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Shepherd R, Angus LM, Mansell T, Arman B, Kim BW, Lange K, Burgner D, Kerr JA, Pang K, Zajac JD, Saffery R, Cheung A, Novakovic B. Impact of Distinct Antiandrogen Exposures on the Plasma Metabolome in Feminizing Gender-affirming Hormone Therapy. J Clin Endocrinol Metab 2024; 109:2857-2871. [PMID: 38609170 PMCID: PMC11479691 DOI: 10.1210/clinem/dgae226] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2023] [Revised: 02/06/2024] [Accepted: 04/04/2024] [Indexed: 04/14/2024]
Abstract
CONTEXT The plasma metabolome is a functional readout of metabolic activity and is associated with phenotypes exhibiting sexual dimorphism, such as cardiovascular disease. Sex hormones are thought to play a key role in driving sexual dimorphism. OBJECTIVE Gender-affirming hormone therapy (GAHT) is a cornerstone of transgender care, but longitudinal changes in the plasma metabolome with feminizing GAHT have not been described. METHODS Blood samples were collected at baseline and after 3 and 6 months of GAHT from transgender women (n = 53). Participants were randomized to different anti-androgens, cyproterone acetate or spironolactone. Nuclear magnetic resonance-based metabolomics was used to measure 249 metabolic biomarkers in plasma. Additionally, we used metabolic biomarker data from an unrelated cohort of children and their parents (n = 3748) to identify sex- and age-related metabolite patterns. RESULTS We identified 43 metabolic biomarkers altered after 6 months in both anti-androgen groups, most belonging to the very low- or low-density lipoprotein subclasses, with all but 1 showing a decrease. We observed a cyproterone acetate-specific decrease in glutamine, glycine, and alanine levels. Notably, of the metabolic biomarkers exhibiting the most abundant "sex- and age-related" pattern (higher in assigned female children and lower in assigned female adults, relative to assigned males), 80% were significantly lowered after GAHT, reflecting a shift toward the adult female profile. CONCLUSION Our results suggest an anti-atherogenic signature in the plasma metabolome after the first 6 months of feminizing GAHT, with cyproterone acetate also reducing specific plasma amino acids. This study provides novel insight into the metabolic changes occurring across feminizing GAHT.
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Affiliation(s)
- Rebecca Shepherd
- Molecular Immunity, Infection and Immunity Theme, Murdoch Children's Research Institute, Royal Children's Hospital, Parkville, VIC 3052, Australia
| | - Lachlan M Angus
- Department of Medicine (Austin Health), The University of Melbourne, Parkville, VIC 3052, Australia
- Department of Endocrinology, Austin Health, Heidelberg, VIC 3084, Australia
| | - Toby Mansell
- Department of Paediatrics, The University of Melbourne, Parkville, VIC 3052, Australia
- Inflammatory Origins, Infection and Immunity Theme, Murdoch Children's Research Institute, Royal Children's Hospital, Parkville, VIC 3052, Australia
| | - Bridget Arman
- Therapeutics Discovery and Vascular Function Group, Department of Obstetrics and Gynaecology, University of Melbourne, Mercy Hospital for Women, Heidelberg, VIC 3084, Australia
- Mercy Perinatal, Mercy Hospital for Women, Heidelberg, VIC 3084, Australia
- Department of Obstetrics and Gynaecology, University of Melbourne, Mercy Hospital for Women, Heidelberg, VIC 3084, Australia
| | - Bo Won Kim
- Molecular Immunity, Infection and Immunity Theme, Murdoch Children's Research Institute, Royal Children's Hospital, Parkville, VIC 3052, Australia
- Department of Paediatrics, The University of Melbourne, Parkville, VIC 3052, Australia
| | - Katherine Lange
- Department of Paediatrics, The University of Melbourne, Parkville, VIC 3052, Australia
- The Centre for Community Child Health, Murdoch Children's Research Institute, Royal Children's Hospital, Parkville, VIC 3052, Australia
| | - David Burgner
- Department of Paediatrics, The University of Melbourne, Parkville, VIC 3052, Australia
- Inflammatory Origins, Infection and Immunity Theme, Murdoch Children's Research Institute, Royal Children's Hospital, Parkville, VIC 3052, Australia
| | - Jessica A Kerr
- Department of Paediatrics, The University of Melbourne, Parkville, VIC 3052, Australia
- Department of Psychological Medicine, University of Otago, Christchurch 8011, New Zealand
- Murdoch Children's Research Institute, Centre for Adolescent Health, Population Health Theme, Parkville, VIC 3052, Australia
- Department of Paediatrics, University of Melbourne, Parkville, VIC 3052, Australia
| | - Ken Pang
- Brain and Mind Research, Murdoch Children's Research Institute, Royal Children's Hospital, Parkville, VIC 3052, Australia
- Department of Adolescent Medicine, Royal Children's Hospital, Parkville, VIC 3052, Australia
| | - Jeffrey D Zajac
- Department of Medicine (Austin Health), The University of Melbourne, Parkville, VIC 3052, Australia
- Department of Endocrinology, Austin Health, Heidelberg, VIC 3084, Australia
| | - Richard Saffery
- Molecular Immunity, Infection and Immunity Theme, Murdoch Children's Research Institute, Royal Children's Hospital, Parkville, VIC 3052, Australia
- Department of Paediatrics, The University of Melbourne, Parkville, VIC 3052, Australia
| | - Ada Cheung
- Department of Medicine (Austin Health), The University of Melbourne, Parkville, VIC 3052, Australia
- Department of Endocrinology, Austin Health, Heidelberg, VIC 3084, Australia
| | - Boris Novakovic
- Molecular Immunity, Infection and Immunity Theme, Murdoch Children's Research Institute, Royal Children's Hospital, Parkville, VIC 3052, Australia
- Department of Paediatrics, The University of Melbourne, Parkville, VIC 3052, Australia
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Zeigler G, Harrington CA, Rosendale N, Ganos C, Roldan V, Pace A, Alick-Lindstrom S, Orozco-Poore C, Deeb W, Hansen ML, L'Erario ZP. Neurologic Care for Transgender and Gender-Diverse People: A Review of Current Evidence and Clinical Implications. Neurol Clin Pract 2024; 14:e200332. [PMID: 38919931 PMCID: PMC11195436 DOI: 10.1212/cpj.0000000000200332] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2024] [Accepted: 04/11/2024] [Indexed: 06/27/2024]
Abstract
Purpose of Review To summarize the literature on neurologic care for transgender and gender-diverse (TGD) people and provide implications for clinical practice. Recent Findings There are limited data on the frequency and management of neurologic conditions among TGD people. TGD people have a higher prevalence of various neurologic conditions compared with cisgender or general population cohorts, including migraine, subjective cognitive decline, sleep disturbances, functional disorders, and cerebrovascular disease. Gender-affirming hormone therapy interacts with commonly prescribed neurologic medications and increases stroke risk among transfeminine people. Sex hormones and sex chromosomes may play a role in neurodegeneration and disability progression in neuroimmunologic diseases. Clitoral reduction surgeries on intersex children can cause neurologic disability and sexual dysfunction in adulthood. Socioeconomic disparities among TGD people contribute to health care barriers. Summary Neurologists should consider the unique experiences and health care needs of TGD people in their clinical practice and research protocols.
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Affiliation(s)
- Gwen Zeigler
- Department of Neurology (GZ), Albany Medical College, NY; Department of Neurology (CAH), The Ohio State University College of Medicine, Columbus; Department of Neurology and Weill Institute for Neurosciences (NR), University of California San Francisco; Movement Disorder Clinic (CG), Edmond J. Safra Program in Parkinson's Disease, Division of Neurology, University of Toronto, Toronto Western Hospital, Ontario, Canada; Facultad de Medicina Alberto Hurtado (VR), Universidad Peruana Cayetano Heredia, Lima, Peru; Department of Neurology (AP), Icahn School of Medicine at Mount Sinai, New York, NY; Department of Neurology (SA-L), University of Texas Southwestern Medical Center, Dallas; Department of Pediatric Neurology (CO-P), University of California, Los Angeles; Department of Neurology (WD), UMass Memorial Medical Center and UMass Medical School, Worcester; The Ohio State University Wexner Medical Center (MLH), Columbus; Greenburgh Pride (ZPLE), Westchester, NY
| | - Cole A Harrington
- Department of Neurology (GZ), Albany Medical College, NY; Department of Neurology (CAH), The Ohio State University College of Medicine, Columbus; Department of Neurology and Weill Institute for Neurosciences (NR), University of California San Francisco; Movement Disorder Clinic (CG), Edmond J. Safra Program in Parkinson's Disease, Division of Neurology, University of Toronto, Toronto Western Hospital, Ontario, Canada; Facultad de Medicina Alberto Hurtado (VR), Universidad Peruana Cayetano Heredia, Lima, Peru; Department of Neurology (AP), Icahn School of Medicine at Mount Sinai, New York, NY; Department of Neurology (SA-L), University of Texas Southwestern Medical Center, Dallas; Department of Pediatric Neurology (CO-P), University of California, Los Angeles; Department of Neurology (WD), UMass Memorial Medical Center and UMass Medical School, Worcester; The Ohio State University Wexner Medical Center (MLH), Columbus; Greenburgh Pride (ZPLE), Westchester, NY
| | - Nicole Rosendale
- Department of Neurology (GZ), Albany Medical College, NY; Department of Neurology (CAH), The Ohio State University College of Medicine, Columbus; Department of Neurology and Weill Institute for Neurosciences (NR), University of California San Francisco; Movement Disorder Clinic (CG), Edmond J. Safra Program in Parkinson's Disease, Division of Neurology, University of Toronto, Toronto Western Hospital, Ontario, Canada; Facultad de Medicina Alberto Hurtado (VR), Universidad Peruana Cayetano Heredia, Lima, Peru; Department of Neurology (AP), Icahn School of Medicine at Mount Sinai, New York, NY; Department of Neurology (SA-L), University of Texas Southwestern Medical Center, Dallas; Department of Pediatric Neurology (CO-P), University of California, Los Angeles; Department of Neurology (WD), UMass Memorial Medical Center and UMass Medical School, Worcester; The Ohio State University Wexner Medical Center (MLH), Columbus; Greenburgh Pride (ZPLE), Westchester, NY
| | - Christos Ganos
- Department of Neurology (GZ), Albany Medical College, NY; Department of Neurology (CAH), The Ohio State University College of Medicine, Columbus; Department of Neurology and Weill Institute for Neurosciences (NR), University of California San Francisco; Movement Disorder Clinic (CG), Edmond J. Safra Program in Parkinson's Disease, Division of Neurology, University of Toronto, Toronto Western Hospital, Ontario, Canada; Facultad de Medicina Alberto Hurtado (VR), Universidad Peruana Cayetano Heredia, Lima, Peru; Department of Neurology (AP), Icahn School of Medicine at Mount Sinai, New York, NY; Department of Neurology (SA-L), University of Texas Southwestern Medical Center, Dallas; Department of Pediatric Neurology (CO-P), University of California, Los Angeles; Department of Neurology (WD), UMass Memorial Medical Center and UMass Medical School, Worcester; The Ohio State University Wexner Medical Center (MLH), Columbus; Greenburgh Pride (ZPLE), Westchester, NY
| | - Valeria Roldan
- Department of Neurology (GZ), Albany Medical College, NY; Department of Neurology (CAH), The Ohio State University College of Medicine, Columbus; Department of Neurology and Weill Institute for Neurosciences (NR), University of California San Francisco; Movement Disorder Clinic (CG), Edmond J. Safra Program in Parkinson's Disease, Division of Neurology, University of Toronto, Toronto Western Hospital, Ontario, Canada; Facultad de Medicina Alberto Hurtado (VR), Universidad Peruana Cayetano Heredia, Lima, Peru; Department of Neurology (AP), Icahn School of Medicine at Mount Sinai, New York, NY; Department of Neurology (SA-L), University of Texas Southwestern Medical Center, Dallas; Department of Pediatric Neurology (CO-P), University of California, Los Angeles; Department of Neurology (WD), UMass Memorial Medical Center and UMass Medical School, Worcester; The Ohio State University Wexner Medical Center (MLH), Columbus; Greenburgh Pride (ZPLE), Westchester, NY
| | - Anna Pace
- Department of Neurology (GZ), Albany Medical College, NY; Department of Neurology (CAH), The Ohio State University College of Medicine, Columbus; Department of Neurology and Weill Institute for Neurosciences (NR), University of California San Francisco; Movement Disorder Clinic (CG), Edmond J. Safra Program in Parkinson's Disease, Division of Neurology, University of Toronto, Toronto Western Hospital, Ontario, Canada; Facultad de Medicina Alberto Hurtado (VR), Universidad Peruana Cayetano Heredia, Lima, Peru; Department of Neurology (AP), Icahn School of Medicine at Mount Sinai, New York, NY; Department of Neurology (SA-L), University of Texas Southwestern Medical Center, Dallas; Department of Pediatric Neurology (CO-P), University of California, Los Angeles; Department of Neurology (WD), UMass Memorial Medical Center and UMass Medical School, Worcester; The Ohio State University Wexner Medical Center (MLH), Columbus; Greenburgh Pride (ZPLE), Westchester, NY
| | - Sasha Alick-Lindstrom
- Department of Neurology (GZ), Albany Medical College, NY; Department of Neurology (CAH), The Ohio State University College of Medicine, Columbus; Department of Neurology and Weill Institute for Neurosciences (NR), University of California San Francisco; Movement Disorder Clinic (CG), Edmond J. Safra Program in Parkinson's Disease, Division of Neurology, University of Toronto, Toronto Western Hospital, Ontario, Canada; Facultad de Medicina Alberto Hurtado (VR), Universidad Peruana Cayetano Heredia, Lima, Peru; Department of Neurology (AP), Icahn School of Medicine at Mount Sinai, New York, NY; Department of Neurology (SA-L), University of Texas Southwestern Medical Center, Dallas; Department of Pediatric Neurology (CO-P), University of California, Los Angeles; Department of Neurology (WD), UMass Memorial Medical Center and UMass Medical School, Worcester; The Ohio State University Wexner Medical Center (MLH), Columbus; Greenburgh Pride (ZPLE), Westchester, NY
| | - Casey Orozco-Poore
- Department of Neurology (GZ), Albany Medical College, NY; Department of Neurology (CAH), The Ohio State University College of Medicine, Columbus; Department of Neurology and Weill Institute for Neurosciences (NR), University of California San Francisco; Movement Disorder Clinic (CG), Edmond J. Safra Program in Parkinson's Disease, Division of Neurology, University of Toronto, Toronto Western Hospital, Ontario, Canada; Facultad de Medicina Alberto Hurtado (VR), Universidad Peruana Cayetano Heredia, Lima, Peru; Department of Neurology (AP), Icahn School of Medicine at Mount Sinai, New York, NY; Department of Neurology (SA-L), University of Texas Southwestern Medical Center, Dallas; Department of Pediatric Neurology (CO-P), University of California, Los Angeles; Department of Neurology (WD), UMass Memorial Medical Center and UMass Medical School, Worcester; The Ohio State University Wexner Medical Center (MLH), Columbus; Greenburgh Pride (ZPLE), Westchester, NY
| | - Wissam Deeb
- Department of Neurology (GZ), Albany Medical College, NY; Department of Neurology (CAH), The Ohio State University College of Medicine, Columbus; Department of Neurology and Weill Institute for Neurosciences (NR), University of California San Francisco; Movement Disorder Clinic (CG), Edmond J. Safra Program in Parkinson's Disease, Division of Neurology, University of Toronto, Toronto Western Hospital, Ontario, Canada; Facultad de Medicina Alberto Hurtado (VR), Universidad Peruana Cayetano Heredia, Lima, Peru; Department of Neurology (AP), Icahn School of Medicine at Mount Sinai, New York, NY; Department of Neurology (SA-L), University of Texas Southwestern Medical Center, Dallas; Department of Pediatric Neurology (CO-P), University of California, Los Angeles; Department of Neurology (WD), UMass Memorial Medical Center and UMass Medical School, Worcester; The Ohio State University Wexner Medical Center (MLH), Columbus; Greenburgh Pride (ZPLE), Westchester, NY
| | - Margaret L Hansen
- Department of Neurology (GZ), Albany Medical College, NY; Department of Neurology (CAH), The Ohio State University College of Medicine, Columbus; Department of Neurology and Weill Institute for Neurosciences (NR), University of California San Francisco; Movement Disorder Clinic (CG), Edmond J. Safra Program in Parkinson's Disease, Division of Neurology, University of Toronto, Toronto Western Hospital, Ontario, Canada; Facultad de Medicina Alberto Hurtado (VR), Universidad Peruana Cayetano Heredia, Lima, Peru; Department of Neurology (AP), Icahn School of Medicine at Mount Sinai, New York, NY; Department of Neurology (SA-L), University of Texas Southwestern Medical Center, Dallas; Department of Pediatric Neurology (CO-P), University of California, Los Angeles; Department of Neurology (WD), UMass Memorial Medical Center and UMass Medical School, Worcester; The Ohio State University Wexner Medical Center (MLH), Columbus; Greenburgh Pride (ZPLE), Westchester, NY
| | - Z Paige L'Erario
- Department of Neurology (GZ), Albany Medical College, NY; Department of Neurology (CAH), The Ohio State University College of Medicine, Columbus; Department of Neurology and Weill Institute for Neurosciences (NR), University of California San Francisco; Movement Disorder Clinic (CG), Edmond J. Safra Program in Parkinson's Disease, Division of Neurology, University of Toronto, Toronto Western Hospital, Ontario, Canada; Facultad de Medicina Alberto Hurtado (VR), Universidad Peruana Cayetano Heredia, Lima, Peru; Department of Neurology (AP), Icahn School of Medicine at Mount Sinai, New York, NY; Department of Neurology (SA-L), University of Texas Southwestern Medical Center, Dallas; Department of Pediatric Neurology (CO-P), University of California, Los Angeles; Department of Neurology (WD), UMass Memorial Medical Center and UMass Medical School, Worcester; The Ohio State University Wexner Medical Center (MLH), Columbus; Greenburgh Pride (ZPLE), Westchester, NY
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3
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Balcerek MI, Hovelroud R, Ruhl M, Nolan BJ. Giant Intracranial Meningiomas Requiring Surgery in 2 Transgender Women Treated With Cyproterone Acetate. JCEM CASE REPORTS 2024; 2:luae173. [PMID: 39416271 PMCID: PMC11482003 DOI: 10.1210/jcemcr/luae173] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/16/2024] [Indexed: 10/19/2024]
Abstract
Progestin-associated meningioma is a rare complication of cyproterone acetate (CPA), an anti-androgen commonly prescribed in feminizing hormone therapy regimens for transgender and gender-diverse individuals. A dose-response association has been observed, particularly with longer-term exposure to doses ≥ 50 mg daily; however, the dose below which CPA use is safe remains unclear. We herein report the cases of 2 transgender women using CPA who developed meningioma. Novel aspects of our cases include: (i) the presence of symptomatic giant meningiomas (> 5 cm), including multiple meningiomas in one patient, requiring urgent surgical intervention; (ii) meningioma development with both high-dose, long duration and low-dose, shorter duration CPA; and (iii) the presence of a PIK3CA missense variant in one patient, which may play a role in the pathogenesis of progestin-associated meningioma. Our cases highlight the real-world risk of this likely underreported adverse effect and underscore the importance of clinician vigilance for neurological sequelae. We suggest using the lowest dose of CPA that maintains adequate androgen suppression, with consideration of alternative anti-androgens where appropriate.
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Affiliation(s)
- Matthew I Balcerek
- Department of Endocrinology and Diabetes, Royal Brisbane and Women's Hospital, Herston, QLD 4029, Australia
- Faculty of Medicine, Royal Brisbane Clinical Unit, The University of Queensland, Herston, QLD 4029, Australia
| | - Rachel Hovelroud
- Department of Diabetes and Endocrinology, Townsville University Hospital, Townsville, QLD 4817, Australia
| | - Matthew Ruhl
- Department of Chemical Pathology, Pathology Queensland, Herston, QLD 4029, Australia
| | - Brendan J Nolan
- Department of Diabetes and Endocrinology, Princess Alexandra Hospital, Woolloongabba, QLD 4102, Australia
- Trans Health Research Group, University of Melbourne, Parkville, VIC 3052, Australia
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4
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Sagar RC, Millson-Brown V. Gender-affirming hormone treatment modalities for transfemale & non-binary transfeminine individuals: A UK perspective. Best Pract Res Clin Endocrinol Metab 2024; 38:101921. [PMID: 39232976 DOI: 10.1016/j.beem.2024.101921] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/06/2024]
Abstract
Gender incongruence and the number of people seeking gender affirming hormone treatment has dramatically risen in the last two decades. In the UK, transgender women and non-binary transfeminine individuals are typically treated with simultaneous suppression of endogenous testosterone production through anti-androgens and exogenous oestradiol replacement. Oestrogen replacement comes in different forms and is primarily given as transdermal (gel or patch) or oral preparations in the UK. Decisions around preparation choice are based on a combination of individual preference and/or mitigating the chance of complications based on individual risk profiles. Time frames to achieve female physical changes are largely predictable and managing expectations of individuals prior to commencing treatment is highly important. Common complications include venous thromboembolism, liver dysfunction and effects on fertility, thus individuals should be thoroughly counselled prior to commencing treatment. This article provides an overview of the management and considerations of gender-affirming hormone treatment in transgender women and non-binary transfeminine individuals.
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Affiliation(s)
- Rebecca C Sagar
- Leeds Institute of Cardiovascular and Metabolic Medicine, School of Medicine, University of Leeds, LS2 9JT, United Kingdom
| | - Victoria Millson-Brown
- Gender Identity Service, The Newsam Centre, Seacroft Hospital, Leeds LS14 6UH, United Kingdom.
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Berner AM, Atkinson SE. The implications of hormone treatment for cancer risk, screening and treatment in transgender individuals. Best Pract Res Clin Endocrinol Metab 2024; 38:101909. [PMID: 38964988 DOI: 10.1016/j.beem.2024.101909] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/06/2024]
Abstract
There is evidence that gender-affirming hormone treatment (GAHT) for transgender individuals modulates their risk for specific malignancies including breast and prostate cancer, and meningiomas. However, there is insufficient data to make precise risk estimates accounting for age and inherited cancer risk. As such, screening recommendations remain broad. Even less evidence exists for best practice in the management of active or historical cancers in the transgender population. Guidance is therefore mainly extrapolated from cisgender populations but with considerations of the significant benefits of GAHT in the face of any hormonal risk. Clinical experience, the multidisciplinary team and shared decision making with the patient are vital in providing person-centred care, while further research is acquired.
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Affiliation(s)
- Alison May Berner
- Barts Cancer Institute, Queen Mary University of London, United Kingdom; Gender Identity Clinic London, Tavistock and Portman NHS Trust, United Kingdom.
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Korpaisarn S, Arunakul J, Chaisuksombat K, Rattananukrom T. Effectiveness of low dose cyproterone acetate compared to standard dose in feminizing hormone treatment: a single institutional retrospective pilot study. Sex Med 2024; 12:qfae063. [PMID: 39315307 PMCID: PMC11416909 DOI: 10.1093/sexmed/qfae063] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2024] [Revised: 07/30/2024] [Accepted: 09/03/2024] [Indexed: 09/25/2024] Open
Abstract
Background Data regarding the effectiveness of low-dose cyproterone acetate (CPA) in testosterone suppression as feminizing hormone therapy (FHT) in individuals assigned male at birth (AMAB) are sparse. Aim To assess the effectiveness in testosterone suppression using low-dose CPA (<25 mg/day) compared to standard-dose CPA (25-50 mg/day) in FHT. Methods A retrospective cohort study of 59 individuals AMAB using CPA was done at a tertiary care center in Bangkok, Thailand between January 2014 and July 2022. Outcomes The main outcomes included a median time when the testosterone was suppressed (<50 ng/dL), the proportion of individuals AMAB who achieved the targeted testosterone level at 3 months, and the testosterone level at each follow-up. Changes in clinical data were assessed. Results Among 59 individuals AMAB, 37 initiated CPA with available testosterone levels at the 3-month follow-up. Twenty-two individuals AMAB started with low-dose CPA (12.5 mg/day), and 15 individuals AMAB started with standard-dose CPA. The median time to reach targeted testosterone was 3 months in both groups (adjusted hazard ratio 0.60, P = .489). At 3 months, 72.7% of those on low-dose CPA and 86.7% of those on standard-dose CPA achieved targeted testosterone (adjusted relative risk 0.85, P = .606). Testosterone levels at all follow-up visits were not significantly different. The standard dose group had higher high-density lipoprotein cholesterol (HDL-C) but lower low-density lipoprotein cholesterol (LDL-C) and alanine aminotransferase (ALT). Clinical Translation This study supports a paradigm shift toward using lower-dose CPA in FHT. Strengths and Limitations This is one of a few studies showing the effectiveness of low-dose CPA in testosterone suppression within 3 months. Limitations include a small sample size and missing data. Conclusions Testosterone suppression is comparable between CPA 12.5 mg/day and the standard dose in FHT.
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Affiliation(s)
- Sira Korpaisarn
- Department of Medicine, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Ratchathewi, Bangkok 10400, Thailand
| | - Jiraporn Arunakul
- Department of Pediatric, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Ratchathewi, Bangkok 10400, Thailand
| | - Kewalin Chaisuksombat
- Department of Pediatric, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Ratchathewi, Bangkok 10400, Thailand
| | - Teerapong Rattananukrom
- Department of Medicine, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Ratchathewi, Bangkok 10400, Thailand
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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] [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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Heinen CS. Medical Management of Gender Diversity. Oral Maxillofac Surg Clin North Am 2024; 36:151-159. [PMID: 38281895 DOI: 10.1016/j.coms.2023.12.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2024]
Abstract
This article provides context on the experiences and medical care of individuals who experience gender dysphoria for the benefit of oral and maxillofacial surgeons. The mechanism of action, effects, and side effects of medical therapies used for gender-affirming care are reviewed. Specific guidance for anesthetic care is given. Trauma-informed tools for care of transgender and gender-diverse patients are offered.
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Affiliation(s)
- Corinne S Heinen
- Family Medicine and Internal Medicine, Division of Allergy and Infectious Disease, University of Washington, Seattle, WA, USA; Harborview Medical Center, 325 9th Avenue, Box 359930, Seattle, WA 98104, USA.
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9
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Volpe SG, Ahmad J, Patel RA, Rosendale N. Neurological care for LGBT+ people. Nat Rev Neurol 2024; 20:288-297. [PMID: 38499761 DOI: 10.1038/s41582-024-00944-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/19/2024] [Indexed: 03/20/2024]
Abstract
Sexual and gender minority (LGBT+) people face unique health disparities that must be considered by health-care providers to ensure equitable and inclusive care. Although traditionally LGBT+ health has not been integrated into neurology training, sexual orientation and gender identity have direct relevance to neurological health, driven by both systemic and interpersonal factors. In this Review, we summarize the evidence for associations between sexual orientation and gender identity with the prevalence and outcomes of various neurological conditions, including neurodegenerative diseases, epilepsy, stroke and neurodevelopmental disorders, among others. We describe important clinical considerations pertaining to LGBT+ people and recommend language and practices to promote inclusive care, as well as highlight gaps in need of further research and possible strategies to minimize these, including systematic collection of sexual orientation and gender identity and use of inclusive language.
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Affiliation(s)
| | - Joya Ahmad
- College of Medicine, SUNY Downstate Health Sciences University, New York City, NY, USA
| | - Roshni Abee Patel
- Neurology Service, Jesse Brown VA Medical Center, Chicago, IL, USA
- Department of Neurological Sciences, Rush University Medical Center, Chicago, IL, USA
| | - Nicole Rosendale
- Department of Neurology, University of California San Francisco, San Francisco, CA, USA.
- Weill Institute for Neurosciences, University of California San Francisco, San Francisco, CA, USA.
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10
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Roland N, Neumann A, Hoisnard L, Duranteau L, Froelich S, Zureik M, Weill A. Use of progestogens and the risk of intracranial meningioma: national case-control study. BMJ 2024; 384:e078078. [PMID: 38537944 PMCID: PMC10966896 DOI: 10.1136/bmj-2023-078078] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/22/2024] [Indexed: 04/06/2024]
Abstract
OBJECTIVE To assess the risk of intracranial meningioma associated with the use of selected progestogens. DESIGN National case-control study. SETTING French National Health Data System (ie, Système National des Données de Santé). PARTICIPANTS Of 108 366 women overall, 18 061 women living in France who had intracranial surgery for meningioma between 1 January 2009 and 31 December 2018 (restricted inclusion periods for intrauterine systems) were deemed to be in the case group. Each case was matched to five controls for year of birth and area of residence (90 305 controls). MAIN OUTCOME MEASURES Selected progestogens were used: progesterone, hydroxyprogesterone, dydrogesterone, medrogestone, medroxyprogesterone acetate, promegestone, dienogest, and intrauterine levonorgestrel. For each progestogen, use was defined by at least one dispensation within the year before the index date (within three years for 13.5 mg levonorgestrel intrauterine systems and five years for 52 mg). Conditional logistic regression was used to calculate odds ratio for each progestogen meningioma association. RESULTS Mean age was 57.6 years (standard deviation 12.8). Analyses showed excess risk of meningioma with use of medrogestone (42 exposed cases/18 061 cases (0.2%) v 79 exposed controls/90 305 controls (0.1%), odds ratio 3.49 (95% confidence interval 2.38 to 5.10)), medroxyprogesterone acetate (injectable, 9/18 061 (0.05%) v 11/90 305 (0.01%), 5.55 (2.27 to 13.56)), and promegestone (83/18 061 (0.5%) v 225/90 305 (0.2 %), 2.39 (1.85 to 3.09)). This excess risk was driven by prolonged use (≥one year). Results showed no excess risk of intracranial meningioma for progesterone, dydrogesterone, or levonorgestrel intrauterine systems. No conclusions could be drawn concerning dienogest or hydroxyprogesterone because of the small number of individuals who received these drugs. A highly increased risk of meningioma was observed for cyproterone acetate (891/18 061 (4.9%) v 256/90 305 (0.3%), odds ratio 19.21 (95% confidence interval 16.61 to 22.22)), nomegestrol acetate (925/18 061 (5.1%) v 1121/90 305 (1.2%), 4.93 (4.50 to 5.41)), and chlormadinone acetate (628/18 061 (3.5%) v 946/90 305 (1.0%), 3.87 (3.48 to 4.30)), which were used as positive controls for use. CONCLUSIONS Prolonged use of medrogestone, medroxyprogesterone acetate, and promegestone was found to increase the risk of intracranial meningioma. The increased risk associated with the use of injectable medroxyprogesterone acetate, a widely used contraceptive, and the safety of levonorgestrel intrauterine systems are important new findings.
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Affiliation(s)
- Noémie Roland
- EPI-PHARE Scientific Interest Group, French National Agency for Medicines and Health Products Safety, French National Health Insurance, Saint-Denis, France
| | - Anke Neumann
- EPI-PHARE Scientific Interest Group, French National Agency for Medicines and Health Products Safety, French National Health Insurance, Saint-Denis, France
| | - Léa Hoisnard
- EpiDermE Epidemiology in Dermatology and Evaluation of Therapeutics, EA7379, Paris Est Créteil University UPEC, Créteil, France
| | - Lise Duranteau
- Department of Medical Gynaecology, Bicêtre Hospital, Assistance Publique-Hôpitaux de Paris, Paris Saclay University, 94270, Le Kremlin-Bicêtre, France
| | - Sébastien Froelich
- Department of Neurosurgery, Lariboisière University Hospital, Paris-Cité University, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Mahmoud Zureik
- EPI-PHARE Scientific Interest Group, French National Agency for Medicines and Health Products Safety, French National Health Insurance, Saint-Denis, France
- University Versailles St-Quentin-en-Yvelines, Montigny le Bretonneux, France
| | - Alain Weill
- EPI-PHARE Scientific Interest Group, French National Agency for Medicines and Health Products Safety, French National Health Insurance, Saint-Denis, France
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11
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Tang J, Mou M, Zheng X, Yan J, Pan Z, Zhang J, Li B, Yang Q, Wang Y, Zhang Y, Gao J, Li S, Yang H, Zhu F. Strategy for Identifying a Robust Metabolomic Signature Reveals the Altered Lipid Metabolism in Pituitary Adenoma. Anal Chem 2024; 96:4745-4755. [PMID: 38417094 DOI: 10.1021/acs.analchem.3c03796] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/01/2024]
Abstract
Despite the well-established connection between systematic metabolic abnormalities and the pathophysiology of pituitary adenoma (PA), current metabolomic studies have reported an extremely limited number of metabolites associated with PA. Moreover, there was very little consistency in the identified metabolite signatures, resulting in a lack of robust metabolic biomarkers for the diagnosis and treatment of PA. Herein, we performed a global untargeted plasma metabolomic profiling on PA and identified a highly robust metabolomic signature based on a strategy. Specifically, this strategy is unique in (1) integrating repeated random sampling and a consensus evaluation-based feature selection algorithm and (2) evaluating the consistency of metabolomic signatures among different sample groups. This strategy demonstrated superior robustness and stronger discriminative ability compared with that of other feature selection methods including Student's t-test, partial least-squares-discriminant analysis, support vector machine recursive feature elimination, and random forest recursive feature elimination. More importantly, a highly robust metabolomic signature comprising 45 PA-specific differential metabolites was identified. Moreover, metabolite set enrichment analysis of these potential metabolic biomarkers revealed altered lipid metabolism in PA. In conclusion, our findings contribute to a better understanding of the metabolic changes in PA and may have implications for the development of diagnostic and therapeutic approaches targeting lipid metabolism in PA. We believe that the proposed strategy serves as a valuable tool for screening robust, discriminating metabolic features in the field of metabolomics.
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Affiliation(s)
- Jing Tang
- College of Pharmaceutical Sciences, The Second Affiliated Hospital, Zhejiang University School of Medicine, Zhejiang University, Hangzhou 310058, China
- Department of Bioinformatics, Chongqing Medical University, Chongqing 400016, China
| | - Minjie Mou
- College of Pharmaceutical Sciences, The Second Affiliated Hospital, Zhejiang University School of Medicine, Zhejiang University, Hangzhou 310058, China
| | - Xin Zheng
- Multidisciplinary Center for Pituitary Adenoma of Chongqing, Department of Neuosurgery, Xinqiao Hospital, Army Medical University, Chongqing 400037, China
| | - Jin Yan
- Multidisciplinary Center for Pituitary Adenoma of Chongqing, Department of Neuosurgery, Xinqiao Hospital, Army Medical University, Chongqing 400037, China
| | - Ziqi Pan
- College of Pharmaceutical Sciences, The Second Affiliated Hospital, Zhejiang University School of Medicine, Zhejiang University, Hangzhou 310058, China
| | - Jinsong Zhang
- College of Pharmaceutical Sciences, The Second Affiliated Hospital, Zhejiang University School of Medicine, Zhejiang University, Hangzhou 310058, China
| | - Bo Li
- School of Pharmaceutical Sciences, Chongqing University, Chongqing 401331, China
| | - Qingxia Yang
- School of Pharmaceutical Sciences, Chongqing University, Chongqing 401331, China
| | - Yunxia Wang
- College of Pharmaceutical Sciences, The Second Affiliated Hospital, Zhejiang University School of Medicine, Zhejiang University, Hangzhou 310058, China
| | - Ying Zhang
- College of Pharmaceutical Sciences, The Second Affiliated Hospital, Zhejiang University School of Medicine, Zhejiang University, Hangzhou 310058, China
| | - Jianqing Gao
- College of Pharmaceutical Sciences, The Second Affiliated Hospital, Zhejiang University School of Medicine, Zhejiang University, Hangzhou 310058, China
| | - Song Li
- Multidisciplinary Center for Pituitary Adenoma of Chongqing, Department of Neuosurgery, Xinqiao Hospital, Army Medical University, Chongqing 400037, China
| | - Hui Yang
- Multidisciplinary Center for Pituitary Adenoma of Chongqing, Department of Neuosurgery, Xinqiao Hospital, Army Medical University, Chongqing 400037, China
| | - Feng Zhu
- College of Pharmaceutical Sciences, The Second Affiliated Hospital, Zhejiang University School of Medicine, Zhejiang University, Hangzhou 310058, China
- Innovation Institute for Artificial Intelligence in Medicine of Zhejiang University, Alibaba-Zhejiang University Joint Research Center of Future Digital Healthcare, Hangzhou 330110, China
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12
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Zepf FD, König L, Kaiser A, Ligges C, Ligges M, Roessner V, Banaschewski T, Holtmann M. [Beyond NICE: Updated Systematic Review on the Current Evidence of Using Puberty Blocking Pharmacological Agents and Cross-Sex-Hormones in Minors with Gender Dysphoria]. ZEITSCHRIFT FUR KINDER- UND JUGENDPSYCHIATRIE UND PSYCHOTHERAPIE 2024; 52:167-187. [PMID: 38410090 DOI: 10.1024/1422-4917/a000972] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/28/2024]
Abstract
Beyond NICE: Updated Systematic Review on the Current Evidence of Using Puberty Blocking Pharmacological Agents and Cross-Sex-Hormones in Minors with Gender Dysphoria Abstract: Objective: The suppression of physiological puberty using puberty-blocking pharmacological agents (PB) and prescribing cross-sex hormones (CSH) to minors with gender dysphoria (GD) is a current matter of discussion, and in some cases, PB and CSH are used in clinical practice for this particular population. Two systematic reviews (one on PB, one on CSH treatment) by the British National Institute for Clinical Excellence (NICE) from 2020 indicated no clear clinical benefit of such treatments regarding critical outcome variables. In particular, these two systematic NICE reviews on the use of PB and CSH in minors with GD detected no clear improvements of GD symptoms. Moreover, the overall scientific quality of the available evidence, as discussed within the above-mentioned two NICE reviews, was classified as "very low certainty" regarding modified GRADE criteria. Method: The present systematic review presents an updated literature search on this particular topic (use of PB and CSH in minors with GD) following NICE principles and PICO criteria for all relevant new original research studies published since the release of the two above-mentioned NICE reviews (updated literature search period was July 2020-August 2023). Results: The newly conducted literature search revealed no newly published original studies targeting NICE-defined critical and important outcomes and the related use of PB in minors with GD following PICO criteria. For CSH treatment, we found two new studies that met PICO criteria, but these particular two studies had low participant numbers, yielded no significant additional clear evidence for specific and clearly beneficial effects of CSH in minors with GD, and could be classified as "low certainty" tfollowing modified GRADE criteria. Conclusions: The currently available studies on the use of PB and CSH in minors with GD have significant conceptual and methodological flaws. The available evidence on the use of PB and CSH in minors with GD is very limited and based on only a few studies with small numbers, and these studies have problematic methodology and quality. There also is a lack of adequate and meaningful long-term studies. Current evidence doesn't suggest that GD symptoms and mental health significantly improve when PB or CSH are used in minors with GD. Psychotherapeutic interventions to address and reduce the experienced burden can become relevant in children and adolescents with GD. If the decision to use PB and/or CSH is made on an individual case-by-case basis and after a complete and thorough mental health assessment, potential treatment of possibly co-occurring mental health problems as well as after a thoroughly conducted and carefully executed individual risk-benefit evaluation, doing so as part of clinical studies or research projects, as currently done in England, can be of value in terms of generation of new research data. The electronic supplement (ESM) 1 is an adapted and abreviated English version of this work.
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Affiliation(s)
- Florian D Zepf
- Department of Child and Adolescent Psychiatry, Psychosomatic Medicine and Psychotherapy, Jena University Hospital, Friedrich Schiller University Jena, Jena, Germany
- German Center for Mental Health (DZPG), Site Jena-Magdeburg-Halle, Jena, Germany
| | - Laura König
- Department of Child and Adolescent Psychiatry, Psychosomatic Medicine and Psychotherapy, Jena University Hospital, Friedrich Schiller University Jena, Jena, Germany
- German Center for Mental Health (DZPG), Site Jena-Magdeburg-Halle, Jena, Germany
| | - Anna Kaiser
- Central Institute of Mental Health, Medical Faculty Mannheim/Heidelberg University, Mannheim, Germany
| | - Carolin Ligges
- Department of Child and Adolescent Psychiatry, Psychosomatic Medicine and Psychotherapy, Jena University Hospital, Friedrich Schiller University Jena, Jena, Germany
- German Center for Mental Health (DZPG), Site Jena-Magdeburg-Halle, Jena, Germany
| | - Marc Ligges
- Department of Child and Adolescent Psychiatry, Psychosomatic Medicine and Psychotherapy, Jena University Hospital, Friedrich Schiller University Jena, Jena, Germany
- German Center for Mental Health (DZPG), Site Jena-Magdeburg-Halle, Jena, Germany
| | - Veit Roessner
- Department of Child and Adolescent Psychiatry, TU Dresden, Dresden, Germany
- German Center for Child and Adolescent Health (DZJK), partner site Leipzig-Dresden, Germany
| | - Tobias Banaschewski
- Central Institute of Mental Health, Medical Faculty Mannheim/Heidelberg University, Mannheim, Germany
- German Center for Mental Health (DZPG), partner site Mannheim-Heidelberg-Ulm, Germany
| | - Martin Holtmann
- LWL-Universitätsklinik Hamm der Ruhr-Universität Bochum, Hamm, Germany
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13
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Dzialach L, Sobolewska J, Zak Z, Respondek W, Witek P. Prolactin-secreting pituitary adenomas: male-specific differences in pathogenesis, clinical presentation and treatment. Front Endocrinol (Lausanne) 2024; 15:1338345. [PMID: 38370355 PMCID: PMC10870150 DOI: 10.3389/fendo.2024.1338345] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2023] [Accepted: 01/22/2024] [Indexed: 02/20/2024] Open
Abstract
Prolactinomas (PRLomas) constitute approximately half of all pituitary adenomas and approximately one-fifth of them are diagnosed in males. The clinical presentation of PRLomas results from direct prolactin (PRL) action, duration and severity of hyperprolactinemia, and tumor mass effect. Male PRLomas, compared to females, tend to be larger and more invasive, are associated with higher PRL concentration at diagnosis, present higher proliferative potential, are more frequently resistant to standard pharmacotherapy, and thus may require multimodal approach, including surgical resection, radiotherapy, and alternative medical agents. Therefore, the management of PRLomas in men is challenging in many cases. Additionally, hyperprolactinemia is associated with a significant negative impact on men's health, including sexual function and fertility potential, bone health, cardiovascular and metabolic complications, leading to decreased quality of life. In this review, we highlight the differences in pathogenesis, clinical presentation and treatment of PRLomas concerning the male sex.
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Affiliation(s)
- Lukasz Dzialach
- Department of Internal Medicine, Endocrinology and Diabetes, Medical University of Warsaw, Warsaw, Poland
| | - Joanna Sobolewska
- Department of Internal Medicine, Endocrinology and Diabetes, Medical University of Warsaw, Warsaw, Poland
| | - Zuzanna Zak
- Department of Internal Medicine, Endocrinology and Diabetes, Medical University of Warsaw, Warsaw, Poland
| | - Wioleta Respondek
- Department of Internal Medicine, Endocrinology and Diabetes, Mazovian Brodnowski Hospital, Warsaw, Poland
| | - Przemysław Witek
- Department of Internal Medicine, Endocrinology and Diabetes, Medical University of Warsaw, Warsaw, Poland
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14
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Leone AG, Casolino R, Trapani D, Miceli R, Massagrande M, Morano F, La Verde N, Dalu D, Berardi R, Marsoni S, Lambertini M, Iula B, Carieri E, Converti M, Di Maio M, Beretta GD, Perrone F, Pietrantonio F, Cinieri S. Position paper of the Italian association of medical oncology on health disparities among transgender and gender-diverse people: the Assisi recommendations. EClinicalMedicine 2023; 65:102277. [PMID: 37877000 PMCID: PMC10590834 DOI: 10.1016/j.eclinm.2023.102277] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/16/2023] [Revised: 09/28/2023] [Accepted: 10/02/2023] [Indexed: 10/26/2023] Open
Abstract
Transgender and gender-diverse individuals experience substantial health disparities across the cancer care continuum. Despite well recognized unique healthcare needs, there are barriers in accessing cancer prevention and treatment services, influenced by disadvantages in key social-economic determinants of health which result in worse clinical outcomes, as compared to the general population. The Italian Association of Medical Oncology (AIOM) acknowledges the critical relevance of this issue. The "Assisi Recommendations" here summarize the outcomes of the "AIOM Oncology Ethics Day" dedicated to gender differences in oncology and cancer care of transgender and gender-diverse people. The recommendations generated during a 2-day multidisciplinary discussion address the various aspects of cancer care experience of transgender and gender-diverse people. The promotion of research in this field, through the generation of new evidence and the collection of prospective data, has been identified as a priority action to mitigate these disparities. By acknowledging the challenges of cancer care in transgender and gender-diverse people and recognizing the need for dedicated policy and clinical recommendations, AIOM demonstrates its commitment to improving the health and well-being of all patients with cancer, regardless of their gender identity or any other personal or social circumstances, as part of health-for-all societal vision.
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Affiliation(s)
- Alberto Giovanni Leone
- Medical Oncology Department, Fondazione IRCCS Istituto Nazionale dei Tumori, Via G. Venezian 1, Milan 21033, Italy
| | - Raffaella Casolino
- Wolfson Wohl Cancer Research Centre, Institute of Cancer Sciences, University of Glasgow, Glasgow, UK
| | - Dario Trapani
- European Institute of Oncology, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), Milan, Italy
- Department of Oncology and Hemato-oncology (DIPO), University of Milan, Milan, Italy
| | - Rosalba Miceli
- Department of Biostatistics for Clinical Research, Fondazione IRCCS Istituto Nazionale dei Tumori, Via G. Venezian 1, Milan 21033, Italy
| | | | - Federica Morano
- Medical Oncology Department, Fondazione IRCCS Istituto Nazionale dei Tumori, Via G. Venezian 1, Milan 21033, Italy
| | - Nicla La Verde
- Department of Oncology, Luigi Sacco Hospital, ASST Fatebenefratelli Sacco, Milan, Italy
| | - Davide Dalu
- Department of Oncology, Luigi Sacco Hospital, ASST Fatebenefratelli Sacco, Milan, Italy
| | - Rossana Berardi
- Oncology Clinic, Università Politecnica delle Marche, AOU delle Marche, Ancona, Italy
| | - Silvia Marsoni
- IFOM - the FIRC Institute of Molecular Oncology, Milan, Italy
| | - Matteo Lambertini
- Department of Internal Medicine and Medical Specialties (DiMI), School of Medicine, University of Genova, Genova, Italy
- Department of Medical Oncology, U.O. Clinica di Oncologia Medica, IRCCS Ospedale Policlinico San Martino, Genova, Italy
| | - Bianca Iula
- ACET - Associazione per la Cultura e l’etica Transgenere (Association for Transgender Culture and Ethics), Milan, Italy Degree: N/A
| | | | - Manlio Converti
- AMIGAY Aps - Associazione Italiana Medici e Personale Sanitario, LGBTQIA+ e Friendly (Italian Association of LGBTQIA+ Medical care Providers), Italy
| | - Massimo Di Maio
- Department of Oncology, University of Turin, A.O. Ordine Mauriziano, Turin, Italy
- National Secretary of the Italian Association of Medical Oncology (AIOM), Italy
| | - Giordano Domenico Beretta
- UOC Oncologia Medica, ASL Pescara P.O., Pescara, Italy
- National President of the Italian Foundation of Medical Oncology (Fondazione AIOM), Italy
| | - Francesco Perrone
- Clinical Trial Unit, Istituto Nazionale Tumori, IRCCS, Fondazione G. Pascale, Napoli, Italy
- President-elect of the Italian Association of Medical Oncology (AIOM), Italy
| | - Filippo Pietrantonio
- Medical Oncology Department, Fondazione IRCCS Istituto Nazionale dei Tumori, Via G. Venezian 1, Milan 21033, Italy
| | - Saverio Cinieri
- Medical Oncology Unit, Ospedale di Summa A. Perrino, Brindisi, Italy
- National President of the Italian Association of Medical Oncology (AIOM), Italy
| | - the Italian Foundation of Medical Oncology (Fondazione AIOM)
- Medical Oncology Department, Fondazione IRCCS Istituto Nazionale dei Tumori, Via G. Venezian 1, Milan 21033, Italy
- Wolfson Wohl Cancer Research Centre, Institute of Cancer Sciences, University of Glasgow, Glasgow, UK
- European Institute of Oncology, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), Milan, Italy
- Department of Oncology and Hemato-oncology (DIPO), University of Milan, Milan, Italy
- Department of Biostatistics for Clinical Research, Fondazione IRCCS Istituto Nazionale dei Tumori, Via G. Venezian 1, Milan 21033, Italy
- ELMA Research, Milan, Italy
- Department of Oncology, Luigi Sacco Hospital, ASST Fatebenefratelli Sacco, Milan, Italy
- Oncology Clinic, Università Politecnica delle Marche, AOU delle Marche, Ancona, Italy
- IFOM - the FIRC Institute of Molecular Oncology, Milan, Italy
- Department of Internal Medicine and Medical Specialties (DiMI), School of Medicine, University of Genova, Genova, Italy
- Department of Medical Oncology, U.O. Clinica di Oncologia Medica, IRCCS Ospedale Policlinico San Martino, Genova, Italy
- ACET - Associazione per la Cultura e l’etica Transgenere (Association for Transgender Culture and Ethics), Milan, Italy Degree: N/A
- Independent Researcher, Italy Degree: N/A
- AMIGAY Aps - Associazione Italiana Medici e Personale Sanitario, LGBTQIA+ e Friendly (Italian Association of LGBTQIA+ Medical care Providers), Italy
- Department of Oncology, University of Turin, A.O. Ordine Mauriziano, Turin, Italy
- National Secretary of the Italian Association of Medical Oncology (AIOM), Italy
- UOC Oncologia Medica, ASL Pescara P.O., Pescara, Italy
- National President of the Italian Foundation of Medical Oncology (Fondazione AIOM), Italy
- Clinical Trial Unit, Istituto Nazionale Tumori, IRCCS, Fondazione G. Pascale, Napoli, Italy
- President-elect of the Italian Association of Medical Oncology (AIOM), Italy
- Medical Oncology Unit, Ospedale di Summa A. Perrino, Brindisi, Italy
- National President of the Italian Association of Medical Oncology (AIOM), Italy
| | - Italian Association of Medical Oncology (AIOM)
- Medical Oncology Department, Fondazione IRCCS Istituto Nazionale dei Tumori, Via G. Venezian 1, Milan 21033, Italy
- Wolfson Wohl Cancer Research Centre, Institute of Cancer Sciences, University of Glasgow, Glasgow, UK
- European Institute of Oncology, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), Milan, Italy
- Department of Oncology and Hemato-oncology (DIPO), University of Milan, Milan, Italy
- Department of Biostatistics for Clinical Research, Fondazione IRCCS Istituto Nazionale dei Tumori, Via G. Venezian 1, Milan 21033, Italy
- ELMA Research, Milan, Italy
- Department of Oncology, Luigi Sacco Hospital, ASST Fatebenefratelli Sacco, Milan, Italy
- Oncology Clinic, Università Politecnica delle Marche, AOU delle Marche, Ancona, Italy
- IFOM - the FIRC Institute of Molecular Oncology, Milan, Italy
- Department of Internal Medicine and Medical Specialties (DiMI), School of Medicine, University of Genova, Genova, Italy
- Department of Medical Oncology, U.O. Clinica di Oncologia Medica, IRCCS Ospedale Policlinico San Martino, Genova, Italy
- ACET - Associazione per la Cultura e l’etica Transgenere (Association for Transgender Culture and Ethics), Milan, Italy Degree: N/A
- Independent Researcher, Italy Degree: N/A
- AMIGAY Aps - Associazione Italiana Medici e Personale Sanitario, LGBTQIA+ e Friendly (Italian Association of LGBTQIA+ Medical care Providers), Italy
- Department of Oncology, University of Turin, A.O. Ordine Mauriziano, Turin, Italy
- National Secretary of the Italian Association of Medical Oncology (AIOM), Italy
- UOC Oncologia Medica, ASL Pescara P.O., Pescara, Italy
- National President of the Italian Foundation of Medical Oncology (Fondazione AIOM), Italy
- Clinical Trial Unit, Istituto Nazionale Tumori, IRCCS, Fondazione G. Pascale, Napoli, Italy
- President-elect of the Italian Association of Medical Oncology (AIOM), Italy
- Medical Oncology Unit, Ospedale di Summa A. Perrino, Brindisi, Italy
- National President of the Italian Association of Medical Oncology (AIOM), Italy
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15
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Carroll R, Sepulveda B, McLeod L, Stephenson C, Carroll RW. Characteristics and gender affirming healthcare needs of transgender and non-binary students starting hormone therapy in a student health service in Aotearoa New Zealand. J Prim Health Care 2023; 15:106-111. [PMID: 37390028 DOI: 10.1071/hc23040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2023] [Accepted: 05/26/2023] [Indexed: 07/02/2023] Open
Abstract
Introduction Traditionally, gender-affirming hormonal therapy (GAHT) is initiated in secondary care, but a primary care based approach has been developed to reduce access barriers. Aim We aim to describe the demographics, hormone choices, and additional referrals made for young people initiating GAHT in a primary care setting in Aotearoa New Zealand. Methods Clinical notes were reviewed for all patients who commenced GAHT between 1 July 2020 to the end of 2022 at a tertiary education health service. Data were collected on age, ethnicity, gender, type of hormones prescribed, and any additional referrals. Results Eighty five patients commenced GAHT during the review period (64% assigned male at birth and starting oestrogen-based GAHT, 36% assigned female at birth and commencing testosterone-based GAHT). Fourty seven percent of patients identified as transgender female, 38% as non-binary, and 15% as transgender male. Spironolactone was the most common choice of testosterone blocker (81%). The choice of oestrogen formulation was fairly equal between patches (54%) and tablets (46%). Eighty percent of those assigned male at birth chose to preserve fertility, 54% requested voice therapy, and 87% of those assigned female at birth requested top surgery. Discussion There is a need for improved understanding of non-binary gender-affirmation needs, in particular those of Māori and Pasifika youth. An informed consent approach in primary care can reduce barriers and distress for transgender youth seeking GAHT. The high unmet need for top surgery for transgender people assigned female at birth requires attention.
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Affiliation(s)
- Rona Carroll
- Department of Primary Health Care and General Practice, University of Otago, Wellington, New Zealand; and Mauri Ora Student Health and Counselling Service, Victoria University of Wellington, New Zealand
| | - Bianca Sepulveda
- Mauri Ora Student Health and Counselling Service, Victoria University of Wellington, New Zealand
| | - Lane McLeod
- University of Otago Medical School, Wellington, New Zealand
| | | | - Richard W Carroll
- Endocrine, Diabetes and Research Centre, Te Whatu Ora Capital, Coast and Hutt Valley
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16
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Rahmat A, De Nie I, Wiepjes CM, Den Heijer M, Rustemeyer T, De Blok CJM, Dreijerink KMA. Skin cancer incidence in transgender individuals receiving gender-affirming hormone treatment: a nationwide cohort study in the Netherlands. Int J Dermatol 2023. [PMID: 37140088 DOI: 10.1111/ijd.16707] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2022] [Revised: 03/15/2023] [Accepted: 04/18/2023] [Indexed: 05/05/2023]
Abstract
BACKGROUND Development of skin cancer, in particular melanoma, has been linked to sex hormones. We aimed to determine the incidence of skin cancer in transgender individuals receiving gender-affirming hormone treatment (GAHT). METHODS In this nationwide retrospective cohort study, clinical information of participants who visited our clinic between (the years) 1972 and 2018 and received GAHT was integrated with national pathology and cancer statistics data in order to assess skin cancer incidence. Standardized incidence ratios (SIRs) were calculated. RESULTS The cohort consisted of 2,436 trans women and 1,444 trans men. The median age at the start of GAHT was 31 years (IQR 24-42) in trans women and 24 years (IQR 20-32) in trans men. The median follow-up time for trans women was 8 years (IQR 3-18) with a total follow-up time of 29,152 years and 4 years (IQR 2-12) with a total follow-up time of 12,469 years for trans men. Eight trans women were diagnosed with melanoma (SIR 1.80 [95% CI 0.83-3.41] vs. all men; SIR 1.40 [0.65-2.65] vs. all women), and seven developed squamous cell carcinoma (SIR 0.78 [0.34-1.55] vs. all men; SIR 1.15 [0.50-2.27] vs. all women). Two trans men developed melanoma (SIR 1.05 [0.18-3.47] vs. all men; SIR 0.77 [0.14-2.70] vs. all women). CONCLUSIONS GAHT did not appear to affect skin cancer incidence in this large cohort of transgender individuals. As skin cancer incidence increases with age and the proportion of elderly subjects is currently limited in this cohort, it will be worthwhile to repeat this analysis in the future.
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Affiliation(s)
- Amirun Rahmat
- Center of Expertise on Gender Dysphoria, Amsterdam UMC, Location VU University Medical Center, De Boelelaan 1118, 1081 HZ, Amsterdam, the Netherlands
| | - Iris De Nie
- Center of Expertise on Gender Dysphoria, Amsterdam UMC, Location VU University Medical Center, De Boelelaan 1118, 1081 HZ, Amsterdam, the Netherlands
| | - Chantal M Wiepjes
- Center of Expertise on Gender Dysphoria, Amsterdam UMC, Location VU University Medical Center, De Boelelaan 1118, 1081 HZ, Amsterdam, the Netherlands
| | - Martin Den Heijer
- Center of Expertise on Gender Dysphoria, Amsterdam UMC, Location VU University Medical Center, De Boelelaan 1118, 1081 HZ, Amsterdam, the Netherlands
| | - Thomas Rustemeyer
- Department of Dermatology, Amsterdam UMC, Location AMC, Meibergdreef 9, 1105 AZ, Amsterdam, the Netherlands
| | - Christel J M De Blok
- Center of Expertise on Gender Dysphoria, Amsterdam UMC, Location VU University Medical Center, De Boelelaan 1118, 1081 HZ, Amsterdam, the Netherlands
| | - Koen M A Dreijerink
- Center of Expertise on Gender Dysphoria, Amsterdam UMC, Location VU University Medical Center, De Boelelaan 1118, 1081 HZ, Amsterdam, the Netherlands
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17
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Leone AG, Trapani D, Schabath MB, Safer JD, Scout NFN, Lambertini M, Berardi R, Marsoni S, Perrone F, Cinieri S, Miceli R, Morano F, Pietrantonio F. Cancer in Transgender and Gender-Diverse Persons: A Review. JAMA Oncol 2023; 9:556-563. [PMID: 36757703 DOI: 10.1001/jamaoncol.2022.7173] [Citation(s) in RCA: 19] [Impact Index Per Article: 19.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/10/2023]
Abstract
Importance Transgender and gender-diverse individuals face unique challenges, including barriers to health care access and inequities in treatment, that may influence cancer risk and outcomes. Observations In this narrative review, a scoping review was conducted focusing on primary and secondary prevention and epidemiology of cancer, barriers to health care services, and health care practitioners' knowledge about specific issues pertaining to transgender and gender-diverse individuals. PubMed, the Cochrane Library, and Embase, were reviewed for citations from their inception to December 31, 2021. This review revealed that transgender and gender-diverse people had a high prevalence of tobacco consumption and alcohol use and high rates of infection with human papillomavirus (HPV) and HIV. Transgender and gender-diverse individuals were less likely to adhere to cancer screening programs and had a higher incidence of HIV- and HPV-associated cancers. Social and economic determinants seemed to drive these disparities in risk factors and outcomes. A lack of knowledge about gender minorities' health needs among health care practitioners was evidenced, and it represented a major hurdle to cancer prevention, care, and survivorship for transgender and gender-diverse individuals. Discrimination, discomfort caused by gender-labeled oncological services, stigma, and lack of cultural sensitivity of health care practitioners were other barriers met by transgender and gender-diverse persons in the oncology setting. Conclusions and Relevance The findings suggest that transgender and gender-diverse peoples' needs in the cancer care continuum are not optimally addressed. Effective solutions are needed to offer the best care to every patient in a person-centric and gender diversity-sensitive environment.
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Affiliation(s)
| | - Dario Trapani
- European Institute of Oncology, IRCCS, Milan, Italy.,Dana Farber Cancer Institute, Harvard Medical School, Boston, Massachusetts
| | | | - Joshua D Safer
- Division of Endocrinology, Icahn School of Medicine at Mount Sinai, New York, New York.,Mount Sinai Center for Transgender Medicine and Surgery, New York, New York
| | - N F N Scout
- National LGBT Cancer Network, Providence, Rhode Island
| | - Matteo Lambertini
- Department of Internal Medicine and Medical Specialties, School of Medicine, University of Genova, Genova, Italy.,Department of Medical Oncology, Unità Operativa Clinica di Oncologia Medica, IRCCS Ospedale Policlinico San Martino, Genova, Italy
| | - Rossana Berardi
- Oncology Clinic, Università Politecnica delle Marche, Ospedali Riuniti di Ancona, Ancona, Italy
| | - Silvia Marsoni
- IFOM, FIRC Institute of Molecular Oncology, Milan, Italy
| | - Francesco Perrone
- Clinical Trial Unit, Istituto Nazionale Tumori, IRCCS, Fondazione G. Pascale, Napoli, Italy
| | - Saverio Cinieri
- Medical Oncology Unit, Ospedale di Summa A. Perrino, Brindisi, Italy
| | - Rosalba Miceli
- Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | - Federica Morano
- Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
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18
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Defreyne J, Vander Stichele C, Iwamoto SJ, T'Sjoen G. Gender-affirming hormonal therapy for transgender and gender-diverse people-A narrative review. Best Pract Res Clin Obstet Gynaecol 2023; 86:102296. [PMID: 36596713 PMCID: PMC11197232 DOI: 10.1016/j.bpobgyn.2022.102296] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2022] [Accepted: 11/07/2022] [Indexed: 12/23/2022]
Abstract
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.
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Affiliation(s)
- J Defreyne
- Department of Endocrinology and Center for Sexology, Ghent University Hospital, Ghent, Belgium.
| | - Clara Vander Stichele
- Department of Endocrinology and Center for Sexology, Ghent University Hospital, Ghent, Belgium.
| | - Sean J Iwamoto
- Division of Endocrinology, Metabolism and Diabetes, Department of Medicine, University of Colorado School of Medicine, Anschutz Medical Campus, and Rocky Mountain Regional VA Medical Center, Aurora, CO, USA.
| | - G T'Sjoen
- Department of Endocrinology and Center for Sexology, Ghent University Hospital, Ghent, Belgium.
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19
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OH JW, Yun Y, Lee ES. A Review of Gender-Affirming Hormone Therapy for Transgender and Gender Diverse Adults in South Korea. J Menopausal Med 2022; 28:92-102. [PMID: 36647272 PMCID: PMC9843037 DOI: 10.6118/jmm.22039] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2022] [Revised: 12/21/2022] [Accepted: 12/21/2022] [Indexed: 01/14/2023] Open
Abstract
Recently, gender-affirming hormone therapy for gender incongruence has become an issue in various countries and organizations with various guidelines. In South Korea, several clinical treatments are also used with many possible options. These treatments include masculinizing (female-to-male [FTM]) or feminizing (male-to-female [MTF]) hormone therapies, with regimens usually driven by standards of hormonal replacement therapy for hypogonadism (i.e., hypogonadal natal men and postmenopausal women). This cross-sex hormone therapy can change patients' physical appearance to better match their gender identity and expression. Regarding masculinizing therapy, injection and transdermal gel types of testosterone are used according to international guidelines. Progesterone is utilized in the form of oral pills, injections, or intrauterine devices to suppress menstruation and avoid pregnancy. Essentially, feminizing therapy uses androgen blockers along with estrogen. This is because estrogen alone cannot exert sufficient androgen-suppressing effects. In South Korea, the most commonly used androgen blockers are spironolactone and cyproterone acetate. Gonadotropin-releasing hormone (GnRH) agonist is also available. Regarding estrogen, oral pills, injections, and transdermal gels are utilized. This review introduces these gender-affirming hormone therapies in South Korea and discusses the side effects of each regimen.
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Affiliation(s)
- Jeong-Won OH
- Department of Obstetrics and Gynecology, Soon Chun Hyang University Seoul Hospital, Soon Chun Hyang University College of Medicine, Seoul, Korea
| | - Yeoul Yun
- Department of Obstetrics and Gynecology, Soon Chun Hyang University Seoul Hospital, Soon Chun Hyang University College of Medicine, Seoul, Korea
| | - Eun Sil Lee
- Department of Obstetrics and Gynecology, Soon Chun Hyang University Seoul Hospital, Soon Chun Hyang University College of Medicine, Seoul, Korea
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20
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Coleman E, Radix AE, Bouman WP, Brown GR, de Vries ALC, Deutsch MB, Ettner R, Fraser L, Goodman M, Green J, Hancock AB, Johnson TW, Karasic DH, Knudson GA, Leibowitz SF, Meyer-Bahlburg HFL, Monstrey SJ, Motmans J, Nahata L, Nieder TO, Reisner SL, Richards C, Schechter LS, Tangpricha V, Tishelman AC, Van Trotsenburg MAA, Winter S, Ducheny K, Adams NJ, Adrián TM, Allen LR, Azul D, Bagga H, Başar K, Bathory DS, Belinky JJ, Berg DR, Berli JU, Bluebond-Langner RO, Bouman MB, Bowers ML, Brassard PJ, Byrne J, Capitán L, Cargill CJ, Carswell JM, Chang SC, Chelvakumar G, Corneil T, Dalke KB, De Cuypere G, de Vries E, Den Heijer M, Devor AH, Dhejne C, D'Marco A, Edmiston EK, Edwards-Leeper L, Ehrbar R, Ehrensaft D, Eisfeld J, Elaut E, Erickson-Schroth L, Feldman JL, Fisher AD, Garcia MM, Gijs L, Green SE, Hall BP, Hardy TLD, Irwig MS, Jacobs LA, Janssen AC, Johnson K, Klink DT, Kreukels BPC, Kuper LE, Kvach EJ, Malouf MA, Massey R, Mazur T, McLachlan C, Morrison SD, Mosser SW, Neira PM, Nygren U, Oates JM, Obedin-Maliver J, Pagkalos G, Patton J, Phanuphak N, Rachlin K, Reed T, Rider GN, Ristori J, Robbins-Cherry S, Roberts SA, Rodriguez-Wallberg KA, Rosenthal SM, Sabir K, Safer JD, Scheim AI, Seal LJ, Sehoole TJ, Spencer K, St Amand C, Steensma TD, Strang JF, Taylor GB, Tilleman K, T'Sjoen GG, Vala LN, Van Mello NM, Veale JF, Vencill JA, Vincent B, Wesp LM, West MA, Arcelus J. Standards of Care for the Health of Transgender and Gender Diverse People, Version 8. INTERNATIONAL JOURNAL OF TRANSGENDER HEALTH 2022; 23:S1-S259. [PMID: 36238954 PMCID: PMC9553112 DOI: 10.1080/26895269.2022.2100644] [Citation(s) in RCA: 718] [Impact Index Per Article: 359.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/15/2023]
Abstract
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.
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Affiliation(s)
- E Coleman
- Institute for Sexual and Gender Health, Department of Family Medicine and Community Health, University of Minnesota Medical School, Minneapolis, MN, USA
| | - A E Radix
- Callen-Lorde Community Health Center, New York, NY, USA
- Department of Medicine, NYU Grossman School of Medicine, New York, NY, USA
| | - W P Bouman
- Nottingham Centre for Transgender Health, Nottingham, UK
- School of Medicine, University of Nottingham, Nottingham, UK
| | - G R Brown
- James H. Quillen College of Medicine, East Tennessee State University, Johnson City, TN, USA
- James H. Quillen VAMC, Johnson City, TN, USA
| | - A L C de Vries
- Department of Child and Adolescent Psychiatry, Amsterdam UMC Location Vrije Universiteit Amsterdam, Amsterdam, Netherlands
- Center of Expertise on Gender Dysphoria, Amsterdam UMC Location Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - M B Deutsch
- Department of Family & Community Medicine, University of California-San Francisco, San Francisco, CA, USA
- UCSF Gender Affirming Health Program, San Francisco, CA, USA
| | - R Ettner
- New Health Foundation Worldwide, Evanston, IL, USA
- Weiss Memorial Hospital, Chicago, IL, USA
| | - L Fraser
- Independent Practice, San Francisco, CA, USA
| | - M Goodman
- Emory University Rollins School of Public Health, Atlanta, GA, USA
| | - J Green
- Independent Scholar, Vancouver, WA, USA
| | - A B Hancock
- The George Washington University, Washington, DC, USA
| | - T W Johnson
- Department of Anthropology, California State University, Chico, CA, USA
| | - D H Karasic
- University of California San Francisco, San Francisco, CA, USA
- Independent Practice at dankarasic.com
| | - G A Knudson
- University of British Columbia, Vancouver, Canada
- Vancouver Coastal Health, Vancouver, Canada
| | - S F Leibowitz
- Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA
| | - H F L Meyer-Bahlburg
- New York State Psychiatric Institute, New York, NY, USA
- Department of Psychiatry, Columbia University, New York, NY, USA
| | | | - J Motmans
- Transgender Infopunt, Ghent University Hospital, Gent, Belgium
- Centre for Research on Culture and Gender, Ghent University, Gent, Belgium
| | - L Nahata
- Department of Pediatrics, The Ohio State University College of Medicine, Columbus, OH, USA
- Endocrinology and Center for Biobehavioral Health, The Abigail Wexner Research Institute at Nationwide Children's Hospital, Columbus, OH, USA
| | - T O Nieder
- University Medical Center Hamburg-Eppendorf, Interdisciplinary Transgender Health Care Center Hamburg, Institute for Sex Research, Sexual Medicine and Forensic Psychiatry, Hamburg, Germany
| | - S L Reisner
- Harvard Medical School, Boston, MA, USA
- Harvard T. H. Chan School of Public Health, Boston, MA, USA
| | - C Richards
- Regents University London, UK
- Tavistock and Portman NHS Foundation Trust, London, UK
| | | | - V Tangpricha
- Division of Endocrinology, Metabolism & Lipids, Department of Medicine, Emory University School of Medicine, Atlanta, GA, USA
- Atlanta VA Medical Center, Decatur, GA, USA
| | - A C Tishelman
- Boston College, Department of Psychology and Neuroscience, Chestnut Hill, MA, USA
| | - M A A Van Trotsenburg
- Bureau GenderPRO, Vienna, Austria
- University Hospital Lilienfeld-St. Pölten, St. Pölten, Austria
| | - S Winter
- School of Population Health, Curtin University, Perth, WA, Australia
| | - K Ducheny
- Howard Brown Health, Chicago, IL, USA
| | - N J Adams
- University of Toronto, Ontario Institute for Studies in Education, Toronto, Canada
- Transgender Professional Association for Transgender Health (TPATH)
| | - T M Adrián
- Asamblea Nacional de Venezuela, Caracas, Venezuela
- Diverlex Diversidad e Igualdad a Través de la Ley, Caracas, Venezuela
| | - L R Allen
- University of Nevada, Las Vegas, NV, USA
| | - D Azul
- La Trobe Rural Health School, La Trobe University, Bendigo, Australia
| | - H Bagga
- Monash Health Gender Clinic, Melbourne, Victoria, Australia
- Monash University, Melbourne, Victoria, Australia
| | - K Başar
- Department of Psychiatry, Hacettepe University, Ankara, Turkey
| | - D S Bathory
- Independent Practice at Bathory International PLLC, Winston-Salem, NC, USA
| | - J J Belinky
- Durand Hospital, Guemes Clinic and Urological Center, Buenos Aires, Argentina
| | - D R Berg
- National Center for Gender Spectrum Health, Institute for Sexual and Gender Health, Department of Family Medicine and Community Health, University of Minnesota Medical School, Minneapolis, MN, USA
| | - J U Berli
- Oregon Health & Science University, Portland, OR, USA
| | - R O Bluebond-Langner
- NYU Langone Health, New York, NY, USA
- Hansjörg Wyss Department of Plastic Surgery, New York, NY, USA
| | - M-B Bouman
- Center of Expertise on Gender Dysphoria, Amsterdam UMC Location Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
- Department of Plastic Surgery, Amsterdam UMC Location Vrije Universiteit Amsterdam, , Amsterdam, Netherlands
| | - M L Bowers
- Icahn School of Medicine at Mount Sinai, New York, NY, USA
- Mills-Peninsula Medical Center, Burlingame, CA, USA
| | - P J Brassard
- GrS Montreal, Complexe CMC, Montreal, Quebec, Canada
- Université de Montreal, Quebec, Canada
| | - J Byrne
- University of Waikato/Te Whare Wānanga o Waikato, Hamilton/Kirikiriroa, New Zealand/Aotearoa
| | - L Capitán
- The Facialteam Group, Marbella International Hospital, Marbella, Spain
| | | | - J M Carswell
- Harvard Medical School, Boston, MA, USA
- Boston's Children's Hospital, Boston, MA, USA
| | - S C Chang
- Independent Practice, Oakland, CA, USA
| | - G Chelvakumar
- Nationwide Children's Hospital, Columbus, OH, USA
- The Ohio State University, College of Medicine, Columbus, OH, USA
| | - T Corneil
- School of Population & Public Health, University of British Columbia, Vancouver, BC, Canada
| | - K B Dalke
- Penn State Health, PA, USA
- Penn State College of Medicine, Hershey, PA, USA
| | - G De Cuypere
- Center for Sexology and Gender, Ghent University Hospital, Gent, Belgium
| | - E de Vries
- Nelson Mandela University, Gqeberha, South Africa
- University of Cape Town, Cape Town, South Africa
| | - M Den Heijer
- Center of Expertise on Gender Dysphoria, Amsterdam UMC Location Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
- Department of Endocrinology, Amsterdam UMC Location Vrije Universiteit Amsterdam, , Amsterdam, Netherlands
| | - A H Devor
- University of Victoria, Victoria, BC, Canada
| | - C Dhejne
- ANOVA, Karolinska University Hospital, Stockholm, Sweden
- Department of Medicine Huddinge, Karolinska Institutet, Stockholm, Sweden
| | - A D'Marco
- UCTRANS-United Caribbean Trans Network, Nassau, The Bahamas
- D M A R C O Organization, Nassau, The Bahamas
| | - E K Edmiston
- University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - L Edwards-Leeper
- Pacific University, Hillsboro, OR, USA
- Independent Practice, Beaverton, OR, USA
| | - R Ehrbar
- Whitman Walker Health, Washington, DC, USA
- Independent Practice, Maryland, USA
| | - D Ehrensaft
- University of California San Francisco, San Francisco, CA, USA
| | - J Eisfeld
- Transvisie, Utrecht, The Netherlands
| | - E Elaut
- Center for Sexology and Gender, Ghent University Hospital, Gent, Belgium
- Department of Clinical Experimental and Health Psychology, Ghent University, Gent, Belgium
| | - L Erickson-Schroth
- The Jed Foundation, New York, NY, USA
- Hetrick-Martin Institute, New York, NY, USA
| | - J L Feldman
- Institute for Sexual and Gender Health, Institute for Sexual and Gender Health, Department of Family Medicine and Community Health, University of Minnesota Medical School, Minneapolis, MN, USA
| | - A D Fisher
- Andrology, Women Endocrinology and Gender Incongruence, Careggi University Hospital, Florence, Italy
| | - M M Garcia
- Department of Urology, Cedars-Sinai Medical Center, Los Angeles, CA, USA
- Departments of Urology and Anatomy, University of California San Francisco, San Francisco, CA, USA
| | - L Gijs
- Institute of Family and Sexuality Studies, Department of Neurosciences, KU Leuven, Leuven, Belgium
| | | | - B P Hall
- Duke University Medical Center, Durham, NC, USA
- Duke Adult Gender Medicine Clinic, Durham, NC, USA
| | - T L D Hardy
- Alberta Health Services, Edmonton, Alberta, Canada
- MacEwan University, Edmonton, Alberta, Canada
| | - M S Irwig
- Harvard Medical School, Boston, MA, USA
- Beth Israel Deaconess Medical Center, Boston, MA, USA
| | | | - A C Janssen
- Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA
- Northwestern Feinberg School of Medicine, Chicago, IL, USA
| | - K Johnson
- RMIT University, Melbourne, Australia
- University of Brighton, Brighton, UK
| | - D T Klink
- Department of Pediatrics, Division of Pediatric Endocrinology, Ghent University Hospital, Gent, Belgium
- Division of Pediatric Endocrinology and Diabetes, ZNA Queen Paola Children's Hospital, Antwerp, Belgium
| | - B P C Kreukels
- Center of Expertise on Gender Dysphoria, Amsterdam UMC Location Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
- Department of Medical Psychology, Amsterdam UMC Location Vrije Universiteit Amsterdam, , Amsterdam, Netherlands
| | - L E Kuper
- Department of Psychiatry, Southwestern Medical Center, University of Texas, Dallas, TX, USA
- Department of Endocrinology, Children's Health, Dallas, TX, USA
| | - E J Kvach
- Denver Health, Denver, CO, USA
- University of Colorado School of Medicine, Aurora, CO, USA
| | - M A Malouf
- Malouf Counseling and Consulting, Baltimore, MD, USA
| | - R Massey
- WPATH Global Education Institute
- Department of Psychiatry & Behavioral Sciences, Emory University School of Medicine, Atlanta, GA, USA
| | - T Mazur
- Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, NY, USA
- John R. Oishei Children's Hospital, Buffalo, NY, USA
| | - C McLachlan
- Professional Association for Transgender Health, South Africa
- Gender DynamiX, Cape Town, South Africa
| | - S D Morrison
- Division of Plastic Surgery, Seattle Children's Hospital, Seattle, WA, USA
- Division of Plastic Surgery, Department of Surgery, University of Washington Medical Center, Seattle, WA, USA
| | - S W Mosser
- Gender Confirmation Center, San Francisco, CA, USA
- Saint Francis Memorial Hospital, San Francisco, CA, USA
| | - P M Neira
- Johns Hopkins Center for Transgender Health, Baltimore, MD, USA
- Johns Hopkins Medicine Office of Diversity, Inclusion and Health Equity, Baltimore, MD, USA
| | - U Nygren
- Division of Speech and Language Pathology, Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Stockholm, Sweden
- Speech and Language Pathology, Medical Unit, Karolinska University Hospital, Stockholm, Sweden
| | - J M Oates
- La Trobe University, Melbourne, Australia
- Melbourne Voice Analysis Centre, East Melbourne, Australia
| | - J Obedin-Maliver
- Stanford University School of Medicine, Department of Obstetrics and Gynecology, Palo Alto, CA, USA
- Department of Epidemiology and Population Health, Stanford, CA, USA
| | - G Pagkalos
- Independent PracticeThessaloniki, Greece
- Military Community Mental Health Center, 424 General Military Training Hospital, Thessaloniki, Greece
| | - J Patton
- Talkspace, New York, NY, USA
- CytiPsychological LLC, San Diego, CA, USA
| | - N Phanuphak
- Institute of HIV Research and Innovation, Bangkok, Thailand
| | - K Rachlin
- Independent Practice, New York, NY, USA
| | - T Reed
- Gender Identity Research and Education Society, Leatherhead, UK
| | - G N Rider
- National Center for Gender Spectrum Health, Institute for Sexual and Gender Health, Department of Family Medicine and Community Health, University of Minnesota Medical School, Minneapolis, MN, USA
| | - J Ristori
- Andrology, Women Endocrinology and Gender Incongruence, Careggi University Hospital, Florence, Italy
| | | | - S A Roberts
- Harvard Medical School, Boston, MA, USA
- Division of Endocrinology, Boston's Children's Hospital, Boston, MA, USA
| | - K A Rodriguez-Wallberg
- Department of Reproductive Medicine, Karolinska University Hospital, Stockholm, Sweden
- Department of Oncology-Pathology, Karolinska Institute, Stockholm, Sweden
| | - S M Rosenthal
- Division of Pediatric Endocrinology, UCSF, San Francisco, CA, USA
- UCSF Child and Adolescent Gender Center
| | - K Sabir
- FtM Phoenix Group, Krasnodar Krai, Russia
| | - J D Safer
- Icahn School of Medicine at Mount Sinai, New York, NY, USA
- Mount Sinai Center for Transgender Medicine and Surgery, New York, NY, USA
| | - A I Scheim
- Epidemiology and Biostatistics, Dornsife School of Public Health, Drexel University, Philadelphia, PA, USA
- Epidemiology and Biostatistics, Schulich School of Medicine and Dentistry, Western University, Ontario, Canada
| | - L J Seal
- Tavistock and Portman NHS Foundation Trust, London, UK
- St George's University Hospitals NHS Foundation Trust, London, UK
| | | | - K Spencer
- National Center for Gender Spectrum Health, Institute for Sexual and Gender Health, Department of Family Medicine and Community Health, University of Minnesota Medical School, Minneapolis, MN, USA
| | - C St Amand
- University of Houston, Houston, TX, USA
- Mayo Clinic, Rochester, MN, USA
| | - T D Steensma
- Center of Expertise on Gender Dysphoria, Amsterdam UMC Location Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
- Department of Medical Psychology, Amsterdam UMC Location Vrije Universiteit Amsterdam, , Amsterdam, Netherlands
| | - J F Strang
- Children's National Hospital, Washington, DC, USA
- George Washington University School of Medicine, Washington, DC, USA
| | - G B Taylor
- Atrium Health Department of Obstetrics and Gynecology, Division of Female Pelvic Medicine and Reconstructive Surgery, Charlotte, NC, USA
| | - K Tilleman
- Department for Reproductive Medicine, Ghent University Hospital, Gent, Belgium
| | - G G T'Sjoen
- Center for Sexology and Gender, Ghent University Hospital, Gent, Belgium
- Department of Endocrinology, Ghent University Hospital, Gent, Belgium
| | - L N Vala
- Independent Practice, Campbell, CA, USA
| | - N M Van Mello
- Center of Expertise on Gender Dysphoria, Amsterdam UMC Location Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
- Department of Obstetrics and Gynaecology, Amsterdam UMC Location Vrije Universiteit Amsterdam, Amsterdam, Netherlands
| | - J F Veale
- School of Psychology, University of Waikato/Te Whare Wānanga o Waikato, Hamilton/Kirikiriroa, New Zealand/Aotearoa
| | - J A Vencill
- Department of Psychiatry & Psychology, Mayo Clinic, Rochester, MN, USA
- Division of General Internal Medicine, Mayo Clinic, Rochester, MN, USA
| | - B Vincent
- Trans Learning Partnership at https://spectra-london.org.uk/trans-learning-partnership, UK
| | - L M Wesp
- College of Nursing, University of Wisconsin MilwaukeeMilwaukee, WI, USA
- Health Connections Inc., Glendale, WI, USA
| | - M A West
- North Memorial Health Hospital, Robbinsdale, MN, USA
- University of Minnesota, Minneapolis, MN, USA
| | - J Arcelus
- School of Medicine, University of Nottingham, Nottingham, UK
- Bellvitge Biomedical Research Institute (IDIBELL), L'Hospitalet de Llobregat, Barcelona, Spain
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21
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Samoyeau T, Provost C, Roux A, Legrand L, Dezamis E, Plu-Bureau G, Pallud J, Oppenheim C, Benzakoun J. Meningioma in patients exposed to progestin drugs: results from a real-life screening program. J Neurooncol 2022; 160:127-136. [PMID: 36066786 DOI: 10.1007/s11060-022-04124-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2022] [Accepted: 08/26/2022] [Indexed: 10/14/2022]
Abstract
PURPOSE To report the results of systematic meningioma screening program implemented by French authorities in patients exposed to progestin therapies (cyproterone (CPA), nomegestrol (NA), and chlormadinone (CMA) acetate). METHODS We conducted a prospective monocentric study on patients who, between September 2018 and April 2021, underwent standardized MRI (injection of gadolinium, then a T2 axial FLAIR and a 3D-T1 gradient-echo sequence) for meningioma screening. RESULTS Of the 210 included patients, 15 (7.1%) had at least one meningioma; seven (7/15, 47%) had multiple meningiomas. Meningiomas were more frequent in older patients and after exposure to CPA (13/103, 13%) compared to NA (1/22, 4%) or CMA (1/85, 1%; P = 0.005). After CPA exposure, meningiomas were associated with longer treatment duration (median = 20 vs 7 years, P = 0.001) and higher cumulative dose (median = 91 g vs. 62 g, P = 0.014). Similarly, their multiplicity was associated with higher dose of CPA (median = 244 g vs 61 g, P = 0.027). Most meningiomas were ≤ 1 cm3 (44/58, 76%) and were convexity meningiomas (36/58, 62%). At diagnosis, patients were non-symptomatic, and all were managed conservatively. Among 14 patients with meningioma who stopped progestin exposure, meningioma burden decreased in 11 (79%) cases with no case of progression during MR follow-up. CONCLUSION Systematic MR screening in progestin-exposed patients uncovers small and multiple meningiomas, which can be managed conservatively, decreasing in size after progestin discontinuation. The high rate of meningiomas after CPA exposure reinforces the need for systematic screening. For NA and CMA, further studies are needed to identify patients most likely to benefit from screening.
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Affiliation(s)
- Thomas Samoyeau
- Institut de Psychiatrie et Neurosciences de Paris (IPNP), INSERM U 1266, IMA-BRAIN, Paris, France.,Université Paris Cité, Paris, France.,Service de Neuroradiologie, GHU Paris Psychiatrie et Neurosciences, Hôpital Sainte-Anne, Paris, France
| | - Corentin Provost
- Institut de Psychiatrie et Neurosciences de Paris (IPNP), INSERM U 1266, IMA-BRAIN, Paris, France.,Université Paris Cité, Paris, France.,Service de Neuroradiologie, GHU Paris Psychiatrie et Neurosciences, Hôpital Sainte-Anne, Paris, France
| | - Alexandre Roux
- Institut de Psychiatrie et Neurosciences de Paris (IPNP), INSERM U 1266, IMA-BRAIN, Paris, France.,Université Paris Cité, Paris, France.,Service de Neurochirurgie, GHU Paris Psychiatrie et Neurosciences, Hôpital Sainte-Anne, Paris, France
| | - Laurence Legrand
- Institut de Psychiatrie et Neurosciences de Paris (IPNP), INSERM U 1266, IMA-BRAIN, Paris, France.,Université Paris Cité, Paris, France.,Service de Neuroradiologie, GHU Paris Psychiatrie et Neurosciences, Hôpital Sainte-Anne, Paris, France
| | - Edouard Dezamis
- Institut de Psychiatrie et Neurosciences de Paris (IPNP), INSERM U 1266, IMA-BRAIN, Paris, France.,Université Paris Cité, Paris, France.,Service de Neurochirurgie, GHU Paris Psychiatrie et Neurosciences, Hôpital Sainte-Anne, Paris, France
| | - Geneviève Plu-Bureau
- Université Paris Cité, Paris, France.,Unité de gynécologie endocrinienne, Hôpital Cochin-Port-Royal, 123 Boulevard Port-Royal, Paris, France.,Obstetrical Perinatal and Pediatric Epidemiology Research Team, EPOPé, Centre for Epidemiology and Statistics Sorbonne Paris Cité (CRESS), INSERM U1153, Paris, France
| | - Johan Pallud
- Institut de Psychiatrie et Neurosciences de Paris (IPNP), INSERM U 1266, IMA-BRAIN, Paris, France.,Université Paris Cité, Paris, France.,Service de Neurochirurgie, GHU Paris Psychiatrie et Neurosciences, Hôpital Sainte-Anne, Paris, France
| | - Catherine Oppenheim
- Institut de Psychiatrie et Neurosciences de Paris (IPNP), INSERM U 1266, IMA-BRAIN, Paris, France.,Université Paris Cité, Paris, France.,Service de Neuroradiologie, GHU Paris Psychiatrie et Neurosciences, Hôpital Sainte-Anne, Paris, France
| | - Joseph Benzakoun
- Institut de Psychiatrie et Neurosciences de Paris (IPNP), INSERM U 1266, IMA-BRAIN, Paris, France. .,Service de Neuroradiologie, GHU Paris Psychiatrie et Neurosciences, Hôpital Sainte-Anne, Paris, France.
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22
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Hoisnard L, Laanani M, Passeri T, Duranteau L, Coste J, Zureik M, Froelich S, Weill A. Risk of intracranial meningioma with three potent progestogens: a population-based case-control study. Eur J Neurol 2022; 29:2801-2809. [PMID: 35621369 PMCID: PMC9543130 DOI: 10.1111/ene.15423] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2022] [Revised: 05/20/2022] [Accepted: 05/23/2022] [Indexed: 12/01/2022]
Abstract
Background and purpose A dose‐dependent association between the use of cyproterone acetate (CPA) and intracranial meningioma has been identified but data for other potent progestogens are scarce. The association was assessed between intracranial meningioma surgery and exposure to three potent progestogens: CPA (≥25 mg/day), nomegestrol acetate (NOMAC) (3.75–5 mg/day) and chlormadinone acetate (CMA) (2–10 mg/day). Methods In this nationwide population‐based case–control study, cases underwent surgery for intracranial meningioma in France from 2009 to 2018. They were matched to five control subjects for sex, year of birth and area of residence. Progestogen exposure was defined as progestogen use within the year before surgery for cases or the same date for their controls. Results In total, 25,216 cases were included (75% women, median age 58 years). Progestogen exposure was noted for 9.9% of cases (2497/25,216) and 1.9% (2382/126,080) of controls, with an odds ratio (OR) of 6.7 (95% confidence interval [CI] 6.3–7.1). The OR was 1.2 (1.0–1.4) for short‐term use (<1 year) and 9.5 (8.8–10.2) for prolonged use. A strong association was identified for prolonged use of CPA (OR = 22.7, 95% CI 19.5–26.4), NOMAC (OR = 6.5, 95% CI 5.8–7.2) and CMA (OR = 4.7, 95% CI 4.5–5.3). Progestogen exposure increased the risk of meningioma for all histological grades and anatomical sites, particularly for the anterior and middle skull base: OR = 35.7 (95% CI 26.5–48.2) and 23.9 (95% CI 17.8–32.2) for CPA. The estimated number of attributable cases was 2124 (95% CI 2028–2220) (212/year). Conclusion A strong association between prolonged exposure to potent progestogens and surgery for meningioma was observed. The risk increased from CMA to NOMAC to CPA. Individuals should be informed of this risk. This study highlights a strong association between prolonged use of nomegestrol and chlormadinone acetate (two potent progestogens) and intracranial meningioma, although weaker than that of cyproterone acetate. The estimated number of cases was higher than 2000 in France over 10 years.
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Affiliation(s)
- Léa Hoisnard
- EPI-PHARE Scientific Interest Group in Epidemiology of Health Products, French National Agency for Medicines and Health Products Safety, French National Health Insurance, 93200, Saint-Denis, France
| | - Moussa Laanani
- EPI-PHARE Scientific Interest Group in Epidemiology of Health Products, French National Agency for Medicines and Health Products Safety, French National Health Insurance, 93200, Saint-Denis, France
| | - Thibault Passeri
- Department of Neurosurgery, Lariboisière Hospital, AP-HP, University of Paris, 75010, Paris, France
| | - Lise Duranteau
- Department of Medical Gynaecology, Bicêtre Hospital, AP-HP, University Paris Saclay, 94270, Le Kremlin-Bicêtre, France
| | - Joël Coste
- Biostatistics and Epidemiology Unit - Cochin Hospital, AP-, HP, 75010, Paris, France
| | - Mahmoud Zureik
- EPI-PHARE Scientific Interest Group in Epidemiology of Health Products, French National Agency for Medicines and Health Products Safety, French National Health Insurance, 93200, Saint-Denis, France
| | - Sébastien Froelich
- Department of Neurosurgery, Lariboisière Hospital, AP-HP, University of Paris, 75010, Paris, France
| | - Alain Weill
- EPI-PHARE Scientific Interest Group in Epidemiology of Health Products, French National Agency for Medicines and Health Products Safety, French National Health Insurance, 93200, Saint-Denis, France
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23
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D'hoore L, T'Sjoen G. Gender-affirming hormone therapy: An updated literature review with an eye on the future. J Intern Med 2022; 291:574-592. [PMID: 34982475 DOI: 10.1111/joim.13441] [Citation(s) in RCA: 24] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
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.
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Affiliation(s)
- Laurens D'hoore
- Department of Endocrinology, Ghent University Hospital, Ghent, Belgium
| | - Guy T'Sjoen
- Department of Endocrinology, Ghent University Hospital, Ghent, Belgium.,Center for Sexology and Gender, Ghent University Hospital, Ghent, Belgium
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24
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Fisher AD, Senofonte G, Cocchetti C, Guercio G, Lingiardi V, Meriggiola MC, Mosconi M, Motta G, Ristori J, Speranza AM, Pierdominici M, Maggi M, Corona G, Lombardo F. SIGIS-SIAMS-SIE position statement of gender affirming hormonal treatment in transgender and non-binary people. J Endocrinol Invest 2022; 45:657-673. [PMID: 34677807 DOI: 10.1007/s40618-021-01694-2] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2021] [Accepted: 10/10/2021] [Indexed: 01/29/2023]
Abstract
PURPOSE Gender Incongruence (GI) is a marked and persistent incongruence between an individual's experienced and the assigned gender at birth. In the recent years, there has been a considerable evolution and change in attitude as regards to gender nonconforming people. METHODS According to the Italian Society of Gender, Identity and Health (SIGIS), the Italian Society of Andrology and Sexual Medicine (SIAMS) and the Italian Society of Endocrinology (SIE) rules, a team of experts on the topic has been nominated by a SIGIS-SIAMS-SIE Guideline Board on the basis of their recognized clinical and research expertise in the field, and coordinated by a senior author, has prepared this Position statement. Later on, the present manuscript has been submitted to the Journal of Endocrinological Investigation for the normal process of international peer reviewing after a first internal revision process made by the SIGIS-SIAMS-SIE Guideline Board. RESULTS In the present document by the SIGIS-SIAMS-SIE group, we propose experts opinions concerning the psychological functioning, gender affirming hormonal treatment, safety concerns, emerging issues in transgender healthcare (sexual health, fertility issues, elderly trans people), and an Italian law overview aimed to improve gender non-conforming people care. CONCLUSION In this Position statement, we propose experts opinions concerning the psychological functioning of transgender people, the gender-affirming hormonal treatment (full/partial masculinization in assigned female at birth trans people, full/partial feminization and de-masculinization in assigned male at birth trans people), the emerging issues in transgender health care aimed to improve patient care. We have also included an overview of Italian law about gender affirming surgery and registry rectification.
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Affiliation(s)
- A D Fisher
- Andrology, Women's Endocrinology and Gender Incongruence Unit, Florence University Hospital, Viale Pieraccini 6, 50139, Florence, Italy
| | - G Senofonte
- Laboratory of Seminology, Sperm Bank "Loredana Gandini", Department of Experimental Medicine, Sapienza University of Rome, 00185, Rome, Italy
| | - C Cocchetti
- Andrology, Women's Endocrinology and Gender Incongruence Unit, Florence University Hospital, Viale Pieraccini 6, 50139, Florence, Italy
| | - G Guercio
- Studio Legale Avv. Giovanni Guercio, Via Antonio Mordini, 14, 00195, Rome, Italy
| | - V Lingiardi
- Department of Dynamic and Clinical Psychology, and Health Studies, Sapienza University of Rome, Via degli Apuli 1, 00185, Roma, Italy
| | - M C Meriggiola
- Gynecology and Physiopathology of Human Reproduction, Department of Medical and Surgical Sciences (DIMEC), IRCCS Azienda Ospedaliero-Universitaria di Bologna, University of Bologna, Bologna, Italy
| | - M Mosconi
- Gender Identity Development Service, Hospital S. Camillo-Forlanini, Rome, Italy
| | - G Motta
- Division of Endocrinology, Diabetology and Metabolism, Department of Medical Sciences, University of Turin, Corso Dogliotti 14, 10126, Turin, Italy
| | - J Ristori
- Andrology, Women's Endocrinology and Gender Incongruence Unit, Florence University Hospital, Viale Pieraccini 6, 50139, Florence, Italy
| | - A M Speranza
- Department of Dynamic and Clinical Psychology, and Health Studies, Sapienza University of Rome, Via degli Apuli 1, 00185, Roma, Italy
| | - M Pierdominici
- Center for Gender Specific Medicine, Istituto Superiore di Sanità, Rome, Italy
| | - M Maggi
- Department of Experimental, Clinical and Biomedical Sciences, Careggi University Hospital, Viale Pieraccini 6, 50139, Florence, Italy
| | - G Corona
- Endocrinology Unit, Medical Department, Maggiore-Bellaria Hospital, Azienda-Usl, Bologna, Italy
| | - F Lombardo
- Laboratory of Seminology, Sperm Bank "Loredana Gandini", Department of Experimental Medicine, Sapienza University of Rome, 00185, Rome, Italy.
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25
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Biagetti B, Simò R. Molecular Pathways in Prolactinomas: Translational and Therapeutic Implications. Int J Mol Sci 2021; 22:ijms222011247. [PMID: 34681905 PMCID: PMC8538771 DOI: 10.3390/ijms222011247] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2021] [Revised: 10/11/2021] [Accepted: 10/16/2021] [Indexed: 11/17/2022] Open
Abstract
Prolactinoma has the highest incidence rate among patients with functional pituitary tumours. Although mostly benign, there is a subgroup that can be aggressive. Some clinical, radiological and pathology features have been associated with a poor prognostic. Therefore, it can be considered as a group of heterogeneous tumours. The aim of this paper is to give an overview of the molecular pathways involved in the behaviour of prolactinoma in order to improve our approach and gain deeper insight into the better understanding of tumour development and its management. This is essential for identifying patients harbouring aggressive prolactinoma and to establish personalised therapeutics options.
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26
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de Blok CJ, Wiepjes CM, van Velzen DM, Staphorsius AS, Nota NM, Gooren LJ, Kreukels BP, den Heijer M. Mortality trends over five decades in adult transgender people receiving hormone treatment: a report from the Amsterdam cohort of gender dysphoria. Lancet Diabetes Endocrinol 2021; 9:663-670. [PMID: 34481559 DOI: 10.1016/s2213-8587(21)00185-6] [Citation(s) in RCA: 57] [Impact Index Per Article: 19.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2021] [Revised: 07/05/2021] [Accepted: 07/05/2021] [Indexed: 02/02/2023]
Abstract
BACKGROUND Increased mortality in transgender people has been described in earlier studies. Whether this increased mortality is still present over the past decades is unknown. Therefore, we aimed to investigate trends in mortality over five decades in a large cohort of adult transgender people in addition to cause-specific mortality. METHODS We did a retrospective cohort study of adult transgender people who visited the gender identity clinic of Amsterdam University Medical Centre in the Netherlands. Data of transgender people who received hormone treatment between 1972 and 2018 were linked to Statistics Netherlands. People were excluded if they used alternating testosterone and oestradiol treatment, if they started treatment younger than age 17 years, or if they had ever used puberty-blockers before gender-affirming hormone treatment. Standardised mortality ratios (SMRs) were calculated using general population mortality rates stratified by age, calendar period, and sex. Cause-specific mortality was also calculated. FINDINGS Between 1972 and 2018, 8831 people visited the gender identity clinic. 4263 were excluded from the study for a variety of reasons, and 2927 transgender women and 1641 transgender men were included in the study, with a total follow-up time of 40 232 person-years for transgender women and 17 285 person-years for transgender men. During follow-up, 317 (10·8%) transgender women died, which was higher than expected compared with general population men (SMR 1·8, 95% CI 1·6-2·0) and general population women (SMR 2·8, 2·5-3·1). Cause-specific mortality in transgender women was high for cardiovascular disease, lung cancer, HIV-related disease, and suicide. In transgender men, 44 people (2·7%) died, which was higher than expected compared with general population women (SMR 1·8, 95% CI 1·3-2·4) but not general population men (SMR 1·2, 95% CI 0·9-1·6). Cause-specific death in transgender men was high for non-natural causes of death. No decreasing trend in mortality risk was observed over the five decades studied. INTERPRETATION This observational study showed an increased mortality risk in transgender people using hormone treatment, regardless of treatment type. This increased mortality risk did not decrease over time. The cause-specific mortality risk because of lung cancer, cardiovascular disease, HIV-related disease, and suicide gives no indication to a specific effect of hormone treatment, but indicates that monitoring, optimising, and, if necessary, treating medical morbidities and lifestyle factors remain important in transgender health care. FUNDING None.
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Affiliation(s)
- Christel Jm de Blok
- Department of Internal Medicine, Division of Endocrinology, Amsterdam University Medical Centres, VU University Medical Centre, Amsterdam, The Netherlands; Centre of Expertise on Gender Dysphoria, Amsterdam University Medical Centres, VU University Medical Centre, Amsterdam, The Netherlands
| | - Chantal M Wiepjes
- Department of Internal Medicine, Division of Endocrinology, Amsterdam University Medical Centres, VU University Medical Centre, Amsterdam, The Netherlands; Centre of Expertise on Gender Dysphoria, Amsterdam University Medical Centres, VU University Medical Centre, Amsterdam, The Netherlands
| | - Daan M van Velzen
- Department of Internal Medicine, Division of Endocrinology, Amsterdam University Medical Centres, VU University Medical Centre, Amsterdam, The Netherlands; Centre of Expertise on Gender Dysphoria, Amsterdam University Medical Centres, VU University Medical Centre, Amsterdam, The Netherlands
| | - Annemieke S Staphorsius
- Department of Internal Medicine, Division of Endocrinology, Amsterdam University Medical Centres, VU University Medical Centre, Amsterdam, The Netherlands; Centre of Expertise on Gender Dysphoria, Amsterdam University Medical Centres, VU University Medical Centre, Amsterdam, The Netherlands
| | - Nienke M Nota
- Department of Internal Medicine, Division of Endocrinology, Amsterdam University Medical Centres, VU University Medical Centre, Amsterdam, The Netherlands; Centre of Expertise on Gender Dysphoria, Amsterdam University Medical Centres, VU University Medical Centre, Amsterdam, The Netherlands
| | - Louis Jg Gooren
- Department of Internal Medicine, Division of Endocrinology, Amsterdam University Medical Centres, VU University Medical Centre, Amsterdam, The Netherlands; Centre of Expertise on Gender Dysphoria, Amsterdam University Medical Centres, VU University Medical Centre, Amsterdam, The Netherlands
| | - Baudewijntje Pc Kreukels
- Centre of Expertise on Gender Dysphoria, Amsterdam University Medical Centres, VU University Medical Centre, Amsterdam, The Netherlands; Department of Medical Psychology, Amsterdam University Medical Centres, VU University Medical Centre, Amsterdam, The Netherlands
| | - Martin den Heijer
- Department of Internal Medicine, Division of Endocrinology, Amsterdam University Medical Centres, VU University Medical Centre, Amsterdam, The Netherlands; Centre of Expertise on Gender Dysphoria, Amsterdam University Medical Centres, VU University Medical Centre, Amsterdam, The Netherlands.
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27
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Tangpricha V. Health disparities in transgender people. Lancet Diabetes Endocrinol 2021; 9:641-643. [PMID: 34481557 DOI: 10.1016/s2213-8587(21)00211-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2021] [Accepted: 07/26/2021] [Indexed: 11/27/2022]
Affiliation(s)
- Vin Tangpricha
- Division of Endocrinology, Metabolism and Lipids, Department of Medicine, Emory University School of Medicine, Atlanta, GA 30322, USA; Atlanta VA Medical Center, Decatur, GA, USA.
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28
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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] [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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29
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Hranilovich JA, Kaiser EA, Pace A, Barber M, Ziplow J. Headache in transgender and gender-diverse patients: A narrative review. Headache 2021; 61:1040-1050. [PMID: 34363408 DOI: 10.1111/head.14171] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2021] [Revised: 05/14/2021] [Accepted: 05/18/2021] [Indexed: 12/26/2022]
Abstract
OBJECTIVE To summarize the unique aspects of managing headache in gender minorities and current research in this area including the potential relationship between gender-affirming hormone therapy (GAHT) and headache. BACKGROUND The study of headache in gender minorities is intrinsically important. Gender minorities are medically underserved, and their medical care to date has been limited by socioeconomic disadvantages including stigma and an unsupportive clinical environment. Despite the rising population of transgender and gender-diverse adults and youth, headache research has also been limited. Knowledge of hormonal effects on headache in cisgender patients raises the question of possible effects of GAHT on transgender patients. METHODS/RESULTS The manuscript is a narrative review of current best practices in treating transgender patients, including the use of appropriate terminology and ways to create a supportive environment. It also contains current guidelines on GAHT and reviews drug-drug interactions and secondary headache related to hormone therapy. We also review transgender headache research and related research on hormonal effects on headache in cisgender individuals. CONCLUSION Creating a supportive environment for transgender and gender-diverse patients and being knowledgeable about GAHT are key to providing quality headache care. This review identifies further research needs for this population including the epidemiology of headache disorders in sexual minorities and the potential effects of GAHT on headache disorders in transgender patients.
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Affiliation(s)
- Jennifer A Hranilovich
- Division of Neurology, Department of Pediatrics, Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, CO, USA
| | - Eric A Kaiser
- Department of Neurology, University of Pennsylvania, Philadelphia, PA, USA
| | - Anna Pace
- Department of Neurology, Icahn School of Medicine at Mount Sinai, The Mount Sinai Hospital, New York, NY, USA
| | - Mark Barber
- Department of Neurology, Icahn School of Medicine at Mount Sinai, The Mount Sinai Hospital, New York, NY, USA
| | - Jason Ziplow
- Department of Neurology, Children's Hospital of Philadelphia, Philadelphia, PA, USA
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Millward CP, Phillips E, Alalade AF, Gilkes CE. Gender-affirming hormone therapy associated with multiple meningiomas and atypical histology in a transgender woman. BMJ Case Rep 2021; 14:14/7/e242813. [PMID: 34261631 DOI: 10.1136/bcr-2021-242813] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
We present a 69-year-old transgender woman who underwent gender-affirming surgery in 1998 and gender-affirming hormone therapy (cyproterone acetate (CPA) and estradiol) since this time. Following an MRI scan to investigate tremor in 2013, an incidental left anterior clinoid and right petrous meningioma were identified. Subtotal surgical resection was achieved for the anterior clinoid meningioma (WHO grade 1, meningothelial subtype). At follow-up in 2016, an olfactory groove meningioma and left greater wing of sphenoid meningioma were identified. By 2017, both tumours, along with the petrous meningioma, demonstrated significant growth. In 2018, clinical decline was evident and MRI demonstrated further tumour growth. Surgery was scheduled and the olfactory groove meningioma was completely resected (WHO grade 2, chordoid subtype). Hormones were stopped, after which regression of the petrous meningioma was observed. This case demonstrates an association between high-dose CPA and estradiol and the development, growth and regression of meningiomas in a transgender woman.
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Affiliation(s)
- Christopher Paul Millward
- Institute of Systems, Molecular, and Integrative Biology, University of Liverpool, Liverpool, UK .,Department of Neurosurgery, The Walton Centre NHS Foundation Trust, Liverpool, UK
| | - Eleri Phillips
- Department of Neurosurgery, The Walton Centre NHS Foundation Trust, Liverpool, UK
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Even Zohar N, Sofer Y, Yaish I, Serebro M, Tordjman K, Greenman Y. Low-Dose Cyproterone Acetate Treatment for Transgender Women. J Sex Med 2021; 18:1292-1298. [PMID: 37057422 DOI: 10.1016/j.jsxm.2021.04.008] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2021] [Revised: 04/11/2021] [Accepted: 04/14/2021] [Indexed: 01/27/2023]
Abstract
BACKGROUND Transgender women with intact gonads receive lifelong hormonal treatment to suppress physiologic androgen production, the optimal efficacious and safe cyproterone acetate (CPA) dose has not been established. AIM To assess the effectiveness and safety of low-dose (10-20 mg/day) compared with high-dose (50-100 mg/day) CPA treatment. METHODS We conducted a historical cohort study of transgender women treated at a tertiary center for transgender health. OUTCOME MEASURES Serum levels of testosterone, estradiol, prolactin, gonadotrophins, liver enzymes, and lipids. RESULTS There were 38 transgender women in the low-dose group and 26 in the high-dose group. Age (median 24.9 years, interquartile range [IQR] 21-30 vs 25 years, IQR 19-35) and follow-up time (median 12 months, IQR 6-23 vs 15 months, IQR 12-36) were similar in the low- and high-dose groups, respectively. Serum gonadotropins and testosterone were suppressed to a similar level at all time points in both groups. Prolactin levels increased significantly in both groups, however, with a more substantial increase in the high- vs the low-dose group (804 ± 121 vs 398 ± 69 mIU/ml at 12 months, respectively, P = .004). Total cholesterol, high-density lipoprotein, low-density lipoprotein, and triglyceride levels were not significantly affected by the dose. CLINICAL IMPLICATIONS We suggest an adjustment of current clinical practice guidelines to recommend lower doses of CPA for the treatment of transgender women. STRENGTHS & LIMITATIONS This is the first demonstration that low-dose CPA treatment of transgender women is effective. Limitations include a relatively small sample and retrospective study design. CONCLUSION Low-dose CPA treatment of transgender women is as effective as high-dose treatment and possibly safer. Zohar NE, Sofer Y, Yaish I, et al. Low-Dose Cyproterone Acetate Treatment for Transgender Women. J Sex Med 2021;18:1292-1298.
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Affiliation(s)
- Naomi Even Zohar
- Institute of Endocrinology, Metabolism, Diabetes and Hypertension, Tel Aviv-Sourasky Medical Center, Tel Aviv, Israel
| | - Yael Sofer
- Institute of Endocrinology, Metabolism, Diabetes and Hypertension, Tel Aviv-Sourasky Medical Center, Tel Aviv, Israel
| | - Iris Yaish
- Institute of Endocrinology, Metabolism, Diabetes and Hypertension, Tel Aviv-Sourasky Medical Center, Tel Aviv, Israel
| | - Merav Serebro
- Institute of Endocrinology, Metabolism, Diabetes and Hypertension, Tel Aviv-Sourasky Medical Center, Tel Aviv, Israel
| | - Karen Tordjman
- Institute of Endocrinology, Metabolism, Diabetes and Hypertension, Tel Aviv-Sourasky Medical Center, Tel Aviv, Israel; Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Yona Greenman
- Institute of Endocrinology, Metabolism, Diabetes and Hypertension, Tel Aviv-Sourasky Medical Center, Tel Aviv, Israel; Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.
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Pregnall AM, Churchwell AL, Ehrenfeld JM. A Call for LGBTQ Content in Graduate Medical Education Program Requirements. ACADEMIC MEDICINE : JOURNAL OF THE ASSOCIATION OF AMERICAN MEDICAL COLLEGES 2021; 96:828-835. [PMID: 34031304 DOI: 10.1097/acm.0000000000003581] [Citation(s) in RCA: 47] [Impact Index Per Article: 15.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
Abstract
A well-developed body of literature demonstrates that lesbian, gay, bisexual, transgender, and queer (LGBTQ) individuals experience poorer health outcomes and report worse health care experiences than straight/cisgender individuals. Many reforms since 2010 have addressed the LGBTQ-related education of future health care professionals at the undergraduate medical education (UME) level; however, reforms at the graduate medical education (GME) level are lagging, and new literature suggests that didactic education at the UME level is not enough to prepare future physicians to properly and compassionately care for LGBTQ patients. Recently, the Accreditation Council for Graduate Medical Education (ACGME) implemented a major revision of its Common Program Requirements that requires residents to demonstrate, as a competence, respect and responsiveness to diverse populations. Given these revisions and the ongoing failure of many GME training programs to adequately prepare future physicians to care for LGBTQ patients, the authors argue that now is the time for the ACGME to develop and implement LGBTQ health-related residency requirements. In addition, the authors outline a path by which the academic medical community may develop and implement these requirements.
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Affiliation(s)
- Andrew M Pregnall
- A.M. Pregnall is LGBTQ health intern, Vanderbilt Program for LGBTQ Health, Vanderbilt University Medical Center, Nashville, Tennessee; ORCID: https://orcid.org/0000-0001-9629-0636
| | - André L Churchwell
- A.L. Churchwell is professor of medicine (cardiology), professor of radiology and radiological sciences, professor of biomedical engineering, and senior associate dean, Diversity Affairs, Vanderbilt University School of Medicine, and chief diversity officer, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Jesse M Ehrenfeld
- J.M. Ehrenfeld is senior associate dean and director, Advancing a Healthier Wisconsin Endowment, the Medical College of Wisconsin, Milwaukee, Wisconsin
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Rosendale N, Wong JO, Flatt JD, Whitaker E. Sexual and Gender Minority Health in Neurology: A Scoping Review. JAMA Neurol 2021; 78:747-754. [PMID: 33616625 DOI: 10.1001/jamaneurol.2020.5536] [Citation(s) in RCA: 33] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Importance Little is known about the neurologic health needs of sexual and gender minority (SGM) individuals, and existing research indicates health care disparities for this group. Objective To describe the current state of science in SGM neurology and highlight areas of knowledge and gaps to guide future research. Evidence Review All articles published before April 12, 2020, in PubMed, Embase, Web of Science, PsycInfo, CINAHL, and BIOSIS Previews were searched using a search string encompassing SGM descriptors and neurologic disorders. A total of 8359 items were found and entered into EndNote, and 2921 duplicates were removed. A blind title and abstract review was performed followed by full-text review in duplicate, with conflicts settled through consensus, to identify 348 articles eligible for data abstraction. Articles presenting primary data about an identified adult SGM population addressing a clinical neurology topic were included. Descriptive statistics were used for abstracted variables. Findings Of 348 studies, 205 (58.9%) were case reports or series, 252 (72.4%) included sexual minority cisgender men, and 247 (70.9%) focused on HIV. An association was found between autism spectrum disorder and gender dysphoria in 9 of 16 studies (56.3%), and a higher risk of ischemic stroke in transgender women was shown in other studies. Literature in neuroinfectious disease, the most common topic, largely focused on HIV (173 of 200 studies [86.5%]). Findings in other neurologic topics were limited by lack of data. Conclusions and Relevance In this rigorous compendium of SGM neurology literature, several deficiencies were found: most studies focused on a limited breadth of neurologic pathology, included only a portion of the overall SGM community, and did not assess other aspects of sociodemographic diversity that may contribute to disparities in health care access and outcomes among SGM individuals. Expanding neurologic research to include broader representation of SGM individuals and incorporating sociodemographic factors, like race/ethnicity and socioeconomic status, are essential steps toward providing equitable neurologic care for this community.
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Affiliation(s)
- Nicole Rosendale
- Department of Neurology, University of California, San Francisco Medical Center, San Francisco.,Weill Institute for Neurosciences, University of California, San Francisco
| | | | - Jason D Flatt
- School of Public Health, University of Nevada, Las Vegas
| | - Evans Whitaker
- Health Science Library, University of California, San Francisco
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Angus LM, Nolan BJ, Zajac JD, Cheung AS. A systematic review of antiandrogens and feminization in transgender women. Clin Endocrinol (Oxf) 2021; 94:743-752. [PMID: 32926454 DOI: 10.1111/cen.14329] [Citation(s) in RCA: 28] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2020] [Revised: 09/02/2020] [Accepted: 09/03/2020] [Indexed: 01/01/2023]
Abstract
Antiandrogens are frequently used with estradiol in transgender women seeking feminization. Antiandrogens act by various mechanisms to decrease the production or effects of testosterone, but it is unclear which antiandrogen is most effective at feminization. A systematic review was performed using PRISMA guidelines. We searched online databases (Medline, Embase and PsycINFO) and references of relevant articles for studies of antiandrogens in transgender women aged 16+ years to achieve feminization (namely changes in breast size, body composition, facial or body hair) or changes in serum total testosterone concentration when compared to placebo, estradiol alone or an alternative antiandrogen. Four studies fulfilled eligibility criteria and were included in a narrative review. The addition of cyproterone acetate, leuprolide and medroxyprogesterone acetate may be more effective than spironolactone or estradiol alone at suppressing the serum total testosterone concentration. Body composition changes appear similar in transgender women treated with estradiol and additional cyproterone acetate or leuprolide. No eligible studies adequately evaluated the effects of antiandrogens on breast development or facial and body hair reduction. It remains unclear which antiandrogen is most effective at achieving feminization. Cyproterone acetate, medroxyprogesterone acetate and leuprolide may be more effective than spironolactone at suppressing the serum total testosterone concentration. However, due to spironolactone's antagonism of the androgen receptor, it is unclear whether this results in clinically meaningful differences in feminization. Further research with clinically meaningful endpoints is needed to optimize the use of antiandrogens in transgender women.
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Affiliation(s)
- Lachlan M Angus
- Department of Medicine, The University of Melbourne, Heidelberg, Vic., Australia
- Department of Endocrinology, Austin Health, Ivanhoe, Vic., Australia
| | - Brendan J Nolan
- Department of Medicine, The University of Melbourne, Heidelberg, Vic., Australia
- Department of Endocrinology, Austin Health, Ivanhoe, Vic., Australia
| | - Jeffrey D Zajac
- Department of Medicine, The University of Melbourne, Heidelberg, Vic., Australia
- Department of Endocrinology, Austin Health, Ivanhoe, Vic., Australia
| | - Ada S Cheung
- Department of Medicine, The University of Melbourne, Heidelberg, Vic., Australia
- Department of Endocrinology, Austin Health, Ivanhoe, Vic., Australia
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Raven LM, Guttman-Jones M, Muir CA. Hyperprolactinemia and association with prolactinoma in transwomen receiving gender affirming hormone treatment. Endocrine 2021; 72:524-528. [PMID: 33398769 DOI: 10.1007/s12020-020-02563-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2020] [Accepted: 11/22/2020] [Indexed: 11/24/2022]
Abstract
PURPOSE Approximately 0.6% of the adult population identifies as transgender. Gender affirming hormone treatment (GAHT) is required by many to develop physical and psychological characteristics that align with their gender identity. Once started, GAHT is continued lifelong and at higher doses than conventionally used in the management of cis-gendered women. Hyperprolactinemia and pituitary lactotroph adenomas are a potential consequence of GAHT. METHODS Case series of three transfeminine women with hyperprolactinemia during gender affirming hormone treatment. RESULTS We report two new cases of prolactinoma and one new case of marked hyperprolactinemia without pituitary adenoma associated with GAHT in transwomen at different stages of hormonal transition. Novel aspects of our case series include the first report of a prolactinoma in a transwoman associated with spironolactone and the alternate progestin medroxyprogesterone acetate and documentation of the transient changes in prolactin from baseline (prior to feminizing hormones) in two transwomen which demonstrate that marked hyperprolactinemia develops early in the course of GAHT. CONCLUSIONS Transgender women receiving GAHT may be at increased risk for prolactinoma. As the number of transwomen seeking GAHT continues to increase, hyperprolactinemia and GAHT-associated prolactinoma may become an increasingly important component of endocrine practice. Screening of prolactin levels in transwomen receiving GAHT could potentially prevent morbidity related to hyperprolactinemia and allow for early detection of prolactin secreting pituitary adenomas.
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Affiliation(s)
- Lisa M Raven
- Department of Endocrinology, St. Vincent's Hospital, Sydney, NSW, Australia
| | | | - Christopher A Muir
- Department of Endocrinology, St. Vincent's Hospital, Sydney, NSW, Australia.
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Malaize H, Samoyeau T, Zanello M, Roux A, Benzakoun J, Peeters S, Zah-Bi G, Edjlali M, Tauziede-Espariat A, Dezamis E, Parraga E, Chrétien F, Varlet P, Plu-Bureau G, Oppenheim C, Pallud J. Evolution of the neurosurgical management of progestin-associated meningiomas: a 23-year single-center experience. J Neurooncol 2021; 152:279-288. [PMID: 33449307 DOI: 10.1007/s11060-021-03696-9] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2020] [Accepted: 01/04/2021] [Indexed: 12/19/2022]
Abstract
PURPOSE The improving knowledge of interactions between meningiomas and progestin refines the management of this specific condition. We assessed the changes over time of the management of progestin-associated meningiomas. METHODS We retrospectively studied consecutive adult patients who had at least one meningioma in the context of progestin intake (October 1995-October 2018) in a tertiary adult Neurosurgical Center. RESULTS 71 adult women with 125 progestin-associated meningiomas were included. The number of progestin-associated meningioma patients increased over time (0.5/year before 2008, 22.0/year after 2017). Progestin treatment was an approved indication in 27.0%. A mean of 1.7 ± 1.2 meningiomas were discovered per patient (median 1, range 1-6). Surgery was performed on 36 (28.8%) meningiomas and the histopathologic grading was WHO grade 1 in 61.1% and grade 2 in 38.9%. The conservative management of meningiomas increased over time (33.3% before 2008, 64.3% after 2017) and progestin treatment withdrawal increased over time (16.7% before 2008, 95.2% after 2017). Treatment withdrawal varied depending on the progestin derivative used (88.9% with cyproterone acetate, 84.6% with chlormadinone acetate, 28.6% with nomegestrol acetate, 66.7% with progestin derivative combination). The main reason for therapeutic management of meningiomas was the presence of clinical signs. Among the 54 meningiomas managed conservatively for which the progestin had been discontinued, MRI follow-up demonstrated a regression in 29.6%, a stability in 68.5%, and an ongoing growth in 1.9% of cases. CONCLUSIONS Conservative management, including progestin treatment discontinuation, has grown over time with promising results in terms of efficacy and safety.
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Affiliation(s)
- Henri Malaize
- Department of Neurosurgery, Service de Neurochirurgie, GHU site Sainte-Anne, Paris, France
- Université de Paris, Paris, France
| | - Thomas Samoyeau
- Université de Paris, Paris, France
- Department of Neuroradiology, GHU site Sainte-Anne, Paris, France
| | - Marc Zanello
- Department of Neurosurgery, Service de Neurochirurgie, GHU site Sainte-Anne, Paris, France
- Université de Paris, Paris, France
- Institut de Psychiatrie et Neurosciences de Paris (IPNP), UMR S1266, INSERM, IMA-BRAIN, Paris, France
| | - Alexandre Roux
- Department of Neurosurgery, Service de Neurochirurgie, GHU site Sainte-Anne, Paris, France
- Université de Paris, Paris, France
- Institut de Psychiatrie et Neurosciences de Paris (IPNP), UMR S1266, INSERM, IMA-BRAIN, Paris, France
| | - Joseph Benzakoun
- Université de Paris, Paris, France
- Department of Neuroradiology, GHU site Sainte-Anne, Paris, France
- Institut de Psychiatrie et Neurosciences de Paris (IPNP), UMR S1266, INSERM, IMA-BRAIN, Paris, France
| | - Sophie Peeters
- Department of Neurosurgery, University of California, Los Angeles, Los Angeles, CA, USA
| | - Gilles Zah-Bi
- Department of Neurosurgery, Service de Neurochirurgie, GHU site Sainte-Anne, Paris, France
- Université de Paris, Paris, France
| | - Myriam Edjlali
- Université de Paris, Paris, France
- Department of Neuroradiology, GHU site Sainte-Anne, Paris, France
- Institut de Psychiatrie et Neurosciences de Paris (IPNP), UMR S1266, INSERM, IMA-BRAIN, Paris, France
| | | | - Edouard Dezamis
- Department of Neurosurgery, Service de Neurochirurgie, GHU site Sainte-Anne, Paris, France
- Université de Paris, Paris, France
| | - Eduardo Parraga
- Department of Neurosurgery, Service de Neurochirurgie, GHU site Sainte-Anne, Paris, France
- Université de Paris, Paris, France
| | - Fabrice Chrétien
- Université de Paris, Paris, France
- Department of Neuropathology, GHU site Sainte-Anne, Paris, France
| | - Pascale Varlet
- Université de Paris, Paris, France
- Institut de Psychiatrie et Neurosciences de Paris (IPNP), UMR S1266, INSERM, IMA-BRAIN, Paris, France
- Department of Neuropathology, GHU site Sainte-Anne, Paris, France
| | - Geneviève Plu-Bureau
- Obstetrical, Perinatal and Pediatric Epidemiology Research Team, Center for Epidemiology and Biostatistics, INSERM U1153, Paris-Descartes University, Paris, France
- Gynecology Endocrinology Unit, University Hospital Paris Centre, Cochin Hospital, APHP, Paris, France
| | - Catherine Oppenheim
- Université de Paris, Paris, France
- Department of Neuroradiology, GHU site Sainte-Anne, Paris, France
- Institut de Psychiatrie et Neurosciences de Paris (IPNP), UMR S1266, INSERM, IMA-BRAIN, Paris, France
| | - Johan Pallud
- Department of Neurosurgery, Service de Neurochirurgie, GHU site Sainte-Anne, Paris, France.
- Université de Paris, Paris, France.
- Institut de Psychiatrie et Neurosciences de Paris (IPNP), UMR S1266, INSERM, IMA-BRAIN, Paris, France.
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Cyproterone acetate and meningioma: a nationwide-wide population based study. J Neurooncol 2021; 151:331-338. [PMID: 33394263 DOI: 10.1007/s11060-020-03672-9] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2020] [Accepted: 12/02/2020] [Indexed: 12/22/2022]
Abstract
BACKGROUND The study the characteristics of surgical meningiomas in female patients who took CPA and to compare this population to a non-CPA control group. MATERIALS AND METHODS We processed the French Système National des Données de Santé (SNDS) database to retrieve appropriate cases operated between 2007 and 2017. RESULTS 1 101 female patients (3.8%) who used to take CPA and underwent a meningioma surgery were extracted from a nationwide population based cohort of 28 924 patients. Median age at CPA prescription was 42 years IQR[36.7-48.9]. The median time between CPA start and surgery was 5.5 years IQR[3.1-7.9]. The median age at surgery was significantly lower in patients who were treated by CPA (47 years, IQR[42-54) compared to the non-CPA population (61 years, IQR[51-70], p < 0.001). Median CPA dose was 40 g, IQR[19-72]. There was a strong correlation between CPA dose and duration (r = 0.58, 95%CI[0.54-0.62], p < 0.001). Middle skull base was the most common (39%) location with a anterior skull base insertion being also far more common compared to the usual population with 21.9% of the tumour. This skull base predominance of CPA-associated meningioma is highly significant (p < 0.001). Increased CPA dose raised the risk of having multiple meningioma surgeries (p < 0.001) and multiple meningioma locations (p < 0.001). Tumour grading was not modified by CPA treatment (p = 0.603). Benign or grade I meningioma accounting for 92%, atypical or grade II for 6.1% and malignant or grade III for 1.9%. CONCLUSION In the past 10 years, a significant number of CPA-induced meningiomas have been removed, modifying the global pyramid of age at surgery for female patients. These tumours occur well before the usual age and are preferentially located on the anterior and middle skull base.
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Le Rhun E, Weller M. Sex-specific aspects of epidemiology, molecular genetics and outcome: primary brain tumours. ESMO Open 2020; 5:e001034. [PMID: 33234601 PMCID: PMC7689067 DOI: 10.1136/esmoopen-2020-001034] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2020] [Revised: 10/12/2020] [Accepted: 10/14/2020] [Indexed: 11/16/2022] Open
Abstract
Recent years have seen a great interest in sex-specific aspects of many diseases, including cancer, in part because of the assumption that females have often not been adequately represented in early drug development and determination of safety, tolerability and efficacy in clinical trials. Brain tumours represent a highly heterogeneous group of neoplastic diseases with strong variation of incidence by age, but partly also by sex. Most gliomas are more common in men whereas meningiomas, the most common primary intracranial tumours, are more common in females. Potential sex-specific genetic risk factors and specific sex biology have been reported in a tumour-specific manner. Several small studies have indicated differences in tolerability and safety of, as well as benefit from, treatment by sex, but no conclusive data have been generated. Exploring sex-specific aspects of neuro-oncology should be studied more systematically and in more depth in order to uncover the biological reasons for known sex differences in this disease.
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Affiliation(s)
- Emilie Le Rhun
- Departments of Neurology and Neurosurgery, Clinical Neuroscience Center and Brain Tumor Center, University Hospital Zurich, Zurich, Switzerland.
| | - Michael Weller
- Department of Neurology, Clinical Neuroscience Center and Brain Tumor Center, University Hospital and University of Zurich, Zurich, Switzerland
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Emmert AS, Hussein AE, Slobodian O, Krueger B, Bhabhra R, Hagen MC, Pickle S, Forbes JA. Case Report of Transgender Patient with Gonadotropic Dysfunction Secondary to Craniopharyngioma: Toward Improving Understanding of Biopsychosocial Dynamics of Gender Identity in Neurosurgical Care. World Neurosurg 2020; 145:448-453. [PMID: 33045454 DOI: 10.1016/j.wneu.2020.09.168] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2020] [Revised: 09/28/2020] [Accepted: 09/30/2020] [Indexed: 11/17/2022]
Abstract
BACKGROUND There is a paucity of information in the literature linking possible neuroendocrinologic repercussions of anterior pituitary insufficiency from tumor-associated mass effect with gender identity in transindividuals. The authors present the case of a 26-year-old transgender woman who was found to have a sellar/suprasellar neoplasm after reporting loss of vision in a bitemporal distribution. CASE DESCRIPTION Magnetic resonance imaging demonstrated a 2.6-cm complex cystic and solid sellar/suprasellar mass, suggestive of craniopharyngioma, intimately associated with the pituitary stalk. Importantly, this radiographic diagnosis was made 2 years following the initiation of gender-affirming hormone therapy (HT). Laboratory testing following radiographic diagnosis demonstrated evidence of diffuse anterior pituitary insufficiency with decreased morning cortisol, free thyroxine, insulin-like growth factor-1, and testosterone. Following optimization with the endocrinology team, the patient was taken to the operating room for expanded endonasal resection of tumor with lumbar drain insertion and nasoseptal flap coverage. Gross total resection was achieved with marked improvement in vision noted following surgery. The patient continued her HT following surgery. CONCLUSIONS In hindsight, the neuroendocrinologic manifestations of the craniopharyngioma may have influenced distressing pubertal experiences that distanced her from her assigned male sex, as well as the desired effects of feminization HT in this patient, ultimately delaying her presentation to the neurosurgery service and diagnosis of craniopharyngioma. As the first report of the neurosurgical evaluation and treatment of a transgender patient with anterior pituitary insufficiency secondary to craniopharyngioma, this case examines the biopsychosocial interplay between the development of gender identity and the neuroendocrinologic manifestations of craniopharyngioma.
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Affiliation(s)
- A Scott Emmert
- Department of Neurosurgery, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Ahmed E Hussein
- Department of Neurosurgery, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Olesia Slobodian
- Department of Neurosurgery, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Bryan Krueger
- Department of Neurosurgery, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Ruchi Bhabhra
- Department of Internal Medicine, Division of Endocrinology, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Matthew C Hagen
- Department of Pathology and Laboratory Medicine, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Sarah Pickle
- Department of Family and Community Medicine, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Jonathan A Forbes
- Department of Neurosurgery, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA.
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Thibaut F, Cosyns P, Fedoroff JP, Briken P, Goethals K, Bradford JMW. The World Federation of Societies of Biological Psychiatry (WFSBP) 2020 guidelines for the pharmacological treatment of paraphilic disorders. World J Biol Psychiatry 2020; 21:412-490. [PMID: 32452729 DOI: 10.1080/15622975.2020.1744723] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
Objectives: The primary aim of these guidelines is to evaluate the role of pharmacological agents in the treatment and management of patients with paraphilic disorders, with a focus on the treatment of adult males. Because such treatments are not delivered in isolation, the role of specific psychotherapeutic interventions is also briefly covered. These guidelines are intended for use in clinical practice by clinicians who diagnose and treat patients, including sexual offenders, with paraphilic disorders. The aim of these guidelines is to bring together different views on the appropriate treatment of paraphilic disorders from experts representing different countries in order to aid physicians in clinical decisions and to improve the quality of care.Methods: An extensive literature search was conducted using the English-language-literature indexed on MEDLINE/PubMed (1990-2018 for SSRIs) (1969-2018 for hormonal treatments), supplemented by other sources, including published reviews.Results: Each treatment recommendation was evaluated and discussed with respect to the strength of evidence for its efficacy, safety, tolerability, and feasibility. The type of medication used depends on the severity of the paraphilic disorder and the respective risk of behaviour endangering others. GnRH analogue treatment constitutes the most relevant treatment for patients with severe paraphilic disorders.Conclusions: An algorithm is proposed with different levels of treatment for different categories of paraphilic disorders accompanied by different risk levels.
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Affiliation(s)
- Florence Thibaut
- Department of Psychiatry and Addictive Disorders, University Hospital Cochin, University of Paris, INSERM U1266, Institute of Psychiatry and Neurosciences, Paris, France
| | - Paul Cosyns
- Collaborative Antwerp Psychiatric Research Institute (CAPRI), University of Antwerp, Antwerp, Belgium
| | - John Paul Fedoroff
- Division of Forensic Psychiatry, The Royal Institute of Mental Health Research, University of Ottawa, Ottawa, ON, Canada
| | - Peer Briken
- Institute for Sex Research, Sexual Medicine and Forensic Psychiatry, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany
| | - Kris Goethals
- Collaborative Antwerp Psychiatric Research Institute (CAPRI), University of Antwerp and University Forensic Centre, Antwerp University Hospital, Antwerp, Belgium
| | - John M W Bradford
- The Royal Institute of Mental Health Research, University of Ottawa, McMaster University, Ottawa & Hamilton, ON, Canada
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Greene DN, Schmidt RL, Winston McPherson G, Rongitsch J, Imborek KL, Dickerson JA, Drees JC, Humble RM, Nisly N, Dole NJ, Dane SK, Frerichs J, Krasowski MD. Reproductive Endocrinology Reference Intervals for Transgender Women on Stable Hormone Therapy. J Appl Lab Med 2020; 6:15-26. [PMID: 32674116 DOI: 10.1093/jalm/jfaa028] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2019] [Accepted: 11/25/2019] [Indexed: 01/29/2023]
Abstract
BACKGROUND Transgender women and nonbinary people seeking feminizing therapy are often prescribed estrogen as a gender-affirming hormone, which will alter their reproductive hormone axis. Testosterone, estradiol, and other reproductive hormones are commonly evaluated to assess therapy, but reference intervals specific to transgender women have not been established. The objective of this study was to derive reference intervals for commonly measured analytes related to reproductive endocrinology in a cohort of healthy gender nonconforming individuals on stable feminizing hormone therapy. METHODS Healthy transgender individuals who had been prescribed estrogen (n = 93) for at least a year were recruited from internal medicine and primary care clinics that specialize in transgender medical care. Total testosterone and estradiol were measured using immunoassay and mass spectrometry; LH, FSH, sex hormone binding globulin, prolactin, progesterone, anti-mullerian hormone (AMH), and dehydroepiandrosterone sulfate (DHEAS) were measured using immunoassay; free testosterone was calculated. Reference intervals (central 95%) were calculated according to Clinical Laboratory Standards Institute guidelines. RESULTS The distribution of results for transgender women was different than what would be expected from cisgender men or women across all measurements. Use of spironolactone was associated with changes in the result distribution of AMH, FSH, LH, and progesterone. Compared to liquid chromatography coupled to tandem mass spectrometry (LC/MS/MS), immunoassay was sufficient for the majority of estradiol and total testosterone measurements; free testosterone added little clinical value beyond total testosterone. CONCLUSION Reference intervals specific to transgender women should be applied when evaluating reproductive endocrine analytes. Spironolactone is a significant variable for result interpretation of some tests.
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Affiliation(s)
- Dina N Greene
- Department of Laboratory Medicine, University of Washington, Seattle, WA
| | | | | | | | - Katherine L Imborek
- Department of Family Medicine, University of Iowa Hospitals and Clinics, Iowa City, IA
| | | | - Julia C Drees
- The Permanente Medical Group Regional Laboratories, Berkeley, CA
| | - Robert M Humble
- Department of Pathology, University of Iowa Hospitals and Clinics, Iowa City, IA
| | - Nicole Nisly
- Department of Internal Medicine, University of Iowa Hospitals and Clinics, Iowa City, IA
| | - Nancy J Dole
- Department of Internal Medicine, University of Iowa Hospitals and Clinics, Iowa City, IA
| | - Susan K Dane
- Department of Pathology, University of Iowa Hospitals and Clinics, Iowa City, IA
| | - Janice Frerichs
- Department of Pathology, University of Iowa Hospitals and Clinics, Iowa City, IA
| | - Matthew D Krasowski
- Department of Pathology, University of Iowa Hospitals and Clinics, Iowa City, IA
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Kleinschmidt-DeMasters BK. Pituitary Adenomas in Transgender Individuals? J Neuropathol Exp Neurol 2020; 79:62-66. [PMID: 31769844 DOI: 10.1093/jnen/nlz118] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2019] [Revised: 08/22/2019] [Accepted: 10/31/2019] [Indexed: 11/12/2022] Open
Abstract
Transgender individuals may receive long-term hormonal treatment as part of their sexual transition; limited literature has suggested that they consequently may be predisposed to development of prolactinomas. We questioned whether we had encountered such cases. Pathology databases were searched for the years 2000-2019 for tissue specimens from transgender individuals; Sixty surgical specimens from 58 individuals and 8 cytology specimens were identified. Two of these 60 were pituitary adenomas, neither of which were lactotroph adenomas (prolactinomas).The first occurred in a 71-year-old transgender male-to-female who had undergone high-dose hormone therapy, followed by orchiectomy 30 years prior. Chronic hypertension, dizziness, and vertigo prompted an endocrine workup which revealed elevated IGF-1 and prolactin; The pituitary mass proved to be a mixed somatotroph/lactotroph adenoma. The second occurred in a 53-year-old transgender male-to-female who was being evaluated by an endocrinologist prior to initiating hormone therapy for transition when a slightly elevated prolactin level was discovered. This pituitary macroadenoma proved to be a gonadotroph adenoma. The most common surgical specimens were 33 bilateral mastectomies, 13 hysterectomies, and 4 orchiectomies, almost all for gender transition purposes rather than medical conditions. Pathologists may wish to be aware of the occurrence of pituitary adenomas in transgender individuals, although the incidence is quite low.
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Affiliation(s)
- Bette K Kleinschmidt-DeMasters
- Departments of Pathology, Neurosurgery, Neurology, University of Colorado Health Sciences Center, Aurora, Colorado (BKK-D)
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43
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Patel S, Abramowitz J. HYPERPROLACTINEMIA IN A TRANSGENDER MALE. AACE Clin Case Rep 2020; 6:e5-e8. [PMID: 32984514 PMCID: PMC7279772 DOI: 10.4158/accr-2019-0272] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2019] [Accepted: 09/05/2019] [Indexed: 10/06/2023] Open
Abstract
OBJECTIVE We present a case of hyperprolactinemia in a transgender male. We discuss the various etiologies for hyperprolactinemia in this population of patients and discuss management options. METHODS We present a case report and review of the literature. A 29-year-old transgender male treated with gender-affirming hormone therapy with testosterone presented with hyperprolactinemia. RESULTS Labs revealed an elevated prolactin level. The patient completed further laboratory evaluation as well as imaging with a pituitary magnetic resonance imaging which all revealed normal results. He was wearing a tightly fitted breast binder while awaiting bilateral mastectomy. After bilateral mastectomy prolactin normalized, suggesting breast binding as the cause of the elevated prolactin. CONCLUSION This is the only case in the literature which highlights breast binding as a possible cause of an elevated prolactin level. Our case report illustrates the various etiologies associated with an elevated prolactin level and highlights the importance of considering unique etiologies in populations such as transgender males.
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Wilson LM, Baker KE, Sharma R, Dukhanin V, McArthur K, Robinson KA. Effects of antiandrogens on prolactin levels among transgender women on estrogen therapy: A systematic review. INTERNATIONAL JOURNAL OF TRANSGENDER HEALTH 2020; 21:391-402. [PMID: 34993517 PMCID: PMC8726721 DOI: 10.1080/15532739.2020.1819505] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/04/2023]
Abstract
BACKGROUND Gender-affirming hormone therapy for transgender women includes estrogen and antiandrogens (cyproterone acetate, spironolactone, or gonadotropin-releasing hormone agonists). Both estrogen and antiandrogens are reported to increase prolactin levels. The objective is to systematically review the evidence of the effects of antiandrogens on prolactin levels, hyperprolactinemia, and prolactinomas among transgender women on estrogen therapy. METHODS We searched PubMed, Embase, and PsycInfo up to May 2020. We included studies with at least 3 months follow-up that evaluated the effects of antiandrogens among transgender women and reported on prolactin levels, hyperprolactinemia, or image-confirmed prolactinomas. Two reviewers independently screened studies for eligibility, serially abstracted data, and independently assessed risk of bias and graded strength of evidence. FINDINGS We included 17 studies (16 publications): 8 prospective cohorts, 8 retrospective cohorts, and 1 cross-sectional study, each with a moderate to serious risk of bias. Among transgender women on estrogen, prolactin levels increased by over 100% with cyproterone acetate and by up to 45% with spironolactone. However, we were unable to isolate the effects of antiandrogens from estrogen therapy. We were unable to draw conclusions about effects of antiandrogens on hyperprolactinemia and prolactinomas. INTERPRETATION Prolactin levels may be increased in transgender women who are taking both estrogens and an antiandrogen. Future research is needed to determine the effects of different antiandrogens on prolactin levels separately from estrogen therapy. Ideally, future studies would be prospective, provide either a comparison of two different antiandrogens or compare combination of estrogen and antiandrogen therapy to estrogen alone, and control for possible confounders.
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Affiliation(s)
- Lisa M. Wilson
- Department of Health Policy and Management, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD, USA
- CONTACT Lisa M. Wilson Department of Health Policy and Management, Johns Hopkins Bloomberg Schools of Public Health, Baltimore, MD, USA
| | - Kellan E. Baker
- Department of Health Policy and Management, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD, USA
| | - Ritu Sharma
- Department of Health Policy and Management, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD, USA
| | - Vadim Dukhanin
- Department of Health Policy and Management, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD, USA
| | - Kristen McArthur
- Department of Health Policy and Management, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD, USA
| | - Karen A. Robinson
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
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Abstract
Gender-affirming hormonal treatment (HT) in transgender people is considered safe in general, but the question regarding (long-term) risk on sex hormone-related cancer remains. Because the risk on certain types of cancer differs between men and women, and some of these differences are attributed to exposure to sex hormones, the cancer risk may be altered in transgender people receiving HT. Although reliable epidemiologic data are sparse, the available data will be discussed in this article. Furthermore, recommendations for cancer screening and prevention will be discussed as well as whether to withdraw HT at time of a cancer diagnosis.
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Affiliation(s)
- Christel J M de Blok
- Department of Internal Medicine, Amsterdam UMC, VU University Medical Center, Amsterdam, the Netherlands; Center of Expertise on Gender Dysphoria, Amsterdam UMC, VU University Medical Center, PO Box 7057, 1007 MB Amsterdam, the Netherlands
| | - Koen M A Dreijerink
- Department of Internal Medicine, Amsterdam UMC, VU University Medical Center, Amsterdam, the Netherlands; Center of Expertise on Gender Dysphoria, Amsterdam UMC, VU University Medical Center, PO Box 7057, 1007 MB Amsterdam, the Netherlands
| | - Martin den Heijer
- Department of Internal Medicine, Amsterdam UMC, VU University Medical Center, Amsterdam, the Netherlands; Center of Expertise on Gender Dysphoria, Amsterdam UMC, VU University Medical Center, PO Box 7057, 1007 MB Amsterdam, the Netherlands.
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Yang Q, Wang Y, Zhang S, Tang J, Li F, Yin J, Li Y, Fu J, Li B, Luo Y, Xue W, Zhu F. Biomarker Discovery for Immunotherapy of Pituitary Adenomas: Enhanced Robustness and Prediction Ability by Modern Computational Tools. Int J Mol Sci 2019; 20:E151. [PMID: 30609812 PMCID: PMC6337483 DOI: 10.3390/ijms20010151] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2018] [Revised: 12/25/2018] [Accepted: 12/26/2018] [Indexed: 12/15/2022] Open
Abstract
Pituitary adenoma (PA) is prevalent in the general population. Due to its severe complications and aggressive infiltration into the surrounding brain structure, the effective management of PA is required. Till now, no drug has been approved for treating non-functional PA, and the removal of cancerous cells from the pituitary is still under experimental investigation. Due to its superior specificity and safety profile, immunotherapy stands as one of the most promising strategies for dealing with PA refractory to the standard treatment, and various studies have been carried out to discover immune-related gene markers as target candidates. However, the lists of gene markers identified among different studies are reported to be highly inconsistent because of the greatly limited number of samples analyzed in each study. It is thus essential to substantially enlarge the sample size and comprehensively assess the robustness of the identified immune-related gene markers. Herein, a novel strategy of direct data integration (DDI) was proposed to combine available PA microarray datasets, which significantly enlarged the sample size. First, the robustness of the gene markers identified by DDI strategy was found to be substantially enhanced compared with that of previous studies. Then, the DDI of all reported PA-related microarray datasets were conducted to achieve a comprehensive identification of PA gene markers, and 66 immune-related genes were discovered as target candidates for PA immunotherapy. Finally, based on the analysis of human protein⁻protein interaction network, some promising target candidates (GAL, LMO4, STAT3, PD-L1, TGFB and TGFBR3) were proposed for PA immunotherapy. The strategy proposed together with the immune-related markers identified in this study provided a useful guidance for the development of novel immunotherapy for PA.
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Affiliation(s)
- Qingxia Yang
- School of Pharmaceutical Sciences, Chongqing University, Chongqing 401331, China.
- College of Pharmaceutical Sciences, Zhejiang University, Hangzhou 310058, China.
| | - Yunxia Wang
- College of Pharmaceutical Sciences, Zhejiang University, Hangzhou 310058, China.
| | - Song Zhang
- College of Pharmaceutical Sciences, Zhejiang University, Hangzhou 310058, China.
| | - Jing Tang
- School of Pharmaceutical Sciences, Chongqing University, Chongqing 401331, China.
- College of Pharmaceutical Sciences, Zhejiang University, Hangzhou 310058, China.
| | - Fengcheng Li
- College of Pharmaceutical Sciences, Zhejiang University, Hangzhou 310058, China.
| | - Jiayi Yin
- College of Pharmaceutical Sciences, Zhejiang University, Hangzhou 310058, China.
| | - Yi Li
- College of Pharmaceutical Sciences, Zhejiang University, Hangzhou 310058, China.
| | - Jianbo Fu
- College of Pharmaceutical Sciences, Zhejiang University, Hangzhou 310058, China.
| | - Bo Li
- School of Pharmaceutical Sciences, Chongqing University, Chongqing 401331, China.
| | - Yongchao Luo
- College of Pharmaceutical Sciences, Zhejiang University, Hangzhou 310058, China.
| | - Weiwei Xue
- School of Pharmaceutical Sciences, Chongqing University, Chongqing 401331, China.
| | - Feng Zhu
- School of Pharmaceutical Sciences, Chongqing University, Chongqing 401331, China.
- College of Pharmaceutical Sciences, Zhejiang University, Hangzhou 310058, China.
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