Long-term treatment of transsexuals with cross-sex hormones: extensive personal experience

Exploration of functional health, mental well-being and cross-sex hormone use in a sample of Thai male-to-female transgendered persons (kathoeys)

Transgender people sometimes use cross-sex hormones without medical supervision. The use of cross-sex hormones, as well as the functional health and mental well-being, among male-to-female transgendered people ('kathoeys') in Chiang Mai, Thailand, was studied. Sixty kathoeys were interviewed regarding their use of cross-sex hormones and their family relationships. Individuals also completed the Life Orientation Test Revised (LOT-R) to assess dispositional optimism, the Social Functioning Questionnaire (SFQ) and the Short Form Health Survey 36 (SF-36). Three categories were established as follows: those who never cross-dress, those who sometimes cross-dress and those who always cross-dress in public. Of the 60 subjects, 44 had used hormones for prolonged periods (9.7±6.1 years). Their use was related to the permanence of cross-dressing but unrelated to functional health and mental well-being. Fifty percent of subjects had overdosed on commonly used oral contraceptives. Three people used injectable oestrogen in a higher-than-recommended dose. Self-acceptance was high or reasonably good (83%) compared to no acceptance (17%), and neither was related to the permanence of cross-dressing. Their acceptance by parents and siblings was also relatively high (85% and 89%, respectively). The permanence of cross-dressing had no effect on the scores of optimism, SF-36 scores and social functioning. Acceptance by oneself or one's parents did not seem to affect most aspects of functional health and mental well-being, but non-acceptance by siblings generated lower scores on the social functioning and general mental health subscales. Stressors tended to include physical rather than social factors. In conclusion, the unsupervised use of cross-sex hormones was common among kathoeys, and 50% of the sample had overdosed on them. Acceptance was relatively good, except by siblings. New strategies are needed for a more responsible use of cross-sex hormones.

Sex and life expectancy

BACKGROUND

A sexual dimorphism in human life expectancy has existed in almost every country for as long as records have been kept. Although human life expectancy has increased each year, females still live longer, on average, than males. Undoubtedly, the reasons for the sex gap in life expectancy are multifaceted, and it has been discussed from both sociological and biological perspectives. However, even if biological factors make up only a small percentage of the determinants of the sex difference in this phenomenon, parity in average life expectancy should not be anticipated.

OBJECTIVE

The aim of this review is to highlight biological mechanisms that may underlie the sexual dimorphism in life expectancy.

METHODS

Using PubMed, ISI Web of Knowledge, and Google Scholar, as well as cited and citing reference histories of articles through August 2012, English-language articles were identified, read, and synthesized into categories that could account for biological sex differences in human life expectancy.

RESULTS

The examination of biological mechanisms accounting for the female-based advantage in human life expectancy has been an active area of inquiry; however, it is still difficult to prove the relative importance of any 1 factor. Nonetheless, biological differences between the sexes do exist and include differences in genetic and physiological factors such as progressive skewing of X chromosome inactivation, telomere attrition, mitochondrial inheritance, hormonal and cellular responses to stress, immune function, and metabolic substrate handling among others. These factors may account for at least a part of the female advantage in human life expectancy.

CONCLUSIONS

Despite noted gaps in sex equality, higher body fat percentages and lower physical activity levels globally at all ages, a sex-based gap in life expectancy exists in nearly every country for which data exist. There are several biological mechanisms that may contribute to explaining why females live longer than men on average, but the complexity of the human life experience makes research examining the contribution of any single factor for the female advantage difficult. However, this information may still prove important to the development of strategies for healthy aging in both sexes.

Medical management of adult transsexual persons

Gender identity disorder (GID), or transsexualism, is an increasingly recognized medical condition with an expanding body of medical literature to support the use of established therapeutic guidelines. Transsexualism can be effectively managed through exogenous cross-sex hormone administration used to induce development of desired sex characteristics, as well as use of other agents, such as aldosterone antagonists, aimed at decreasing physical characteristics of the undesired sex. Many complications can arise with the use of the available therapies, and these must be considered before determining the appropriate course of action. This review describes methods, including both pharmacotherapy and surgical interventions, for effective medical management of both male and female adults with GID. In addition, specific goals of therapy as well as safety aspects with long-term use of pharmacotherapeutic agents are discussed. This review also discusses some special considerations for treating patients with significant, yet common, comorbid diseases such as human immunodeficiency virus infection, acquired immunodeficiency syndrome, and viral hepatitis, as these conditions may complicate the clinical course and preclude some patients from using certain therapies. Pharmacist involvement in the management of transsexualism can be extremely beneficial to patients and other health care providers. Pharmacists can help determine the appropriate therapy, optimize dosages, monitor for adverse effects, and educate patients on what to expect during their therapy. Pharmacists should become knowledgeable about guidelines and current literature on transsexualism, understand the monitoring parameters for safe and effective therapy, and establish themselves as partners in the collaborative management of this disorder.

Long-term cross-sex hormone treatment is safe in transsexual subjects

The European Journal of Endocrinology recently published a paper (Asscheman et al.) presenting mortality data from more than a thousand transsexuals followed for a median time of 18 years and who had undergone previous or were currently on long term cross-sex hormonal treatment. Transsexualism is a rare condition and in scientific literature there are few reports on the long-term safety of different treatment protocols and on the physical and psychological outcomes of medical treatments. The safety of long-term high doses oestrogen or testosterone in subjects of the opposite sex has been debated and data on long term effects are scant at best. The Asscherman paper therefore represents a very important and reassuring reference for professionals working in this field suggesting that mortality is increased among transsexuals although due to causes unrelated to cross sex replacement therapy. These results will benefit the care and treatment of these subjects.

Altered arterial stiffness in male-to-female transsexuals undergoing hormonal treatment

AIM

Male-to-female (MTF) transsexuals are treated with estrogen with and without progestin through a variety of routes. The aim of this study is to evaluate the arterial stiffness in MTF transsexuals undergoing hormonal treatment.

METHODS

We evaluated the arterial stiffness in 156 MTF transsexuals (22 untreated and 129 treated with estrogen only or plus progestin) using a volume-plethysmographic apparatus equipped with a multi-element applanation tonometry sensor.

RESULTS

MTF transsexuals treated with parenteral estrogen were significantly older than untreated MTF transsexuals. Hematocrit, uric acid and activated partial thromboplastin time in treated MTF transsexuals were significantly lower than in untreated MTF transsexuals. The level of high-density lipoprotein cholesterol in MTF transsexuals treated with oral estrogen was significantly higher than in untreated MTF transsexuals or those treated with parenteral estrogen with and without progestin. The systolic blood pressure in MTF transsexuals treated with estrogen only is significantly lower than that in untreated MTF transsexuals. The brachial-ankle pulse wave velocity was significantly decreased in MTF transsexuals treated with estrogen compared to that in untreated MTF transsexuals or in those treated with estrogen plus progestin. The carotid augmentation index in MTF transsexuals treated with oral estrogen was significantly lower than that in MTF transsexuals treated with parenteral estrogen or oral estrogen plus progestin.

CONCLUSIONS

Estrogen treatment is likely to have some beneficial effects on lipid metabolism and vascular function in MTF transsexuals; however, progestin administered with estrogen may have adverse effects on arterial stiffness.

Children and adolescents with gender identity disorder referred to a pediatric medical center

OBJECTIVES

To describe the patients with gender identity disorder referred to a pediatric medical center. We identify changes in patients after creation of the multidisciplinary Gender Management Service by expanding the Disorders of Sex Development clinic to include transgender patients.

METHODS

Data gathered on 97 consecutive patients <21 years, with initial visits between January 1998 and February 2010, who fulfilled the following criteria: long-standing cross-gender behaviors, provided letters from current mental health professional, and parental support. Main descriptive measures included gender, age, Tanner stage, history of gender identity development, and psychiatric comorbidity.

RESULTS

Genotypic male:female ratio was 43:54 (0.8:1); there was a slight preponderance of female patients but not significant from 1:1. Age of presentation was 14.8 ± 3.4 years (mean ± SD) without sex difference (P = .11). Tanner stage at presentation was 4.1 ± 1.4 for genotypic female patients and 3.6 ± 1.5 for genotypic male patients (P = .02). Age at start of medical treatment was 15.6 ± 2.8 years. Forty-three patients (44.3%) presented with significant psychiatric history, including 20 reporting self-mutilation (20.6%) and suicide attempts (9.3%).

CONCLUSIONS

After establishment of a multidisciplinary gender clinic, the gender identity disorder population increased fourfold. Complex clinical presentations required additional mental health support as the patient population grew. Mean age and Tanner Stage were too advanced for pubertal suppressive therapy to be an affordable option for most patients. Two-thirds of patients were started on cross-sex hormone therapy. Greater awareness of the benefit of early medical intervention is needed. Psychological and physical effects of pubertal suppression and/or cross-sex hormones in our patients require further investigation.

The health and well-being of prostate cancer patients and male-to-female transsexuals on androgen deprivation therapy: a qualitative study with comments on expectations and estrogen

Both male-to-female transsexuals and advanced prostate cancer (PCa) patients are treated with androgen-suppressing drugs that have emasculating effects. Additionally, transsexuals take estrogenic compounds to feminize their bodies. We explore the quality of life of these populations, based on interviews with 12 individuals from each group. Overall, the transsexuals had a better psychological response to chemical castration than the PCa patients. The transsexuals showed more enthusiasm about the changes in their life; they viewed their lives as beginning anew, accepted their reduced libido, and were more comfortable with their increased emotionality. Different responses in the two groups are not surprising given that they undergo androgen deprivation under very different medical contexts. However, the fact that the transwomen are able to conceptualize the effects as positive suggests that some androgen-deprived PCa patients may benefit from reconceptualizing their changes within a positive framework. Additionally, difference in the two populations may be attributed, in part, to the fact that the transsexuals take supplemental estrogen. Circumstantial evidence suggests that estrogen in androgen-deprived males may improve sleep quality, help retain sexual interest, and protect cognitive function. This suggests that PCa patients may benefit from using estradiol for androgen suppression.

Effects of intramuscular testosterone undecanoate on body composition and bone mineral density in female-to-male transsexuals

INTRODUCTION

The most common treatment regimen in female-to-male transsexuals is administration of short-acting testosterone esters intramuscularly every 2 weeks.

AIM

The aim of this study was to evaluate the effect of long-acting intramuscular testosterone undecanoate on body composition and bone mineral density during cross-sex hormone therapy in female-to-male transsexuals.

METHODS

Forty-five female-to-male transsexuals (FtMs) were treated with injections of testosterone undecanoate 1,000 mg intramuscularly every 12 weeks over 24 months.

MAIN OUTCOME MEASURES

Body composition, bone mineral density, hormone parameters, and lipids were compared after 12 months and after 24 months with baseline values. Sonographic findings in the ovaries and endometrium, clinical and adverse effects during the study period were recorded.

RESULTS

There was a significant increase in lean mass in the FtMs during the study period in comparison with baseline values, whereas no change in BMI, fat mass, and bone mineral density was observed. There was a significant decline in gonadotropins, estradiol, dehydroepiandrosterone sulphate, sex hormone-binding globulin, and high-density lipoprotein, while testosterone and triglyceride levels increased significantly after 12 and 24 months. Ovaries remained unchanged and no noticeable endometrial pathology was observed. No mortality or morbidity was observed during the study period. We observed a cessation of menstrual bleeding, an increase in clitoral growth, libido, body and beard hair growth, deepened voices and decline in breast size. There was a significant increase in hemoglobin, hematocrit, glutamic-pyruvic transaminase, gamma-glutamyl transferase, and an increase in systolic blood pressure during the study period.

CONCLUSIONS

There was an increase in lean mass during the study period in FtMs treated with testosterone undecanoate. Transsexual patients should be monitored for adverse effects on lipid profiles, blood pressure, and erythrocytosis during intramuscular testosterone undecanoate therapy.

Long-term follow-up of transsexual persons undergoing sex reassignment surgery: cohort study in Sweden

CONTEXT

The treatment for transsexualism is sex reassignment, including hormonal treatment and surgery aimed at making the person's body as congruent with the opposite sex as possible. There is a dearth of long term, follow-up studies after sex reassignment.

OBJECTIVE

To estimate mortality, morbidity, and criminal rate after surgical sex reassignment of transsexual persons.

DESIGN

A population-based matched cohort study.

SETTING

Sweden, 1973-2003.

PARTICIPANTS

All 324 sex-reassigned persons (191 male-to-females, 133 female-to-males) in Sweden, 1973-2003. Random population controls (10:1) were matched by birth year and birth sex or reassigned (final) sex, respectively.

MAIN OUTCOME MEASURES

Hazard ratios (HR) with 95% confidence intervals (CI) for mortality and psychiatric morbidity were obtained with Cox regression models, which were adjusted for immigrant status and psychiatric morbidity prior to sex reassignment (adjusted HR [aHR]).

RESULTS

The overall mortality for sex-reassigned persons was higher during follow-up (aHR 2.8; 95% CI 1.8-4.3) than for controls of the same birth sex, particularly death from suicide (aHR 19.1; 95% CI 5.8-62.9). Sex-reassigned persons also had an increased risk for suicide attempts (aHR 4.9; 95% CI 2.9-8.5) and psychiatric inpatient care (aHR 2.8; 95% CI 2.0-3.9). Comparisons with controls matched on reassigned sex yielded similar results. Female-to-males, but not male-to-females, had a higher risk for criminal convictions than their respective birth sex controls.

CONCLUSIONS

Persons with transsexualism, after sex reassignment, have considerably higher risks for mortality, suicidal behaviour, and psychiatric morbidity than the general population. Our findings suggest that sex reassignment, although alleviating gender dysphoria, may not suffice as treatment for transsexualism, and should inspire improved psychiatric and somatic care after sex reassignment for this patient group.

Does low testosterone affect adaptive properties of adipose tissue in obese men?

Obesity and (pre)diabetes in males is associated with low serum testosterone and increased oestradiol levels. It is unknown whether these changes in sex steroids are part of a vicious circle resulting in an increase of risk for metabolic complications of obesity, or whether it presents merely an epiphenomenon. The risk for metabolic complications in obesity seems to be determined by adaptation and integrity of adipose tissue. It is unknown whether the typical changes in sex steroids seen in obese men are desirable or ominous with respect to these functions. However, it might be clinically relevant, as low serum testosterone can be treated, and well with different forms of interventional therapy. The present review provides a short summary on findings, obstacles and future research needed to gain better insight into consequences of changes in sex steroids for adaptation of adipose tissue in obese men.

Role of estrogen in normal male function: clinical implications for patients with prostate cancer on androgen deprivation therapy

PURPOSE

Patients with prostate cancer on androgen deprivation therapy with luteinizing hormone-releasing hormone agonists experience deleterious side effects, including sexual dysfunction, hot flashes and osteoporosis. Estrogen may relieve or reduce some of these side effects. We explore the role of estrogen in normal male function, emphasizing sexual interest and performance.

MATERIALS AND METHODS

We reviewed the literature on androgen deprivation therapy, estrogen and sexual function in males using PubMed® and other sources.

RESULTS

Estrogen receptors are present in tissues involved in sexual behavior including several brain centers and pelvic floor muscles. Exogenous estrogens can restore some sexual interest to greater than castrate level in castrated animals. This has also been reported for certain androgen deprived patients (eg voluntarily castrated men, male-to-female transsexuals) who take exogenous estrogens and others who are on high dose antiandrogens which increase endogenous estradiol levels. Estrogen also helps prevent hot flashes and bone mineral loss, which commonly occur with luteinizing hormone-releasing hormone agonist treatment. However, estrogen may cause gynecomastia and increases the risk of breast cancer. Thus, patients with prostate cancer should be informed about the pros and cons of estrogen therapy before starting androgen deprivation therapy. Based on these data estrogen is likely to have maximal benefits in men if initiated simultaneously with androgen deprivation therapy. Because estrogen autoregulates its own receptors, a constant dose of estrogen will not likely produce a constant serum concentration, suggesting that its effectiveness could be optimized if administered cyclically.

CONCLUSIONS

Prospective studies on the ability of parenteral estrogen to preserve sexual interest at greater than castrate level in patients with prostate cancer are warranted.

Development of a symptomatic intracranial meningioma in a male-to-female transsexual after initiation of hormone therapy

Transsexual patients are routinely treated with sex hormone therapy, which may be a risk factor for meningiomas, although the data are largely inconclusive. Here we describe a male-to-female transsexual patient treated with estradiol patches, who developed an occipital meningioma causing generalized seizures. This is the second report of a male-to-female transsexual patient who developed a symptomatic meningioma after sex hormone treatment, adding to the growing evidence that sex hormones contribute to the pathogenesis of meningiomas. Meningiomas may therefore complicate hormone therapy and sex hormones may be contraindicated in transsexual candidates with meningiomas identified upon screening.

Endocrine treatment of transsexual persons: an Endocrine Society Clinical Practice Guideline: commentary from a European perspective

The treatment of transsexual subjects is a challenging task for the endocrinologist who, in collaboration with the mental health professional and the surgeon, is called upon to confirm the diagnosis and adjust hormonal treatment aimed at suppressing endogenous sex hormones and to develop hormone characteristics of the desired gender. These guidelines are structured to provide evidence-based suggestions or, where evidence is lacking, expert recommendations on diagnostic procedures and hormonal treatment in adolescent and adult transsexuals, including long-term care and eligibility for surgery. The multidisciplinary approach to treatment, the additional diagnostic role of hormone administration and the need to maintain hormone levels within the physiological range are key suggestions stressed in the guidelines which are particularly important for an endocrinologist unfamiliar with this field. The need for psychological assessment before surgery is not common in many countries and should be stressed further in the guidelines. Some important issues such as time and method of hormone withdrawal before surgery together with when and which hormones should be administered after sex reassignment surgery has been completed also remain unclear. These guidelines represent a pivotal document for endocrinologists setting a standard for the care of transsexuals and providing directions for future research.

Endogenous estrogen levels are associated with endothelial function in males independently of lipid levels

Estrogens and androgens may play an important role in vascular health in both sexes. The aim of this study was to examine the relation of endogenous sex hormone levels with early markers of atherosclerosis in a cohort of apparently healthy males. 124 males (age 46.25 ± 9.56) attending a preventive medicine program were examined for unrecognised features of the metabolic syndrome. Flow-mediated dilatation (FMD) and intima-media thickness (IMT) of the common carotid artery were evaluated. Obesity parameters were recorded; estradiol, testosterone, SHBG, free testosterone, insulin, as well as glucose and lipid levels were measured. FMD was positively correlated with estradiol (r = 0.201, P = 0.041) and negatively with total cholesterol (r = -0.205, P = 0.022), low density lipoproteins (r = -0.232, P = 0.009), and triglyceride levels (r = -0.179, P = 0.046). In multivariate analysis, the association of FMD with estrogen was independent of BMI and lipid levels. No significant association between FMD and testosterone levels was found. Subjects with an increased mean IMT (> 0.73 mm, i.e., > 3rd tertile) had lower levels of free (P = 0.021) and bioavailable (P = 0.016) testosterone. In multivariate logistic regression analysis, this association was no longer significant when age or cholesterol levels were considered. Endogenous estrogen levels are associated with FMD, independently of age and lipid levels, showing a protective effect in middle-age male subjects. Circulating androgens are associated, although not independently, with structural changes such as the IMT of carotid artery; this effect is possibly influenced by lipid levels and age.

[Emotional instability and suicidal behavior as a consequence of transsexualism]

This contribution describes a case that led to hospitalization in our psychiatric clinic due to emotional instability and suicidal behavior resulting from a gender identity disorder (female to male transsexualism). During inpatient treatment that lasted for almost 4 months, considerable improvement of the patient's emotional instability and suicidal behavior could be achieved. Treatment success was maintained up to follow-up (18 months after discharge). The syndrome-oriented pharmacotherapy with quetiapine and valproate which had been administered as off-label medication to stabilize the patient's mood could be considered the effective factor. A few months after release from inpatient care, cross-gender hormone therapy was initiated accompanied by outpatient psychotherapy.

Alterations in Lipids and Adipocyte Hormones in Female-to-Male Transsexuals

Testosterone therapy in men and women results in decreased high-density lipoprotein cholesterol (HDL) and increased low-density lipoprotein cholesterol (LDL). We sought to determine whether testosterone therapy has this same effect on lipid parameters and adipocyte hormones in female-to-male (FTM) transsexuals. Twelve FTM transsexuals provided a fasting lipid profile including serum total cholesterol, HDL, LDL, and triglycerides prior to and after 1 year of testosterone therapy (testosterone enanthate or cypionate 50-125 mg IM every two weeks). Subjects experienced a significant decrease in mean serum HDL (52 +/- 11 to 40 +/- 7 mg/dL) (P < .001). The mean LDL (P = .316), triglyceride (P = .910), and total cholesterol (P = .769) levels remained unchanged. In a subset of subjects, we measured serum leptin levels which were reduced by 25% but did not reach statistical significance (P = .181) while resistin levels remained unchanged. We conclude that testosterone therapy in FTM transsexuals can promote an increased atherogenic lipid profile by lowering HDL and possibly reduce serum leptin levels. However, long-term studies are needed to determine whether decreases in HDL result in adverse cardiovascular outcomes.

Proliferative and anti-proliferative effects of dietary levels of phytoestrogens in rat pituitary GH3/B6/F10 cells - the involvement of rapidly activated kinases and caspases

Background

Phytoestogens are a group of lipophillic plant compounds that can have estrogenic effects in animals; both tumorigenic and anti-tumorigenic effects have been reported. Prolactin-secreting adenomas are the most prevalent form of pituitary tumors in humans and have been linked to estrogen exposures. We examined the proliferative effects of phytoestrogens on a rat pituitary tumor cell line, GH₃/B₆/F₁₀, originally subcloned from GH₃ cells based on its ability to express high levels of the membrane estrogen receptor-α.

Methods

We measured the proliferative effects of these phytoestrogens using crystal violet staining, the activation of several mitogen-activated protein kinases (MAPKs) and their downstream targets via a quantitative plate immunoassay, and caspase enzymatic activities.

Results

Four phytoestrogens (coumestrol, daidzein, genistein, and trans-resveratrol) were studied over wide concentration ranges. Except trans-resveratrol, all phytoestrogens increased GH₃/B₆/F₁₀ cell proliferation at some concentration relevant to dietary levels. All four phytoestrogens attenuated the proliferative effects of estradiol when administered simultaneously. All phytoestrogens elicited MAPK and downstream target activations, but with time course patterns that often differed from that of estradiol and each other. Using selective antagonists, we determined that MAPKs play a role in the ability of these phytoestrogens to elicit these responses. In addition, except for trans-resveratrol, a serum removal-induced extrinsic apoptotic pathway was blocked by these phytoestrogens.

Conclusion

Phytoestrogens can block physiological estrogen-induced tumor cell growth in vitro and can also stimulate growth at high dietary concentrations in the absence of endogenous estrogens; these actions are correlated with slightly different signaling response patterns. Consumption of these compounds should be considered in strategies to control endocrine tumor cell growth, such as in the pituitary.

Passing through the wall: on outings, exodus, angels, and the ark

Classicists have argued that angels in Christian theology were modeled on the eunuchs of antiquity; with angels providing the same services to the Lord in Heaven that eunuchs provided to emperors on Earth. I apply this idea toward understanding the cherubim on the ark in Exodus 25 and the death of Aaron's sons in Leviticus 10. I also suggest that the angel-eunuch analogy can help us understand the psychological impact of androgen deprivation therapy on modern prostate cancer patients. Appreciating this analogy can help prostate cancer patients accept and adapt to the changes they experience.

Endocrine treatment of transsexual persons: an Endocrine Society clinical practice guideline

OBJECTIVE

The aim was to formulate practice guidelines for endocrine treatment of transsexual persons.

EVIDENCE

This evidence-based guideline was developed using the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) system to describe the strength of recommendations and the quality of evidence, which was low or very low.

CONSENSUS PROCESS

Committees and members of The Endocrine Society, European Society of Endocrinology, European Society for Paediatric Endocrinology, Lawson Wilkins Pediatric Endocrine Society, and World Professional Association for Transgender Health commented on preliminary drafts of these guidelines.

CONCLUSIONS

Transsexual persons seeking to develop the physical characteristics of the desired gender require a safe, effective hormone regimen that will 1) suppress endogenous hormone secretion determined by the person's genetic/biologic sex and 2) maintain sex hormone levels within the normal range for the person's desired gender. A mental health professional (MHP) must recommend endocrine treatment and participate in ongoing care throughout the endocrine transition and decision for surgical sex reassignment. The endocrinologist must confirm the diagnostic criteria the MHP used to make these recommendations. Because a diagnosis of transsexualism in a prepubertal child cannot be made with certainty, we do not recommend endocrine treatment of prepubertal children. We recommend treating transsexual adolescents (Tanner stage 2) by suppressing puberty with GnRH analogues until age 16 years old, after which cross-sex hormones may be given. We suggest suppressing endogenous sex hormones, maintaining physiologic levels of gender-appropriate sex hormones and monitoring for known risks in adult transsexual persons.

Prevalence of low bone mass in relation to estrogen treatment and body composition in male-to-female transsexual persons

Bone health is a parameter of interest in the daily follow-up of male-to-female (M --> F) transsexual persons both before and after sex reassignment surgery (SRS) due to an intensely changing hormonal milieu. We have studied body composition, areal, geometric, and volumetric bone parameters, using DXA and peripheral quantitative computed tomography at different sites in 50 M --> F transsexual persons, at least 3 yr after the start of the hormonal treatment and 1 yr after SRS. In this cross-sectional study, hormone levels and markers of bone metabolism were assessed using immunoassays. Prevalence of low bone mass as defined by a Z-score < or = -2.0 according to DXA criteria was 26% at lumbar spine and 2% at the total hip. We found no major differences in hormonal parameters between participants with a Z-score < or = or > -2.0. Markers of bone turnover were comparable between subjects with or without low bone mass, indicating a stable bone turnover at the time of investigation. No significant differences in bone size or density were observed between patients on transdermal vs. oral estrogens. Low bone mass is not uncommon in M --> F transsexual persons. Smaller bone size, and a strikingly lower muscle mass compared with men appear to underlie these findings.

Testosterone and the breast

Although women have been treated with testosterone (T) for female sexual dysfunction since the 1950s, the role of T in normal female physiology is not yet fully defined. One of the major safety concerns of androgen therapy is whether androgens have a stimulatory effect on the breast that could lead to breast carcinomas. The proposed mechanisms for such stimulation include local estrogen production from the aromatase enzyme complex present in the breast tissue or by the direct stimulation of the androgen receptor. Predominant data from in vitro studies have shown that androgens actually have apoptotic and antiproliferative effects and not stimulatory effects. Animal models have shown similar results to in vitro studies, finding that androgens inhibit breast cancer growth. Prospective and retrospective epidemiological analyses have shown mixed outcomes, with no clear consensus regarding androgen use and breast cancer risk. Hyperandrogenism in patients with polycystic ovarian syndrome with elevated levels of endogenous T is not associated with an increased risk of breast cancer and may, in fact, be protective. Another human model with excess of T is female-to-male transgenderism, in which genotypic women are treated with large doses of exogenous T with no increased risk. High-dose androgen therapy also has been effective in treating patients with advanced breast cancer. Thus, the preponderance of data suggests that T use in females is not associated with an increased risk of breast carcinoma.