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Table.  Baseline Clinical and Demographic Characteristics of Patients With Alopecia After Masculinizing Hormone Therapy (MHT)
Baseline Clinical and Demographic Characteristics of Patients With Alopecia After Masculinizing Hormone Therapy (MHT)
1.
Irwig  MS.  Testosterone therapy for transgender men.   Lancet Diabetes Endocrinol. 2017;5(4):301-311. doi:10.1016/S2213-8587(16)00036-XPubMedGoogle ScholarCrossref
2.
Wierckx  K, Van de Peer  F, Verhaeghe  E,  et al.  Short- and long-term clinical skin effects of testosterone treatment in trans men.   J Sex Med. 2014;11(1):222-229. doi:10.1111/jsm.12366PubMedGoogle ScholarCrossref
3.
Wierckx  K, Van Caenegem  E, Schreiner  T,  et al.  Cross-sex hormone therapy in trans persons is safe and effective at short-time follow-up: results from the European network for the investigation of gender incongruence.   J Sex Med. 2014;11(8):1999-2011. doi:10.1111/jsm.12571PubMedGoogle ScholarCrossref
4.
Marks  DH, Senna  MM.  Androgenetic alopecia in gender minority patients.   Dermatol Clin. 2020;38(2):239-247. doi:10.1016/j.det.2019.10.010PubMedGoogle ScholarCrossref
5.
Coleman  E., Bockting  W., Botzer  M.,  et al.  Standards of care for the health of transsexual, transgender, and gender-nonconforming people, version 7.   Int J Transgend. 2012;13(4):165-232. doi:10.1080/15532739.2011.700873Google ScholarCrossref
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    Research Letter
    February 10, 2021

    Incidence and Factors Associated With Androgenetic Alopecia Among Transgender and Gender-Diverse Patients Treated With Masculinizing Hormone Therapy

    Author Affiliations
    • 1Boston University School of Medicine, Boston, Massachusetts
    • 2The Fenway Institute, Fenway Health, Boston, Massachusetts
    • 3Beth Israel Deaconess Medical Center, Department of Dermatology, Boston, Massachusetts
    • 4Beth Israel Deaconess Medical Center, Department of Medicine, Boston, Massachusetts
    • 5Harvard Medical School, Boston, Massachusetts
    • 6Kaiser Permanente Mid-Atlantic Permanente Medical Group, Department of Dermatology, Rockville, Maryland
    JAMA Dermatol. 2021;157(3):348-349. doi:10.1001/jamadermatol.2020.5475

    Transgender and gender-diverse individuals (TGD) undergoing gender affirmation with testosterone, or masculinizing hormone therapy (MHT), may experience adverse dermatologic effects, including acne and androgenetic alopecia (AGA).1 In a cross-sectional study2 of 50 transmen receiving MHT for an average of 10 years, most patients (63.3%) developed AGA, including 31% who developed moderate-to-severe AGA. Several prospective studies have shown rates of AGA among TGD patients receiving MHT ranging between 5% to 17% within the first year of therapy.2,3 These rates appear to be affected by the age of patients started on MHT and the presence of a family history of AGA.4 In general, it appears that TGD individuals develop AGA within 2 to 5 years of starting MHT.1-5 In this study, we examine the proportion of a large population of TGD patients receiving MHT who developed AGA over the course of a mean duration of 3.4 years as well as medications prescribed for AGA among this cohort.

    Methods

    We conducted a retrospective cohort study using electronic medical records from Fenway Health, a community health care and research center with expertise in caring for the lesbian, gay, bisexual, transgender, queer, intersex, and plus community in the greater Boston area. We included all patients who started MHT between January 2014 and December 2017, were aged 18 years or older at the time of MHT initiation, and whose assigned sex at birth was female. We collected baseline demographic characteristics at MHT initiation and comorbidities up to 1 year after MHT initiation (Table). A diagnosis of AGA was defined using International Statistical Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) codes for AGA (L64.x-L65.x). Initial analysis was performed on May 2020 and data on medical treatment for AGA and treatment efficacy were found in the clinical electronic health records. Analyses were performed using STATA statistical software (version 16.0, STATA Corp). This study was determined to be exempt from review by the institutional review board of Fenway Institute of Health, because all data used were deidentified.

    Results

    Of 988 patients, the total proportion of patients with AGA increased from 4 of 988 (0.4%) prior to MHT initiation to 31 of 988 (3.1%) after MHT, with 27 of 984 (2.7%) patients developing AGA after starting MHT. The median duration of MHT prior to AGA diagnosis was 1035 days (IQR, 781-1153 days), or 2.8 years. The incidence of AGA diagnosis was 2 of 984 (0.2%) in the first year of MHT, and 4 of 982 (0.4%) in the second, 10 of 978 (1.0%) in the third, 8 of 760 (1.1%) in the fourth, 2 of 455 (0.4%) in the fifth, and 1 of 206 (0.5%) in the sixth year of MHT, respectively. Among the 31 AGA patients, 22 (71%) were prescribed finasteride for treatment, 3 (9.7%) were prescribed topical minoxidil, and 6 (19.4%) were not prescribed medication. The median age of all patients diagnosed with post-MHT AGA was 26 years (IQR, 23.7-30.0) (Table).

    Discussion

    The proportion of patients with AGA increased from 4 (0.4%) to 31 (3.1%) after MHT initiation, with the highest incidence in the fourth year of MHT and the median duration of MHT prior to diagnosis 2.8 years. This is consistent with prior studies showing a delayed development of AGA in transgender patients receiving MHT. However, the proportion of patients affected in this study was lower than prospective studies2,3 of MHT patients in which 5% to 17%% of patients developed AGA. This was most likely due to the ascertainment of AGA being limited to ICD-10 diagnoses in the electronic medical record, patients not mentioning mild cases of hair loss to clinicians, or the relatively young age of patients in this study. Limitations of this study include the fact that median duration of follow-up was only 3.4 years and did not capture the prevalence of AGA for long-term use of MHT. The patient cohort examined was overwhelmingly White and may not reflect AGA prevalence among a diverse racial and ethnic population. Finally, treatment success for AGA could not be assessed due to lack of follow-up information in the electronic health records.

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    Article Information

    Accepted for Publication: December 4, 2020.

    Published Online: February 10, 2021. doi:10.1001/jamadermatol.2020.5475

    Corresponding Author: Erica Dommasch, MD, MPH, Department of Dermatology, Beth Israel Deaconess Medical Center, Harvard Medical School, 330 Brookline Ave, Shapiro 2, Boston, MA 02115 (edommasc@bidmc.harvard.edu).

    Author Contributions: Dr Dommasch had full access to all the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

    Concept and design: Thoreson, Grasso, Potter, Dommasch.

    Acquisition, analysis, or interpretation of data: Thoreson, Grasso, King, Peebles, Dommasch.

    Drafting of the manuscript: Thoreson.

    Critical revision of the manuscript for important intellectual content: Thoreson, Potter, King, Peebles, Dommasch.

    Statistical analysis: Thoreson, Grasso, King, Dommasch.

    Obtained funding: Dommasch.

    Administrative, technical, or material support: Grasso, King.

    Supervision: Potter, Peebles, Dommasch.

    Conflict of Interest Disclosures: None reported.

    Funding/Support: Funding provided by the Stern Grant, an intradepartmental grant through the Department of Dermatology, Beth Israel Deaconess Medical Center.

    Role of the Funder/Sponsor: The Beth Israel Deaconess Medical Center had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

    References
    1.
    Irwig  MS.  Testosterone therapy for transgender men.   Lancet Diabetes Endocrinol. 2017;5(4):301-311. doi:10.1016/S2213-8587(16)00036-XPubMedGoogle ScholarCrossref
    2.
    Wierckx  K, Van de Peer  F, Verhaeghe  E,  et al.  Short- and long-term clinical skin effects of testosterone treatment in trans men.   J Sex Med. 2014;11(1):222-229. doi:10.1111/jsm.12366PubMedGoogle ScholarCrossref
    3.
    Wierckx  K, Van Caenegem  E, Schreiner  T,  et al.  Cross-sex hormone therapy in trans persons is safe and effective at short-time follow-up: results from the European network for the investigation of gender incongruence.   J Sex Med. 2014;11(8):1999-2011. doi:10.1111/jsm.12571PubMedGoogle ScholarCrossref
    4.
    Marks  DH, Senna  MM.  Androgenetic alopecia in gender minority patients.   Dermatol Clin. 2020;38(2):239-247. doi:10.1016/j.det.2019.10.010PubMedGoogle ScholarCrossref
    5.
    Coleman  E., Bockting  W., Botzer  M.,  et al.  Standards of care for the health of transsexual, transgender, and gender-nonconforming people, version 7.   Int J Transgend. 2012;13(4):165-232. doi:10.1080/15532739.2011.700873Google ScholarCrossref
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