Gender Affirming Care Flashcards
Define Intersex
Varied conditions in which born with genitalia that does not fit typical definitions of F/M
*Socially constructed category
What happened in 1979 regarding gender affirming care?
Harry Benjamin International Gender Dysphoria Association formed and published first standards of care. Now known as WPATH
What is tucking and its risks?
Hide external genitalia (usually male)
- Guide testicles into ing canal
- Wrap penis in scrotum
Risks = skin breakdown, UTI, hernia
What would you advise your trans pt in regards to binding?
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
Contraindications to HRT?
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
Estrogen HRT goals and risks?
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
What hormone is used for HRT for trans women? What form of delivery is preferred and why?
Specifically 17-beta-estradiol
- transdermal due to more stable levels and minimized risk of VTE
which hormone delivery method provides the fastest RATE of change?
Injection > tablet > patch
What changes are noticed first with estrogen HRT?
- 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)
What does estrogen HRT do to male libido and fx?
Decreased sex drive and decreased spontaneous/stimulated erections
What does estrogen HRT do to body/facial hair?
Thinning and slowed growth of body/facial hair.
What should you counsel your trans male pts on regarding estrogen HRT and breast development?
It rarely produces lobular development
- follows Tanner stages 2-5
- maximal development 2-3y w/ varied results
- Changes start 3-6 mos
What does estrogen do to skin?
- Softer
- less oil
- less acne
What does estrogen do to voice?
Nothing
What does estrogen do to male genitalia?
- decrease testicle size
- reduce sperm/semen quantity
What other category of drugs are available for trans women besides estrogens?
Anti-androgens
Name some anti-androgen 5-alpha-reductase inhibitors
- finasteride
- dutasteride
Anti-androgen diuretic/non-steroidal/ER agonist meds?
- spironolactone
- drospirenone
Which is the no-no med for anti-androgen therapy in the non-steroidal class and why?
Bicalutamide = fulminant hepatitis and death
What meds would you caution combining with spironolactone/drospirenone and why?
ACE/ARB due to combined effect of hyperK, hyponatremia, and hypotension
To ensure best possible outcome in breast development in trans women what med should you avoid and why?
Spironolactone due to potential risk of premature breast bud fusion
If you had a trans female pt complaining of insomnia which med might you start/increase?
Progesterone
What the hell is a SERM and what would you use it for? Med and dose? S/Es?
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
What pretreatment labs would you draw for feminizing GAHT? Labs once on tx?
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
Do pts on estradiol need to stop therapy before/after surgical procedures?
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
What is common range for Test therapy?
+/- 400-800 mg/dl but LARGELY based on goals and crit levels
Which has more rapid changes test or estrogen?
Test
Testosterone risk factors?
VTE due to increased RBC production
- teratogen so potential infertility
T starting dose? How to increase?
50-100 mg/wk
- 60 mg/wk common starting dose
- can double each dose every 2 wks
When does menses stop on T?
2-6M
When does libido increase on T?
1-3M
What might you consider in dosing T for a pt who has high want for deeper voice?
Start low and slow on T as high dose could impair thickening/lengthening of cords
Body hair changes on T?
3-6M
Clitoral enlargement on T?
3-6M
Is there increased CV risk on T?
No
What is finasteride helpful for? Dose?
patterned hair loss OR too heavy secondary hair
- 1-5 mg daily or EOD, use lowest dose necessary, monitor for regression of changes
What type of T tx for clitoral enlargement works best?
Systemic, not topical
Trans men on T that do not have cessation of menses can add which meds?
Aromatase inhibitors (anastrozole 1 mg PO daily)
OR
- SERM as last resort (raloxifene 30 mg po daily to star)
Pretreatment labs for masculinizing HRT?
None. Not helpful
- After tx initiation total T and CBC w/out diff Q3M
In transwomen who are on/were on estradiol have been shown to still be fertile?
Yes. Decreased volume, concentration, and motility of sperm, but still viable for IVF.
Trans men are able to continue T and still deliver babies?
True per 2014 study of 41 trans men who delivered without complications.
What else can be cryopreserved for future fertility besides sperm/eggs?
Embryo for $12K + annual $
How much does surrogacy cost?
50-100K
What might E HRT cause in HIV tx?
Maybe reduction in unboosted fosamprenavir or tenofovir but E levels remain unchanged
*most data from ethinyl estradiol/OCPs in cis-women
