Gender Affirming Care

Question 1

Feminizing GAH Therapy :

1. Whats the general approach?
2. Feminizing GAH dosing most often requires ___ than those given to ?

Answer 1

1. Androgen blocker + estradiol
2. higher doses, hypogonadal females

Question 2

ANTI-Androgens :

1. Role in GAH?
2. Whats the DOC?
   - Avoid which drug?
   -Target Dose?
   -AE’s? (3)
3. 5 alpha reductase inhibs
   -Which drug is preferred over the other?
   -Less effective than ___
   -Typically reserved for which pt’s? (2)

Answer 2

1. Reduces masculinization associated w/reduced testosterone and minimizes breast devel
2. Spironolactone
   -eplerenone
   -200-400 mg/day
   -Hyperkalemia, nocturia, orthostasis
3. dutasteride over finasteride
   -spirono
   -those that cant tolerate spirono, those seeking partial feminization

Question 3

Estrogen Formulations and Dosing

1. Whats the DOC?
   -Typical PO starting dose of?
   -Typical TD patch starting dose?
2. Whats the issue with conjugated estrogens?
3. Ethinyl Estradiol
   -Associated with?

Answer 3

1. 17Beta Estradiol
   -2 mg PO bid
   -100 mcg daily
2. Inability to accurately measure blood levels
3. incr thrombotic risk

Question 4

1. tablet form has easier? (2)
2. Wats a disadvantage of PO form?
3. Patch is able to ___
   -Preferred in pt’s with ?
   -Good option for pt’s with ? (2)
   -Replace patch every ?
4. Disadvantage :
   Patch is visible to others
   -can cause ___
   -ADhesion issues
   -May require ___
5. Injection is able to ___
   -Faster ___
   -Disadvantages to injection would be? (2)

Answer 4

1. dose adjusting and ease of monitoring levels
2. Undergoes first pass metab
3. bypass first pass metab
   -incr thromboembolic risk (age > 45, smokers, obesity)
   -mood and anxiety disorders
   -72 hrs (Enhanced adherence)
4. skin irritation
   -multiple patches bc max strength in single patch is 100 mcg/day
5. bypass first pass metab
   -onset
   -cyclical fluctuations in hormones, injection site rxns

Question 5

What are some irreversible feminizing effects? (2)

When do these effects start onsetting?

Answer 5

Breast growth, and decreased spermatognesis

It takes a couple of months! (3-6) and expected max can be years (2-3)

Question 6

AE’s of estrogen?
S,D,M,W,V,L,E,H,H,G,H,M

Answer 6

sexual dysfunction
decr libido
migraines
weight gain
venous thromboembolism
low bone mass
elevated liver enzymes
Hypertriglyceridemia
htn
gallstones
hot flashes
mood swings

Question 7

CI to Estrogen? (3)

Answer 7

1. VTE related to underlying hypercoag state
   -Risk signif incr with concurrent tobacco use
2. Estrogen sensitive neoplasm (heightened risk at age of 50)
3. End stage liver disease, Severe hepatic impairment

Question 8

Monitoring Feminizing Hormones :

1.level of estradiol?
2. Testosterone?
3. Other labs? (5)
4. When should u monitor?

Answer 8

1. 100-200 pg/mL
2. testost <55 ng/dL
3. potass, renal function, LFTS, lipids, prolactin
4. Ongoing, more freq during initiation and titration , then q6-12 months. 3 months, 6 months, annually, prn

Question 9

Masculinizing GAH Therapy
1. General approach?
-Masculinizing GAH dosing most often ___ to that given to ?

Answer 9

1. Testosterone monotherapy
2. similar, hypogonadal males

Question 10

Testosterone FOrms :

1. Injectable SQ or IM
   -Wats DOC?
   -Which route is preferred?
   -Dose?
2. Benefits of SQ admin over IM? (3)
3. TD patch or gel
   -Good option for pts with ?
   -Patch associated with ?
   -Gel associated with?
4. Patch Starting Dose?
5. Gel Starting Dose?

Answer 10

1. Cypionate
   -SQ, over IM
   -Starting Dose : 50-100 mg q2wks, or 25-50 mg q1week
   - Typical Dose : 100-200 mg q2weeks or 50-100 mg q1week
2. Smaller, less painful needle
   -incr pt satisfaction –> better adherence
   -may avoid scarring /fibrosis from long term IM therapy
3. Concomitant mental health conditions
   -skin irritation
   -risk of secondary exposure
4. 4 mg qPM
5. 25 mg qAM

Question 11

What are some irreversible masculinizing hormone effects? (3)

What are some adverse effects?

What are some desired suppressive effects?

Desired enhancement?

Answer 11

facial/body hair growth , deepened voice , clitoral enlargement

clitoral enlargement, vaginal atrophy, incr skin oil or acne, scalp hair loss

Loss of menses

Incr muscle mass and strength, body fat redistribution, deep voice, facial and body hair growth

Question 12

AE’s of Testosterone

1. Polycythemia/Erythrocytosis
   -Which admin may have less effect?
2. W____
3. M___
   4.M
   5.M__
   6.Incr__
   7.I
   8.P
4. (from dr casey’s printout, I and S)

Answer 12

1. TD
2. weight gain (incr visceral fat, fluid retention, incr appetite)
3. mood lability
4. migraines
5. metab syndromes (Obesity, HLD, glucose intol)
6. Incr sex drive
7. infertility
8. pelvic pain
9. Insomnia and sweating

Question 13

Testosterone CI ?

Monitoring ?
Other labs?
Drug interactions? (3)

Answer 13

Pregnancy

Testost 300-1100 ng/dL
Estradiol < 50 pg/mL

CBC (hemoglobin/Hct), LFTs , lipids

Warfarin, cyclosporine, insulin

Question 14

For the first 6-12 months of GAC, use what to calculate CrCl?

Thereafter, what should u use to calculate CrCl?

Answer 14

Sex assigned at birth

Gender identity