Polycystic Ovarian Syndrome and Trans Men: Is There a Link?

Polycystic ovary syndrome (PCOS) is an endocrine disorder characterized by cyst formation in the ovaries and increased testosterone and luteinising hormone (LH) levels.

Symptoms of PCOS include irregular periods, acne, infertility, obesity, virilisation, and sleep apnea, as well as mood swings, depression, anxiety, and poor self-esteem. PCOS can also increase the risk of uterine cancer. While some of the virilizing effects of PCOS may be seen as desirable to trans men, like facial and body hair growth, the associations with obesity, elevated cholesterol and insulin resistance are likely to result in increased cardiovascular risk.

PCOS is found in 5-15% of people assigned female at birth. While relatively common, the underlying causes of PCOS are not yet fully understood. There may be a genetic link, but the gene involved and mode of inheritance have not been identified.

Although it is not entirely clear how androgens are involved with PCOS, studies suggest that excessive androgen is closely related to the development of PCOS. Several studies have demonstrated that the androgen-exposed ovaries of trans men show PCOS-like features:

• Ovarian cortex is thickened and shows marked collagenization
• Ovarian stroma contains greater numbers of cystic and cystic atretic follicles
• Diffuse ovarian stromal hyperplasia
• Luteinization of stromal cells

Despite a number of studies linking PCOS and trans men, a 2012 study concluded that high-dose androgen administered to FTMs does change the ovarian cortex and stroma but it does not induce PCOS. A more recent study published in 2018 also concluded that "testosterone therapy does not induce or exacerbate the metabolic features associated with PCOS."

Most people with PCOS are not trans but there are high rates of PCOS in FTM transsexuals. If you think you might have PCOS, definitely speak with your doctor about it.

Studies About Transgender Men and PCOS

NEW! Exogenous Testosterone Does Not Induce Or Exacerbate The Metabolic Features Associated With Pcos Among Transgender Men.
Chan KJ, Liang JJ, Jolly D, Weinand JD, Safer JD. Endocr Pract. 2018 Apr 6. doi: 10.4158/EP-2017-0247. [Epub ahead of print]
This retrospective chart review of 34 transgender men found that testosterone therapy does not induce or exacerbate the metabolic features associated with PCOS.

Excessive androgen exposure in female-to-male transsexual persons of reproductive age induces hyperplasia of the ovarian cortex and stroma but not polycystic ovary morphology
Keiko Ikeda, Tsuyoshi Baba, Hiroko Noguchi, Kunihiko Nagasawa, Toshiaki Endo, Tamotsu Kiya, and Tsuyoshi Saito. Hum. Reprod. (2013) 28 (2): 453-461 first published online November 27, 2012.
Does administration of androgen to female-to-male transsexual persons (FTMs) of reproductive age induce polycystic ovary (PCO) morphology? Although it is not entirely clear how androgen acts in PCOS, there is no doubt that excessive androgen is closely related to the pathogenesis of PCOS. Several investigators have reported that the androgen-exposed ovaries of FTMs show PCOS-like features, that is, the ovarian cortex is thickened and shows marked collagenization, and the ovarian stroma contains greater numbers of cystic and cystic atretic follicles. Interestingly, we recently noticed that the resected ovaries of SRS patients visiting our gender clinic did not always show a PCO morphology, despite exposure to androgen. Our results indicate that high-dose androgen administered to FTMs of reproductive age changes the ovarian cortex and stroma, in a manner that is similar to the Stein–Leventhal ovary but it does not induce PCO morphology.

Histology of genital tract and breast tissue after long-term testosterone administration in a female-to-male transsexual population.
Grynberg M, Fanchin R, Dubost G, Colau JC, Brémont-Weil C, Frydman R, Ayoubi JM. Reprod Biomed Online. 2010 Apr;20(4):553-8.
The present data confirms and expands the putative associations between long-term androgen administration and abnormalities in ovarian architecture with macroscopic and microscopic characteristics of PCO, increased risk of endometrial atrophy and fibrotic breast tissue with marked glandular reduction.

Association between polycystic ovary syndrome and female-to-male transsexuality
Tsuyoshi Baba, Toshiaki Endo, Hiroyuki Honnma, Yoshimitsu Kitajima, Takuhiro Hayashi, Hiroshi Ikeda, Naoya Masumori, Hirofumi Kamiya, Osamu Moriwaka, and Tsuyoshi Saito. Hum. Reprod. (2007) 22 (4): 1011-1016 first published online December 13, 2006
Of the 69 participating FTM cases, 40 (58.0%) were found to have PCOS. Our findings show that many cases of FTM transsexuality are associated with PCOS and hyperandrogenaemia, which suggests that they are important factors in the pathogenesis of FTM transsexualism.

A higher rate of hyperandrogenic disorders in female-to-male transsexuals.
Bosinski HA, Peter M, Bonatz G, Arndt R, Heidenreich M, Sippell WG, Wille R. Psychoneuroendocrinology. 1997 Jul;22(5):361-80.
Hyperandrogenism with polycystic ovarian syndrome (PCOS) and adrenocortical hyperresponsiveness to ACTH seems to be a common finding in FTM. This offers support for a hormonal factor in the genesis of FM-TS. Because the prevalence of PCOS and NC-CAH in the female population is higher than FM-TS, the true nature of this factor and its interaction with environmental influences remains unknown.

Ovarian morphology in long-term androgen-treated female to male transsexuals. A human model for the study of polycystic ovarian syndrome?
Pache TD, Chadha S, Gooren LJ, Hop WC, Jaarsma KW, Dommerholt HB, Fauser BC. Histopathology. 1991 Nov;19(5):445-52.
TSX ovaries were enlarged and displayed a two-fold increase in cystic follicles and a 3.5-fold increase in atretic follicles; the ovarian cortex was collagenized and three-times thicker. Theca interna hyperplasia and luteinization were uniformly observed in TSX cystic follicles. Stromal hyperplasia was a constant finding in TSX ovaries, accompanied by clusters of luteinized stromal cells in 12 cases. Eventually, these findings met the histological criteria for the diagnosis of polycystic ovaries. These observations demonstrate that androgens alone may induce polycystic changes.

The effects of long term testosterone administration on pulsatile luteinizing hormone secretion and on ovarian histology in eugonadal female to male transsexual subjects.
Spinder T, Spijkstra JJ, van den Tweel JG, Burger CW, van Kessel H, Hompes PG, Gooren LJ. J Clin Endocrinol Metab. 1989 Jul;69(1):151-7.
Studies of ovarian histopathology in 26 transsexual subjects after long term androgen treatment revealed multiple cystic follicles in 18 subjects (69.2%), diffuse ovarian stromal hyperplasia in 21 subjects (80.8%), collagenization of the tunica albuginea in 25 subjects (96.2%), and luteinization of stromal cells in 7 subjects (26.9%). Findings consistent with criteria for the pathological diagnosis of polycystic ovaries, that is 3 of the 4 findings listed above, were present in 18 of the 26 subjects (69.2%).

Histopathological effects of exogenously administered testosterone in 19 female to male transsexuals.
Futterweit W, Deligdisch L. J Clin Endocrinol Metab. 1986 Jan;62(1):16-21.
Findings consistent with polycystic ovaries were thus present in 13 of the 19 patients based on the presence of 3 of the above 4 findings. The data suggest that increased blood levels and presumably increased ovarian concentrations of testosterone may produce the morphological features of polycystic ovarian disease.

The effects of long-term androgen treatment on the ovary.
Amirikia H, Savoy-Moore RT, Sundareson AS, Moghissi KS. Fertil Steril. 1986 Feb;45(2):202-8.
Study concludes that exogenous androgen can thicken the tunica albuginea and basal membrane and that these histologic changes are similar to those seen in PCO ovaries under excess endogenous androgen production.

Last updated: 04/08/18