An enhanced recovery after surgery protocol for facial feminization surgery reduces perioperative opioid usage, pain, and hospital stay.

BACKGROUND: Prescription drug misuse in transgender individuals is estimated to be three times higher than that of the general population in the United States, suggesting that opioid-reduction strategies deserve significant consideration in gender-affirming surgeries. In this work, we describe the implementation of an enhanced recovery after surgery (ERAS) protocol to reduce opioid use after facial feminization surgery. METHODS: A total of 79 patients who underwent single-stage facial feminization surgery before (n = 38) or after (n = 41) ERAS protocol implementation were included. Primary outcomes assessed were perioperative opioid consumption (morphine equivalent dose/kilogram, MED/kg), average patient-reported pain scores, and length of hospital stay. Comparisons between groups and multivariable linear regression analyses were conducted to define the contribution of the ERAS protocol to each of the three primary outcomes. RESULTS: Age, body mass index, mental health diagnoses, and length of surgery did not differ between pre-ERAS and ERAS groups. Compared to pre-ERAS patients, patients treated under the ERAS protocol consumed less opioids (median [interquartile range, IQR], 0.8 [0.5-1.1] versus 1.5 [1.0-2.1] MED/kg, p < 0.001), reported lower pain scores (2.5 ± 1.8 versus 3.7 ± 1.6, p = 0.002), and required a shorter hospital stay (median [IQR], 27.3 [26.3-49.8] versus 32.4 [24.8-39.1] h, p < 0.001). When controlling for other contributing variables such as previous gender-affirming surgeries, mental health diagnoses, and length of surgery using multivariable linear regression analyses, ERAS protocol implementation independently predicted reduced opioid use, lower pain scores, and shorter hospital stay after facial feminization surgery. CONCLUSIONS: The current work details an ERAS protocol for facial feminization surgery that reduces perioperative opioid consumption, patient-reported pain scores, and hospital stays.

Prostate cancer in transgender women: considerations for screening, diagnosis and management.

Transgender individuals represent 0.55% of the US population, equivalent to 1.4 million transgender adults. In transgender women, feminisation can include a number of medical and surgical interventions. The main goal is to deprive the phenotypically masculine body of androgens and simultaneously provide oestrogen therapy for feminisation. In gender-confirming surgery (GCS) for transgender females, the prostate is usually not removed. Due to limitations of existing cohort studies, the true incidence of prostate cancer in transgender females is unknown but is thought to be less than the incidence among cis-gender males. It is unclear how prostate cancer develops in androgen-deprived conditions in these patients. Six out of eleven case reports in the literature presented with metastatic disease. It is thought that androgen receptor-mediated mechanisms or tumour-promoting effects of oestrogen may be responsible. Due to the low incidence of prostate cancer identified in transgender women, there is little evidence to drive specific screening recommendations in this patient subpopulation. The treatment of early and locally advanced prostate cancer in these patients warrants an individualised thoughtful approach with input from patients' reconstructive surgeons. Both surgical and radiation treatment for prostate cancer in these patients can profoundly impact the patient's quality of life. In this review, we discuss the evidence surrounding screening and treatment of prostate cancer in transgender women and consider the current gaps in our knowledge in providing evidence-based guidance at the molecular, genomic and epidemiological level, for clinical decision-making in the management of these patients.

Postoperative Pain and Opioid Use after Facial Feminization Surgery.

The objective of this study is to characterize surgical pain after facial feminization surgery (FFS) and delineate postoperative opioid usage. It is a retrospective cohort study. It was performed in a multicenter integrated health care system. Electronic medical records were reviewed for patient demographic characteristics, medical history, pain medication prescriptions, and responses to a postoperative pain survey. Student's t-test and the Mann-Whitney U-test were used for bivariate analysis. Fisher's exact tests were used for categorical data. Seventy-four patients who underwent FFS were included. The mean (standard deviation) reported "average" postoperative pain score was 4.3 (2.3) out of 10. A total of 58% of patients reported pain lasting 5 or fewer days after surgery. The severity and duration of postoperative pain was similar between patients who underwent partial-FFS or full-FFS. A total of 68% of patients required fewer than 15 opioid tablets. There were no significant differences in the quantity of opioids prescribed or used between patients who underwent partial-FFS or full-FFS. Older age and premorbid mood disorder did not correlate with greater severity/duration of pain or number of opioids used after surgery. Most patients required fewer than 15 opioid tablets after surgery and experienced less than a week of postoperative pain. Patients undergoing full-FFS did not appear to experience significantly greater pain than those undergoing fewer procedures. Older age and premorbid mood disorder were not predictors of worse pain outcomes or greater opioid utilization.

Bicalutamide as an Androgen Blocker With Secondary Effect of Promoting Feminization in Male-to-Female Transgender Adolescents.

PURPOSE: The purpose of the study was to describe the novel use of bicalutamide in transgender youth. METHODS: This is a retrospective review of patients with gender dysphoria followed in the pediatric endocrine clinic at Riley Hospital for Children. RESULTS: Of 104 patients with gender dysphoria, 23 male-to-female adolescents received bicalutamide 50 mg daily as a second-line puberty blocker after insurance company denial of a gonadotropin-releasing hormone analog. Six patients received estrogen concurrently. Of 13 patients treated exclusively with bicalutamide seen in follow-up, 84.6% had breast development within 6 months, the majority being ≥ Tanner stage III. CONCLUSIONS: Bicalutamide may be an alternative to gonadotropin-releasing hormone analogs in transgender male-to-female youth who are also ready to undergo physical transition.

Effects of exposure to the xenoestrogen octylphenol and subsequent transfer to clean water on liver and gonad ultrastructure during early development of Zoarces viviparus embryos.

Female eelpouts (Zoarces viviparus L.) are exposed during early pregnancy to nominal concentrations of 100 microg/L of 4-tert-octylphenol (OP) or 0.5 microg/L of 17beta-estradiol (E2). Effects on maternal metabolism and on liver and gonad development in embryos were examined and compared with controls (C) during exposure and after transfer to clean water (depuration). In the mother fish, significantly higher concentrations of plasma vitellogenin (vtg) and calcium were found in the two exposed groups, when compared with the C group after exposure and depuration. When compared, however, with the respective values after exposure, vtg had decreased significantly after depuration. The hepatosomatic index was normalized after depuration. In both exposed groups, the hepatocytes were rounded and not distinctly polygonal as in the controls. The amount of glycogen was considerably less while the number of mitochondria increased, and the rER significantly proliferated after exposure as well as after depuration. The gonads of nine of more than 28 embryos in the group treated with OP exhibited a number of abnormalities as compared with the normal gonad development in both sexes. Feminization of the male gonads in the exposed specimens and a number of histopathological features were observed in all the abnormal gonads, whereas reliable male features, such as formation of seminiferous tubules or spermioduct, were not observed. This study showed that 4t-tert-OP and 17beta-estradiol exert estrogenic effects during very early development of the embryos and that depuration had a positive effect on the motherfish and her embryos.

Inhibition of p-450 aromatase prevents feminisation and induces protection during cysticercosis.

Cysticercotic male mice undergo an impressive feminisation process, characterised by 200 times increased serum 17beta-estradiol levels while testosterone and dihydrotestosterone are 90% reduced, which results in elevated parasite burden. Administration of Fadrozole (an aromatase inhibitor) in male and female mice suppressed the production of 17beta-estradiol, accompanied with a 70% reduction in parasite burden. This protective effect was associated in male mice with a recovery of the specific cellular immune response. Interleukin-6 (IL-6) serum levels, and its production by splenocytes, was augmented by 80%, together with a 10-fold increase in its expression in testes of infected male mice. Fadrozole treatment returned these levels to baseline values. Aromatase expression in the testes of infected male mice was not affected by Fadrozole. These results suggest that aromatase and IL-6 are key molecules in the production of the feminisation undergone by infected male mice and to Fadrozole treatment as a possible new therapeutic approach to cysticercosis.

Growth hormone therapy of Turner syndrome: the impact of age of estrogen replacement on final height. Genentech, Inc., Collaborative Study Group.

Clinical trials of recombinant human GH therapy in Turner syndrome that began more than a decade ago show that GH accelerates the linear growth rate. Several studies indicate that final height is also improved, although the magnitude of the increase has been debated. The age at which feminization is induced could be an important factor in determining the patient's ultimate growth response. To test this, 60 patients from a large (n = 117), previously unreported, clinical trial of GH treatment were randomly assigned to begin conjugated estrogens at either 12 or 15 yr of age. The 60 patients were all less than 11 yr of age at entry (mean, 9.5 yr) and received 0.375 mg/kg x week of GH for nearly 6 yr on a daily or three times weekly regimen. Height gain was calculated by comparing the study patients' final or near final heights to their pretreatment projected heights as well as to those of a separate set of age-matched, historical control patients. Patients in whom estrogen treatment was delayed until age 15 yr gained an average of 8.4 +/- 4.3 cm over their projected height, whereas those starting estrogen at 12 yr gained only 5.1 +/- 3.6 cm, on the average (P < 0.01). Analysis of the interval data showed that growth was stimulated for approximately 2 yr after estrogen initiation, but then declined in association with bone age advancement. Patients who were older than 11 yr at entry (n = 57) all initiated estrogen 1 yr after beginning GH and showed a mean gain in adult height of 4.7 cm, similar to those given estrogen at age 12 yr. Multivariate analysis revealed that the number of years of GH therapy before estrogen treatment was a strong factor in predicting height gained, indicating that the timing of estrogen introduction is an important determinant of final height in this cohort of GH-treated patients with Turner syndrome matched for baseline age and other characteristics.

[Feminizing syndrome and gynecomastia in males].

Gynecomastia is one of the common symptoms of feminizing syndrome in males. Causes of feminizing syndrome are considered the increase of serum level of estrogen, prolactin, LH and hCG and testosterone deficiency. The condition of gynecomastia was commonly silent. Gynecomastia is classified three groups those are physiological, pathological and ideopathic gynecomastia. Physiological gynecomastia was reported to break out healthy males. Ideopathic gynecomastia is the main cause in medicine. Characterization of pathological gynecomastia are known side effect of drugs, testosterone deficiency and increased estrogen production. Gynecomastia is making satisfactory progress by treatment of the causes, but long term of the history merely have need resection.

Familial adrenal feminization probably due to increased steroid aromatization.

5/10 members of a North African family (father, 2 male and 2 female siblings) had gynaecomastia, early growth and short final stature. The 8-year-old propositus had advanced bone age, facial acne, gynaecomastia, pubic hair and prepubertal testicular volume. Basal oestrone (E1) was elevated (670 pmol/l) and increased with adrenocorticotropic hormone (ACTH; 826 pmol/l). After human chorionic gonadotropin stimulation testosterone (T) responded normally whereas E1 and oestradiol (E2) remained unchanged. ACTH-dependent adrenal feminization was confirmed by a transient reduction of breast tissue following dexamethasone or cypropterone acetate treatment. Testolactone increased T/E2 (from 5.6 to 20.3) and A/E1 (from 3.4 to 31.4) ratios and temporarily reduced the breast tissue. In conclusion, this is a familial type of adrenal feminization with increased adrenal androgen aromatization. This is the first time that male-to-male and male-to-female transmission has been reported.