Jun 122017

There are a lot of unknowns when it comes to hormone therapy for trans people. Which androgen is best for trans men? Are there long-term risks if they don’t have their ovaries or testes removed? And can we develop a way to give trans men testosterone that doesn’t involve needles or creams? This week’s paper tried to answer one question: What happens to trans men’s uteruses with all that testosterone?

Loverro et al recruited 12 trans men in Italy to participate. After examinations making sure they didn’t have any lurking cancers that might flourish with extra testosterone, they received intramuscular testosterone therapy. On average they were on testosterone for 32 months (roughly 2.5 years) before going on to have hysterectomy/oophorectomy. The uterus and ovaries wer then examined under the microscope. Estrogen and testosterone levels were also tracked throughout the study and up to one year after surgery.

What did they find?

First — a caveat. I’m not going to present all the nitty gritty details of the results. I don’t think the percent of Ki-67 receptors found in each tissue type is useful for most people. Nor do I think the details of exactly what their hormone levels were was useful. (They were in the therapeutic ranges). So I’m keeping my analysis here at the ten thousand foot view.

Loverro et al found that the uteruses did not atrophy with testosterone. The uteruses continued to be in an active state. Several trans men had a secretory uterus. That means their uteruses were building up the lining. In cis women that’s during the phase just before ovulation (when the egg is released). In trans men who don’t menstruate it’s harder to tell what’s going on. They also found that the muscular layer in the uterus was bigger, just like all muscles get bigger with testosterone.

When they examined the ovaries, they found that most of them were large with multiple follicles. The larger size was mostly from more connective tissue (collagen). That means more stuff in between the hormone producing cells, not more hormone producing cells. Multiple follicles were also found, just like in polycystic ovarian syndrome. That is a known effect of testosterone. And just like in PCOS, the larger follicles probably caused fewer menses. All of these ovarian changes were likely an effect of the testosterone.

That’s nice and all. But what does it mean?

It’s important to know that the uterus does not atrophy. That means trans men are still at risk for endometrial and uterine cancers. We don’t have any long term information on whether trans men are at high, low, or average risk for those cancers. However trans men should definitely seek medical advice if they experience spotting, cramping, or unexplained weight loss. As always, they should follow up with a primary care provider, like a family medicine, internal medicine, or ob/gyn doctor.

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

May 292017

Medical transition for trans people has only been available in the United States since the 1970’s. Because it’s so new we only have limited data about long term risks and benefits. When I was first learning about trans health I was frustrated by the lack of data. Are trans women protected from heart attacks like cis women are? Do trans men have lower risk for osteoporosis like their cis men peers do? We simply don’t know.

Today’s study is an exploration of the long term morbidity and mortality of trans people who have had surgery. Morbidity and mortality are just fancy words. Morbidity refers to disease or suffering. For example, morbidity may refer to how many people had a heart attack but are alive. Or how many people live with depression, or low back pain. Mortality is how many people died.

Who did they study?

Simonsen et al took advantage of the Denmark health system. In Denmark, there is one national health system. So they were able to look up how many trans people there are in Denmark. They were then able to figure out who had had gender-related surgery. Using medical billing codes, they looked at the diseases and disorders those trans people were diagnosed with. And they used death certificates to determine cause of death. They looked at records from 1970 to April 2014.

In total Simonsen et al looked at the records of 104 trans people. 56 were trans women and 48 were trans men. Surgery was performed between 1978 and 2010. So the patients with the most recent surgery would have been 4 years post surgery.

Most trans women (65%) started hormones age 22-42 and had surgery 9-23 years before the study. Trans men started at similar ages, 21-38 and had surgery 4-1

Beech trees in Denmark, where this study of morbidity and mortality was done

Beech trees in Denmark, where this study of morbidity and mortality was done

6 years before the study.

Their findings

In total, 20 trans people (19%) were diagnosed with a disease/disorder before surgery. That increased to 24 after surgery (23.2%). However, the difference wasn’t statistically significant. That means the difference was likely because of chance.

Diseases seen in this study included cancer, cardiovascular disease, musculoskeletal disease, chronic lung disease, and alcoholic liver disease. Almost all of the diseases were related to behavior and not to hormone therapy or the surgery.

Cardiovascular disease was seen in 10.7% of trans women and 25% of trans men. Compare that to 3.5% of cis women and 4.4% of cis men. The high rate of cardiovascular disease is likely a result of smoking, since high rates of chronic lung disease were also soon. Chronic lung disease includes COPD, which is usually caused by smoking tobacco. Chronic lung disease was seen in 3.8% of trans people. In comparison, 1.3% of cis people had chronic lung disease. There was no difference between before and after surgery in either cardiovascular disease or lung disease.

In contrast, there was a difference seen with alcohol. Alcohol-related diseases were seen in 3.8 of trans people before surgery. After surgery that number dropped to zero.

Musculoskeletal disease was unique. It was found in 10.5% of trans people, compared to 13.9% of the general cis population. So musculoskeletal disease was the only one that trans people, as a population, had less of.

Cancer rates were also higher in trans people. 6.2% of trans men and 3.6% of trans women were diagnosed with cancer. The general population rates are 1.6% of cis men and 2.4% of cis women. The cancer rates seem to be because of increased risk of lung cancer from smoking, however Simonsen et al did not publish the details.

What about deaths?

10 trans people had died in Denmark between 1970 and 2014. That’s 9.4% of all the trans people in Denmark. The average age of death was 53.5 years. The average age of death for the general population in Denmark is 81.9 years for women and 78 years for men. The causes of death were mostly from smoking and alcohol abuse. However, two trans people committed suicide. One was 19 years after surgery, the other was 26 years after surgery.

What do these results mean?

First, that gender-related surgery for trans people does not increase the risk for medical disease. There was no change in disease before and after surgery.

Second, rates of cardiovascular disease, lung disease, cancer, and alcohol-related disease are higher in trans people than in cis people. Smoking tobacco and alcohol seem to be the cause, not hormones. And smoking and alcohol are likely because of stress from discrimination and gender dysphoria.

Third, the average life expectancy for trans people in Denmark is much lower than the general life expectancy. Again, this is because of smoking, alcohol, and suicide.

What are the caveats?

This was a tiny sample. While 104 trans people is a large sample for trans research, it’s a small sample to try to draw large conclusions from. Worse, some of the sub groups were miniscule. It’s near impossible to draw accurate conclusions from only 4 people with lung disease, or 2 suicides.

I was also surprised at the lack of HIV-related diagnoses in this study. HIV is prevalent in trans women in the US for complex reasons. Is the rate lower in Denmark? I don’t know.

And as always, this was one study in one country. Every culture and country is different, with different levels of discrimination and different cultural standards. So we can’t make assumptions about other cultures based on this one study.

Despite the limitation, this is an excellent exploratory study. We should continue to look for more data coming out of Denmark to see what more we can learn.

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

Feb 202017

“Brain tumor” are two words that strike fear into most hearts. They conjure images of thin patients with heads shaved and large fresh scars on their heads, of rapid neurological deterioration, and of sick children. Not all brain tumors are the same, however. Some are aggressive malignant cancer. Those are the bad actors like medullablastoma. They grow and spread quickly, and are very difficult to treat. Others are benign. These grow slowly, and either don’t spread or are very slow to spread. Benign brain tumors include meningioma, which we’re talking about today.

Meningioma is a tumor of the meninges, a thin layer that covers the brain. Meningiomas are benign. They don’t tend to metastasize (spread to other areas of the body). Instead, they grow and can grow enough that they squish parts of the brain. This causes headaches, loss of vision, and changes in thinking and mood.

Brain tumors are rare. So are meningiomas. They affect roughly 97/100,000 people. We don’t yet know exactly what causes them. But by looking are who tends to get them, we have some guesses. Exposure to radiation of the head seems to increase the risk. So does having a condition called Neurofibromatosis II. And meningiomas are more common in cisgender women than in cisgender men. Why? Because of hormones. Like breast cancer, meningioma can grow in response to estrogen or progesterone. Cis men who have been treated for prostate cancer (involving androgen deprivation therapy) are at higher risk. And perhaps trans women are too.

Today’s Paper

And that’s what brings us to today’s paper. We’ve covered meningiomas in trans women once before, but it’s time to take another look now that we have more data.

Today’s paper discusses three new cases of meningioma in trans women. In total now, 8 cases have been discussed in the medical literature. It’s a very small number, but enough to start seeing some patterns.

Of these three new cases, all were over the age of 45, were post-vaginoplasty, and were on cyproterone acetate along with an estrogen. All had surgery to remove the tumor, and they did well. The decision to continue hormone therapy was made on a case-by-case basis.

The authors noted a previous paper that found that cyproterone acetate was associated with meningioma. This was particularly true with doses above 25mg a day. Among the eight cases of meningioma in trans women in the literature, only one was not on cyproterone acetate. Doses ranged from 10mg to 100mg, with most being on 50mg or 100mg. The authors also found reports of higher rates of meningioma among people who use progesterone-like medications. Removing hormone therapy (especially cyproterone acetate) frequently helps to shrink the tumor.

What should you do with this information?

First, don’t panic about meningioma. It’s rare and benign.

There is no screening for meningioma. Instead, if you have any unusual symptoms like changes in your vision or headaches, talk with your doctor.

If you are a trans woman, consider taking the smallest dose of hormones possible. In general, high doses increase side effects and don’t help with transition. If you are diagnosed with a meningioma, have an honest conversation with your doctors about your hormone therapy.

And, of course, be sure to live as healthy a life as you can. Don’t go jumping into volcanos or nuclear power plants. Eat a balanced diet, get some exercise, avoid most drugs, and take care of yourself.

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

Dec 192016

Given recent events in US politics, today’s study was especially timely. I thought I’d move it up in the queue. Yes, there’s a queue. In today’s study, Owen-Smith et al tried to answer the question “Is there a relationship between depression in transgender people and tolerance of transgender people in their surrounding community?” Logically it makes sense. But we have very little data. Science needs data. So Owen-Smith et al surveyed trans people with the help of a local trans organization.

Dr William' Pink Pills, once marketed as a depression "treatment"

Dr William’ Pink Pills, once marketed as a depression “treatment”

To measure tolerance, they used a simple 1-5 rating scale. They also asked about mistreatment and discrimination in the past 12 months. For depression they used two different scales: the Beck Depression Inventory (BDI) and the Center for Epidemiologic Studies Depression (CESD). The BDI was designed to detect and diagnose Major Depressive Disorder. In contrast, the CESD was designed to detect depressive symptoms, not necessarily the disorder. Between those two scales Owen-Smith et al captured both depressive disorder and depressive symptoms.

As with all studies they also asked about demographics. Age, education, race/ethnicity, and so on. Because this is a study of trans people they asked about hormonal and surgical status. If the participants hadn’t gotten hormones or surgery, Owen-Smith et al asked whether they wanted them.

What did they find?

In total, 399 people completed the study. 70% were trans women. 85% were white. 57% had completed college. 32% were currently receiving hormones and 7% had had surgery.

And 1 in 4 (~24%) said that most people in their area were tolerant of trans people. Roughly half (47%) of the sample had experienced abuse or discrimination. Perhaps surprisingly, there was no difference in abuse based on the tolerance of the participant’s area.

Roughly half of the group were depressed or had depressive symptoms. And this did differ based on the tolerance of the area. Trans people from less tolerant areas were more likely to have depression. In addition, the more abuse they had experienced the more likely it was that they experienced depression. Wanting or receiving hormone therapy was also associated with depression. In contrast, having a college degree was protective. Other factors like surgical status and race had no effect on depression.

What does this mean?

From this study, it seems that being in an area that is perceived to be intolerant of transgender people is associated with depression in trans people. Although this study can only show correlation, not causation we can potentially still make inferences. It may be that as areas become more tolerant, depression rates among trans people go down. Or that as more areas show their tolerance, depression rates will go down. Certainly this study seems to suggest that.

As always, this study has limitations. Its sample was probably not representative of the entire trans community, being mostly white well educated trans women. Results may be different in different groups of trans people.

Depression has serious effects on quality of life. Trans people are at high risk for depression already, with around half having symptoms. Compare that to roughly 4-9% (less than 1 in 10) of the broader population. And the worst outcome of depression, suicide, is high among trans people too. Anything that we can do to decrease suicide, we should do.

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

Dec 052016

Too often gender and sexual minority health is distilled down to just the Human Immunodeficiency Virus (HIV)…as if that’s the only disease that could possibly be relevant. Some small amount of time might then be dedicated to STD’s like gonorrhea. But really it’s all about HIV. But ignoring all the other aspects of GSM health ignores the diversity of our communities. When I started Open Minded Health I wanted to avoid that topic. I saw so much time and so many resources being dedicated to HIV…I wanted to do something different.

Halfway through my third year of medical school now, I’m beginning to change my mind. We still need to avoid focusing only on HIV. But this one single disease has caused so much devastation, so much individual and cultural harm… I can’t just ignore it here on Open Minded Health. The focus here will still be on non-HIV aspects of GSM health care, but I’ll be sneaking in some articles on HIV too when I think it’s appropriate. Don’t worry, OMH won’t become “All AIDS all the time.”

Which all brings me to today’s article!

Literature Review

Radix, Sevelius, and Deutsch did a literature review looking at HIV in transgender women. Trans women, as a group, have the highest risk for HIV infection of all groups. Although we don’t have great data yet, the best estimate is that 19% of trans women are living with HIV.

Worse, preliminary data show that trans women are less likely to know their HIV status. As a group they’re likely to have higher viral loads. That means their HIV is not suppressed. One study in particular found that among trans women who were diagnosed, only 77% were referred to primary care, 65% were taking anti-retrovirals, and only 55% had suppressed their viral load.

HIV treatment 101

Diagram of an HIV particle

HIV cannot be cured. It causes harm by destroying part of the immune system. The goal of treatment is to reduce the number of copies of the virus, the “viral load”. The lower the viral load, the better your immune system can work (measured as a “CD4 count”). This has two benefits. First, you live longer. You’re less likely to get an infection or cancer. Second, you’re less likely to spread HIV to others. HAART is the modern gold standard of treatment. HAART stands for “highly active antiretroviral therapy”. Think of it as the new improved ART, or antiretroviral therapy. HAART is a mix of 3+ drugs that work to keep the viral from copying itself.

Trans women and HIV

Why are trans women at such high risk for HIV? Previous studies suggest it comes down to social issues. Trans women are often more visibly “trans” than trans men, and are a easier target for discrimination. They may be more likely to work in the sex industry. In that industry, anal sex is what they likely end up performing, and anal sex is the most likely to spread HIV. In addition, substance use is higher in trans populations. Sharing needles and items used for snorting can also spread HIV.

For whatever reason though trans women are at high risk. Why such a lower rate of treatment? Why are only 65% taking antiretrovirals? First there’s always cost. HAART can cost $10,000 per year and more. Second, some studies suggest that trans women may prioritize hormone therapy over HIV treatment.

HAART and hormones

Lastly, there are some very real concerns about interactions between HAART medications and hormone therapy. Both estrogen and HAART medications are processed by the liver and often by the same enzymes. Estrogen may change the amount of HAART medications that stay in the body, or vice versa.

According to this paper, the only research that’s been done so far on estrogen and HIV therapy has been done with cisgender women on birth control. As long time readers of OMH know, birth control is not hormone therapy. Birth control has both estrogen and progesterone. And the type of estrogen is different between birth control and transgender hormone therapy. Still, it’s what we have to use. These studies showed that some antiretroviral medications do change the blood level of estrogen, and that the levels of some antiretrovirals are changed by estrogen.  However we don’t know if that effect is true with the type of estrogen in transgender hormone therapy…and we don’t know if the differences in the blood levels has a real clinical effect.

I won’t go into detail of which HAART medications did what. Antiretroviral medication names are notoriously difficult to read, pronounce, and remember. Instead, here’s the important part: It is very important for your health care provider to know what you are taking. If you’re taking estrogen, tell your provider. That way they can check for drug-drug interactions and adjust medications appropriately.

What about anti-androgens, like spironolactone, finasteride, and GnRH agonists? Do they interact with antiretrovirals? There are no studies specifically about them and antiretrovirals. No interactions are known. We just don’t know.

The potential effects of transgender hormone therapy on antiretroviral medication blood levels may not even matter in HIV treatment in the end. Why? Well, we don’t just put someone on HAART and never see them again. Physicians check the viral load to see if HAART is working. So they know if doses or medications need to be changed. If there’s an interaction between drugs, they’ll see that the viral load isn’t low and they’ll change the drugs anyway.


In other words: There is no clear reason to avoid HAART while on hormone therapy.

Get tested, know your status, and get treatment if needed. Doing so will allow you to live for many, many years to come.

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

Citation: Radix A et al. Journal of the International AIDS Society 2016, 19(Suppl 2):20810