Glycemic Control During Gender-Affirming Therapy in a Patient With Type 1 Diabetes

A 20-year-old transgender woman (natal male with feminine gender identity) with a 15-year history of type 1 diabetes presented to the clinic to begin gender-affirming hormone therapy. The patient was diagnosed with type 1 diabetes at the age of 5 years. Around the time of diagnosis of type 1 diabetes, she experienced two episodes of diabetic ketoacidosis but has had no additional episodes since adolescence. At initial presentation to the endocrinology clinic, her A1C was 6.8% (51 mmol/mol) on therapy with insulin detemir 33 units each night and mealtime insulin lispro at a 1:8 insulin-to-carbohydrate ratio. At this time, she was experiencing approximately one episode of hypoglycemia per week.The patient reported gender dysphoria since the age of 15 or 16 years but had no prior gender-affirming hormonal therapy or surgery. She had a history of post-traumatic stress disorder, anxiety, suicidal ideation, and suicide attempt. The patient’s family history was unknown because she was raised in the foster care system.On social history, she had no history of tobacco use. She had a history of being abused by her biological father and foster parents. At the time of presentation, she had had two sexual partners and no history of sexually transmitted infections.Baseline laboratory test values before starting gender-affirming therapy included thyroid-stimulating hormone 3.301 units/mL, prolactin 7.0 ng/mL, estradiol <20 pg/mL (<73.4 pmol/L), and testosterone 473.9 ng/dL (16.4 nmol/L). Her total cholesterol was 145 mg/dL (3.75 mmol/L), triglycerides were 44 mg/dL (0.50 mmol/l), LDL cholesterol was 73 mg/dL (1.89 …