Collaborative Management of Estrogen-Induced Severe Hyperlipidemia in Transsexual Female

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.