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Endocrinology > Hormonal Therapy for Gender Affirmation > Flashcards

Hormonal Therapy for Gender Affirmation Flashcards

1
Q

Gender Incongruence

A
  • Used to be gender dysphoria
  • “A marked and persistent incongruence between the gender felt or experienced and the gender assigned to birth”
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2
Q

What are the following criteria for gender incongruence?

A
  • Strong dislike or disagreement with primary or secondary sexual characteristics due to incongruence with the experienced gender
  • Strong desire to get rid of some of those sexual characteristics due to the incongruence with the experienced gender
  • Strong desire to have the primary or secondary sexual characteristics of the experienced gender
  • Strong desire to be treated and accepted as a person of the felt gender
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3
Q

What are the estrogenic therapy?

A
  • Estradiol tablets
  • Estradiol transdermal patches
  • Estradiol intramuscular injection
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4
Q

Estradiol tablets

A
  • Start 2-6 mg, split dose if possible
  • Bioequivalent, most potent
  • Greater risk of VTE for PO
  • Cheapest
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5
Q

Estradiol transdermal patches

A
  • Start 0.025-0.2 mg
  • Switch daily or twice a week (brand dependent)
  • Steady release, avoids first-pass
  • Can be a burden with multiple patches
  • Thought to be safest option, but used less often
  • Most expensive
  • Trans women will still have menstrual periods
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6
Q

What are the 2 types of estradiol intramuscular injection?

A

Valerate and Cypionate

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7
Q

Estradiol Intramuscular injection

A
  • 5-30 mg IM/2 weeks
  • 2-10 mg IM/week—preferred
  • Faster breast growth
  • SubQ
  • Most considered
  • On shortage
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8
Q

What are the anti-androgen therapies for feminizing therapy?

A
  • Spironolactone
  • Finasteride
  • Cyproterone Acetate
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9
Q

Spironolactone

A
  • Aldosterone antagonist
  • Start 50 mg BID or 100 mg QD
  • Max recommended = 300 mg QD
  • Potassium concern
  • BP concern
  • Urination!
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10
Q

Finasteride

A
  • 5-alpha-reductase inhibitor (DHT)
  • Start 1 mg QD PO
  • Max Recommended = 5 mg QD PO
  • Possibly better for hair growth
  • Lacking data on usefulness in lowering T
  • Dutasteride also possible to use
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11
Q

Cyproterone Acetate

A
  • 10 mg QD
  • Preferred in Europe
  • Meningioma
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12
Q

Micronized Progesterone

A
  • Guidelines suggest not to use
  • Medroxy vs Micronized
  • Start 100 mg PO QHS
  • Max recommended = 300 mg PO QHS
  • Will make drowsy, help sleep
  • Don’t stick it in your butt
  • Peanut oil!
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13
Q

What are the benefits of progestin in feminizing therapy?

A
  • Suppress LH and T, plus T DHT
  • Increase bone density
  • Improves sleep
  • Breast maturation
  • Fat distribution and skin/hair changes
  • Improved cardiovascular function
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14
Q

What are the risk of estrogen therapy?

A

o Many “non-clinically significant”
o VTE
* Exogenous estrogen (oral)
* Smoking tobacco
* Age > 35
o Infertility
o “Estrogen Dominant” Profile

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15
Q

What are some monitoring parameters of estrogen therapy?

A
  • Lipid panel
  • Metabolic profile
  • Liver function (esp if use oral)
  • Prolactin
  • Estradiol (E2) vs Total estrogen (E1, E2, E3)–> 100-200 pg/mL
  • Take estradiol levels
  • Testosterone–> < 50 ng/dL
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16
Q

What are the testosterone components of masculinizing therapy?

A
  • Testosterone intramuscular injection
  • Testosterone transdermal patch
  • Testosterone transdermal cream/gel
17
Q

What are the two types of testosterone intramuscular injection?

A

Enanthate or Cypionate

18
Q

Testosterone intramuscular injection

A
  • 50 mg – 100mg IM (SQ) q week
  • Sesame vs cottonseed oil
    • Enanthate sesame seed oil
    • Cypionate cottonseed oil
  • Can try 100-200 mg IM q 2 week if patient desires
  • Undecanoate
19
Q

Testosterone Transdermal patch

A
  • Start 2.5 mg-7.5 mg QD
20
Q

Testosterone Transdermal Cream/gel

A

Start 50 mg - 100 mg QD

21
Q

What are some adjunctive therapy for masculinizing therapy?

A
  • Depo-Provera
  • Finasteride
  • Aromatase inhibitors
22
Q

Depo-Provera

A
  • 150 mg q 3 months
  • Can be used to halt stubborn menses
  • Can use Mirena instead
  • Reduce risk of pregnancy
  • High risk profile
23
Q

Finasteride

A
  • 1 mg QD
  • Can be used to halt balding, but will conflict with T–> DHT
24
Q

Aromatase inhibitors

A
  • Prevents estrogen production from androgens
  • No real evidence
  • Really expensive
25
Q

What are the risks of testosterone therapy?

A
  • Many “non-clinically significant”
  • Polycythemia
  • Infertility
  • “Testosterone dominant” profile
  • Pregnancy is ABSOLUTE contraindication
26
Q

What are some monitoring parameters of testosterone?

A
  • Lipid panel
  • CBC
  • Urine HCG
  • Estradiol (E2)/ Total estrogen
  • Testosterone level = “endogenous male range, average”–> 350-700 ng/dL

Endocrinology (10 decks)

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