4 Transgender Patients in Primary Care Flashcards

Question

Someone who is attracted to people of both binary genders

Answer 1

A marked incongruence between one’s experienced/expressed gender and natal gender of at least 6 months in duration, as manifested by at least two of the following: 1. Incongruence between one’s own gender and primary/secondary sex characteristics (or anticipated secondary sex characteristics in adolescents 2. Strong desire to be rid of one’s primary/secondary sex characteristics (or to prevent their development) 3. Strong desire for the primary/secondary sex characteristics of the other gender 4. Strong desire to be of the gender other than one’s natal gender 5. Strong desire to be treated as the other gender 6. Strong conviction that one has feelings and reactions of the other gender The condition is associated with clinically significant distress or impairment in social, occupational, or other important areas of functioning Specify if: 1. The condition exists with a disorder of sex development 2. The condition is posttransitional

Answer 2

Informed consent model - PCPs perform the initial assessment, including physical health and any mental health risks before proceeding with care. Referrals are made as needed to specialists Behavioral Health Model (aka Standards Model) - a letter of referral is necessary from a psychologist to assist in the medical transition assessment

Answer 3

World Professional Association for Transgender Health Has evolved to better support the patient’s autonomy in choosing whether or not to seek a psychologist’s care for medical transition (though psychologist letters are still required for gender confirming surgeries)

Answer 4

They teach the key points of what the hormones do to one’s body and what the permanent and impermanent changes will be

Answer 5

The pitch of voice becomes deeper Increased growth, thickening and darkening of body hair Growth of facial hair Possible hair loss at the temples and crown (male pattern baldness) with possible complete baldness Increase in the size of the clitoris/phallus

Answer 6

Menstrual periods will stop, usually within a few months Possible weight gain (fat will tend to go to abdomen and mid-section rather than buttocks/hips/thighs) Increased muscle mass and upper body strength Possible feelings of more physical energy Skin changes, including acne that may be severe Increased sex drive Changes in mood or thinking; decreased emotional reactions; possible increased feelings of anger or aggression; possible mood improvement

Answer 7

Loss of fertility (may want to harvest eggs), but NOT reliable birth control Changes in cholesterol, higher BP, and other changes —> inc CVD risk Increased risk of DM, appetite/weight changes, sleep apnea Abnormal LFTs Increased H/H and sweating Weakening of tendons —> increased risk of injury Worsening/triggering of HA and migraines Increase in frustration, irritability or anger, aggression and impulse control Worsening of bipolar disorder, schizophrenia, and psychotic disorders

Answer 8

Very high risk of erythrocytosis (hematocrit >50%) ``` Moderate risk: • Liver dysfunction • CAD • CVD • HTN • Breast or uterine CA (b/c of neglecting screenings!) ```

Answer 9

Several months —> 3-5 years

Answer 10

Several months —> 3-5 years

Answer 11

Breast growth and development Testicles will get smaller and softer Testicles will produce less sperm, and you will become infertile (varies, person to person)

Answer 12

Loss of muscle mass and decreased strength, particularly in upper body Weight gain - tends to go to the buttocks and thighs Skin will become softer and acne may decrease Facial and body hair will get softer and lighter and grow more slowly (most women will choose to have electrolysis or laser therapy) Male pattern baldness may slow down or stop (but hair doesn’t grow back) Reduced sex drive Decreased erections Changes in mood or thinking, increasing emotional reactions Will not change the bone structure of the face or body, will not shrink adam’s apple

Answer 13

Loss of fertility (still use birth control) Increased risk of DVT, PE, MI, stroke, death*** (esp if smoker, >45, HTN, HLD, DM, or FH of CVD) HTN DM N/V Gallbladder disease Elevated LFTs May cause or worsen HAs/migraines Prolactinomas May worsen depression or cause mood swings Increased risk of breast cancer (higher than in natal men but lower than in natal women)***

Answer 14

Very high risk of thromboembolic disease ``` Moderate risk: Macroprolactinoma Breast cancer Coronary artery disease Cerebrovascular disease Cholelithiasis Hypertriglyceridemia ```

Answer 15

Increased urine production and frequency; changes in kidney function Drop in BP and feeling lightheaded Increased thirst Increase in the potassium leading to muscle weakness, nerve problems, and heart arrhythmias

Answer 16

Testosterone Cypionate or Enthanate • 1-3 ml syringe and 18g needle to draw • 23-25g 1 1/4 in needle to inject IM or SQ • Injected every other week Testosterone Topical Gel 1% (packet or pump) Testosterone Patch (may be cut PRN)

Answer 17

1. Estradiol Oral/Sublingual (cheaper, easier) 2. Estradiol transdermal 3. Estradiol valerate IM 4. Estradiol cypionate IM

Answer 18

Androgen Blockers: • Spironolactone • Finasteride Progestin Preparations (not necessarily necessary): • Medroxyprogesterone acetate • Micronized progesterone

Answer 19

1. Evaluation q3months for signs of virilization and any adverse effects**** 2. Blood lab for total T every 3 mo for first year (goal is 400-700ng/dL up to 900ng/dL 3. Measure H/H at baseline and q3mo for first year, then 1-2x per year*** 4. Monitor body weight and BP at every appt 5. Fasting lipids should be done at baseline and annually 6. If cervical tissue remains, reg pap screening**** 7. Osteoporosis screening 8. If no mastectomy, mammography screening per ACS

Answer 20

1. Eval q3mo first year for signs of feminization and any adverse effects 2. Measure total T and estradiol every 3 mo during first year; Serum T should be <50ng/dL, Estradiol should be 100-200pg/mL 3. For pts using spironolactone, electrolytes q3mo with attention to potassium 4. Cancer screening for prostate 5. Bone mineral density is recommended at baseline, with BMD at age 60 or if therapy stopped

Answer 21

Vaginoplasty/clitoro-labioplasty (complications = urethral stenosis, fistulas, hair growth within the neovagina) Mammoplasty (complications = capsule formation, implant rupture)

Answer 22

Mastectomy (complications = nipple necrosis, skin flap complications, contour irregularities, scarring) Metoidoplasty - frees the testosterone enlarged natal clitoris from the labia minors and suspensory ligament, and lengthening of urethra (complications = urethral fistula) Phalloplasty - construction of phallus with neourethra and erectile prosthesis (complications = urethral stenosis and fistulas, flap loss, necrosis) Scrotoplasty - adjunct to metoidioplasty/phalloplasty (complications = risk of infection during expansion period)