Meningioma Growth in Transsexual Patients in the Setting of Gender-Reaffirming Estrogen Therapy

Introduction: Two-thirds of meningiomas occur in women. They are known to enlarge or become symptomatic during pregnancy and there is an increased incidence of meningiomas in women with breast carcinoma. Approximately 70% of meningiomas express progesterone receptors while 30% express estrogen receptors. Transsexual male-to-female patients often take estrogen or steroidal antiandrogens. Here, we report on two transsexual patients who presented with meningiomas, which grew after starting gender-reaffirming hormonal therapy.

Methods: The authors performed a literature review on PubMed on using the keywords “meningioma estrogen transgender,” “meningioma estrogen transsexual,” “meningioma cyproterone acetate transgender,” and “meningioma cyproterone acetate transsexual.” We found 13 studies and found 1 overlapping study, in which case we excluded the 3 patients and used the primary paper for obtaining patient information.

Results: We have treated two patients who presented after initiating gender-affirming hormonal therapy. Patient 1 underwent CPA and estradiol therapy for 49 years, whereas patient 2 used estrogen gel, spironolactone and CPA for 3 years. Both patients underwent surgery for their symptomatic meningiomas after counseling regarding the risks and benefits of continuing with hormone treatment. Patient one had multiple meningiomas in the planum sphenoidale, sphenoid wing and parietal convexity. Patient two had a planum sphenoidale meningioma. On histology, patient one had a transitional meningioma with ER+ (40%)/PR+ (70%), and patient two had a meningothelial meningioma which was ER-/PR+. There have been 24 reported cases in the literature of transsexual patients with meningiomas discovered after commencement of gender-reaffirming therapy. All patients were on cyproterone acetate (CPA) (ranging from 10 to 200 mg/day) except for one. 20 patients were also on estrogen therapy. On average, patients presented 13.8 years (range: 4–32 years) after starting hormone therapy with a mean cumulative exposure of 327 g (range: 11.2–1,092 g) of CPA by the time of presentation. The locations were reported on 16 patients and did not have a predilection for any specific location. 4 patients had meningothelial meningiomas. Only 1 patient was reported to have a grade II meningioma. Five of the 6 patients with reports had progesterone receptor-positive meningiomas, and only one of 6 had estrogen receptor-positivity in conjunction. Twelve patients underwent surgery, with one patient undergoing surgery and stopping hormone therapy. Four were surveilled radiographically, and 8 patients had discontinuation of the hormone therapy.

Discussion: There was high variance in the amount of CPA exposure until presentation. This may be partially due to the slow growth of meningiomas, which may be asymptomatic for some time. Patients undergoing gender-reaffirming hormone therapy are not regularly screened radiographically; therefore, it is unclear at what stage exposure to CPA and estrogen treatment may lead to increased risk of meningioma development. Whether this is a cumulative effect or based on concentration of therapy is unclear. Most of the patients reported had CPA dosing of 50 to 100 mg/day. However, one patient had only 20 mg/week and presented with seizures 11 years after starting therapy. A prospective study on this unique cohort of patients is needed to determine the potential need for cranial screening of meningiomas.

 

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Artikel online veröffentlicht:
01. Februar 2023