Asymptomatic idiopathic intracranial hypertension post female to male gender transition

Abstract

A 23- year-man post female to male (FTM) gender transition was found to have bilateral papilloedema at a routine optician visit. The patient was referred on for formal ophthalmological and neurological assessments. Optical coherence tomography (OCT) confirmed the presence of bilateral papilloedema. The patient was entirely asymptomatic and had no medical history. He took testosterone intramuscularly once per month. Neurological examination was otherwise normal. Investigations including routine blood panels, CT brain, MRI brain and cerebral MR venogram were all normal. Lumbar puncture yielded cerebrospinal fluid (CSF) normal in appearance but demonstrated raised intracranial pressure. In the absence of other causative aetiologies a diagnosis of idiopathic intracranial hypertension (IIH) was made. Treatment was commenced with acetazolamide and the patient was discharged with outpatient ophthalmological and neurological follow-up.

Idiopathic Intracranial Hypertension in Female-to-Male Transgender Patients on Exogenous Testosterone Therapy

“…Among previously reported patients, the time to presentation after initiation of testosterone was reported in ten cases, ranging from one patient who "just started" to 2 patients who presented after 4 years. 8,[12][13][14][15][16] Patient 4, who had undergone intramuscular testosterone therapy for 2 years followed by 7 years of topical testosterone therapy, represents the longest reported interval between FTM hormone therapy initiation and presentation for IIH. The present series illustrates the possible underrecognized risk of FTM transitioning testosterone therapy in causing IIH, which may necessitate ONSF in severe cases.…”

“…This is in line with the 15 reported FTM transgender patients in the literature; of the 13 patients with BMI reported, 6 were overweight, 4 were obese, and 3 were morbidly obese. [8][9][10][11][12][13][14][15][16] Only 1 patient in the literature reported a "normal" BMI, although an exact number was not provided. 7 The authors hypothesize that the patients in the series were at risk for developing IIH given their body habitus and that the exogenous testosterone may have contributed to the precipitation of symptoms over time.…”

“…1 The role of androgens in IIH is emerging, as these patients share many characteristics with other androgenexcess states, including polycystic ovarian syndrome (PCOS). [2][3][4][5][6] Supporting this theory of androgen excess, there have been 15 cases reported in the literature of patients undergoing femaleto-male (FTM) gender transition with exogenous testosterone therapy who were diagnosed with IIH. [7][8][9][10][11][12][13][14][15][16] Transgender and gender nonbinary individuals are a growing demographic in the United States.…”

“…[2][3][4][5][6] Supporting this theory of androgen excess, there have been 15 cases reported in the literature of patients undergoing femaleto-male (FTM) gender transition with exogenous testosterone therapy who were diagnosed with IIH. [7][8][9][10][11][12][13][14][15][16] Transgender and gender nonbinary individuals are a growing demographic in the United States. It is estimated that 0.39% to 2.7% of the population identify as transgender, which appears to be increasing, especially among younger individuals.…”

Hypogonadism and Intracranial Hypertension: A Case Report and Brief Review

“…Based on these findings, researchers have suggested a “pathophysiological window” of abnormal circulating androgen levels in humans that is above the normal range for females but below the normal range for males [ 4 , 8 ]. There are defined sexually dimorphic roles of androgens in metabolic diseases [ 10 ]. Men with androgen deficiency and women with androgen excess share a largely overlapping adverse metabolic phenotype.…”