Sublingual Estradiol Offers No Apparent Advantage Over Combined Oral Estradiol and Cyproterone Acetate for Gender-Affirming Hormone Therapy of Treatment-Naive Trans Women: Results of a Prospective Pilot Study

Purpose

Chronic gender-affirming hormone therapy (GAHT) with sublingual estradiol (SLE) has not been studied. We aimed to compare GAHT with SLE only, to combined oral (CO) estradiol and cyproterone acetate, in treatment-naive trans women.

Methods

Twenty-two trans women enrolled into either the CO arm or the SLE-only arm (0.5 mg four times daily) in this 6-month prospective study. Anthropometric and laboratory variables were collected at baseline and 3 and 6 months. At the study beginning and end, body composition was measured by dual-energy X-ray absorptiometry and bioelectrical impedance, and gender dysphoria, sexual desire, and function were assessed by validated questionnaires.

Results

Subjects in the SLE were older, 26.3±5.8 years versus 20.1±2.3 years, p=0.006. All anthropometric, body composition, and laboratory variables were identical at baseline. Although dysphoria appeared greater, and sexual function lower at baseline in the CO group, this canceled out after age adjustment. Both treatments induced similar biochemical and hormonal changes. Creatinine, hemoglobin and cholesterol decreased significantly, while testosterone was suppressed to the same level in both groups: 3.22 [1.47-5.0] nmol/L in the SLE group and 2.41 [0.55-8.5] nmol/L in the CO, p=0.65. Significant changes in body composition toward a more feminine body were noted in both groups. Dysphoria did not significantly improve in either group, while sexual desire and function decreased at six months in both, p<0.001.

Conclusions

Both treatments achieved similar clinical changes. At this stage, SLE, which repeatedly induces alarming excursions of serum estradiol throughout the day, appears to offer no advantage over the CO approach.

Sperm parameters in Israeli transgender women before and after cryopreservation

BACKGROUND

The application of fertility preservation, initially intended for oncological patients prior to gonadotoxic treatment, has extended in recent years to transgender and gender-non-conforming individuals undergoing therapy for gender compatibility.

OBJECTIVES

To examine semen quality and survival in transgender women pursuing semen cryopreservation in the presence or absence of gender-affirming hormonal medication.

MATERIALS AND METHODS

In this retrospective cohort study, we reviewed data of 74 consecutive transgender women presenting for semen cryopreservation at a single center between 2000 and 2019. Semen parameters before and after cryopreservation were compared to a control group composed of 100 consecutive sperm bank donor candidates. A subgroup analysis of subjects who had used gender-affirming hormonal treatment was also performed.

RESULTS

Compared to the control group, transgender women had lower total sperm count (144.0 vs. 54.5 million, respectively, p < 0.001), lower sperm motility percentage (65.0% vs. 51.0%, respectively, p < 0.001), and lower total motile sperm count (94.0 vs. 27.0 million, respectively, p < 0.001). Values were further decreased in transgender women who had received hormonal treatment before sperm cryopreservation. Post-thawing motility rate remained lower in the transgender group compared to the control group (20.0% vs. 45.0%, respectively, p < 0.001), and the total motile count remained lower as well (2.7 vs. 9.0 million, respectively, p < 0.001). Following sperm cryopreservation, the post-thaw decreases in total motile sperm count were higher in the transgender group compared with the control group (91.5% vs. 90.0%). Further subdivision in the transgender group showed that the decrease in total motile sperm count was lower for transgender women who did not use gender-affirming hormonal treatment compared to those who did (-89.7% vs. -92.6%, respectively, p < 0.01).

DISCUSSION AND CONCLUSION

Sperm parameters in transgender women are poor compared to candidates for sperm donation representing the general population. Specimens collected after discontinuation of gender-affirming hormone treatments were further impaired. Moreover, post-thawing sperm total motile count, motility, and overall sperm survival were reduced in transgender women.

Transgender men's preferences when choosing obstetricians and gynecologists

BACKGROUND

Transgender men are a marginalized population with unique health care needs. However, their usage of health services is low because of considerable discrimination. A major factor in their avoidance is patient-provider interactions.

METHODS

This cross-sectional study included 102 transgender men who anonymously completed a 55-item questionnaire in clinic, between 10/2017 and 01/2019. In addition, 92 transgender women filled out the part about family physician's preferences. We examined which characteristics transgender men prefer in their obstetricians/gynecologists in order to promote their usage of healthcare services.

RESULTS

A small majority of the transgender men (54.1%) had no gender preference for their obstetrician/gynecologist, while 42.9% preferred a female obstetrician/gynecologist and 3.1% preferred a male obstetrician/gynecologist. Most transgender men with a same-gender preference preferred female obstetricians/gynecologists for both invasive procedures (e.g., pelvic examination, 97.4%) and non-invasive procedures (e.g., cesarean section, 60%). The reasons for preferences regarding invasive procedures were feeling comfortable, embarrassment and feeling that female obstetricians/gynecologists are gentler. Transgender men who preferred female obstetricians/gynecologists ranked ability (90.5%), sexual tolerance (92.9%) and gender identity tolerance (90.5%) as the top three desirable qualities of obstetricians/gynecologists, while the responders who did not prefer female ranked ability (94.6%), experience (92.9%) and knowledge (92.9%) as the top three qualities. Transgender men with female preferences considered female obstetricians/gynecologists to be more accepting of gender identity compared to the responders that did not prefer females (47.5% vs. 9.1%, P < .001)..

CONCLUSION

A small majority of the transgender men exhibited no gender preference when choosing an obstetrician/gynecologist, although 42.9% preferred females. The latter choice was associated with the assumption that female obstetricians/gynecologists are more tolerant towards their transgender men patients. Educating the medical staff about their special needs and establishing dedicated SGM centers staffed with high percentages of female healthcare providers are highly recommended.

Functional ovarian reserve in transgender men receiving testosterone therapy: evidence for preserved anti-Müllerian hormone and antral follicle count under prolonged treatment

STUDY QUESTION

Is the functional ovarian reserve in transgender men affected by testosterone therapy?

SUMMARY ANSWER

Serum anti-Müllerian Hormone (AMH) levels slightly decrease during testosterone treatment but remain within the normal range, suggesting preserved follicular ovarian reserve.

WHAT IS KNOWN ALREADY

Few small studies have investigated the impact of gender-affirming treatment on reproduction in transgender men. Conflicting results were reached concerning ovarian morphology and AMH levels in this context.

STUDY DESIGN, SIZE, DURATION

The study consisted of two arms. The first arm was a prospective pilot study, which enrolled 56 transgender men (median age 22.5 [interquartile range (IQR)-19-27.7] years), 27 of whom had polycystic ovary syndrome (PCOS), prior to the initiation of gender-affirming testosterone therapy. A structured assessment was conducted prior to, and at 3 and 12 months after treatment initiation. The second arm was a cross-sectional study that comprised 47 transgender men (median age 24 [IQR-20-31] years) who received testosterone for a median duration of 35 [IQR 13-62] months. The main outcome measures were serum AMH and antral follicle count (AFC) as indices of ovarian follicular reserve.

PARTICIPANTS/MATERIALS, SETTING, METHODS

The study was conducted at a tertiary center for transgender health. Gender-affirming therapy was administered according to standard practice. AFC was determined by pelvic (abdominal or transvaginal) ultrasound and blood collection for measurements of AMH, testosterone, estradiol, LH and FSH was performed at the designated time-points.

MAIN RESULTS AND THE ROLE OF CHANCE

Prospective arm for the entire group we observed a decrease of 0.71 ng/ml in AMH levels between baseline and 12 months (P = 0.01). When expressed in age-specific percentiles, AMH went from the 47.37th to the 40.25th percentile at 12 months (P < 0.001). In a sub-group analysis, a decline of 9.52 points in age-specific percentile was seen in subjects with PCOS (P < 0.001), while no changes were detected in the non-PCOS group. Testosterone treatment did not affect AFC over time in the entire cohort. In the sub-group analysis, a mean decrease of 5.0 follicles was detected between baseline and the 12 months assessment (P = 0.047) only in subjects with PCOS. In the cross-sectional study, AMH inversely correlated with age but not with treatment duration. Notably AMH did not deviate from the 50th age-specific percentile. Finally, four men fathered biological children after being under testosterone treatment for up to 12 years.

LIMITATIONS, REASONS FOR CAUTION

The limited sample size of the pilot study should be kept in mind. An additional limitation is the lack of a control group in the prospective study, as each participant served as his own control. Also, roughly 40% of the ultrasound examinations were performed transabdominally, potentially affecting the accuracy of the AFC measurements.As study participants were quite young, our reassuring data may not apply to older transgender men, either because of an age-related decline in ovarian reserve or to possible long-term effects of testosterone therapy. Furthermore, the chances for fertility preservation may be more limited in subjects with PCOS.

WIDER IMPLICATIONS OF THE FINDINGS

This is an additional contribution to the emerging evidence that prolonged testosterone treatment may not be a major obstacle to later fertility potential in transgender men desirous of having children. Larger confirmatory studies, and particularly more with reproductive outcome data, are needed for evidence-based fertility counseling prior to treatment initiation in these subjects.

STUDY FUNDING/COMPETING INTEREST(S)

This study received no funding. The authors have no competing interests to declare.

TRIAL REGISTRATION NUMBER

N/A.

Low-Dose Cyproterone Acetate Treatment for Transgender Women

BACKGROUND

Transgender women with intact gonads receive lifelong hormonal treatment to suppress physiologic androgen production, the optimal efficacious and safe cyproterone acetate (CPA) dose has not been established.

AIM

To assess the effectiveness and safety of low-dose (10-20 mg/day) compared with high-dose (50-100 mg/day) CPA treatment.

METHODS

We conducted a historical cohort study of transgender women treated at a tertiary center for transgender health.

OUTCOME MEASURES

Serum levels of testosterone, estradiol, prolactin, gonadotrophins, liver enzymes, and lipids.

RESULTS

There were 38 transgender women in the low-dose group and 26 in the high-dose group. Age (median 24.9 years, interquartile range [IQR] 21-30 vs 25 years, IQR 19-35) and follow-up time (median 12 months, IQR 6-23 vs 15 months, IQR 12-36) were similar in the low- and high-dose groups, respectively. Serum gonadotropins and testosterone were suppressed to a similar level at all time points in both groups. Prolactin levels increased significantly in both groups, however, with a more substantial increase in the high- vs the low-dose group (804 ± 121 vs 398 ± 69 mIU/ml at 12 months, respectively, P = .004). Total cholesterol, high-density lipoprotein, low-density lipoprotein, and triglyceride levels were not significantly affected by the dose.

CLINICAL IMPLICATIONS

We suggest an adjustment of current clinical practice guidelines to recommend lower doses of CPA for the treatment of transgender women.

STRENGTHS & LIMITATIONS

This is the first demonstration that low-dose CPA treatment of transgender women is effective. Limitations include a relatively small sample and retrospective study design.

CONCLUSION

Low-dose CPA treatment of transgender women is as effective as high-dose treatment and possibly safer. Zohar NE, Sofer Y, Yaish I, et al. Low-Dose Cyproterone Acetate Treatment for Transgender Women. J Sex Med 2021;18:1292-1298.

The Effect of the PCSK9 Inhibitor Evolocumab on Aldosterone Secretion among High Cardiovascular Risk Patients: A Pilot Study

Elevated low-density lipoprotein (LDL) cholesterol is one of the leading causes of cardiovascular disease. Proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitors reduce LDL cholesterol levels with subsequent reductions in cardiovascular morbidity. Elevated aldosterone levels are also associated with a greater risk of cardiovascular morbidity. There are currently no published data on the impact of PCSK9 inhibitor monotherapy on the secretion of aldosterone. The aim of this study was to examine the effect of monotherapy with the PSCK9 inhibitor evolocumab on the lipid profile and aldosterone secretion level in high-risk cardiovascular patients. Lipid profile, sodium, potassium, aldosterone, cortisol, plasma renin activity, and adrenocorticotropic hormone (ACTH) levels were analyzed at baseline and after 3 months of evolocumab therapy. Each participant underwent a 250 mcg ACTH stimulation test upon study entry. Eight women and seven men were included in the study. Their median total cholesterol, LDL cholesterol, lipoprotein (a), apolipoprotein B100, and baseline and stimulated aldosterone levels were significantly lower after 3 months of evolocumab therapy. These heretofore unreported findings indicate that reductions in unstimulated and stimulated aldosterone secretion under evolocumab therapy could be associated with reductions in cardiovascular events, a possibility that warrants further investigation.

A Cross Sectional Analysis of the Prevalence of Co-Morbidities in Older Transgender Individuals Receiving Hormone Affirming Therapy in Comparison With the General Population

Background: Transgender individuals feel an incongruity between the assigned gender at birth and their gender identity. Because the prevalence of cardiovascular risk factors and morbidity associated with cross-sex hormonal therapy is not well established, particularly in the older transgender population, we set out to compare it to that of the general population. Methods: Data were collected from medical records of transgender patients treated in the Endocrine Institute at the Tel Aviv-Sourasky Medical Center until October 2018. Data from the Israel National Health Survey INHIS-3 2013-2015 were used as reference. Results: 104 (75 transgender women and 29 transgender men) patients over 35 y were identified. The median follow up time was 3 y (1-6.1). Transgender women had a high standardized prevalence rate (SPR) of overweight, smoking and engaging in physical exercise, but not of dyslipidemia compared with cisgender men and women. The SPR for overweight was high in transgender males compared with cisgender men and women. The SPR for smoking and dyslipidemia was high in transgender men compared with cisgender women but not men. Depression and anxiety were markedly increased in transgender women compared with cisgender men [SPR 5.5 (95% CI 3.3-8.5), p&lt;0.001] and women [SPR 2.8 (95% CI 1.7-4.3), p&lt;0.001] in the control population. The SPR of hypertension, diabetes and cerebrovascular disease was not elevated among transgender patients. Conclusions: The prevalence of cardiovascular risk factors but not cardiovascular morbidity was higher in the transgender patients compared with the general population. Further studies including a larger population and a longer follow up time are needed to better assess the impact of a high prevalence of risk factors on cardiovascular morbidity on the long run.

Pain and transition: evaluating fibromyalgia in transgender individuals

OBJECTIVES

As members of a gender minority, transgender individuals face many challenges. Many experience distress, depression, anxiety and suicidal ideation related to gender non-conformity and transphobia. Stress and trauma may contribute to the development of fibromyalgia (FM) syndrome, characterised by widespread pain and fatigue. The prevalence of FM among transgenders is not known.

METHODS

Transgender participants were recruited at a specialised clinic. Questionnaires included the Widespread Pain Index (WPI), the Symptom Severity Score (SSS) and the SF-36. Data concerning hormonal treatment protocols was retrieved from charts. The current prevalence of FM was determined, as well as the prevalence before and after testosterone treatment among TM. Pearson correlations were calculated between all measures.

RESULTS

115 participants were recruited, 62.6% transgender men (TM), 37.4% transgender women (TW). 17 individuals (14.8%) fulfilled the 2011 modified ACR FM criteria, for a rate of 19.4% among TM and 6.98% among TW. Among TM, FM was associated with younger age, smoking and SF-36 sub-scales related to physical functioning, role limitation due to physical pain, fatigue, pain and general health. Among TW, FM was associated with social status, employment, depression, existing medical treatment and substance abuse, as well as SF-36 subscales related to role limitations affected due to pain.

CONCLUSIONS

Fibromyalgia symptoms are highly prevalent among Israeli transgender individuals and may be related to psychological distress and gender dysphoria. Healthcare professionals treating transgenders should remain vigilant for the occurrence of chronic pain, fatigue and other FM-related symptoms and be prepared to treat and/or refer such patients accordingly.

Good pain, bad pain: illness perception and physician attitudes towards rheumatoid arthritis and fibromyalgia patients

OBJECTIVES

Rheumatoid arthritis (RA) and fibromyalgia syndrome (FM) are common diagnoses encountered in rheumatology practice, but do not enjoy the same status. We aimed to examine physician's illness perceptions regarding these two rheumatologic disorders and to evaluate how they correlate with their relationship with these patients.

METHODS

Forty-five rheumatologists were enrolled in the study. Demographic data were registered. Measures collected included the Brief Illness Perception Questionnaire (BIPQ) and the Difficult Doctor- Patient Relation Questionnaire (DDPRQ-10). Both were recorded twice, related to FM and RA. Empathy and burnout were also assessed.

RESULTS

Of 45 physicians included in the study, only 53% were willing to accept FM patients. FM was considered a more severe disease than RA (FM-BIPQ mean score 54, SD 5.5 versus RA-BIPQ mean 45.6 SD 6.5, p<0.00) in terms of treatment control, understanding and emotional response generated by the disease. Doctor-patient relationship was perceived more difficult with FM patients compared to RA patients (FM-DDPRQ mean score 35.1, SD 9.2 versus RA-DDPRQ mean 19.6, SD 7.1, p<0.00), and was significantly correlated to the patient's concern about the illness (p<0.034) and patient's emotional response (p<0.036). Resistance to accept FM patients was largely influenced by difficult doctor-patient relationship. Higher levels of empathy were found in physicians experiencing less difficulty with FM patients.

CONCLUSIONS

FM patients were perceived as more difficult than RA patients, with a high level of concern and emotional response. A high proportion of physicians were reluctant to accept them because they feel emotional/psychological difficulties meeting and coping with these patients.

Adoption of the transoral endoscopic vestibular approach by head and neck surgeons without prior laparoscopic/robotic experience

BACKGROUND

Transoral endoscopic vestibular approach (TOEVA) for thyroidectomy (TOETVA) and parathyroidectomy (TOEPVA) is gaining popularity, yet knowledge is based on a limited number of studies, mostly performed by surgeons experienced in laparoscopic\robotic surgery.

METHODS

All patients who underwent TOEVA at our institution between February 2018 and October 2019 were followed prospectively. Main outcomes were ability to accomplish surgery endoscopically (failure defined as conversion to open approach) and complications.

RESULTS

Seventy-one patients (52 TOETVA and 19 TOEPVA) were included. 98% (51/52) and 100% (19/19) of TOETVA and TOEPVA surgeries were accomplished endoscopically, respectively. Transient vocal cord and mental nerve injuries rates were 8.4% (6/71) and 2.8% (2/71), respectively. Thyroid carcinoma was diagnosed in 27 patients (51.9%), all completely excised with clean margins.

CONCLUSIONS

Adoption of the TOEVA suggested framework by head and neck surgeons without prior experience in laparoscopic/robotic techniques is feasible resulting in nearly 100% of surgeries accomplished endoscopically.

Long-term all-cause mortality and its association with cardiovascular risk factors in thyroid cancer survivors: an Israeli population-based study

BACKGROUND

The global incidence of thyroid cancer (TC) has risen considerably during the last three decades, while prognosis is generally favorable. We assessed the long-term all-cause mortality in TC survivors compared to the general population, and its association with cardiovascular risk factors.

METHODS

Individuals diagnosed with TC during 2001-2014 (TC group) and age- and sex-matched individuals from the same Israeli healthcare system without thyroid disease or a cancer history (non-TC group) were compared. Cox regression hazard ratios (HRs) and 95% confidence intervals (95%CIs) for all-cause mortality were calculated by exposure status.

RESULTS

During a 15-year follow-up (median 8 years), 577 TC survivors out of 5677 (10.2%) TC patients and 1235 individuals out of 23,962 (5.2%) non-TC patients died. The TC survivors had an increased risk of all-cause mortality (HR = 1.89, 95%CI 1.71-2.10), after adjusting for cardiovascular risk factors already present at follow-up initiation. This increased risk was most pronounced in the 55- to 64-year-old age group (HR = 1.49, 95%CI 1.33-1.67). The TC survivors who died by study closure had more hypertension (14.6% vs. 10.3%, P = 0.002), more dyslipidemia (11.4% vs. 7.2%, P <  0.001), and more cardiovascular disease (33.6% vs. 22.3%, P = 0.05) compared to those who died in the non-TC group.

CONCLUSIONS

This large cohort study showed higher all-cause mortality with a higher prevalence of hypertension, dyslipidemia, and cardiovascular disease among TC survivors compared to matched non-TC individuals. Primary and secondary prevention of cardiovascular risk factors in TC survivors is mandatory.

Fertility preservation rates among transgender women compared with transgender men receiving comprehensive fertility counselling

RESEARCH QUESTION

What is the fertility preservation rate among transgender women who have received professional fertility counselling compared with transgender men?

DESIGN

This retrospective cohort study included 56 transgender women and 56 transgender men referred for comprehensive fertility counselling at the Gender Clinic of the Tel Aviv Sourasky Medical Center's Fertility Institute between January 2017 and April 2019. Statistical analyses were performed to compare transgender men with transgender women who preserved fertility and transgender people who preserved fertility and those that did not.

RESULTS

The fertility preservation rate of transgender women was significantly higher than that of transgender men (85.7% versus 35.7%, respectively, P < 0.001). The fertility preservation rate among transgender women was associated with being older and not having undergone gender-affirming hormone (GAH) treatment. The fertility preservation rate was higher among adolescent transgender boys compared with adolescent transgender girls (35% versus 6.25%, respectively, P = 0.005). The duration of GAH treatment among the transgender men who preserved fertility was 70 months compared with 18.6 months for transgender women (P = 0.05). All transgender boys opted for oocyte cryopreservation, while half of the transgender men who had not started GAH opted for oocyte cryopreservation, and half of those who had already started on GAH opted for embryo cryopreservation.

CONCLUSIONS

High fertility preservation rates among transgender individuals were found after comprehensive fertility counselling. Fertility preservation rates among adults were higher among transgender women compared with transgender men, while the opposite was found in transgender adolescents.

SUN-042 Low Dose Cyproterone Acetate for the Treatment of Transgender Women - a Retrospective Study

Introduction : Transgender women with intact gonads receive lifelong hormonal treatment in order to suppress physiologic androgen production. Cyproterone acetate (CA) is the most comon antiandrogenic drug prescribed for this indication in Europe, with a dose range between 25-100 mg/day. Aim: To assess the effectiveness and safety of low dose (&lt;20 mg/day), compared with high dose (&gt;50 mg/day) CA treatment. Methods: Historical cohort study of transgender women treated in our department between January 2000 and October 2018. Results: There were 42 transgender women in the low dose group (LDG) and 32 in the high dose group (HDG). Age (27.9 ± 1.6 vs.28.9 ± 1.7 years) and follow up time (16.2 ± 2.2 vs. 20.1 ± 2.1 months) were similar in the LDG and HDG, respectively. At the last available visit, testosterone levels were effectively and similarly suppressed in both treatment groups (0.6 ± 0.1 vs 0.8 ± 0.3 nmol/l; p=0.37, for LDG and HDG respectively). Prolactin (659 ± 64 vs 486 ± 42 mIU/ml, p=0.02), LDL cholesterol (96.1 ± 5 vs 78.5 ± 4 mg/dl, p= 0.02) and triglycerides (93.3 ± 9 vs 69 ± 5 mg/dl; p=0.02) were higher in the HDG compared with LDG respectively. Side effects were common in the HDG (four cases of increased liver enzymes, one case of pulmonary embolism and one case of sudden death). Conclusion: We show for the first time that anti-androgenic treatment of transgender women with low dose CA is as effective as high dose treatment, but safer. We suggest incorporation of this observation in future guidelines.

Scarless Neck Feminization: Transoral Transvestibular Approach Chondrolaryngoplasty

Importance: Chondrolaryngoplasty or reduction of laryngeal prominence is a gender affirmation surgery for transgender women, or for male patients desiring an aesthetic surgery. Several variations of the procedure were suggested, yet to date, all described chondrolaryngoplasty procedures involved a visible neck scar. Objective: To describe a novel technique for scarless chondrolaryngoplasty, transoral endoscopic vestibular approach (TOEVA)-chondrolaryngoplasty, and to report the results of first ever performed cases. Design, Setting, and Participants: This was a prospective cohort at an academic referral center. Adult transgender women, interested in chondrolaryngoplasty who never had previous surgery of their neck or vocal folds, were offered both transcervical chondrolaryngoplasty and scarless TOEVA-chondrolaryngoplasty. Four patients aged 21 to 33 years, who preferred TOEVA-chondrolaryngoplasty, were consented and recruited. Interventions: The surgical technique was successfully examined on two cadavers. Subsequently, all surgical procedures were conducted according to the described study protocol and technique, between April and June 2019. Main Outcomes: Vocal assessment was recorded preoperatively and repeated 4 to 6 weeks after surgery for comparison. Surgical documentations as well as adverse surgical events and complications were recorded. To measure outcome, 1-2 months postoperatively, all patients filled an outcome instrument for aesthetic chondrolaryngoplasty (seven questions on a 5-point Likert scale) based on previously designed questionnaires for chondrolaryngoplasty and facial plastic surgery. Results: Duration of operative time ranged from 90 to 150 min. No adverse events or complications were recorded during surgery. All patients were discharged 1 day postoperatively. A single patient had a mild temporary mental hypoesthesia that resolved 2 months after surgery, no other complications were encountered. Vocal folds' function remained unchanged in all four patients. All operated patients were highly satisfied with the surgical results as measured by the outcome instrument; three out of the four patients responded with perfect scores, and the fourth patient responded with 90% of the perfect score. Conclusions: This report is the first description of scarless chondrolaryngoplasty through TOEVA. On a series of four patients, TOEVA-chondrolaryngoplasty appeared to be safe, with no adverse events or major complication, and with extremely high patient satisfaction. Further clinical evidence is required to establish a widespread use of this surgical technique.

OR25-5 High Prevalence of Psychopathologies Among Transgender Subjects Presenting at a Large Tertiary Transgender Health Center: Implication for the Treating Clinicians

Background and aim of study: Although gender dysphoria is no longer considered a mental illness, transgender people are at risk for psychopathologic morbidities. Endocrinologists play a central role in the gender-affirming process that transgender people chose to undergo, and may be ill-prepared to recognize and manage psychologic difficulties already present before, or those that arise during hormone treatment. We sought to characterize the patient population currently under our care, in particular with respect to their mental health, and to address the question of possible differences in psychopathologies between transwomen (TW) and transmen (TM). Methods: Records of all adult transgender people treated during the last decade at the center for transgender health in our medical center were reviewed. Social, demographic, and clinical data were recorded. The mandatory psychological assessment provided at the first visit was inspected for the inclusion of any psychiatric diagnosis. All psychoactive medications taken, addictions, and suicidal or non suicidal self-injury attempts were noted. Results: A total of 405 subjects were followed for a mean duration of 2.4±0.1 y. The cohort consisted of 221 TW, and 184 TM (TW:TM=1.2:1). TM were significantly younger 26.1±7.3 vs 31.3±11, and presented at a younger age 23.6±7.2 vs 29.1±10.7 than TW (P<0.0001 for both). TW tended to be in a relationship more often than TM (35/221, vs 18/184, P=0.08), and to be parents (27/221 vs 9/184, P=0.03). There was no significant difference in the level of education, but TM were more frequently employed than TW (P=0.0002). TM had generally more family and friends support (P=0.04). Despite those differences, TW did not differ from TM in any of the psychopathologies, which were highly prevalent, and well in excess of the rates for the general population . 35% of all subjects had at least one psychiatric diagnosis, and 22% were currently medicated. Major depression was present in 85 subjects (21%), anxiety disorders in 40 (9.9%). 27 subjects had attempted suicide (6.7%), while 10 had self-inflicted non suicidal injuries (2.5%), including one case of self-performed orchiectomy. Smoking was extremely prevalent as 164 subjects smoked (40.5%). Substance abuse and addictions, albeit underreported, were also common and coexisted with smoking in each instance. Alcohol abuse was reported by 2.5%, cannabis by 2.7%, cocaine and heroin abuse by 2.5% each. Assessing the effect of gender reaffirming hormonal therapy on the prevalence or severity of these pathologies was beyond the scope of this study. Conclusions: Our findings highlight the need to prepare endocrinologists for the high prevalence and severity of psychopathologic conditions in transgender people. A mental health professional should be an essential part of any multidisciplinary team of clinicians treating the transgender population.

OR11-3 Evidence for Preserved Ovarian Reserve in Transgender Men Receiving Testosterone Therapy: Anti-Mullerian Hormone Serum Levels Decrease Modestly after One Year of Treatment

Background: Although successful pregnancies carried by transgender men have been reported, long-term effects of testosterone therapy on fertility remain unknown. Aims: To study markers of ovarian reserve during testosterone therapy. Methods: Prospective open-label study of transgender men prior and during treatment with testosterone. Sampling was conducted at baseline and 12 months after treatment initiation. Main outcome measures: Anti-Mullerian Hormone (AMH), gonadotropins and sex steroid serum levels; endometrial thickness and antral follicular count determined by pelvic US. Results: 52 subjects (23.4±6.1 y) were recruited, 32% of which were in a stable relationship. 17% expressed desire to have children while 26 (50%) were unsure about future parenthood. Four (7%) have already undergone fertility preservation procedures. Interestingly, 5 participants (9%) that initially were sexually attracted to women became bisexual under testosterone treatment. Complete data is available for 32 subjects. In the course of 12 months of treatment, AMH levels decreased from 5.65±0.52ng/ml at baseline to 4.89±0.65 ng/ml (p=0.036). Antral follicular count (16.9±1.4, 13.9±1.7) and endometrial thickness (6.9±0.7, 5.6±0.5 mm) remained unchanged. As expected, testosterone levels increased (0.84±0.1, 7 ±0.7 nmol/l; p<0.0001) and estradiol levels decreased (90.8±7.9, 55.4±4.6 pmol/l; p=0.0013) during therapy, with a concomitant decrease in LH (7.56±0.7, 3.8±0.6 mIU/ml; p=0.0012), but not FSH (5.1±0.41, 4±0.3; p=0.07 mIU/ml) levels. Conclusion: AMH levels slightly decrease during testosterone treatment but remain within the normal, "healthy" range, thus likely indicating well-preserved ovarian reserve. This assumption is corroborated by the unchanged antral follicular count. The significance of these findings on fertility potential remains to be explored. Unless otherwise noted, all abstracts presented at ENDO are embargoed until the date and time of presentation. For oral presentations, the abstracts are embargoed until the session begins. Abstracts presented at a news conference are embargoed until the date and time of the news conference. The Endocrine Society reserves the right to lift the embargo on specific abstracts that are selected for promotion prior to or during ENDO.

A Single Radioactive Iodine Treatment Has a Deleterious Effect on Ovarian Reserve in Women with Thyroid Cancer: Results of a Prospective Pilot Study

BACKGROUND

Women of reproductive age with differentiated thyroid cancer (DTC) often need radioactive iodine (RAI) treatment after surgery. In contrast to the well-documented effect of RAI on testicular function, the potential negative effects of this treatment on ovarian reserve have been largely dismissed. The objective of this pilot study was to examine the possibility that RAI treatment is deleterious to the ovarian reserve by prospectively measuring the concentration of anti-Müllerian hormone (AMH) after RAI treatment.

METHODS

Thirty premenopausal women (M_age = 34 years; range 20-45 years) with a new diagnosis of DTC scheduled to undergo RAI ablation were recruited for this study. All of them had TNM stage 1 disease (T1-3, N0, or N1, M0), and were scheduled to receive RAI activities ranging from 30 to 150 mCi. AMH was measured at baseline and at 3, 6, 9, and 12 months after the administration of RAI.

RESULTS

Of the 30 women, only 24 returned after the baseline assessment. RAI treatment resulted in a significant decrease in AMH concentrations at three months, from 3.25 ± 2.75 to 1.9 ± 1.74 ng/mL (p < 0.0001). Only partial recovery was subsequently documented. Eighty-two percent of subjects had final values below baseline levels, such that at one year, serum AMH was still 32% lower than prior to treatment (2.36 ± 1.88 ng/mL; p < 0.005). The only two continuous variables that correlated with the extent of AMH reduction at three months were the woman's age (r = 0.51; p = 0.02) and the age at menarche (r = 0.48; p = 0.03). Importantly, the RAI dose was not associated with the extent of AMH reduction and neither were smoking or the use of birth control pills. Older subjects (≥35 years) were significantly more likely to experience a marked AMH reduction at three months (63.7 ± 18.5% vs. 33.1 ± 29.2%; p = 0.01). The only predictor of recovery after one year was the extent of AMH decrease at three months: the lower the decline, the higher the chances for recovery.

CONCLUSIONS

RAI in DTC has a rapid and profound effect on ovarian reserve, with only a partial recovery potential. In an era of declining human fertility, it is of relevance to recognize the potentially adverse effect of RAI in women of reproductive age. AMH measurement may be useful as a tool in this decision-making process.

Treatment of clinically nonfunctioning pituitary adenomas with dopamine agonists

OBJECTIVE

Clinically nonfunctioning pituitary adenoma (NFPA) remains the only pituitary tumor subtype for which no effective medical therapy is available or recommended. We evaluated dopamine agonist (DA) therapy for preventing growth of postsurgical pituitary tumor remnants.

DESIGN

The study design included historical cohort analysis of clinical results at two pituitary referral centers with different standard practices for postoperative NFPA management: DA therapy or conservative follow-up.

METHODS

Seventy-nine patients followed for 8.8±6.5 years were treated with DA, initiated upon residual tumor detection on postoperative MRI (preventive treatment (PT) group, n=55), or when tumor growth was subsequently detected during follow-up (remedial treatment (RT) group, n=24). The control group (n=60) received no medication. Tumoral dopamine and estrogen receptor expression assessed by quantitative RT-PCR and immunostaining were correlated with response to treatment.

RESULTS

Tumor mass decreased, remained stable, or enlarged, respectively, in 38, 49, and 13% of patients in the PT group, and in 0, 53, and 47% of control subjects; shrinkage or stabilization was achieved in 58% of enlarging tumors in the RT group, P < 0.0001.Fifteen-year progression-free survival rate was 0.805, 0.24, and 0.04, respectively, for PT, RT, and control groups (P<0.001). About 42% of patients in the control group required additional surgery or radiotherapy, compared with 38 and 13% subjects in the RT and PT groups, respectively (P=0.002). Outcome measures were not related to NFPA D2R abundance.

CONCLUSIONS

Dopamine agonist therapy in patients with NFPA is associated with decreased prevalence of residual tumor enlargement after transsphenoidal surgical resection.