based Practice Research Program, Mayo Clinic, Rochester, Minnesota 55905
- Mayo Clinic Libraries, Mayo Clinic, Rochester, Minnesota 55905
| | - M Hassan Murad
- Evidence-Based Practice Research Program, Mayo Clinic, Rochester, Minnesota 55905
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Abstract
Transgender women experience lifelong gender dysphoria due to a gender assignment at birth that is incongruent with their gender identity. They often seek hormone therapy, with or without surgery, to improve their gender dysphoria and to better align their physical and psychological features with a more feminine gender role. Some of the desired physical changes from oestrogen and anti-androgen therapy include decreased body and facial hair, decreased muscle mass, breast growth, and redistribution of fat. Overall the risks of treatment are low, but include thromboembolism, the risk of which depends on the dose and route of oestrogen administration. Other associated conditions commonly seen in transgender women include increased risks of depression and osteoporosis. The risk of hormone-sensitive cancer seems to be low in transgender women, with no increased risk of breast cancer compared with women and no increase in prostate cancer when compared with men. The evidence base for the care of transgender women is limited by the paucity of high-quality research, and long-term longitudinal studies are needed to inform future guidelines.
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Affiliation(s)
- Vin Tangpricha
- Division of Endocrinology, Metabolism and Lipids, Department of Medicine, Emory University School of Medicine and Atlanta VA Medical Center, Atlanta, GA, USA.
| | - Martin den Heijer
- Department of Endocrinology and Center of Expertise on Gender Dysphoria, VU University Medical Center, Amsterdam, Netherlands
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50
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Mamoojee Y, Seal LJ, Quinton R. Transgender hormone therapy: understanding international variation in practice. Lancet Diabetes Endocrinol 2017; 5:243-246. [PMID: 28340645 DOI: 10.1016/s2213-8587(17)30068-2] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2016] [Revised: 01/16/2017] [Accepted: 01/17/2017] [Indexed: 12/13/2022]
Affiliation(s)
- Yaasir Mamoojee
- Department of Endocrinology, Newcastle-upon-Tyne Hospitals NHS Trust, Newcastle-upon-Tyne, UK
| | - Leighton J Seal
- Department of Endocrinology, St George's Hospital Medical School, London, UK; Department of Endocrinology, St George's Healthcare NHS Trust, London, UK; Gender Identity Clinic, West London Mental Health NHS Trust, London, UK
| | - Richard Quinton
- Department of Endocrinology, Newcastle-upon-Tyne Hospitals NHS Trust, Newcastle-upon-Tyne, UK; Endocrine Research Group, Institute of Genetic Medicine, University of Newcastle-upon-Tyne, Newcastle-upon-Tyne, NE1 3BZ, UK.
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