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Grock S, Weinreb J, Williams KC, Weimer A, Fadich S, Patel R, Geft A, Korenman S. Priorities for efficacy trials of gender-affirming hormone therapy with estrogen: collaborative design and results of a community survey. Hormones (Athens) 2024; 23:287-295. [PMID: 38311658 PMCID: PMC11219452 DOI: 10.1007/s42000-024-00532-3] [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] [Received: 05/30/2023] [Accepted: 01/17/2024] [Indexed: 02/06/2024]
Abstract
PURPOSE Treatment guidelines for gender-affirming hormone therapy with estrogen (GAHT-E) recommend specific dosing regimens based on limited data. Well-controlled efficacy trials are essential to tailoring treatment to patient goals as the guidelines recommend. The goal of this study was to take a foundational step toward designing community-centered effectiveness trials for gender-diverse individuals seeking GAHT-E. METHODS Our team developed a cross-sectional survey based on broad clinical experience and consultation with our community advisory board. The survey included 60 items covering demographics, transition history, goals and priorities for treatment, indicators of treatment success, sexual function goals, and future research priorities. The survey was distributed during the summer of 2021, primarily through social networks designed for gender-expansive individuals seeking treatment with estrogen. RESULTS A total of 1270 individuals completed the survey. Overall treatment goals most frequently rated "extremely important" or "very important" were the following: (1) improved satisfaction with life (81%), (2) appearing more feminine (80%), (3) appearing less masculine (77%), (4) improved mental health (76%), and (5) being seen as your true gender by others (75%). The three body characteristics most frequently rated "highest priority" or "high priority" among changes were the following: (1) facial hair (85%), (2) breast shape or size (84%), and (3) body shape (80%). The highest-rated research priority was comparing feminization with different routes of estrogen administration. CONCLUSION The goals and experiences of individuals seeking GAHT-E are diverse. Future clinical trials of GAHT-E should be grounded in the needs and priorities of community stakeholders.
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Affiliation(s)
- Shira Grock
- Division of Endocrinology, Diabetes and Metabolism, University of California, Los Angeles, David Geffen School of Medicine, Los Angeles, CA, 90095, USA.
- University of California, Los Angeles, David Geffen School of Medicine, Los Angeles, CA, 90095, USA.
- UCLA Gender Health Program, University of California, Los Angeles, David Geffen School of Medicine, Los Angeles, CA, 90095, USA.
| | - Jane Weinreb
- University of California, Los Angeles, David Geffen School of Medicine, Los Angeles, CA, 90095, USA
- Division of Endocrinology, Diabetes and Metabolism, VA Greater Los Angeles Healthcare System, Los Angeles, CA, 90073, USA
| | - Kristen C Williams
- UCLA Gender Health Program, University of California, Los Angeles, David Geffen School of Medicine, Los Angeles, CA, 90095, USA
| | - Amy Weimer
- University of California, Los Angeles, David Geffen School of Medicine, Los Angeles, CA, 90095, USA
- UCLA Gender Health Program, University of California, Los Angeles, David Geffen School of Medicine, Los Angeles, CA, 90095, USA
- Department of Medicine, University of California, Los Angeles, David Geffen School of Medicine, Los Angeles, CA, 90095, USA
| | - Sarah Fadich
- University of California, Los Angeles, David Geffen School of Medicine, Los Angeles, CA, 90095, USA
| | - Reema Patel
- Division of Endocrinology, Diabetes and Metabolism, University of California, Los Angeles, David Geffen School of Medicine, Los Angeles, CA, 90095, USA
- University of California, Los Angeles, David Geffen School of Medicine, Los Angeles, CA, 90095, USA
- UCLA Gender Health Program, University of California, Los Angeles, David Geffen School of Medicine, Los Angeles, CA, 90095, USA
| | - Atara Geft
- Division of Endocrinology, Diabetes and Metabolism, VA Greater Los Angeles Healthcare System, Los Angeles, CA, 90073, USA
- Division of General Internal Medicine, VA Greater Los Angeles Healthcare System, Los Angeles, CA, 90073, USA
| | - Stanley Korenman
- Division of Endocrinology, Diabetes and Metabolism, University of California, Los Angeles, David Geffen School of Medicine, Los Angeles, CA, 90095, USA
- University of California, Los Angeles, David Geffen School of Medicine, Los Angeles, CA, 90095, USA
- UCLA Gender Health Program, University of California, Los Angeles, David Geffen School of Medicine, Los Angeles, CA, 90095, USA
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2
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Coelingh Bennink HJT, Schultz IJ, Schmidt M, Jordan VC, Briggs P, Egberts JFM, Gemzell-Danielsson K, Kiesel L, Kluivers K, Krijgh J, Simoncini T, Stanczyk FZ, Langer RD. Progesterone from ovulatory menstrual cycles is an important cause of breast cancer. Breast Cancer Res 2023; 25:60. [PMID: 37254150 DOI: 10.1186/s13058-023-01661-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2023] [Accepted: 05/22/2023] [Indexed: 06/01/2023] Open
Abstract
Many factors, including reproductive hormones, have been linked to a woman's risk of developing breast cancer (BC). We reviewed the literature regarding the relationship between ovulatory menstrual cycles (MCs) and BC risk. Physiological variations in the frequency of MCs and interference with MCs through genetic variations, pathological conditions and or pharmaceutical interventions revealed a strong link between BC risk and the lifetime number of MCs. A substantial reduction in BC risk is observed in situations without MCs. In genetic or transgender situations with normal female breasts and estrogens, but no progesterone (P4), the incidence of BC is very low, suggesting an essential role of P4. During the MC, P4 has a strong proliferative effect on normal breast epithelium, whereas estradiol (E2) has only a minimal effect. The origin of BC has been strongly linked to proliferation associated DNA replication errors, and the repeated stimulation of the breast epithelium by P4 with each MC is likely to impact the epithelial mutational burden. Long-lived cells, such as stem cells, present in the breast epithelium, can carry mutations forward for an extended period of time, and studies show that breast tumors tend to take decades to develop before detection. We therefore postulate that P4 is an important factor in a woman's lifetime risk of developing BC, and that breast tumors arising during hormonal contraception or after menopause, with or without menopausal hormone therapy, are the consequence of the outgrowth of pre-existing neoplastic lesions, eventually stimulated by estrogens and some progestins.
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Affiliation(s)
| | - Iman J Schultz
- Pantarhei Bioscience BV, P.O. Box 464, 3700 AL, Zeist, The Netherlands
| | - Marcus Schmidt
- Department of Obstetrics and Gynaecology, University Medical Center Mainz, Mainz, Germany
| | - V Craig Jordan
- Department of Breast Medical Oncology, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Paula Briggs
- Sexual and Reproductive Health, Liverpool Women's NHS Foundation Trust, Liverpool, UK
| | | | | | - Ludwig Kiesel
- Department of Gynaecology and Obstetrics, University of Münster, Münster, Germany
| | - Kirsten Kluivers
- Department of Obstetrics and Gynaecology, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Jan Krijgh
- Pantarhei Bioscience BV, P.O. Box 464, 3700 AL, Zeist, The Netherlands
| | - Tommaso Simoncini
- Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Frank Z Stanczyk
- Department of Obstetrics and Gynaecology, University of Southern California, Keck School of Medicine, Los Angeles, CA, USA
| | - Robert D Langer
- Department of Family Medicine and Public Health, University of California San Diego School of Medicine, San Diego, CA, USA
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3
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Beatty AS, Tam D. Fibroadenoma in a transgender woman. J Surg Case Rep 2023; 2023:rjad202. [PMID: 37090904 PMCID: PMC10118391 DOI: 10.1093/jscr/rjad202] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2023] [Accepted: 03/25/2023] [Indexed: 04/25/2023] Open
Abstract
A breast fibroadenoma is a common benign condition that is typically seen in younger women. Rarely has it been described in men and often because of prescribed medications, but for transgender women, this occurrence is even rarer. Endocrine therapy plays a key role in the transition of a transwoman from male to female of which oestrogen is the most common form. The use of cross-sex hormones such as oestrogen is becoming increasingly more utilized in this transition helping in feminization but also secondary breast development. However, this does result in the development of other breast pathologies that were almost never seen in their cis-male counterparts. Herein, we present the case of a 27-year-old transwoman who presented with a palpable breast lump after being on oral oestrogen therapy for 6 years. She proceeded to an excisional biopsy, which confirmed the lesion to be a benign fibroadenoma.
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Affiliation(s)
- Andrew S Beatty
- Correspondence address. Department of General Surgery, The Prince Charles Hospital, Brisbane, QLD, Australia. Tel: +61 7 3139 4000; Fax: +61 7 3139 4050; E-mail:
| | - Diana Tam
- Department of General Surgery, The Prince Charles Hospital, Brisbane, QLD, Australia
- Department of General Surgery, The Royal Brisbane Women’s Hospital Brisbane, Brisbane, QLD, Australia
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4
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Hayward JH. Updates in Transgender Breast Imaging. Semin Ultrasound CT MR 2023; 44:23-34. [PMID: 36792271 DOI: 10.1053/j.sult.2022.10.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Transgender patients are seen in breast imaging centers for routine screening mammography and diagnostic imaging of the symptomatic breast. This comprehensive review of transgender breast imaging aims to update the radiologist on appropriate terminology, breast cancer risk in different patient populations, screening guidelines, and diagnostic scenarios. The chapter concludes with practical tips on how to optimize the patient experience.
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Affiliation(s)
- Jessica H Hayward
- Department of Radiology and Biomedical Imaging, University of California, San Francisco.
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5
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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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6
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Sudhakar D, Huang Z, Zietkowski M, Powell N, Fisher AR. Feminizing gender‐affirming hormone therapy for the transgender and gender diverse population: An overview of treatment modality, monitoring, and risks. Neurourol Urodyn 2022. [DOI: 10.1002/nau.25097] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2022] [Accepted: 11/06/2022] [Indexed: 11/21/2022]
Affiliation(s)
| | - Zhong Huang
- Pritzker School of Medicine University of Chicago Chicago Illinois USA
| | - Maeson Zietkowski
- Pritzker School of Medicine University of Chicago Chicago Illinois USA
| | - Natasha Powell
- Pritzker School of Medicine University of Chicago Chicago Illinois USA
| | - Andrew R. Fisher
- Department of Obstetrics and Gynecology University of Chicago Chicago Illinois USA
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7
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Abstract
Transgender and gender diverse (TGD) individuals may undergo a wide range of care during gender transition including mental health counseling, gender-affirming hormonal therapy, and various surgeries. Hormone therapy effectively converts the hormonal milieu into that of the affirmed gender and produces measurable alterations in serum markers for coronary artery disease and other hematologic conditions (eg, erythrocytosis, venous thrombosis). Although illegal in the United States, some transgender women may receive silicone injections for breast and soft tissue augmentation, which can lead to devastating local complications, as well as silicone migration, pulmonary embolism, systemic reactions, and death. Smoking rates are higher among transgender and sexual minority populations, placing them at elevated risk of smoking-related diseases, including lung cancer. Some opportunistic infections may be more common in the TGD populations, attributable to higher rates of coexisting infection with human immunodeficiency virus. Radiologists should be aware that these patients may develop cancer of their natal organs (eg, breast, prostate), especially as some of these tissues are not completely removed during gender-affirming surgery, which may manifest with thoracic involvement by secondary neoplasia. As more TGD patients seek medical care, thoracic radiologists can reasonably expect to interpret imaging performed in this population and should be aware of possible disease processes and potential complications of hormonal and surgical therapies.
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8
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Milionis C, Ilias I, Koukkou E. Progesterone in gender-affirming therapy of trans women. World J Biol Chem 2022; 13:66-71. [PMID: 35721880 PMCID: PMC10558402 DOI: 10.4331/wjbc.v13.i3.66] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2021] [Revised: 02/28/2022] [Accepted: 04/22/2022] [Indexed: 02/06/2023] Open
Abstract
Progesterone is an endogenous steroid hormone with an important role for the physiology of the female reproductive system and the mammary gland. It has additional significant actions in other tissues, such as the cardiovascular system, the central nervous system, and bones. The present article explores potential clinical implications from the addition of bioidentical progesterone to gender-affirming treatment of trans women. For this purpose, it provides an overview of the physiological action of progesterone in target tissues and speculates on possible benefits for gender transitioning. Progesterone is expected to exert moderate anti-androgen action through suppression of the hypothalamic-pituitary-gonadal axis and inhibition of the conversion of testosterone to dihydrotestosterone. It may also contribute to breast maturation. In the long-term, progesterone could prevent bone loss and protect cardiovascular health. The potential benefits are mainly inferred by extrapolating evidence from biological actions in cisgender women and medical assumptions and hence, clinicians need to be cautious when applying these data into practice. Further research is needed to ascertain the efficacy and safety of progesterone in current hormonal regimens.
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Affiliation(s)
- Charalampos Milionis
- Department of Endocrinology, Diabetes and Metabolism, Elena Venizelou Hospital, Athens GR-11521, Greece
| | - Ioannis Ilias
- Department of Endocrinology, Diabetes and Metabolism, Elena Venizelou Hospital, Athens GR-11521, Greece
| | - Eftychia Koukkou
- Department of Endocrinology, Diabetes and Metabolism, Elena Venizelou Hospital, Athens GR-11521, Greece
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9
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Nolan BJ, Frydman AS, Leemaqz SY, Carroll M, Grossmann M, Zajac JD, Cheung AS. Effects of low-dose oral micronised progesterone on sleep, psychological distress, and breast development in transgender individuals undergoing feminising hormone therapy: a prospective controlled study. Endocr Connect 2022; 11:e220170. [PMID: 35521814 PMCID: PMC9175584 DOI: 10.1530/ec-22-0170] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2022] [Accepted: 04/06/2022] [Indexed: 11/24/2022]
Abstract
Objective The role of micronised progesterone in hormone regimens for transgender individuals undergoing feminising hormone therapy remains uncertain. We aimed to determine the effect of oral micronised progesterone on sleep quality, psychological distress, and breast development in transgender individuals undergoing feminising hormone therapy. Design Prospective case-control study. Twenty-three transgender individuals on stable oestradiol treatment newly commencing 100 mg oral progesterone (n = 23) and controls continuing standard care (n = 19) were assessed over 3 months. Methods Pittsburgh Sleep Quality Index (PSQI), Kessler psychological distress scale (K10), and Tanner stage to assess breast development were assessed at 0 and 3 months. Non-parametric analysis of covariance was used to compare differences between groups. Results Compared with controls over 3 months, there was no difference in PSQI (P = 0.35), K10 (P = 0.64), or Tanner stage (P = 0.42). There was no significant difference in the proportion of individuals with clinically significant improvement in PSQI (25% vs 22%, P = 0.84). One individual had a significant deterioration in psychological distress that improved following the cessation of progesterone. Conclusions Low-dose progesterone was not associated with changes in sleep quality, psychological distress, or breast development over 3 months follow-up, though there was significant inter-individual variability. Larger, placebo-controlled trials are required to further evaluate different doses of progesterone in feminising hormone therapy regimens.
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Affiliation(s)
- Brendan J Nolan
- Department of Endocrinology, Austin Health, Heidelberg, Victoria, Australia
- Department of Medicine (Austin Health), University of Melbourne, Heidelberg, Victoria, Australia
| | - Aviva S Frydman
- Department of Endocrinology, Austin Health, Heidelberg, Victoria, Australia
| | - Shalem Y Leemaqz
- College of Medicine and Public Health, Flinders University, Adelaide, South Australia, Australia
| | - Meg Carroll
- Department of Medicine (Austin Health), University of Melbourne, Heidelberg, Victoria, Australia
| | - Mathis Grossmann
- Department of Endocrinology, Austin Health, Heidelberg, Victoria, Australia
- Department of Medicine (Austin Health), University of Melbourne, Heidelberg, Victoria, Australia
| | - Jeffrey D Zajac
- Department of Endocrinology, Austin Health, Heidelberg, Victoria, Australia
- Department of Medicine (Austin Health), University of Melbourne, Heidelberg, Victoria, Australia
| | - Ada S Cheung
- Department of Endocrinology, Austin Health, Heidelberg, Victoria, Australia
- Department of Medicine (Austin Health), University of Melbourne, Heidelberg, Victoria, Australia
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10
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Cocchetti C, Romani A, Collet S, Greenman Y, Schreiner T, Wiepjes C, den Heijer M, T’Sjoen G, Fisher AD. The ENIGI (European Network for the Investigation of Gender Incongruence) Study: Overview of Acquired Endocrine Knowledge and Future Perspectives. J Clin Med 2022; 11:jcm11071784. [PMID: 35407392 PMCID: PMC8999511 DOI: 10.3390/jcm11071784] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2022] [Revised: 03/21/2022] [Accepted: 03/22/2022] [Indexed: 02/06/2023] Open
Abstract
Literature on the efficacy and safety of gender-affirming hormonal treatment (GAHT) in transgender people is limited. For this reason, in 2010 the European Network for the Investigation of Gender Incongruence (ENIGI) study was born. The aim of this review is to summarize evidence emerging from this prospective multicentric study and to identify future perspectives. GAHT was effective in inducing desired body changes in both trans AMAB and AFAB people (assigned male and female at birth, respectively). Evidence from the ENIGI study confirmed the overall safety of GAHT in the short/mid-term. In trans AMAB people, an increase in prolactin levels was demonstrated, whereas the most common side effects in trans AFAB people were acne development, erythrocytosis, and unfavorable changes in lipid profile. The main future perspectives should include the evaluation of the efficacy and safety of non-standardized hormonal treatment in non-binary trans people. Furthermore, long-term safety data on mortality rates, oncological risk, and cardiovascular, cerebrovascular and thromboembolic events are lacking. With this aim, we decided to extend the observation of the ENIGI study to 10 years in order to study all these aspects in depth and to answer these questions.
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Affiliation(s)
- Carlotta Cocchetti
- Andrology, Women’s Endocrinology and Gender Incongruence Unit, Florence University Hospital, Viale Pieraccini 6, 50100 Florence, Italy; (C.C.); (A.R.)
| | - Alessia Romani
- Andrology, Women’s Endocrinology and Gender Incongruence Unit, Florence University Hospital, Viale Pieraccini 6, 50100 Florence, Italy; (C.C.); (A.R.)
| | - Sarah Collet
- Department of Endocrinology, Center for Sexology and Gender, Ghent University Hospital, 9000 Ghent, Belgium; (S.C.); (G.T.)
| | - Yona Greenman
- Institute of Endocrinology and Metabolism, Tel Aviv Sourasky Medical Center, Tel Aviv University, Tel Aviv 6997801, Israel;
| | - Thomas Schreiner
- Department of Endocrinology, Oslo University Hospital, 0130 Oslo, Norway;
| | - Chantal Wiepjes
- Department of Endocrinology, Amsterdam University Medical Center, VUmc, 1018 WT Amsterdam, The Netherlands; (C.W.); (M.d.H.)
- Center of Expertise on Gender Dysphoria, Amsterdam University Medical Center, VUmc, 1018 WT Amsterdam, The Netherlands
| | - Martin den Heijer
- Department of Endocrinology, Amsterdam University Medical Center, VUmc, 1018 WT Amsterdam, The Netherlands; (C.W.); (M.d.H.)
- Center of Expertise on Gender Dysphoria, Amsterdam University Medical Center, VUmc, 1018 WT Amsterdam, The Netherlands
| | - Guy T’Sjoen
- Department of Endocrinology, Center for Sexology and Gender, Ghent University Hospital, 9000 Ghent, Belgium; (S.C.); (G.T.)
| | - Alessandra Daphne Fisher
- Andrology, Women’s Endocrinology and Gender Incongruence Unit, Florence University Hospital, Viale Pieraccini 6, 50100 Florence, Italy; (C.C.); (A.R.)
- Correspondence:
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11
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Patel H, Samaha Y, Ives G, Lee TY, Cui X, Ray E. Chest Feminization in Male-to-Female Transgender Patients: A Review of Options. Transgend Health 2022; 6:244-255. [PMID: 34993297 DOI: 10.1089/trgh.2020.0057] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Management of a transgender (TG) woman's gender dysphoria is individualized to address the sources of her distress. This typically involves some combination of psychological therapy, hormone modulation, and surgical intervention. Breast enhancement is the most commonly pursued physical modification in this population. Because hormone manipulation provides disappointing results for most TG women, surgical treatment is frequently required to achieve the goal of a feminine chest. Creating a female breast from natal male chest anatomy poses significant challenges; the sexual dimorphism requires a different approach than that used in cisgender breast augmentation. The options and techniques used continue to evolve as experience in this field grows.
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Affiliation(s)
- Harsh Patel
- Department of Surgery, Cedars Sinai Medical Center, Los Angeles, California, USA
| | - Yasmina Samaha
- Department of Surgery, Cedars Sinai Medical Center, Los Angeles, California, USA
| | - Graham Ives
- Department of Surgery, Cedars Sinai Medical Center, Los Angeles, California, USA
| | - Tian-Yu Lee
- Department of Surgery, Cedars Sinai Medical Center, Los Angeles, California, USA
| | - Xiaojiang Cui
- Department of Surgery, Cedars Sinai Medical Center, Los Angeles, California, USA
| | - Edward Ray
- Department of Surgery, Cedars Sinai Medical Center, Los Angeles, California, USA
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12
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Nolan BJ, Cheung AS. Relationship Between Serum Estradiol Concentrations and Clinical Outcomes in Transgender Individuals Undergoing Feminizing Hormone Therapy: A Narrative Review. Transgend Health 2021; 6:125-131. [PMID: 34414268 DOI: 10.1089/trgh.2020.0077] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Transgender, including gender diverse and nonbinary, individuals are treated with estradiol with or without antiandrogen to align their physical appearance with their gender identity, improve mental health and quality of life. Consensus guidelines give target ranges for serum estradiol concentration based on premenopausal female reference ranges. However, limited studies have evaluated the relationship between serum estradiol concentrations and clinical outcomes in transgender individuals undergoing feminizing hormone therapy. The available evidence has not found that higher serum estradiol concentrations, together with suppressed testosterone, enhance breast development, or produce more feminine changes to body composition. However, ensuring testosterone suppression appears to be an important factor to maximize these physical changes. Higher serum estradiol concentrations have been associated with higher areal bone mineral density. Although the resultant long-term clinical implications are yet to be determined, this could be a consideration for individuals with low bone mass. The precise serum estradiol concentration that results in adequate feminization without increasing the risk of complications (thromboembolic disease, cholelithiasis) remains unknown. Further prospective trials are required.
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Affiliation(s)
- Brendan J Nolan
- Department of Endocrinology, Austin Health, Heidelberg, Victoria, Australia.,Department of Medicine (Austin Health), University of Melbourne, Heidelberg, Victoria, Australia
| | - Ada S Cheung
- Department of Endocrinology, Austin Health, Heidelberg, Victoria, Australia.,Department of Medicine (Austin Health), University of Melbourne, Heidelberg, Victoria, Australia
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13
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Sonnenblick EB, Chaudhry S, Lee KA, Jaffer S, Fang F, Ting J, Margolies LR. MRI Features of Free Liquid Silicone in the Transgender Female Breast. JOURNAL OF BREAST IMAGING 2021; 3:322-331. [PMID: 38424775 DOI: 10.1093/jbi/wbab016] [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] [Received: 08/26/2020] [Indexed: 03/02/2024]
Abstract
OBJECTIVE To define MRI features of free liquid silicone injection (FLSI) of the breast in transgender women considering surgical management. METHODS This study was IRB-approved. MRI images from transgender women with FLSI imaged between 2009 and 2019 were reviewed. Presence and location of fibrotic masses (FMs) in the breast(s) and pectoralis muscle and patterns of granulomas were correlated with clinicopathologic findings. Background enhancement was quantified. Comparisons were performed using two-tailed Fisher exact and Student's t test. RESULTS Of 21 transgender women with FLSI (mean age 46.8 years), 13/21 (61.9%) had a dominant FM measuring over 4 cm; these were limited to breast and pectoralis in 6/21 (28.6%), breast in 9/21 (42.9%), and pectoralis only in 2/21 (9.5%). Four of 21 patients (19.0%) had no FMs, and 4/21 (19.0%) had masses under 4 cm. Mean size of the dominant FM was 7.4 cm (range 4-12 cm). FMs were enhancing in 5/13 (38.5%) and contained T2 high signal granulomas in 8/13 (61.5%). While 18/21 (85.8%) of cases showed mild to moderate overall background enhancement, the majority 7/13 (61.5%) of dominant FM were non-enhancing. About half of cases (11/21, 52.4%) had diffuse foci, and half (10/21, 47.6%) had diffuse foci and masses throughout the breast and pectoralis muscle. These foci and masses displayed T2 high signal in 13/21 (61.9%). There were no occult carcinomas observed. CONCLUSION MRI performed on symptomatic FLSI patients considering surgical treatment is helpful in assessing the extent of silicone infiltration and fibrotic reaction of the breast and pectoralis muscle.
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Affiliation(s)
- Emily B Sonnenblick
- Icahn School of Medicine at Mount Sinai, Department of Diagnostic, Molecular, and Interventional Radiology, New York, NY, USA
| | - Shivani Chaudhry
- Icahn School of Medicine at Mount Sinai, Department of Diagnostic, Molecular, and Interventional Radiology, New York, NY, USA
| | - Karen A Lee
- Icahn School of Medicine at Mount Sinai, Department of Diagnostic, Molecular, and Interventional Radiology, New York, NY, USA
| | - Shabnam Jaffer
- Icahn School of Medicine at Mount Sinai, Department of Pathology, Molecular, and Cell Based Medicine, New York, NY, USA
| | - Frank Fang
- Icahn School of Medicine at Mount Sinai, Department of Plastic and Reconstructive Surgery, New York, NY, USA
| | - Jess Ting
- Icahn School of Medicine at Mount Sinai, Department of Plastic and Reconstructive Surgery, New York, NY, USA
| | - Laurie R Margolies
- Icahn School of Medicine at Mount Sinai, Department of Diagnostic, Molecular, and Interventional Radiology, New York, NY, USA
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14
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Badowski ME, Britt N, Huesgen EC, Lewis MM, Miller MM, Nowak K, Sherman E, Smith RO. Pharmacotherapy considerations in transgender individuals living with human immunodeficiency virus. Pharmacotherapy 2021; 41:299-314. [PMID: 33404067 DOI: 10.1002/phar.2499] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2020] [Revised: 12/03/2020] [Accepted: 12/05/2020] [Indexed: 12/28/2022]
Abstract
Pharmacotherapy considerations are often a concern for transgender individuals who are living with human immunodeficiency virus (HIV) due to concerns for drug-drug interactions between their hormone and antiretroviral therapies. Many of the first-line therapies offered to patients for the management of HIV have reduced concerns for safety, resistance, and drug-drug interactions. In this review, we highlight common medications and important considerations for caring for transgender people living with HIV.
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Affiliation(s)
- Melissa E Badowski
- College of Pharmacy, University of Illinois at Chicago, Chicago, Illinois, USA
| | - Nicholas Britt
- School of Pharmacy, The University of Kansas, Kansas City, Kansas, USA
| | | | - Michelle M Lewis
- Department of Medicine, The University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma, USA
| | - Misty M Miller
- College of Pharmacy, The University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma, USA
| | | | - Elizabeth Sherman
- College of Pharmacy, Nova Southeastern University, Fort Lauderdale, Florida, USA
| | - Renata O Smith
- College of Pharmacy, University of Illinois at Chicago, Chicago, Illinois, USA
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15
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Meyer G, Boczek U, Bojunga J. Hormonal Gender Reassignment Treatment for Gender Dysphoria. DEUTSCHES ARZTEBLATT INTERNATIONAL 2021; 117:725-732. [PMID: 33559593 DOI: 10.3238/arztebl.2020.0725] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/16/2020] [Revised: 01/16/2020] [Accepted: 06/25/2020] [Indexed: 01/04/2023]
Abstract
BACKGROUND No data are available at present on the prevalence of gender dysphoria (trans-identity) in Germany. On the basis of estimates from the Netherlands, it can be calculated that approximately 15 000 to 25 000 persons in Germany are affected. Persons suffering from gender dysphoria often experience significant distress and have a strong desire for gender reassignment treatment. METHODS This review is based on pertinent publications retrieved by a selective search in the PubMed database employing the searching terms "transsexualism," "transgender," "gender incongruence," "gender identity disorder," "gender-affirming hormone therapy," and "gender dysphoria." RESULTS In view of its far-reaching consequences, some of which are irreversible, hormonal gender reassignment treatment should only be initiated after meticulous individual consideration, with the approval of the treating psychiatrist/psychotherapist and after extensive information of the patient by an experienced endo - crinologist. Before the treatment is begun, the patient must be extensively screened for risk factors. The contraindications include severe preexisting thromboembolic diseases (mainly if untreated), hormone-sensitive tumors, and uncontrolled pre - existing chronic diseases such as arterial hypertension and epilepsy. Finding an appropriate individual solution is the main objective even if contraindications are present. Male-to-female treatment is carried out with 17β-estradiol or 17β-estradiol valerate in combination with cyproterone acetate or spironolactone as an antiandrogen, female-to-male treatment with transdermal or intramuscular testosterone preparations. The treatment must be monitored permanently with clinical and laboratory follow-up as well as with gynecological and urological early-detection screening studies. Prospective studies and a meta-analysis (based on low-level evidence) have documented an improvement in the quality of life after gender reassignment treatment. Female-to-male gender-incongruent persons often have difficulty being accepted in a gynecological practice as a male patient. CONCLUZION Further prospective studies for the quantification of the risks and benefits of hormonal treatment would be desirable. Potential interactions of the hormone preparations with other medications must always be considered.
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Affiliation(s)
- Gesine Meyer
- Medical Clinic I: Gastroenterology and Hepatology, Pneumology and Allergology, Endocrinology and Diabetology, Nutritional Medicine, University Hospital Frankfurt, Frankfurt, Germany
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16
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Aranda G, Halperin I, Gomez-Gil E, Hanzu FA, Seguí N, Guillamon A, Mora M. Cardiovascular Risk Associated With Gender Affirming Hormone Therapy in Transgender Population. Front Endocrinol (Lausanne) 2021; 12:718200. [PMID: 34659112 PMCID: PMC8515285 DOI: 10.3389/fendo.2021.718200] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2021] [Accepted: 09/02/2021] [Indexed: 11/13/2022] Open
Abstract
Transgender men and women represent about 0.6 -1.1%% of the general population. Gender affirming hormone therapy (GAHT) helps ameliorate gender dysphoria and promote well-being. However, these treatments' cardiovascular (CV) effects are difficult to evaluate due to the limited number of extensive longitudinal studies focused on CV outcomes in this population. Furthermore, these studies are mainly observational and difficult to interpret due to a variety of hormone regimens and observation periods, together with possible bias by confounding factors (comorbidities, estrogen types, smoking, alcohol abuse, HIV infection). In addition, the introduction of GAHT at increasingly earlier ages, even before the full development of the secondary sexual characteristics, could lead to long-term changes in CV risk compared to current data. This review examines the impact of GAHT in the transgender population on CV outcomes and surrogate markers of CV health. Furthermore, we review available data on changes in DNA methylation or RNA transcription induced by GAHT that may translate into changes in metabolic parameters that could increase CV risk.
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Affiliation(s)
- Gloria Aranda
- Group of Endocrine Disorders, Institut d’Investigacions Biomèdiques August Pi I Sunyer- Hospital Clinic, Barcelona, Spain
| | - Irene Halperin
- Group of Endocrine Disorders, Institut d’Investigacions Biomèdiques August Pi I Sunyer- Hospital Clinic, Barcelona, Spain
- Endocrinology Department, Hospital Clinic, Barcelona, Spain
| | | | - Felicia A. Hanzu
- Group of Endocrine Disorders, Institut d’Investigacions Biomèdiques August Pi I Sunyer- Hospital Clinic, Barcelona, Spain
- Endocrinology Department, Hospital Clinic, Barcelona, Spain
| | - Núria Seguí
- Endocrinology Department, Hospital Clinic, Barcelona, Spain
| | - Antonio Guillamon
- Departamento de Psicobiologia, Universidad Nacional de Educación a Distancia (UNED), Madrid, Spain
| | - Mireia Mora
- Group of Endocrine Disorders, Institut d’Investigacions Biomèdiques August Pi I Sunyer- Hospital Clinic, Barcelona, Spain
- Endocrinology Department, Hospital Clinic, Barcelona, Spain
- *Correspondence: Mireia Mora,
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17
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von Vaupel-Klein AM, Walsh RJ. Considerations in genetic counseling of transgender patients: Cultural competencies and altered disease risk profiles. J Genet Couns 2020; 30:98-109. [PMID: 33368789 PMCID: PMC7898523 DOI: 10.1002/jgc4.1372] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2020] [Revised: 11/24/2020] [Accepted: 11/27/2020] [Indexed: 12/29/2022]
Abstract
Transgender people are a growing population with specific healthcare needs, barriers to care, and disease risk factors. Cultural competencies for working with transgender people in healthcare settings are essential to reduce barriers to care and combat the associated health disparities. Genetic counselors support their patients to understand and manage medically and personally complex life events and decisions. A genetic counselor caring for a transgender patient or a patient with a transgender relative will therefore require specific cultural competencies and medical knowledge that may not have been covered in their training. Transgender health is also a relatively young field in which new insights may quickly become fundamental. The present paper therefore provides an overview of current best practices for culturally sensitive working with transgender patients, and an introduction to the additional considerations for assessment of disease risk in transgender people. Guidance on how to ensure communication with patients and other stakeholders is inclusive and affirming of transgender identities, is offered. Medical interventions used for gender transitions are described, and their (potential) effects on cancer and cardiovascular disease risk are discussed. Furthermore, the effects of sociocultural risk factors such as minority stress are outlined. In sum, we invite the reader to consider the specific biological, psychological, and social context of the consultation. Finally, we explore culturally competent approaches to pedigree charting and physical examinations with transgender people and provide recommendations for practice.
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Affiliation(s)
| | - Reubs J Walsh
- Department of Clinical, Neuro- and Developmental Psychology, Faculty of Behavioural and Movement Sciences, Vrije Universiteit Amsterdam, Amsterdam, Netherlands.,Gender Identity Research and Education Society (GIRES), Ashtead, UK
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18
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Fortin CN, Moravek MB. Medical transition for gender diverse patients. CURRENT OBSTETRICS AND GYNECOLOGY REPORTS 2020; 9:166-177. [PMID: 36714061 PMCID: PMC9881054 DOI: 10.1007/s13669-020-00297-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Purpose of review The purpose of this review is to provide an up-to-date overview of gender-affirming hormone therapy, including the various hormone regimens available, the efficacy and potential risks of these treatments, and considerations for surveillance and long-term care. Recent findings Recent studies reaffirm that hormone therapy has positive physical and psychological effects for many transgender individuals. The overall risks of treatment are low. Transgender women may have an increased risk of venous thromboembolism and breast cancer based on recent cohort studies, but these findings have yet to be confirmed with randomized controlled trials. Important long-term considerations include metabolic, cardiovascular, and skeletal health. Summary High-quality, long-term studies on the effectiveness and safety of various gender-affirming hormone treatment regimens are lacking, but the currently available evidence suggests that it is overall safe and effective with appropriate oversight.
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Affiliation(s)
| | - Molly B. Moravek
- Corresponding author: L4001 Women’s Hospital, 1500 E Medical Center Dr, Ann Arbor, MI,
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19
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Prince JCJ, Safer JD. Endocrine treatment of transgender individuals: current guidelines and strategies. Expert Rev Endocrinol Metab 2020; 15:395-403. [PMID: 32990485 DOI: 10.1080/17446651.2020.1825075] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/19/2020] [Accepted: 09/15/2020] [Indexed: 01/07/2023]
Abstract
INTRODUCTION This review summarizes gender affirming medical and surgical care available to transgender individuals, along with proposals to improve medically and culturally appropriate care. AREAS COVERED Transgender individuals are those whose gender identity differs from that recorded at birth (usually based on visualization of external sexual anatomy). In order to align the body with the patient's gender identity, clinicians can provide hormone therapy (HT) to bring sex hormone levels to the range associated with the patient's gender identity. At steady state, monitoring for maintenance of levels, as well as for known risks and complications, is required. Treating clinicians should have knowledge of trans assessment criteria, hormone therapy, surgical options, primary care, and mental health needs of transgender patients. A narrative literature review was conducted using Pubmed and EMBASE with articles then selected for relevance. The initial search terms were: androgen suppression, antiandrogen, breast development, chest reconstruction, cisgender, estrogen, fertility preservation, gender-affirming surgery, gender identity, gender incongruence, genital reconstruction, hormone replacement, hyperlipidemia, orchiectomy, prolactin, prostate atrophy, spermatogenesis, spironolactone, testosterone, thrombogenesis, transgender, and virilization. EXPERT OPINION Although guidelines exist and examples of training are available, systematic formal training must be implemented to truly mainstream high-quality gender-affirming health care .
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Affiliation(s)
| | - Joshua D Safer
- Center for Transgender Medicine and Surgery, Icahn School of Medicine at Mount Sinai , New York, NY, USA
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20
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Risque sénologique chez les patients transgenres : à propos des recommandations américaines sur le dépistage des néoplasies mammaires. IMAGERIE DE LA FEMME 2020. [DOI: 10.1016/j.femme.2020.07.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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21
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Coelingh Bennink HJT, Egberts JFM, Mol JA, Roes KCB, van Diest PJ. Breast Cancer and Major Deviations of Genetic and Gender-related Structures and Function. J Clin Endocrinol Metab 2020; 105:5864415. [PMID: 32594127 DOI: 10.1210/clinem/dgaa404] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2020] [Accepted: 06/24/2020] [Indexed: 11/19/2022]
Abstract
We have searched the literature for information on the risk of breast cancer (BC) in relation to gender, breast development, and gonadal function in the following 8 populations: 1) females with the Turner syndrome (45, XO); 2) females and males with congenital hypogonadotropic hypogonadism and the Kallmann syndrome; 3) pure gonadal dysgenesis (PGD) in genotypic and phenotypic females and genotypic males (Swyer syndrome); 4) males with the Klinefelter syndrome (47, XXY); 5) male-to-female transgender individuals; 6) female-to-male transgender individuals; 7) genotypic males, but phenotypic females with the complete androgen insensitivity syndrome, and 8) females with Mayer-Rokitansky-Küster-Hauser (MRKH) syndrome (müllerian agenesis). Based on this search, we have drawn 3 major conclusions. First, the presence of a Y chromosome protects against the development of BC, even when female-size breasts and female-level estrogens are present. Second, without menstrual cycles, BC hardly occurs with an incidence comparable to males. There is a strong correlation between the lifetime number of menstrual cycles and the risk of BC. In our populations the BC risk in genetic females not exposed to progesterone (P4) is very low and comparable to males. Third, BC has been reported only once in genetic females with MRKH syndrome who have normal breasts and ovulating ovaries with normal levels of estrogens and P4. We hypothesize that the oncogenic glycoprotein WNT family member 4 is the link between the genetic cause of MRKH and the absence of BC women with MRKH syndrome.
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Affiliation(s)
| | | | - Jan A Mol
- Faculty of Veterinary Medicine, University of Utrecht, GA Utrecht, the Netherlands
| | - Kit C B Roes
- Department of Health Evidence, Section Biostatistics, Radboud University Medical Centre, GA Nijmegen, the Netherlands
| | - Paul J van Diest
- Department of Pathology, University Medical Center Utrecht, GA Utrecht, the Netherlands
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22
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Zaveri S, Yao A, Schmidt H. Breast Implant-Associated Anaplastic Large Cell Lymphoma Following Gender Reassignment Surgery: A Review of Presentation, Management, and Outcomes in the Transgender Patient Population. Eur J Breast Health 2020; 16:162-166. [PMID: 32656514 DOI: 10.5152/ejbh.2020.5480] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2020] [Accepted: 05/30/2020] [Indexed: 01/13/2023]
Abstract
Breast implant-associated anaplastic large cell lymphoma (BIA-ALCL) is a rare peripheral T-cell lymphoma with approximately 650-700 reported cases worldwide. The incidence, however, is increasing as more practitioners become aware of the diagnosis, and recent studies show that early diagnosis and treatment is critical to improve prognosis. There have been four cases of BIA-ALCL in total reported in the transgender population in the literature. These reported cases were reviewed in detail to determine presentation and management of BIA-ALCL in transgender patients compared to the larger population of BIA-ALCL patients. This review highlights BIA-ALCL in transgender women, a population that is often excluded from breast screening and follow-up. Transgender women may not routinely go through the same post-operative follow-up protocols as patients with breast implants for breast cancer reconstruction and can thus be at risk for delayed recognition and diagnosis. BIA-ALCL is a rare complication of breast implantation, and it is important to counsel all patients undergoing implant placement, including transgender women, on its risk.
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Affiliation(s)
- Shruti Zaveri
- Department of Surgery, The Mount Sinai Hospital, New York, NY, USA
| | - Alice Yao
- Division of Plastic and Reconstructive Surgery, Department of Surgery, The Mount Sinai Hospital, New York, NY, USA
| | - Hank Schmidt
- Dubin Breast Center, Tisch Cancer Institute, The Mount Sinai Hospital, New York, NY, USA
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23
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Ferri RL, Rosen-Carole CB, Jackson J, Carreno-Rijo E, Greenberg KB. ABM Clinical Protocol #33: Lactation Care for Lesbian, Gay, Bisexual, Transgender, Queer, Questioning, Plus Patients. Breastfeed Med 2020; 15:284-293. [PMID: 32330392 DOI: 10.1089/bfm.2020.29152.rlf] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
A central goal of The Academy of Breastfeeding Medicine is the development of clinical protocols for managing common medical problems that may impact breastfeeding success. These protocols serve only as guidelines for the care of breastfeeding mothers and infants and do not delineate an exclusive course of treatment or serve as standards of medical care. Variations in treatment may be appropriate according to the needs of an individual patient.
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Affiliation(s)
- Rita Lynne Ferri
- University of Rochester School of Medicine and Dentistry, Rochester, New York, USA
| | - Casey Braitsch Rosen-Carole
- University of Rochester School of Medicine and Dentistry, Rochester, New York, USA.,Department of Pediatrics and University of Rochester School of Medicine and Dentistry, Rochester, New York, USA.,Department of Obstetrics and Gynecology, University of Rochester School of Medicine and Dentistry, Rochester, New York, USA
| | - Jason Jackson
- University of Rochester School of Medicine and Dentistry, Rochester, New York, USA.,Department of Pediatrics and University of Rochester School of Medicine and Dentistry, Rochester, New York, USA
| | - Elizabeth Carreno-Rijo
- University of Rochester School of Medicine and Dentistry, Rochester, New York, USA.,Department of Pediatrics and University of Rochester School of Medicine and Dentistry, Rochester, New York, USA
| | - Katherine Blumoff Greenberg
- University of Rochester School of Medicine and Dentistry, Rochester, New York, USA.,Department of Pediatrics and University of Rochester School of Medicine and Dentistry, Rochester, New York, USA.,Department of Obstetrics and Gynecology, University of Rochester School of Medicine and Dentistry, Rochester, New York, USA
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24
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Latack K, Adidharma W, Nolan IT, Crowe CS, Sowder LL, Satterwhite T, Morrison SD. Staying on Top of Breast Implant Illness: An Analysis of Chest Feminization Experiences. Plast Reconstr Surg 2020; 145:885e-886e. [PMID: 32221263 DOI: 10.1097/prs.0000000000006691] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Affiliation(s)
- Kyle Latack
- Keck School of Medicine, University of Southern California, Los Angeles, Calif
| | - Widya Adidharma
- Section of Plastic Surgery, Department of Surgery, University of Michigan School of Medicine, Ann Arbor, Mich
| | - Ian T Nolan
- Hansjörg Wyss Department of Plastic Surgery, New York University School of Medicine, New York, N.Y
| | - Christopher S Crowe
- Division of Plastic Surgery, Department of Surgery, University of Washington School of Medicine, Seattle, Wash
| | | | | | - Shane D Morrison
- Division of Plastic Surgery, Department of Surgery, University of Washington School of Medicine, Seattle, Wash
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25
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Hodax JK, Wagner J, Sackett-Taylor AC, Rafferty J, Forcier M. Medical Options for Care of Gender Diverse and Transgender Youth. J Pediatr Adolesc Gynecol 2020; 33:3-9. [PMID: 31154017 DOI: 10.1016/j.jpag.2019.05.010] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2018] [Revised: 05/21/2019] [Accepted: 05/23/2019] [Indexed: 12/12/2022]
Abstract
Increasing numbers of transgender and gender diverse (TGD) youth are presenting for medical care, including seeking more information and access to services from gynecologic and reproductive health experts. Such experts are well positioned to provide affirming, comprehensive services, including education, hormonal interventions, menstrual management, contraception, and various gynecological procedures. Early medical guidance and support for the TGD community has been associated with long-term positive emotional and physical health outcomes. In this article medical interventions that reproductive health experts can offer to their TGD patients are discussed.
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Affiliation(s)
- Juanita K Hodax
- Department of Pediatrics, University of Washington, Seattle, Washington; Division of Endocrinology, Seattle Children's Hospital, Seattle, Washington.
| | - Jill Wagner
- Warren Alpert School of Medicine, Brown University, Providence, Rhode Island; Division of Adolescent Medicine, Hasbro Children's Hospital, Providence, Rhode Island
| | | | - Jason Rafferty
- Warren Alpert School of Medicine, Brown University, Providence, Rhode Island; Division of Adolescent Medicine, Hasbro Children's Hospital, Providence, Rhode Island; Department of Child Psychiatry, Emma Pendleton Bradley Hospital, Riverside, Rhode Island; Department of Pediatrics, Thundermist Health Centers, Woonsocket, Rhode Island
| | - Michelle Forcier
- Warren Alpert School of Medicine, Brown University, Providence, Rhode Island; Division of Adolescent Medicine, Hasbro Children's Hospital, Providence, Rhode Island
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26
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Parikh U, Mausner E, Chhor CM, Gao Y, Karrington I, Heller SL. Breast Imaging in Transgender Patients: What the Radiologist Should Know. Radiographics 2020; 40:13-27. [DOI: 10.1148/rg.2020190044] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Affiliation(s)
- Ujas Parikh
- From the Department of Radiology, New York University School of Medicine, 160 E 34th St, New York, NY 10016
| | - Elizabeth Mausner
- From the Department of Radiology, New York University School of Medicine, 160 E 34th St, New York, NY 10016
| | - Chloe M. Chhor
- From the Department of Radiology, New York University School of Medicine, 160 E 34th St, New York, NY 10016
| | - Yiming Gao
- From the Department of Radiology, New York University School of Medicine, 160 E 34th St, New York, NY 10016
| | - Ian Karrington
- From the Department of Radiology, New York University School of Medicine, 160 E 34th St, New York, NY 10016
| | - Samantha L. Heller
- From the Department of Radiology, New York University School of Medicine, 160 E 34th St, New York, NY 10016
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27
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García-Acosta JM, San Juan-Valdivia RM, Fernández-Martínez AD, Lorenzo-Rocha ND, Castro-Peraza ME. Trans* Pregnancy and Lactation: A Literature Review from a Nursing Perspective. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2019; 17:ijerph17010044. [PMID: 31861638 PMCID: PMC6981677 DOI: 10.3390/ijerph17010044] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/18/2019] [Revised: 12/13/2019] [Accepted: 12/14/2019] [Indexed: 11/16/2022]
Abstract
Pregnancy and lactation involve two aspects that are socially and culturally associated with women. However, there are a few biological differences between male and female breast tissue. Lactation and pregnancy are viable processes that do not depend on sex. Even for the latter, it is only necessary to have an organ capable of gestation. Ways to favor mammogenesis and lactogenesis in trans* women have been established. There are protocols to promote lactation in trans* women, usually used for adoptive mothers or those whose children have been born through gestational surrogacy. Chestfeeding a baby could be the cause of feelings as diverse as gender dysphoria in the case of trans* men, and euphoria and affirmation of femininity in trans* women. This study involves a review of the available scientific literature addressing medical aspects related to pregnancy and lactation in trans* individuals, giving special attention to nursing care during perinatal care. There are scarce studies addressing care and specifically nursing care in trans* pregnancy and lactation. Our study indicates the factors that can be modified and the recommendations for optimizing the care provided to these individuals in order to promote and maintain the lactation period in search of improvement and satisfaction with the whole process.
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Affiliation(s)
- Jesús Manuel García-Acosta
- Faculty of Nursing, University of La Laguna, Canary Islands Public Health Service, 38010 Tenerife, Canary Islands, Spain
- Correspondence: ; Tel.: +34-6-8700-7510
| | | | - Alfredo David Fernández-Martínez
- Department of Education Counseling Universities, Culture and Sports, Government of the Canary Islands, 38010 Tenerife, Canary Islands, Spain;
| | - Nieves Doria Lorenzo-Rocha
- The Faculty of Nursing Nª Sª de La Candelaria, University of La Laguna, Canary Islands Public Health Service, 38010 Tenerife, Canary Islands, Spain; (N.D.L.-R.); (M.E.C.-P.)
| | - Maria Elisa Castro-Peraza
- The Faculty of Nursing Nª Sª de La Candelaria, University of La Laguna, Canary Islands Public Health Service, 38010 Tenerife, Canary Islands, Spain; (N.D.L.-R.); (M.E.C.-P.)
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28
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Dutra E, Lee J, Torbati T, Garcia M, Merz CNB, Shufelt C. Cardiovascular implications of gender-affirming hormone treatment in the transgender population. Maturitas 2019; 129:45-49. [PMID: 31547912 PMCID: PMC6761990 DOI: 10.1016/j.maturitas.2019.08.010] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2019] [Revised: 08/13/2019] [Accepted: 08/19/2019] [Indexed: 01/25/2023]
Abstract
Transgender men and women represent a growing population in the United States and Europe, with 0.5% of adults and 3% of youth identifying as transgender. Globally, an estimated 0.3-0.5% of the population identify as transgender. Despite the increasing percentage of individuals whose gender identity, gender expression and behavior differ from their assigned sex at birth, health outcomes in transgenders have been understudied. Many transgender people seek treatment with cross-sex hormone therapy starting from a young age and frequently at high doses in order to obtain the secondary sex characteristics of the desired gender. There is a need to understand the potential long-term health consequences of cross-sex hormone therapy, given that cardiovascular disease is the leading disease-specific cause of death in this population. This review discusses the cardiovascular risks of gender-affirming hormone treatments with respect to transgender women and transgender men.
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Affiliation(s)
- Erika Dutra
- Barbra Streisand Women's Heart Center, Cedars-Sinai Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA, United States
| | - Julie Lee
- Barbra Streisand Women's Heart Center, Cedars-Sinai Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA, United States
| | - Tina Torbati
- Barbra Streisand Women's Heart Center, Cedars-Sinai Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA, United States
| | - Maurice Garcia
- Division of Urology, Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, CA, United States; Cedars-Sinai Transgender Surgery and Health Program, Cedars-Sinai Medical Center, Los Angeles, CA, United States
| | - C Noel Bairey Merz
- Barbra Streisand Women's Heart Center, Cedars-Sinai Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA, United States
| | - Chrisandra Shufelt
- Barbra Streisand Women's Heart Center, Cedars-Sinai Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA, United States.
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29
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Agana MG, Greydanus DE, Indyk JA, Calles JL, Kushner J, Leibowitz S, Chelvakumar G, Cabral MD. Caring for the transgender adolescent and young adult: Current concepts of an evolving process in the 21st century. Dis Mon 2019; 65:303-356. [DOI: 10.1016/j.disamonth.2019.07.004] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
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Salas-Humara C, Sequeira GM, Rossi W, Dhar CP. Gender affirming medical care of transgender youth. Curr Probl Pediatr Adolesc Health Care 2019; 49:100683. [PMID: 31735692 PMCID: PMC8496167 DOI: 10.1016/j.cppeds.2019.100683] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
The number of gender diverse and transgender youth presenting for treatment are increasing. This is a vulnerable population with unique medical needs; it is essential that all pediatricians attain an adequate level of knowledge and comfort caring for these youth so that their health outcomes may be improved. There are several organizations which provide clinical practice guidelines for the treatment of transgender youth including the WPATH and the Endocrine Society and they recommend that certain eligibility criteria should be met prior to initiation of gender affirming hormones. Medical intervention for transgender youth can be broken down into stages based on pubertal development: pre-pubertal, pubertal and post-pubertal. Pre-pubertally no medical intervention is recommended. Once puberty has commenced, youth are eligible for puberty blockers; and post-pubertally, youth are eligible for feminizing and masculinizing hormone regimens. Treatment with gonadotropin releasing hormone agonists are used to block puberty. Their function is many-fold: to pause puberty so that the youth may explore their gender identity, to delay the development of (irreversible) secondary sex characteristics, and to obviate the need for future gender affirmation surgeries. Masculinizing hormone regimens consists of testosterone and feminizing hormone regimens consist of both estradiol as well as spironolactone. In short term studies gender affirming hormone treatment with both estradiol and testosterone has been found to be safe and improve mental health and quality of life outcomes; additional long term studies are needed to further elucidate the implications of gender affirming hormones on physical and mental health in transgender patients. There are a variety of surgeries that transgender individuals may desire in order to affirm their gender identity; it is important for providers to understand that desire for medical interventions is variable among persons and that a discussion about individual desires for surgical options is recommended.
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Affiliation(s)
- Caroline Salas-Humara
- NYU School of Medicine, Department of Pediatrics, Division of Adolescent Medicine, New York, NY, United States.
| | - Gina M Sequeira
- UPMC Children's Hospital of Pittsburgh, Center for Adolescent and Young Adult Health, United States
| | - Wilma Rossi
- Children's Hospital of Philadelphia, United States
| | - Cherie Priya Dhar
- Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, United States
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Iwamoto SJ, Defreyne J, Rothman MS, Van Schuylenbergh J, Van de Bruaene L, Motmans J, T’Sjoen G. Health considerations for transgender women and remaining unknowns: a narrative review. Ther Adv Endocrinol Metab 2019; 10:2042018819871166. [PMID: 31516689 PMCID: PMC6719479 DOI: 10.1177/2042018819871166] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2019] [Accepted: 07/31/2019] [Indexed: 12/17/2022] Open
Abstract
Transgender (trans) women (TW) were assigned male at birth but have a female gender identity or gender expression. The literature on management and health outcomes of TW has grown recently with more publication of research. This has coincided with increasing awareness of gender diversity as communities around the world identify and address health disparities among trans people. In this narrative review, we aim to comprehensively summarize health considerations for TW and identify TW-related research areas that will provide answers to remaining unknowns surrounding TW's health. We cover up-to-date information on: (1) feminizing gender-affirming hormone therapy (GAHT); (2) benefits associated with GAHT, particularly quality of life, mental health, breast development and bone health; (3) potential risks associated with GAHT, including cardiovascular disease and infertility; and (4) other health considerations like HIV/AIDS, breast cancer, other tumours, voice therapy, dermatology, the brain and cognition, and aging. Although equally deserving of mention, feminizing gender-affirming surgery, paediatric and adolescent populations, and gender nonbinary individuals are beyond the scope of this review. While much of the data we discuss come from Europe, the creation of a United States transgender cohort has already contributed important retrospective data that are also summarized here. Much remains to be determined regarding health considerations for TW. Patients and providers will benefit from larger and longer prospective studies involving TW, particularly regarding the effects of aging, race and ethnicity, type of hormonal treatment (e.g. different oestrogens, anti-androgens) and routes of administration (e.g. oral, parenteral, transdermal) on all the topics we address.
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Affiliation(s)
- Sean J. Iwamoto
- University of Colorado School of Medicine, Division of Endocrinology, Metabolism and Diabetes, 12801 East 17th Avenue, Mail Stop: 8106, Aurora, CO 80045, USA
- UCHealth Integrated Transgender Program, Anschutz Medical Campus, Aurora, CO, USA
- Division of Endocrinology, Rocky Mountain Regional VA Medical Center, Aurora, CO, USA
| | - Justine Defreyne
- Department of Endocrinology, Ghent University Hospital, Ghent, Belgium
| | - Micol S. Rothman
- Division of Endocrinology, Metabolism and Diabetes, University of Colorado School of Medicine, Anschutz Medical Campus, Aurora, CO, USA
- UCHealth Integrated Transgender Program, Anschutz Medical Campus, Aurora, CO, USA
| | | | | | - Joz Motmans
- Center for Sexology and Gender, Ghent University Hospital, Ghent, Belgium
- Center for Research on Culture and Gender, Ghent University, 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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Iwamoto SJ, T'Sjoen G, Safer JD, Davidge-Pitts CJ, Wierman ME, Glodowski MB, Rothman MS. Letter to the Editor: "Progesterone Is Important for Transgender Women's Therapy-Applying Evidence for the Benefits of Progesterone in Ciswomen". J Clin Endocrinol Metab 2019; 104:3127-3128. [PMID: 30860591 DOI: 10.1210/jc.2019-00249] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2019] [Accepted: 03/06/2019] [Indexed: 11/19/2022]
Affiliation(s)
- Sean J Iwamoto
- Division of Endocrinology, Metabolism & Diabetes, Department of Medicine, University of Colorado School of Medicine, Aurora, Colorado
- Division of Endocrinology, Rocky Mountain Regional Veterans Affairs Medical Center, Aurora, Colorado
- UCHealth Integrated Transgender Program, UCHealth University of Colorado Hospital, Aurora, Colorado
| | - Guy T'Sjoen
- Department of Endocrinology and Center for Sexology and Gender, Ghent University Hospital, Ghent, Belgium
| | - Joshua D Safer
- Center for Transgender Medicine and Surgery, Mount Sinai Health System and Icahn School of Medicine at Mount Sinai, New York, New York
| | - Caroline J Davidge-Pitts
- Division of Endocrinology, Metabolism and Nutrition, Department of Internal Medicine, Mayo Clinic, Rochester, Minnesota
| | - Margaret E Wierman
- Division of Endocrinology, Metabolism & Diabetes, Department of Medicine, University of Colorado School of Medicine, Aurora, Colorado
- Division of Endocrinology, Rocky Mountain Regional Veterans Affairs Medical Center, Aurora, Colorado
| | - Michele B Glodowski
- Division of Endocrinology, Diabetes and Metabolism, New York University School of Medicine, New York, New York
| | - Micol S Rothman
- Division of Endocrinology, Metabolism & Diabetes, Department of Medicine, University of Colorado School of Medicine, Aurora, Colorado
- UCHealth Integrated Transgender Program, UCHealth University of Colorado Hospital, Aurora, Colorado
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Prior JC. Response to Letter to the Editor: "Progesterone Is Important for Transgender Women's Therapy-Applying Evidence for the Benefits of Progesterone in Ciswomen". J Clin Endocrinol Metab 2019; 104:3129-3130. [PMID: 30860583 DOI: 10.1210/jc.2019-00524] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2019] [Accepted: 03/06/2019] [Indexed: 11/19/2022]
Affiliation(s)
- Jerilynn C Prior
- Department of Medicine/Division of Endocrinology, Centre for Menstrual Cycle and Ovulation Research, School of Population and Public Health, University of British Columbia, Vancouver, British Columbia, Canada
- British Columbia Women's Health Research Institute, Vancouver, British Columbia, Canada
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Prior JC. Progesterone Is Important for Transgender Women's Therapy-Applying Evidence for the Benefits of Progesterone in Ciswomen. J Clin Endocrinol Metab 2019; 104:1181-1186. [PMID: 30608551 DOI: 10.1210/jc.2018-01777] [Citation(s) in RCA: 41] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/21/2018] [Accepted: 12/28/2018] [Indexed: 01/06/2023]
Abstract
BACKGROUND Although the 2017 Endocrine Society Guidelines for gender dysphoria stipulated that cross-sex hormone therapy (CHT) achieve gonadal steroid levels equivalent to those of a cisperson of the chosen sex, for transgender women (male-to-female gender dysphoria), current gonadal therapy is usually estradiol. Accumulated evidence indicates that normally ovulatory menstrual cycles are necessary for ciswomen's current fertility, as well as for later-life bone and cardiovascular health and the prevention of breast and endometrial cancers. EVIDENCE ACQUISITION Extensive past clinical experience with transgender women's CHT using estradiol/estrogen combined with progesterone/medroxyprogesterone and pioneering the addition of spironolactone. Comprehensive progesterone physiology research plus a brief review of transgender women's literature to assess current therapy and clinical outcomes, including morbidity and mortality. PURPOSE To emphasize that both ovarian hormones, progesterone as well as estradiol, are theoretically and clinically important for optimal transgender women's CHT. EVIDENCE SYNTHESIS It is important to add progesterone to estradiol and an antiandrogen in transgender women's CHT. Progesterone may add the following: (i) more rapid feminization, (ii) decreased endogenous testosterone production, (iii) optimal breast maturation to Tanner stages 4/5, (iv) increased bone formation, (v) improved sleep and vasomotor symptom control, and (vi) cardiovascular health benefits. CONCLUSIONS Evidence has accrued that normal progesterone (and ovulation), as well as physiological estradiol levels, is necessary during ciswomen's premenopausal menstrual cycles for current fertility and long-term health; transgender women deserve progesterone therapy and similar potential physiological benefits.
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Affiliation(s)
- Jerilynn C Prior
- Centre for Menstrual Cycle and Ovulation Research, Department of Medicine/Division of Endocrinology, School of Population and Public Health, University of British Columbia, Vancouver, British Columbia, Canada
- British Columbia Women's Health Research Institute, Vancouver, British Columbia, Canada
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Fakin RM, Zimmermann S, Kaye K, Lunger L, Weinforth G, Giovanoli P. Long-Term Outcomes in Breast Augmentation in Trans-Women: A 20-Year Experience. Aesthet Surg J 2019; 39:381-390. [PMID: 29901707 DOI: 10.1093/asj/sjy143] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND Breast augmentation in trans-women requires special consideration and thorough preoperative planning. OBJECTIVES This study aimed to present our long-term outcome and experience gained over the past 21 years. METHODS Trans-women who have undergone breast augmentation since 1995 were reviewed for primary surgery, type of incision, implant site, implant size and shape, and revisions. RESULTS A total of 138 patients with a follow-up of 4.6 years (range, 2.0-13.3) were included. In 112 patients (82.4%), the inframammary incision was chosen. Subpectoral implantation was performed in 70 patients (51.5%). Round breast implants (91 patients, 66.9%, P = 0.010) with low projection (103 patients, 75.7%, P < 0.001) were favored. The implant size used during 2011-2016 of 363.3 ± 97.3 cc was significantly increased as compared to the implant size reported during 1995-1999 (mean difference, +142.1 cc, P < 0.001) and 2000-2004 (mean difference, +113.5 cc, P < 0.001). Simultaneously, revision rates dropped significantly over time (52.9% during 1995-1999 as compared to 6.9% during 2011-2016, P < 0.001). Overall, request for larger implants was the most common indication for revision (13 patients, 9.4%) after 6 months (range, 4.0-18.7). At revision, implant volume was 355.4 ± 132.8 cc, showing significant increase of 107.0 ± 48.1 cc as compared to primary implants (+30.0%, P = 0.048). CONCLUSIONS Request for larger breast implants was the most common reason for revision. Depending on the various degrees of breast tissue growth due to hormonal therapy, whenever applicable, we recommend round, low projection implants with a mean size of 360 cc in the prepectoral pocket. LEVEL OF EVIDENCE: 4
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Affiliation(s)
- Richard M Fakin
- Division of Plastic Surgery and Hand Surgery, University Hospital Zurich, Zurich, Switzerland
| | - Simon Zimmermann
- Division of Plastic Surgery and Hand Surgery, University Hospital Zurich, Zurich, Switzerland
| | - Kai Kaye
- Division of Plastic Surgery and Hand Surgery, University Hospital Zurich, Zurich, Switzerland
| | - Lukas Lunger
- Division of Urology, Klinikum Rechts der Isar, Technical University of Munich, Munich, Germany
| | - Geraldine Weinforth
- Division of Plastic Surgery and Hand Surgery, University Hospital Zurich, Zurich, Switzerland
| | - Pietro Giovanoli
- Division of Plastic Surgery and Hand Surgery, University Hospital Zurich, Zurich, Switzerland
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T'Sjoen G, Arcelus J, Gooren L, Klink DT, Tangpricha V. Endocrinology of Transgender Medicine. Endocr Rev 2019; 40:97-117. [PMID: 30307546 DOI: 10.1210/er.2018-00011] [Citation(s) in RCA: 159] [Impact Index Per Article: 31.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2018] [Accepted: 06/21/2018] [Indexed: 02/08/2023]
Abstract
Gender-affirming treatment of transgender people requires a multidisciplinary approach in which endocrinologists play a crucial role. The aim of this paper is to review recent data on hormonal treatment of this population and its effect on physical, psychological, and mental health. The Endocrine Society guidelines for transgender women include estrogens in combination with androgen-lowering medications. Feminizing treatment with estrogens and antiandrogens has desired physical changes, such as enhanced breast growth, reduction of facial and body hair growth, and fat redistribution in a female pattern. Possible side effects should be discussed with patients, particularly those at risk for venous thromboembolism. The Endocrine Society guidelines for transgender men include testosterone therapy for virilization with deepening of the voice, cessation of menses, and increases of muscle mass and facial and body hair. Owing to the lack of evidence, treatment of gender nonbinary people should be individualized. Young people may receive pubertal suspension, consisting of GnRH analogs, later followed by sex steroids. Options for fertility preservation should be discussed before any hormonal intervention. Morbidity and cardiovascular risk with cross-sex hormones is unchanged among transgender men and unclear among transgender women. Sex steroid-related malignancies can occur but are rare. Mental health problems such as depression and anxiety have been found to reduce considerably following hormonal treatment. Future studies should aim to explore the long-term outcome of hormonal treatment in transgender people and provide evidence as to the effect of gender-affirming treatment in the nonbinary population.
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Affiliation(s)
- Guy T'Sjoen
- Department of Endocrinology, Ghent University Hospital, Ghent, Belgium.,Center for Sexology and Gender, Ghent University Hospital, Ghent, Belgium
| | - Jon Arcelus
- Institute of Mental Health, Jubilee Campus, University of Nottingham, Nottingham, United Kingdom.,Nottingham Centre for Transgender Health, Nottingham, United Kingdom
| | - Louis Gooren
- University Hospital, Vrije Universiteit of Amsterdam, Amsterdam, Netherlands
| | | | - Vin Tangpricha
- Division of Endocrinology, Metabolism, and Lipids, Department of Medicine, Emory University, Atlanta, Georgia
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Howe E. Ethical rationales for past and present military medical practices. J ROY ARMY MED CORPS 2018; 165:273-278. [PMID: 30530790 DOI: 10.1136/jramc-2018-001036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2018] [Revised: 09/27/2018] [Accepted: 09/27/2018] [Indexed: 11/04/2022]
Abstract
This paper reviews changes in the ethical challenges that have arisen in military medicine over the past four decades. This includes the degree, if any, to which providers during the Vietnam conflict have carried out what we now refer to as harsh interrogation measures in an attempt to extract information from captured enemy soldiers, the extent, if any, to which the USA used medicine as a means to try to win over the hearts and minds of civilians in occupied territory and how providers should treat service members who return from the front with combat fatigue. An issue that arose during the first Gulf War in 1991 is discussed, namely US service persons being required to take botulism vaccine without their consent. Finally, present challenges are discussed including interrogation measures such as waterboarding and the ethical issues posed in the recent past by the exclusion of gay service members and those posed presently by the inclusion of transgender members. Two ethical values are suggested that have remained constant, namely giving priority to the individual needs of service personnel over those of the unit when there are no urgent combat needs and the reliance on individual virtue when what they should do is morally unclear.
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Affiliation(s)
- Edmund Howe
- Department of Psychiatry, Uniformed Services University of the Health Sciences, Bethesda, MD 20814, USA
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Martinerie L, Condat A, Bargiacchi A, Bremont-Weill C, de Vries MC, Hannema SE. MANAGEMENT OF ENDOCRINE DISEASE: Approach to the management of children and adolescents with Gender Dysphoria. Eur J Endocrinol 2018; 179:R219-R237. [PMID: 30049812 DOI: 10.1530/eje-18-0227] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2018] [Revised: 07/07/2018] [Accepted: 07/25/2018] [Indexed: 02/03/2023]
Abstract
Over the past 20 years, the care for transgender adolescents has developed throughout many countries following the "Dutch Approach" initiated in the 90's in pioneer countries as the Netherlands, United States and Canada, with increasing numbers of children and adolescents seeking care in transgender clinics. This medical approach has considerable positive impacts on the psychological outcomes of these adolescents and several studies have been recently published underlining the relative safety of such treatments. This paper reviews the current standards of care for transgender children and adolescents with particular emphasis on disparities among countries and short to medium-term outcomes. Finally it highlights ethical considerations regarding categorization of gender dysphoria, timing of treatment initiation, infertility, and how to deal with the long-term consequences.
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Affiliation(s)
- L Martinerie
- Department of Pediatric Endocrinology, Centre de Référence des Maladies Endocriniennes Rares de la Croissance, Robert Debré Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France
- Paris Diderot University, Sorbonne Paris Cité, Paris, France
- INSERM Unit 1145, Le Kremlin-Bicêtre, France
| | - A Condat
- Department of Adolescent and Child Psychiatry, Pitié-Salpétrière Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France
- CESP INSERM 1018, ED3C, Université Paris Descartes, Paris, France
| | - A Bargiacchi
- Department of Adolescent and Child Psychiatry, Robert Debré Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - C Bremont-Weill
- Department of Endocrinology, Cochin Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - M C de Vries
- Departments of Medical Ethics and Health Law, Leiden University Medical Center, Leiden, The Netherlands
- Departments of Pediatrics, Leiden University Medical Center, Leiden, The Netherlands
| | - S E Hannema
- Departments of Pediatrics, Leiden University Medical Center, Leiden, The Netherlands
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de Blok CJM, Klaver M, Wiepjes CM, Nota NM, Heijboer AC, Fisher AD, Schreiner T, T'Sjoen G, den Heijer M. Breast Development in Transwomen After 1 Year of Cross-Sex Hormone Therapy: Results of a Prospective Multicenter Study. J Clin Endocrinol Metab 2018; 103:532-538. [PMID: 29165635 DOI: 10.1210/jc.2017-01927] [Citation(s) in RCA: 53] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2017] [Accepted: 11/15/2017] [Indexed: 02/04/2023]
Abstract
CONTEXT Breast development is a key feature of feminization and therefore important to transwomen (male-to-female transgender persons). It is not exactly known when breast development starts after initiating cross-sex hormone therapy (CHT) and how much growth may be expected. OBJECTIVE To investigate breast development in transwomen during their first year of CHT and whether clinical or laboratory parameters predict breast development. DESIGN This study was performed as part of the European Network for the Investigation of Gender Incongruence, which is a prospective multicenter cohort study. SETTING Gender clinics in Amsterdam, Ghent, and Florence. PARTICIPANTS Transwomen who completed the first year of CHT (n = 229). INTERVENTION CHT. MAIN OUTCOME MEASURES Breast development in centimeter and cup size. RESULTS The median age of the included transwomen was 28 years (range, 18 to 69). Mean breast-chest difference increased to 7.9 ± 3.1 cm after 1 year of CHT, mainly resulting in less than an AAA cup size (48.7%). Main breast development occurred in the first 6 months of therapy. Serum estradiol levels did not predict breast development after 1 year of CHT (first quartile, 3.6 cm [95% confidence interval (CI), 2.7 to 4.5], second quartile, 3.2 cm [95% CI, 2.3 to 4.2], third quartile, 4.4 cm [95% CI, 3.5 to 5.3], and fourth quartile, 3.6 cm [95% CI, 2.7 to 4.5]). CONCLUSION This study shows that, after 1 year of CHT, breast development is modest and occurs primarily in the first 6 months. No clinical or laboratory parameters were found that predict breast development.
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Affiliation(s)
- Christel Josefa Maria de Blok
- Department of Endocrinology and Center of Expertise on Gender Dysphoria, VU University Medical Center, Amsterdam, The Netherlands
| | - Maartje Klaver
- Department of Endocrinology and Center of Expertise on Gender Dysphoria, VU University Medical Center, Amsterdam, The Netherlands
| | - Chantal Maria Wiepjes
- Department of Endocrinology and Center of Expertise on Gender Dysphoria, VU University Medical Center, Amsterdam, The Netherlands
| | - Nienke Marije Nota
- Department of Endocrinology and Center of Expertise on Gender Dysphoria, VU University Medical Center, Amsterdam, The Netherlands
| | - Annemieke Corine Heijboer
- Department of Clinical Chemistry, Endocrine Laboratory, VU University Medical Center, Amsterdam, The Netherlands
- Laboratory of Endocrinology, Academic Medical Center, Amsterdam, The Netherlands
| | - Alessandra Daphne Fisher
- Sexual Medicine and Andrology Unit, Department of Experimental, Clinical, and Biomedical Sciences, University of Florence, Florence, Italy
| | - Thomas Schreiner
- Department of Endocrinology, Oslo University Hospital, Oslo, Norway
| | - 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, VU University Medical Center, Amsterdam, The Netherlands
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Abstract
PURPOSE This review will inform radiologists about the evidence base regarding radiographic imaging for transgender individuals and considerations for providing culturally sensitive care for this population. FINDINGS Transgender individuals are increasingly referred for both screening and diagnostic breast imaging. It is important that the clinic environment is welcoming, the medical staff utilize accepted terminology and patients are able to designate their gender and personal history to ensure appropriate care. Hormone and surgical treatments used for transition by many transgender women and men may change the approach to imaging. SUMMARY Although not yet evidence-based, screening mammography is currently suggested for transgender women with risk factors, including those receiving hormone treatment over 5 years. The risk for breast cancer in transgender individuals is still being defined.
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Affiliation(s)
- Emily B. Sonnenblick
- Department of Radiology, Icahn School of Medicine at Mt Sinai, One Gustav Levy Place, New York, NY 10029 USA
| | - Ami D. Shah
- Department of Radiology, Icahn School of Medicine at Mt Sinai, One Gustav Levy Place, New York, NY 10029 USA
| | - Zil Goldstein
- Department of Medicine, Center for Transgender Medicine and Surgery at Mt. Sinai , 275 Seventh Avenue, New York, NY 10011 USA
| | - Tamar Reisman
- Department of Medicine, Icahn School of Medicine at Mt. Sinai, 275 Seventh Avenue, New York, NY 10011 USA
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Cunha FS, Domenice S, Sircili MHP, de Mendonca BB, Costa EMF. Low estrogen doses normalize testosterone and estradiol levels to the female range in transgender women. Clinics (Sao Paulo) 2018; 73:e86. [PMID: 29723345 PMCID: PMC5910633 DOI: 10.6061/clinics/2018/e86] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/16/2017] [Accepted: 11/08/2017] [Indexed: 02/01/2023] Open
Abstract
OBJECTIVE The ideal dosage of cross-sex hormones remains unknown. The aim of this study was to evaluate the luteinizing hormone, follicle-stimulating hormone, testosterone, estradiol and prolactin levels after low-dose estrogen therapy with or without cyproterone acetate in transgender women. METHODS The serum hormone and biochemical profiles of 51 transgender women were evaluated before gonadectomy. Hormone therapy consisted of conjugated equine estrogen alone or combined with cyproterone acetate. The daily dose of conjugated equine estrogen was 0.625 mg in 41 subjects and 1.25 mg in 10 subjects, and the daily dose of cyproterone acetate was 50 mg in 42 subjects and 100 mg in one subject. RESULTS Estrogen-only therapy reduced the testosterone, luteinizing hormone and follicle-stimulating hormone levels from 731.5 to 18 ng/dL, 6.3 to 1.1 U/L and 9.6 to 1.5 U/L, respectively. Estrogen plus cyproterone acetate reduced the testosterone, luteinizing hormone and follicle-stimulating hormone levels from 750 to 21 ng/dL, 6.8 to 0.6 U/L and 10 to 1.0 U/L, respectively. The serum levels of luteinizing hormone, follicle-stimulating hormone, testosterone, estradiol and prolactin in the patients treated with estrogen alone and estrogen plus cyproterone acetate were not significantly different. The group receiving estrogen plus cyproterone acetate had significantly higher levels of gamma-glutamyltransferase than the group receiving estrogen alone. No significant differences in the other biochemical parameters were evident between the patients receiving estrogen alone and estrogen plus cyproterone acetate. CONCLUSION In our sample of transgender women, lower estrogen doses than those usually prescribed for these subjects were able to adjust the testosterone and estradiol levels to the physiological female range, thus avoiding high estrogen doses and their multiple associated side effects.
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Affiliation(s)
- Flávia Siqueira Cunha
- Unidade de Endocrinologia do Desenvolvimento, Laboratorio de Hormonios e Genetica Molecular LIM42, Disciplina de Endocrinologia, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, BR
- *Corresponding author. E-mail:
| | - Sorahia Domenice
- Unidade de Endocrinologia do Desenvolvimento, Laboratorio de Hormonios e Genetica Molecular LIM42, Disciplina de Endocrinologia, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, BR
| | - Maria Helena Palma Sircili
- Unidade de Endocrinologia do Desenvolvimento, Laboratorio de Hormonios e Genetica Molecular LIM42, Disciplina de Endocrinologia, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, BR
| | - Berenice Bilharinho de Mendonca
- Unidade de Endocrinologia do Desenvolvimento, Laboratorio de Hormonios e Genetica Molecular LIM42, Disciplina de Endocrinologia, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, BR
| | - Elaine Maria Frade Costa
- Unidade de Endocrinologia do Desenvolvimento, Laboratorio de Hormonios e Genetica Molecular LIM42, Disciplina de Endocrinologia, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, BR
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Changes in hormonal and metabolic parameters in transgender subjects on cross-sex hormone therapy: A cohort study. Maturitas 2018; 107:92-96. [DOI: 10.1016/j.maturitas.2017.10.012] [Citation(s) in RCA: 40] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2017] [Revised: 08/25/2017] [Accepted: 10/13/2017] [Indexed: 11/20/2022]
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Richards SM, Pine-Twaddell ED, Ioffe OB, Bellavance EC. A Case of Benign Phyllodes Tumor in a Transgender Woman Receiving Cross-Sex Hormones. Int J Surg Pathol 2017; 26:356-359. [PMID: 29169272 DOI: 10.1177/1066896917743011] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Phyllodes tumor is a relatively uncommon fibroepithelial neoplasm of the breast characterized by proliferation of both stromal and epithelial elements. Benign phyllodes tumors are distinguished from fibroadenomas by their prominent leaf-like architecture and exaggerated intracanalicular stromal growth pattern. Typically, these lesions affect older natal females; however, we present what we believe is the first reported case of benign phyllodes tumor in a hormonally treated transgender woman.
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Affiliation(s)
| | | | - Olga B Ioffe
- 1 University of Maryland Medical Center, Baltimore, MD, USA
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Hembree WC, Cohen-Kettenis PT, Gooren L, Hannema SE, Meyer WJ, Murad MH, Rosenthal SM, Safer JD, Tangpricha V, T'Sjoen GG. Endocrine Treatment of Gender-Dysphoric/Gender-Incongruent Persons: An Endocrine Society Clinical Practice Guideline. J Clin Endocrinol Metab 2017; 102:3869-3903. [PMID: 28945902 DOI: 10.1210/jc.2017-01658] [Citation(s) in RCA: 1185] [Impact Index Per Article: 169.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2017] [Accepted: 08/24/2017] [Indexed: 12/18/2022]
Abstract
OBJECTIVE To update the "Endocrine Treatment of Transsexual Persons: An Endocrine Society Clinical Practice Guideline," published by the Endocrine Society in 2009. PARTICIPANTS The participants include an Endocrine Society-appointed task force of nine experts, a methodologist, and a medical writer. EVIDENCE This evidence-based guideline was developed using the Grading of Recommendations, Assessment, Development, and Evaluation approach to describe the strength of recommendations and the quality of evidence. The task force commissioned two systematic reviews and used the best available evidence from other published systematic reviews and individual studies. CONSENSUS PROCESS Group meetings, conference calls, and e-mail communications enabled consensus. Endocrine Society committees, members and cosponsoring organizations reviewed and commented on preliminary drafts of the guidelines. CONCLUSION Gender affirmation is multidisciplinary treatment in which endocrinologists play an important role. Gender-dysphoric/gender-incongruent persons seek and/or are referred to endocrinologists to develop the physical characteristics of the affirmed gender. They require a safe and effective hormone regimen that will (1) suppress endogenous sex hormone secretion determined by the person's genetic/gonadal sex and (2) maintain sex hormone levels within the normal range for the person's affirmed gender. Hormone treatment is not recommended for prepubertal gender-dysphoric/gender-incongruent persons. Those clinicians who recommend gender-affirming endocrine treatments-appropriately trained diagnosing clinicians (required), a mental health provider for adolescents (required) and mental health professional for adults (recommended)-should be knowledgeable about the diagnostic criteria and criteria for gender-affirming treatment, have sufficient training and experience in assessing psychopathology, and be willing to participate in the ongoing care throughout the endocrine transition. We recommend treating gender-dysphoric/gender-incongruent adolescents who have entered puberty at Tanner Stage G2/B2 by suppression with gonadotropin-releasing hormone agonists. Clinicians may add gender-affirming hormones after a multidisciplinary team has confirmed the persistence of gender dysphoria/gender incongruence and sufficient mental capacity to give informed consent to this partially irreversible treatment. Most adolescents have this capacity by age 16 years old. We recognize that there may be compelling reasons to initiate sex hormone treatment prior to age 16 years, although there is minimal published experience treating prior to 13.5 to 14 years of age. For the care of peripubertal youths and older adolescents, we recommend that an expert multidisciplinary team comprised of medical professionals and mental health professionals manage this treatment. The treating physician must confirm the criteria for treatment used by the referring mental health practitioner and collaborate with them in decisions about gender-affirming surgery in older adolescents. For adult gender-dysphoric/gender-incongruent persons, the treating clinicians (collectively) should have expertise in transgender-specific diagnostic criteria, mental health, primary care, hormone treatment, and surgery, as needed by the patient. We suggest maintaining physiologic levels of gender-appropriate hormones and monitoring for known risks and complications. When high doses of sex steroids are required to suppress endogenous sex steroids and/or in advanced age, clinicians may consider surgically removing natal gonads along with reducing sex steroid treatment. Clinicians should monitor both transgender males (female to male) and transgender females (male to female) for reproductive organ cancer risk when surgical removal is incomplete. Additionally, clinicians should persistently monitor adverse effects of sex steroids. For gender-affirming surgeries in adults, the treating physician must collaborate with and confirm the criteria for treatment used by the referring physician. Clinicians should avoid harming individuals (via hormone treatment) who have conditions other than gender dysphoria/gender incongruence and who may not benefit from the physical changes associated with this treatment.
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Affiliation(s)
- Wylie C Hembree
- New York Presbyterian Hospital, Columbia University Medical Center, New York, New York 10032
| | | | - Louis Gooren
- VU University Medical Center, 1007 MB Amsterdam, Netherlands
| | | | - Walter J Meyer
- University of Texas Medical Branch, Galveston, Texas 77555
| | - M Hassan Murad
- Mayo Clinic Evidence-Based Practice Center, Rochester, Minnesota 55905
| | - Stephen M Rosenthal
- University of California San Francisco, Benioff Children's Hospital, San Francisco, California 94143
| | - Joshua D Safer
- Boston University School of Medicine, Boston, Massachusetts 02118
| | - Vin Tangpricha
- Emory University School of Medicine and the Atlanta VA Medical Center, Atlanta, Georgia 30322
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de Boer M, van der Sluis WB, de Boer JP, Overbeek LIH, van Leeuwen FE, Rakhorst HA, van der Hulst RRWJ, Hijmering NJ, Bouman MB, de Jong D. Breast Implant-Associated Anaplastic Large-Cell Lymphoma in a Transgender Woman. Aesthet Surg J 2017; 37:NP83-NP87. [PMID: 29036941 DOI: 10.1093/asj/sjx098] [Citation(s) in RCA: 37] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Breast implant-associated anaplastic large-cell lymphoma (BIA-ALCL) is a rare but serious complication in patients with breast implants, Patients are at risk of BIA-ALCL whether they receive breast implants for cosmetic reasons or for reconstructive purposes after surgery for breast cancer or prophylactic mastectomy. During the past decade, an increased number of reports have addressed BIA-ALCL. Herein, we describe BIA-ALCL in a transgender woman. The patient received breast implants as part of her gender transition and was diagnosed with BIA-ALCL 20 years later. The patient underwent several revisional operations in the 20 years after her primary breast surgery to treat unexplained pain with low-grade fever, severe capsular contracture (Baker grade III-IV), and several instances of implant rupture. In July 2016, the patient presented to our office with "late-onset" periprosthetic seroma 5 years after her last revisional breast surgery. She was diagnosed with BIA-ALCL without capsular invasion based on results of cytologic analysis of the periprosthetic seroma and histologic evaluation of the periprosthetic capsule. This diagnosis was verified further by results of immunohistochemical testing, which indicated expression of CD30 and T-cell markers in the periprosthetic seroma only. Our intentions with this case report are to demonstrate that all patients who undergo breast implantation, including transgender women, are at risk of BIA-ALCL and to highlight the importance of cytomorphologic and immunohistochemical screening of seroma fluid in patients with late-onset periprosthetic seroma. LEVEL OF EVIDENCE 5.
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Affiliation(s)
- Mintsje de Boer
- Department of Plastic, Reconstructive, and Hand Surgery, Maastricht University Medical Center, Maastricht, the Netherlands. Department of Plastic, Reconstructive, and Hand Surgery, VU University Medical Center, Amsterdam, the Netherlands. Department of Oncology, Netherlands Cancer Institute, Amsterdam. Dutch Nationwide Network and Registry of Histo- and Cytopathology, Houten, the Netherlands. Division of Epidemiology, Netherlands Cancer Institute, Amsterdam. Department of Plastic, Reconstructive, and Hand Surgery, MST, Enschede, the Netherlands, Dutch Society of Plastic Surgery. Division of Plastic, Reconstructive, and Hand Surgery, Maastricht University Medical Center. Department of Pathology, VU University Medical Center. Department of Plastic, Reconstructive, and Hand Surgery, VU University Medical Center. Center of Expertise on Gender Dysphoria at the VU University Medical Center. Division of Pathology, VU University Medical Center. Dutch BIA-ALCL Consortium
| | - Wouter B van der Sluis
- Department of Plastic, Reconstructive, and Hand Surgery, Maastricht University Medical Center, Maastricht, the Netherlands. Department of Plastic, Reconstructive, and Hand Surgery, VU University Medical Center, Amsterdam, the Netherlands. Department of Oncology, Netherlands Cancer Institute, Amsterdam. Dutch Nationwide Network and Registry of Histo- and Cytopathology, Houten, the Netherlands. Division of Epidemiology, Netherlands Cancer Institute, Amsterdam. Department of Plastic, Reconstructive, and Hand Surgery, MST, Enschede, the Netherlands, Dutch Society of Plastic Surgery. Division of Plastic, Reconstructive, and Hand Surgery, Maastricht University Medical Center. Department of Pathology, VU University Medical Center. Department of Plastic, Reconstructive, and Hand Surgery, VU University Medical Center. Center of Expertise on Gender Dysphoria at the VU University Medical Center. Division of Pathology, VU University Medical Center. Dutch BIA-ALCL Consortium
| | - Jan P de Boer
- Department of Plastic, Reconstructive, and Hand Surgery, Maastricht University Medical Center, Maastricht, the Netherlands. Department of Plastic, Reconstructive, and Hand Surgery, VU University Medical Center, Amsterdam, the Netherlands. Department of Oncology, Netherlands Cancer Institute, Amsterdam. Dutch Nationwide Network and Registry of Histo- and Cytopathology, Houten, the Netherlands. Division of Epidemiology, Netherlands Cancer Institute, Amsterdam. Department of Plastic, Reconstructive, and Hand Surgery, MST, Enschede, the Netherlands, Dutch Society of Plastic Surgery. Division of Plastic, Reconstructive, and Hand Surgery, Maastricht University Medical Center. Department of Pathology, VU University Medical Center. Department of Plastic, Reconstructive, and Hand Surgery, VU University Medical Center. Center of Expertise on Gender Dysphoria at the VU University Medical Center. Division of Pathology, VU University Medical Center. Dutch BIA-ALCL Consortium
| | - Lucy I H Overbeek
- Department of Plastic, Reconstructive, and Hand Surgery, Maastricht University Medical Center, Maastricht, the Netherlands. Department of Plastic, Reconstructive, and Hand Surgery, VU University Medical Center, Amsterdam, the Netherlands. Department of Oncology, Netherlands Cancer Institute, Amsterdam. Dutch Nationwide Network and Registry of Histo- and Cytopathology, Houten, the Netherlands. Division of Epidemiology, Netherlands Cancer Institute, Amsterdam. Department of Plastic, Reconstructive, and Hand Surgery, MST, Enschede, the Netherlands, Dutch Society of Plastic Surgery. Division of Plastic, Reconstructive, and Hand Surgery, Maastricht University Medical Center. Department of Pathology, VU University Medical Center. Department of Plastic, Reconstructive, and Hand Surgery, VU University Medical Center. Center of Expertise on Gender Dysphoria at the VU University Medical Center. Division of Pathology, VU University Medical Center. Dutch BIA-ALCL Consortium
| | - Flora E van Leeuwen
- Department of Plastic, Reconstructive, and Hand Surgery, Maastricht University Medical Center, Maastricht, the Netherlands. Department of Plastic, Reconstructive, and Hand Surgery, VU University Medical Center, Amsterdam, the Netherlands. Department of Oncology, Netherlands Cancer Institute, Amsterdam. Dutch Nationwide Network and Registry of Histo- and Cytopathology, Houten, the Netherlands. Division of Epidemiology, Netherlands Cancer Institute, Amsterdam. Department of Plastic, Reconstructive, and Hand Surgery, MST, Enschede, the Netherlands, Dutch Society of Plastic Surgery. Division of Plastic, Reconstructive, and Hand Surgery, Maastricht University Medical Center. Department of Pathology, VU University Medical Center. Department of Plastic, Reconstructive, and Hand Surgery, VU University Medical Center. Center of Expertise on Gender Dysphoria at the VU University Medical Center. Division of Pathology, VU University Medical Center. Dutch BIA-ALCL Consortium
| | - Hinne A Rakhorst
- Department of Plastic, Reconstructive, and Hand Surgery, Maastricht University Medical Center, Maastricht, the Netherlands. Department of Plastic, Reconstructive, and Hand Surgery, VU University Medical Center, Amsterdam, the Netherlands. Department of Oncology, Netherlands Cancer Institute, Amsterdam. Dutch Nationwide Network and Registry of Histo- and Cytopathology, Houten, the Netherlands. Division of Epidemiology, Netherlands Cancer Institute, Amsterdam. Department of Plastic, Reconstructive, and Hand Surgery, MST, Enschede, the Netherlands, Dutch Society of Plastic Surgery. Division of Plastic, Reconstructive, and Hand Surgery, Maastricht University Medical Center. Department of Pathology, VU University Medical Center. Department of Plastic, Reconstructive, and Hand Surgery, VU University Medical Center. Center of Expertise on Gender Dysphoria at the VU University Medical Center. Division of Pathology, VU University Medical Center. Dutch BIA-ALCL Consortium
| | - René R W J van der Hulst
- Department of Plastic, Reconstructive, and Hand Surgery, Maastricht University Medical Center, Maastricht, the Netherlands. Department of Plastic, Reconstructive, and Hand Surgery, VU University Medical Center, Amsterdam, the Netherlands. Department of Oncology, Netherlands Cancer Institute, Amsterdam. Dutch Nationwide Network and Registry of Histo- and Cytopathology, Houten, the Netherlands. Division of Epidemiology, Netherlands Cancer Institute, Amsterdam. Department of Plastic, Reconstructive, and Hand Surgery, MST, Enschede, the Netherlands, Dutch Society of Plastic Surgery. Division of Plastic, Reconstructive, and Hand Surgery, Maastricht University Medical Center. Department of Pathology, VU University Medical Center. Department of Plastic, Reconstructive, and Hand Surgery, VU University Medical Center. Center of Expertise on Gender Dysphoria at the VU University Medical Center. Division of Pathology, VU University Medical Center. Dutch BIA-ALCL Consortium
| | - Nathalie J Hijmering
- Department of Plastic, Reconstructive, and Hand Surgery, Maastricht University Medical Center, Maastricht, the Netherlands. Department of Plastic, Reconstructive, and Hand Surgery, VU University Medical Center, Amsterdam, the Netherlands. Department of Oncology, Netherlands Cancer Institute, Amsterdam. Dutch Nationwide Network and Registry of Histo- and Cytopathology, Houten, the Netherlands. Division of Epidemiology, Netherlands Cancer Institute, Amsterdam. Department of Plastic, Reconstructive, and Hand Surgery, MST, Enschede, the Netherlands, Dutch Society of Plastic Surgery. Division of Plastic, Reconstructive, and Hand Surgery, Maastricht University Medical Center. Department of Pathology, VU University Medical Center. Department of Plastic, Reconstructive, and Hand Surgery, VU University Medical Center. Center of Expertise on Gender Dysphoria at the VU University Medical Center. Division of Pathology, VU University Medical Center. Dutch BIA-ALCL Consortium
| | - Mark-Bram Bouman
- Department of Plastic, Reconstructive, and Hand Surgery, Maastricht University Medical Center, Maastricht, the Netherlands. Department of Plastic, Reconstructive, and Hand Surgery, VU University Medical Center, Amsterdam, the Netherlands. Department of Oncology, Netherlands Cancer Institute, Amsterdam. Dutch Nationwide Network and Registry of Histo- and Cytopathology, Houten, the Netherlands. Division of Epidemiology, Netherlands Cancer Institute, Amsterdam. Department of Plastic, Reconstructive, and Hand Surgery, MST, Enschede, the Netherlands, Dutch Society of Plastic Surgery. Division of Plastic, Reconstructive, and Hand Surgery, Maastricht University Medical Center. Department of Pathology, VU University Medical Center. Department of Plastic, Reconstructive, and Hand Surgery, VU University Medical Center. Center of Expertise on Gender Dysphoria at the VU University Medical Center. Division of Pathology, VU University Medical Center. Dutch BIA-ALCL Consortium
| | - Daphne de Jong
- Department of Plastic, Reconstructive, and Hand Surgery, Maastricht University Medical Center, Maastricht, the Netherlands. Department of Plastic, Reconstructive, and Hand Surgery, VU University Medical Center, Amsterdam, the Netherlands. Department of Oncology, Netherlands Cancer Institute, Amsterdam. Dutch Nationwide Network and Registry of Histo- and Cytopathology, Houten, the Netherlands. Division of Epidemiology, Netherlands Cancer Institute, Amsterdam. Department of Plastic, Reconstructive, and Hand Surgery, MST, Enschede, the Netherlands, Dutch Society of Plastic Surgery. Division of Plastic, Reconstructive, and Hand Surgery, Maastricht University Medical Center. Department of Pathology, VU University Medical Center. Department of Plastic, Reconstructive, and Hand Surgery, VU University Medical Center. Center of Expertise on Gender Dysphoria at the VU University Medical Center. Division of Pathology, VU University Medical Center. Dutch BIA-ALCL Consortium
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Tangpricha V, den Heijer M. Oestrogen and anti-androgen therapy for transgender women. Lancet Diabetes Endocrinol 2017; 5:291-300. [PMID: 27916515 PMCID: PMC5366074 DOI: 10.1016/s2213-8587(16)30319-9] [Citation(s) in RCA: 112] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2016] [Revised: 08/18/2016] [Accepted: 08/22/2016] [Indexed: 01/03/2023]
Abstract
Transgender women experience lifelong gender dysphoria due to a gender assignment at birth that is incongruent with their gender identity. They often seek hormone therapy, with or without surgery, to improve their gender dysphoria and to better align their physical and psychological features with a more feminine gender role. Some of the desired physical changes from oestrogen and anti-androgen therapy include decreased body and facial hair, decreased muscle mass, breast growth, and redistribution of fat. Overall the risks of treatment are low, but include thromboembolism, the risk of which depends on the dose and route of oestrogen administration. Other associated conditions commonly seen in transgender women include increased risks of depression and osteoporosis. The risk of hormone-sensitive cancer seems to be low in transgender women, with no increased risk of breast cancer compared with women and no increase in prostate cancer when compared with men. The evidence base for the care of transgender women is limited by the paucity of high-quality research, and long-term longitudinal studies are needed to inform future guidelines.
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Affiliation(s)
- Vin Tangpricha
- Division of Endocrinology, Metabolism and Lipids, Department of Medicine, Emory University School of Medicine and Atlanta VA Medical Center, Atlanta, GA, USA.
| | - Martin den Heijer
- Department of Endocrinology and Center of Expertise on Gender Dysphoria, VU University Medical Center, Amsterdam, Netherlands
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Mamoojee Y, Seal LJ, Quinton R. Transgender hormone therapy: understanding international variation in practice. Lancet Diabetes Endocrinol 2017; 5:243-246. [PMID: 28340645 DOI: 10.1016/s2213-8587(17)30068-2] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2016] [Revised: 01/16/2017] [Accepted: 01/17/2017] [Indexed: 12/13/2022]
Affiliation(s)
- Yaasir Mamoojee
- Department of Endocrinology, Newcastle-upon-Tyne Hospitals NHS Trust, Newcastle-upon-Tyne, UK
| | - Leighton J Seal
- Department of Endocrinology, St George's Hospital Medical School, London, UK; Department of Endocrinology, St George's Healthcare NHS Trust, London, UK; Gender Identity Clinic, West London Mental Health NHS Trust, London, UK
| | - Richard Quinton
- Department of Endocrinology, Newcastle-upon-Tyne Hospitals NHS Trust, Newcastle-upon-Tyne, UK; Endocrine Research Group, Institute of Genetic Medicine, University of Newcastle-upon-Tyne, Newcastle-upon-Tyne, NE1 3BZ, UK.
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Seal LJ. A review of the physical and metabolic effects of cross-sex hormonal therapy in the treatment of gender dysphoria. Ann Clin Biochem 2015; 53:10-20. [PMID: 25933804 DOI: 10.1177/0004563215587763] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/28/2015] [Indexed: 11/17/2022]
Abstract
This review focuses on the effect that cross-gender sex steroid therapy has on metabolic and hormonal parameters. There is an emphasis on those changes that result in significant clinical effects such as the positive effects of the development of secondary sexual characteristics and negative effects such as haemostatic effects and thromboembolism in transwomen or dyslipidaemia in transmen. There is also a description of the current hormonal regimens used at the largest UK gender identity clinic. The overall safety of these treatments in the context of long-term outcome data is reviewed.
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Affiliation(s)
- Leighton J Seal
- St George's Hospital Medical School, London, UK St George's Healthcare NHS Trust, London, UK West London Mental Health NHS Trust Gender Identity Clinic West London Mental Health NHS Trust, London, UK
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Colebunders B, T'Sjoen G, Weyers S, Monstrey S. Hormonal and Surgical Treatment in Trans‐Women with BRCA1 Mutations: A Controversial Topic. J Sex Med 2014; 11:2496-9. [DOI: 10.1111/jsm.12628] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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