Ex. 5 L13 (56) Flashcards
What is gender-affirming care?
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
Diagnostic Criteria for Gender Dysphoria
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
Why do we have to diagnose gender dysphoria
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
Personalized Patient-Centered Care
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
Cornerstones of Gender-affirming hormone therapy (GAHT)
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
Fertility preservation and sexual health: Transgender Men and testosterone:
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
Fertility preservation and sexual health: Transgender women - estradiol
Estradiol decreases sperm production, may be unable to produce healthy sperm after stopping estradiol
May desire to bank sperm prior to starting estradiol
Baseline Laboratory Monitoring for all patients
Basic or complete metabolic profile
Complete blood count
Hepatitis A, B, C
HIV
Transgender Men - Testosterone
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
Testosterone side effects
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
Testosterone Lab Monitoring
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
Timeline of Hormone Effects for Transgender Men
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
Transgender women and Estradiol
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
Estradiol side effects
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
Trans women - anti-androgens
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
Anti-Androgen Side effects
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)
Transgender Women - Progesterone
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
Estradiol and Spironolactone Lab Monitoring
Renal function
Potassium if one spironolactone
Lipid profile
HgbA1c/fasting glucose
Estradiol
Timeline of Hormone effects of transgender women
GAHT in Non-Binary individuals
-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
Testosterone and Estradiol Injections - Syringe and Needle requirements
-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
Considerations for Transgender Health Care in Adults
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
