Background : Gender dysphoria is the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) diagnosis that describes the distress and unease experienced if an individual’s gender identity and sex are not congruent. Many transgender patients will seek cross-sex hormone therapy (CSHT) in order to transition to that of the desired gender. There are established guidelines that offer dosing and monitoring guidance for initiating hormone therapy in both transgender women and transgender men and the VA Pharmacy Benefits Management Services (VA PBM) has also issued a directive to assist. However, these guidelines are not based on randomized controlled trials, but extrapolated from other indications or from expert opinions. Additionally, there are limited low-quality studies evaluating the effects of CSHT.
Methods : A retrospective chart review was conducted to assess all transgender women veterans aged 18 years and above being seen by the Transgender Care Clinic at the VA Loma Linda Healthcare System (VALLHCS) between March 1, 2012 to October 31, 2016. For inclusion in the study, CSHT is defined as estradiol (all forms), spironolactone, and goserelin and patients should have had 6 weeks of therapy. Any patients who are prescribed progestins at any point during the study period will be excluded. Transgender women not on CSHT or who have had sex-reassignment surgery will also be excluded along with transgender men veterans. All outcomes were evaluated using descriptive statistics. Sixty-three patients were screened and 24 patients included. Three patients met inclusion criteria, but only hormone values were collected.
Results : Clinical manifestations occurred within 12-18 months for all endpoints. Percentage of patients in the therapeutic range for testosterone was consistently less 50% at most time points. Most patients reached the therapeutic range of estradiol after 3-6 months. The most common adverse reactions were lipid panel and mood changes. One patient experienced a transient ischemic attack (TIA) while on estradiol. Average satisfaction was above 3.0 until 42-55 months.
Conclusions : Transgender women veterans at the Transgender Care Clinic at VALLHS experienced clinical manifestations after 12-18 months and mild adverse reactions. However, the documentation of efficacy in the clinic could be improved. The testosterone levels indicate that the hormone is difficult to suppress and may be a better marker of extent of feminization vs. estradiol. Most patients reach the therapeutic range for estradiol. The patient who experienced a TIA had other comorbidities that could increase the patient’s risk of TIA, which may indicate that estradiol was not solely responsible. Patients were satisfied with their care