Medical Management of Adult Transsexual Persons
Transsexual patients commonly present with significant comorbidities that complicate their therapeutic plan. Human immunodeficiency virus (HIV) infection, acquired immunodeficiency syndrome (AIDS), and hepatitis C have been seen in this population, although the data describing cross-sex hormone use in these populations are lacking.
A 2007 systematic review evaluating U.S. HIV behavioral prevention literature reported an increased frequency of HIV in the transsexual population. This was attributed to mental health disorders, physical abuse, social and economic problems, risky sexual behavior, and untreated transsexualism. A discrepancy found between serotesting and patient self-reporting of HIV infection suggested that many of these individuals were unaware of their serostatus. The FtM patients were not associated with HIV as consistently as were MtF patients; however, preventive strategies should be discussed with all transsexual patients. Education and HIV testing for these individuals should be of high importance.
The treatment of HIV in MtF persons can prove particularly difficult. Little has been reported about the treatment of HIV in this population; however, studies have examined the use of antiretroviral therapy in combination with oral contraceptives in biologic female patients. Significant and unpredictable changes in estradiol levels were seen when oral contraceptives were used in combination with nonnucleoside reverse transcriptase inhibitors (NNRTIs) or protease inhibitors. Some NNRTIs decreased levels of estrogens by up to 29%, whereas others increased levels by up to 37%. Similarly, some protease inhibitors decreased estrogen levels by up to 47% and others increased levels by up to 48%. The dose of estrogen in oral contraceptives is much lower than the amount needed for the treatment of MtF persons, so extrapolating these results to MtF patients is unreliable. Clinicians should be aware that the possibility for interaction exists. Patients must fully understand the risks of estrogen therapy and the increased risk of adverse events before combining estrogen and antiretroviral therapy. Adjusting and closely monitoring the dosage of estrogen must be considered when treating MtF patients who are also taking antiretroviral therapy.
Hypogonadal men with immunodeficiency due to HIV or AIDS were found to have an increased level of sex hormone-binding globulin (SHBG). This, in turn, can falsely elevate levels of free and total testosterone. Thus, in transsexual patients with HIV or AIDS, clinicians should use a calculated free testosterone level that accounts for elevated SHBG levels and albumin concentrations. Again, this has not been validated in the transsexual patient population, however, clinicians should be aware of the laboratory abnormalities that may exist in this patient population.
Cases of estrogen or testosterone use in transsexual patients with viral hepatitis have not been published to our knowledge. Caution is advised when using estrogen preparations in patients with hepatic dysfunction. A few studies found it safe for biologic women with hepatitis B or C to use transdermal estradiol. Again, the doses used in these women would be much lower than the doses used to treat MtF individuals, and the results should be extrapolated with caution.
Oral testosterone use should be avoided due to the potential for hepatic toxicity. One published case reported hepatic adenoma that developed in a transsexual individual after 3 years of oral testosterone therapy. No studies have evaluated the use of testosterone replacement in the FtM patient with hepatic impairment.
Special Populations
Transsexual patients commonly present with significant comorbidities that complicate their therapeutic plan. Human immunodeficiency virus (HIV) infection, acquired immunodeficiency syndrome (AIDS), and hepatitis C have been seen in this population, although the data describing cross-sex hormone use in these populations are lacking.
Human Immunodeficiency Virus and Acquired Immunodeficiency Syndrome
A 2007 systematic review evaluating U.S. HIV behavioral prevention literature reported an increased frequency of HIV in the transsexual population. This was attributed to mental health disorders, physical abuse, social and economic problems, risky sexual behavior, and untreated transsexualism. A discrepancy found between serotesting and patient self-reporting of HIV infection suggested that many of these individuals were unaware of their serostatus. The FtM patients were not associated with HIV as consistently as were MtF patients; however, preventive strategies should be discussed with all transsexual patients. Education and HIV testing for these individuals should be of high importance.
The treatment of HIV in MtF persons can prove particularly difficult. Little has been reported about the treatment of HIV in this population; however, studies have examined the use of antiretroviral therapy in combination with oral contraceptives in biologic female patients. Significant and unpredictable changes in estradiol levels were seen when oral contraceptives were used in combination with nonnucleoside reverse transcriptase inhibitors (NNRTIs) or protease inhibitors. Some NNRTIs decreased levels of estrogens by up to 29%, whereas others increased levels by up to 37%. Similarly, some protease inhibitors decreased estrogen levels by up to 47% and others increased levels by up to 48%. The dose of estrogen in oral contraceptives is much lower than the amount needed for the treatment of MtF persons, so extrapolating these results to MtF patients is unreliable. Clinicians should be aware that the possibility for interaction exists. Patients must fully understand the risks of estrogen therapy and the increased risk of adverse events before combining estrogen and antiretroviral therapy. Adjusting and closely monitoring the dosage of estrogen must be considered when treating MtF patients who are also taking antiretroviral therapy.
Hypogonadal men with immunodeficiency due to HIV or AIDS were found to have an increased level of sex hormone-binding globulin (SHBG). This, in turn, can falsely elevate levels of free and total testosterone. Thus, in transsexual patients with HIV or AIDS, clinicians should use a calculated free testosterone level that accounts for elevated SHBG levels and albumin concentrations. Again, this has not been validated in the transsexual patient population, however, clinicians should be aware of the laboratory abnormalities that may exist in this patient population.
Viral Hepatitis
Cases of estrogen or testosterone use in transsexual patients with viral hepatitis have not been published to our knowledge. Caution is advised when using estrogen preparations in patients with hepatic dysfunction. A few studies found it safe for biologic women with hepatitis B or C to use transdermal estradiol. Again, the doses used in these women would be much lower than the doses used to treat MtF individuals, and the results should be extrapolated with caution.
Oral testosterone use should be avoided due to the potential for hepatic toxicity. One published case reported hepatic adenoma that developed in a transsexual individual after 3 years of oral testosterone therapy. No studies have evaluated the use of testosterone replacement in the FtM patient with hepatic impairment.