The Comparison of Gender Dysphoria, Body Image Satisfaction and Quality of Life Between Treatment-Naive Transgender Males With and Without Polycystic Ovary Syndrome

Androgen receptor expression in recurrent granulosa cell tumor of the ovary: Clinical considerations of treatment and surveillance in a transgender male

Granulosa cell tumors (GCT) represent a rare subtype of ovarian cancers. A majority of these tumors express androgen receptor (AR), making them hormonally sensitive. AR positivity not only suggests a potential role of anti-androgen therapy in treating these tumors but also poses a cause for concern: female to male (FTM) transgender patients undergoing exogenous testosterone therapy may be at risk for recurrence, progression, or even incidence of this type of cancer. Although treatment of GCT in transgender individuals has not been well-described, the impact of exogenous hormone use on cancer physiology and treatment should be considered, while also addressing gender dysphoria throughout treatment and in surveillance. Here, we describe a FTM transgender patient with recurrent AR-positive adult granulosa cell tumor after starting testosterone supplementation, along with a literature review to explore the current knowledge of ovarian changes observed following FTM gender transition and subsequent risk of ovarian cancer.

Androgen Inhibition of Reproductive Neuroendocrine Function in Females and Transgender Males

Ovarian function is controlled by pituitary secretion of luteinizing hormone (LH) and follicle stimulating hormone (FSH), which in turn are governed by gonadotropin releasing hormone (GnRH) secreted from the brain. A fundamental principle of reproductive axis regulation is negative feedback signaling by gonadal sex steroids back to the brain to fine-tune GnRH and gonadotropin secretion. Endogenous negative feedback effects can be mimicked by exogenous steroid treatments, including androgens, in both sexes. Indeed, a growing number of clinical and animal studies indicate that high levels of exogenous androgens, in the typically male physiological range, can inhibit LH secretion in females, as occurs in males. However, the mechanisms by which male-level androgens inhibit GnRH and LH secretion still remain poorly understood, and this knowledge gap is particularly pronounced in transgender men (individuals designated female at birth but identifying as male). Indeed, many transgender men take long-term gender-affirming hormone therapy that mimics male-level testosterone levels. The impact of such gender-affirming testosterone on the reproductive axis, both at the ovarian and neuroendocrine level, is a long-understudied area that still requires further investigation. Importantly, the few concepts of androgen actions in females mostly come from studies of polycystic ovary syndrome, which does not recapitulate a similar androgen milieu or a pathophysiology of inhibited LH secretion as occurs in testosterone-treated transgender men. This review summarizes clinical evidence indicating that exogenous androgens can impair neuroendocrine reproductive function in both female individuals and transgender men and highlights emerging experimental data supporting this in recently developed transgender rodent models.

The prevalence, phenotype and cardiometabolic risk of polycystic ovary syndrome in treatment-naïve transgender people assigned female at birth

PURPOSE

Polycystic ovary syndrome (PCOS) is the most common endocrine disorder among women of reproductive age. We aimed to investigate the prevalence and phenotypic characteristics of PCOS in testosterone treatment-naïve transgender people assigned female at birth (AFAB), as well as to determine whether cardiometabolic risk factors vary based on the presence of PCOS and its components.

METHODS

Evaluation of 112 testosterone treatment-naïve transgender adults AFAB for PCOS and its individual components, including androgen excess, ovulatory dysfunction and polycystic ovarian morphology (PCOM).

RESULTS

In our cohort, 79.5% of transgender individuals AFAB had at least one component of PCOS. The prevalence of PCOS was 38.4% (43/112). Phenotype C was the most common phenotype (17.8%), followed by phenotype B (10.7%). Transgender individuals AFAB with at least one component of PCOS had higher blood pressure (BP) measurements and higher fasting plasma glucose levels compared to those with none. Sixty-one subjects (54%) had hyperandrogenism (HA), with 20 (17.9%) having HA without other components of PCOS. When compared to those without HA, transgender individuals AFAB with HA had higher body mass index (BMI), BP, triglyceride and lower HDL-cholesterol levels.

CONCLUSION

PCOS and androgen excess appear to be prevalent among transgender people AFAB. Transgender individuals AFAB with HA or PCOS may exhibit an unfavorable cardiometabolic risk profile compared to those without any PCOS component. Assessment of androgen excess and the specific components of PCOS at baseline could inform long-term management.

Standards of Care for the Health of Transgender and Gender Diverse People, Version 8

Background: Transgender healthcare is a rapidly evolving interdisciplinary field. In the last decade, there has been an unprecedented increase in the number and visibility of transgender and gender diverse (TGD) people seeking support and gender-affirming medical treatment in parallel with a significant rise in the scientific literature in this area. The World Professional Association for Transgender Health (WPATH) is an international, multidisciplinary, professional association whose mission is to promote evidence-based care, education, research, public policy, and respect in transgender health. One of the main functions of WPATH is to promote the highest standards of health care for TGD people through the Standards of Care (SOC). The SOC was initially developed in 1979 and the last version (SOC-7) was published in 2012. In view of the increasing scientific evidence, WPATH commissioned a new version of the Standards of Care, the SOC-8. Aim: The overall goal of SOC-8 is to provide health care professionals (HCPs) with clinical guidance to assist TGD people in accessing safe and effective pathways to achieving lasting personal comfort with their gendered selves with the aim of optimizing their overall physical health, psychological well-being, and self-fulfillment. Methods: The SOC-8 is based on the best available science and expert professional consensus in transgender health. International professionals and stakeholders were selected to serve on the SOC-8 committee. Recommendation statements were developed based on data derived from independent systematic literature reviews, where available, background reviews and expert opinions. Grading of recommendations was based on the available evidence supporting interventions, a discussion of risks and harms, as well as the feasibility and acceptability within different contexts and country settings. Results: A total of 18 chapters were developed as part of the SOC-8. They contain recommendations for health care professionals who provide care and treatment for TGD people. Each of the recommendations is followed by explanatory text with relevant references. General areas related to transgender health are covered in the chapters Terminology, Global Applicability, Population Estimates, and Education. The chapters developed for the diverse population of TGD people include Assessment of Adults, Adolescents, Children, Nonbinary, Eunuchs, and Intersex Individuals, and people living in Institutional Environments. Finally, the chapters related to gender-affirming treatment are Hormone Therapy, Surgery and Postoperative Care, Voice and Communication, Primary Care, Reproductive Health, Sexual Health, and Mental Health. Conclusions: The SOC-8 guidelines are intended to be flexible to meet the diverse health care needs of TGD people globally. While adaptable, they offer standards for promoting optimal health care and guidance for the treatment of people experiencing gender incongruence. As in all previous versions of the SOC, the criteria set forth in this document for gender-affirming medical interventions are clinical guidelines; individual health care professionals and programs may modify these in consultation with the TGD person.