ResearchPad - transgender-medicine-and-research https://www.researchpad.co Default RSS Feed en-us © 2020 Newgen KnowledgeWorks <![CDATA[SUN-043 Galactorrhea and Hyperprolactinemia in a Transgender Female]]> https://www.researchpad.co/article/elastic_article_6969 Background: Galactorrhea is a rare manifestation of hyper-prolactinemia in males and post-menopausal females, however the hormonal milieu of the transgender female may increase its incidence

Clinical Case: A 43 year old transgender female presented with three years of bilateral breast discharge. She had chronic, stable headaches and fatigue, but no vision changes or other symptoms. Notably, she had breast augmentation surgery with saline breast implants placed shortly before the galactorrhea commenced. She was on a stable dose of estradiol tablets 1 mg twice daily for six years. On physical exam she had pronounced bilateral breast discharge of a milky quality with nipple compression. Prolactin levels were checked several times and were 40-50 ng/mL, TSH was 2.36 uIU/mL. An MRI showed a left inferior pituitary lesion measuring 6 mm x 3 mm x 5 mm with no mass effect on adjacent structures. Her breast discharge was not bothersome to her, and her pituitary lesion was small. It was unclear whether there was a relationship between her prolactin levels and the lesion seen on MRI, as we expected more pronounced prolactin elevation with a prolactinoma. Instead, given the timing of her symptoms in relation to her breast augmentation surgery, her galactorrhea and hyper-prolactinemia were thought to be the result of nipple irritation related to her breast implants combined with a hyper-estrogenemic state.

Clinical Lessons: In the setting of a prolactin secreting micro-adenoma, galactorrhea in a male is highly unusual. This case highlights the importance of recognizing that the unique medical and surgical characteristics of male to female transgender patients can lead to hyper-prolactinemia and galactorrhea.

Reference: Reisman T, Goldstein Z. Case report: induced lactation in a transgender woman. Transgender Health. 2018;3(1):24-26.

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<![CDATA[SUN-041 Hispanic Medical Student’s Knowledge and Attitudes Towards Transgender Patient’s Care]]> https://www.researchpad.co/article/elastic_article_6481 Transgenders are characterized by having a gender identity and/or expression that is different from their sex at birth. There are guidelines about the proper management of this population. However, health disparities are still present. The lack of education and training about transgender care in the medical curriculum is one of the most significant contributors to these disparities. The aim of this study is to explore the knowledge and attitudes towards transgender care among Hispanic medical students at the University of Puerto Rico (UPR). Medical students (MS) from the UPR were invited to participate in an online anonymous questionnaire to assess their attitudes and knowledge about the healthcare of transgender patients. Data was analyzed as percentages and as means using Likert scale. Responses from pre-clinical and clinical MS were compared. A total of 141 participants were recruited. The majority of MS (80%) claimed to be exposed to transgender patients at least once. A total of 74% of MS reported feeling comfortable taking care of transgender patients. The overall Likert scale score for perceived knowledge about transgender topics among pre-clinical and clinical MS were 2.91 and 2.68, respectively. The scores for how comfortable students felt about working with transgender patients were 3.99 and 4.13 for both pre-clinical and clinical MS, respectively. Sixty percent of MS reported not being familiar with hormonal regimens used for gender reassignment therapy. Significantly more pre-clinical MS thought that discussing sexual behavior with transgender patients was more challenging than discussing it with heterosexual patients when compared to clinical MS (2.90 and 2.36 respectively; p=0.02). The majority of medical students (87%) believed that physicians are responsible for the treatment of transgender patients. Our study reveals that even though there is willingness to treat transgender patients among UPR medical students, there are limitations in their knowledge and training regarding specific healthcare topics. Strategies to improve MS knowledge and training about this topic must be considered.

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<![CDATA[SUN-040 Hormone Replacement Therapy in Transgender Unmasks Testicular Tumor]]> https://www.researchpad.co/article/elastic_article_6287 Introduction In transwomen, hormonal replacement therapy typically usually consists of anti-androgen and/or estrogens. Per Endocrine Society 2017 guidelines, patients should be evaluated every 3 months in the first year for appropriate signs of feminization and adverse reactions. This includes measuring serum testosterone every 3 months initially and the testosterone level should be < 50 ng/dL. We describe a case of a transwoman patient diagnosed with testicular seminoma during surveillance of hormonal replacement therapy (HRT). Case presentation A 31-year-old male-to-female transgender presents to the endocrine clinic for HRT. She previously had seen another provider for HRT and was started on estradiol valerate 5 mg weekly and leuprolide 3.75 mg every month. After 5 months of therapy, she reported that her testosterone level remained elevated, so spironolactone 100 mg BID was subsequently added. Despite adherence, she was dismayed at how little physical changes she achieved after 1.5 years of HRT. She denies taking exogenous substances or OTC mediation containing androgens. Her examination reveals a male habitus and musculature with male voice, male diamond pubic hair pattern, adult penis size and scrotum measuring 20 cc’s bilaterally. Initial labs revealed total testosterone 131 ng/dl, free testosterone 30.8 ng/dl, bioavailable testosterone 64.6 ng/dl, SHBG 12 nmol/L, LH < 0.07 IU/L, FSH < 0.1 IU/L, and estradiol 146 pg/ml. Due to non-suppressed testosterone level despite undetectable gonadotropins, adrenal androgen labs were obtained which was normal. However, her HCG-beta tumor marker was elevated, 12 IU/L (0-3). This prompted a scrotal ultrasound which revealed 3.2 cm right testis mass. Follow-up PET/CT revealed increased activity localized to the right testis without findings of metastasis. Patient underwent right orchiectomy with pathology revealing seminoma stage 1A pT1bMx. At 2 months postop, her total testosterone is now 8 ng/dl, and she reports that her breast tissue has increased and skin softened. Conclusion Hyperandrogenism can be easily diagnosed in females given more obvious clinical features; however, except for precocious puberty, there are typically no obvious features of exogenous testosterone production in males. Thus, typically no workup is undertaken in males to look for underlying cause, including testicular cancer. While presence of scrotal mass is the most common initial presentation, patients can be asymptomatic until tumor burden is high and there is metastasis. Transwomen should be monitored by obtaining estradiol and testosterone levels following the Endocrine Society guidelines. If patient is on GnRH agonist, her testosterone level should be almost completely suppressed (T <50). A testosterone level > 50 ng/dL while on GnRH therapy should warrant workup for exogenous sources, including testicular cancer and adrenal abnormalities.

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<![CDATA[SUN-042 Low Dose Cyproterone Acetate for the Treatment of Transgender Women - a Retrospective Study]]> https://www.researchpad.co/article/elastic_article_6240 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 (<20 mg/day), compared with high dose (>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.

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<![CDATA[SUN-047 Cosmetic Injection of Silicone in a Transgender Person Leading to Granulomatous Disease with Hypercalcemia and Terminal Kidney Failure]]> https://www.researchpad.co/article/elastic_article_6074 Background: Granulomatous disease secondary to cosmetic injection of silicone is an uncommon cause of hypercalcemia. Transgender persons with limited access to appropriate surgery commonly use this procedure as an alternative, which can cause serious complications. Clinical Case: Forty year old transgender women with a 7-year history of nephrolithiasis treated with lithotripsy, pyelotomy and requiring the installation of a pig tail. She is admitted at the emergency room due to renal failure. Non-contrast CT rules out acute obstruction and lab tests conclude terminal kidney failure so she is started with dialysis and discharged. Two months later she returns with fever, she is diagnosed with central venous catheter-related bloodstream infection associated to the dialysis catheter and is started with antibiotics. Physical exam reveals pigmented, indurated nodular areas in her buttocks, hips and legs. The patient is re-interrogated and admits to have had injections of industrial silicone at the age of 22 in the described nodular areas. Regarding her transition process she had a vaginoplasty at 25 years old and was started with estrogens at that time but abandoned controls thereafter. Laboratory: Calcium 10, 8 (8,6-10,2 mg/dl), P 6 (2,5-4,5 mg/dl), PTH 17 (12-88 pg / ml), 25OHVD 3 (30ng / ml). Abdominal and thorax CT showed multiple pulmonary nodules, hilar, axillar and retroperitoneal adenopathies, hepatosplenomegaly, and subcutaneous granulomas with calcification in the buttocks and lumbar areas. HVB, HVC, VDRL and HIV serologies were negative as were ANA, pANCA and Rheumatoid Factor. Myelogram was normal. Biopsy of the involved skin and axillary lymph nodes revealed foreign body granulomatous reaction. Real Time PCR determination of the CYP27B1 mRNA showed a positive expression of this gene in the lesions confirming increased 1 alpha-hydroxylase activity as the cause of hypercalcemia. Tc-99m MDP scintigraphy showed increased activity in the soft tissue of the hips, buttocks and legs. Currently she maintains dialysis with normal values of calcium and is following regular controls in our gender program. Conclusion: Granulomatous disease due to cosmetic injection of silicone is a cause of hypercalcemia that should be suspected in the appropriate context. It is important to educate the transgender community about the possible severe adverse effects of these not authorized procedures.

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<![CDATA[SUN-048 Cardiometabolic Effects of Cross-Sex Hormone Therapy in Transgender Patients]]> https://www.researchpad.co/article/elastic_article_6013 Background: Sex hormones are believed to play an important role in development and progression of cardiovascular disease. However, the gender gap in onset and mortality is not yet completely understood. Transsexuals undergoing hormone therapy are a promising collective for analysing the effects of sex hormones on cardiometabolic disease. Methods: Aim of this study is to identify gender specific cardiovascular changes attributed to high-dose cross-sex hormone therapy (HT) in male-to-female (MtF) and female to male (FtM) transgender patients by performing an oral glucose tolerance test (OGTT) and 3 Tesla magnet resonance spectroscopy for hepatic (HCL) and myocardial (MYCL) lipid content analysis. The control group (CON) is conducted by age, sex and BMI matched healthy individuals. Results: Until now we included 26 MtF,14 FtM patients and 12 age and BMI matched healthy controls. The mean age was comparable in all 3 groups (MtF 30.12±2.31, FtM 29.72±1,91, CON 30,23±1.22 as well as BMI (22.59±3.81, 21.62±2.53, 21.33±1.20 kg/m2, p=ns, respectively). The mean hormone therapy duration was similar in both groups (MtF 4.58±1.20 vs FtM 2.35±0,95, p=0,29). HOMA Index did not significantly differ between the groups (MtF 1,78±0,92 vs FtM 1,96±1.22 vs CON 1,8±1.01, p=0,3 vs 0,4 vs 0,3 respectively). HCL was significantly higher in MtF than FtM (1,50±0,41 % vs 0.54±0,33 %, p=0,022, respectively). We also found a significant correlation between ejection fraction (EF) and Testosterone levels (Spearmans Rho 0,80, p=0.002). Conclusio: These preliminary data could indicate a positive effect of Testosterone therapy on heart function. Contradictory to current data we found a higher HCL in MtF than FtM suggesting a not so protective estrogen effect when looking at the liver. Long-term studies are warranted to assess whether cross-sex HT results in different outcomes regarding cardiovascular disease.

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<![CDATA[SUN-039 Estradiol Dose and Concentrations in Transfeminine Individuals]]> https://www.researchpad.co/article/Ndc56d434-2215-4780-a4d3-f82e325ad6fc <![CDATA[SUN-051 Gender Dysphoria - Data from One Hundred Patients]]> https://www.researchpad.co/article/Nb91f97d3-0287-4916-8b1e-6d082044d864 <![CDATA[SUN-044 Gonadotropin Releasing Hormone (GnRH) Agonist Therapy Induces a Sustained Reduction in Plasma Testosterone Levels and Is Well Tolerated in Transwomen Veterans]]> https://www.researchpad.co/article/Nba802cf6-19bd-424e-a59e-9c06f31023ab 50yr) transwomen. Leuprolide was in general well tolerated requiring discontinuation in just one patient due to severe fatigue. Three subjects (10%) experienced hot flashes which did not lead to discontinuation of medication. In the non-Leuprolide group, of 33 subjects, the follow-up was relatively inconsistent and only 12 subjects were regularly followed throughout a year with stable treatment. The decline in plasma testosterone was of a lower magnitude versus the leuprolide group (55% vs 89%, p <0.05). The testosterone levels declined from 393±42 to 180±44 ng/dl at 6 months. Body weight, and lipid profile: triglyceride, and plasma HDL concentration did not change significantly with or without GnRH agonist therapy. In conclusion, GnRH agonist therapy led to a sustained suppression of plasma testosterone levels in transwomen and was not associated with worsening lipid profile, was effective, and well tolerated in transwomen regardless of their age and may be considered an adjunct to the ant-androgen and estrogen therapy. ]]> <![CDATA[SUN-053 Evaluation of a 52-Year-Old Transgender Man During the First Year of Testosterone Therapy - Biochemical Changes, Body Composition and Cardiovascular Aspects at the Ergometric Test: A Case Report]]> https://www.researchpad.co/article/N5d043f4c-d8be-42eb-bbe4-40295faf89c8 <![CDATA[SUN-LB8 Cross Sex Hormone Therapy and Breast Cancer in Transgender Male to Female]]> https://www.researchpad.co/article/N5da11772-f1b1-4cd9-8d08-20654b1e9ec3 <![CDATA[SUN-052 Effects of Cross-Sex Hormone Therapy on Lipid Metabolism in Transgender Women and Men]]> https://www.researchpad.co/article/N09e2dd29-0232-4156-b479-c94972df6240 <![CDATA[SUN-049 Male Pattern Baldness and Waist-Hip Ratio as Markers of Arterial Stiffness in Transgender Men Undergoing Long-Term Testosterone Therapy]]> https://www.researchpad.co/article/N7aefe7c0-2b42-4985-a795-38ccf915cb07 140 and/or diastolic blood pressure > 90mmHg or under pharmacological treatment, and dyslipidemia as total cholesterol ≥ 240 mg/dL and/or LDL-c≥ 160 mg/dL and/or HDL-c < 40 mg/dL and/or triglycerides > 200 mg/dL, or under pharmacological treatment. Current smoking has been investigated. The aortic stiffness, assessed by VOPcf and cIMT, was measured using the Complior® device and carotid ultrasound, respectively. Results: TM’s Ferriman degree was 21 ± 6 and AGA was identified in 70% of them. The WHR was 0.9 ± 0.1. TM with AGA showed higher cIMT than TM without AGA (0.66 ± 0.1mm vs. 0.54 ± 0.07mm, p = 0.001), as well as higher WHR (0.93 ± 0.08 vs.0.87 ± 0.04, p = 0.02), higher score in terminal body hair (Ferriman 23 ± 6 vs. 18 ± 6, p = 0.007) and higher frequency of hypertension (94% vs. 6%, p = 0.01). The cIMT positively correlated with age (p = 0.01) and WHR (p = 0.002). The VOPcf was positively correlated with the age (p = 0.0001), androgen treatment duration (p = 0.01) and WHR (p = 0.04). There was a positive correlation between androgen treatment duration and WHR (p = 0.01). There was no difference in the VOPcf values, age, T treatment duration, serum T levels, frequency of dyslipidemia and smoking between the groups. Conclusion: The severe vertex AGA pattern may be considered a possible marker of arterial stiffness in TM undergoing long-term testosterone therapy. ]]> <![CDATA[SUN-050 Isolated Hyperprolactinemia Caused by Chest Binding in a Transgender Male]]> https://www.researchpad.co/article/Na57a8fea-66f3-4e92-bd6c-62d29576b6e6 <![CDATA[SUN-LB9 Pharmacokinetics of Sublingual Versus Oral Estradiol in Transgender Women]]> https://www.researchpad.co/article/N8ceb39fe-9851-4050-a45f-e010af92096c <![CDATA[SUN-046 Prevalence of Polycythaemia with Different Formulations of Testosterone Therapy in Transmasculine Individuals]]> https://www.researchpad.co/article/Ne44d8e64-e589-41c7-a58d-377a4f070112 6 months were included. Groups included those receiving (1) intramuscular testosterone undecanoate (n=125), (2) intramuscular testosterone enantate (n=31), or (3) transdermal testosterone (n=24). Outcome was prevalence of polycythaemia (defined as haematocrit >0.5). Results: Mean age was 28.4 (8.8) years with a median duration of testosterone therapy 37.7 (24.2) months. 27% were smokers. There was no difference between groups in serum total testosterone concentration measured. Whilst there was no difference between groups in haematocrit, there was a higher proportion of patients with polycythemia in those who were on intramuscular testosterone enantate (23.3%) than on transdermal testosterone (0%), p=0.040. There was no statistically significant difference in polycythaemia between intramuscular testosterone undecanoate (15%) and transdermal, p=0.066 nor between intramuscular testosterone enantate and undecanoate, p=0.275. Conclusions: One in four individuals treated with intramuscular testosterone enantate and one in six treated with testosterone undecanoate had polycythaemia. No individual treated with transdermal testosterone had polycythaemia. This highlights the importance of regular monitoring of haematocrit in transmasculine individuals treated with testosterone and findings may inform treatment choices. ]]>