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Clinical Decision Making RRPA > Gender Affirming Care > Flashcards

Gender Affirming Care Flashcards

1
Q

Define Intersex

A

Varied conditions in which born with genitalia that does not fit typical definitions of F/M
*Socially constructed category

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2
Q

What happened in 1979 regarding gender affirming care?

A

Harry Benjamin International Gender Dysphoria Association formed and published first standards of care. Now known as WPATH

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3
Q

What is tucking and its risks?

A

Hide external genitalia (usually male)

  • Guide testicles into ing canal
  • Wrap penis in scrotum

Risks = skin breakdown, UTI, hernia

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4
Q

What would you advise your trans pt in regards to binding?

A

Get from trans specific company

  • Correct size measure fullest are of chest
  • There are used binder programs
  • No more than 8-12 hrs, take off to sleep
  • Breathing exercises, stretch arm/chest when not bound
  • can try thin undershirt or non-irritating body powder (Gold Bond) to avoid excessive sweating
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5
Q

Contraindications to HRT?

A

Testosterone

  • pregnant
  • acute unstable physical/mental health
  • Untreated polycythemia
  • T sensitive neoplasm

Estrogen

  • Acute unstable mental/physical health
  • active ER positive neoplasm
  • *Hx VTE not contra to estrogen
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6
Q

Estrogen HRT goals and risks?

A

Serum estradiol 50-200 pg/mL, goal T < 55 ng/dl

  • levels above UNL possibly associated w/ inc clot risk
  • too low = increased bone loss
  • non-gendered/non-binary may want intermediate ranges and physical changes
    • Can potentially cause infertility
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7
Q

What hormone is used for HRT for trans women? What form of delivery is preferred and why?

A

Specifically 17-beta-estradiol

- transdermal due to more stable levels and minimized risk of VTE

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8
Q

which hormone delivery method provides the fastest RATE of change?

A

Injection > tablet > patch

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9
Q

What changes are noticed first with estrogen HRT?

A
  • psychological (immediate)
  • Libido/sexual function (1-3 mos)
  • breasts/body fat redist/decreased muscle mass and strength/genitalia, skin (3-6 mos)
  • Body hair (longest @ 6-12 mos)
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10
Q

What does estrogen HRT do to male libido and fx?

A

Decreased sex drive and decreased spontaneous/stimulated erections

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11
Q

What does estrogen HRT do to body/facial hair?

A

Thinning and slowed growth of body/facial hair.

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12
Q

What should you counsel your trans male pts on regarding estrogen HRT and breast development?

A

It rarely produces lobular development

  • follows Tanner stages 2-5
  • maximal development 2-3y w/ varied results
  • Changes start 3-6 mos
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13
Q

What does estrogen do to skin?

A
  • Softer
  • less oil
  • less acne
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14
Q

What does estrogen do to voice?

A

Nothing

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15
Q

What does estrogen do to male genitalia?

A
  • decrease testicle size

- reduce sperm/semen quantity

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16
Q

What other category of drugs are available for trans women besides estrogens?

A

Anti-androgens

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17
Q

Name some anti-androgen 5-alpha-reductase inhibitors

A
  • finasteride

- dutasteride

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18
Q

Anti-androgen diuretic/non-steroidal/ER agonist meds?

A
  • spironolactone

- drospirenone

19
Q

Which is the no-no med for anti-androgen therapy in the non-steroidal class and why?

A

Bicalutamide = fulminant hepatitis and death

20
Q

What meds would you caution combining with spironolactone/drospirenone and why?

A

ACE/ARB due to combined effect of hyperK, hyponatremia, and hypotension

21
Q

To ensure best possible outcome in breast development in trans women what med should you avoid and why?

A

Spironolactone due to potential risk of premature breast bud fusion

22
Q

If you had a trans female pt complaining of insomnia which med might you start/increase?

A

Progesterone

23
Q

What the hell is a SERM and what would you use it for? Med and dose? S/Es?

A

Selective Estrogen Receptor Modulator

  • used to block breast development in setting of estrogen HRT
  • Rx: raloxifene. opposes estrogen activity in breast/uterus, but improves activity at bone/liver
  • start at 1/2 tab of 60 mg tab, increase as needed
  • not studied for GAHRT but approved by Fenway
  • Common S/Es = hot flashes, arthralgias/myalgias, infection, URI, cough, HA, rarely VTE/stroke
24
Q

What pretreatment labs would you draw for feminizing GAHT? Labs once on tx?

A

None. Not helpful and typically not needed.

  • Once started on GAHT estradiol and total T Q3M w/ goal E 50-200 pg/mL, T<55 mg/dl
  • BMP only needed if rx’d spiro Q3M looking for hyperK
25
Q

Do pts on estradiol need to stop therapy before/after surgical procedures?

A

No evidence suggesting so unless risk factors of (smoking, fam hx, excessive doses or synthetic estrogen use).
- Alternative is to lower dose and/or change to transdermal route if not already

26
Q

What is common range for Test therapy?

A

+/- 400-800 mg/dl but LARGELY based on goals and crit levels

27
Q

Which has more rapid changes test or estrogen?

A

Test

28
Q

Testosterone risk factors?

A

VTE due to increased RBC production

- teratogen so potential infertility

29
Q

T starting dose? How to increase?

A

50-100 mg/wk

  • 60 mg/wk common starting dose
  • can double each dose every 2 wks
30
Q

When does menses stop on T?

A

2-6M

31
Q

When does libido increase on T?

A

1-3M

32
Q

What might you consider in dosing T for a pt who has high want for deeper voice?

A

Start low and slow on T as high dose could impair thickening/lengthening of cords

33
Q

Body hair changes on T?

A

3-6M

34
Q

Clitoral enlargement on T?

A

3-6M

35
Q

Is there increased CV risk on T?

A

No

36
Q

What is finasteride helpful for? Dose?

A

patterned hair loss OR too heavy secondary hair

- 1-5 mg daily or EOD, use lowest dose necessary, monitor for regression of changes

37
Q

What type of T tx for clitoral enlargement works best?

A

Systemic, not topical

38
Q

Trans men on T that do not have cessation of menses can add which meds?

A

Aromatase inhibitors (anastrozole 1 mg PO daily)
OR
- SERM as last resort (raloxifene 30 mg po daily to star)

39
Q

Pretreatment labs for masculinizing HRT?

A

None. Not helpful

- After tx initiation total T and CBC w/out diff Q3M

40
Q

In transwomen who are on/were on estradiol have been shown to still be fertile?

A

Yes. Decreased volume, concentration, and motility of sperm, but still viable for IVF.

41
Q

Trans men are able to continue T and still deliver babies?

A

True per 2014 study of 41 trans men who delivered without complications.

42
Q

What else can be cryopreserved for future fertility besides sperm/eggs?

A

Embryo for $12K + annual $

43
Q

How much does surrogacy cost?

A

50-100K

44
Q

What might E HRT cause in HIV tx?

A

Maybe reduction in unboosted fosamprenavir or tenofovir but E levels remain unchanged
*most data from ethinyl estradiol/OCPs in cis-women

Clinical Decision Making RRPA (3 decks)

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