Protocol of a drug-drug interaction study between bictegravir/emtricitabine/tenofovir alafenamide and feminizing hormones in trans women living with HIV.

AIMS: Trans/transfeminine women are disproportionally affected by HIV. Concerns regarding negative drug-drug interactions (DDIs) between ART drugs and gender-affirming hormone therapy (GAHT), specifically feminizing hormone therapy (FHT), may contribute to the lower ART uptake by trans women with HIV compared with their cis counterparts. The aim of this study is to investigate the bidirectional pharmacokinetic effects of components of FHT regimens (oral oestradiol and androgen-suppressing medications) with the ART regimen (bictegravir/emtricitabine/tenofovir alafenamide [B/F/TAF)]. METHODS: We present a protocol for a three-armed, parallel-group, longitudinal (6-month), DDI study. Group 1 includes 15 3trans women with HIV taking FHT and ART; group 2 includes 15 premenopausal cis women with HIV taking ART; group 3 includes 15 trans women without HIV taking FHT. Women with HIV must be on or switch to B/F/TAF at baseline and be virally suppressed for ≥3 months. Trans women must be taking a stable regimen of ≥2 mg daily oral oestradiol and an anti-androgen (pharmaceutical, and/or surgical, and/or medical) for ≥3 months. Plasma ART drug concentrations will be sampled at Month 2 and compared between groups 1 and 2. Serum oestradiol concentrations will be sampled at baseline and Month 2 visits and compared between groups 1 and 3. The primary outcomes are B/F/TAF pharmacokinetic parameters (Cmin, Cmax and AUC) and oestradiol concentrations (Cmin, C4h, Cmax and AUC) at month 2. DISCUSSION: This study is of global importance as it provides critical information regarding safe coadministration of B/F/TAF and FHT, both of which are life-saving therapies for trans women with HIV.

Transgender health objectives of training for adult Endocrinology and Metabolism programs: Outcomes of a modified-Delphi study.

BACKGROUND: Transgender people encounter significant barriers when seeking timely, high-quality healthcare, resulting in unmet medical needs with increased rates of diabetes, asthma, chronic obstructive pulmonary disease, and HIV. The paucity of postgraduate medical education to invest in standardization of transgender health training sustains these barriers, leaving physicians feeling unprepared and averse to provide transgender health care. Closing this education gap and improving transgender healthcare necessitates the development of consensus-built transgender health objectives of training (THOOT), particularly in Adult Endocrinology and Metabolism Residency programs. METHODS: We conducted a two-round modified-Delphi process involving a nationally representative panel of experts, including Adult Endocrinology and Metabolism program directors, physician content experts, residents, and transgender community members, to identify THOOT for inclusion in Canadian Endocrinology and Metabolism Residency programs. Participants used a 5-point Likert scale to assess THOOT importance for curricular inclusion, with opportunities for written feedback. Data was collected through Qualtrics and analyzed after each round. FINDINGS: In the first Delphi round, panelists reviewed and rated 81 literature extracted THOOT, achieving consensus on all objectives. Following panelists' feedback, 5 THOOT were added, 9 removed, 34 consolidated into 12 objectives, and 47 were rephrased or retained. In the second Delphi round, panelists assessed 55 THOOT. Consensus was established for 8 THOOT. Program directors' post-Delphi feedback further consolidated objectives to arrive at 4 THOOT for curriculum inclusion. CONCLUSIONS: To our knowledge, this is the first time a consensus-based approach has been used to establish THOOT for any subspecialty postgraduate medicine program across Canada or the United States. Our results lay the foundation towards health equity and social justice in transgender health medical education, offering a blueprint for future innovations.

Clinical Outcomes of Left Atrial Appendage Occlusion Versus Switch of Direct Oral Antcoagulant in Atrial Fibrillation: A Territory-Wide Retrospective Analysis.

Background Left atrial appendage occlusion (LAAO) has emerged as an alternative to oral anticoagulation therapy for stroke prevention in atrial fibrillation, but data comparing LAAO with direct oral anticoagulant (DOAC) are sparse. Methods and Results This cohort study compared LAAO (with or without prior anticoagulation) with a switch of one DOAC to another DOAC by 1:2 propensity score matching. The primary outcome was a composite of all-cause mortality, ischemic stroke, and major bleeding. A total of 2350 patients (874 in the LAAO group and 1476 in the DOAC switch group) were included. After a mean follow-up of 1052±694 days, the primary outcome developed in 215 (24.6%) patients in the LAAO group and in 335 (22.7%) patients in the DOAC switch group (hazard ratio [HR], 0.94 [95% CI, 0.80-1.12]; P=0.516). The LAAO group had a lower all-cause mortality (HR, 0.49 [95% CI, 0.39-0.60]; P<0.001) and cardiovascular mortality (HR, 0.49 [95% CI, 0.32-0.73]; P<0.001) but similar risk of ischemic stroke (HR, 0.83 [95% CI, 0.63-1.10]; P=0.194). The major bleeding risk was similar overall (HR, 1.18 [95% CI, 0.94-1.48], P=0.150) but was lower in the LAAO group after 6 months (HR, 0.71 [95% CI, 0.51-0.97]; P=0.032). Conclusions LAAO conferred a similar risk of composite outcome of all-cause mortality, ischemic stroke, and major bleeding, as compared with DOAC switch. The risks of all-cause mortality and cardiovascular mortality were lower with LAAO.

Oestradiol concentrations in trans women with HIV suppressed on unboosted integrase inhibitor regimens versus trans women without HIV taking oral oestradiol: a pilot study.

BACKGROUND: Feminizing hormone therapy (FHT) is essential to many trans women. Concern about negative drug interactions between FHT and ART can be an ART adherence barrier among trans women with HIV. OBJECTIVES: In this single-centre, parallel group, cross-sectional pilot study, we measured serum oestradiol concentrations in trans women with HIV taking FHT and unboosted integrase strand transfer inhibitor (INSTI)-based ART versus trans women without HIV taking FHT. METHODS: We included trans women with and without HIV, aged ≥18 years, taking ≥2 mg/day of oral oestradiol for at least 3 months plus an anti-androgen. Trans women with HIV were on suppressive ART ≥3 months. Serum oestradiol concentrations were measured prior to medication dosing and 2, 4, 6 and 8 h post-dose. Median oestradiol concentrations were compared between groups using Wilcoxon rank-sum tests. RESULTS: Participants (n = 8 with HIV, n = 7 without) had a median age of 32 (IQR: 28, 39) years. Among participants, the median oral oestradiol dose was 4 mg (range 2-6 mg). Participants had been taking FHT for a median of 4 years (IQR: 2, 8). Six trans women with HIV were taking bictegravir/emtricitabine/tenofovir alafenamide and two were taking dolutegravir/abacavir/lamivudine. All oestradiol concentrations were not significantly different between groups. Eleven (73%) participants had target oestradiol concentrations in the range 200-735 pmol/L at C4h (75% among women with HIV, 71% among those without HIV). CONCLUSIONS: Oestradiol concentrations were not statistically different in trans women with HIV compared with those without HIV, suggesting a low probability of clinically relevant drug-drug interactions between FHT and unboosted INSTI-based ART.

Feminizing hormone therapy in a Canadian cohort of transgender women with and without HIV.

BACKGROUND: Potential bidirectional drug-drug interactions between feminizing hormone therapy (FHT) and antiretroviral therapy (ART) are of concern for trans women with HIV and their healthcare providers. This study aimed to characterize patterns of FHT and ART among trans women with HIV and to compare serum hormone levels to trans women without HIV. METHODS: Charts of trans women were reviewed at seven HIV primary care or endocrinology clinics in Toronto and Montreal from 2018 to 2019. ART regimens, FHT use, serum estradiol, and serum testosterone levels were compared on the basis of HIV status (positive, negative, missing/unknown). RESULTS: Of 1495 trans women, there were 86 trans women with HIV, of whom 79 (91.8%) were on ART. ART regimens were most commonly integrase inhibitor-based (67.4%), many boosted with ritonavir or cobicistat (45.3%). Fewer (71.8%) trans women with HIV were prescribed FHT, compared to those without HIV (88.4%) and those with missing/unknown status (90.2%, p < 0.001). Among trans women on FHT with recorded serum estradiol (n = 1153), there was no statistical difference in serum estradiol between those with HIV (median: 203 pmol/L, IQR: 95.5, 417.5) and those with negative (200 mol/L [113, 407]) or missing/unknown HIV status (227 pmol/L [127.5, 384.5) (p = 0.633). Serum testosterone concentrations were also similar between groups. CONCLUSIONS: In this cohort, trans women with HIV were prescribed FHT less often than trans women with negative or unknown HIV status. There was no difference in serum estradiol or testosterone levels of trans women on FHT regardless of HIV status, providing reassurance regarding potential drug-drug interactions between FHT and ART.

Parathyroid hormone-driven algorithms after thyroid surgery: Not one-size-fits-all.

BACKGROUND: Underreported variation in parathyroid hormone (PTH) assays exists. Using quality improvement methods, we aimed to develop an institution-specific PTH-based protocol to predict hypocalcemia after thyroidectomy. METHODS: We retrospectively reviewed patients who underwent total/completion thyroidectomy. A receiver operating curve (ROC) determined postoperative PTH cut-offs predictive of hypocalcemia. The stakeholders developed PTH-driven calcium management guidelines. Post-implementation outcomes were prospectively measured. RESULTS: Pre-implementation, 95 patients were assessed. PTH ≤1.5 pmol/L (14.1 pg/ml) predicted hypocalcemia (96%sensitivity), and ≥2.8 pmol/L (26.4 pg/ml) predicted normocalcemia (99%specificity) (area under curve = 0.97, SEM = 0.018). PTH on the day of and morning after surgery were identically predictive. Post-implementation, 64 patients were assessed. Hypocalcemia occurred with PTH >2.8 pmol/L in 2 cases (3.1%). Calcium over-prescribing decreased from 13.7% to 3.1% (p = 0.06). Length of stay (LOS) > 2 nights decreased from 13% to 3.1% (p = 0.05). CONCLUSION: A PTH-driven calcium management protocol post-thyroidectomy effectively reduces unnecessary calcium replacement and LOS. Given the variability in PTH assays, each institution may need to use individual cut-offs.

The Effect of Gender-Affirming Hormone Therapy on Measures of Kidney Function: A Systematic Review and Meta-Analysis.

BACKGROUND AND OBJECTIVES: Gender-affirming hormone therapy modifies body composition and lean muscle mass in transgender persons. We sought to characterize the change in serum creatinine, other kidney function biomarkers, and GFR in transgender persons initiating masculinizing and feminizing gender-affirming hormone therapy. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS: We searched PubMed, EMBASE, the Cochrane Library, and ClinicalTrials.gov from inception to September 16, 2020 for randomized controlled trials, observational studies, and case series that evaluated the change in serum creatinine, other kidney function biomarkers, and GFR before and after the initiation of gender-affirming hormone therapy in adult transgender persons. Two reviewers independently screened and abstracted data, and disagreements were resolved by a third reviewer. A random effects meta-analysis was performed to determine the change in outcomes over follow-up of 3, 6, and 12 months. RESULTS: Of the 4758 eligible studies, 26 met the inclusion criteria, including nine studies that recruited 488 transgender men and 593 women in which data were meta-analyzed. There was heterogeneity in study design, populations, gender-affirming hormone therapy routes, and dosing. At 12 months after initiating gender-affirming hormone therapy, serum creatinine increased by 0.15 mg/dl (95% confidence interval, 0.00 to 0.29) in 370 transgender men and decreased by -0.05 mg/dl (95% confidence interval, -0.16 to 0.05) in 361 transgender women. No study reported the effect of gender-affirming hormone therapy on albuminuria, proteinuria, cystatin C, or measured GFR. CONCLUSIONS: Gender-affirming hormone therapy increases serum creatinine in transgender men and does not affect serum creatinine in transgender women. The effect on gender-affirming hormone therapy on other kidney function biomarkers and measured GFR is unknown. CLINICAL TRIAL REGISTRY NAME AND REGISTRATION NUMBER: Change in Kidney Function Biomarkers in Transgender Persons on Gender Affirmation Hormone Therapy-A Systematic Review and Meta-Analysis, CRD42020214248.

Short report: Characterizing HIV care among a clinical sample of transgender women living with HIV.

INTRODUCTION: This study aimed to characterize and identify factors associated with HIV care among transgender (trans) women living with HIV (TWLWH) in two urban centres in Canada. METHODS: Retrospective data were collected from clinic charts of TWLWH aged 16 years and older across seven family medicine, endocrinology and/or HIV clinics in Montreal and Toronto, Canada, from 2018 to 2019 (n = 86). We assessed the proportion of individuals being ever engaged in HIV care [defined as having any recorded antiretroviral therapy (ART) regimen and/or viral load], current ART use, and most recent viral load (suppressed [<200 copies/ml] vs. unsuppressed) overall and compared across subgroups using χ2 tests. RESULTS: All TWLWH in our sample [100.0%, 95% confidence interval (CI): 95.8-100.0%] were engaged in HIV care; most (93.0%, 95% CI: 85.4-97.4%) were currently using ART and most (93.4%, 95% CI: 85.3-97.8%) with complete data (n = 71/76) were virally suppressed. A higher proportion of trans women of colour (100.0%) reported current ART use compared with white trans women (76.9%, p = 0.017). A higher proportion of those with no documented history of injection drug use (IDU; 96.6%) were virally suppressed compared with those with a history of IDU (66.7%, p = 0.022). Although not statistically significant, 96.2% of those currently reporting feminizing hormone use were virally suppressed, compared with 85.0% of those not reporting use (p = 0.202). CONCLUSIONS: Once engaged in HIV care, TWLWH in Canada appear to have excellent ART use and viral suppression. Findings can be leveraged to identify target populations to enhance HIV care and to further explore the relationship between gender-affirming medical care and HIV care.

Gynecomastia in a Transgender Boy: A Case Report.

OBJECTIVE: To describe the case of a 17-year-old transgender boy who experienced breast development while on testosterone, having been suppressed with a gonadotropin-releasing hormone (GnRH) agonist prior to testosterone therapy. CASE REPORT: A 17-year-old transgender boy presented with breast development after having been on a GnRH agonist and then testosterone since the age of 11 years, having never experienced breast development before, which was consistent with pubertal gynecomastia. A small decrease in the testosterone dose resulted in a significant reduction of gynecomastia. Despite the improvement, he went on to undergo chest surgery with the removal of the breast tissue. DISCUSSION: Pubertal gynecomastia is a common phenomenon in the cisgender male population. However, it has not been previously described in transgender boys. The potential mechanisms for its occurrence were discussed. CONCLUSION: Transgender boys who undergo GnRH agonist treatment for puberty suppression and subsequently receive testosterone therapy for puberty induction may develop gynecomastia. Judicious adjustment of the testosterone therapy may lead to an improvement.

Learning by chance: Investigating gaps in transgender care education amongst family medicine, endocrinology, psychiatry and urology residents.

BACKGROUND: The transgender (trans) population is one of the most underserved in health care. Not only do they face discrimination and stigma from society as a whole, they also have difficulty accessing transition-related care, leading to adverse outcomes such as suicide. We aimed to increase understanding on how our current postgraduate education system contributes to a lack of care for trans patients. METHODS: Our study consisted of 11 semi-structured interviews conducted in 2016 with residents in the following specialties: family medicine (3), endocrinology (3), psychiatry (3), and urology (2). We used Framework Analysis to qualitatively analyze our data. RESULTS: Residents described a lack of trans care education in the core curriculum, in part due to a lack of exposure to experts in this area. They also expressed discomfort when dealing with trans patients, due to inexperience and lack of knowledge. Furthermore, residents in each specialty had false assumptions that other specialties had sufficient knowledge and expertise in trans care. DISCUSSION: This study highlights how the lack of teaching and clinical experiences with trans patients during residency contributes to the poor access to healthcare. By systematically embedding trans care in the curriculum, medical education can play a prominent role in addressing the healthcare disparities of this underserved population.

CONTEXTE: La population transgenre (trans) est l'une des plus mal desservies en matière de soins de santé. Non seulement les transgenres font-ils face à de la discrimination et stigmatisation provenant de la société en général, mais ils ont aussi de la difficulté à accéder aux soins liés à leur transition, ce qui mène souvent à des résultats particulièrement néfastes tel le suicide. Notre but était de mieux comprendre comment le système d'enseignement postgradué actuel contribue au manque de soins pour les patients trans. MÉTHODES: Notre recherche consistait en onze entrevues semi-structurées effectuées en 2016 auprès de résidents des spécialités suivantes : médecine familiale (3), endocrinologie (3), psychiatrie (3) et urologie (2). Nous avons utilisé une méthode ¼Framework Analysis ¼ pour analyser qualitativement nos données. RÉSULTATS: Les résidents ont décrit un manque de formation en soins pour les transgenres dans le cursus de base; celui-ci étant causé en partie par un manque d'exposition aux experts dans ce domaine. Ils ont aussi exprimé un inconfort au moment de prendre en charge les patients trans qu'ils ont expliqué par leur inexpérience et manque de connaissances. De plus, les résidents de chaque spécialité entretenaient la fausse idée que les autres spécialités possédaient la connaissance et l'expertise nécessaires en soins trans. DISCUSSION: Cette étude met en lumière comment le manque d'enseignement et d'expérience clinique auprès des patients trans durant la résidence contribue à l'accès très limité de ces derniers aux soins de santé. En intégrant systématiquement les soins trans dans le cursus, la formation médicale peut jouer un rôle majeur lorsqu'il s'agit de combler les disparités en soins de santé de cette population mal desservie.

Thrombus removal prior to recanalization in vein graft occlusion intervention.

A saphenous vein graft chronic total occlusion intervention is uncommonly performed, partly due to the high risk of distal embolization. We described a strategy in which after successful wiring of a saphenous vein graft chronic total occlusion, balloon dilatation was performed to create a blind sac within the lesion, followed by aspiration thrombectomy to remove all the dislodged debris. Thereafter, balloon dilatation and stenting were safely performed in the distal occluded segment, to achieve complete recanalization.

Missed opportunities: are residents prepared to care for transgender patients? A study of family medicine, psychiatry, endocrinology, and urology residents.

BACKGROUND: The transgender (trans) population faces multiple barriers in accessing health care, with knowledge deficits of health care providers contributing substantially. Trans patients report having to teach health care professionals about their own health needs. We compared perceptions of trans-care education and training across family medicine, psychiatry, endocrinology, and urology residency training programs at the University of Toronto. METHODS: We surveyed residents to assess their perceptions of and attitudes towards trans-care, exposure to trans patients, knowledge of trans-specific clinical care, and the state of trans-care education within their training. We used Likert scale data to identify patterns across residency programs. We collected open-ended responses to further explain quantitative findings where appropriate. RESULTS: Of 556 residents approached, 319 participated (response rate = 57.4%). Nearly all endocrinology and psychiatry residents agreed that trans-care falls within their scope of practice, while only 71% and 50% of family medicine and urology residents did, respectively. Though participants were at different stages of their postgraduate training when surveyed, only 17% of all participants predicted they would feel competent to provide specialty-specific trans-care by the end of their residency and only 12% felt that their training was adequate to care for this population. CONCLUSION: Though the study revealed a willingness to serve this population, there was a lack of clinical exposure and trans-related teaching within postgraduate curricula resulting in feelings of unpreparedness to meet the health care needs of this underserved population.

Concurrent transcatheter transfemoral tricuspid valve-in-valve and aortic valve implantation using a 3D printed model for pre-OT planning.

Re-operation of a tricuspid bioprosthesis carries high morbidity and mortality, especially when carried out with other concomitant valvular heart surgery. Concurrent transcatheter valve implantation has evolved as an alternative option. Here we report on a 77-year-old lady who suffered from symptomatic severe recurrent stenosis of a tricuspid bioprosthesis (Sorin Pericarbon More, 27) and moderate to severe aortic stenosis (AS) who was declined for redo open heart surgery as it was deemed very high risk. We used a 3D customised printed right heart model for pre-OT rehearsal. Percutaneous V-in-V TVR using a 26 mm Edwards SAPIEN 3 was performed under general anaesthesia via the right femoral vein and showed a satisfactory result in one single attempt. We also evaluated the necessity of aortic valve intervention in detail before and after V-in-V TVR. After confirmation of severe AS, a 26 mm Medtronic CoreValve Evolut R was deployed in the non-calcified rheumatic aortic valve without any predilatation or post-dilatation via the right femoral artery. No significant gradient or leakage was seen. This case shows the feasibility and safety of concurrent transfemoral V-in-V TVR and TAVI. Rehearsal using a 3D printed model helped to increase the accuracy and success rate of the procedure. The transcatheter approach allows detailed haemodynamic assessment after each valvular intervention in the case of multiple valve interventions.

Angiographic study of the clinical liaison of drug-eluting stent and paclitaxel-eluting balloon in unifocal side branch ostium stenosis (ASCLEPIUS).

A reliable stenting strategy for treating isolated side branch (SB) ostium stenosis is not well established. The purpose of this study was to examine the 6-month angiographic outcome of a novel technique, called the shoulder technique, on this lesion subtype. Symptomatic patients with isolated SB ostium stenosis, defined as ≥75% diameter stenosis at SB ostium and <50% diameter stenosis in main vessel (MV), were treated with paclitaxel-eluting balloon in MV and drug-eluting stent in SB using the shoulder technique. Angiographic restudy was performed at 5-9 months and clinical follow-up was scheduled regularly every 3 months. There were 46 patients of age 66 ± 12 years with male predominance (76%) recruited. Diagonal ostium (67%) was the most frequent target lesion site. The size and length of paclitaxel-eluting balloon and drug-eluting stent used in MV and SB were 3.01 ± 0.25 and 20 ± 4 mm, and 2.39 ± 0.25 and 17 ± 6 mm, respectively. Angiographic restudy was performed on 43 (93.5%) patients at 6.5 ± 1.6 months. The late loss in MV and SB were 0.04 ± 0.19 and 0.19 ± 0.32 mm, respectively. Angiographic restensosis was seen in 2 (4.7%) patients at SB, whereas no stenosis was induced in MV. Improvement of symptom was reported in 36 (78%) patients. At 1-year follow-up, no death, myocardial infarction, and stent thrombosis was observed; target vessel revascularization was performed on 3 (6.5%) patients. Treatment of isolated SB ostium stenosis using the shoulder technique is associated with a favorable short-term angiographic outcome.

Dislodged stent after stent reverse controlled antegrade and retrograde subintimal tracking (CART) - Is stent reverse CART a necessary tool or an unnecessary evil?

We report a case of stent reverse controlled antegrade and retrograde subintimal tracking (CART) in left anterior descending artery (LAD) chronic total occlusion. Reverse CART is the method used to make a connection between the retrograde wire and the antegrade true lumen by using a balloon to dilate the antegrade space and pushing the retrograde wire into this space. We successfully crossed the septal channel from right coronary to the LAD, and proceeded to reverse CART, which was unsuccessful. After demonstrating that both the retrograde and antegrade wires were in the same subintimal space by intravascular ultrasound (IVUS), we placed the distal stent edge at the connection point of the wires and deployed the stent. We could easily wire the stent lumen with the retrograde conquest 9 g wire. Afterwards we tried to push the retrograde corsair microcatheter through the CTO and into the antegrade guiding, but unfortunately, the retrograde corsair could not pass into the antegrade guiding and was stuck just outside the antegrade guiding ostium. At this point IVUS showed that the stent had been dislodged from the LAD and pushed into the aorta just outside the left main by the retrograde corsair because the retrograde wire passed into the stent lumen through a distal side strut opening and not through the true distal end of the stent. Due to unstable hemodynamics we had to remove the retrograde system and this led to stent embolism. The case illustrates stent dislodgement after stent reverse CART and stresses the importance of using IVUS to check fully the retrograde wire path before pushing the corsair. We discuss the role of stent reverse CART in the contemporary reverse CART era and conclude that it should be relegated to the very last resort after trying transit balloon technique. We conclude that stent reverse CART is mostly an unnecessary evil. .

Differential Effects of Cyproterone Acetate vs Spironolactone on Serum High-Density Lipoprotein and Prolactin Concentrations in the Hormonal Treatment of Transgender Women.

INTRODUCTION: Spironolactone and cyproterone acetate (CPA) are the two main antiandrogen medications used in feminizing hormone therapy in transgender women. Previous studies have suggested that these two agents might have opposite effects on high-density lipoprotein (HDL) level when used in this context, and limited data have suggested CPA increases prolactin more than spironolactone. AIM: To compare the effects of spironolactone and CPA on HDL and prolactin serum concentrations in transgender women. METHODS: A retrospective chart review was conducted at three clinical sites in Toronto, Ontario, Canada. Patients were selected if they (i) identified as a transgender woman, (ii) had newly started spironolactone or CPA with estrogen or restarted spironolactone or CPA after a washout period of at least 6 months, and (iii) had not used other antiandrogens within the previous 6 months. MAIN OUTCOME MEASURES: HDL and prolactin concentrations between the two treatment groups at baseline and at 12 months. RESULTS: Eighty-two patients were included in the spironolactone group and 31 patients were included in the CPA group. Baseline HDL and prolactin levels were not significantly different between the two groups. At 12 months, HDL increased by 0.10 mmol/L (SD = 0.24) in the spironolactone group but decreased by 0.07 mmol/L (SD = 0.21) in the CPA group (P = .002). The difference remained significant after adjusting for baseline HDL, use of lipid-lowering drugs, and age. The change in prolactin was +3.10 µg/L (SD = 5.70) in the spironolactone group and +11.8 µg/L (SD = 8.63) in the CPA group (P < 0.001). This difference also remained significant after adjusting for baseline prolactin level. CONCLUSION: These data suggest that spironolactone use in transgender women increases HDL levels and that CPA has the opposite effect. CPA also is associated with a larger increase in prolactin. These factors should be considered when choosing between these two antiandrogen agents.

Osteomalacia-Inducing Tumors of the Brain: A Case Report, Review and a Hypothesis.

BACKGROUND: Osteomalacia-inducing tumors (OIT) are mesenchymal tumors that characteristically secrete fibroblast growth factor 23, resulting in a paraneoplastic syndrome of hypophosphatemic osteomalacia. These tumors are known to occur in soft tissues and bones in various sites. It is very unusual for OITs to occur intracranially, with only 10 reported intracranial cases since their discovery in 1959. The most common intracrainal OITs are phosphaturic mesenchymal tumors and hemangiopericytomas. We report a case of hypophosphatemic osteomalacia caused by a tumor in the right anterior cranial fossa. We also hypothesize, based on our review of the literature, that this entity is underdiagnosed. CASE DESCRIPTION: A 49-year-old woman had a history of a nonhealing ankle fracture that required repeated surgery over 3 years. She subsequently was found to have severe hypophosphatemia and evidence of osteomalacia together with multiple occult fractures. A diagnosis of tumor-induced osteomalacia was suspected. An elevated serum fibroblast growth factor 23 level confirmed the diagnosis. An octreotide scan that was performed to locate the responsible tumor revealed an area of avid uptake in the right frontal lobe. Magnetic resonance imaging showed a large right anterior fossa extra-axial mass. The patient was referred for surgical intervention and was cured clinically after surgical removal of the tumor. Pathologic examination revealed a phosphaturic mesenchymal OIT. Her phosphate levels returned to normal 3 weeks after surgery. CONCLUSIONS: The diagnosis of OIT should be considered in a case of severe hypophosphatemia and metabolic bone disease that is not explained by any other metabolic or hereditary disease. These tumors can occur intracranially and may be confused with a meningioma or a hemangiopericytoma. Taking OIT into consideration in such cases could lead to a shorter time to diagnosis and management, which in our case took 4 years.