Jan 092015
 

This is the start of a new series of posts here on Open Minded Health: Quickies! I often run into items in the medical literature that are too short to do a fully post on, but for whatever reason I think it’s worth covering it anyway.

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This week’s quickie is a case report, which was presented as a poster at a medical conference.

7170317810_f25026d624_mA trans woman in her thirties showed up at the emergency room with gastrointestinal problems. She had nausea, pain, and bleeding. No significant medical history was noted in the report, and she was on a normal dose of hormone therapy. National Phlebotomy Solutions provides and entirely online program for phlebotomist to earn their Phlebotomy Instructor Certification.

When they took her blood to run some lab tests, the sample appeared “as white and turbid as milk.”

Her lab work revealed a triglyceride level of 30,000 mg/dl. For reference, a normal triglyceride level is less than 150. Above 500 is considered “very high.”

She was immediately transferred to the intensive care unit for treatment. Triglycerides that high can cause inflammation of the pancreas. Thankfully all her pancreatic lab values were normal. After a week of treatment, which managed to get her triglycerides down to 3,000, she was sent home. She was instructed to stop estrogen treatment, take new prescribed triglyceride-lowering medications, and to follow up with her physician.

Why did the hospital physicians recommend that this patient stop her estrogen? Because estrogen treatment is known to increase triglyceride levels. Triglyceride levels that high are extremely rare. A much more mild version can, however, happen to anyone who has high estrogen levels. It can happen to cis women in pregnancy or receiving hormone replacement therapy for menopause. It can also happen to trans women on estrogen treatment.

High triglyceride levels are usually “silent” — there are no symptoms. That’s part of the reason it’s important to see a physician regularly for screening, especially if you’re at higher risk. High triglyceride levels are more likely if you…

  • are overweight
  • don’t exercise
  • eat a high-carbohydrate, high-fat diet
  • have other cardiovascular issues
  • are on certain medications
  • or if it runs in your family

Mild elevations in triglyceride levels may be controllable with diet, exercise, and weight control. If those don’t help, your physician may prescribe medications to lower your triglycerides.

For more information on triglycerides, including what they are, normal levels, and how to control them…check out this article by WebMD or ask your primary care provider.

The case report inspiring this post was “Hypertriglyceridemia up to thirty thousand due to estrogen: Conservative Management” and was published in Critical Care Medicine.

Jan 042015
 

8787343055_a2a6eb06bf_mIt’s a new year here at Open Minded Health. I hope you all had a safe, fabulous, and fun new years celebration. Here at OMH it’s time for the yearly questions and answers post.

For the unfamiliar — once a year I take a deep look at all the search queries that bring people here. Often, they’re questions that I didn’t completely answer or that need answering. So in case anyone else has these questions — there are answers here now that Google can find. The questions are anonymous and I reword them to further anonymize them.

This year is all questions about transgender health issues. There’s been a lot published and a lot in the news about trans health issues lately. This next year I’ll try to find other articles to post about too, though. 🙂

Questions!

What are the healthier estrogens that a transgender woman can take?

In order from least risk to most risk: estrogen patch, estrogen injection sublingual/oral estradiol, oral ethinyl estradiol, oral premarin.

But note that that’s an incomplete picture. The estrogen patch isn’t the best for initial transition and is very expensive. Injectable estrogen means sticking yourself with a needle every 1-2 weeks and needing a special letter to fly with medications. By far the cheapest of these options is oral estradiol.

Ethinyl estradiol is the form of estrogen used in birth control. Premarin is conjugated equine estrogens, meaning they’re the estrogens from a pregnant horse. Neither should be the first choice for transition. They’re both higher risk than estradiol.

For transgender women, how long does it take to see the benefits of taking spironolactone?

The rule of thumb is 3 months before changes on hormone therapy.

Where is the incision placed in an orchiectomy for transgender women?

That depends on the surgeon. But I’m know you can find images and personal stories on /r/transhealth and transbucket.

Does a trans man have to stop taking hormones to give birth?

Yes. Trans men and others who can become pregnant who are taking testosterone must stop testosterone treatment before becoming pregnant. Testosterone can cross the placenta and cause serious problems for the fetus. Once the child is delivered and no longer breast feeding testosterone can be resumed.

Once you’re on female hormones, how long does it take to get hair down to your shoulders?

My understanding is that the speed that hair grows doesn’t change. It grows at roughly 1/2 an inch a month. Expect growing it out to shoulder length to take 2-3 years.

As a trans woman on estrogen, are there foods I should avoid?

If you’re on estrogen only, there are no foods you should avoid. Instead eat a healthy varied diet.

If you’re on spironolactone you may need to avoid foods that are high in potassium. Potato skins, sweet potatoes, bananas, and sports supplements are foods you may need to limit or avoid. Ask your physician if you need to avoid these foods.

Is there a special diet that can help me transition?

In general, no. Any effect that food may have is, in general, too subtle to make a difference. The possible exception is foods that are very high in phytoestrogens — like soy. Phytoestrogens are chemicals in plants that act a little like estrogen in the body. There are a few case reports in the medical literature of people developing breasts when they eat a lot (and I do mean a lot) of soy. But they’re unusual. Ask your physician before you make radical changes in your diet. In general — just eat a healthy, varied diet.

I’m a trans guy taking testosterone and having shortness of breath. Do I need to worry?

See a physician as soon as you can. Shortness of breath may be a sign of something serious. Taking testosterone raises your risk for polycythemia (too many red blood cells in the blood), which can manifest as shortness of breath.

How often do trans women get injections of estrogen?

Most women have their injection every week to two weeks.

Can I still masturbate while I’m on estrogen?

Yes. Many trans women have difficulty getting or maintaining an erection though.

Can I get a vaginoplasty before coming out as transgender or transitioning?

Generally speaking, no. Surgeons follow the WPATH standards of care which require hormone therapy and letters of recommendation from physicians and therapists before vaginoplasty.

Are there risks to having deep penetrative sex if you’re a trans woman?

I’m assuming you’re referring to vaginal sex post-vaginoplasty. The vagina after a vaginoplasty is not as stretchy or as sturdy as most cis vaginas. It’s possible to cause some tearing if the sex is vigorous or if there are sharp edges (e.g., a piercing or rough fingernails).

Things you can do that might help prevent injury: Make sure you’re well healed after surgery. Dilate regularly as recommended by your surgeon. Use lots of lubrication, and try to go gently at first. Topical estrogen creams may also be helpful for lubrication and flexibility.

Is it safe to be on trans hormone therapy if you have a high red blood count?

Depends. If you’re a trans man looking for testosterone, you may need treatment first to control the high red blood cell count. Testosterone encourages the body to make more red blood cells, which would make the problem worse.

What kinds of injection-free hormone therapy are available to trans men?

Topical testosterone is available for trans men. It’s a slower transition and it’s expensive, but it exists and it works. Oral testosterone should never be used because of the risk of liver damage.

What can cause cloudy vision in trans women on hormone therapy?

Seek medical care. It could be unrelated, but changes to vision are not a good sign.

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And that’s it for this year! Next week we’ll be back to normal posts. 🙂

Aug 302014
 
Image of needle and syringe - click through to see source

Needles and syringes no longer look like this. Isn’t that wonderful?

Testosterone therapy for transgender men, and others who desire testosterone supplementation, typically involves intramuscular injections of testosterone. Intramuscular injections deliver the medication deep within a large muscle — typically a thigh muscle. From there the hormone can slowly work its way into the bloodstream to do its magic. Few other options exist, and those that do are either expensive or less effective (e.g., creams). Testosterone should not be taken as a pill because it’s very bad for the liver in that form. One possible alternative that has been discussed recently is subcutaneous testosterone injections.

Subcutaneous injections go just under the skin. Most people don’t get subcutaenous injections. The most common subcutaneous injection may be insulin injections for people with diabetes. Subcutaneous injections are also how fluids are given to cats in veterinary care.

Subcutaneous testosterone has been in sporadic recent use for trans men without any research showing how well it works. But that’s changed now with the publication of the article I’m going to summarize. 🙂 So let’s hop into it!

This was a study involving 36 male-identified trans youth from ages 13-24 (minors had parental consent). None had been exposed to hormones before. Hormone levels and other lab values were measured at the beginning and after six months.

For those interested in the specific technicalities of how the hormone was given, keep reading this paragraph. For those not, skip down to the next one! They were given testosterone cypionate suspended in sesame oil that was made at a local compounding pharmacy. The young men were given the injections by the clinical staff at first, but slowly taught to self-inject. Dosing was biweekly and started at 25mg per week, slowly increasing after that for some with a final dose ranging from 25-75mg.

So what did they find? How did it go? Positively!

About 92% of the young men in this study had testosterone levels in the “male” range at the 6 month check up. Similar goes for estrogen levels — by that 6 month check up their estradiol levels were down in the “male” range too. 85% of the young men who had been menstruating had stopped by that 6 month check up. Most periods stopped roughly around the 3 month mark. Other factors, like hemoglobin (red blood cell concentration) and cholesterol shifted but were not of clinical significance.

Two of the young men had allergic reactions to the sesame oil and were switched to cottonseed oil. This is a pretty well known reaction that happens in intramuscular injections too. Some also noticed small bumps around where they injected for a few days after injection. Those were the only reported side effects. Nobody reported unhappiness with their testosterone treatment method or asked to be switched to a different method.

All in all, a well put together study. Subcutaneous injection of testosterone so far appears to be a possible alternative to intramuscular injection. But it’s worth noting that commercial testosterone is intended for intramuscular injection and that type is not what was tested here. It may not be safe or effective to inject an intramuscular formulation as a subcutaneous one — ask your physician before changing how you use your medications!

As always: this is just one study. More need to be done to confirm these results. Regardless, I think these are good first results and look forward to seeing more.

Study was published in LGBT Health. Abstract is publicly available.

Disclaimer: I have personally met Dr. Olson (lead author of this study), worked with her in a small capacity, and have attended her talks at conferences. My interactions and impressions of her may have biased my interpretation on this study. However, I do my best to keep those preconceptions from affecting my judgment.

Jun 032014
 

6763959_10420a4b6a_mThe biggest news for May of 2014 is really that Medicare lifted the blanket ban on covering genital surgeries for trans people. The National Center for Transgender Equality has a good summary (PDF) of what the decision actually means. If you’re trans and interested in surgery and are a Medicare recipient, I recommend calling the physician who’s prescribing your hormones and consulting with them about next steps. The news was covered in multiple outlets including the NY Times and CNN.

The other piece of news I spotted that is not getting as much traction as I’d like is this: Urine is NOT sterile! For a long time it’s been believed that urine produced by healthy people is sterile – at least until it passes through the urethra. Turns out not to be the case. Something to keep in mind if you have contact with urine. Source

Interested in the other news? Read on!

  • Work continues on the possibility of three-parent babies. While much of the research and reporting talks about preventing mitochondrial diseases, I still think it opens a wonderful door for three-parent poly households. The latest news is fairly political, but supportive.
  • Another study out of Europe indicates that transgender hormone therapy is safe. This was a 1-year study of both men and women, just over 100 people total No deaths or serious adverse reactions were reported. Highly recommend you skim the abstract for yourself! For US readers, please do note though that the hormones used in the study were different formulations than those used in the US. Source.
  • A published case study reminds us that not all “odd” physical things during medical transition are related to transition. This was a case of a trans man who had undiagnosed acromegaly from a benign brain tumor. Eek! He was correctly diagnosed and treated, thankfully. Source.
  • A Swedish review of transgender-related records found a transition regret rate of 2.2%. Other prevalence data, including the usual male:female ratios, are included. Source.
  • A study of gay men found that they have worse outcomes from prostate cancer treatments than straight men. Source.
May 082014
 

CC BY 2.0) - flickr user stevendepoloA little belated, but here’s the GSM health news that came out around April this year, in no particular order…

  • There was a new meta analysis of intestinal vaginoplasties published in April. This meta analysis overall found that rate and severity of complications was “low”, with stenosis the most common complication. There were no reports of cancer. Sexual satisfaction was high, but there were no quality of life measures reported. Quality of studies were reported to be low, though, and there was a distinct lack of use of standardized measures. Source.
  • Oncology Times released a review of cancer and cancer screenings in transgender people. Highly recommend you take a look at the source.
  • A study finds that trans men on testosterone have lower levels of anxiety, depression and anger than trans men not on testosterone. Source.
  • A review of current hormonal transition effects and aging determined that, based on current data, “Older [trans people] can commence cross-sex hormone treatment without disproportionate risks.” They note that monitoring for cardiovascular health is especially important for trans women, especially those who are on progesterones. Strength or type of hormones may need to be modified in order to minimize risk. Source.
  • As much of the sex positive community has known for a long time, the BMI of cis women is (in general) not correlated with sexual activity. Source.
  • In Croatian medical students knowledge about homosexuality was correlated with positive attitudes. Source.
  • Science is awesome! The Lancet reported success in engineering vaginas for 4 women with MRKHS. No complications over the 8 years of follow up, and satisfaction with sexual functioning. Fingers crossed that this technique can be used in the future for many more women! Source.
  • Remember that sexual orientation is not the same as behavior? In a recent analysis of previously collected data, 11.2% of heterosexual-identified sexually active (presumably cisgender) women reported ever having a same-sex partner. Another way of looking at it: 1 in 10 straight women have had sex with another woman. Source.
  • Don’t forget about aftercare and cuddling! Post-sex affection appears to be correlated with relationship satisfaction. Source.
  • Unsurprising but sad: Young LGB people are more likely to binge drink alcohol when they’ve been exposed to discrimination and homophobia. Source.