"Pelvic ultrasound evaluation in transgender male during testosterone therapy" G. Senofonte, E. Marcoccia, C. Boccherini, M. Marasco, A. Perlorca, G. Nigro, A. Giancotti, M. Mosconi, F. Lombardo

Introduction: Gender dysphoria (GD) is characterised by significant distress and/or poor social functioning due to a non-congruence between an individual’s assigned gender and the perceived gender identity. In Female to Male subjects, androgen therapy aims to induce physical changes (such as hair growth, tone voice decrease, fat mass redistribution, breast volume reduction, etc) and cessation of menses. The latest guidelines (Hembree, 2017) suggest a higher risk of malignancies (uterus and ovaries) and of endometrial hyperplasia than cis-gender female, secondary to testosterone therapy. Therefore, a radical hysteroannesisectomy is recommended after 2 years of therapy. Aims: The aim of this study is the acquisition of data from pelvic ultrasound surveillance in Transgender Male in order to evaluate endometrial thickness, uterine and ovarian volume. Materials and Methods: FtM subjects referred to the outpatient clinic of Endocrinology and Andrology of the Department of Experimental Medicine, “Sapienza” University of Rome, for Gender Dysphoria, sent by their mental health specialists. We recruited 26 patients (mean age 27.3 ± 11.0) with the following inclusions criteria: diagnosis of gender dysphoria, participation on follow-up, no previous testosterone therapy; exclusions criteria were: history of gynaecological surgery/hysterectomy, menopause. Each patient underwent clinical evaluation, blood testosterone test and US evaluation before starting therapy (T0) and after six months of therapy (T 6). The hormone therapy consisted of intramuscolar testosterone undecanoate 250 mg-every 28 days. Results: Twenty-six subjects underwent the baseline evaluation: mean uterine volume was 49.4 ± 21.7 cc, mean endometrial thickness was 5.0 ± 3.5 mm, mean right ovarian volume was 5.9 ± 5.3 cc, mean left ovarian volume was 7.5 ± 6.8 cc and mean endometrial thickness was 5.0 ± 3.5 mm. At this time, 12 patients finished six months therapy and returned for control. The cessation of menses occurred in all patients after a median of 2 months (approximately 2 testosterone undecanoate injections). There was no significant difference in post therapy mean uterine volume (49.4 ± 21.7 cc vs 49.9 ± 29.0 cc, T0 vs T6, p = 0.43) and in endometrial thickness (5.0 ± 3.5 mm vs 2.7 ± 1.0 mm, T0 vs T6, p = 0.15). Instead we detected a significant decrease in mean left ovarian volume (7.5 ± 6.8 cc vs 2.7 ± 1.1, T0 vs T6, p = 0.002) and right ovarian volume (5.9 ± 5.3 cc vs 2.3 ± 1.7, T0 vs T6, p =0.010). Blood tests confirmed a significant increase of testosterone levels after six months of therapy (1.3 ± 0.9 vs 13.4 ± 4.5 nnmol/L, T0 vs T6; p=0.001). We did not detect any significant correlation between testosterone levels under treatment and ovarian volume. Conclusions: Testosterone therapy induces marked physical changes, as demonstrated by menses cessation and reduction of ovarian volume, although apparently not correlated with mean blood testosterone level. No significant difference were found in endometrial thickness and uterine volume, though these results may be due in part to the small number of enrolled subjects. Future increase of study cohort and longer follow up will strengthen our results and possibly provide information on risk of malignancies in trangender males.