Persistent Virilization and Vasomotor Symptoms in a Transman 5 Years Post Testosterone Withdrawal

A 23-year-old transman, who had ceased testosterone therapy 5 years prior, presented with severe heat intolerance, flushing, sweating, and nausea, along with increased facial hair growth. Despite a history of gender-affirming care starting at age 14, including testosterone therapy, progesterone, etonogestrel implant, hysterectomy, and bilateral mastectomy, the patient experienced persistent virilization symptoms. Physical examination revealed male pattern alopecia, terminal facial hair, acne, and other features, with elevated levels of total testosterone and DHEA. A diagnosis of PCOS was made based on hirsutism and polycystic ovaries. The patient's symptoms resolved after a trial of low dose oral estradiol, suggesting that the symptoms may have been due to hormonal feedback alterations. The case highlights the need for baseline hormonal level assessments before initiating hormonal affirming care, the importance of screening transmen for PCOS, and the aggressive treatment of metabolic and cardiovascular risk factors in this population.