Collaborative Management of Estrogen-Induced Severe Hyperlipidemia in Transsexual Female

Case Report

J Fam Med. 2014;1(3): 4.

Collaborative Management of Estrogen-Induced Severe Hyperlipidemia in Transsexual Female

Thompson AM PharmD, BCPS1*, Saseen JJ PharmD, BCPS, BCACP1, 2 and Eckel RHMD3

1Department of Clinical Pharmacy, University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences, USA

2Department of Family Medicine, University of Colorado School of Medicine, USA

33Division of Endocrinology, Metabolism and Diabetes and Division of Cardiology, University of Colorado School of Medicine, USA

*Corresponding author: Thompson AM PharmD, BCPS, Department of Clinical Pharmacy, University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences, USA

Received: November 11, 2014; Accepted: December 10, 2014; Published: December 12,2014


Estrogen therapy is commonly used in male to female transsexual individuals to replace endogenous sex hormones with desired sex hormones. We describe a 52 year old transsexual female who developed severe hypertriglyceridemia, without symptoms of pancreatitis, while taking esterified estrogen (Menest®) 3.75 mg daily. After discontinuing estrogen, starting rosuvastatin 20 mg daily and following a no fat diet, the patient’s triglycerides fell to 983 mg/dL. Subsequent changes resulting in a lipid medication regimen of omega-3 fatty acids 4 g daily and gemfibrozil 600 mg twice daily led to a lipid panel of: TC = 142 mg/dL; TG=361 mg/dL; HDL-C = 33 mg/dL; LDL-C = 37 mg/dL while on transdermal estrogen. Although it is known that oral estrogens may lead to hypertriglyceridemia, to our knowledge this is only the second case report of estrogen-induced hypertriglyceridemia in a transsexual female. Management of hypertriglyceridemia in this patient was complicated by the financial status of the patient; therefore, the patient was managed within a family medicine clinic in collaboration with a clinical pharmacist and an outside endocrinologist. This case emphasizes an important, yet often overlooked, adverse effect of hypertriglyceridemia with oral estrogen therapy in this population. The risk of pancreatitis from elevated triglycerides is real and can be life-threatening; thus, monitoring for hypertriglyceridemia should not be overlooked and when hypertriglyceridemia is present transdermal estrogen should be used and monitored.

Keywords: Hypertriglyceridemia; Estrogen; Transsexual; Triglycerides; Cholesterol


TC: Total Cholesterol; TG: TriGlycerides; HDL-C: High Density Lipoprotein Cholesterol; LDL-C: Low Density Lipoprotein Cholesterol; mg: milligrams; dL: deciliter; DHA: Docosahexaenoic Acid; EPA: Eicosapentaenoic Acid; DES: DiEthylStilbestrol; WPATH: World Professional Association for Transgender Health

Case Presentation

A 52 year old, 74 inch, 114kg, Caucasian biological male who selfidentifies as a female was referred to pharmacotherapy clinic for a pharmacoeconomic evaluation due to issues affording her estrogen therapy. She had not been able to afford gender reassignment surgery due to unemployment. She expressed concern regarding recent laboratory results and reported very elevated total cholesterol and triglycerides levels. Upon review, her previous laboratory values from one week prior were: total cholesterol (TC) = 1298 mg/dL, high density lipoprotein cholesterol (HDL-C) = 60 mg/dL, and triglycerides (TG) = 7018 mg/dL. A fasting lipid panel was repeated and revealed the following: TC = 1142 mg/dL; HDL-C = 50 mg/dL; TG = 9255 mg/dL (Table 1). She denied abdominal pain and xanthomatosis. Laboratory values for kidney and liver function were all within normal limits. The patient reported no signs or symptoms of pancreatitis.

A review of diet revealed the patient typically skipped breakfast and occasionally skipped lunch. When she did eat lunch she ate a peanut butter or turkey sandwich on multi-grain bread. The night prior to the most recent fasting lipid panel, the patient had eaten 2 homemade hamburgers with mustard, pickles, and barb-b-que sauce for dinner. She occasionally snacked on chips and ate out about 2 times per month (at fast food restaurants). Her diet was significantly dictated by her limited financial resources, and she reported spending ~$120 per month on food.

The patient’s past medical history was significant for hypertension and hearing loss. Her family history was significant for high cholesterol and colon cancer. The patient denied alcohol and tobacco use.

She was taking oral esterified estrogen (Menest®) 3.75 mg daily, medroxyprogesterone 5 mg daily 7 days of every month, spironolactone 25 mg four times daily and olmesartan-hydrochlorothiazide 20- 12.5 mg daily. The patient reported no known drug allergies. She was not on any lipid-lowering medications at the time of her laboratory evaluation. She reported using rosuvastatin in the past but discontinuing it due to fatigue. She was uncertain when she took rosuvastatin and what dose she had taken. The patient reported taking oral estrogen for years, but she could not quantify an exact duration. She reported when she was in school to become a medical assistant, the instructor would use her blood as an example as it would become lactescent when it sat overnight.

Due to financial limitations, she was unable to afford referral an endocrinologist and was therefore managed within the family medicine setting. Management was a collaborative effort among a family medicine physician, nurse practitioner, clinical pharmacist and an outside endocrinologist. She was started on a no fat diet (e.g. vegetables, fruits, brown rice) and rosuvastatin 20 mg daily as the clinic had free samples available. Oral estrogen was stopped. She was instructed to return to clinic for fasting lipid panels every 3 days until her triglycerides fell to less than 1000 mg/dL. Due to patient specific limitations, the patient opted to get fasting lipid panels measured once weekly. After approximately 3 weeks, the patient’s triglycerides fell to 983mg/dL, fenofibrate 134 mg daily was prescribed, and rosuvastatin was increased to 40 mg daily. The patient was unable to pick up fenofibrate, but after another 2 weeks of rosuvastatin 40 mg daily, the patient’s triglycerides fell to 435 mg/dL. At this time, transdermal estradiol was initiated, and a moderate amount of fat was slowly reintroduced into her diet. When the patient was able to obtain fenofibrate, it was discontinued after 1 day due to the development of a rash. Omega 3 fatty acids were initiated. The patient was initially started on Lovaza® 2 g twice daily, but she then switched to over the counter fish oil 4 grams daily after her free samples were exhausted. The patient was instructed to take 4 grams of docosahexaenoic acid/ eicosapentaenoic acid (DHA/EPA). Over the next several months, rosuvastatin was decreased to 10 mg daily and then discontinued (due to low density lipoprotein cholesterol (LDL-C) levels ranging from 13-46 mg/dL) and gemfibrozil 600 mg twice daily was initiated. After 4 weeks of gemfibrozil and omega-3 fatty acids, her fasting lipid panel had improved: TC = 142 mg/dL; TG=361 mg/dL; HDL-C = 33 mg/dL; LDL-C = 37 mg/dL (Table 1).

Citation:Thompson AM, Saseen JJ and Eckel. Collaborative Management of Estrogen-Induced Severe Hyperlipidemia in Transsexual Female. J Fam Med. 2014;1(3): 4. ISSN:2380-0658