Care of Trans Patients

Question 1

Indications for mammography screening in trans women

Answer 1

screen if:

• > 50yo + hormone tx hx
• • additional risks: fhx, obesity, estrogen and progestin use > 5 yrs

Question 2

Osteoporosis screening rx for transmen

Answer 2

- Bone density at age
60 or earlier based
on risk factors
- Consider in those
not compliant with
hormone therapy

Question 3

Osteoporosis screening rx for transwomen

Answer 3

- Bone density at age 60
or earlier based on risk
factors
- Consider in those not
compliant with hormone
therapy

Question 4

Breast cancer screening @ transmen

Answer 4

-Perform chest wall
examination after
chest surgery
-otherwise mammography
as recommended for
cisgender women

Question 5

Main principles for gender-affirming hormone therapy

Answer 5

1. reduce endogenous
   hormone levels and their associated sex characteristics
2. replace with hormones of the preferred sex

Question 6

Risks with estrogen therapy

Answer 6

• thromboembolic disease (~2-6%); decreased w/transdermal
• coronary artery disease
• cerebrovascular disease
• severe migraine headaches
• liver dysfunction
• macroprolactinoma
• increased insulin resist/Fast BG
• increased triglyceride

Question 7

Risks with testosterone

Answer 7

• erythrocytosis (HCT > 50%)

- increased insulin resist/Fast BG

Question 8

Goal hormone levels for transwomen

Answer 8

-estrogen @ normal range for
cisgender women of reproductive age (< 200
pg/mL)
-testosterone levels should be suppressed < 55 ng/dL

Question 9

Goal hormone levels for transmen

Answer 9

-Goal testosterone =
320 - 1,000 ng/dL measured
at intervals specific to the preparation used
(ie, midway between injections for tx w/ Test cypionate).
-Estradiol levels < 50ng/dL

Question 10

Lab monitoring for transwomen

Answer 10

• estradiol/testosterone q3mo x 1 yr, then q6-12 mo after goal
• serum prolactin prn sx of prolactinoma
• serum electrolytes w/spironolactone

Question 11

Lab monitoring for transmen

Answer 11

• estradiol/testosterone, +/- SHBG/albumin (for testosterone bioavailability) q3mo x 1 yr, then q6-12 mo after goal
• CBC, LFTs q3mo x 1yr, then q6-12 months

Question 12

Physical changes timeline for transwomen on hormones

Answer 12

• decreased libido/spontaneous erections for first 3 mo

- breast growth @ 3-6mo

Question 13

Physical changes timeline for transmen on hormones

Answer 13

• fat redistribution first 6 mo
• facial/body hair slow x up to 4-5 yrs
• amenorrhea @ 1-6 mo

Question 14

Types of hormones used in gender-affirming therapy for transwomen

Answer 14

• estrogens (estradiol or 17-beta-estradiol)
• progesterone
• androgen blockers (sprio, 5-alpha-reductase inhibitors e.g. finasteride, dustasteride)

Question 15

Estrogen formulations

Answer 15

• oral/SL (daily, TDD>2mg = BID dosing)
• transdermal (patch) - frequency depends on formulation
• injection (estradiol valerate IM, estradiol cypionate IM) q2wk dosing (can go weekly if cyclical sx)

Question 16

Progesterone formulations

Answer 16

• oral, QHS dosing
• medroxyprogesterone acetate (provera)
• micronized progesterone

Question 17

Anti-androgen medication classes

Answer 17

• spironolactone (main SE is hyperK, can have diuresis, orthostasis)
• 5-alpha-reductase: finasteride, dustasteride
• other anti-androgens not used in US: cyproterone acetate (assoc w/fulminant hepatitis), bicalutamide (risk to liver, fulminant hepatitis)
• (if unable to suppress/work-up negative): GnRH analogs = leuporelin (Lupron), triptorelin (Decapeptyl)

Question 18

Work-up for persistently elevated testosterone in transwomen

Answer 18

• adherence/access
• exogenous testosterone use
• eval for testicular neoplasm: scrotal exam, hcg, LDH, AFP, +/- scrotal imaging

Question 19

Management of persistently elevated testosterone in transwomen

Answer 19

• work-up for exogenous testosterone source
• GnRH analogs
• orchiectomy

Question 20

Lab monitoring to ensure adequate bone density maintenance

Answer 20

LH/FSH suppression can be used as a surrogate marker (in addition to clinical effect/testosterone levels) that indicates adequate sex hormone levels for maintaining bone density