Abstract
Background:
Lactation induction in transgender women is a clinical and research priority in the field of breastfeeding medicine. To date, there are four case reports detailing successful induced lactation in transgender patients who wished to breastfeed. The Academy of Breast Feeding Medicine does not formally recommend a specific medication regimen for transgender patients due to lack of high-quality research.
Case Presentation:
A 50-year-old transgender woman with a hypercoagulable disorder who was able to lactate and breastfeed with novel hormone regimen management at a gender care clinic. Her baseline hormone treatment was an estradiol 0.3 mg transdermal patch every 72 hours and micronized progesterone 200 mg daily.
Results:
Within four weeks of initiating a modified hormone regimen (estradiol 0.4 mg patch every 72 hours, progesterone 300 mg daily, metoclopramide 10 mg three times daily), the patient was lactating spontaneously. On multiple occasions, she breastfed and expressed up to 30 mL of milk through pumping.
Conclusion:
This report offers a new effective hormone regimen for transgender patients who wish to lactate and cannot access domperidone—the galactagogue used in previous case reports. It also provides a review of previously published case reports on this subject. Future research in this field should prioritize cohort studies of transgender patients who desire lactation to further assess patient attitudes, experiences, and outcomes.
Introduction
Lactation induction in transgender women has been a topic of increasing interest for medical professionals and researchers over the past several years. Breastfeeding confers a plethora of medical and social benefits to both members of a lactating individual–infant dyad, 1 and furthermore, inequitable access to lactation and breastfeeding care for transgender patient populations is increasingly being recognized as a reproductive rights issue.2,3 To date, there are four published case reports that describe the treatment protocols and lactation experiences of transgender patients,4–7 two of which perform a macroanalysis on the nutritional content of the milk produced.5,7
As it currently stands, The Academy of Breastfeeding Medicine's (ABM) current clinical protocol for lactation care for lesbian, gay, bisexual, transgender, queer, and other sexual and gender minorities patients states there is not enough high-quality research on the benefits or risks of any lactation-inducing or augmenting medications for the academy to recommend specific medication management regimens for transgender patients and their providers.8,9 Existing literature that captures both patient and provider perspectives on this issue demonstrates that both parties support further research into clinical management for transgender patients who wish to lactate, as well publication of appropriate protocols.2,10,11
This report presents the fifth published case of lactation in a transgender woman and offers several important contributions to the existing literature. First, of all five cases, this is the only one reporting on the use of metoclopramide for lactation induction. In addition, this report synthesizes information from the previously published case reports and presents a comprehensive comparison of treatment, management, and outcomes across existing literature.
Case Presentation
The patient was a 50-year-old assigned-male-at-birth transgender woman with a medical history of discoid systemic lupus erythematosus (2011) and antiphospholipid antibody and a surgical history of simple bilateral orchiectomy (2018) and full depth vaginoplasty (2019, revision in 2020). She had no history of tobacco use and drank a minimal amount of alcohol (<1 standard drink per month). Her family history was notable for Hashimoto's thyroiditis in her mother and sister. The patient's initial consultation with our gender care clinic was in the fall of 2018 at which time she was initiated on gender-affirming hormone therapy.
The patient first expressed the unique desire to breastfeed her expected grandchild at an appointment with her endocrinologist in the spring of 2022. She disclosed that this was a last-minute idea that came to her very close to her daughter's due date. Her primary motivation for inducing lactation was to experience the bond from breastfeeding that she had not been able to experience with her own five children. 12 , * At the time, the patient's hormone therapy was as follows: estradiol 0.3 mg transdermal patch every 72 hours and micronized progesterone 200 mg oral once daily. She was also taking hydroxychloroquine sulfate daily. Patient's laboratories from the same month before lactation induction showed estradiol 182 pg/mL, progesterone 13.8 ng/mL, and prolactin 34.49 ng/mL.
Treatment
A summary of the patient's medical management and points of data collection are given in Table 1, alongside comparable data reported from the previous four case reports. To initiate lactation induction, the patient was first advised to increase her estradiol dose to 0.4 mg transdermal patch every 72 hours, and she was extensively counseled on her increased risk of venous thromboembolism (VTE) due to higher estrogen levels, age greater than 40 years, and her hypercoagulable disorder. At the same time, she started manual pumping and nipple stimulation three to four times per day in five-minute increments; she reports these sessions were clustered in the evening due to her personal time constraints, and they produced “clumps” of milk.
Comparison of Five Case Report Patient Characteristics, Medical Management, and Outcomes
Indicates dose and/or route change from baseline hormone therapy regimen.
Excludes medications that were stopped during lactation induction.
BID, twice daily; EKG, electrocardiogram; PO, per os/by mouth; QID, four times daily; QD, once daily; SL, sublingual; TD, transdermal; TID, three times daily.
After discussion and counseling on VTE risk, the patient's progesterone was increased from 200 to 300 mg daily. Finally, the patient was prescribed metoclopramide oral 10 mg three times per day and told to initiate one month after the increase in estrogen and progesterone. Ultimately, metoclopramide was started one week after the initial visit.
Outcome
The patient was next seen in the clinic 17 weeks after her last visit. She reported that with her new hormone regimen (estradiol 0.4 mg transdermal every 72 hours, micronized progesterone 300 mg daily, metoclopramide 10 mg three times daily), along with manual pumping five to six times per day for 45 minutes per session, she had experienced spontaneous let down of milk. She started to see a few drops of white, watery milk per day approximately three weeks after adding metoclopramide.
The patient reported that she lactated for a total of two weeks and nursed the four-month-old infant on multiple occasions. Her peak milk production was 30 mL from her larger right breast, and 8 mL from her smaller left breast. In addition, she noticed breast maturation and filling in because of her treatment.
At five weeks after initiating treatment changes for lactation induction, she reverted to her previous medication regimen (estradiol 0.3 mg transdermal every 72 hours, micronized progesterone 200 mg daily, discontinued metoclopramide). She states that she stopped pursuing her personal goal to breastfeed due to logistical barriers, such as the need to take care of her grandchild while her daughter was pumping.
The patient tearfully reported this was a significant and emotional experience for her that felt very different from formula feeding her other children; she states she has a special bond with this baby for which she is grateful. She regrets that she had not known about the possibility sooner and wished that other transgender women could know that breastfeeding a baby can be a reality. She reported unforeseen benefits, including female gender affirmation and full breast maturation. The patient did not experience any side effects from her treatment regimen.
Discussion
This is the fifth case report of induced lactation in a transgender woman for the purpose of breastfeeding. It details a different treatment protocol than previous reports, noteably using metoclopramide rather than domperidone. The common strategy in all four prior cases was increasing estradiol, progesterone, and prolactin levels to mimic pregnancy followed by a reduction of estradiol and progesterone to mimic delivery and induce lactation. This strategy is referred to as the Newman–Goldfarb Protocol, originally based on the medical management of a patient who wanted to breastfeed an infant born through gestational surrogacy. 13
Domperidone is not available in the United States, as it has not been approved by the U.S. Food and Drug Administration, 14 and the limited body of research examining its lactation augmentation efficacy and safety has largely been conducted with nontransgender patient populations. 15
This case, by contrast, uses a different modified protocol based on the patient's medical history. Although the patients from the prior case reports did not have medical histories that required significant considerations when following existing protocols for nonpuerperal induced lactation, this patient's age (50-years-old), coagulable risk factors (discoid systemic lupus erythematosus, antiphospholipid syndrome), and lack of access to domperidone required an alternative medication regimen. Metoclopramide was substituted for domperidone, and the estradiol administration was transdermal rather than oral.
Metoclopramide has been identified in a limited capacity in the literature and anecdotal clinical practice as a galactagogue with the potential to induce lactation, but it has been researched and assessed even less than domperidone has in the literature to date.15,16 This case report demonstrates the successful use of metoclopramide along with modifications to the patient's existing hormone replacement therapy to induce lactation, without adverse health effects.
Conversations with the subject before, during, and after treatment revealed important insights for the ongoing discussions about the role of lactation induction and breastfeeding in gender-affirming care. Of the four major benefits that the patient reported after her treatment, two were in line with her pretreatment goals (production of breast milk and breastfeeding her grandchild), whereas the third and fourth were unanticipated (breast maturation and gender identity affirmation). This is in line with existing literature identifying unique considerations for lactation in this patient population, including stigma reduction, social support, and gender dysphoria/affirmation counseling. 3
The subject's anecdotal reflections raise questions about when and how lactation counseling should be initiated by providers, what education interventions are necessary for informed patient decision making, and whether lactation induction may confer benefits to transgender women who are not planning on breastfeeding.
One limitation of this report was the patient's semi-independent medication adjustments that were not documented in her electronic medical record; however, this was mitigated by a clarifying interview with the patient. Furthermore, the patient's duration of treatment was relatively short compared with other cases, so this report is not able to present information about the safety and efficacy of this protocol beyond five to six weeks.
Future directions
More research about medical management of transgender individuals who desire to lactate should be a priority. Domperidone and metoclopramide are severely under researched as medications for lactation induction and augmentation, both in the general population and transgender patients, specifically.14–16 The literature would benefit from larger cohort studies using galactagogue-induced lactation protocols in transgender patients, and there should be particular urgency in investigating the benefits and risks of metoclopramide in the United States.
Furthermore, efforts should be made through surveys, interviews, and focus groups to understand the priorities, needs, and questions of transgender individuals who wish to either lactate, breastfeed, or both. Finally, evidence-based information about lactation in transgender patients should be incorporated into continuing medical education and current guidelines for providers so that they can apply this knowledge appropriately to their patients.
Footnotes
Acknowledgment
We thank our patient who was interviewed and reviewed the article before submission. She will remain anonymous.
Authors' Contributions
E.D.T. contributed to conceptualization, methodology, analysis, and writing—original draft; S.K. carried out conceptualization, methodology, analysis, writing—review and editing, and investigation; A.W. was involved in conceptualization, methodology, analysis, and writing—review and editing; H.P. took care of conceptualization and methodology; A.B.D. was in charge of conceptualization and writing—review and editing; and C.E.K. was in charge of conceptualization, methodology, analysis, writing—review and editing, and supervision.
Disclosure Statement
The authors whose names are listed above certify that they have no affiliations with or involvement in any organization or entity with any financial interest (such as honoraria; educational grants; participation in speakers' bureaus; membership, employment, consultancies, stock ownership, or other equity interest; and expert testimony or patent-licensing arrangements), or nonfinancial interest (such as personal or professional relationships, affiliations, knowledge, or beliefs) in the subject matter or materials discussed in this article.
Funding Information
No funding was received for this article.