Gender Affirming Care

Question 1

Meds for feminizing gender affirming hormone therapy

Answer 1

estradiol +/- anti-androgen +/- progesterone

develops feminine secondary sex characteristics & suppresses masculine secondary sex characteristics

Question 2

17-beta estradiol vs Ethinyl estradiol

Answer 2

• ethinyl estradiol has much higher risk of VTE versus 17-beta estradiol & should NOT be prescribed as part of GAHT

Question 3

Estradiol in feminizing GAHT

Answer 3

• should be 17-beta estradiol NOT ethinyl estradiol
• transdermal estradiol has lowest risk of VTE
• only absolute contraindication = active estrogen-sensitive cancer
• migraine with aura is not a contraindication for feminization GAHT

Question 4

Anti-Androgen use in feminizing GAHT

Answer 4

• used in combo with estradiol
  
  • can cause menopause like symptoms and bone loss in long term
• can be d/c’d after gonadectomy (loss of testes)
• Spironolactone:
  
  • anti-androgen receptor activity & suppresses testosterone synthesis
  • SEs: increased urination, orthostasis, risk for hyperkalemia
• 5-alpha reductase inhibitors (finasteride, dutasteride)
  
  • blocks conversion of testosterone to dihydrotestosterone (DHT)
    
    • beneficial for those who have hair loss despite low serum testosterone levels
• SEs:
  
  • decreased libido and erectile function

Question 5

Progesterone Use in Feminizing GAHT

Answer 5

• addition of progesterone to their GAHT regimen may improve breast development, mood, libido, & sleep
• medroxyprogesterone acetate (Provera) & micronized progesterone are MC used

Question 6

Feminizing GAHT Lab Monitoring

Answer 6

• check prolactin only if sx of prolactinoma: visual changes, headache, galactorrhea
• Goals:
  
  • estradiol: ~50-400 pg/mL
  • Total Testosterone: < 45 ng/dL
  • ** typically normal physiologic ranges for cisgender females
• Creatinine: upper limit of normal → male value
• Hgb/hct: lower limit → female, upper limit → male
• Alk Phos: upper limit → male

Question 7

Masculinizing GAHT: Testosterone

Answer 7

• absolute contraindications:
  
  • active testosterone sensitive cancer
  • pregnancy
  • polycythemia with a hematocrit of ≥54%
• SEs_:_
  
  • Acne, male pattern balding (can tx with finasteride), atrophic vaginitis, irregular bleeding, polycythemia

Question 8

Masculinizing GAHT: lab monitoring

Answer 8

• Goals:
  
  • total testosterone: 300-1000 ng/dL
    
    • *normal physiologic range for cisgender men
    • **supratherapeutic dosing NOT recommended
    • subtherapeutic dosing is okay
• Creatinine: upper limit of normal → male values
• Hgb/HCT: lower limit → male; upper limit → male
• Alk phos: upper limit → male