2001 review article is unfortunately one of the more recent publications on the subject. (1)
The
perioperative use of estrogen cross-sex hormone therapy (csHT) is a topic of
controversy in both transgender women as well as in cisgender women taking
menopausal HRT or combined oral contraceptives (OCP). Little data exists in any context with
respect to perioperative venous thromboembolic risks (VTE) in those patients
taking estrogen of any type and for any reason.
Most guidelines are based on consensus opinion and of varying vintage.
This review article aimed to review perioperative estrogen therapy from the
reference frame of the anasthesiologist.
While the article reviews a number of conditions of interest, the
section focusing on perioperative VTE will be discussed here.
It is first mentioned that studies of VTE in estrogen therapy of any kind
suggest relative risk of 2-3 for users vs. non-users. While these studies are still equivocal and
suggest that the risk is greatest in the first year of therapy, the 2-3x
increase in risk likely translates into a real world increase of 1-2 cases per
10,000 women per year. Furthermore, there
may be a subset of users at baseline higher risk due to occult prothrombotic
states, which have a 6.2% baseline prevalence in the general population, but a
60.2% prevalence in those with a personal or family history of VTE.
The authors conclude that no evidence-based recommendations can be made with
respect to withholding perioperative estrogen therapy, nor with respect to
postoperative VTE prophylaxis with heparin.
Recommendations from various British bodies and organizations are
presented showing a range of conflicting and equivocal recommendations. Providers are advised to rely on clinical
judgment.
Comments:
This 11 year old article unfortunately represents one of the more recent
publications on the issue of perioperative VTE and estrogen therapy; randomized
controlled trials are sorely lacking. In
the discussion the author mentions that withholding perioperative OCP may
result in an unwanted pregnancy with attendant risks and morbidity; it is
recommended that physicians consider these risks when analyzing the pros and
cons on an individual basis. The same
thought process should be applied for transwomen, who may experience
significant emotional symptoms from hormone withdrawal in what is for many an
already extremely stressful event. In
the case of transwomen, it is likely safe to continue csHT in the perioperative
period if they have no personal or family risk factors, have been on csHT for
> 1 year, wear sequential compression devices postoperatively, and have
received informed consent about the minimal absolute risk increase. Providers should also keep in mind the
background rate of VTE in major pelvic surgery without the use of estrogens.
References:
1) Brighouse, D. Hormone Replacement Therapy and Anaesthesia. British Journal of Anaesthesia 86(5): 709-16.
Wednesday, May 30, 2012
Reducing Pain Associated with Pelvic Speculum Exams
Use of gel vs. water resulted in a slight reduction in pain score on pelvic speculum exams in cisgender women without interfering with cervical cytology results. (1)
Pelvic examinations can be uncomfortable for transgender men for a variety of reasons. Virginal status or infrequent penetration, vaginal atrophy due to hormone therapy, and psychological factors may impair or even prevent a successful pelvic examination. Patients may have had past experiences that were painful and may be reluctant to permit necessary pelvic screening or care.
Cisgender women undergoing pelvic examinations also may experience discomfort. Historically providers have been hesitant to use lubricating gel when collecting cervical cytology or chlamydia testing specimens out of concern that gels may interfere with test results, and have instead used water for speculum lubrication. However a growing body of evidence suggests that certain lubricant products that do not contain carbomers do not interfere with such tests. Investigators aimed to evaluate the pain associated with pelvic speculum examinations using gel lubricant as compared to water.
This was a single-blind randomized controlled trial of 119 women assigned to either a gel (n=59) or water (n=60) group. Pain scores were recorded on a 0-10 visual analog scale (VAS) after insertion of the speculum, but before visualization of the cervix. Study size was determined based on a power calculation to detect a VAS difference of 0.9, which has been shown in the literature to be a threshold of clinical significance. Menopausal women, pregnant or recently parous women as well as those with pelvic pathology were excluded. The overwhelming majority of subjects were patients presenting for routine pelvic screening examinations. A single physician performed all examinations.
The gel group reported a statistically significant lower VAS score than the water group (1.41 vs. 2.15, difference 0.74). 33.9% in the gel group reported a score of 0, vs. 10% in the water group. None of the 35 gel or 38 water patients who underwent cytology had unsatisfactory results.
Comments:
The authors identified a statistically significant reduction in VAS scores when using gel vs. water lubricant in routine pelvic examinations, with no observed cases of unsatisfactory cytology results. The findings do not cross the threshold of clinical significance. However these findings may have applicability in transgender men who may have baseline higher pain scores than the study group seen here; pain scores of 1-2 are remarkably low. As one’s pain climbs on the pain scale, non-linear differences may be encountered which could cross the threshold of clinical significance. In the very least clinicians should be reassured by this and other data that using a small amount of gel lubricant for pelvic examinations is reasonable and will not impact cytology results if the gel used does not contain carbomers. Further study in populations more likely to experience pain on pelvic speculum examination (transgender men, menopausal women) would be useful.
References:
1) Hill DA, Lamvu G. Effect of lubricating gel on patient comfort during vaginal speculum examination: a randomized controlled trial. Obstetrics & Gynecology. 2012;119(2, Part 1):227
Pelvic examinations can be uncomfortable for transgender men for a variety of reasons. Virginal status or infrequent penetration, vaginal atrophy due to hormone therapy, and psychological factors may impair or even prevent a successful pelvic examination. Patients may have had past experiences that were painful and may be reluctant to permit necessary pelvic screening or care.
Cisgender women undergoing pelvic examinations also may experience discomfort. Historically providers have been hesitant to use lubricating gel when collecting cervical cytology or chlamydia testing specimens out of concern that gels may interfere with test results, and have instead used water for speculum lubrication. However a growing body of evidence suggests that certain lubricant products that do not contain carbomers do not interfere with such tests. Investigators aimed to evaluate the pain associated with pelvic speculum examinations using gel lubricant as compared to water.
This was a single-blind randomized controlled trial of 119 women assigned to either a gel (n=59) or water (n=60) group. Pain scores were recorded on a 0-10 visual analog scale (VAS) after insertion of the speculum, but before visualization of the cervix. Study size was determined based on a power calculation to detect a VAS difference of 0.9, which has been shown in the literature to be a threshold of clinical significance. Menopausal women, pregnant or recently parous women as well as those with pelvic pathology were excluded. The overwhelming majority of subjects were patients presenting for routine pelvic screening examinations. A single physician performed all examinations.
The gel group reported a statistically significant lower VAS score than the water group (1.41 vs. 2.15, difference 0.74). 33.9% in the gel group reported a score of 0, vs. 10% in the water group. None of the 35 gel or 38 water patients who underwent cytology had unsatisfactory results.
Comments:
The authors identified a statistically significant reduction in VAS scores when using gel vs. water lubricant in routine pelvic examinations, with no observed cases of unsatisfactory cytology results. The findings do not cross the threshold of clinical significance. However these findings may have applicability in transgender men who may have baseline higher pain scores than the study group seen here; pain scores of 1-2 are remarkably low. As one’s pain climbs on the pain scale, non-linear differences may be encountered which could cross the threshold of clinical significance. In the very least clinicians should be reassured by this and other data that using a small amount of gel lubricant for pelvic examinations is reasonable and will not impact cytology results if the gel used does not contain carbomers. Further study in populations more likely to experience pain on pelvic speculum examination (transgender men, menopausal women) would be useful.
References:
1) Hill DA, Lamvu G. Effect of lubricating gel on patient comfort during vaginal speculum examination: a randomized controlled trial. Obstetrics & Gynecology. 2012;119(2, Part 1):227
Transdermal Estradiol Reduces Risk of Venus Thromboembolism in Menopausal Hormone Replacement Therapy
Matched cohort study looks at risk reduction of using transdermal estrogen vs. oral in menopausal hormone therapy. (1)
In
this matched cohort study of incidence of VTE in women using menopausal HRT,
investigators attempted to quantify the risk reduction for VTE events
associated with transdermal relative to oral estrogens. Claims records from a health insurance
database of 30 million people living in the US were reviewed over the period of
January 2002 - October 2009 for patients who had received at least two
dispensings of a transdermal or oral estradiol and were over age 35. Users of other estrogens such as vaginal or
injections and those with a prior VTE were excluded. At total of 27,018 women were enrolled in
each cohort. Interestingly while only 22.4%
of women in each cohort had undergone hysterectomy, a minority of the women
were using a progestagen. Primary
outcome measures were the overall VTE risk as well as hospitalization-related
VTE, as measured by incidence rate.
Mean drug exposure times were 391 days for transdermal estrogen and 401 days for oral estrogens. A total of 115 VTE events were encountered in the transdermal group vs. 164 in the oral group; a statistically significant difference. Further analysis revealed more pronounced statistically significant reductions in VTE incidence among hospitalized women and reductions in PE incidence.
Mean drug exposure times were 391 days for transdermal estrogen and 401 days for oral estrogens. A total of 115 VTE events were encountered in the transdermal group vs. 164 in the oral group; a statistically significant difference. Further analysis revealed more pronounced statistically significant reductions in VTE incidence among hospitalized women and reductions in PE incidence.
Comments:
Yet another study highlighting the likely benefits of transdermal HRT with
respect to VTE risk. While this study
did not compare incidence to a control population, overall VTE incidence in
both cohorts was slightly higher than reported baseline incidences. This raises the possibility of an overall
skewing of the sample population, though it may not affect internal validity of
the results. It is noteworthy that the
average times on HRT was just over 1 year in both cohorts; given that the risk of VTE is highest in the
first year of HRT, this may explain such skewing. Further studies should compare oral vs.
transdermal VTE incidences in those on longer term HRT when the overall VTE
risk is lower, and specifically in transgender populations.
It is possible that there might be a skewing of results toward higher incidences of VTE as the investigators included all oral estrogen forms including conjugated equine estrogens in the oral therapy arm.
It is possible that there might be a skewing of results toward higher incidences of VTE as the investigators included all oral estrogen forms including conjugated equine estrogens in the oral therapy arm.
References:
.
Transdermal Estrogen Safe With Respect to Venous Thromboembolism?
Oral estrogen shows increased risk of VTE, but transdermal does not in a French prospective cohort. (1)
Several studies have suggested that route of estrogen administration can affect risk of venous thromboembolism (VTE) in women using postmenopausal hormone replacement therapy (HRT). The authors reviewed data from a prospective cohort of French teachers born between years 1925 and 1950 who completed biennial self-administered questionnaires on a range of health issues. In those who self-reported a thromoboembolic event, follow-up questions as well as a query of the subject’s physician(s) futher populated the data on such events. Death certificates were reviewed for deceased subjects and revealed 68 additional events (all PE). Thromboembolic events (deep vein thrombosis (DVT) or pulmonary embolism (PE)) were included if they were diagnosed by an imaging procedure. Exclusion criteria for events included superficial vein thromboses, upper-extremity DVT, central retinal vein obstruction and recurrent events. Subject exclusion criteria were history of cancer, VTE prior to study period, recurrent VTE, or nonidopathic VTE.
A total of 549 incidents of VTE (415 DVT, 134 PE) were identified in 80,308 women who met inclusion criteria out of the total study enrollment of 98,995. Of those 549 women with a VTE during the study perior, 181 were never users, 66 were past users, and 255 were current users of HRT. An additional 47 women were using “other” or “unknown” treatments. Progestagens were used in all but 26 of the women using HRT (micronized progesterone – 47, pregnane deriviatives – 91, norpregnane derivatives – 69, nortestosterone derivatives – 22).
Mean age at the start of follow-up period was 54, with women followed over an average of 10.1 years. The hazard ratio for VTE with oral estrogen use was 1.7 (95% CI: 1.1-2.8) and with transdermal estrogens was 1.1 (95% CI: 0.8-1.8). Use of a norpregnane derivative was independently associated with an increased risk of VTE (HR 1.8, 95% CI: 1.2-2.7), while other progestagens were not.
Comments:
The investigators have obtained results consistent with prior studies (ESTHER) that suggest transdermal estrogens with or without a non-norpregnane progestagen may be safe with respect to VTE. The current study has a number of limitations; it was a self-reporting survey with a non-trivial exclusion of almost one-fifth of respondents. While 9.9% of respondents reported tobacco use (a known risk factor for VTE in HRT), the authors did not report prevalence of smokers in each arm of the study. Since this was simply an observational cohort study, patients at higher risk of VTE based on their individual physician’s clinical impression may have guided the use of HRT type and route or may have prevented the use of HRT all together. Lastly the study was funded by the manufacturer of a transdermal estrogen product. Nevertheless this study is yet another in a growing series of investigations which suggest that estrogen route and progestagen type can impact VTE risk. While these results can not be generalized to transgender populations, they are suggestive and are helpful for guiding future research.
It is possible that there may be a skewing towards a higher incidence of VTE as the investigators did not separate out users of 17-beta estradiol vs. conjugated equine estrogens (Premarin).
References:
Several studies have suggested that route of estrogen administration can affect risk of venous thromboembolism (VTE) in women using postmenopausal hormone replacement therapy (HRT). The authors reviewed data from a prospective cohort of French teachers born between years 1925 and 1950 who completed biennial self-administered questionnaires on a range of health issues. In those who self-reported a thromoboembolic event, follow-up questions as well as a query of the subject’s physician(s) futher populated the data on such events. Death certificates were reviewed for deceased subjects and revealed 68 additional events (all PE). Thromboembolic events (deep vein thrombosis (DVT) or pulmonary embolism (PE)) were included if they were diagnosed by an imaging procedure. Exclusion criteria for events included superficial vein thromboses, upper-extremity DVT, central retinal vein obstruction and recurrent events. Subject exclusion criteria were history of cancer, VTE prior to study period, recurrent VTE, or nonidopathic VTE.
A total of 549 incidents of VTE (415 DVT, 134 PE) were identified in 80,308 women who met inclusion criteria out of the total study enrollment of 98,995. Of those 549 women with a VTE during the study perior, 181 were never users, 66 were past users, and 255 were current users of HRT. An additional 47 women were using “other” or “unknown” treatments. Progestagens were used in all but 26 of the women using HRT (micronized progesterone – 47, pregnane deriviatives – 91, norpregnane derivatives – 69, nortestosterone derivatives – 22).
Mean age at the start of follow-up period was 54, with women followed over an average of 10.1 years. The hazard ratio for VTE with oral estrogen use was 1.7 (95% CI: 1.1-2.8) and with transdermal estrogens was 1.1 (95% CI: 0.8-1.8). Use of a norpregnane derivative was independently associated with an increased risk of VTE (HR 1.8, 95% CI: 1.2-2.7), while other progestagens were not.
Comments:
The investigators have obtained results consistent with prior studies (ESTHER) that suggest transdermal estrogens with or without a non-norpregnane progestagen may be safe with respect to VTE. The current study has a number of limitations; it was a self-reporting survey with a non-trivial exclusion of almost one-fifth of respondents. While 9.9% of respondents reported tobacco use (a known risk factor for VTE in HRT), the authors did not report prevalence of smokers in each arm of the study. Since this was simply an observational cohort study, patients at higher risk of VTE based on their individual physician’s clinical impression may have guided the use of HRT type and route or may have prevented the use of HRT all together. Lastly the study was funded by the manufacturer of a transdermal estrogen product. Nevertheless this study is yet another in a growing series of investigations which suggest that estrogen route and progestagen type can impact VTE risk. While these results can not be generalized to transgender populations, they are suggestive and are helpful for guiding future research.
It is possible that there may be a skewing towards a higher incidence of VTE as the investigators did not separate out users of 17-beta estradiol vs. conjugated equine estrogens (Premarin).
References:
Transgender Men and HIV
Of 59 transmen presenting for HIV screening at public health clinics in San Francisco, none tested positive. However the sample may not be representative of the population. (1)
Transgender men (transmen) may be at risk for HIV infection. Transmen may have male sexual partners and therefore be identified as men who have sex with men (MSM). Transmen may also have sex with transgender women (transwomen). HIV prevalences in San Francisco, USA have been found to be 24% among MSM and 35% among transwomen. Historically only a few cases of HIV in transmen have been reported in San Francisco. The authors aimed to identify the prevalence of HIV among those transmen presented to one of 17 public health clinics in San Francisco during 2009. These sites perform 25% of all HIV tests in the city.
A total of 64 HIV tests were performed on 59 unique self-identified transmen in 2009 at these sites, representing 0.4% of all tests performed. Median age was 27, with 79% ages 18-37. Whites comprised 73% of the sample and 64% identified as gay/lesbian/queer. With respect to sexual practices in the prior 12 months, 61% had a male sexual partner (51% vaginal receptive, 19% anal insertive, 39% anal receptive), 63% had female partners (55% vaginal or anal sex) and 47% had transgender partners (42% vaginal or anal sex); 44% had 6 or more sexual partners in the prior year. Unprotected vaginal or anal sex was reported by 63% in the past 12 months, with 10% reporting having had vaginal or anal sex with a known HIV+ person. None of the subjects tested positive for HIV (98% negative, 2% missing).
Comments:
This study demonstrates a number of interesting findings. First it confirms what is already anecdotally well known; that transmen have a range of sexual partners, practices and orientations. It also demonstrates an absence of HIV in a population of transmen who are actively engaging in a variety of high risk behaviors. This absence suggests that transmen are still in a “pre-epidemic” phase with respect to HIV and that there is substantial opportunity to develop HIV prevention measures targeting this population. It also raises the question if there are factors (anatomical, functional, behavioral) that alter transmale succeptability to HIV infection to a level lower than that of other populations.
The study also has a number of limitations. The study population was primarily white transmen between the ages of 18-35, and only comprised of 25% of all HIV tests performed in San Francisco during the study period. Barriers may exist for younger transmen or transmen of color to accessing HIV testing at any location. Older transmen may be more likely to have insurance and a primary care provider and seek testing at a private office. Some transmen may not self-identify themselves when completing a survey.
The study demonstrates the complexities and pitfalls of data collection on transgender populations. The survey used contains numerous flaws and oversights with respect to demographics and sexual practices. For example, sexual activity with a transgender person is not broken down by transmale/transfemale. It is unclear if respondents identified transgender partners by their affirmed gender, their transgender status, or both. It is assumed that by “man” and “woman” the researchers intended to refer to cisgender men and women – such assumptions are counter to the “two-step” recommendation for data collection (Step 1: “What was the sex you were assigned at birth?”; Step 2: “What is your gender identity?”) which allows a more complete and culturally sensitive collection of data. Anal and vaginal sex with a transgender person or a woman (presumably cisgender) were grouped together and not qualified by insertive or receptive relative to the subject. Further study with a greater level of detail with respect to demographics and sexual practices as well as a wider catchment of age ranges and ethnicities is essential to identify and manage HIV risks in transgender men.
References:
1) Chen S, McFarland W, Thompson HM, Raymond HF. Transmen in San Francisco: What do We Know from HIV Test Site Data? AIDS and Behavior. 2010 Dec 9;15(3):659–62
Transgender men (transmen) may be at risk for HIV infection. Transmen may have male sexual partners and therefore be identified as men who have sex with men (MSM). Transmen may also have sex with transgender women (transwomen). HIV prevalences in San Francisco, USA have been found to be 24% among MSM and 35% among transwomen. Historically only a few cases of HIV in transmen have been reported in San Francisco. The authors aimed to identify the prevalence of HIV among those transmen presented to one of 17 public health clinics in San Francisco during 2009. These sites perform 25% of all HIV tests in the city.
A total of 64 HIV tests were performed on 59 unique self-identified transmen in 2009 at these sites, representing 0.4% of all tests performed. Median age was 27, with 79% ages 18-37. Whites comprised 73% of the sample and 64% identified as gay/lesbian/queer. With respect to sexual practices in the prior 12 months, 61% had a male sexual partner (51% vaginal receptive, 19% anal insertive, 39% anal receptive), 63% had female partners (55% vaginal or anal sex) and 47% had transgender partners (42% vaginal or anal sex); 44% had 6 or more sexual partners in the prior year. Unprotected vaginal or anal sex was reported by 63% in the past 12 months, with 10% reporting having had vaginal or anal sex with a known HIV+ person. None of the subjects tested positive for HIV (98% negative, 2% missing).
Comments:
This study demonstrates a number of interesting findings. First it confirms what is already anecdotally well known; that transmen have a range of sexual partners, practices and orientations. It also demonstrates an absence of HIV in a population of transmen who are actively engaging in a variety of high risk behaviors. This absence suggests that transmen are still in a “pre-epidemic” phase with respect to HIV and that there is substantial opportunity to develop HIV prevention measures targeting this population. It also raises the question if there are factors (anatomical, functional, behavioral) that alter transmale succeptability to HIV infection to a level lower than that of other populations.
The study also has a number of limitations. The study population was primarily white transmen between the ages of 18-35, and only comprised of 25% of all HIV tests performed in San Francisco during the study period. Barriers may exist for younger transmen or transmen of color to accessing HIV testing at any location. Older transmen may be more likely to have insurance and a primary care provider and seek testing at a private office. Some transmen may not self-identify themselves when completing a survey.
The study demonstrates the complexities and pitfalls of data collection on transgender populations. The survey used contains numerous flaws and oversights with respect to demographics and sexual practices. For example, sexual activity with a transgender person is not broken down by transmale/transfemale. It is unclear if respondents identified transgender partners by their affirmed gender, their transgender status, or both. It is assumed that by “man” and “woman” the researchers intended to refer to cisgender men and women – such assumptions are counter to the “two-step” recommendation for data collection (Step 1: “What was the sex you were assigned at birth?”; Step 2: “What is your gender identity?”) which allows a more complete and culturally sensitive collection of data. Anal and vaginal sex with a transgender person or a woman (presumably cisgender) were grouped together and not qualified by insertive or receptive relative to the subject. Further study with a greater level of detail with respect to demographics and sexual practices as well as a wider catchment of age ranges and ethnicities is essential to identify and manage HIV risks in transgender men.
References:
1) Chen S, McFarland W, Thompson HM, Raymond HF. Transmen in San Francisco: What do We Know from HIV Test Site Data? AIDS and Behavior. 2010 Dec 9;15(3):659–62
Monday, January 2, 2012
Hormone-treated transsexuals report less social distress, anxiety and depression
Cross sectional, descriptive study of transsexuals in Spain suggests that cross-sex hormone therapy reduces symptoms of anxiety and depression, as well as social anxiety. (1)
Most studies of the efficacy of trans related medical practices on reducing anxiety and depression have focused on surgical procedures. Limited quantitative data exist on the role cross-sex hormone therapy (csHT) may play in reducing anxiety and depression independent of surgical interventions (THJC Nov 5, 2011). This team of investigators at a single gender specialty center in Barcelona, Spain conducted a cross sectional, descriptive study of measures of anxiety, depression and social anxiety in 120 FTM and MTF transsexuals currently receiving csHT and 67 on a waiting list who were not yet treated. Social anxiety was measured using the Social Anxiety and Distress Scale (SADS) and anxiety and depression were measured using the Hospital Anxiety and Depression Scale, both of which have been validated in Spanish.
Results demonstrated that csHT was assosciated with lower scores of anxiety and depression as well as social anxiety. A subgroup analysis of transsexuals on csHT who had also had a surgical intervention vs. those who had not showed no difference in scores on any of the scales. Interestingly, scores of anxiety and depression as well as social anxiety were within control ranges across all respondent groups.
Comments:
That csHT independent of surgical status is associated with reduced symptoms of anxiety and depression and social anxiety is no surprise to clinicians experienced in working with transsexuals. More longitudinal study in this area is important since in many cultures and settings csHT is the only intervention that is available or desired. It is interesting that transsexuals both pre- and receiving csHT had anxiety, depression and social anxiety scores within the control ranges; While this might be the case in this population in Barcelona, a liberal city in a nation with a strong environment of LGBT rights and government-funded trans care, the results found here may not be applicable in other dissimilar settings. Furthermore, the population studied was almost exclusively heterosexual (i.e. trans women attracted to men and trans men attracted to women) and may represent a group more conforming to gender binaries than a larger umbrella trans population.
References:
1) Gómez-Gil E, Zubiaurre-Elorza L, Esteva I, Guillamon A, Godás T, Cruz Almaraz M, et al. Hormone-treated transsexuals report less social distress, anxiety and depression. Psychoneuroendocrinology [Internet]. 2011 Sep 19 [cited 2012 Jan 2];Available from: http://www.ncbi.nlm.nih.gov/pubmed/21937168
Most studies of the efficacy of trans related medical practices on reducing anxiety and depression have focused on surgical procedures. Limited quantitative data exist on the role cross-sex hormone therapy (csHT) may play in reducing anxiety and depression independent of surgical interventions (THJC Nov 5, 2011). This team of investigators at a single gender specialty center in Barcelona, Spain conducted a cross sectional, descriptive study of measures of anxiety, depression and social anxiety in 120 FTM and MTF transsexuals currently receiving csHT and 67 on a waiting list who were not yet treated. Social anxiety was measured using the Social Anxiety and Distress Scale (SADS) and anxiety and depression were measured using the Hospital Anxiety and Depression Scale, both of which have been validated in Spanish.
Results demonstrated that csHT was assosciated with lower scores of anxiety and depression as well as social anxiety. A subgroup analysis of transsexuals on csHT who had also had a surgical intervention vs. those who had not showed no difference in scores on any of the scales. Interestingly, scores of anxiety and depression as well as social anxiety were within control ranges across all respondent groups.
Comments:
That csHT independent of surgical status is associated with reduced symptoms of anxiety and depression and social anxiety is no surprise to clinicians experienced in working with transsexuals. More longitudinal study in this area is important since in many cultures and settings csHT is the only intervention that is available or desired. It is interesting that transsexuals both pre- and receiving csHT had anxiety, depression and social anxiety scores within the control ranges; While this might be the case in this population in Barcelona, a liberal city in a nation with a strong environment of LGBT rights and government-funded trans care, the results found here may not be applicable in other dissimilar settings. Furthermore, the population studied was almost exclusively heterosexual (i.e. trans women attracted to men and trans men attracted to women) and may represent a group more conforming to gender binaries than a larger umbrella trans population.
References:
1) Gómez-Gil E, Zubiaurre-Elorza L, Esteva I, Guillamon A, Godás T, Cruz Almaraz M, et al. Hormone-treated transsexuals report less social distress, anxiety and depression. Psychoneuroendocrinology [Internet]. 2011 Sep 19 [cited 2012 Jan 2];Available from: http://www.ncbi.nlm.nih.gov/pubmed/21937168
Friday, December 2, 2011
Vaginal Prolapse, Pelvic Floor Function, and Related Symptoms 16 Years After Sex Reassignment Surgery in Transsexuals
Cross sectional study of 52 MTF patients assessing for prolapse and related bladder, bowel and sexual problems found 3.8% of patients having prolapse warranting surgical repair, 47% with voiding difficulties, and 75% reporting that sexual complaints in some way interfered with their enjoyment of life. (1)
Pelvic organ prolapse affects 50% of non-transsexual parous women over age 50, though not all women with clinical signs of prolapse are symptomatic. The authors aimed to assess the prevalence of pelvic organ prolapse in a cross sectional study of post-vaginoplasty MTF transsexual patients with a median age of 57 (range 39-69 years) under care at a single Swiss tertiary referral gynecology & endocrinology service. The medial postoperative time was 16 years (range 13-29 years). 49 patients had undergone scrotal inversion and 3 patients had undergone sigmoideocolpoplasty at 14 different surgical centers distributed between Switzerland, the UK, France, the US and Thailand. Objective measurement by a single examiner using the International Continence Society - Pelvic Organ Prolapse scoring (ICS-POP) and subjective symptom survey using the Sheffield Pelvic Organ Prolapse Quality-of-Life Questionnaire (SPS-Q) were conducted.
7.5% of patients were found on exam to have an ICS-POP score greater than 2, with 3.8% of patients requiring surgical repair. 47% of patients reported voiding difficulties, 24.6% reported urgency, 17% urge incontinence, and 23% stress incontinence. With respect to sexual satisfaction, 22.6% reported "never" and 26.4% reported "occasionally". The paper includes a discussion of various anatomical considerations in pelvic surgery on transsexuals and also looked at outcomes in 3 FTM patients.
Comments:
This paper is useful in reminding us that vaginoplasty is not a risk-free procedure, and that a non-trivial percentage of patients will experience bothersome urinary and sexual symptoms that can impact quality of life. Primary care providers and surgeons should discuss known and unknown risks and percentages during the informed consent process prior to surgery. These data are also useful in the ongoing development of government policies which allow changing legal documents to reflect the affirmed gender without requiring surgical intervention; As more data emerge showing that surgery can be associated with substantial morbidity, the justification of surgery as a requirement for changing documents becomes weaker.
The paper has several strengths and several weaknesses. Using a single examiner eliminates inter-examiner reliability issues with respect to ICS-POP scoring. At the same time, decision to perform pelvic surgical repair in cases of prolapse is more often guided by patient symptomatology and response to conservative treatment. The study sample was rather large, but skewed towards an older population with an average age of 57. The study population also represented an all-comer population from surgeons in a range of countries, but individual outcomes by surgeon or country were not reported. Being a tertiary referral center, referral bias may have caused a higher prevalence of pathology in the study population. The ICS-POP and SPS-Q scales have not been validated in transsexuals, and given the discussed anatomical differences may not be applicable or clinically relevant. Comparisons are made to the prevalence of pelvic symptoms in parous non-transsexual women; Weather or not this comparison is applicable vs. comparisons between groups of transsexual women by age or surgical technique, or comparison with pre- or non-op transsexual women are subjects to ponder.
References:
1) Kuhn A, Santi A, Birkhäuser M. Vaginal prolapse, pelvic floor function, and related symptoms 16 years after sex reassignment surgery in transsexuals. Fertil. Steril. 2011 Jun;95(7):2379–82.
Pelvic organ prolapse affects 50% of non-transsexual parous women over age 50, though not all women with clinical signs of prolapse are symptomatic. The authors aimed to assess the prevalence of pelvic organ prolapse in a cross sectional study of post-vaginoplasty MTF transsexual patients with a median age of 57 (range 39-69 years) under care at a single Swiss tertiary referral gynecology & endocrinology service. The medial postoperative time was 16 years (range 13-29 years). 49 patients had undergone scrotal inversion and 3 patients had undergone sigmoideocolpoplasty at 14 different surgical centers distributed between Switzerland, the UK, France, the US and Thailand. Objective measurement by a single examiner using the International Continence Society - Pelvic Organ Prolapse scoring (ICS-POP) and subjective symptom survey using the Sheffield Pelvic Organ Prolapse Quality-of-Life Questionnaire (SPS-Q) were conducted.
7.5% of patients were found on exam to have an ICS-POP score greater than 2, with 3.8% of patients requiring surgical repair. 47% of patients reported voiding difficulties, 24.6% reported urgency, 17% urge incontinence, and 23% stress incontinence. With respect to sexual satisfaction, 22.6% reported "never" and 26.4% reported "occasionally". The paper includes a discussion of various anatomical considerations in pelvic surgery on transsexuals and also looked at outcomes in 3 FTM patients.
Comments:
This paper is useful in reminding us that vaginoplasty is not a risk-free procedure, and that a non-trivial percentage of patients will experience bothersome urinary and sexual symptoms that can impact quality of life. Primary care providers and surgeons should discuss known and unknown risks and percentages during the informed consent process prior to surgery. These data are also useful in the ongoing development of government policies which allow changing legal documents to reflect the affirmed gender without requiring surgical intervention; As more data emerge showing that surgery can be associated with substantial morbidity, the justification of surgery as a requirement for changing documents becomes weaker.
The paper has several strengths and several weaknesses. Using a single examiner eliminates inter-examiner reliability issues with respect to ICS-POP scoring. At the same time, decision to perform pelvic surgical repair in cases of prolapse is more often guided by patient symptomatology and response to conservative treatment. The study sample was rather large, but skewed towards an older population with an average age of 57. The study population also represented an all-comer population from surgeons in a range of countries, but individual outcomes by surgeon or country were not reported. Being a tertiary referral center, referral bias may have caused a higher prevalence of pathology in the study population. The ICS-POP and SPS-Q scales have not been validated in transsexuals, and given the discussed anatomical differences may not be applicable or clinically relevant. Comparisons are made to the prevalence of pelvic symptoms in parous non-transsexual women; Weather or not this comparison is applicable vs. comparisons between groups of transsexual women by age or surgical technique, or comparison with pre- or non-op transsexual women are subjects to ponder.
References:
1) Kuhn A, Santi A, Birkhäuser M. Vaginal prolapse, pelvic floor function, and related symptoms 16 years after sex reassignment surgery in transsexuals. Fertil. Steril. 2011 Jun;95(7):2379–82.
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