Hair Loss with Gender Affirming Hormonal Treatment in AFAB People

Slight Acceleration of Androgenetic Alopecia in AFAB Transgender People

in the United States, 1.6 million people age 13 and over identify as transgender. That’s 1.3 million adults and 300,000 youth.

A significant proportion of people who identify as transgender are youth. About 18 % of individuals who identify as transgender are youth. 0.9 % of adults in North Carolina identify as trangnender compared to 0.2 % is Missouri.  3 % of youth in New York identify as transgender.

Germany and Sweden have some of the world’s greatest proportion of people who identify as transgender. It is estimated that approximately three percent of all people who live in Germany and Sweden identify as transgender, gender fluid, or nonbinary. Somewhere between the US statistics and Germany/Sweden are countires like India, Argentina, Spain, Australia and Canada. where 2 % identify as transgender, gender fluid, or nonbinary.

Gender-affirming hormonal treatment (GAHT) is usually the very first medical intervention requested by transgender people in order to align their body with their perceived gender. These medical interventions generally involve  administration of testosterone (T) in AFAB (assigned female at birth) trans people and estrogens and/or antiandrogens in AMAB (assigned male at birth) trans people.

Hair loss is often a concern on GAHT given to AFAB given the  androgens that are required to obtain virilization. I was interested in a new report providing more information on the dermatological changes in patients undergoing GAHT.

Cocchetti C et al. 2022

Authors of a new multicenter study set out to   was to assess dermatological changes in transgender people after the start of gender-affirming hormonal treatment (GAHT).

In their study, all trans AFAB people received T treatment to obtain virilization.   Testosterone sources included intramuscular  injections of T undecanoate  or combination of T esters  or transdermal T gel

Treatment of trans AMAB people consisted of both estrogens and antiandrogens, in order to obtain a full feminization and de-masculinization .  All patients received cyproterone acetate (50 mg/daily) combined with estradiol valerate or estradiol patches or estradiol hemihydrate gel .

There were 193 AMAB and 291 AFAB patients studied at baseline and then again at 6 and 12 months. Hair loss was assessed by the Hamilton Norwood scale. Acne and hair on the body was also assessed in the study

In AFAB people, Hamilton Norwood increase over the 12 months from 1.07 to 1.21 Testosterone levels rose from 1.2 to 22 nmol/L. There was also an increase in acne scores and hair on the body (as assessed by the Ferriman Gallwey score)

In AMAB, Hamilton Norwood ratings decreased from 2.00 to 1.76 although this was not statistically Significant. Testosterone reduced from 19.0 to 0.70 nmol/L and estradiol increased from 89 to 200 pmol/L

Comments

This is an interesting study which highlights that slight worsening of androgenetic hair loss occurs in AFAB people over 12 months of observation. The changes don’t happen all that much in the first 6 months but happen to a greater degree in the second 6 months.

 We don’t have longer term data – especially what happens to hair over the first five years.

 It’s easy to conclude that the changes are not significant. However, over 5 years, it likely will be significant. In fact, the authors point out one patient in the study AFAB who went from Hamilton Norwood 1 to 3 in just 12 months.

 More studies are needed to better understand how to provide care. Topical antiandrogens and topical and oral minoxidil are first line in my clinic to help AFAB transgender people  improve and maintain hair.

REFERENCE

C Cocchetti et al. Effects of hormonal treatment on dermatological outcome in transgender people: a multicentric prospective study (ENIGI). J Endocrinol Invest. 2022 Nov 8.