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Jayasena CN, Devine K, Barber K, Comninos AN, Conway GS, Crown A, Davies MC, Ewart A, Seal LJ, Smyth A, Turner HE, Webber L, Anderson RA, Quinton R. Society for endocrinology guideline for understanding, diagnosing and treating female hypogonadism. Clin Endocrinol (Oxf) 2024. [PMID: 39031660 DOI: 10.1111/cen.15097] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2023] [Revised: 03/18/2024] [Accepted: 05/27/2024] [Indexed: 07/22/2024]
Abstract
Female hypogonadism (FH) is a relatively common endocrine disorder in women of premenopausal age, but there are significant uncertainties and wide variation in its management. Most current guidelines are monospecialty and only address premature ovarian insufficiency (POI); some allude to management in very brief and general terms, and most rely upon the extrapolation of evidence from the studies relating to physiological estrogen deficiency in postmenopausal women. The Society for Endocrinology commissioned new guidance to provide all care providers with a multidisciplinary perspective on managing patients with all forms of FH. It has been compiled using expertise from Endocrinology, Primary Care, Gynaecology and Reproductive Health practices, with contributions from expert patients and a patient support group, to help clinicians best manage FH resulting from both POI and hypothalamo-pituitary disorders, whether organic or functional.
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Affiliation(s)
- Channa N Jayasena
- Section of Investigative Medicine, Hammersmith Hospital, Imperial College London, London, UK
| | - Kerri Devine
- Department of Endocrinology, Diabetes & Metabolism, Newcastle-upon-Tyne Hospitals NHS Foundation Trust, Newcastle-upon-Tyne, UK
- Translational & Clinical Research Institute, University of Newcastle-upon-Tyne, Newcastle-upon-Tyne, UK
| | - Katie Barber
- Community Gynaecology (NHS), Principal Medical Limited, Bicester, Oxfordshire, UK
- Oxford Menopause Ltd, Ardington, Wantage, UK
| | - Alexander N Comninos
- Division of Diabetes, Endocrinology & Metabolism, Imperial College London, London, UK
- Department of Endocrinology, Imperial College Healthcare NHS Trust, London, UK
| | - Gerard S Conway
- Reproductive Medicine Unit, University College London Hospitals, London, UK
| | - Anna Crown
- Department of Endocrinology, Royal Sussex County Hospital, University Hospitals Sussex NHS Foundation Trust, Brighton, UK
| | - Melanie C Davies
- Reproductive Medicine Unit, University College London Hospitals, London, UK
| | - Ann Ewart
- Kallman Syndrome and Congenital Hypogonadotropic Hypogonadism Support Group, Dallas, Texas, United States
| | - Leighton J Seal
- Department of Endocrinology, St George's Hospital Medical School, London, UK
| | - Arlene Smyth
- UK Turner Syndrome Support Society, Clydebank, UK
| | - Helen E Turner
- Department of Endocrinology, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Lisa Webber
- Department of Obstetrics & Gynaecology, Singapore General Hospital, Singapore
| | - Richard A Anderson
- MRC Centre for Reproductive Health, University of Edinburgh, Edinburgh, UK
| | - Richard Quinton
- Section of Investigative Medicine, Hammersmith Hospital, Imperial College London, London, UK
- Department of Endocrinology, Diabetes & Metabolism, Newcastle-upon-Tyne Hospitals NHS Foundation Trust, Newcastle-upon-Tyne, UK
- Translational & Clinical Research Institute, University of Newcastle-upon-Tyne, Newcastle-upon-Tyne, UK
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Tominaga Y, Kobayashi T, Matsumoto Y, Moriwake T, Oshima Y, Okumura M, Horii S, Sadahira T, Katayama S, Iwata T, Nishimura S, Bekku K, Edamura K, Sugimoto M, Kobayashi Y, Watanabe M, Namba Y, Matsumoto Y, Nakatsuka M, Araki M. Trans men can achieve adequate muscular development through low-dose testosterone therapy: A long-term study on body composition changes. Andrology 2024. [PMID: 38563871 DOI: 10.1111/andr.13640] [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: 12/25/2023] [Revised: 02/17/2024] [Accepted: 03/15/2024] [Indexed: 04/04/2024]
Abstract
BACKGROUND Transgender individuals undergo the gender-affirming hormone therapy (GAHT) to achieve physical changes consistent with their gender identity. Few studies are available on the long-term safety and efficacy of GAHT. OBJECTIVES To investigate the long-term physical effects and the safety of the testosterone therapy for trans men and to assess the impact of differential hormone dose. MATERIALS AND METHODS Trans men who initiated GAHT between May 2000 and December 2021 were included in this retrospective analysis. Physical findings (body mass index, body fat percentage (BFP), lean body mass (LBM), and grip strength), blood testing results (hemoglobin, hematocrit, uric acid, creatinine, total cholesterol, triglycerides, and total testosterone), and menstrual cessation were recorded. We assessed the effects of testosterone on body composition changes and laboratory parameters, comparing a low-dose group (≤ 62.5 mg/wk) to a high-dose group (> 62.5 mg/wk). RESULTS Of 291 participants, 188 patients (64.6%) were in the low-dose group and 103 (35.4%) in the high-dose group. Cumulative menstrual cessation rates up to 12 months were not significantly different between groups. Both groups showed a decrease in BFP and an increase in LBM during the first year of therapy, followed by a slight increase in both over the long term. The high-dose group exhibited greater LBM gains during the first year. Higher hormone doses and lower initial LBM values were associated with LBM increases at 3 and 6 months (3 mo, P = 0.006, P < 0.001; 6 mo, P = 0.015, P < 0.001). There were no long-term, dose-dependent side effects such as polycythemia or dyslipidemia. CONCLUSION Long-term GAHT for trans men is safe and effective. Low-dose testosterone administration is sufficient to increase LBM in trans men. Higher testosterone doses can lead to an earlier increase in muscle mass.
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Affiliation(s)
- Yusuke Tominaga
- Department of Urology, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Tomoko Kobayashi
- Department of Urology, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Yuko Matsumoto
- Department of Urology, Good Life Hospital, Hiroshima, Japan
| | - Takatoshi Moriwake
- Department of Urology, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Yoshitaka Oshima
- Department of Neuropsychiatry, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Misa Okumura
- Department of Urology, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Satoshi Horii
- Department of Urology, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Takuya Sadahira
- Department of Urology, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Satoshi Katayama
- Department of Urology, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Takehiro Iwata
- Department of Urology, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Shingo Nishimura
- Department of Urology, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Kensuke Bekku
- Department of Urology, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Kohei Edamura
- Department of Urology, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Morito Sugimoto
- Department of Urology, Onomichi Municipal Hospital, Hiroshima, Japan
| | - Yasuyuki Kobayashi
- Department of Urology, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Masami Watanabe
- Center for Innovative Clinical Medicine, Okayama University Graduate School of Medicine, Okayama, Japan
| | - Yuzaburo Namba
- Gender Center, Okayama University Hospital, Okayama, Japan
| | | | - Mikiya Nakatsuka
- Faculty of Health Sciences, Okayama University Graduate School of Medicine, Okayama, Japan
| | - Motoo Araki
- Department of Urology, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
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Cortez S, Moog D, Lewis C, Williams K, Herrick C, Fields M, Gray T, Guo Z, Nicol G, Baranski T. Effectiveness and Safety of Different Estradiol Regimens in Transgender Women (TREAT Study): Protocol for a Randomized Controlled Trial. JMIR Res Protoc 2023; 12:e53092. [PMID: 38133914 PMCID: PMC10770781 DOI: 10.2196/53092] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2023] [Revised: 11/02/2023] [Accepted: 11/03/2023] [Indexed: 12/23/2023] Open
Abstract
BACKGROUND Current guidelines for gender-affirming hormone therapy (GAHT) for transgender women are mostly based on clinical experience from experts in the field and treatments used on postmenopausal women. While care is currently provided with the best available evidence, there is a critical gap in knowledge about the safest and most effective estradiol routes of administration for GAHT in transgender women; this statement is supported by the World Professional Association for Transgender Health on their Standards of Care for the Health of Transgender and Gender Diverse People, version 8. Furthermore, the reported rates of cardiometabolic adverse events in transgender women highlight the importance of investigating changes in lipoproteins, glucose, and insulin sensitivity, among other markers while receiving GAHT. OBJECTIVE This study aims to evaluate the degree of testosterone suppression achieved at 1, 6, and 12 months in treatment-naive transgender women when randomized to GAHT with estradiol and spironolactone as antiandrogens. As a secondary aim, this study will assess the treatment effect on metabolic and coagulation factors from baseline to 6 and 12 months after initiating GAHT. METHODS This is a prospective pilot, open-label, randomized clinical trial conducted at an adult transgender clinic in a tertiary medical center. The 3 treatment arms include once-daily sublingual 17-β estradiol, twice-daily sublingual 17-β estradiol, and transdermal 17-β estradiol. All participants received spironolactone as an antiandrogen. Transgender women aged 18 to 45 years who are being evaluated for the initiation of GAHT with 17-β estradiol and did not have a history of coagulopathy, cigarette smoking, liver disease, dyslipidemia requiring treatment, or use of gonadotropin-releasing hormone agonist were eligible to enroll. The main outcome is the total testosterone suppression at 1 and 6 months after the initiation of GAHT, and the secondary outcome is to assess treatment effect in a lipid panel; homeostatic model assessment for insulin resistance; coagulation factors II, IX, and XI; Von Willebrand factor; activated protein C resistance; protein C; and protein S at baseline, 6 months, and 12 months after therapy is initiated. RESULTS This study was funded in March 2022, and enrollment concluded in August 2022. It was concluded in July 2023, and currently, the results are being analyzed for publication. CONCLUSIONS The Transgender Estradiol Affirming Therapy (TREAT) study offers a rigorous and reproducible approach to answer important questions regarding GAHT in transgender women, specifically, the most effective 17-β estradiol regimen to suppress testosterone levels to 50 ng/dL, as currently recommended. TRIAL REGISTRATION ClinicalTrials.gov NCT05010707; https://clinicaltrials.gov/study/NCT05010707. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID) DERR1-10.2196/53092.
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Affiliation(s)
- Samuel Cortez
- Division of Pediatric Endrocinology, Department of Pediatrics, Washington University School of Medicine, St Louis, MO, United States
| | - Dominic Moog
- Washington University School of Medicine, St Louis, MO, United States
| | - Christopher Lewis
- Division of Pediatric Endrocinology, Department of Pediatrics, Washington University School of Medicine, St Louis, MO, United States
| | - Kelley Williams
- Division of Endocrinology, Diabetes, and Lipid Metabolism, Department of Medicine, Washington University School of Medicine, St Louis, MO, United States
| | - Cynthia Herrick
- Division of Endocrinology, Diabetes, and Lipid Metabolism, Department of Medicine, Washington University School of Medicine, St Louis, MO, United States
- Division of Public Health Sciences, Department of Surgery, Washington University School of Medicine, St Louis, MO, United States
| | - Melanie Fields
- Division of Pediatric Hematology/Oncology, Department of Pediatrics, Washington University School of Medicine, St Louis, MO, United States
- Department of Neurology, Washington University School of Medicine, St Louis, MO, United States
| | - Teddi Gray
- Department of Psychiatry, Washington University School of Medicine, St Louis, MO, United States
| | - Zhaohua Guo
- Department of Psychiatry, Washington University School of Medicine, St Louis, MO, United States
| | - Ginger Nicol
- Department of Psychiatry, Washington University School of Medicine, St Louis, MO, United States
| | - Thomas Baranski
- Division of Endocrinology, Diabetes, and Lipid Metabolism, Department of Medicine, Washington University School of Medicine, St Louis, MO, United States
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Martinez CA, Rikhi R, Fonseca Nogueira N, Pester MS, Salazar AS, Ashinne B, Aguilar N, Melara A, Porras V, Parker M, Mendez A, Cyrus E, De Santis JP, Jones DL, Brown TT, Hurwitz BE, Alcaide ML. Estrogen-Based Gender-Affirming Hormone Therapy and Subclinical Cardiovascular Disease in Transgender Women with HIV. LGBT Health 2023; 10:576-585. [PMID: 37459150 PMCID: PMC10712365 DOI: 10.1089/lgbt.2023.0010] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/07/2023] Open
Abstract
Purpose: Transgender women (TW) are disproportionately affected by HIV infection and cardiovascular disease (CVD). This study evaluated whether estrogen-based gender-affirming hormone therapy (GAHT) in TW with HIV (TWH-GAHT) is associated with indices of subclinical CVD. Methods: Of the 40 HIV-seropositive persons enrolled, 20-60 years of age, on antiretroviral treatment with undetectable viral load, assessments were performed on 15 TWH; of these persons, 11 were GAHT treated. These TWH-GAHT were matched with HIV+ cisgender men and women based on age, ethnicity/race, body mass index, and antihypertensive medication use. Sex hormones, and cardiometabolic (waist circumference, blood pressure, insulin resistance, lipid profile, and C-reactive protein), vascular (flow-mediated dilation [FMD] and arterial stiffness), and proinflammatory measures were obtained. Results: TWH-GAHT displayed elevated estradiol and suppressed testosterone levels relative to normative ranges. Analyses indicated the TWH-GAHT displayed lower low-density lipoprotein compared with cisgender groups (p < 0.05). Although no difference was seen on FMD, the central augmentation index of aortic stiffness was higher in cisgender HIV+ women than cisgender HIV+ men (p < 0.05). No other group difference on subclinical CVD markers was observed. For TWH, partial correlations indicated associations of certain sex hormones with selected cardiometabolic outcomes and the inflammatory cytokine, interleukin-8. Conclusion: When well matched to HIV+ cisgender men and women, subclinical CVD pathophysiology did not appear elevated in TWH-GAHT, although tendencies emerged suggesting that some subclinical CVD indices may be higher, but others lower than cisgender groups. Longitudinal studies of TWH are needed to more precisely evaluate the moderating effect of GAHT on cardiometabolic pathophysiology.
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Affiliation(s)
- Claudia A. Martinez
- Division of Cardiovascular Medicine, Department of Medicine, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Rishi Rikhi
- Division of Cardiology, Department of Medicine, Wake Forest University School of Medicine, Winston-Salem, North Carolina, USA
| | - Nicholas Fonseca Nogueira
- Division of Infectious Diseases, Department of Medicine, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Mollie S. Pester
- Behavioral Medicine Research Center and Department of Psychology, University of Miami, Miami/Coral Gables, Florida, USA
| | - Ana S. Salazar
- Division of Infectious Diseases, Department of Medicine, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Beteal Ashinne
- Division of Cardiology, Department of Medicine, University of Washington, Seattle, Washington, USA
| | - Natalie Aguilar
- Division of Cardiovascular Medicine, Department of Medicine, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Abraham Melara
- Division of Infectious Diseases, Department of Medicine, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Valeria Porras
- Division of Cardiovascular Medicine, Department of Medicine, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Meela Parker
- Behavioral Medicine Research Center and Department of Psychology, University of Miami, Miami/Coral Gables, Florida, USA
| | - Armando Mendez
- Division of Endocrinology, Diabetes and Metabolism, Department of Medicine, Miller School of Medicine, University of Miami, Miami, Florida, USA
| | - Elena Cyrus
- Department of Population Health Sciences, College of Medicine, University of Central Florida, Orlando, Florida, USA
| | - Joseph P. De Santis
- School of Nursing and Health Studies, University of Miami, Miami, Florida, USA
| | - Deborah L. Jones
- Division of Infectious Diseases, Department of Medicine, University of Miami Miller School of Medicine, Miami, Florida, USA
- Behavioral Medicine Research Center and Department of Psychology, University of Miami, Miami/Coral Gables, Florida, USA
| | - Todd T. Brown
- Division of Endocrinology, Diabetes, and Metabolism, Department of Medicine, Johns Hopkins University, Baltimore, Maryland, USA
| | - Barry E. Hurwitz
- Behavioral Medicine Research Center and Department of Psychology, University of Miami, Miami/Coral Gables, Florida, USA
- Division of Endocrinology, Diabetes and Metabolism, Department of Medicine, Miller School of Medicine, University of Miami, Miami, Florida, USA
| | - Maria L. Alcaide
- Division of Infectious Diseases, Department of Medicine, University of Miami Miller School of Medicine, Miami, Florida, USA
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Birnbaum A, Karamitopoulos M, Carter CW. Musculoskeletal health considerations for the transgender athlete. PHYSICIAN SPORTSMED 2023; 51:387-393. [PMID: 35373697 DOI: 10.1080/00913847.2022.2057787] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2021] [Accepted: 03/21/2022] [Indexed: 10/18/2022]
Abstract
BACKGROUND In addition to the familiar sports-related injuries and conditions experienced by cisgender athletes, transgender athletes may also face unique challenges to maintaining their musculoskeletal health. Encouraging sports medicine professionals to become familiar with accepted nomenclature and terminology related to transgender athletes will enable open communication on the field, in the athletic training facility, and office. OBJECTIVE Understanding contemporary medical and surgical gender-affirming treatments and the unique ways in which the musculoskeletal system might be affected by each - such as impairments in bone health, changes in ligamentous function and the potential increased risk for deep venous thromboembolism - is essential for provision of optimal musculoskeletal care to transgender athletes. Knowledge of the existing participation policies for transgender athletes is also key for enabling sports medicine professionals to effectively counsel athletes about the need for specialized protective equipment. Additionally, this knowledge is important for appropriately managing therapeutic use exemptions in the competitive sports setting. CONCLUSION This article provides an overview of the current accepted nomenclature, common gender-affirming medical and surgical treatments, unique musculoskeletal health considerations, and participation policies for transgender athletes.
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Affiliation(s)
- Amy Birnbaum
- Department of Orthopedic Surgery, NYU Langone Health, New York, NY, USA
| | | | - Cordelia W Carter
- Department of Orthopedic Surgery, NYU Langone Health, New York, NY, USA
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Conlon DM, Welty FK, Reyes-Soffer G, Amengual J. Sex-Specific Differences in Lipoprotein Production and Clearance. Arterioscler Thromb Vasc Biol 2023; 43:1617-1625. [PMID: 37409532 PMCID: PMC10527393 DOI: 10.1161/atvbaha.122.318247] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2022] [Accepted: 06/19/2023] [Indexed: 07/07/2023]
Abstract
Therapeutic approaches to reduce atherogenic lipid and lipoprotein levels remain the most effective and assessable strategies to prevent and treat cardiovascular disease. The discovery of novel research targets linked to pathways associated with cardiovascular disease development has enhanced our ability to decrease disease burden; however, residual cardiovascular disease risks remain. Advancements in genetics and personalized medicine are essential to understand some of the factors driving residual risk. Biological sex is among the most relevant factors affecting plasma lipid and lipoprotein profiles, playing a pivotal role in the development of cardiovascular disease. This minireview summarizes the most recent preclinical and clinical studies covering the effect of sex on plasma lipid and lipoprotein levels. We highlight the recent advances in the mechanisms regulating hepatic lipoprotein production and clearance as potential drivers of disease presentation. We focus on using sex as a biological variable in studying circulating lipid and lipoprotein levels.
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Affiliation(s)
| | | | - Gissette Reyes-Soffer
- Department of Medicine, Division of Preventive Medicine and Nutrition, Columbia University College of Physicians and Surgeons
| | - Jaume Amengual
- Department of Food Science and Human Nutrition and Division of Nutritional Sciences. University of Illinois Urbana Champaign
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Howarth S, Quinton R, Mohammed A. Estradiol treatment in a large cohort of younger women with congenital hypogonadism: how much is enough? Clin Endocrinol (Oxf) 2023; 98:454-456. [PMID: 36342078 DOI: 10.1111/cen.14845] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2022] [Revised: 10/31/2022] [Accepted: 11/03/2022] [Indexed: 11/09/2022]
Affiliation(s)
- Sophie Howarth
- Translational & Clinical Research Institute, Newcastle University, Newcastle-upon-Tyne, UK
| | - Richard Quinton
- Department of Endocrinology, Diabetes & Metabolism, Newcastle-upon-Tyne Hospitals NHS Trust
- Translational & Clinical Research Institute, Newcastle University, Newcastle-upon-Tyne, UK
| | - Azmi Mohammed
- Department of Endocrinology, Diabetes & Metabolism, County Durham & Darlington NHS Trust, Darlington, UK
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Milionis C, Ilias I, Venaki E, Koukkou E. The metabolic effects of hormonal treatment in transgender males: Safety of the testosterone gender-affirming therapy. INTERNATIONAL JOURNAL OF RISK & SAFETY IN MEDICINE 2023; 34:21-28. [PMID: 35964205 DOI: 10.3233/jrs-200087] [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: 01/18/2023]
Abstract
BACKGROUND Gender dysphoria is characterised by a sense of distress because of discordance between the self-perception of gender identity and the assigned sex. Hormonal treatment of transgender males uses testosterone to induce and preserve masculinisation. OBJECTIVE The study investigated the safety of testosterone therapy in transgender males. METHODS The present study used a retrospective file review of transgender male subjects who were treated with testosterone (initially transdermal testosterone gel and subsequently parenteral testosterone undecanoate) for at least 18 months and had subsequently achieved a serum testosterone level within the normal range of cisgender male counterparts. Changes in somatometric data and blood biomarkers were investigated. RESULTS The mean testosterone serum levels after approximately 18 months of treatment were about 545 ng/dL (SD ± 94 ng/dL). There was a statistically significant rise in body mass index (𝜒d = +1.23 kg/m2) with a reduction in blood glucose (𝜒d = -5.33 mg/dL) as well as statistically significant increases in aspartate transaminase (𝜒d = +4.3 U/L), haemoglobin (𝜒d = +1.72 g/dL), and haematocrit (𝜒d = +4.76%). In contrast, there were no significant changes in the lipidaemic profile of the subjects. CONCLUSIONS Treatment with testosterone is routinely used for the promotion of virilising physical changes in transgender males. However, the likelihood of adverse effects of continuous treatment is still unclear. This study contributed to the notion that achieving testosterone levels within the target range is a prerequisite for the safety of the gender-affirming treatment.
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Affiliation(s)
- Charalampos Milionis
- Department of Endocrinology, Diabetes and Metabolism, General Hospital "Elena Venizelou", Athens, Greece
| | - Ioannis Ilias
- Department of Endocrinology, Diabetes and Metabolism, General Hospital "Elena Venizelou", Athens, Greece
| | - Evaggelia Venaki
- Department of Endocrinology, Diabetes and Metabolism, General Hospital "Elena Venizelou", Athens, Greece
| | - Eftychia Koukkou
- Department of Endocrinology, Diabetes and Metabolism, General Hospital "Elena Venizelou", Athens, Greece
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Rytz CL, Turino Miranda K, Ronksley PE, Dumanski SM, Saad N, Raj SR, Somayaji R, Ganshorn H, Newbert AM, Peace L, Ahmed SB. Serum oestradiol levels and risk of adverse cardiovascular events associated with gender-affirming oestrogen therapy: a protocol for a systematic review and meta-analysis. BMJ Open 2022; 12:e064961. [PMID: 36328386 PMCID: PMC9639097 DOI: 10.1136/bmjopen-2022-064961] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
INTRODUCTION The use of gender-affirming oestrogen therapy (GAOT) is an integral part of the gender-affirming transition process for transgender women (assigned male at birth who identify as women) and gender-diverse individuals. However, its use may present significant cardiovascular implications, which may be influenced by systemic oestradiol levels. Therefore, we aim to establish the association between serum oestradiol levels and incidence of adverse cardiovascular events in individuals using GAOT. METHODS AND ANALYSIS We will conduct a systematic review addressing the association between serum oestradiol levels and risk of adverse cardiovascular events in individuals using GAOT. Our primary outcome is the incidence of adverse cardiovascular events, our secondary outcome is the incidence of cardiovascular-related mortality and our tertiary outcome is cardiovascular-related risk factors. Electronic databases (Cochrane Central Register of Controlled Trials, Embase, MEDLINE and Web of Science) will be searched from inception until September 2022. Two investigators will independently complete screening to determine appropriateness of inclusion. Extracted data will include information on serum sex hormone levels (oestradiol and testosterone), participants, GAOT (route of administration, formulations, dosages and duration of exposure), incidence of cardiovascular outcomes, study quality and risk of bias. Inter-reviewer reliability will be calculated at both phases. Data will be presented both descriptively and meta-analysed using a random effects model, if appropriate. Heterogeneity will be explored and meta-regressed if noted. ETHICS AND DISSEMINATION Ethics approval is not needed. We will disseminate findings through international conferences, distributions to transgender and gender-diverse support organisations, decision-makers and key stakeholders. The final systematic review will be published in a peer-reviewed journal. TRIAL REGISTRATION NUMBER CRD42021247717.
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Affiliation(s)
- Chantal L Rytz
- Libin Cardiovascular Institute, University of Calgary, Calgary, Alberta, Canada
- Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Keila Turino Miranda
- Libin Cardiovascular Institute, University of Calgary, Calgary, Alberta, Canada
- Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Paul E Ronksley
- Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Sandra M Dumanski
- Libin Cardiovascular Institute, University of Calgary, Calgary, Alberta, Canada
- Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
- O'Brien Institute of Public Health, University of Calgary, Calgary, Alberta, Canada
| | - Nathalie Saad
- Libin Cardiovascular Institute, University of Calgary, Calgary, Alberta, Canada
- Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Satish R Raj
- Libin Cardiovascular Institute, University of Calgary, Calgary, Alberta, Canada
- Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Ranjani Somayaji
- Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
- O'Brien Institute of Public Health, University of Calgary, Calgary, Alberta, Canada
| | - Heather Ganshorn
- Libraries and Cultural Resources, University of Calgary, Calgary, Alberta, Canada
| | | | | | - Sofia B Ahmed
- Libin Cardiovascular Institute, University of Calgary, Calgary, Alberta, Canada
- Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
- O'Brien Institute of Public Health, University of Calgary, Calgary, Alberta, Canada
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Pitak-Arnnop P, Messer-Peti R, Tangmanee C, Neff A, Meningaud JP. Prostate cancer awareness among transgender women after gender-affirming surgery. Prostate 2022; 82:1060-1067. [PMID: 35416318 DOI: 10.1002/pros.24355] [Citation(s) in RCA: 1] [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: 02/15/2022] [Revised: 04/02/2022] [Accepted: 04/04/2022] [Indexed: 11/09/2022]
Abstract
BACKGROUND The prostate gland remains unresected during gender-affirming surgery (GAS) for transgender women (TGW), and may develop malignancies in later life. We sought to evaluate prostate cancer awareness (PCA) among post-GAS TGW. METHODS The investigators implemented a cross-sectional study and enrolled a sample of Thai post-GAS TGW without medical background. Predictor variables were categorized as demographic, clinical, operative, or postoperative. The outcome variable was PCA (yes/no). Appropriate statistics were computed, and a p-value ≤ 0.05 was considered statistically significant. RESULTS The sample consisted of 100 Thai post-GAS TGW (4% bisexual, 12% bachelor [or higher] graduates, 51% service workers, 64% had monthly net income <40,000 TB [or ca. 1050 Euro], 92% operated by plastic surgeons) with a mean age of 26.2 ± 5.4 years (range: 18-45). On bivariate analysis, PCA was significantly associated with educational level (p = 0.007; adjusted odd ratio [ORadj. ]: 5.85; 95% confidence interval [95% CI]: 1.65-20.69), being operated ≥ 10 years (p = 0.01; ORadj. : 0.16; 95% CI: 0.04-0.76), self-recognition of the remaining prostate gland (p = 0.0001; ORadj. : 0.02; 95% CI: 0-0.12), and emphasis on PCA by the GAS operator (p = 0.01; ORadj. : 0.07; 95% CI: 0.01-0.63). Multiple linear regression analysis revealed a statistically significant, positive correlation (r = 0.78; p = 0.0001) among these four predictors, and continued to confirm the positive effect on PCA in TGW with high education and realization of the prostate gland (r = 0.56; p = 0.04) or information on PCA by the operator (r = 0.68; p = 0.003). CONCLUSION The GSA operator should intensively inform TGW about the remnant prostate and the risk of PC, especially those with low and middle levels of education attained.
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Affiliation(s)
- Poramate Pitak-Arnnop
- Department of Oral and Craniomaxillofacial Plastic Surgery, University Hospital of Giessen and Marburg, UKGM GmbH, Campus Marburg, Faculty of Medicine, Philipps-University of Marburg, Marburg, Germany
| | - Robert Messer-Peti
- Department of Urology, Caritas Hospital Bad Mergentheim and Tauberfranken Prostate Centre - Academic Teaching Hospital of Julius-Maximilians-University of Würzburg, Bad Mergentheim, Germany
| | - Chatpong Tangmanee
- Department of Statistics, Chulalongkorn Business School, Bangkok, Thailand
| | - Andreas Neff
- Department of Oral and Craniomaxillofacial Plastic Surgery, University Hospital of Giessen and Marburg, UKGM GmbH, Campus Marburg, Faculty of Medicine, Philipps-University of Marburg, Marburg, Germany
| | - Jean-Paul Meningaud
- Department of Plastic, Reconstructive, Aesthetic and Maxillofacial Surgery, Henri Mondor University Hospital, AP-HP, Faculty of Medicine, University Paris-Est Créteil Val de Marne (Paris XII), Créteil, France
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11
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Hughto JM, Hughes L, Yee K, Downing J, Ellison J, Alpert A, Jasuja G, Shireman TI. Improving Data-Driven Methods to Identify and Categorize Transgender Individuals by Gender in Insurance Claims Data. LGBT Health 2022; 9:254-263. [PMID: 35290746 PMCID: PMC9150133 DOI: 10.1089/lgbt.2021.0433] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Purpose: Prior algorithms enabled the identification and gender categorization of transgender people in insurance claims databases in which sex and gender are not simultaneously captured. However, these methods have been unable to categorize the gender of a large proportion of their samples. We improve upon these methods to identify the gender of a larger proportion of transgender people in insurance claims data. Methods: Using 2001-2019 Optum's Clinformatics® Data Mart insurance claims data, we adapted prior algorithms by combining diagnosis, procedure, and pharmacy claims to (1) identify a transgender sample; and (2) stratify the sample by gender category (trans feminine and nonbinary [TFN], trans masculine and nonbinary [TMN], unclassified). We used logistic regression to estimate the burden of 13 chronic health conditions, controlling for gender category, age, race/ethnicity, enrollment length, and census region. Results: We identified 38,598 unique transgender people, comprising 50% [n = 19,252] TMN, 26% (n = 10,040) TFN, and 24% (n = 9306) unclassified individuals. In adjusted models, relative to TMN people, TFN people had significantly higher odds of most chronic health conditions, including HIV, atherosclerotic cardiovascular disorder, myocardial infarction, alcohol use disorder, and drug use disorder. Notably, TMN individuals had significantly higher odds of post-traumatic stress disorder and depression than TFN individuals. Conclusion: By combining complex administrative claims-based algorithms, we identified the largest U.S.-based sample of transgender individuals and inferred the gender of >75% of the sample. Adjusted models extend prior research documenting key health disparities by gender category. These methods may enable researchers to explore rare and sex-specific conditions in hard-to-reach transgender populations.
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Affiliation(s)
- Jaclyn M.W. Hughto
- Center for Health Promotion and Health Equity, Brown University School of Public Health, Providence, Rhode Island, USA
- Department of Behavioral and Social Sciences, Brown University School of Public Health, Providence, Rhode Island, USA
- Department of Epidemiology, Brown University School of Public Health, Providence, Rhode Island, USA
- The Fenway Institute, Fenway Health, Boston, Massachusetts, USA
| | - Landon Hughes
- Department of Health Behavior and Health Education, University of Michigan School of Public Health, Ann Arbor, Michigan, USA
- Population Studies Center, Institute for Social Research, University of Michigan, Ann Arbor, Michigan, USA
| | - Kim Yee
- Health Policy and Management, Oregon Health and Science University-Portland State University School of Public Health, Portland, Oregon, USA
| | - Jae Downing
- Health Policy and Management, Oregon Health and Science University-Portland State University School of Public Health, Portland, Oregon, USA
| | - Jacqueline Ellison
- Department of Health Services Policy and Practice, Brown University School of Public Health, Providence, Rhode Island, USA
- Center for Gerontology and Healthcare Research, Brown University School of Public Health, Providence, Rhode Island, USA
| | - Ash Alpert
- Department of Health Services Policy and Practice, Brown University School of Public Health, Providence, Rhode Island, USA
- Center for Gerontology and Healthcare Research, Brown University School of Public Health, Providence, Rhode Island, USA
| | - Guneet Jasuja
- Center for Healthcare Organization and Implementation Research, VA Bedford Healthcare System, Bedford, Massachusetts, USA
- Section of General Internal Medicine, Boston University School of Medicine, Boston, Massachusetts, USA
| | - Theresa I. Shireman
- Department of Health Services Policy and Practice, Brown University School of Public Health, Providence, Rhode Island, USA
- Center for Gerontology and Healthcare Research, Brown University School of Public Health, Providence, Rhode Island, USA
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12
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Hranilovich JA, Kaiser EA, Pace A, Barber M, Ziplow J. Headache in transgender and gender-diverse patients: A narrative review. Headache 2021; 61:1040-1050. [PMID: 34363408 DOI: 10.1111/head.14171] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2021] [Revised: 05/14/2021] [Accepted: 05/18/2021] [Indexed: 12/26/2022]
Abstract
OBJECTIVE To summarize the unique aspects of managing headache in gender minorities and current research in this area including the potential relationship between gender-affirming hormone therapy (GAHT) and headache. BACKGROUND The study of headache in gender minorities is intrinsically important. Gender minorities are medically underserved, and their medical care to date has been limited by socioeconomic disadvantages including stigma and an unsupportive clinical environment. Despite the rising population of transgender and gender-diverse adults and youth, headache research has also been limited. Knowledge of hormonal effects on headache in cisgender patients raises the question of possible effects of GAHT on transgender patients. METHODS/RESULTS The manuscript is a narrative review of current best practices in treating transgender patients, including the use of appropriate terminology and ways to create a supportive environment. It also contains current guidelines on GAHT and reviews drug-drug interactions and secondary headache related to hormone therapy. We also review transgender headache research and related research on hormonal effects on headache in cisgender individuals. CONCLUSION Creating a supportive environment for transgender and gender-diverse patients and being knowledgeable about GAHT are key to providing quality headache care. This review identifies further research needs for this population including the epidemiology of headache disorders in sexual minorities and the potential effects of GAHT on headache disorders in transgender patients.
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Affiliation(s)
- Jennifer A Hranilovich
- Division of Neurology, Department of Pediatrics, Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, CO, USA
| | - Eric A Kaiser
- Department of Neurology, University of Pennsylvania, Philadelphia, PA, USA
| | - Anna Pace
- Department of Neurology, Icahn School of Medicine at Mount Sinai, The Mount Sinai Hospital, New York, NY, USA
| | - Mark Barber
- Department of Neurology, Icahn School of Medicine at Mount Sinai, The Mount Sinai Hospital, New York, NY, USA
| | - Jason Ziplow
- Department of Neurology, Children's Hospital of Philadelphia, Philadelphia, PA, USA
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13
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Risk for Venous Thromboembolism in Transgender Patients Undergoing Cross-Sex Hormone Treatment: A Systematic Review. J Sex Med 2021; 18:1280-1291. [PMID: 37057420 DOI: 10.1016/j.jsxm.2021.04.006] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2020] [Revised: 04/08/2021] [Accepted: 04/13/2021] [Indexed: 01/06/2023]
Abstract
BACKGROUND Feminizing and masculinizing hormone treatments are established components of management in transgender patients. Exogenous hormones have been associated with hemostatic effects, which are well-studied in cis-gender individuals on hormone replacement therapy (HRT). Unfortunately, comprehensive understanding of their effects on venous thromboembolism (VTE) risk in the transgender population is lacking. AIM This manuscript aims to identify the risk of VTE among transgender individuals undergoing cross-sex hormone therapy. METHODS A Systematic review of the literature was performed in March 2020 for studies reporting VTE rates in transgender patients undergoing hormone treatment and rates in cis-gender patients on HRT. Data regarding demographics, hormone therapy, and VTE incidence were collected and pooled for analysis. OUTCOME The primary outcome of interest was the development of a VTE event in association with concurrent hormone administration. RESULTS Overall, 22 studies were included with 11 reporting VTE rates among transgender patients, 6 in cis-female patients, and 5 in cis-male patients. Data from 9,180 transgender patients (6,068 assigned male at birth [AMAB] and 3,112 assigned female at birth [AFAB]) undergoing hormone treatment and 103,713 cis-gender patients (18,748 female and 84,965 male) undergoing HRT were pooled. The incidence of VTE was higher in AMAB patients compared to AFAB patients (42.8 vs 10.8 VTE per 10,000 patient years; P = .02). The rate of VTE incidences in AMAB patients appears similar or higher than the rate demonstrated in cis-females on HRT. VTE incidence in AFAB patients, however, is similar to the published rates in cis-males on HRT. CLINICAL IMPLICATIONS AMAB patients on hormone therapy have higher VTE rates than AFAB patients. AMAB and AFAB patients may have similar VTE incidence to cis-female and cis-male patients on hormone replacement therapy, respectively. STRENGTHS & LIMITATIONS This is the first study to aggregate and quantify the development of VTE events in association with hormone therapy in transgender patients. It places these values in the context of rates published in more widely studied populations. It is limited by its retrospective data and heterogenic data. CONCLUSION Surgical planning regarding perioperative and postoperative VTE prophylaxis or cessation of hormone therapy should take into account each patient's Caprini risk assessment and the nature of each intervention. Kotamarti VS, Greige N, Heiman AJ, et al. Risk for Venous Thromboembolism in Transgender Patients Undergoing Cross-Sex Hormone Treatment: A Systematic Review. J Sex Med 2021;18:1280-1291.
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14
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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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15
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Allen AN, Jiao R, Day P, Pagels P, Gimpel N, SoRelle JA. Dynamic Impact of Hormone Therapy on Laboratory Values in Transgender Patients over Time. J Appl Lab Med 2020; 6:27-40. [PMID: 33313748 DOI: 10.1093/jalm/jfaa192] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2020] [Accepted: 10/06/2020] [Indexed: 01/09/2023]
Abstract
BACKGROUND Known physiological changes occur while transgender patients are taking hormone therapy (HT). However, knowledge is limited about when laboratory values stabilize and if there are any long-term impacts, making it challenging for physicians to provide adequate gender-affirming care. We aim to analyze laboratory values with HT use over 5 years and after discontinuation of HT to define when values achieve stability. METHODS We performed a multicenter retrospective analysis of 126 transgender women (TW) and 91 transgender men (TM) at consecutive clinic visits. Labs included complete metabolic panel, complete blood count, lipids, and hormone levels and were monitored for 5 years. Absolute measurement and percentage change from baseline were calculated for each analyte value. We collected the laboratory studies described from patients off HT and the duration of discontinuation to determine the time to return to baseline levels. RESULTS During HT, red blood cell (RBC; erythrocyte) indexes reach stable levels within 6 months (P < 0.001) and are unchanged long term. Some analytes such as HDL and platelets showed increases beyond the first year of HT in TW (P = 0.001 and P < 0.001, respectively). LDL and alanine aminotransferase increased beyond 1 year in TM (P < 0.005 and P < 0.001, respectively), whereas HDL decreased beyond 1 year (P < 0.001). Time for laboratory values to return to baseline occurred around 10 weeks. CONCLUSIONS Most analytes reach stable levels within 6 months (RBC and creatinine), whereas others change in the long term (LDL, HDL, platelets). This information can be used to guide physicians as they monitor their transgender patients in all stages of their progress through HT.
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Affiliation(s)
- Amber N Allen
- School of Medicine, University of Texas Southwestern Medical Center, Dallas, TX
| | - Rhoda Jiao
- School of Medicine, University of Texas Southwestern Medical Center, Dallas, TX
| | - Philip Day
- Department of Community and Family Medicine, University of Texas Southwestern Medical Center, Dallas, TX
| | - Patti Pagels
- Department of Community and Family Medicine, University of Texas Southwestern Medical Center, Dallas, TX
| | - Nora Gimpel
- Department of Community and Family Medicine, University of Texas Southwestern Medical Center, Dallas, TX
| | - Jeffrey A SoRelle
- Department of Pathology, University of Texas Southwestern Medical Center, Dallas, TX
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16
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Pivonello R, Auriemma RS, Pivonello C, Isidori AM, Corona G, Colao A, Millar RP. Sex Disparities in COVID-19 Severity and Outcome: Are Men Weaker or Women Stronger? Neuroendocrinology 2020; 111:1066-1085. [PMID: 33242856 PMCID: PMC7900484 DOI: 10.1159/000513346] [Citation(s) in RCA: 70] [Impact Index Per Article: 17.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2020] [Accepted: 11/25/2020] [Indexed: 12/11/2022]
Abstract
The coronavirus disease 2019 (COVID-19) outbreak, caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), is a global public health issue which has profound effects on most aspects of societal well-being, including physical and mental health. A plethora of studies globally have suggested the existence of a sex disparity in the severity and outcome of COVID-19 patients, mainly due to mechanisms of virus infection, immune response to the virus, development of systemic inflammation, and consequent systemic complications, particularly thromboembolism. Epidemiological data report a sex difference in the severity of COVID-19, with a more favorable course of the disease in women compared to men regardless of age, although the rate of SARS-CoV-2 infection seems to be similar in both sexes. Sex hormones, including androgens and estrogens, may not only impact virus entry and load, but also shape the clinical manifestations, complications, and ultimately the outcome of the disease. The current review comprehensively summarizes the current literature on sex disparities in susceptibility and outcome of COVID-19 as well as the literature underpinning the pathophysiological and molecular mechanisms, which may provide a rationale to a sex disparity. These mechanisms include sex hormone influence on factors that facilitate virus entry and priming, immune and inflammatory response, as well as coagulation and thrombosis diathesis. Based on present evidence, women appear to be relatively protected from COVID-19 because of a more effective immune response and a less pronounced systemic inflammation, with consequent moderate clinical manifestations of the disease, together with a lesser predisposition to thromboembolism. Conversely, men appear to be particularly susceptible to COVID-19 because of a less effective immune response with consequent severe clinical manifestations of the disease, together with a greater predisposition to thromboembolism. In the elderly, generally characterized by the phenomenon of inflammaging, sex disparities in overall mortality following SARS-CoV-2 infection are even more palpable as elderly men appear to be more prone to severe COVID-19 because of a greater predisposition to infections, a weaker immune defense, and an enhanced thrombotic state compared to women. The information revealed from the review highlights potential novel therapeutic approaches employing the administration of hormonal or antihormonal therapy in combination with antiviral drugs in COVID-19 patients.
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Affiliation(s)
- Rosario Pivonello
- Dipartimento di Medicina Clinica e Chirurgia, Sezione di Endocrinologia, Unità di Andrologia e Medicina della Riproduzione e della Sessualità Maschile e Femminile (FERTISEXCARES), Università Federico II di Napoli, Naples, Italy,
- UNESCO Chair for Health Education and Sustainable Development, Federico II University, Naples, Italy,
| | - Renata S Auriemma
- Dipartimento di Medicina Clinica e Chirurgia, Sezione di Endocrinologia, Università Federico II di Napoli, Naples, Italy
| | - Claudia Pivonello
- Dipartimento di Medicina Clinica e Chirurgia, Sezione di Endocrinologia, Università Federico II di Napoli, Naples, Italy
| | - Andrea M Isidori
- Department of Experimental Medicine, "Sapienza" University of Rome, Rome, Italy
| | - Giovanni Corona
- Endocrinology Unit, Medical Department, Maggiore-Bellaria Hospital, Bologna, Italy
| | - Annamaria Colao
- UNESCO Chair for Health Education and Sustainable Development, Federico II University, Naples, Italy
- Dipartimento di Medicina Clinica e Chirurgia, Sezione di Endocrinologia, Università Federico II di Napoli, Naples, Italy
| | - Robert P Millar
- Centre for Neuroendocrinology, Department of Immunology, Faculty of Health Sciences, University of Pretoria, Pretoria, South Africa
- Neurosciences Institute and Institute of Infectious Diseases and Molecular Medicine, University of Cape Town, Cape Town, South Africa
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