Societal pressure to help young women transition can create a major medical dilemma. Before any prescribed course is followed, a qualified psychiatrist should be consulted. The use of super physiological doses of androgens to facilitate transition comes with significant risk to the patient. As a model, we need only look at the adverse effects of androgen excess in Poly Cystic Ovary Syndrome (PCOS) to understand the gravity of the decision to administer androgens to otherwise healthy young biological women.

Studies of the clinical features of PCOS showed that obesity was present in slightly more than 50% of women. Obesity tends to be abdominal in PCOS women, and even lean effected women may have a fat distribution favoring visceral depots.  Clinically, an increase in the upper body or central distribution of fat gives rise to an increased waist to hip ratio compared to obese women without PCOS. This fat distribution pattern has been termed android obesity and is seen in other hyperandrogenic states, diabetes, and hyperlipidemia. There is a preponderance of visceral fat similar to the distribution of adipose tissue in non-PCOS individuals with insulin resistance.

Women with PCOS tend to be insulin resistant and as a result have compensatory hyperinsulinemia. The prevalence of insulin resistance in PCOS has been reported to be 20 to 40%. Approximately 60% of insulin resistant PCOS women are obese suggesting that there is a high degree of correlation between obesity and insulin resistance. Several other studies have demonstrated that insulin resistance is very common in obese PCOS women specifically, the abdominal (androgen) phenotype, although it may be present in normal weight PCOS women. Generally, the degree of insulin resistance in mild, though the prevalence of glucose intolerance and subsequent diabetes has been reported to be as high as 31% and 7.5% respectively. In these women progression to diabetes appears to be rapid.  Commonly, fasting hyperglycemia is not evident; instead there is a primary dysfunction of postprandial glucose uptake that results in severe peripheral insulin resistance.

Worsening insulin resistance in the long run is a significant risk factor for impaired glucose tolerance and Type II diabetes. Clinical trials have demonstrated that impaired glucose tolerance is present in as many as 30 to 40% of PCOS women in the USA at their first clinical visit and to a somewhat less extent in Europe, while it is relatively uncommon in their normal-weight counterparts.

The sequelae of diabetes are all to well-known heart disease, nephropathy, neuropathy, retinopathy etc. Caution should be the guiding principle.

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