TRANSGENDER

AN OVERVIEW

Dr Jabira Habeeb
Dept of OBG
• Heterosexual VS ……..
The LGBTQQIAAP+
Community!!
LGBTQQIAAP+

• lesbian
• Gay
• Bisexual
• Transgender
• Transsexual
• Queer
• Questioning
• Intersex –Structurally /Anatomically Mix
• Asexual/Aromanitc
• Ally
• Pansexual
GENDER ROLES/ GENDER IDENTITY
…

Transgender-a person whose gender identity is different

from the sex assigned at birth

Cisgender – a person whose gender identity aligns

with the sex assigned at birth

Nonbinary – a person experiencing or/and expressing an

identity other than male or female – BI GENDER or A
GENDER
BIOLOGICAL DETERMINANTS…?
HORMONES

Androgen synthesis disorders: Individuals are commonly raised as

females

• 5Alpha-reductase-2 deficienciesvarying levels of inadequacies in

masculinization of the external genitalia
• Testosterone mediated neuro cognitive behavior and signals to non
sexual organ is maintained
• 17B-hydroxysteroid dehydrogenase-3 (17B-HSD-3) deficiencies:
In utero testosterone deficiency.
• In both group gender roles from female to male were seen in around
50 %
• Genetic females (46, XX) with gender ambiguity, such as those with
congenital adrenal hyperplasia (CAH)
An excess of prenatal androgen exposure

A review of 263genetic females with CAH examined

94.8% (n=250), did not manifest any gender identity disorder
5.29% (n= 13) of these genetic females manifested Transgender
This is higher than general population.
• These studies clearly indicate that more factors are involved in gender
expression than simply prenatal hormone exposure.
• 16 genetic males (46, XY) with cloacal exstrophy, a complex pelvic
defect occurring during embryo-genesis
• Fourteen of the 16 sub-jects with cloacal exstrophy were assigned
female sex at birth due primarily to the appearance of their external
genitalia
• 8 out of 14 Female -GI- MALE, 6 out of 14 – GI- Female
• 2 male - GI- male
• Individuals have intact androgen exposure and only manifest
structural defects, one would expect that all individuals would have
GI- as male
• BUT??
Structural determinants:
• post mortem studies evaluating the brain structures of TG have found
changes in the central subdivision of the bed nucleus of the stria
terminalis (BSTe).
• More research required
Genetics
• No specific genes found till date
• Genetic link suggested because 32 % concordance seen in
monozygotic wins
• And no concordance was detected in dizygotic
Environment
Theories of child rearing suggested but
No evidence
Unique primary
care needs of
TRANSGENDE
RS
TRANSMEN

• Cervical pap smear& HPV

screening (J Path clin res 2018)

• Mammogram (ACS 2018)

• STI screening

• Immunizations- HPV,
Hepatitis A, Hepatitis B

Counselling against
unwanted pregnancies!
TRANSWOMEN

• Breast examination and

mammogram after prolonged
hormone therapy

• STI screening

• HIV pre exposure prophylaxis

• Anal examination for prostate

evaluation

ACOG 2011
• Being a TRANSGENDER is not a
psychiatric condition !!

BUT

• Mental health experts have a

major role to play here..

To identify the personal

goals
To advice on the
practicalities of changing the
gender role
American Psychiatric Association 2013
The goal of
treatment..

To improve the quality of life by facilitating their

transition….

to a physical state that closely represents their sense of

themselves !
Gender affirming therapies

• MTF hormone
therapies

• FTM hormone
therapies

• Gender reassigning
surgeries
WPATH Standards of Care (7th
edition) Criteria
• Persistent well documented gender
dysphoria

• Capacity to make fully informed decisions

• Significant mental health concerns

addressed

• Age of legal maturity recommended for GRS

• At least 12 months of continuous hormone

therapy before GRS
 Heredity limits the
tissue response to
hormones

More is
not always better!!

Transgender hormone
therapy
TRANSWOMEN….

• MTF hormone therapy

• Goals- Induce female secondary

sex changes
Suppress male secondary
changes
Optimize safety
Pretreatment
assessment

• Detailed history- medical & sexual

• Mental health assessment

• Documentation of prior hormone

use

• Thromboembolic risks

• Any comorbid conditions

evaluated
• Address safety concerns

• Assess readiness for gender transition

• Obtain informed consent

• Investigations-LFT, RFT, Lipid profile,

S.Electrolytes

• Baseline Testosterone & Estradiol

levels

WPATH 2012
MTF HORMONE THERAPY
• Primary medication
ESTROGEN THERAPY
• 17 β Estradiol (E2) more potent than E1

• Oral route better

absorption,cheaper,effective but more
risk of VTE,Requires compliance

• IM- Expensive, injection site pain

• Transdermal route consistent

concentration, lowest risk of VTE
But difficult to titrate and expensive

• HIV is not a contraindication!!

 ORAL tablets 2-10 mg
daily

SUBLINGUAL 1-5 mg
daily
ESTRADI
OL TRANSDERMAL GEL 2-4
measures (500μg) daily

PATCHES 50-150 μg
twice weekly or 0.1-0.4mg daily
Desired effects..

• Induce breast formation

• Promote female pattern fat distribution ONSET IN 3-6 M

• Decrease overall lean body mass COMPLETION IN 2yr

• Decrease male pattern hair growth

• Decrease libido & erectile function

RISKS !!

• Short term risks

VTE –” Double “the risk
Stroke, MI, PE
• Less common risks
Hypertriglyceridemia
Prolactinoma growth

Cholelithiasis

Ann Intern Med. 2018;169:205-215

Long term risks……..

Increased risk of Ca Breast ??

NO DATA AVAILABLE !!
TRANSDERMA
L PATCHES
SAFER…

ORAL ESTRADIOL

• Increases the risk of

VTE
• First pass
metabolism in liver
• Increase in
prothrombotic
factors
GOAL –
TESTOSTERONE- LESS THAN 55 NG/DL
ESTRADIOL – 100 -200 PG/ML
 Secondary drugs.

ANTI ANDROGENS/ANDROGEN SUPPRESSORS

• SPIRINOLACTONE oral 100-200mg

Suppress androgen
production

• FINESTERIDE/DUTASTERIDE
oral 1-5mg/0.5mg

T---X---DHT / Inhibit terminal hair

growth

• BICALUTAMIDE oral 50mg

Androgen R blocker
 Monitoring..

• Initial follow up at 3 months

• Serum Estradiol, Testosterone, Lipid panel,

Metabolic profile

• Follow up…3m, 6m, annually

• BREAST CANCER SCREENING…..Mammogram

after 5 years of therapy

• PROSTATE CANCER SCREENING

 Penectomy

Orchidectomy

Vaginoplasty

Clitoroplasty
MTF Labioplasty
Surgeries Cricothyroid approximation(phonosurgery)

Thyroid cartilage reduction

Breast augmentation

Feminising facial surgery

• 40-50% transwomen do not require breast
augmentation surgeries after hormone
therapy

• Risk of Ca Breast is lower

• Mammogram recommended

After 5 years of E2 therapy

Age > 50
years
Strong family history
Vaginoplasty & Labioplasty

• Most commonly performed

• Penile skin inversion technique

• Vaginal stricture- 12-14 %

• Vaginal dilatation 1-2 times per week

indefinitely

• Annual speculum examination

Ann Plast Surg.2018;80:684-691
Fertility options..

• Sperm cryopreservation
• Surgical sperm extraction
• Testicular tissue
cryopreservation
TRANSMEN….
• FTM hormone therapy

• Goals…Diminish the female

secondary sex characteristics
Induce the male
characteristics

Primary therapy------ TESTOSTERONES

Exogenous Testosterone administered

Titrated to physiological male range
• Increase in muscle mass

• Decrease in fat mass

• Increased libido

• Increase in facial hair

• Male pattern baldness

• Voice deepening …
6-12 weeks

• Increased body hair

• Clitoromegaly
• Breast atrophy

• Cessation of menses – TAKES 6 MONTHS

 Testosterone esters (SUSTANON)
250-500mg IM every 2-6 weeks

Testosterone enanthate
250-500mg IM every 2-6 weeks
TESTOSTERO
NE
Testosterone gel(1.6%)
5mg daily

Testosterone undecanoate (NEBIDO)

1gm IM every 10-14 weeks
IM,TOPICAL,SQ IMPLANT,BUCCAL,ORAL

• IM – CHEAP,EFFECTIVE,EASILY AVAILABLE
• TOPICAL EXPENSIVE,CONSISTENT CONC
• ORAL VARIABLE CONC,LIMITED AVAILABILITY
• GOAL- TESTOSTERONE LEVEL – 320- 1000 NG/DL
• ESTRADIOL – LESSTHAN 50 PG/ML
 Adjuvant therapies..

• GNRH Agonists
• Progestins

• To suppress menstruation
before Testosterone
therapy
• Erythrocytosis (16%)

• Increased erythropoietin production due to testosterone

• Venesection advised

• Treatment not discontinued

• Rarely..
Liver dysfunction
VTE
Destabilization of mental health disorders

• Less severe..
Acne
Male pattern baldness
(50%)
Desired by many transmen…!
ATTENTION !!
• NO evidence that exogenous Testosterone causes Ca Breast

BUT..

• Association with Ca Endometrium noted in 2 published reports

Care of TGD adults- Peer review draft GTG,RCOG consultation

document
JULY-AUGUST 2022
• Fertility diminished

But…

• Additional contraceptives needed

as…

• Testosterone causes virilization of

fetus
• It is a teratogen!!

WPATH SOC 2012

Monitoring
• Follow up….3m, 6m, then
annually

• Wt, BP monitored

• Serum Testosterone, E2, CBC,

LFT, RFT, Lipid panel

• Risk evaluation

• Pelvic examination??
LIFELONG TESTOSTERONE therapy
needed...

To maintain the secondary sex

characters,

EVEN AFTER OOPHORECTOMY !

• Screening for Ca Breast

recommended
if mastectomy NOT done
Clin Endo (Oxf). 2015;83;597-606
 • Endometrium
assessed every 2
years

• Recurrent vaginal
bleeding…….EM
biopsy

ULTRA SOUND…. WPATH 2012

• Hysterectomy ….

• After 4-5 years of

Testosterone therapy

• To reduce the risk of Ca

Endometrium

• Due to unopposed estrogen

due to aromatization of
Testosterone

• TLH preferred over VH

WPATH SOC 2012
 • B/L mastectomy &
Chest
reconstruction

• Hysterectomy ±
Vaginectomy
•
Oophorectomy

• Metoidioplasty
• Urethroplasty
• Scrotoplasty

• Penile implants /
GRS for transmen Testicular
prosthesis
 • Most common….

Bilateral
Mastectomy

“Chest or Top”Surgery

TOP SURGERY
B/L Oophorectomy

• To reduce the risk of hypogonadism

BUT……….

• No increased risk of ovarian malignancy

even if ovaries are retained along with
testosterone therapy

• So, routine ovarian screening NOT

recommended

Curr Opin Endo Diabetes Obes.2014;21:233-238

Fertility preservation
in transmen

• Proper counseling prior to

therapy

• Oocyte or embryo freezing

• Ovarian tissue
cryopreservation

N Engl J Med.2018;378:400-401
Pregnancy in
Transmen!!

• Transmen who don’t undergo

GRS
• Menstruation returns after
Testosterone discontinuation

• “ Pregnant People” THAN

“Expectant Mothers”

British Medical Association 2016