Perception of Pain During Gender Affirming Hormone Therapy

°C (Arithmetic mean after 3 measurement repetitions) With the Limits Method, the perception and pain thresholds are recorded as the first detected stimulus in the context of increasing stimulus intensities. This test will be performed with the Thermal Sensory Analyzer (TSA II, Medoc).

A thermode equipped with a Peletier element and a cooling water supply is placed on the skin. Then the following parameters are determined using the Limits method:

• Cold detection thresholds
• Heat detection thresholds
• Thermal difference thresholds for the detection of paradoxical heat sensations The contact area of the respective thermodes is 9.0 cm². By pressing a stop switch, which is connected to a computer unit, a threshold value determination can be made after a continuous ascending or descending temperature range with the thermode contact area, starting from a base temperature of 32°C. The temperature changes at a rate of 1°C/s.

°C (Arithmetic mean after 3 measurement repetitions)

With the Limits Method, the perception and pain thresholds are recorded as the first detected stimulus in the context of increasing stimulus intensities. This test will be performed with the Thermal Sensory Analyzer (TSA II, Medoc).

A thermode equipped with a Peletier element and a cooling water supply is placed on the skin. Then the following parameters are determined using the Limits method:

• Cold detection thresholds
• Heat detection thresholds
• Thermal difference thresholds for the detection of paradoxical heat sensations The contact area of the respective thermodes is 9.0 cm². By pressing a stop switch, which is connected to a computer unit, a threshold value determination can be made after a continuous ascending or descending temperature range with the thermode contact area, starting from a base temperature of 32°C. The temperature changes at a rate of 1°C/s.

°C With the Limits Method, the perception and pain thresholds are recorded as the first detected stimulus in the context of increasing stimulus intensities. This test will be performed with the Thermal Sensory Analyzer (TSA II, Medoc).

A thermode equipped with a Peletier element and a cooling water supply is placed on the skin. Then the following parameters are determined using the Limits method:

• Cold detection thresholds
• Heat detection thresholds
• Thermal difference thresholds for the detection of paradoxical heat sensations The contact area of the respective thermodes is 9.0 cm². By pressing a stop switch, which is connected to a computer unit, a threshold value determination can be made after a continuous ascending or descending temperature range with the thermode contact area, starting from a base temperature of 32°C. The temperature changes at a rate of 1°C/s.

Number of Paradoxical heat sensation out of 3

The paradoxical heat sensations (PHS) can occur during the determination of the TSL (thermal sensory limen) by thrice alternating cold and warm stimuli. A paradoxical heat sensation occurs when the patient expresses heat perceptions during an actual cold stimulus, contrary to what is indicated by the software, or vice versa. In the aforementioned thermal threshold measurement, alternating high and low temperatures are set on the thermode. The study participant does not know the sequence and must recognize the respective tendency. Alternating the temperature changes is done without resetting the initial temperature. PHS has no unit, it is given as a number: PHS 0; 1; 2 or 3, depending on the number of false temperature perceptions.

°C (Arithmetic mean after 3 measurement repetitions) With the Limits Method, the perception and pain thresholds are recorded as the first detected stimulus in the context of increasing stimulus intensities. This test will be performed with the Thermal Sensory Analyzer (TSA II, Medoc).

A thermode equipped with a Peletier element and a cooling water supply is placed on the skin. Then the following parameters are determined using the Limits method:

• Cold detection thresholds
• Heat detection thresholds
• Thermal difference thresholds for the detection of paradoxical heat sensations The contact area of the respective thermodes is 9.0 cm². By pressing a stop switch, which is connected to a computer unit, a threshold value determination can be made after a continuous ascending or descending temperature range with the thermode contact area, starting from a base temperature of 32°C. The temperature changes at a rate of 1°C/s.

°C (Arithmetic mean after 3 measurement repetitions) With the Limits Method, the perception and pain thresholds are recorded as the first detected stimulus in the context of increasing stimulus intensities. This test will be performed with the Thermal Sensory Analyzer (TSA II, Medoc).

A thermode equipped with a Peletier element and a cooling water supply is placed on the skin. Then the following parameters are determined using the Limits method:

• Cold detection thresholds
• Heat detection thresholds
• Thermal difference thresholds for the detection of paradoxical heat sensations The contact area of the respective thermodes is 9.0 cm². By pressing a stop switch, which is connected to a computer unit, a threshold value determination can be made after a continuous ascending or descending temperature range with the thermode contact area, starting from a base temperature of 32°C. The temperature changes at a rate of 1°C/s.

mN (geometric mean of 5 even suprathreshold and 5 even subthreshold stimulus strengths)

The mechanical detection threshold is measured with a set of standardized von Frey filaments. The von Frey filaments used in this test are glass fiber filaments with different diameters and varying lengths and with a spherical contact surface of approximately 0.5 mm diameter. The set used for the test consists of filaments with the strengths 0.25, 0.5, 1, 2, 4, 8, 16, 32, 64, 128, 256 and 512 mN. The contact time on the skin surface should be about 2 s during testing. To determine the tactile detection threshold, the geometric mean of 5 straight suprathreshold and subthreshold stimulus strengths is determined using a modified Levels method.

mN (geometric mean of 5 even suprathreshold and 5 even subthreshold stimulus strengths) Needle stimulators (Pinprick) are used to determine the mechanical pain threshold. The models used consist of blunt needles with a fixed stimulation intensity of 8, 16, 32, 64, 128, 256 and 512 mN and a blunt circular skin contact surface with a diameter of 0.25 mm. The individual needle stimulators (pinpricks) are applied in 5 series of ascending and descending stimulus intensity with a skin contact time of about 1-2 s at a perpendicular angle to the skin. Likewise in this test, the actual mechanical pain threshold is calculated according to the Levels method as the geometric mean of 5 just above-threshold and 5 just below-threshold stimulus intensities.

Geometric mean of all numeric values (scale 1-100) Needle stimulators (Pinprick) are used to determine the mechanical pain threshold. The models used consist of blunt needles with a fixed stimulation intensity of 8, 16, 32, 64, 128, 256 and 512 mN and a blunt circular skin contact surface with a diameter of 0.25 mm. The individual needle stimulators (pinpricks) are applied in 5 series of ascending and descending stimulus intensity with a skin contact time of about 1-2 s at a perpendicular angle to the skin. Likewise in this test, the actual mechanical pain threshold is calculated according to the Levels method as the geometric mean of 5 just above-threshold and 5 just below-threshold stimulus intensities.

Geometric mean of all numeric values (scale 1-100) A set consisting of the previously described needle stimulators, a cotton swab, a soft brush and a cotton ball will be used to determine the mechanical pain sensitivity of the skin and to detect the presence of any dynamic mechanical allodynia to light touch stimuli. Stimulus-response behaviours to needle stimuli and primarily non-painful, light touch stimuli are sequenced and evaluated. Subjects are asked to rate the perception of the stimulus on a numerical rating scale from 0 to 100 (0= no pain; 100= most pain imaginable). In the same test procedure, the extent of any dynamic mechanical allodynia is also determined, using the cotton ball (3 mN), cotton swab (100 mN) and standardised brush (Somedic, Sweden; 200-400 mN). These 3 tactile stimuli are stroked over the subject's skin by the examiner for about 2 s for at least 2 cm. Again, the subjects rate the stimulus on a numerical scale from 0 to 100.

Wind-up quotient (Sensation intensity of the stimulus series 1Hz/single stimulus) Needle stimulators with an intensity of 256 mN are used to determine the wind-up phenomenon. To determine wind-up, the sensitivity of the skin to a single stimulus is compared with that to a series of stimuli (10 needle stimuli) in the test area. The subject rates on a numerical pain scale the applied stimuli, i.e., the single stimulus and the entire stimulus series. The application of the single stimulus followed by the stimulus series is repeated 5 times. The wind-up quotient is calculated from the ratio of the perceived pain intensity over the stimulus series divided by the pain intensity after the single stimuli.

Arithmetic mean after 3 measurement repetitions on a 8/8 scale Rydel-Seiffer tuning fork A Rydel-Seiffer tuning fork with a vibration frequency of 64 Hz and an 8/8 scale is used to determine the vibration threshold. To check the threshold values the struck and vibrating tuning fork is placed on the test area, preferably over a bony contact point such as the ankle. The test person indicates when he or she no longer feels the vibrations of the tuning fork. For this point in time, the stimulus intensity is recorded on the scale of the tuning fork. After determining the vibration threshold 3 times, the arithmetic mean of the threshold values can be calculated.

kPa (Arithmetic mean after 3 measurement repetitions) The measurement of the pressure pain threshold is carried out with the aid of a pressure algometer, on a blunt rubberized contact surface of about 1 cm², with which pressure of 0 to 2000 kPa can be applied. The pressure is gradually increased at a rate of 0.5 kg/cm²-s. The pressure pain threshold is documented as the value in Kpa at which the perception of pressure quality first changes to a painful sensory impression. The pressure pain threshold is calculated as an arithmetic mean after 3 repeated measurements.

°C

The temperature of the skin will be measured with a temperature probe.

Consists of 9 items concerning patient mental well-being. The EQ-5D-5L, a validated and internationally used health questionnaire, will also be completed twice at the first study day before the sex hormone therapy is initiated and during the last study day in month 6. It consists of a page with questions on mobility, self-care, usual activities, pain/discomfort and anxiety/depression as well as an assessment of one's own state of health on a scale of 1-100 (100 = best health you can imagine).

Laboratory measurement of follicle stimulating hormone (FSH) in mIU/mL

Laboratory measurement of luteotropic hormone (LH) in mIU/mL

Laboratory measurement of prolactin (PRL) in ng/mL

Laboratory measurement of oestradiol (E2) in pg/mL

Laboratory measurement of sex hormone-binding globulin (SHBG) in nmol/L

Laboratory measurement of testosterone in ng/mL