Apr 252016
 

For many reasons, transgender women as a group are at high risk for sexually transmitted infections (STIs). The types of STIs a trans woman is at risk for changes after vaginoplasty but doesn’t go away. Reports of (neo) vaginal infection by gonorrhea and chlamydia are rare, for example. Trans women with (neo) vaginas may be at higher risk for HIV because of the greater possibility of a vaginal tear. Relatively little is known about the risk for other STIs, such as the human papilloma virus (HPV). Today I take a look at a new paper on HPV infection in post-vaginoplasty trans women.

HPV, the Human Papilloma Virus

HPV, the Human Papilloma Virus

HPV is a virus spread by skin-to-skin contact. There are different types of the virus. Some types cause warts (NSFW link). All warts are caused by a version of HPV. Warts that are on the genitals or anus are caused by specific types of HPV that are considered sexually-transmitted infections (types 6 and 11). The warts can be uncomfortable or painful. They can be very small or grow to become large masses. Warts themselves are fairly harmless otherwise.

The types of HPV that don’t cause warts are more dangerous. Those include types 16, 18, 31, and 33. These types don’t cause warts, but they cause changes that can lead to cancer. Cancers that have been associated with infection include cervical cancer, vaginal cancer, anal cancer, penile cancer, and some throat/oropharyngeal cancers. As you can tell from where these cancers happen, these types of HPV are often sexually transmitted. Screening tests for associated cancers include cervical pap smear, anal pap smear, and testing for the virus.

HPV can be prevented by vaccine and by barriers such as condoms and dental dams. Most vaccines prevent both the cancer-causing and genital wart-causing types. There is no cure for infection. Treatment is limited to removal of warts and treatment for cancers.

What about HPV infection in post-vaginoplasty trans women? Since HPV is a skin-to-skin contact infection, the (neo) vagina can still be infected by HPV. What has been reported in the medical literature about HPV infection? This paper presented 4 cases of vaginal HPV in their clinic and summarized 9 reports that had previously been reported in the medical literature. So they discussed 13 reports of HPV total.

They only reported symptomatic HPV cases. So only women who were having pain, discomfort, or other symptoms from an infection were discussed.

Most of the women had had a penile inversion vaginoplasty. One woman had a sigmoid vaginoplasty, one had a “split skin graft” (NSFW) vaginoplasty, and one was unknown. Split skin graft is a technique that uses skin from elsewhere on the body, and is sometimes used for cis women who were born without a vagina.

Of the four new cases discussed in the article, all came to the clinic with pain, either vaginal or vulvar. Three of the four women had genital warts, which were removed. The fourth had a white discoloration (“leukoplakia”), also caused by human papilloma virus. The pain and symptoms of all four were resolved with treatment and the lesions did not come back. All four were HIV negative and had previously had penis-in-vagina sex with at least one cis man.

There was less reported about the 9 cases that had previously been reported in the medical literature. 7 out of the 9 had genital warts. 6 of those 7 had the warts successfully removed. The 7th had to have a vaginectomy to remove the warts. Of the two who did not have warts, one had vaginal cancer and had to have a vaginectomy and chemo. The last had a pre-cancerous lesion, and we don’t know what happened to her.

The types of treatment for warts varied. Some were removed successfully with medication. Others were removed surgically. Still others were removed with laser or electricity.

Ultimately — all these results sound like what happens with cis women. Warts happen, cause pain or distress, and are treated. Less commonly, HPV causes cancer or pre-cancerous lesions and that is treated.

What this article brings to attention is that trans women need HPV prevention as much as everyone else. HPV vaccination for people up to age 26 is recommended. For those older than 26, barriers during sex with partners is a useful tool.

UCSF recommends “periodic” visual examination of the (neo) vagina to look for changes that may be pre-cancerous lesions. But they don’t define what “periodic” means. Cis women get pap smears every 3-5 years; 3-5 years may be a reasonable range for trans women too, but we just don’t know for sure. So if you’re concerned, talk with your physician about screening.

Want to know more about HPV? The CDC has good information.

Want to read the study for yourself? The abstract is publicly available.

Apr 112016
 

Human immunodeficiency virus (HIV) is a major cause of illness. It particularly effects men who have sex with men (MSM) and trans women. Most studies of HIV and HIV pre-exposure prophylaxis (PrEP) lump MSM and trans women into one group. As if gay men, bisexual men, and trans women all have similar risk factors. In fact — they don’t. They are very, very different groups.

Truvada, the only FDA-approved PrEP preparation

Truvada is the only FDA-approved PrEP preparation right now

For most of the history of HIV, barrier methods and abstinence have been the only ways to prevent the spread of HIV. Today we have treatment-as-prevention and pre-exposure prophylaxis. Treatment-as-prevention involves treating people affected with HIV with HIV-suppressing medications. By reducing the number of viruses a person is carrying around with them, the chances that any one virus can infect another person go down.

Pre-exposure prophylaxis (PrEP) has been available since 2012. It involves taking an HIV-suppressing drug every day. That way, if an HIV virus actually comes into contact with that person the virus won’t be able to infect them. Only one medication is currently approved for use in the United States, and that is Truvada. PrEP prevents HIV infection when taken every day at the same time. All HIV infections that have happened to date while a person was on PrEP occurred because the person took PrEP inconsistently.

This week we look at a study exploring the use of PrEP and HIV risks among trans women specifically. To my knowledge no study until this one has separated out MSM and trans women.

This is important! Not only are trans women at high risk for being infected with HIV…but there have been few HIV prevention guidelines and interventions directly targeting trans women. Both the WHO and CDC HIV PrEP guidelines do not include trans women.

This paper examined data from the iPrEx study, which was a study of the use of PrEP among people assigned male at birth in the US, Brazil, Ecuador, Peru, South Africa, and Thailand. This paper in particular examined differences between trans women and MSM in the iPrEx trial.

What kinds of things did they find?

First — 15% of the participants in the trial were trans woman. They either identified explicitly as trans, or identified as a woman when asked. Compared with MSM participants, trans women were more likely to…

  • less education
  • have more sexual partners and have a history of sex work (64% vs 38% of MSM)
  • more likely to live alone (23% vs 14%)
  • less likely to use a condom for receptive anal sex (14% trans women used a condom vs 45% of MSM)
  • were more likely to use cocaine or methamphetamine (11% vs 7% of MSM)

Not the most heartening information, but also not brand new. It’s been known for a while that trans women do participate in sex work out of lack of options. Higher numbers of sexual partners, lower levels of condom usage, sex work, and substance use are all associated with HIV infection.

What about PrEP and HIV though? Trans women not on hormone therapy and MSM had similar levels of PrEP in their blood. That means they were taking the medications regularly and the medication was doing what it’s supposed to. And this wasn’t because of a hormone effect. The researchers did ask the participants how often they were taking their PrEP. Trans women on hormones were less likely to report always using PREP.

All the trans women who did become infected with HIV during this trial were taking PrEP at the time. In contrast, all the trans women who took PrEP regularly did not become infected with HIV.

It’s also good to note that there were no adverse drug effects noted in this trial. The PrEP medications did not cause significant harm. There were some changes to liver function tests and kidney tests. However those changes didn’t cause medically noticeable harm.

So what are the take-aways here?

  1. PrEP in trans women works when taken daily.
  2. There are significant differences between trans women and MSM. They should not be lumped together in one group.
  3. Further research on potential interactions between PrEP and hormone therapy should be done. This is just to be safe — we want to make sure that PrEP doesn’t effect hormone therapy and that hormone therapy doesn’t effect PrEP

Lastly — if you or your partner(s) are at risk for HIV infection, talk with your doctor about whether PrEP is right for you. It’s a great option in the fight to prevent HIV infection.

Want to read the study for yourself? The abstract is publicly available

Apr 052016
 

Readers,

Open Minded Health is temporarily going to a biweekly post schedule. That is, posts will go from once a week to once every two weeks.

This is for a few reasons. My second year of medical school is coming to an end. I begin prepping for the first, and biggest, of the board exams next week. And I’ll be going into my clinical years in June. The clinical year is one of the busiest years in medical education, only surpassed by residency (the “internship” of medicine).

Going to a biweekly update schedule means updates can still come at regular intervals. I will do my best to make the posts more in depth so the wait is worth it.

I’m also working on a full update to Trans 101. I’ll let you all know when that’s done.

Thank you for continuing to read Open Minded Health!

~Rose

Mar 282016
 

In the United States, spironolactone is the oral anti-androgen of choice for trans women. It’s the cheapest and is well tolerated by most people. Outside of the United States cyproterone acetate, also known as Androcur, is the preferred drug. This week I take a look at this drug, how it works, and why it hasn’t been approved for use in the United States.

The chemical structure of cyproterone

The chemical structure of cyproterone

Cyproterone is an anti-androgen. It blocks androgen receptors, preventing testosterone and other androgens from having their effects. By blocking those receptors, it reduces the amount of testosterone in the body through a mechanism called negative feedback. Cyproterone is chemically similar to progesterone and has some progesterone-like effects as well. Outside of transgender care it’s also used for prostate cancer, as combination antiandrogen and hormonal birth control for cis women (e.g., Dianette), and for chemical castration of sex offenders.

It’s available both as a pill and intramuscular injection. The pill form should be taken every day at the same time after a meal. The dose often used for transition in the literature is 100mg/day. Anecdotally I’ve been told that lower doses, such as 25-50mg/day, have been used. The injection is given once every 1-2 weeks.

Cyproterone acetate is not risk-free and is definitely not for everyone. Most seriously, cyproterone is associated with liver damage. That damage can be severe. It can lead to liver failure even after the drug is stopped. Damage has been reported with doses over 100mg/day. Because of this, people on cyproterone should have their livers regularly monitored with blood tests. The drug should not be combined with other drugs that can cause liver damage. That includes alcohol and many prescription drugs. Individuals with known liver damage/disease should not take cyproterone.

There is also some question of whether the drug is associated with some cancers. In particular, liver cancer and some brain cancers. Specifically, hepatocellular carcinoma and meningioma are the cancers of concern. Researchers are still exploring this connection. Other negative side effects of cyproterone include allergic reactions and worsening of depression.

Many trans women are concerned about fertility. The effects of cyproterone alone, without estrogen, on fertility are somewhat known. Sperm count goes down with oral doses as low as 50mg. Infertility can happen in as little as 2 months. The infertility is reversible once cyproterone is stopped. Fertility returns anywhere from 3-20 months. But remember — no anti-androgen is a birth control method. Please use birth control if you or your partner are at risk of pregnancy.

In the literature, 100mg/day is the dose that seems to be preferred for transition. No cases of liver cancer in trans women have been reported. However some women do have higher levels of liver enzymes. That’s a sign that the drug is causing some damage to liver cells. Transdermal, instead of oral, estrogen is recommended to reduce potential liver damage and blood clots.

Cyproterone is a potential alternative for trans women. So why hasn’t the FDA approved it? That’s a little murky. I wasn’t able to find public document describing the reasoning. But the biggest reason cited by other sources is the concern of liver damage. The FDA is likely trying to do its job and protect the population from drugs that cause more harm than good. In its efforts it may well overstretch. Cyproterone only rarely causes liver problems, and those problems can be screened for with regular blood tests. However it’s important to remember that there are safer alternatives still available. Spironolactone and the GnRH agonists (puberty blockers) are generally safer and mostly well tolerated. Other androgen receptor blockers (e.g., bicalutamide), while not in common use for trans care, are also available and have lower rates of liver damage. So there’s little pressure on the FDA to approve a riskier drug.

So in summary — cyproterone is an androgen receptor blocker in use outside the United States for trans care, prostate cancer, and birth control. It’s biggest side effect is potential liver damage. It’s not FDA-approved for use in the US probably because of that liver damage. People currently using the drug should be under a physician’s supervision.

Want to learn more? The wikipedia article on this drug is super excellent!

Note on references — I pulled most of my information from LexiComp, which I have access to through my university and can’t easily reference. However, prescribing information is publicly available and has much of the same information.