NEW ORLEANS — Preservation of ovarian reserve may be possible during cross-sex hormone treatment, researchers reported here.
In a prospective study of 52 transgender men on testosterone therapy, anti-mullerian hormone (AMH) levels decreased slightly but still remained within the normal, “healthy” range, according to Iris Yaish, MD, of Tel Aviv-Sourasky Medical Center in Israel, and colleagues.
On average, AMH levels started at 5.65 ng/mL before starting testosterone therapy and subsequently dropped to 4.89 ng/mL 12 months after initiation (P=0.036), reported co-author Yona Greenman, MD, also of the Tel Aviv-Sourasky Medical Center, at ENDO 2019, The Endocrine Society annual meeting.
“This assumption is corroborated by the unchanged antral follicle count,” she stated. These levels only slightly decreased, albeit not significantly, a year after starting hormone therapy (16.9 baseline vs 13.9).
Along with antral follicle count, endometrial thickness (baseline 6.9 vs 5.6 mm) and follicle-stimulating hormone (FSH) also slightly dropped (5.1 vs 4 mIU/ml), but it wasn’t a significant change from baseline. Significant changes were noted among these other levels along with therapy:
- Testosterone: 0.84 vs 7 nmol/l
- Estradiol: 90.8 vs 55.4 pmol/l
- Luteinizing hormone: 7.56 vs 3.8 mIU/ml
However, levels before and after testosterone therapy were generally still high, above the normal range of 1.5-4.0 ng/ml, and, in the high range, often indicated polycystic ovary syndrome (PCOS), the authors reported.
Transgender men often choose to receive testosterone as a gender-affirming treatment, but some transgender men may later want their own children through either a surrogate or their own pregnancy.
“We believe this is the first step towards providing transgender people basic rights, such as reproduction,” Greenman stated.
In the open-label study, blood samples and pelvic ultrasounds were performed both at baseline and 12 months after patients initiated treatment. Every 3 weeks, 250 mg of IM testoviron depot (testosterone enanthate) was administered as the therapy, and hormone levels were measured 10 days after injection. Participants completed questionnaires on sociodemographics, family planning, and sexual orientation.
About a third of these individuals already underwent a mastectomy before initiating hormone therapy, while 41% said they had irregular menses, also possibly indicating a higher prevalence of PCOS in this population. Half said they intended to undergo oophorectomy, but only around 13% said they intended to undergo genital surgery.
At baseline, two-thirds of the participants expressed a desire to eventually have children, but only 7% underwent fertility preservation measures before initiating hormone therapy. Prior to testosterone therapy, five individuals who were only sexually attracted to women later became bisexual a year after taking hormones.
An ENDO 2019 attendee noted that transgender men often prefer testosterone levels at or above the normal levels, and asked Greenman if that might pose an added challenge to ovarian preservation.
Greenman agreed that these patients “often want very high levels of testosterone, quickly and immediately. But we really try to give them the safest treatment that we can provide,” which includes attaining testosterone at a physiological healthy male range, “because … they can develop several complications, such as erythrocytosis; many gain weight and some of them also reported an increase in aggressiveness if the testosterone levels were really high. so we really didn’t try to keep [these levels] high.”
Joshua Safer, MD, of Icahn School of Medicine at Mount Sinai in New York City told MedPage Today that “fertility risk is likely the biggest challenge for usual transgender care.”
Safer, who was not involved with the study, explained that “evidence that egg harvest may be feasible even on testosterone therapy represents important hopeful news for transgender men.”
However, Safer, executive director of Mount Sinai’s Center for Transgender Medicine and Surgery, noted that they “just measured a surrogate [markers of ovarian reserve]. Evidence of actual fertility success will be needed going forward.”
Yaish and co-authors disclosed no relevant relationships with industry.