Ex. 5 L13 (56) Flashcards

1
Q

What is gender-affirming care?

A

Addresses social, mental, and medical health needs and well-being

Supports gender diverse people across the lifespan

Holistic and multidisciplinary

Family medicine, primary care, endocrinology, reproductive health, sexual health, mental health, voice and communication, preventative care, (have to monitor native organs, surgeries) chronic disease management, surgery

Inclusive and nonjudgemental

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
2
Q

Diagnostic Criteria for Gender Dysphoria

A

Diagnostic and statistical manual for mental disorders

Marked incongruence between experienced/expressed gender and sex assigned at birth

Assigned sex at birth primary and/or secondary sex characteristics cause dysphoria

Desire/preference to live as other/alternate gender

Associated with clinically significant distress or impairment in social, school, or other important areas of functioning

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
3
Q

Why do we have to diagnose gender dysphoria

A

Billing code for medical care
Not everyone who identifies as trans has gender dysphoria
Gender dysphoria identifies the mood symptoms related to a person’s experience of their body and their place in the world
Identifying as trans or nonbinary itself is NOT a mental health disorder

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
4
Q

Personalized Patient-Centered Care

A

Clinical guidelines are used for patients seeking gender-affirming care

Patient experience and desires are paramount in personalized care

Initial interviews include who patient is out to, what their support system is, trauma informed care, past medical care, any use of non-prescribed hormone therapies

Patient services in addition to family medicine:

OB/GYN/Fertility preservation and reproductive health, speech therapy, music therapy, occupational therapy, clinical pharmacy, psychiatry and therapy, sexual health

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
5
Q

Cornerstones of Gender-affirming hormone therapy (GAHT)

A

GAHT seeks to:
-Suppress endogenous sex hormone secretion determined by the person’s genetic/gonadal sex
-Maintain sex hormone levels within the normal range for the person’s affirmed gender

Provide risks and benefits of treatment

Obtain informed consent

Educate on timeline for changes and realistic expectations

Acknowledge that not all transgender patients will want all available treatment

Focus on patient wishes/patient-centered care

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
6
Q

Fertility preservation and sexual health: Transgender Men and testosterone:

A

Possible loss of fertility - may desire to harvest and bank eggs prior to treatment
If pregnancy occurs, high levels of testosterone may cause harm to the fetus - use contraception if pregnancy is a risk in any way
testosterone is not contraception

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
7
Q

Fertility preservation and sexual health: Transgender women - estradiol

A

Estradiol decreases sperm production, may be unable to produce healthy sperm after stopping estradiol
May desire to bank sperm prior to starting estradiol

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
8
Q

Baseline Laboratory Monitoring for all patients

A

Basic or complete metabolic profile
Complete blood count
Hepatitis A, B, C
HIV

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
9
Q

Transgender Men - Testosterone

A

Bioidentical Testosterone
-Cypionate injection (cottonseed oil) or Enanthate injection (sesame seed oil)
Have to ask about cottonseed oil and sesame seed oil allergy
Topical gel packets or pump formulation
Counseling about site of gel application, drying for at least 2 hours, avoid skin contact with others
Patch
Testosterone dose adjustments based on effects and cessation of menses

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
10
Q

Testosterone side effects

A

Migraine Headache - related to fluctuating estrogen

Hair loss - can treat with finasteride or dutasteride

Polycystic ovarian syndrome: Monitor for hyperlipidemia and diabetes

Acne - Common side effect, peaks in first year of treatment

Screen for osteoporosis and risk of bone loss

Medical risks - coronary artery disease, cerebrovascular disease, hypertension, breast/uterine cancer

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
11
Q

Testosterone Lab Monitoring

A

CBC (for hemoglobin/hematocrit) - may cause erythropoietic effects

Lipid profile

Liver function tests (risk of AST/ALT > 3 times the upper limit)

Fasting glucose/HgbA1c

Serum testosterone

Sex hormone binding globulin/albumin - used to calculate free testosterone

Estradiol - trans men may experience pelvic pain (very common, do not know why) and persistent menses

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
12
Q

Timeline of Hormone Effects for Transgender Men

A

Skin oiliness/acne:
Onset: 1-6 months
Max: 1-2 years

Facial/body hair growth:
Onset: 6-12 months
Max: 4-5 years

Scalp/hair loss:
6-12 months
Max: N/A (treat)

Increased muscle mass/strength
Onset: 6-12 months
Max: 2-5 years

Fat redistribution:
Onset: 1-6 months
Max: 2-5 years

Cessation of menses:
Onset: 1-6 months
Max: N/a (treat menorrhagia)

Clitoral enlargement
Onset: 1-6 months
Max: 1-2 years

Vaginal atrophy
onset: 1-6 months
Max: 1-2 years

Deepening of voice:
Onset: 6-12 months
Max: 1-2 years

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
13
Q

Transgender women and Estradiol

A

Past use of ethinyl estradiol that increased risk of VTE and conjugated estrogens that can’t be monitored

Prefer bioidentical 17-beta estradiol
-Valerate injection (sesame or castor oil) and cypionate injection (cottonseed oil)
Patch - preferred if patient uses tobacco or at higher VTE risk (most common)
Tablet - oral and sublingual dosing

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
14
Q

Estradiol side effects

A

Hyperprolactinemia and galactorrhea - monitor prolactin if symptomatic, have new onset headaches, or taking other medications that increase prolactin

Weight gain

VTE risk

Migraine - exacerbated by estradiol - titrate slowly for patients with a history of migraine, prefer oral or patch formulation

Screen for osteoporosis and bone loss risk

Medical risks include breast cancer, coronary artery disease

Max BMI of 30 for bottom surgery

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
15
Q

Trans women - anti-androgens

A

Used to minimize male secondary sex characteristics

Spironolactone - direct anti-androgen, may suppress testosterone synthesis
diuretic - fluid intake needs to be appropriate, do not take at night

Can use finasteride or dutasteride if spironolactone is not tolerated - block conversion of testosterone to dihydrotestosterone

Bicalutamide may be used but concern for liver function abnormalities limits use

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
16
Q

Anti-Androgen Side effects

A

Spironolactone:

May reduce breast development due to estrogen receptor activity
-If the patient experiences this, can use estradiol only and add spironolactone later
-Orthostasis and polyuria can occur, counsel patients to take in the morning to decrease getting up at night to use bathroom

Finasteride/Dutasteride
-Decreased libido, erectile dysfunction (may be desired)

17
Q

Transgender Women - Progesterone

A

Bioidentical micronized progesterone
-Once daily oral capsule - contains peanut oil - check for peanut allergy

Medroxyprogesterone (synthetic) - oral dosing is preferred, can be considered if the patient has a peanut allergy

Anecdotal improved breast/areolar development but limited evidence of effectiveness

Patient may request it

Do not administer rectally, oral

18
Q

Estradiol and Spironolactone Lab Monitoring

A

Renal function
Potassium if one spironolactone
Lipid profile
HgbA1c/fasting glucose
Estradiol

19
Q

Timeline of Hormone effects of transgender women

A
20
Q

GAHT in Non-Binary individuals

A

-Non-binary may be interested in individualized partial transition
-Non-standardized GAHT is increasingly used to address goals of treatment for non-binary individuals
-Goal is to decrease distress, improve quality of life and mental health, and center patient desires
-Use patient-centered care and personalized medicine

21
Q

Testosterone and Estradiol Injections - Syringe and Needle requirements

A

-A disposable syringe and two needles will be needed for each injection

-A 1mL syringe is necessary due to the small volume and need for accuracy

-A larger gauge needle used to draw up the injection (18g or 20g)

-Needle is switched to a smaller gauge once injection is drawn up

IM injection - 22g or 23 g, 1 inch or 1.5 inch needle

Sq injection - 25 g or 26 g, 5/8 inch needle

need syringe where you can take off and swap needle
-higher gauge to draw up, smaller gauge to inject

22
Q

Considerations for Transgender Health Care in Adults

A

Depression Symptoms have been shown to improve with GAHT
Providers should be aware of patient use of non-prescribed hormone and other drug therapies
-Trans blogs and websites are often consulted by trans individuals who may not have access to health care
-Insurance coverage may be limited related to the diagnosis of gender dysphoria
-Gender-affirming surgeries are desired by some patients, which require specialized surgeons

23
Q
A