Low complication rates of testosterone and estradiol implants for androgen and estrogen replacement therapy in over 1 million procedures

Effects of gender affirming hormone treatment in transgender individuals - a retrospective cohort study

PURPOSE

Gender affirming hormone treatment (GAHT) results in measurable changes to anthropomorphic, biochemical and hormonal variables that are important to patients and their health care professionals to guide treatment. This study sought to quantify changes which occur in response to initiation of GAHT.

METHODS

We performed a retrospective cohort study of outcomes in transgender and gender diverse (TGD) patients starting GAHT. The primary outcome was proportion of patients and time required to achieve optimal hormone levels after commencement of GAHT. Additional analyses were performed to assess whether clinical and biochemical factors were associated with likelihood of achieving target hormone levels.

RESULTS

345 patients were included. Among 154 transmasculine individuals, 116 (75%) achieved a testosterone level >10 nmol/L during follow-up at a median of 4-months (IQR 4-9). No clinical or biochemical factors were significantly associated with likelihood of reaching therapeutic testosterone concentrations in transmen. Among 191 transfeminine individuals, 131 (72%) achieved a testosterone level <2.0 nmol/L during follow-up at a median of 4-months (IQR 3-9). Factors associated with increased likelihood of testosterone suppression were use of subdermal estradiol implants as well as cyproterone acetate as an androgen antagonist. Changes in differing directions were observed during repeated measures of lipids, liver function, and blood count between transmasculine and transfeminine individuals, reflecting the important effects of testosterone and estradiol on biochemical tests ordered as part of routine clinical care.

CONCLUSION

Most TGD patients achieve target testosterone levels within 9 months of GAHT initiation. Adverse effects of GAHT are rare, and are usually mild.

Subcutaneous testosterone pellet therapy for reversal of male osteoporosis: a review and case report

PURPOSE

To describe the effects of consistent levels of testosterone in a pellet form and it's potential to reverse osteoporosis.

METHODS

This is a descriptive case report of a 54 year male with a spontaneous fracture and osteoporosis in the presence of what many consider a normal male testosterone level.

RESULTS

After discovering and documenting osteoporosis by DXA scan, the patient was shown to reverse the diagnosis of osteoporosis in a year on pelleted testosterone therapy. Consistent levels of 943 ng/dL were achieved; the patient also experienced improvements in quality of life and sleep apnea.

CONCLUSION

Testosterone deficiency (TD) is a clinical syndrome and osteoporosis can be found in levels above standard "criteria" of 300. This patient did not realize a benefit on injections both physical and clinically and both improved on pelleted testosterone. This should be further studied and considered for TD in men.

Testosterone Pellet Use in Transgender Men

Purpose

We assessed the efficacy and short-term adverse effects of testosterone pellet use in transgender men to broaden therapeutic options.

Methods

We conducted a retrospective study of 30 transgender men who started testosterone pellets between 2018 and 2020.

Results

Testosterone pellets were started at dosages 675-825 mg per cycle and dose was adjusted according to testosterone levels obtained 1 to 6 months post-testosterone pellet insertion. Pharmacokinetics of testosterone pellet in transgender men was similar to those in cisgender men. Total testosterone levels reached a peak in 1 month and remained in the therapeutic range for ∼4 months in the range of 300-800 ng/dL. After switching over to testosterone pellets, 100% of patients continued to achieve amenorrhea and deepening of their voice. Most of the patients noticed increased hair growth in androgen-dependent regions (96.3%) and improved libido (70%). Adverse events were notable for a rate of polycythemia that was unexpectedly high at 46.67%. Pellet extrusion was found in 13.33% of patients. There was a low rate of pellet site hematoma (6.67%) and cellulitis (3.33%). No thromboembolic or cardiovascular events occurred in any of the patients.

Conclusion

This study reveals that testosterone pellets are a reasonable alternative to other testosterone modalities in transgender men but would use caution in patients with a history of polycythemia or higher risk for thromboembolic events.

Compounded Bioidentical Menopausal Hormone Therapy: ACOG Clinical Consensus No. 6

SUMMARY

Many compounding pharmacies use the phrase "bioidentical hormone" as a marketing term to imply that these preparations are natural and, thus, safer and more effective than U.S. Food and Drug Administration (FDA)-approved menopausal medications that use bioidentical or synthetic hormones or both. However, evidence to support marketing claims of safety and effectiveness is lacking. Compounded bioidentical menopausal hormone therapy should not be prescribed routinely when FDA-approved formulations exist. Clinicians should counsel patients that FDA-approved menopausal hormone therapies are recommended for the management of menopausal symptoms over compounded bioidentical menopausal hormone therapy. If a patient requests the use of compounded bioidentical menopausal hormone therapy, clinicians should educate them on the lack of FDA approval of these preparations and their potential risks and benefits, including the risks specific to compounding. To truly understand the benefits and harms of compounded bioidentical menopausal hormone therapy, high quality placebo-controlled randomized controlled trials with long-term follow-up comparing custom-compounded products with FDA-approved menopausal hormone therapy are needed.

Clinical Approaches to Nestorone Subdermal Implant Therapy in Women's Health

Segesterone acetate (SA) or Nestorone, a fourth-generation progestogen, is a synthetic compound with high progestational activity and no androgenic, glucocorticoid, or anabolic effects. However, due to its oral inactivity, SA must be used by other routes, such as subcutaneous. Thus, considering its peculiar properties, the SA subdermal implant is successfully used in female contraception and postmenopausal hormone replacement therapy (HRT). In recent years, its potential uses in endometriosis, polycystic ovaries syndrome (PCOS), and a new therapeutic possibility for neuroprotection have made this treatment extremely interesting. However, the absence of a standardized dose and the long-term safety of SA implant therapy in women is still controversial. Here, we present the possible indications, doses, limitations, and side effects of SA implant therapy.

Medicinal Leeches to Aid in Post-procedural Hematoma Evacuation

Patients presenting with a post-invasive procedure hematoma can be treated with medicinal leeches to evacuate the hematoma. Our patient, a postmenopausal woman in her 60s, with a past medical history of hypothyroidism, presented to the outpatient clinic with pain, redness, warmth, and swelling on her right thigh. Ten days prior, the patient had undergone a subcutaneous pellet implant procedure in the right thigh for hormonal replacement therapy. The patient developed post-procedure cellulitis and soft tissue infection and was treated with antibiotics. The patient developed a progressively enlarged hematoma at the implant site. The hematoma was treated with medicinal leeches. Two weeks after treatment, the implant area healed. The patient had a family history of von Willebrand disease and a history of prolonged bleeding during childbirth, menstruation, and dental procedures. A von Willebrand panel was obtained, and the results were consistent with a new diagnosis of von Willebrand disease.

Cardiovascular Safety and Benefits of Testosterone Implant Therapy in Postmenopausal Women: Where Are We?

We discuss the CV safety and efficacy data for subcutaneous testosterone therapy (STT) in postmenopausal women. We also highlight new directions and applications of correct dosages performed in a specialized center. To recommend STT, we propose innovative criteria (IDEALSTT) according to total testosterone (T) level, carotid artery intima-media thickness, and calculated SCORE for a 10-year risk of fatal cardiovascular disease (CVD). Despite all the controversies, hormone replacement therapy (HRT) with T has gained prominence in treating pre and postmenopausal women in the last decades. HRT with silastic and bioabsorbable testosterone hormone implants has gained prominence recently due to its practicality and effectiveness in treating menopausal symptoms and hypoactive sexual desire disorder. A recent publication on the complications of STT, looking at a large cohort of patients over seven years, demonstrated its long-term safety. However, the cardiovascular (CV) risk and safety of STT in women are still controversial.

A Personal Prospective on Testosterone Therapy in Women—What We Know in 2022

Hormone replacement therapy continues to be a controversial topic in medicine, with certain narratives regarding safety concerns that are not scientifically established in peer-reviewed literature. These negative narratives, specifically undermining the use of testosterone in women, have caused women to remain without any Food and Drug Administration (FDA)-approved testosterone therapies, while more than 30 FDA-approved testosterone therapies are available for men in the United States. This has resulted in millions of women suffering in silence with very common symptoms of perimenopause and menopause that could easily be addressed with the use of testosterone. There is growing evidence to support the use of physiologic doses of testosterone for sexual function, osteoporosis prevention, brain protection, and breast protection. The safety of testosterone use in women has been evaluated for the past 80 years. A recent publication on the complications of subcutaneous hormone-pellet therapy, looking at a large cohort of patients over 7 years, demonstrated long-term safety. In addition, there have been two large long-term peer-reviewed studies showing a significant reduction in the incidence of invasive breast cancer in women on testosterone therapy. Perhaps it is time for the FDA to consider approving products that would benefit testosterone-deficient women.

Society Position Statements on Bio-Identical Hormones-Misinformation Leads to a Dilemma in Women's Health

This commentary reviews the current status of compounding pharmacies and underscores outdated and inaccurate information in the clinical opinions and position statements of two prominent societies.