The Endocrine Care of Transsexual People

Yona Greenman

Institute of Endocrinology, Metabolism, and Hypertension, Tel Aviv-Sourasky Medical Center, Tel Aviv 64239, Israel

Address correspondence to: Yona Greenman, M.D., Institute of Endocrinology, Metabolism, and Hypertension, Tel Aviv-Sourasky Medical Center, 6 Weizmann Street, Tel Aviv 64239, Israel. E-mail: greenman{at}tasmc.health.gov.il.

To the editor:

I commend the authors and the Journal for publishing Clinical Review 161 on the endocrine treatment of transsexual people (1). Despite the central role the endocrinologist plays in the management of these patients, there are few clinical studies or publications by the endocrine community focusing on this area. This is well reflected by the range of hormonal preparations and dosages used by different centers specializing in the treatment of transsexual people (1). Most of these clinical regimens and protocols are empiric and have not been compared or tested in a controlled and rigorous manner. This leaves the clinical endocrinologist with the responsibility of integrating recommendations from the various centers. Moore et al. (1) embarked on this difficult task and have drawn general guidelines of their own but pointed to the need for randomized clinical trials. I would like to comment on some of the issues dealt with by the authors:

1) Asscheman et al. (2) have reported an incidence of thromboembolic episodes of 2.1% in male-to-female (M->F) patients less than 40 yr of age and in 12% of M->F patients above 40 yr of age under estrogen therapy. This led them to recommend transdermal estrogen administration to subjects over age 40 yr. In a subsequent analysis of 816 M->F transsexuals, the same group reported a substantial decrease in the incidence of thromboembolic events, which could be attributed to their change in clinical practice (3). Because the risk of this severe complication is also significant in younger patients, I would propose the use of transdermal preparations as the first-choice estrogen treatment for all age groups.

2) Hyperprolactinemia is a common finding in M->F transsexual patients, and its degree is positively correlated with the dosage of estrogen (3). Nevertheless, the incidence of prolactinoma is extremely low and probably does not warrant the routine performance of visual field assessment during follow-up, as recommended by the authors (1). Prolactin levels should, in my view, be measured at the initial visit before treatment to exclude the presence of a prolactinoma unrelated to the hormonal treatment. Subsequent prolactin measurements should suffice to detect clearly elevated levels that could raise the possibility of lactotroph hyperplasia, leading to estrogen dose adjustment.

3) Moore et al. (1) recommend assessment of bone mass in M->F transsexuals after surgical castration. Female-to-male (F->M) transsexuals are also at risk for osteoporosis. It has been shown that in the M->F population, estrogen treatment prevented bone loss after testosterone deprivation, whereas in the F->M group, testosterone treatment was in general unable to prevent the decrease in bone mass associated with the decline of serum estradiol levels (4). Furthermore, the change in bone mineral density correlated inversely with serum gonadotrophin levels. High LH levels appeared to be the best predictor of bone loss and reflected hormone undertreatment (4). Therefore, it would be wise to recommend performance of densitometry studies for F->M subjects as well and to incorporate measurements of LH to the other variables to be tested during the follow-up of these patients.

4) Endometrial hyperplasia is a serious concern in testosterone-treated F->M transsexuals. Consequently, periodic uterine sonography, which can be performed through the abdominal wall if technically feasible, is advised until hysterectomy is performed. On the other hand, pelvic exams are very demanding for these patients from the psychological point of view. Because most of them do not have sexual contact that involves intercourse, the performance of routine Pap smears, as recommended, is probably not necessary, based on the recommendations of the U.S. Preventive Services Task Force for screening for cervical cancer (5).

5) Preservation of fertility is an important issue that should be discussed with patients. Freezing and storage of sperm should be proposed to M->F transsexuals before hormone therapy is initiated.

In conclusion, much improvement is needed in the quality of treatment that transsexual people receive, together with an empathic and supportive approach that these patients require.

Received September 17, 2003.

References

  1. Moore E, Wisniewski A, Dobs A 2003 Endocrine treatment of transsexual people: a review of treatment regimens, outcomes, and adverse effects. J Clin Endocrinol Metab 88:3467–3473[Abstract/Free Full Text]
  2. Asscheman H, Gooren LJG, Eklund PL 1989 Mortality and morbidity in transsexual patients with cross-gender hormone treatment. Metabolism 38:869–873[Medline]
  3. Van Kesteren PJM, Asscheman H, Megens JAJ, Gooren LJG 1997 Mortality and morbidity in transsexual patients with cross-gender hormone treatment. Clin Endocrinol (Oxf) 47:337–342[Medline]
  4. Van Kesteren P, Lips P, Gooren LJG, Asscheman H, Megens J 1998 Long-term follow-up of bone mineral density and bone metabolism in transsexuals treated with cross sexual hormones. Clin Endocrinol (Oxf) 48:347–354[CrossRef][Medline]
  5. U.S. Preventive Services Task Force 2003 Screening for cervical cancer. Recommendations and rationale. AHRQ Publication 03-515A. Rockville, MD: Agency for Healthcare Research and Quality