Diabetes mellitus

Recommendations for diabetes screening in transgender patients (regardless of hormone status) do not differ from current national guidelines.

The effect of gender affirming hormone therapy on diabetes risk or disease course is unclear. A Dutch case-control study noted an increased prevalence of type 2 diabetes mellitus among transgender men and women in comparison to both age matched non-transgender male and female groups, however the study did not adjust for other risk factors.[1] A study of the effects of gender affirming hormones on insulin resistance in transgender women and men found that transgender women may experience some increase in markers of insulin resistance, while transgender men exhibited no change.[2] Some data from non-transgender men suggests that testosterone lowers insulin resistance.[3] Data are mixed on the presence of increased rates of polycystic ovarian syndrome (PCOS) in transgender men prior to hormone therapy. While non-transgender female patients with PCOS require close monitoring for development of diabetes due to marked insulin resistance,[4,5] it is unclear if this risk remains once the hormonal milieu has been modified with the addition of testosterone. While insulin resistance serves as a useful surrogate marker to inform risk, outcome studies using a diagnosis of diabetes as the end point have not been conducted.

Otherwise young and healthy transgender people will often seek medical care with the sole purpose of obtaining hormone therapy or surgery. When this care is provided within the context of comprehensive primary care, identification of risk factors such as obesity, PCOS, metabolic syndrome, impaired fasting glucose, or diabetes may occur earlier than would have happened if the person were not transgender. This can be viewed as an opportunity to improve health particularly in transgender women, who may be at increased cardiovascular risk. However, caution should be used to avoid making gender affirming care contingent on tight control of these other conditions. Numerous anecdotes exist of poorly controlled diabetic transgender patients who had improvements in self-care and resultant decline in hemoglobin A1c after initiation of gender affirming hormones.

Management of diabetes in transgender patients has not been specifically studied. Testosterone package inserts recommend monitoring as serum glucose may be lowered in patients with diabetes receiving testosterone. It is reasonable to maintain heightened monitoring of indicators such as fasting glucose and hemoglobin A1c when initiating or adjusting hormone therapy. While the WPATH Standards of Care recommend that conditions such as diabetes be "reasonably well controlled" prior to initiating hormone therapy, no absolute criteria have been proposed, and the potential adverse effects on blood sugar should be weighed in consideration of the benefits of hormone therapy.

Patients with diabetes seeking gender-affirming surgeries represent a special group for whom aggressive treatment to normalize glucose control is desirable. Genital surgeries and breast/chest surgeries involve microvascular techniques. Healing, avoidance of infection, functionality and cosmesis are thought to be improved with better glycemic control. While the presence of diabetes in itself may not be a contraindication for any of these surgeries, careful coordination between the surgeon and the provider managing the diabetes is recommended.[6]

References

1. Wierckx K, Elaut E, Declercq E, Heylens G, De Cuypere G, Taes Y, et al. Prevalence of cardiovascular disease and cancer during cross-sex hormone therapy in a large cohort of trans persons: a case-control study. Eur J Endocrinol Eur Fed Endocr Soc. 2013 Oct;169(4):471-8
2. Elbers JM., Giltay EJ, Teerlink T, Scheffer PG, Asscheman H, Seidell JC, et al. Effects of sex steroids on components of the insulin resistance syndrome in transsexual subjects. Clin Endocrinol (Oxf). 2003;58(5):562-71.
3. Jones TH. Effects of testosterone on Type 2 diabetes and components of the metabolic syndrome. J Diabetes. 2010 Sep;2(3):146-56.
4. Baba T, Endo T, Ikeda K, Shimizu A, Honnma H, Ikeda H, et al. Distinctive features of female-to-male transsexualism and prevalence of gender identity disorder in Japan. J Sex Med. 2011 Jun;8(6):1686-93.
5. Mueller A, Gooren LJ, Naton-Schötz S, Cupisti S, Beckmann MW, Dittrich R. Prevalence of polycystic ovary syndrome and hyperandrogenemia in female-to-male transsexuals. J Clin Endocrinol Metab. 2008 Apr;93(4):1408-11.
6. Ellsworth WA, Colon GA. Management of medical morbidities and risk factors before surgery: smoking, diabetes, and other complicating factors. Semin Plast Surg. 2006 Nov;20(4):205-13.