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Episode 17 Transcript

Transgender Orchiectomy Surgery with Chirag Dave, MD

Erin Everett: Hey everybody. Welcome back to Exclusively Inclusive. I’m your host, Erin Everett, nurse practitioner. Really excited about today’s episode, because I think it’s going to be really helpful and useful for the community. Today we’re going to be having a very special guest, Dr. Chirag Dave. Dr. Chirag Dave is someone that I collaborate with on a regular basis to help with my patients, and he actually is located here in Atlanta and native to Smyrna, Georgia. Dr. Dave is affiliated with Advanced Urology, and has extensive experience in all things urology, especially as it pertains to infertility, andrology, erectile dysfunction, voiding dysfunction, but also, he is able to provide a certain level of gender affirming care for patients, including therapeutic orchiectomies.

Erin Everett: Dr. Dave completed his medical training and degree at Northeast Ohio Medical University, where he graduated in the top 10% of his class, which is no surprise after speaking with him. He also completed a general surgery internship and urology residency at William Beaumont Hospital in Michigan, where he gained considerable experience in general urology and advanced endoscopic laparoscopic and robotic surgeries.

Erin Everett: After completing that, Dr. Dave went on to complete a fellowship in genital urinary reconstruction, sexual and male reproductive medicine at the John Hopkins University School of Medicine in Maryland. It was also here that he was able to gain experience with trans-women and the gender affirming process as it pertains to surgeries. Dr. Dave is very passionate about helping his patients in any way that he can. I can attest to that as he’s helped many of my patients achieve what their normal functioning can be, and to also help them have pain relief with painful erections, allow them to have therapeutic orchiectomies, and also something as simple as providing trans-friendly care for those who have renal stones and other urinary issues.

Erin Everett: Without further ado, I would love to introduce Dr. Dave to our show, and let’s get started. All right. On today’s show, we have Dr. Chirag Dave, welcome to the show.

Chirag Dave: Thank you. Thank you. It’s a pleasure to be with you and to get a chance to virtually meet your audience today.

Erin Everett: Yeah, I’m really excited. I think the things that we have on the list of topics today is going to be really helpful for the community. But before we get started, just tell us a little bit about yourself and where you’re practicing right now, what your passion is, as far as urological care, and maybe a fun fact about you that nobody else knows or wouldn’t expect.

Chirag Dave: Absolutely. I am a native of Smyrna, Georgia. I grew up in Smyrna. I went to school in Marietta, and essentially, I’m Atlanta native, but when I graduated, attended college in Chicago, went to medical school in Ohio, and that’s where I initially became interested in urology. It was during a gynecology rotation, ironically, as a third-year medical student, where I realized urology would afford me the opportunity to be a surgeon, but also follow my patients long-term and address chronic and lifestyle issues. But I think what really attracted me to the field was just the sensitive nature of the problems and how we really had effective solutions that could give immediate gratification to the patients, but also to the treating surgeon and physician as well.

Chirag Dave: That attracted me to urology and ended up doing a five-year urology residency in Michigan at Beaumont. That consisted of one year of general surgery, followed by four years of urology training. During urology training, I was exposed to all aspects of urology, but I became specifically interested in sexual medicine, which included transgender health, but also infertility and reconstructive urology. Following my general urology training, I went and did a fellowship in sexual and reproductive medicine at the Johns Hopkins University in Baltimore, training with Dr. Arthur Burnett, Dr. Amin Herati. That was an outstanding experience.

Chirag Dave: I learned all aspects of sexual health, but also got to be involved in a very busy transgender health program, as well as the reconstructive urology unit. So, was involved in lots of interesting surgeries, but also really got to know the transgender population and some of the sensitivities that goes along with that. Hopefully, that’s given me a unique perspective as a urologist to approach some of these issues from different angles. Then recently, I decided to move back to Atlanta where I’ve joined Advanced Urology. I’m primarily located in the Marietta office, but will work in Sandy Springs as well, and was fortunate to meet you, Erin, and I’ve had the pleasure of taking care of several of your patients. I always love having interesting discussions with you about these patients as well.

Erin Everett: Yeah, super fun stuff.

Chirag Dave: I guess a little known fact about me, besides the fact that I grew up here in Atlanta, I’ve gone on a long circuitous route. My wife is actually a nephrologist, so I consider myself a surgeon of the neurologic system and she’s a medical doctor of the urologic system. We have interesting dinner table conversations to say the least. Our motto is, you’re in good hands. There’s lots of discussions about urine in the house …

Erin Everett: No pun intended.

Chirag Dave: Yeah, exactly.

Erin Everett: That’s so funny. Well, that’s really cool. Well, thanks for that intro. Some of the things that I would like to talk to you about today, really involve, not just the LGBTQ community, but more specifically trans-care. One thing I get asked a lot about, and I know you’ve taken care of a lot of my patients for this particular procedure is orchiectomy. Patients are dying to know what to expect really, like how much does it cost, a round about, of course, because obviously you can’t guarantee price with payers and whatnot and ever-changing rates, but on average, and how successful are you getting it covered by insurance and that type of thing. What pain should be expected post procedurally and what benefits they may have.

Chirag Dave: Sure. Yeah. Gender dysphoria is the medical diagnosis that’s frequently used for patients that are interested in these procedures. It should be considered a permanent method of a hormonal treatment for gender dysphoria. The procedure itself, we call it a simple bilateral orchiectomy, which basically means we’re removing the testicle surgically, but rather than doing, what’s called a radical orchiectomy, which is made through a groin incision or in the lower abdominal areas such as we would do for a patient with testicular cancer, where we need to remove the entire cord, as well as the testicle itself, this can usually be performed as a same day operation through a simple midline scrotal incision.

Chirag Dave: In my practice, it’s usually about a one-inch incision. Obviously the patient is asleep, so they don’t feel or remember anything. We use what we call multimodal pain control. A combination of a general or local anesthesia, but I can perform the operation through that one-inch incision, whereby we would remove the testicles and use a dissolvable suture to sew the incision back together. The operation itself, it takes about half an hour. Like I said, all patients go home on the same day. Most of the patients do very well in terms of pain control. We’ve started using a lot of local pain control, so the nerves that supply that generally very sensitive area. We use numbing medication during the procedure to blunt that response. Most patients just use over the counter Tylenol and Ibuprofen to control the pain.

Chirag Dave: We’ll send them home with a couple of pain pills, only to be used with extreme cases of pain, but the majority of my patients never really even have to fill that prescription or use that medication. Usually, just because of concerns about bleeding or anything like that after the procedure, and I ask them to wear a tight supportive underwear for a few days and refrain from any kind of heavy lifting. Heavy lifting for me is anything more than about seven to 10 pounds, which is about a gallon of milk, if you wanted to compare it to something. But no heavy lifting for about five to seven days after the procedure.

Chirag Dave: After that, things have pretty much returned to normal. Then I’ll usually see those patients about a month after the procedure just to take a look at the incision and make sure things are healing up well, and then basically return them to your practice to continue with their chronic hormonal management. But one thing I will touch on, bilateral orchiectomy is a fairly common procedure in urology, whether it’s for testicular cancer, or whether it’s for hormonal management or prostate cancer or something like that. The orchiectomy that should be performed for gender dysphoria does have some technical considerations, namely, where we place the incision.

Chirag Dave: We’d like the incision to be in a cosmetically appearing location so that if the patient does decide to undergo subsequent gender reassignment, that the scar doesn’t cause any major issues with the cosmetic appearance of gender reassignment later down the line.

Erin Everett: That’s why it’s so important to have a specialist like yourself who’s familiar with that type of thing so that patients can still have that as an option, because the vast majority would love to go on to get vaginoplasty if it’s available to them. That’s awesome. I didn’t realize it was such a quick procedure, so that’s reassuring. Do you have a lot of difficulties getting it covered by insurance, or is it just dependent on whether or not their plan is inclusive of trans-care?

Chirag Dave: Yeah, I would say we’ve had considerable improvement in insurance coverages as a gender dysphoria has increasingly been recognized by a number of insurance companies. I am, by no means, an expert in insurance companies, but certainly, more and more insurance companies have started to recognize the diagnosis. After we’ve made that diagnosis, the American Association recommends that patients be evaluated by two independent psychiatric health professionals. We do require two independent letters just stating that the patient has been evaluated and independent professionals feel that it’s reasonable for the patient to undergo this procedure, just because it’s, obviously, not a reversible procedure in most cases.

Chirag Dave: Just being absolutely sure that everyone’s in agreement that we should move forward, but as long as we meet those requirements and submit the necessary paperwork, I’ve found that the majority of patients have been able to get this covered by insurance. That being said, because it is a 30-minute procedure and can always be completed on an outpatient basis, we do have the opportunity to do this in an ambulatory surgical center where the patient would go home the same day with minimal anesthesia requirements, which can often reduce the cost of the procedure. But to answer your question, a lot of these are being covered by insurance companies nowadays.

Erin Everett: Okay. But it sounds like, should the patient have to pay out of pocket, it’s not totally out of reach.

Chirag Dave: Yeah. Again, I’m not an expert in that area and we can certainly get that information for patients, but I haven’t found it to be an astronomical number or anything like that.

Erin Everett: Yeah. Well, that’s excellent. The other question I had pertaining to orchiectomy was, a lot of patients have concerns about sexual function after the surgery. Obviously a lot of that depends, a lot of sexual function too, depends on hormone levels, but anatomically, because of the surgery, would you expect someone to have an issue maintaining an erection or getting an orgasm?

Chirag Dave: That’s a fantastic question. Something that we’ll always talk to the patients about before they undergo the procedures. Anatomically, if you think of the function of the testicles, the primary responsibility of the testicles are to produce testosterone and to produce sperm. Sperm only makes up about 5% of the ejaculate. The majority of ejaculate comes from the prosthetic secretions and from two structures called the seminal vesicles. Patients should still expect to ejaculate, and that wouldn’t look any different for them. The main issue after an orchiectomy is permanent loss of testosterone. Even in the female sexual dysfunction literature, we’ve started to recognize more and more the importance of testosterone, both for males and females in sexual function.

Chirag Dave: But this is primarily for libido. Libido is defined as your interest in sex or your appetite for sex. Occasionally, patients will need testosterone replacement to replace their libido, but specifically speaking, testosterone is not a treatment for erectile dysfunction, nor would I expect someone who had an orchiectomy or permanently lost their ability to produce testosterone to have complete loss of erections, but we may need to replace testosterone to enhance their libido.

Erin Everett: Oh, excellent. Yeah, that’s very good information for the listeners too, because I get a lot of questions about that. Well, that’s awesome. Basically, postoperatively, you don’t expect any complications, but if there were, what would you say is the most common issue that patients may encounter after this type of surgery?

Chirag Dave: Yeah, we always counsel patients on the risk of all operations, but specifically to this operation, I talked to them about the risk of bleeding. As I mentioned, no heavy lifting, nothing more than a gallon of milk for about five to seven days after the procedure. The tight supportive underwear help. I don’t want patients riding a bike or getting back to the gym too quickly because of the risk of the bleeding. Now, bleeding would generally manifest as what we call a scrotal hematoma. You can have some bruising and some discoloration of the scrotum after the procedure. Generally, it’s not an emergency and we don’t have to do any further procedures on that, but it can certainly delay the wound healing process. That is one of the things that we talk to patients about.

Chirag Dave: The other risk of any operation where you’re incising the skin is infection. Generally, we’ll give patients a preventative antibiotic, but if someone had an active infection of the scrotum, or I was concerned about the skin, we would treat that infection and wait until that was cleared up before we move forward with the surgery. But in general, as long as they understand that the procedure will result in permanent infertility and permanent lack of testosterone production from the testicles. The bleeding and the infection are the two main things that I talk to them about.

Erin Everett: Excellent. Awesome. Well, thank you so much for that information. It’s super helpful.

Erin Everett: Some of the other things too, that I wanted to touch on that I get a lot of questions about as far as urological standpoint in the gender diverse community would be genital atrophy for trans-women, and pain with erections. Typically, and I’ve only very recently started prescribing topical compounded testosterone. It’s like 1% compounded testosterone, just to be applied to the genitals, and daily Cialis. But is there anything else, from your standpoint, or am I off the mark on that? Anecdotally, I’ve seen some good results, but again, it’s only been a handful of people. What are your thoughts on those two issues?

Chirag Dave: No, I think you hit the nail on the head there. I think the benefits of phosphodiesterase 5 inhibitors such as Cialis, such as Viagra, which we can often use at lower doses in these patient populations. If you look at the way those medicines work, they work to increase an enzyme called nitric oxide, which basically enhances erections or clitoral engorgement. But it’s really working by bringing healthy blood supply to the penis. We know that blood has lots of anti-inflammatory and restorative properties in there. By putting patients on those medications, either in an on-demand fashion or at a daily low dose, I think it has a lot of restorative properties, and we’re using those medications in that fashion for a number of patients. I think topical testosterone can be helpful as well. We’ve used topical estrogen for vaginal atrophy for a number of years, but I think the benefits of the topical testosterone can certainly be beneficial as well.

Erin Everett: Yeah. Typically, I don’t even see a large increase in total testosterone too. They end up just, especially if they’ve already had an orchiectomy, they tend to just land in like CIS female ranges, topical T when we apply it that way.

Chirag Dave: Correct. Yeah, it tends to support the local tissues, but a number of studies have been done, both looking at topical estrogen, as well as topical testosterone where they’ve measured blood levels of testosterone and similar to what you’re seeing in your practice. We do not see a lot of systemic absorption or a lot of testosterone that’s absorbed into the bloodstream.

Erin Everett: Yeah. Excellent. As far as those topics go, as far as painful erection and pelvic floor pain and things like that, aside from medicines, do you have a lot of success with pelvic floor, PT, with these patients?

Chirag Dave: Oh my gosh. If I could get every single one of my patients to go to pelvic floor physical therapist, I would die a happy man. It just cannot be understated how detrimental the pelvic floor can be to so many issues in urologic health and sexual health. A tight wound up pelvic floor can really make things go haywire. I am a huge proponent of pelvic floor physical therapy. It’s important that patients understand that this isn’t necessarily a physical therapist that takes care of shoulders and ankles and knees, but someone that’s truly dedicated and has committed their career to the pelvic floor, and can rapidly assess the patient, come to a correct diagnosis and really use a lot of tricks in their tool bag. Can really get our patients rehabilitated and feeling better quickly. Yeah, I agree with you 100%. For a number of urologic sexual health conditions, we’re always asking our patients to see pelvic floor physical therapists.

Erin Everett: Yeah. It seems obviously surprising, but for lay people, I don’t think a lot of lay people realize that their pelvic floor is all muscles. They don’t think about it. Of course, just like you said, with a tight back or tight shoulder, you’re going to have limited range of motion and dysfunction. Well, the same holds for the pelvic floor. I think you’re 100% right with how helpful the physical therapy could be.

Chirag Dave: Yeah. If I can make a plug here, I have no affiliation with this book, but it’s just so wonderful that I tend to recommend it to a lot of my patients, but I believe it’s called, There’s A Headache in My Pelvis. It’s available on Amazon. I’ve had a number of patients that, maybe I had trouble explaining to them the importance of the pelvic floor that have then read the book and come back to me. It just triggered a light bulb that made this all evident for them. But we certainly do a lot in the office in terms of education and pictures and drawings and diagrams and models to just show how intimately involved the pelvic floor is in wrapping the urologic structures. Inflammation and pain of the pelvic floor can definitely cause referred pain to these urologic structures for patients.

Erin Everett: Yeah. That’s awesome. Yeah, I’ll make note of that book, and thank you for the recommendation.

Erin Everett: I was going to ask you, and of course we could probably have an entire episode on this particular urological issue, but briefly, can you speak to interstitial cystitis and how that may or may not impact a patient’s ability to go ahead and get gender reassignment surgery, or if it has any impact at all?

Chirag Dave: Yeah, absolutely. Interstitial cystitis is also defined as bladder pain syndrome. The hallmark of interstitial cystitis is bladder pain. Interstitial cystitis is considered a diagnosis of exclusion. What we mean by that is, these patients generally will complain of pain when their bladder is full and relief when the bladder is empty. But as most conditions are in medicine, there can be some gray areas with the diagnosis. The first step for a urologist is to rule out anything that could be masquerading as interstitial cystitis or bladder pain. We want to rule out a urinary tract infection, we want to rule out a kidney stone, blood in the urine, a prostate infection that could be mimicking these symptoms.

Chirag Dave: Of course, if we found that, we would treat it appropriately, but assuming you’ve ruled all these things out and the patient continues to have pain, one of the first steps is evaluating the bladder and the urethra with a camera. It’s a procedure called a cystoscope. When we look in the bladder, there can be some characteristic findings of interstitial cystitis. If a patient has ulcers throughout the bladder, that’s what we call hunner’s ulcers. We would generally cauterize or burn those ulcers, and that can give patients significant relief. The way I explain it to patients is, if you have interstitial cystitis with ulcers, the urine bathing those ulcers is like putting lemon on an open wound.

Erin Everett: Yeah, I can’t even imagine how painful that would be.

Chirag Dave: Yeah. Of course, we take a biopsy to make sure that it’s nothing more serious, but otherwise, there is benefit to cauterizing those ulcers to basically seal it so that, that very irritative urine isn’t continuously bathing that wound. But this true, what we call ulcerative interstitial cystitis, actually only exists in about 10% of patients. The other 90% would have what’s called glomerulations, or just bleeding and inflammation of the bladder. Those patients benefit from what’s called a hydro-distension, which is where we actually stretch the bladder with water. This is obviously generally done while they’re asleep, but that stretching of the bladder can increase their bladder capacity, which cuts down on urgency and frequency episodes. But it’s actually been shown to treat the pain as well.

Chirag Dave: We can often put a steroid or a numbing medication into the bladder as well. Going back to your previous point about the pelvic floor physical therapist. These 90% of patients with non-ulcerative interstitial cystitis, the majority of them will have a pelvic floor dysfunction to go along with it. We’ll always do a thorough exam of the pelvic floor, but generally, these patients have a chronically guarded pelvis and very hypertonic pelvic floor muscles, where we’ll send almost all of them to a pelvic floor physical therapist to work on relaxing those muscles. In the worst cases, we have to do what’s called trigger point injections where we can actually put steroid and numbing medication into those muscles to speed that relaxation process.

Chirag Dave: But we always tell patients, there’s usually not just one treatment or a magic pill that magically makes interstitial cystitis go away. It’s generally thought of as a chronic condition, and it often requires maintenance therapies such as physical therapy, numbing medications, cystoscopy in the bladder. It can sometimes complicate both the timing, but also the technique of a gender reassignment surgery. It’s difficult to sometimes sign these patients up for operations, such as urethral reconstruction, a neophallus. If they’re having ongoing bladder pain and requiring these recurrent cystoscopies and things like that. I agree with you. We would almost certainly want to calm down the bladder inflammation before we embarked on a major gender reassignment surgery.

Erin Everett: Yeah, it may complicate things and you would definitely want to get it under control, but it wouldn’t necessarily cause someone to not be an eligible candidate.

Chirag Dave: Correct. Yeah, but I would certainly want for them to be symptom free for at least six months or so before we put them through a big operation, than immediately having to put cameras through a neophallus and a newly constructed urethra to do bladder treatments. We would certainly hope to calm down the interstitial cystitis before we do that.

Erin Everett: Right. Not only that, the vaginoplasty itself is an extremely painful procedure, so then you might be chasing the source of pain after that.

Chirag Dave: Absolutely.

Erin Everett: Too, I’m familiar with vaginoplasty, of course I’m less familiar with the preparations, because I find that each surgeon does it differently, but I wonder if a general recommendation is to have patients undergo pelvic floor PT in preparation for the surgery, and if that has helped surgical outcomes. Have you seen anything like that or do you know anything about that?

Chirag Dave: Yeah. I have, and unfortunately, I don’t have a paper that I can quote off the top of my head, but having participated in a number of vaginoplasties, it is quite an involved operation, and obviously the vagina is intimately involved with the pelvic floor as well. I think the pelvic floor physical therapy would certainly be helpful both before and after the vaginoplasty.

Erin Everett: Yeah, for sure. Awesome. That’s more really good information. Did you have anything you wanted to add to that before we move on?

Chirag Dave: Nope. I think we covered it pretty well.

Erin Everett: Awesome. The other thing I wanted to touch on was hormone pellets. I get a lot of questions, especially with trans-men that get injection burnout a lot. I don’t love Androderm, the patch. I feel like a lot of guys get dermatitis from it. Then depending on whether or not they’ve had hysterectomy, or removal of the gonads, I should say, it’s almost more challenging too, to eliminate the menstrual cycle with some of the topical applications. Usually, I do lean very heavily on injectables for that.

Erin Everett: But I got a lot of questions about once they’re well maintained on their transition and their hormones is steady, or if they’ve had removal of the gonads, if pellets are an option. I don’t really have a lot of providers here in Atlanta to refer them to. I get a lot of questions about that, and I know that you do the pellet. Also, I know you do them too, for trans-women. I’d love for you to talk a little bit more about that, because it’s a new thing here. I know it’s very much used out on the West Coast. It’s more progressive in the more progressive areas, but here in Georgia, it’s not considered a very common option for these patients.

Chirag Dave: Yeah, absolutely. Hormone replacement is obviously something near and dear to my heart as an andrologist, but I go through all patients in all scenarios that are looking for hormone replacement that really, we do have a lot of options. The way I try to educate them is, what are these different options? What are the mode of delivery? But also, what are some of the, what we call pharmacokinetics, or how is the patient going to interact with that medication? Generally, hormone replacement exists in a few different preparations. Probably the oldest and most common is the injectables that you talk about. Testosterone cypionate is probably the most common version of that.

Chirag Dave: Most patients will inject themselves every two weeks, sometimes every week. There can be some injection fatigue from that. There can be some pain from that. Obviously, lots of supplies and needles, frequent trips to the pharmacy, but from a pharmacokinetic standpoint, what patients often complain about is they feel great on the first few days of the injection, but by the time two weeks have passed and it’s time for the next injection, they’re really feeling burnt out. They’re really feeling like they need their hormones. That mirrors the pharmacokinetics. If you look at the curve, testosterone levels really spike in the first few days after the injection, but they tend to taper off as time goes. My patients that are on injections, I’ll often have the dose and have them inject every week instead of every two weeks, to overlap those lines and try to give them a more consistent level of testosterone.

Chirag Dave: All of the dermatologic preparations, whether it’s a patch, whether it’s a gel, it’s really difficult for us to know how each individual patient is going to take up that hormone. That forces us to have to titrate the medications, do lots of blood work, and frequently check in on how patients are doing. I always talk to patients about the theoretic risk of transference to a partner or a child or another loved one in the house. When you’re putting these agents on the skin, you certainly need to be careful about that as well. But the pellets have really helped my practice. The pellets, simply put, are subcutaneous pellets that we’ll usually place in the upper outer buttocks area. These pellets, it’s basically a 30 second procedure in my office.

Chirag Dave: The patient is awake laying on their stomach. We sterilize the skin in that area and I put some numbing medication in, and then we have an applicator device where I can put pellets underneath the skin. We have testosterone pellets, we have estrogen pellets. We’re not using progesterone very often in a transdermal fashion, but certainly we can do testosterone and estrogen, or even combination pellets. But these pellets will usually give the patient a slow, steady uptake of either testosterone or estrogen for a three month period.

Chirag Dave: The first time we do it, we’ll usually check blood work about six weeks after the pellet procedure to see what is their mid cycle testosterone or estrogen level. We’ll use that to reach a decision on how many pellets we’re going to put in the next time we do the pellet procedure, but once the patient has reached their steady dose of pellets, then this is just a procedure that they need to come into the office, maybe three or four times a year and just have the pellets placed. Patients that frequently say, “Hey, I love this. I just come to the office, it takes 30 seconds, three or four times a year. I’m not having to inject myself every couple of weeks. I’m not having to go to the pharmacy.” If there’s compliance issues, they’re not having to remember to take their medication, or say, “Hey, did I do this last week? Did I not do this last week? I can’t remember, because I didn’t put it in my phone.”

Chirag Dave: It takes a lot of those things out of place, so patients have liked it. From the pharmacokinetic standpoint, they really like the fact that they get an even distribution of hormones over that entire three month cycle. That’s obviously been very nice for patients as well.

Erin Everett: Yeah. That’s awesome. What kind of levels are you looking for when you say mid cycle?

Chirag Dave: Yeah. I think once you’ve made the diagnosis that hormone replacement therapy is necessary, I’m almost always treating the patient rather than the numbers itself. We like to keep patients in a safe range, and that can vary depending on what condition you’re treating, whether it’s low testosterone, or if this is just post-orchiectomy testosterone replacement. It really varies on what the condition is that you’re treating, but certainly, the patient’s symptoms matter more to me than what the absolute numbers are.

Erin Everett: Yeah, for sure. When you’re doing it for transgender medicine, do you find that the testosterone does aromatize very frequently or you’re not seeing those increased levels?

Chirag Dave: Yeah, we frequently do. If that’s the case and it’s bothersome, then we can add a medicine like Arimidex to prevent that peripheral conversion to aromatase. That’s something that we’ll frequently do for these patients.

Erin Everett: The other question I had pertaining to that is, there’s a lot of talk in the community about endometrial lining with estrogen present. While we know that testosterone is extremely atrophying to the internal biological female organs, and that it’s unlikely, even in the presence of estrogen, for them to develop an endometrial lining. Do you have specific recommendations as it pertains to the pellets on monitoring for that, or it’s not something that you’ve had to encounter before?

Chirag Dave: Yeah, honestly, I haven’t encountered that a whole lot. I’m sure that’s probably something you can teach me on, but I honestly haven’t encountered that a whole lot. What are your thoughts?

Erin Everett: Well, typically, I just tend to monitor the estrogen levels, and I try to treat elevated estriol as I would for a CIS male. Anything over 70, especially if they’re having cramping or bleeding, I treat obviously with Arimidex also, just to get it down onto a normal range, but as far as monitoring for the endometrial lining, I defer to gynecology for that as well, as far as their routine follow-ups. But everybody who has had a trans-vaginal ultrasound has not, to my knowledge, any of my patients, had any kind of endometrial buildup as long as the estrogen levels were not elevated. I was just curious to see, because I find with the topical gels that the estrogen levels stay really high in that population.

Erin Everett: Then I do get concerned, if they are still with a uterus, that it might, even though the testosterone and atrophies in those organs, I still get concerned that with that estrogen, unchallenged estrogen, it could, it could develop. That’s why I was curious what kind of levels you see or how common it is for you to see high estrogen levels with the pellet application.

Chirag Dave: That’s fascinating. Everything you’re getting at just, I think, highlights the importance of a really strong multidisciplinary team, you know how it’s, I think, well-documented in the literature and understood that you have to approach these cases from a number of different angles, and so having a cohesive team that has strong communication is I think key for good outcomes with patients.

Erin Everett: Yeah, absolutely. With the timing of the estrogen, have you seen … what kind of levels do you get with the estrogen? Because typically, I find that the estrogen levels have to really surge and be above like 400 for feminizing effects to occur. Is that the kind of levels that you’d get with the estrogen pellets?

Chirag Dave: Yeah. I haven’t seen levels that high, so I personally haven’t experienced that, but I don’t want to obviously speculate on the podcast or anything like that. But yeah, I haven’t seen levels that high, so that’s interesting. It’s something I’ll have to watch out for, obviously.

Erin Everett: Yeah. Well, I was just curious, have you placed a lot of pellets for trans-women?

Chirag Dave: I wouldn’t say a lot. We definitely do a lot of estrogen replacement for non trans-women, and tons of testosterone replacement for trans-patients. That’s something that we’re doing very commonly. Estrogen, I think is something we can offer, but not something that we’re doing a whole lot of routinely.

Erin Everett: Yeah. Well, cool. We can always navigate that together on a case by case basis. Yeah.

Chirag Dave: Yeah, absolutely.

Erin Everett: Yeah, because that’d be really beneficial, because right now I only have a couple of patients interested in the estrogen pellets, but some of them have fully completed their transition, and so we’re really just looking for maintenance, like if we would a post-menopausal female rather than actually initiating a new puberty. So yeah.

Chirag Dave: Yeah. That’d be great, because we can work on a protocol. I’d love to learn about that with you. I can look up some papers, and even talk to folks around, and we can get a solid pellet program together for them. Yeah.

Erin Everett: Yeah, that would be really helpful. Cool. Well, just to summarize our discussion about pellets, it sounds like both are very viable option as far as testosterone and estrogen. A little less is known about estrogen pellets, but definitely willing to offer it to the patients, and it’s something that we can navigate and discuss with our patients on a case by case basis.

Chirag Dave: Absolutely. Yeah. We, of course are more than happy to see any of your patients and answer any questions they have. Telemedicine is something that’s evolving and new for us that, I think is one of the pleasant surprises that we’ve had amidst this very unfortunate corona pandemic, but that’s certainly given me the opportunity to connect with more patients from the comfort of their own home, or geographically, they’re far away from my office. These are all things that we love to discuss with patients, either in person or online.

Erin Everett: Yeah. That’s good to note too. So you are accepting new patients, if people can’t travel in, you’re able to at least do the initial intake over virtual medicine?

Chirag Dave: Absolutely. Yeah, so our practice and it has seven locations in the Metro Atlanta Area. They’re all full service locations with a surgery center, but also lab and ultrasound services. Very commonly, I’ll meet with folks for their initial telemedicine visit, and there’s labs, there are some precursor workup is required. They can get that done close to home, and then we can have a follow up visit in person, and keep the ball rolling without too much disruption because of travel and things like that.

Erin Everett: Awesome. If patients wanted to connect with you specifically, what’s the best way they could reach you?

Chirag Dave: Absolutely. Our website is www.advancedurology.com, and I can also be reached on all the social media platforms, Twitter, Instagram, and Facebook @ChiragDave_MD. Again, love to hear from patients, love to interact with patients on social media, but we have same day and next day appointments available all the time, and you can book those from our website, advancedurology.com.

Erin Everett: Awesome. We’ll list all of those too in the podcast summary for patients to be able to refer to and get in touch with you. It was so good to speak with you today, and I thank you so much for your time. I know you’re really busy and you had a long day doing surgeries and seeing patients, so I totally appreciate your time, and I think it’s going to be extremely valuable for all my listeners.

Chirag Dave: Thank you so much for having me on today, Erin, and it was a pleasure to meet your audience and the community, and look forward to seeing some of you in the clinics soon.

Erin Everett: Awesome. Thank you.