10/07/18

Transgender Health Care: Conflict of interest statement principles, best practices in Europe and how reproductive/sexual health • My department occasionally receives grants care providers might contribute by Ferring, Cook, e.a.

• I am a politician (Belgian Senate, Petra De Sutter Parliamentary Assembly Council of Europe), University Hospital Gent so don’t believe everything I say

• I am a LGBTI activist and believe in human rights for all

Some definitions Transgender

Transgender rights Transgender rights

1 10/07/18

Transgender Health

Hormonal Treatment Transgender Health

TRANS WOM EN TRANS MEN

Anti androgen therap y Suppression of menses spironolactone progestagens

cyproterone acetate GnRH agonist GnRH agonist

Estrogen therap y Te sto ste ro n e therap y oral, transd erm al or oral, transd erm al or parenteral estradiol parenteral testosterone

Transgender Health Transgender Health

2 10/07/18

Barriers to Medical Care Barriers to Medical Care for Transgender Patients for Transgender Patients

• Economically disadvantaged • Geographic and social isolation • Lack of insurance Coverage • Lack of clinical research and limited medical literature • Provider ignorance • Stigma of Gender Clinics

Morbidity & Mortality in Preventive Health and Transgender Persons Primary Care

• Significant increase in mortality is seen Treat the anatomy that is present: amongst transpeople compared to the general -> If you have it, check it! population. Clinical care should be based on an up-to- • Most of the increase in mortality was due to date anatomical inventory: higher rates of AIDS, suicide, drug-related • Breasts • Penis deaths • Cervix • Prostate • Asscheman’s 2011 review of Dutch patient cohort: 50% higher mortality rate in • Ovaries • Te ste s transwomen • Uterus • Vagina

Transgender Health: Men Transgender Health: Men

• Pap smears • Endometrial hyperplasia As per natal females – Futterweit, et al (1986): 9/19 transmen had proliferative endometrium at the time of hysterectomy; 3/19 had Testosterone can cause atrophy of endometrial hyperplasia. the cervical epithelium mimicking – Perrone, et al (2009): 27 transmen undergoing endometrial bx; all had atrophic endometrium similar to dysplasia menopausal controls. Increase in “unsatisfactory” – Grynberg, et al (2010):112 transmen given androgen for at samples seen: 10.8% (10 times least 6mo prior to THSO - endometrial atrophy in 45% higher than in natal women) – Urban, Teng & Kapp (2010): First case report of endomtrial carcinoma in a transman after 7 years on testosterone tx longer latency to follow-up testing

3 10/07/18

Transgender Health: Men Transgender Health: Men

• Mammograms and CBE – As per natal females if no chest reconstruction – if post-op, yearly chest exam • WPATH SOC 2011 recommend hysterectomy – 2009 Grynberg, et al: 100 mastectomies in transmen after average of 3.7 years on T. and oophorectomy after 5 years of hormone – - 93% with decreased glandular tissue and increased treatment because of unknown effect on fibrous connective tissue genital organs • - 2008 Gooren (Dutch cohort): only 1 reported case of breast cancer in transmen cohort, so 5.9/100,000 incidence • - 2014 Brown (US VA system): 10 reported cases —7 in transmen, but with incidence equal to non-trans general population data (20.0/100,000 VHA yrs)

Transgender Health: Men Transgender Health: Men

• Bone density screening • Cardiovascular Disease • T appears to be overall protective: Larger trabecular bone size after just 1yr, and most studies show preservation of cortical –No increased risk of cardiovascular events in bone(G T’Sjoen 2015) short and medium-term follow ups – Increased muscle mass / mechanical loading –Testosterone can increase blood pressure – Role of aromatization of T to estrogen • Recommendation: Consider DEXA over age 50 and on –Increased LDL and decreased HDL testosterone for >5 years In Asscheman’s 2011 series, only 1 MI in • Measuring LH levels: LH is inversely proportional to bone transmen at age 72 after 42 years of density measures —may be a marker for adequate levels of testosterone to preserve bone mass testosterone tx.

Transgender Health: Men Transgender Health: Women

• Diabetes • Pelvic exam/PAP smear

Slightly higher prevalence of Diabetes type 2 –Pelvic exam to assess surgical site, and then than control, BUT almost all diagnosis made follow ups for general genital issues or concerns BEFORE starting testosterone therapy –Pap only if the penis has been used to create a –Increased endocrine screening prior to neo-cervix initiation of hormone therapy

4 10/07/18

Transgender Health: Women Transgender Health: Women

• The pH and microflora of the neo-vagina • Prolactinoma: – Differs significantly from a natal female vagina 5 cases of prolactinomas have been found in – Lack of lactobacilli (no antimicrobial protection) transwomen — 10mo,14, 18, 20, and 30 years – Alkaline environment — lower estrogen in vaginal after initiation of hormone tx tissue —> no up-regulation of proton pumps and lack of protective mucus production So, unclear when and how long to monitor, since this is quite rare – Mixed microflora of aerobe and anaerobe species — typically found on the skin, intestine, or bacterial Some suggestion that an excessive first year vaginosis increase in serum PRL concentration may – more complex BV - specifically presence of anaerobes identify patients at risk for autonomous PRL — are difficult to treat secretion later in life

Transgender Health: Women Transgender Health: Women

• Mammography and CBE • Prostate exam as per natal men – 1 (2 probable) reported cases of breast cancer in – Androgen antagonists may falsely decrease serum PSA transwomen according to Dutch cohort (Gooren 2013) levels – 3 cases documented through the VHA in the US (Brown – Feminizing hormonal therapy appears to decrease prostate 2014) volume and the risk of prostate cancer but to an unknown – Degree and duration of estrogen exposure degree —effectively receiving androgen deprivation • WHI: Progestin, with estrogen, increases risk of breast therapy! cancer – In natal men, orchiectomy before age 40 appears to • NO increase in incidence of malignancy over the general prevent prostate CA population, BUT the VHA study showed the detection was late – 3 reported cases of prostate cancer in the Dutch cohort and outcomes poorer for transwomen (2011) All three had orchiectomies and started hormone – *Recommendations: Patients over age 50 who have been therapy AFTER age 40. on feminizing endocrine agents over 5 years

Transgender Health: Women Transgender Health: Women

• Bone Density Screening • Somewhat mixed results —Increase in osteopenia and • Cardiovascular Disease osteoporosis compared to natal men, but generally preserved • Higher cardiovascular mortality rate in transwomen than the compared to natal women general population – Observed lower BMD in transwomen PRIOR to start of • Major Factors - Estrogen types (ethinyl estradiol), cyproterone estrogen therapy acetate, serum hormone levels, smoking status, obesity, – Start of androgen-blockers for ~1yr, before prescribing baseline CV health estrogen therapy • Exogenous estrogen can increase blood pressure. • Decreased levels of bone turnover markers in setting of – Spironolactone can lower BP. hormone therapy • Increased HDL and decreased LDL cholesterol, but increased • Recommendations: Consider if over age 60 and off estrogen triglycerides. therapy for longer than 5 years – not routinely indicated prior to orchiectomy

5 10/07/18

Transgender Health: Women Transgender Health: Women

• Cardiovascular Risk —Gooren, et al (2011), 966 transwomen – Longer follow up than previously, revealing increased • Venous thromboembolism mortality rate of CVD • In the Dutch cohorts, rates of 2.6% annually in first year, – Increased weight, visceral fat, impaired glucose sensitivity, falling to 0.4 % thereafter, with 1 – 2% risk of death from PE, small increase in BP; increased HDL, decreased LDL – BUT all but 1 of these patients was using oral ethinyl estradiol – Ethinyl estradiol assoc w/ 3-fold increased risk of CV death • Recommendations: – Similar to CVD rates seen on controlled natal females using OCPs with high dose (50mcg) ethinyl estradiol – Avoid prescribing ethinyl estradiol at any point • Belgian cohorts also showed increased incidence of VT (6-8%), – Consider transdermal or low-dose oral estradiol in patients but ONLY in patients treated with ethinyl estradiol >40 yrs old – Lifestyle behaviors —healthy diet, smoking cessation, exercise —can reduce cardiovascular risk!

Transgender Health: Women Transgender Fertility

• Diabetes: Higher prevalence of DM, but almost all diagnoses made BEFORE starting estrogen therapy in transwomen

Transgender Pregnancy Conclusion

6 10/07/18

Conclusion Conclusion

Conclusion

Thank you for your attention !

7