Hematospermia in a Transgender Woman with Evidence for Endometrial Tissue in the Prostate.

Background/Objective: The frequency of hematospermia in transgender women is unknown. This report aimed to describe the development of hematospermia in a transgender woman. Case Report: A 35-year-old transgender woman treated with estradiol valerate and leuprolide presented with painless rust-tinged ejaculate, urethral bleeding after ejaculation, and intermittent hematuria. Her medical history included gastroesophageal reflux disease, internal hemorrhoids, and attention deficit hyperactivity disorder with negative tobacco smoking and urologic history. Additional medications included emtricitabine-tenofovir disoproxil fumarate and fexofenadine. Physical examination did not reveal constitutional or genitourinary abnormalities. Urinalysis and culture disclosed rare white blood cells with gram-variable bacilli. The chlamydia, gonorrhea, and human immunodeficiency virus test results were negative. Abdominal computed tomography did not reveal bladder or prostate cancer, calcifications, inflammation, or cysts. She continued to have symptoms after this initial workup. One year after the initial symptom onset, transrectal ultrasound disclosed a 1.7-cm midline posterior prostatic cyst with hemorrhagic products, later revealed by magnetic resonance imaging as communicating with the left seminal vesicle. Two ultrasound-guided transperineal biopsy samples revealed benign prostatic tissue with a small focus of Müllerian or endometrial-type tissue, evidenced by immunopositivity for paired-box gene 8 and estrogen receptor in epithelium and cluster of differentiation 10 immunopositivity in stroma. After medical consultation, the patient underwent prostatic cyst aspiration, resection of the transurethral ejaculatory ducts, and orchiectomy. She did not experience any complications after these procedures. Discussion: The etiology of hematospermia may be idiopathic, iatrogenic, anatomic, or pathologic. Conclusion: Occult endometriosis or ectopic Müllerian epithelial tissue growth may occur in transgender women taking feminizing gender-affirming hormone therapy.

Minimizing Venous Thromboembolism in Feminizing Hormone Therapy: Applying Lessons From Cisgender Women and Previous Data.

OBJECTIVE: To review he impact of estrogen-containing feminizing hormone regimens on transgender individuals' risk for VTE. METHODS: We evaluated VTE risk by screening 1170 relevant studies published from 1994 to 2020, focusing on meta-analysis data. RESULTS: The type of oral estrogen, route of administration, patient demographics, and comorbidities may affect the risk of VTE. Venous thrombosis is the most common vascular complication associated with HT. CONCLUSION: Conjugated equine estrogens and 17-ß estradiol appear to be safer than oral ethinyl estradiol. Transdermal estrogen formulations appear to be the least thrombogenic estrogens. Estrogens used concomitantly with progestins increase the risk of VTE compared to estrogens alone. To date, there are no data to demonstrate the benefit of holding HT prior to vaginoplasty or other gender affirming surgeries. For most young, healthy transgender women, there is little risk of VTE with HT, while older patients with risk factors should be discussed case by case.

HIGH BODY MASS INDEX IS A SIGNIFICANT BARRIER TO GENDER-CONFIRMATION SURGERY FOR TRANSGENDER AND GENDER-NONBINARY INDIVIDUALS.

Objective: Transgender and gender-nonbinary individuals (TGNB) are disproportionately impacted by obesity. In addition to the associated health impact, obesity represents a significant barrier to accessing gender-confirmation surgery (GCS). The purpose of this study was to determine the prevalence of obesity among TGNB surgical candidates at an urban academic medical center and evaluate the efficacy of self-monitored weight management. Methods: The study was conducted at the Center for Transgender Medicine and Surgery at Mount Sinai in New York City. Data abstraction from a quality improvement database was completed for patients with a documented body mass index (BMI) and a GCS consult from October 2015 through February 2019. A total of 1,457 TGNB patients with a documented BMI and a GCS consult in the historical period of review were included in analysis. Data were abstracted to determine the prevalence of obesity among GCS candidates and evaluate the current default pre-operative self-monitored weight management protocol. Results: Of 1,457 TGNB patients, 382 (26%) were obese (BMI ≥30 kg/m2) at initial surgical consult. In addition, 369 (27%) were obese at a subsequent follow-up, suggesting no statistically significant change in the rate of obesity among evaluated TGNB despite self-monitored weight management (P = .5272). Conclusion: Obesity is a significant barrier to gender affirming surgery for transgender individuals. Self-monitored weight management is an unsuccessful strategy for improvement even among individuals who would be predicted to be motivated. Abbreviations: BMI = body mass index; CTMS = Center for Transgender Medicine and Surgery (at Mount Sinai); GCS = gender confirmation surgery; TGNB = transgender and gender-nonbinary.

A REVIEW OF BREAST DEVELOPMENT IN CISGENDER WOMEN AND IMPLICATIONS FOR TRANSGENDER WOMEN.

Objective: The objective of this article is to describe the hormonal pathways required for breast development in cisgender women and to review the current available literature describing breast growth and breast cancer risk in transgender women. Methods: Literature review and discussion. Results: Early mammary tissue development occurs prenatally. This process is hormone-independent and occurs similarly in males and females. Breast tissue is quiescent until puberty, at which time surging estrogen levels in cisgender girls mediate breast development and growth. Adult breast tissue composition further evolves in cisgender women during pregnancy, lactation, and menopause, revealing the ever-changing interplay between breast structure and hormonal environment. Conclusion: Breast growth is a significant physical endpoint in the hormonal treatment of transgender women. Transgender hormone regimens, which typically pair an estrogen with an anti-androgen, can help achieve this goal.

Managing the risk of venous thromboembolism in transgender adults undergoing hormone therapy.

Introduction: Venous thromboembolism (VTE) is a potential risk of estrogen therapy. However, data show an improvement in the quality of life for transgender people who use feminizing hormone therapy. With few transgender-specific data, guidance may be drawn from cisgender (nontransgender) data, with a focus on hormonal birth control and postmenopausal hormone replacement therapy (HRT). The aim of this review is to examine the degree to which routes of administration, patient comorbidities, and type of hormone utilized affect the safety of estrogen therapy. Methods: We identified 6,349 studies by searching PubMed with the terms "transgender", "estrogen", "VTE", and "HRT". Of these, there were only 13 studies between 1989 and 2018 that investigated the effects of hormone therapy, including types of estrogens used, in transgender women and men. Results: The data suggest that the route of hormone administration, patient demographics, and patient comorbidities all affect estrogen's link with VTE. For example, avoiding ethinyl estradiol might make the use of hormone therapy in trans feminine individuals safer than oral birth control. Data from both cis and trans groups suggest additional VTE risk associated with the use of progestins. While transdermal estrogens dosed up to 0.1 mg/day or below appear lower risk for VTE than other forms of estrogen, it is unclear whether this is related to the delivery method or a dose effect. Finally, even if the risk from exogenous estrogen use remains significant statistically, the absolute clinical risk remains low. Conclusion: Clinicians should avoid the use of ethinyl estradiol. Additionally, data suggest that progestins should be avoided for transgender individuals. Further study of the relationship between estrogen use and the risk of VTE will serve to inform the safest care strategies for transgender individuals.

Concurrent Milk Ingestion Decreases Absorption of Levothyroxine.

BACKGROUND: Levothyroxine is the most commonly prescribed medication in the United States. Many foods and medications, including calcium supplements, can interfere with levothyroxine absorption. No studies have investigated the effect of cow's milk, a common breakfast staple, on the absorption of oral levothyroxine. Cow's milk contains approximately 450 mg of elemental calcium per 12 oz (355 mL) serving. METHODS: A pharmacokinetic study was conducted in healthy euthyroid subjects to assess levothyroxine absorption with and without concurrent cow's milk consumption. Following an overnight fast, serum total thyroxine (TT4) concentrations were measured at baseline and at one, two, four, and six hours after ingestion of 1000 µg of oral levothyroxine alone or when co-administered with 12 oz (355 mL) of 2% milk. There was a four-week washout period between the two assessments in each subject. RESULTS: Ten subjects (Mage ± SD = 33.7 ± 10.2 years; 60% male) completed the study. The area under the curve (AUC) of TT4 concentrations was significantly lower when levothyroxine was ingested along with 12 oz (355 mL) of 2% cow's milk (M ± SD = 67.3 ± 12.1) compared to that with levothyroxine alone (73.5 ± 17.0; p = 0.02). Also, peak serum TT4 concentrations were significantly lower when cow's milk was co-administered with levothyroxine (M ± SD = 14.1 ± 0.8 µg/dL) than with levothyroxine alone (13.0 ± 0.9 µg/dL; p = 0.04). CONCLUSIONS: This is the first study to demonstrate that concurrent cow's milk ingestion reduces oral levothyroxine absorption. The findings support previous literature showing the interference of elemental calcium and food with thyroid hormone absorption. Patients managed with thyroid hormone should be advised to avoid taking their levothyroxine simultaneously with cow's milk.

Breast Imaging of Transgender Individuals: A Review.

PURPOSE: This review will inform radiologists about the evidence base regarding radiographic imaging for transgender individuals and considerations for providing culturally sensitive care for this population. FINDINGS: Transgender individuals are increasingly referred for both screening and diagnostic breast imaging. It is important that the clinic environment is welcoming, the medical staff utilize accepted terminology and patients are able to designate their gender and personal history to ensure appropriate care. Hormone and surgical treatments used for transition by many transgender women and men may change the approach to imaging. SUMMARY: Although not yet evidence-based, screening mammography is currently suggested for transgender women with risk factors, including those receiving hormone treatment over 5 years. The risk for breast cancer in transgender individuals is still being defined.

Case Report: Induced Lactation in a Transgender Woman.

Objective: Our report describes a case of nonpuerperal induced lactation in a transgender woman. Methods: We present the relevant clinical and laboratory findings, along with a review of the relevant literature. Results: A 30-year-old transgender woman who had been receiving feminizing hormone therapy for the past 6 years presented to our clinic with the goal of being able to breastfeed her adopted infant. After implementing a regimen of domperidone, estradiol, progesterone, and breast pumping, she was able to achieve sufficient breast milk volume to be the sole source of nourishment for her child for 6 weeks. This case illustrates that, in some circumstances, modest but functional lactation can be induced in transgender women.

Interventions to preserve beta-cell function in the management and prevention of type 2 diabetes.

The International Diabetes Federation estimates that there are currently 336 million people worldwide who have type 2 diabetes (T2DM), and the global prevalence of diabetes has more than doubled since 1980. The rapid rise in rates of T2DM echoes a similar rise in rates of obesity, which causes insulin resistance and places an increased insulin secretory demand on pancreatic ß cells. While diabetes is diagnosed clinically by elevated plasma glucose levels, loss of ß-cell function is progressive over time and ß-cell dysfunction is far advanced by the time diabetes is diagnosed. Methods for preserving or restoring ß-cell function are important for the prevention and treatment of T2DM. Interventions that reduce body fat or that change fat biology provide the best evidence for slowing or arresting the deterioration of ß-cell function that causes T2DM. These interventions should form the basis of interventions to prevent and treat T2DM, particularly early in its course.