Estrogen-Induced Pancreatitis: Transgender Females at Risk

Abstract

Estrogen therapy and the consideration of its potential side effects will continue to grow as the number of transgender females presenting to health care services continues to increase. The risks of estrogen therapy in this population are hard to extrapolate from previously identified data in the general population due to variation in birth sex, superior hormone doses required, and extended exposure duration that is often needed. Estrogen therapy is a rare, yet well-known, cause of acute pancreatitis with as many as 40 known reported cases in women and only one other reported case in a transgender female. The presumed mechanism is estrogen-induced hypertriglyceridemia as triglyceride levels were documented as greater than 1,000 mg/dL in most diagnosed patients. The limited data and evidence-based recommendations regarding estrogen therapy treatment and management in transgender women have led to a general lack of understanding among most practitioners. The long-term supraphysiologic doses of sex hormones required for treatment in transgender women and the dose-dependent estrogen-induced elevation in triglycerides are factors that contribute to an increased risk of pancreatitis. Therefore, the utility of regularly scheduled lipid panels in the prevention of pancreatitis increases in this population.

An Unusual Case of the “Terrible Triad” in a Transgender Woman

“…This leads to increased TG-rich chylomicrons, which increase plasma viscosity, causing ischemia and damage to the pancreas [3,5]. Estrogen-induced AP in transgender individuals due to severe HTG has been reported in at least four cases in the medical literature thus far [3,[6][7][8]. Hence, it is recommended that serum TGs should be routinely monitored in transfeminine patients on estrogen therapy, especially in those who have preexisting HTG [8].…”

A Rare Cause of Acute Pancreatitis in a Transgender Female

“…Estrogen is a rare cause of drug-induced pancreatitis with ~40 cases reported worldwide and only 2 published case reports in transgender females [6][7][8] (Table 1). With a growing number of transgender patients presenting within the health care system (9.2 per 100 000) and transgender females requiring supraphysiologic doses of estrogen therapy to maintain secondary sexual characteristics, it is important to understand their risk for and ways to prevent AP.…”

“…In the previous 2 case reports, one patient was taking 2 mg of estradiol twice a day for 10 years, while the second patient was taking a combination of estrogenic and antiandrogenic compounds (conjugated estrogens 0.625 mg, cyproterone 2 mg, and ethinyl estradiol 0.035 mg) for 3 months. 7,8 Prevention requires a goal TG level of <200 mg/dL with the use of a fibrate, niacin, or n-3 fatty acids either alone or in combination. For patients with hyperchylomicronemia, a diet that is restricted from fat and simple sugars is recommended.…”

“…4,5 Estrogen-induced pancreatitis is well documented in females using hormone replacement therapy; however, to our knowledge, there are only 2 other reported cases of estrogen-induced pancreatitis in transgender females. 6,7 In this article, we present a rare case of a transgender female who developed acute severe pancreatitis after a few months of using estrogen as sex change therapy.…”

Central Feminization of Obese Male Mice Reduces Metabolic Syndrome

“…However, global estrogen replacement poses numerous hurdles. In particular, estrogen has tissue specific physiological effects, both positive and negative [ 14 , 15 , 16 ]. Thus, identification of specific sites of estrogen action is imperative to develop selective estrogen therapies that can treat diseases associated with obesity.…”