The Johns Hopkins University, School of Medicine, Division of Endocrinology and Metabolism, Baltimore, Maryland 21287
Address correspondence to Adrian Dobs, M.D., M.H.S., The Johns Hopkins University School of Medicine, Division of Endocrinology and Metabolism, 1830 East Monument Street, Suite 328, Baltimore, Maryland 21287. E-mail: adobs{at}welch.jhu.edu.
To the editor:
We thank Dr. Greenman (1) and Dr. TSjoen et al. (2) for their comments on our recent review article. They each add helpful additions to the recommendations presented in our review. We have a few comments to the issues raised. Both teams suggest the use of transdermal estrogen delivery for all age groups. This is reasonable and supported by the data as outlined. However, this may not offer a transition as immediate and dramatic as often desired by patients. We agree that visual field evaluation need not be done routinely because the development of a prolactinoma is rare. Certainly, freezing and storage of sperm or embryos could be recommended to individuals, although this is not a frequent request.
In regard to Greenmans (1) comment on gynecological surveillance of female-to-male (F M) transsexual people, vaginal ultrasound is a standard of care in following the endometrium in patients at increased risk for hyperplasia or carcinoma (3). However, a transabdominal pelvic ultrasound performed by an experienced technician may be a reasonable, although less ideal, alternative. Most importantly, a patient with new vaginal bleeding or a possible history of hyperplasia should receive prompt and thorough evaluation by endometrial biopsy and/or hysteroscopy. The recommendations from the National Institutes of Cancer and the U.S. Preventive Services Task Force (4) include routine pap smears for all sexually active women with a cervix. In postmenopausal women, the Task Force recommends ceasing cervical cancer screening after at least three negative pap smears as long as there are no abnormal pap smears in the last 10 yr. It is important to remember that individual F
M transsexual people may be at risk for human papillomavirus and cervical cancer through current or past vaginal intercourse. Additionally, it can take years for a cervical abnormality or cancer to develop. Stopping cervical cancer surveillance can be recommended only on a case-by-case basis.
Comments made by the Amsterdam group (2) are very helpful. The prevalence of an abnormal karyotype in this population is unknown, probably small, and probably irrelevant in the decision to treat. Therefore, we do not recommend routine chromosomal analysis unless the history or physical exam is suggestive of an abnormality. We do agree with their group that in many situations, particularly in adolescents or young adults, antiandrogens might be a better first step before using feminizing hormones. However, we also want to emphasize the importance of encouraging full transition. We strongly discourage incomplete treatment, whereby individuals have a mixture of female and male external sexual characteristics.
Developing guidelines in the face of limited data can be challenging. We appreciate the input from experienced clinicians, as above, to enhance the treatment transsexual people receive.
Received October 21, 2003.
References
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