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.

Jun 262015
 

800px-Phaedriel's-orchidVaginoplasties for transgender women have been performed for a little over 80 years. The first known surgery was in 1931. Those early surgeries (link includes surgical images) were a little crude by modern standards. The patients in question already had penectomy (removal of the penis) and orchiectomy (removal of the testes) performed so most erogenous sensation was lost. No labia were formed as far as I can tell, and the vagina was made of skin from the inner thigh.

In the 80-some-odd years that have followed those first surgeries, the techniques have improved tremendously. However there’s little evidence to suggest which techniques are the best. Studies have been small and inconsistent in the factors they examine. Study results may be inaccurate. Without more data, and more consistent measures, nothing can be said for certain. Still, a recent meta analysis pulled what data we do have together into one document. And today I’ll translate and summarize their summary.

There are three basic techniques for vaginoplasty for trans women:

  • Penile inversion. The tissue of the penis itself is used to line the vagina and labia. Parts of the scrotum and/or urethra may also be used.
  • Intestinal graft, either from the ileum (part of the small intestine) or rectosigmoid region (end of the large intestine). This is less common among US surgeons than among non-US surgeons.
  • Non-penile skin graft. This is an older technique, primarily used before 2000. Grafts were often taken from the inner thigh or abdomen.

Penile inversion is the most common technique in the United States today. It’s also the most well researched. In contrast, intestinal grafts are rarely performed by surgeons who specialized in transgender vaginoplasty in the United States today. Intestinal grafts are more commonly performed by non-US surgeons or for individuals who do not have a penis to invert. Lastly, the non-penile skin graft is an older technique that does not appear to be used much anymore.

All three techniques appears to produce overall satisfactory results. The average depth was around 10cm to 13.5 cm, and the vast majority of trans women were satisfied with their depth. The majority of women were also able to have vaginal intercourse (75%) and obtain orgasm (70%+). A majority were also aesthetically pleased by their results (90%) and had an improvement in their quality of life.

All techniques had their own levels of complications. Overall the most common complication was narrowing of the vagina (anywhere from 12%-43% of patients depending on technique). Urine stream changes and increases in risk of urethral infection were also fairly common, affecting 1 in 3 women. Rare serious complications included tissue death, rectal injuries, fistulas, deep vein thrombosis, and pulmonary embolism.

Comparisons between techniques was difficult because the details of each technique differed and the outcome measurements differed too. It does seem that, as far as the researchers could tell, there were fewer complications for intestinal graft vaginoplasties than for penile inversion vaginoplasties.However abdominal discomfort and “foul” vaginal secretions during intercourse have been reported for intestinal graft vaginoplasties, largely with rectosigmoid vaginoplasty. For penile inversion vaginoplasties, using urethral or scrotal skin in addition to penile skin was associated with more complications as well.

More research in general, and more standardized research, is crucial to understanding the best surgical techniques. Patients deserve the best results and the safest surgeries possible. Surgeons have already made great strides. Time to make more!

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

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.

~~

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

Feb 052014
 

This post is a legacy page, and was part of an on-going series, Trans 101 for Trans People. It covers questions about medical transition, hormones, surgeries, or seeking health care for transgender people.

For the material that once lived on this page, please see this page.

Please update your links to the full Trans 101.