Endometrial findings among transgender and gender nonbinary people using testosterone at the time of gender-affirming hysterectomy

NASPAG Clinical Opinion: The Care of Transgender and Gender Nonbinary Adolescents and Young Adults

Transgender and gender nonbinary (TGNB) adolescents and young adults (AYA) may present to clinicians with reproductive health expertise for the spectrum of gynecologic, sexual, and reproductive care. As such, clinicians should be knowledgeable in the many facets of gender-affirming care. This clinical opinion reviews language associated with gender diversity and gender-affirming care; current clinical, social, and political barriers faced by TGNB AYA; and the creation of welcoming and inclusive clinical spaces for TGNB AYA. It discusses social, medical, and surgical affirmation processes, and focuses on gynecologic care topics which may arise in the care of TGNB AYA, including those who undergo medical or surgical therapies. This includes menstrual suppression, breakthrough bleeding on testosterone, sexual health, fertility, and the pelvic care of individuals following gender affirming vulvovaginoplasty.

Endometrial cancer and endometrial changes in transgender men: Insights from Japanese individuals on testosterone

AIM

Endometrial changes in Japanese transgender men (TGM) on testosterone use remain elucidated. This study aims to present TGM with endometrial cancer and insights from a literature review of similar cases. Furthermore, we investigated the correlation between endometrial cancer and severe obesity in TGM who underwent gender-affirming surgery.

METHODS

Between July 2020 and April 2023, two groups were assessed: 2 TGM with endometrial cancer and 43 TGM without cancer who underwent gender-affirming surgery. A literature review for TGM with endometrial cancer was conducted. Clinical data were retrospectively collected, and histopathological evaluation of female genital organs was performed.

RESULTS

Two TGM with endometrial cancer and an additional four similar cases were identified through a literature search. These TGM had severe obesity (body mass index [BMI] ≥30 kg/m2) and long-term testosterone use, indicating a possible link between endometrial cancer and these factors. Subsequently, we investigated the 43 TGM without cancer. We revealed 30% with obesity (BMI ≥25), only three cases of severe obesity (BMI ≥30), and a significant correlation between testosterone use duration and BMI in TGM without cancer. Histological examination revealed focal proliferative endometrium in 51% of cases and polycystic ovarian changes in 77%.

CONCLUSIONS

Our observations suggest a potential link between severe obesity, prolonged testosterone use, and endometrial cancer in transgender men. Histological changes in the female genital tract highlighted frequent focal proliferative endometrium, even under testosterone therapy. Further research should focus on larger, multi-institutional studies to confirm these findings and establish endometrial cancer screening for Japanese TGM.

Reproductive Considerations in the Transgender and Gender Diverse Population: A Review

Many transgender and gender diverse (TGD) individuals will be considering gender-affirming treatments during their reproductive lifespan. These medically necessary treatments have a negative impact on reproductive potential. All TGD individuals should be counseled regarding fertility. Options for fertility preservation for individuals who have undergone puberty include mature oocyte, embryo, and sperm cryopreservation. In prepubertal individuals, ovarian tissue cryopreservation may be considered, but testicular tissue cryopreservation remains experimental only. While there have been advances in the technology and standardization of reproductive health care for this population, many gaps remain in our knowledge which require further research.

Uterine changes in transgender men receiving testosterone therapy

OBJECTIVES

Despite regular gender-affirming hormone therapy (GAHT), the presence of uterine bleeding can occur occasionally and cause profound discomfort. This study aimed to evaluate the histologic features and immunohistochemical expression of estrogen (ER), progesterone (PR), and androgen receptors (AR) in the endometrium and myometrium of transgender men receiving testosterone therapy and relate them to clinical and hormonal characteristics.

DESIGN

Retrospective cross-sectional study.

METHODS

Thirty-four transgender men undergoing gender-affirming surgery were included. Clinical, sociodemographic, and laboratory data as well as anatomopathological and immunohistochemical findings were evaluated.

RESULTS

The participants' mean age was 42.35 (SD, 10.00) years, and body mass index was 28.16 (SD, 5.52) kg/m2. The mean GAHT duration before surgery was 5.36 (SD, 3.24) years. The mean testosterone levels were 814.98 (SD, 407.13) ng/dL, and estradiol levels were 55.22 (SD, 25.27) pg/mL. The endometrium was atrophic in 61.8%, proliferative in 17.6%, and secretory in 20.6%. Immunohistochemical receptor analysis revealed that endometrial epithelial cells expressed ER (90%) and PR (80%), with a lower expression of AR (30%). In stromal tissue, the median ER, PR, and AR expression was lower than that in the epithelium (60%, 70%, and 25%, respectively). The myometrium showed high expression of PR (90%) and ER (70%), with the highest expression of AR (65%) being localized to this region.

CONCLUSIONS

In the present study, GAHT induced an atrophic condition of the endometrium in two-thirds of the transgender men, with a limited AR expression in the endometrial region. The present results suggest that testosterone-based GAHT for a mean of 5 years is safe in transgender men achieving amenorrhea.

Uterine and Ovarian Histopathology After Testosterone for Gender Affirmation: A Systematic Review

Purpose

The objective of this systematic review was to evaluate the effects of testosterone on uterine and ovarian pathology in transmasculine patients at the time of gender-affirming surgery.

Methods

Searches were conducted using MEDLINE, CINAHL with Full Text, Cochrane Library, Scopus, and Europe PMC for articles published before April 5, 2021, containing concepts of testosterone use, uterine histopathology, and transgender population. The initial search yielded a total of 658 abstracts. Studies were analyzed in full text if they reported one or more uterine or ovarian histopathological findings in a noncisgender population receiving testosterone for gender affirmation. Rayyan software was used for the abstract review.

Results

This review was registered with PROSPERO. Twenty-eight full-text articles were reviewed, of which 17 met the inclusion criteria. Two reviewers performed data extraction and risk of bias assessment. Thirteen studies included endometrial histopathology results, representing 522 patients. Endometrial findings demonstrated that 254 patients (48.7%) were atrophic, 243 (46.6%) were proliferative, and 16 (3.0%) were secretory. Twelve patients (2.3%) had endometrial intraepithelial neoplasia (EIN), including one (0.2%) with focal adenocarcinoma. Eleven studies reported ovarian histopathology in 410 patients and 765 ovaries. A total of 143 (34.9%) patients had polycystic-appearing ovaries. Three (0.7%) patients had benign ovarian neoplasms. No ovarian malignancies were reported.

Conclusion

The endometrium was predominately found to be atrophic or proliferative, with low rates of EIN and carcinoma. No ovarian malignancy was observed. Based on this review, patients on testosterone do not have an increased risk of precancerous endometrial lesions due to unopposed hormones in the setting of amenorrhea.

Persistent vaginal bleeding during gender-affirming hormone therapy in transgender men

PURPOSE

While it is common for menstrual cycles to cease within the initial 6 months of treatment, there are instances where some transgender men may not experience this cessation. We analyzed transgender men undergoing gender-affirming hormone therapy (GAHT) with testosterone who experienced breakthrough bleeding in order to identify the factors associated with this condition.

METHODS

In this case-control study, 24 transgender men in the case group and 48 in the control group were assessed for clinical, sociodemographic, hormonal, and body composition variables using dual-energy X-ray absorptiometry. All participants had been on GATH for at least 6 months.

RESULTS

A few transgender men experienced persistent breakthrough bleeding, which was associated with decreased testosterone levels and free androgen index (FAI) compared with controls (p = 0.002 and p = 0.008, respectively). Among individuals with breakthrough bleeding, 50% had testosterone levels below the lowest tertile calculated for the sample, compared with 18.8% on controls (p = 0.007). After therapy adjustment, testosterone levels increased compared with the values obtained in the initial bleeding episode (p = 0.031). Eight transgender men required the addition of an oral progestogen to achieve amenorrhea, and these individuals had higher BMI than those in whom the adjustment of the parenteral testosterone dose was adequate (p = 0.026). A univariate prevalence ratio analysis revealed a negative association of persistent bleeding with testosterone levels (p = 0.028) and FAI levels (p = 0.019).

CONCLUSION

Higher BMI and lower levels of testosterone and FAI were the main factors associated with breakthrough bleeding in transgender men.

Chronic pelvic pain among transgender men and gender diverse adults assigned female at birth

BACKGROUND

There are limited data on pelvic pain among transgender men and gender diverse people, and the impact of testosterone on pelvic pain is poorly understood.

OBJECTIVE

Characterize the prevalence and correlates of chronic pelvic pain (CPP) among transgender men and gender diverse people and examine the association between testosterone use and CPP.

MATERIALS AND METHODS

We used 2020-2022 data from The Population Research in Identity and Disparities for Equality (PRIDE) Study, an online prospective cohort study of sexual and gender minority adults in the United States, to conduct complementary cross-sectional and longitudinal analyses. Our primary outcome was self-reported CPP lasting 3 months or longer measured using the Michigan Body Map.

RESULTS

Among 2579 transgender men and gender diverse people assigned female at birth included in our sample, 457 (18%) reported CPP. CPP correlates included: inflammatory bowel disease, irritable bowel syndrome (IBS), kidney stones, pelvic inflammatory disease, polycystic ovary syndrome (PCOS), uterine fibroids, current hormonal intrauterine device use, prior pregnancy, vaginal delivery, hysterectomy, and oophorectomy. Individuals with CPP reported a high prevalence of IBS (37%), PCOS (20%), uterine fibroids (9%), post-traumatic stress disorder (51%), and severe depression and anxiety symptoms (42% and 25%, respectively). Current testosterone use was associated with a 21% lower prevalence of CPP (adjusted prevalence ratio (aPR) 0.79, 95% confidence interval [CI]: 0.65-0.96). In longitudinal analyses (N = 79), 15 (19%) participants reported any CPP after initiating testosterone: eight (56%) of whom reported CPP prior to testosterone initiation, and seven (47%) who reported new-onset CPP.

DISCUSSION AND CONCLUSIONS

The relationship between CPP and testosterone is complex. Although testosterone use was associated with a lower prevalence of CPP, some transgender and gender diverse individuals experienced new-onset pelvic pain after testosterone initiation. Given the significant impact that CPP can have on mental health and quality of life, future research must examine the role of testosterone in specific underlying etiologies of CPP and identify potential therapies.

Endometriosis in Transgender Men: Bridging Gaps in Research and Care-A Narrative Review

Endometriosis is a debilitating gynecological condition commonly seen in individuals designated female at birth; however, there has been limited research focused on its prevalence and impact among transgender men. This narrative review aims to fill a critical knowledge gap by exploring the epidemiology, clinical manifestations, management strategies, and quality-of-life implications of endometriosis among transgender individuals who identify as male. Specifically, this study seeks to estimate the prevalence rates and describe the symptoms experienced by transgender men undergoing testosterone therapy. Additionally, it addresses the diagnostic challenges posed by hormonal treatments and the lack of culturally competent healthcare services for this population. Recent molecular studies indicate that hormonal imbalances, such as increased estrogen synthesis and progesterone resistance, are significant factors in the persistence of endometriosis symptoms despite testosterone therapy. Moreover, evidence suggests that testosterone therapy may not always suppress endometrial activity completely, contributing to the persistence of symptoms in some individuals. Endometriosis in transgender men requires personalized approaches that consider both testosterone therapy and its interactions with endometriosis, as well as fertility preservation and the psychosocial aspects of treatment. This review emphasizes the necessity of taking an inclusive approach in both research and clinical practice to improve healthcare outcomes for this underserved population. The results demonstrate how continued research, education, and healthcare services tailored specifically to transgender men are necessary to better understand and treat endometriosis, thus improving both their overall health and quality of life.

The Need to Look at Transgender and Gender Diverse People's Health: A Preliminary Descriptive Report on Pain, Sexual Distress, and Health Profile of Five Transmasculine People and One Non-Binary Person with Endometriosis

The sexual health of transgender and gender diverse (TGD) people with endometriosis has been overlooked, and important emotional experiences, such as sexual distress and its correlates, have been ignored. This has prevented a more comprehensive look at the health experiences of TGD individuals. This descriptive online survey study preliminarily explored the experiences of pain symptoms, sexual distress, and mental health of N = 6 TGD individuals diagnosed with endometriosis. Descriptive results showed a mean delay of 10 years from the onset of symptoms to the diagnosis. Endometriosis-related pain was a common symptom, although with low to moderate intensity. Results also showed higher mean levels of pain impact, powerlessness and lack of control, somatization, depression, anxiety, and sexual distress, and lower mean levels of emotional well-being, social support, and worse self-image compared to reports on cisgender women with endometriosis in the literature. These results suggested that sexual and mental health in the context of TGD people with endometriosis has specificities and may be associated with factors that need to be accounted for to provide comprehensive and socially just healthcare, such as the recognition of the impact of endometriosis treatment on symptoms of gender dysphoria. To achieve sexual health equity for TGD people, continuous and updated professional training and inclusive research with multiple informants are necessary.

Androgen-responsive FOXP4 is a target for endometrial carcinoma

Although low estrogen is considered to suppress uterine endometrial carcinoma, the most cases occur in the postmenopausal stage. After menopause, the production of androgen level also declines. Therefore, to resolve the above enigma, we hypothesize that the postmenopausal decline of androgen is a trigger of its progression. In the present study, to validate this hypothesis, we examine the pathological roles of androgen/AR by analyzing clinical data, culturing endometrioid cancer cell lines, and using murine models. Clinical data show that androgen receptor (AR) expression and serum dihydrotestosterone (DHT) are associated with lower disease-free survival (DFS). DHT suppresses malignant behaviors in AR-transfected human endometrial cancer cells (ECC). In ovariectomized Ptenff/PRcre/+ mice, DHT decreases the proliferation of spontaneously developed murine ECC. In AR-transfected human ECC and Ptenff/PRcre/+ mice, DHT suppresses FOXP4 expression. FOXP4-overexpressed human ECC increases, while FOXP4-knocked-down ECC shows decreased malignant behaviors. DHT/AR-mediated ECC suppression is restored by FOXP4 overexpression. The high FOXP4 expression is significantly correlated with low postoperative DFS. These findings indicate that the androgen/AR system suppresses the malignant activity of endometrial carcinoma and that downstream FOXP4 is another target molecule. These findings will also impact developments in clinical approaches to elderly health.

Incidence of breakthrough bleeding in transgender and gender-diverse individuals on long-term testosterone

BACKGROUND

Little is known about the maintenance of amenorrhea among transgender and gender-diverse individuals with uteri who are using long-term testosterone gender-affirming hormone therapy. Emerging data describe breakthrough bleeding among adolescents on long-term testosterone therapy and among adults who are seeking a gender-affirming hysterectomy. More studies are needed to better understand breakthrough bleeding patterns among transgender and gender-diverse individuals with uteri who are using testosterone, including the frequency, timing, and etiology of bleeding and how these patterns may differ between adults and younger populations.

OBJECTIVE

The primary aim of this study was to characterize the incidence and patterns of breakthrough bleeding in a cohort of transgender and gender-diverse individuals who had been on testosterone for longer than 12 months and who had uteri in situ. Secondary aims included identifying the time to first bleed for those who experienced breakthrough bleeding and the risk factors associated with breakthrough bleeding while on testosterone therapy.

STUDY DESIGN

This was an institutional review board-approved, single tertiary center, retrospective chart review of transgender and gender diverse individuals who had been on testosterone for at least 1 year. A primary survival analysis that evaluated the incidence of bleeding was combined with descriptive analyses and an evaluation of the factors associated with bleeding.

RESULTS

Of the 279 patients included in the analysis, the median age of testosterone initiation was 22 years (interquartile range, 19-41), and the median follow-up time was 34 months (range, 12-278). The absolute proportion of individuals who ever experienced breakthrough bleeding on testosterone was 34% (n=96; 95% confidence interval, 29-40). Patients who experienced breakthrough bleeding initiated testosterone at a younger age (20.5 vs 22.0 years; P=.04), had lower mean serum testosterone levels (389.14 vs 512.7 ng/dL; P=.001), were more likely to have a mean testosterone level <320 ng/dL (52% vs 48%; P=.001), and had higher mean estradiol levels (62% vs 49%; P=.003). Survival analyses estimated a breakthrough bleeding incidence rate of 0.09 per year (95% confidence interval, 0.07-1.0). Although 58 people underwent a hysterectomy during the follow-up period, 64% of the cohort who maintained a uterus eventually experienced breakthrough bleeding. The median time to the initial bleeding episode was 22 months (interquartile range, 12-201) after testosterone initiation.

CONCLUSION

These results suggest that a substantial fraction of transgender and gender-diverse individuals who are using testosterone will experience at least 1 episode of breakthrough bleeding even after their initial year of testosterone use. We recommend that clinicians inform all patients that breakthrough bleeding is a common occurrence even after the first year on testosterone therapy.

Impact of continuous testosterone exposure on reproductive physiology, activity, and pain-related behavior in young adult female rats

Testosterone may reduce pain in cisgender women and transgender men. Rodents can provide a useful model for investigating physiological effects of hormone therapy. To this end, continuous-release testosterone or blank (placebo) capsules were implanted s.c. into young adult female rats, and three weeks later rats were either ovariectomized or sham-ovariectomized. Testosterone treatment that mimicked previously reported endogenous levels in males eliminated estrous cycling and decreased uterine weight. Testosterone also significantly increased body weight and suppressed the increases in daily wheel running observed in placebo controls over time. Subsequent ovariectomy or sham-ovariectomy decreased wheel running in all groups, but testosterone-treated rats recovered significantly more quickly than did placebo-treated rats. Neither testosterone nor ovariectomy significantly altered hindpaw mechanical threshold. Two weeks after sham/ovariectomy surgery, injection of Complete Freund Adjuvant (CFA) into one hindpaw reduced wheel running and mechanical threshold in all groups; running significantly decreased from the first to second day after CFA in testosterone- but not in placebo-treated rats. Morphine 1.0 but not 3.2 mg/kg increased CFA-suppressed wheel running similarly in all groups, whereas both doses of morphine increased CFA-suppressed mechanical threshold. These data suggest that weeks-long testosterone treatment with or without ovariectomy may provide a useful physiological model of testosterone therapy as used in human gender transition. Although testosterone administered at levels similar to those in gonadally intact males tended to hasten female rats' recovery from surgery, it did not decrease maximal pain-related behaviors after surgery or hindpaw inflammatory insult, nor did it alter opioid antinociception.

Reproductive capacity after gender-affirming testosterone therapy

Transgender and nonbinary people with female birth sex may utilize testosterone therapy for masculinization. Individuals interested in reproduction using their own gametes should be offered fertility preservation prior to starting testosterone. However, logistical and practical barriers prevent many from accessing fertility preservation options prior to starting testosterone. Some of these transmasculine and nonbinary individuals may later become interested in carrying a pregnancy or using their oocytes for reproduction after being on testosterone. Many questions remain about the reproductive impact of long-term masculinizing testosterone therapy. Emerging literature has documented pregnancies and successful assisted reproduction for some people after taking testosterone, but it is not known whether individuals can expect these successful outcomes. Testosterone appears to impact the reproductive tract, including the ovaries, uterus, and fallopian tubes, but the reversibility and functional impact of these changes also remain unclear. A greater understanding of the impact of masculinizing testosterone on reproductive capacity remains a priority area for future research.

Cancer surveillance for transgender and gender diverse patients with Lynch syndrome: a practice resource of the Collaborative Group of the Americas on Inherited Gastrointestinal Cancer

Transgender and gender diverse (TGD) populations with hereditary cancer syndromes face unique obstacles to identifying and obtaining appropriate cancer surveillance and risk-reducing procedures. There is a lack of care provider knowledge about TGD health management. Lynch syndrome (LS) is one of the most common hereditary cancer syndromes, affecting an estimated 1 in 279 individuals. There are no clinical guidelines specific for TGD individuals with LS, highlighting a need to improve the quality of care for this population. There is an urgent need for cancer surveillance recommendations for TGD patients. This commentary provides recommendations for cancer surveillance, risk-reducing strategies, and genetic counseling considerations for TGD patients with LS.

Preservation of Fertility in Transgender Men on Long-Term Testosterone Therapy: A Systematic Review of Oocyte Retrieval Outcomes During and After Exogenous Androgen Exposure

Testosterone therapy prompts the development of male secondary sexual characteristics coupled with numerous physiological changes; however, the effect of prolonged androgen exposure on transgender men's fertility remains to be fully elucidated. Multiple clinical consensuses advise assisted reproduction before hormone treatment and state that fertility preservation following androgen therapy entails the suspension of testosterone administration. Although the desire for reproduction among transgender men is prevalent, the discontinuation of gender-affirming hormone therapy poses a major challenge due to the anxiety, unease, and gender dysphoria that follow androgen withdrawal. The present investigation aimed to explore the feasibility and outcomes of oocyte retrieval in adult transgender men undergoing testosterone administration before or during fertility preservation. Seven case reports, four cohort studies, and two cross-sectional studies were identified following a systematic literature search on the PubMed/Ovid MEDLINE, Scopus, and ScienceDirect databases. The findings gathered in this review disclose the viability of oocyte retrieval after prolonged androgen exposure and suggest the absence of a direct relationship between the duration of testosterone suspension and fertility preservation outcomes. Although the reports are limited, recent evidence shows that continuous testosterone administration and the use of aromatase inhibitors during ovarian stimulation could potentially reduce the distressing effects of hormonal ovulation induction. New approaches to fertility preservation in transgender men must be further explored to ensure interventions aligned both with the reproductive desire and avoidance of gender dysphoria exacerbation that follow hormone therapy suspension.

Endometriosis in transgender men: recognizing the missing pieces

Endometriosis, traditionally associated with cisgender women, should be recognized as a significant issue for transgender men. This perspective highlights the need to address the unique experiences and challenges faced by transgender men with endometriosis. Diagnostic difficulties arise due to hormone therapy and surgical interventions, which can alter symptoms. Limited research in transgender men undergoing hysterectomy further complicates the understanding of endometriosis in this population. Healthcare providers must be aware of these challenges and adapt the diagnostic approaches accordingly. Education and inclusive care are essential to ensure timely and appropriate management of endometriosis in transgender men, ultimately improving their quality of life.

Endometrial cancer in a transgender male: A rare case and review of the literature

Objective

Endometrial cancer is the most common gynecological malignancy in the United States. Despite the high prevalence amongst cisgender females the prevalence of this gynecological malignancy in transgender men has not been clearly identified. To date, only four reported cases have been described in the literature.

Case

A 36-year-old nulliparous assigned female at birth, transgender premenopausal male underwent a laparoscopic total hysterectomy, bilateral salpingo-oophorectomy, sentinel lymph node mapping and omental biopsy after having an endometrial biopsy that demonstrated well differential endometroid adenocarcinoma. He had been on testosterone therapy for at least five years prior to presenting to his gynecologist with the chief complaint of vaginal bleeding. Final pathology showed FIGO Stage 1A endometroid endometrial carcinoma.

Conclusion

This case report adds to the body of literature demonstrating that transgender men can develop endometrial carcinoma while on exogenous testosterone therapy. In addition, this report illustrates the importance of routine gynecological care in the transgender patient population.

"Lights and Shades" of Fertility Preservation in Transgender Men Patients: A Clinical and Pathological Review

Fertility preservation (FP) is becoming a critical issue in transgender men who desire biological offspring in the future. The prevalence of transgender individuals in the United States is increasing, and as a result, the demand for gender-affirming surgeries (GAS) and associated FP techniques is rising. Despite the growing demand, there is currently no personalized approach to FP for transgender men, and the available techniques have limitations that require further investigation. In the present review we carefully examine the existing literature on this topic to highlight the shortcomings of current methods and areas where additional research is needed to advance the field. Hormonal therapy (HT), which is an integral part of gender transition in transgender men, can have a significant impact on fertility and may increase the risk of various diseases. Moreover, GAS usually leads to permanent sterility in these patients. Therefore, it is essential to provide patients with accurate information about the benefits and potential risks of different FP techniques, taking into account the patient's reproductive goals. This review underscores the complex and multifaceted nature of FP in transgender men and emphasizes the need for further research to develop more effective and personalized approaches to FP for this population.

Androgen signalling in the ovaries and endometrium

Currently, our understanding of hormonal regulation within the female reproductive system is largely based on our knowledge of estrogen and progesterone signalling. However, while the important functions of androgens in male physiology are well known, it is also recognized that androgens play critical roles in the female reproductive system. Further, androgen signalling is altered in a variety of gynaecological conditions, including endometriosis and polycystic ovary syndrome, indicative of regulatory roles in endometrial and ovarian function. Co-regulatory mechanisms exist between different androgens, estrogens, and progesterone, resulting in a complex network of steroid hormone interactions. Evidence from animal knockout studies, in vitro experiments, and human data indicate that androgen receptor expression is cell-specific and menstrual cycle stage-dependent, with important regulatory roles in the menstrual cycle, endometrial biology, and follicular development in the ovaries. This review will discuss the expression and co-regulatory interactions of androgen receptors, highlighting the complexity of the androgen signalling pathway in the endometrium and ovaries, and the synthesis of androgens from additional alternative pathways previously disregarded as male-specific. Moreover, it will illustrate the challenges faced when studying androgens in female biology, and the need for a more in-depth, integrative view of androgen metabolism and signalling in the female reproductive system.

Gender-affirming hormone therapy, mental health, and surgical considerations for aging transgender and gender diverse adults

As the transgender and gender diverse (TGD) population ages, more transfeminine and transmasculine individuals present to clinic to initiate or continue their gender-affirming care at older ages. Currently available guidelines on gender-affirming care are excellent resources for the provision of gender-affirming hormone therapy (GAHT), primary care, surgery, and mental health care but are limited in their scope as to whether recommendations require tailoring to older TGD adults. Data that inform guideline-recommended management considerations, while informative and increasingly evidence-based, mainly come from studies of younger TGD populations. Whether results from these studies, and therefore recommendations, can or should be extrapolated to aging TGD adults remains to be determined. In this perspective review, we acknowledge the lack of data in older TGD adults and discuss considerations for evaluating cardiovascular disease, hormone-sensitive cancers, bone health and cognitive health, gender-affirming surgery, and mental health in the older TGD population on GAHT.

[Contraception for transgender men: A case report and review]

All methods of contraception used by a cisgender woman can theoretically be used by a transgender man. In practice, some contraceptives can aggravate gender dysphoria and should be discarded. On the other hand, contraceptives which make it possible to consolidate amenorrhea or to accentuate the virilization induced by taking testosterone will be better tolerated.

Gender-affirming hormonal therapy for transgender and gender-diverse people-A narrative review

As the number of transgender and gender-diverse (TGD) people accessing gender-affirming care increases, the need for healthcare professionals (HCPs) providing gender-affirming hormonal therapy (GAHT) also increases. This chapter provides an overview of the HCPs interested in getting involved in providing GAHT.

Pelvic Pain in Transgender People Using Testosterone Therapy

Purpose: This descriptive study aimed to assess the characteristics of pelvic pain and explore predictive factors for pelvic pain in transgender (trans) individuals using testosterone therapy. Methods: An online cross-sectional survey was open between August 28, 2020, and December 31, 2020, to trans people presumed female at birth, using testosterone for gender affirmation, living in Australia, and >16 years of age. The survey explored characteristics of pelvic pain following initiation of testosterone therapy, type and length of testosterone therapy, menstruation history, and relevant sexual, gynecological, and mental health experiences. Logistic regression was applied to estimate the effect size of possible factors contributing to pain after starting testosterone. Results: Among 486 participants (median age = 27 years), 351 (72.42%) reported experiencing pelvic pain following initiation of testosterone therapy, described most commonly as in the suprapubic region and as "cramping." Median duration of testosterone therapy was 32 months. Persistent menstruation, current or previous history of post-traumatic stress disorder, and experiences of pain with orgasm were associated with higher odds of pelvic pain after testosterone therapy. No association was observed with genital dryness, intrauterine device use, previous pregnancy, penetrative sexual activities, touching external genitalia, or known diagnoses of endometriosis, vulvodynia, vaginismus, depression, anxiety, or obesity. Conclusions: Pelvic pain is frequently reported in trans people following initiation of testosterone therapy. Given the association with persistent menstruation and orgasm, as well as the known androgen sensitivity of the pelvic floor musculature, further research into pelvic floor muscle dysfunction as a contributor is warranted.

Pelvic pain in transmasculine adolescents receiving testosterone therapy

Background: Pelvic pain is a common complaint among individuals assigned female at birth. However, few studies have explored pelvic pain among transmasculine patients on gender-affirming testosterone treatment, and most of these were performed in adult populations. Aims: The aim of our study was to investigate the prevalence, risk factors, nature and treatment of pelvic pain among trans adolescents on testosterone. Methods: A retrospective cohort study was performed on all trans adolescents started on gender-affirming testosterone treatment at our institution between 2007 and 2020. Results: Among 158 trans adolescents who were started on testosterone therapy and followed-up for at least six months, 37 (23.4%) reported pelvic pain, with a median interval between testosterone initiation and reported onset of pain of 1.6 months (range 0.3-6.4). The prevalence of pelvic pain was higher in patients who were receiving menstrual suppression (n = 36, 26.3%) compared to those who were not (n = 1, 4.8%), giving a risk difference of 21.5% (95% CI 9.8% to 33.2%, p = 0.028). The most common descriptive terms were "cramps" (n = 17, 45.9%) and "similar to previous period pain" (n = 8, 21.6%). A range of different pharmacological strategies were employed, including paracetamol, NSAIDs, danazol, norethisterone, medroxyprogesterone, etonogestrel implant, intra-uterine device, goserelin and pelvic floor physiotherapy, with variable outcomes. Conclusion: In conclusion, we report here - in what is to our knowledge the first time - the prevalence rate of pelvic pain in trans adolescents on gender-affirming testosterone treatment, and observe that a quarter of them described pelvic pain. Limitations of our study include its retrospective nature, which is likely to be associated with under-reporting of pelvic pain, and the limited documentation of the nature and likely causes of this pain within the medical records. Prospective longitudinal studies to better understand the nature, etiology and optimal management of testosterone-associated pelvic pain are therefore warranted.

The role of androgens in transgender medicine

Androgen therapy is the mainstay of treatment in female to male (FtM) transgender persons to increase testosterone levels, suppress oestrogens and treat gender dysphoria. Testosterone is widely used for male hypogonadism, but is comparatively under-investigated in FtM transgender persons. The aim of our study was to identify treatment and safety outcomes associated with testosterone use in transgender medicine. Androgens in FtM transgender persons are effective to lower voice frequency, increase facial hair-growth, and increase hematocrit and hemoglobin levels to adult male reference ranges. A 1.2-fold-3.7-fold higher rate of myocardial infarction has been reported retrospectively, compared to cisgender women. Blood pressure, glycaemic control and body mass index remained unchanged in FtM transgender persons. Androgens in FtM transgender persons have important cardio-metabolic implications. Randomised control trials, longer follow-up periods and studies involving older persons may further improve the management of FtM transgender persons.

A case of endometrial intraepithelial neoplasia in a transgender man on testosterone therapy

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Reports of endometrial cancer in transmasculine individuals taking testosterone are rare.

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The relationship between testosterone therapy and endometrial cancer requires further study.

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Studies of hormone receptor positive cancers are needed to assess the prevalence of and risk factors for gynecologic cancers in transmasculine individuals on testosterone therapy.

Testosterone is commonly used as gender-affirming therapy to induce masculinization in transmasculine individuals. The effects of testosterone therapy on endometrial tissue are complex, and while some patients experience endometrial atrophy while taking testosterone, others do not. Reports of gynecologic malignancies, and endometrial cancer in particular, in transmasculine patients taking testosterone are extremely rare (Urban et al., May 2011, Jeevananthan and Iyengar, 2021, Agnieszka Bobola, 2021). Here we report a case of endometrial intraepithelial neoplasia in a transgender man taking testosterone.

Assessing Fertility Intentions in Patients Presenting for Gender-Affirming Surgery

Purpose: For some transgender and gender-diverse (TGD) individuals, gender-affirming surgery may represent the last opportunity to engage in gamete banking (GB) and other forms of fertility preservation (FP). Previous research has assessed fertility intentions among TGD people initiating hormone therapy. The objective of this study was to describe the fertility intentions of patients seeking gender-affirming surgery. Methods: A retrospective chart review was conducted for 233 patients seeking chest or genital surgery between 2017 and 2019. Data abstracted included interest in having children (biological or non-biological) and GB, and barriers to FP. Associations between fertility intentions, sex assigned at birth, and surgical procedure sought were assessed. Results: Of the 233 records reviewed, 162 (70%) documented information about fertility intentions for patients without a history of sterilizing surgery. At initial consultation, 94% were receiving hormone therapy. Among the 60 patients seeking genital surgery, 30% expressed interest in GB and 38% were not interested in biological children. Among the 102 patients seeking chest surgery, 11% expressed interest in GB and 47% were not interested in biological children. Patients assigned male at birth were more likely to have already completed GB (p < 0.001). Among the patients interested in FP, 41% reported barriers to access. Conclusion: Many TGD people in our study expressed no interest in biological parenthood; however, 30% of patients seeking genital surgery expressed interest in GB. This suggests that some who defer FP when starting hormones may wish to pursue it later in life. Ongoing assessment of fertility intentions and reducing barriers to FP are integral to caring for TGD people.

Gender-affirming hormone therapy: An updated literature review with an eye on the future

In line with increasing numbers of transgender (trans) and gender nonbinary people requesting hormone treatment, the body of available research is expanding. More clinical research groups are presenting data, and the numbers of participants in these studies are rising. Many previous review papers have focused on all available data, as these were scarce, but a more recent literature review is timely. Hormonal regimens have changed over time, and older data may be less relevant for today's practice. In recent literature, we have found that even though mental health problems are more prevalent in trans people compared to cisgender people, less psychological difficulties occur, and life satisfaction increases with gender-affirming hormone treatment (GAHT) for those who feel this is a necessity. With GAHT, body composition and contours change towards the affirmed sex. Studies in bone health are reassuring, but special attention is needed for adolescent and adult trans women, aiming at adequate dosage of hormonal supplementation and stimulating therapy compliance. Existing epidemiological data suggest that the use of (certain) estrogens in trans women induces an increased risk of myocardial infarction and stroke, the reason that lifestyle management can be an integral part of trans health care. The observed cancer risk in trans people does not exceed the known cancer-risk differences between men and women. Now it is time to integrate the mostly reassuring data, to leave the overly cautious approach behind, to not copy the same research questions repeatedly, and to focus on longer follow-up data with larger cohorts.

Executive Summary of the Uterine Cancer Evidence Review Conference

Evidence for uterine cancer prevention, diagnosis, and special issues from the Uterine Cancer Evidence Review Conference is summarized.

The Centers for Disease Control and Prevention recognized the need for educational materials for clinicians on the prevention and early diagnosis of gynecologic cancers. The American College of Obstetricians and Gynecologists convened a panel of experts in evidence review from the Society for Academic Specialists in General Obstetrics and Gynecology and content experts from the Society of Gynecologic Oncology to review relevant literature, best practices, and existing practice guidelines as a first step toward developing evidence-based educational materials for women's health care clinicians about uterine cancer. Panel members conducted structured literature reviews, which were then reviewed by other panel members and discussed at a virtual meeting of stakeholder professional and patient advocacy organizations in January 2021. This article is the evidence summary of the relevant literature and existing recommendations to guide clinicians in the prevention, early diagnosis, and special considerations of uterine cancer. Substantive knowledge gaps are noted and summarized to provide guidance for future research.

The uterus in transgender males

Transgender males experience a disharmony between their birth sex and their intimate sense of gender belonging. Gender-affirming hormone therapy and gender-affirming surgery (GAS) are often inherently part of the gender-affirming process. In this context, we should ask whether it is better to keep or remove the uterus. Keeping the uterus and ovaries avoids a surgical procedure and a pubic scar that often results and preserves fertility and the possibility of carrying a baby. On the other hand, keeping the uterus is often psychologically unbearable for transgender males and the long-term effects of androgens on the uterus and ovaries remain uncertain. Conversely, hysterectomy and oophorectomy as part of the GAS process are part of gender reassignment. New mini-invasive surgery procedures for hysterectomies decrease the risks and limit the likelihood of scars to a minimum. In practice, the data suggest that very few transgender males carry a pregnancy and/or use their oocytes after gender-reaffirming treatment. Clinicians should counsel their transgender male patients on the definitive infertility consequences of hysterectomy and oophorectomy and discuss fertility preservation options before GAS. Individualized approaches must be preferred to systematic procedures regarding the personal decision to keep or not keep the uterus and ovaries.