ICL 17.4: Hormone Therapy in Transgender Patients Flashcards
what is gender?
a person’s internal sense of self and how they fit into the world, from the perspective of gender
what is sex?
historically has referred to the sex assigned at birth, based on assessment of external genitalia, as well as chromosomes and gonads. In everyday language is often used interchangeably with gender, however there are differences, which become important in the context of transgender people
what is gender expression?
the outward manner in which an individual expresses or displays their gender. This may include choices in clothing and hairstyle, or speech and mannerisms. Gender identity and gender expression may differ; for example a woman (transgender or non-transgender) may have an androgynous appearance, or a man (transgender or non-transgender) may have a feminine form of self-expression
what is gender identity disorder?
previous formal diagnosis found in the Diagnostic and Statistical Manual of Mental Disorders (4th edition) for individuals who experience gender dysphoria; these individuals can be transgender or transsexual
what is gender dysphoria?
discomfort or distress that is caused by a discrepancy between a person’s gender identity and that person’s natal sex. Current formal diagnosis found in the DSM (5th edition)
basically the same thing as gender identity disorder but it’s just the DSM4 version of gender ysphoria
what is transgender?
a person whose gender identity differs from the sex that was assigned at birth. May be abbreviated to trans
a transgender man is someone with a male gender identity and a female birth assigned sex;
a transgender woman is someone with a female gender identity and a male birth assigned sex.
anon-transgender person may be referred to as cisgender (cis=same side in Latin)
what is gender nonconforming?
a person whose gender identity differs from that which was assigned at birth, but may be more complex, fluid, multifaceted, or otherwise less clearly defined than a transgender person
genderqueer is another term used by some with this range of identities
what is nonbinary?
: transgender or gender nonconforming person who identifies as neither male nor female
they’re, they and them
what is a trans-masculine or trans-feminine person?
terms to describe gender non-conforming or nonbinary persons, based on the directionality of their gender identity.
a trans-masculine person has a masculine spectrum gender identity, with the sex of female listed on their original birth certificate
a trans-feminine person has a feminine spectrum gender identity, the sex of the male listed on their original birth certificate
what do you have to consider before starting HRT?
- patient readiness and appropriateness
- mental health referral
- informed consent for ignition of gender-affirming hormone therapy by provider
medical providers who feel comfortable making an assessment and diagnosis of gender dysphoria, as well as assessing for capacity to provide informed consent (understand risks, benefits, alternatives, unknowns, limitations, risks of no treatment) are able to initiate gender- affirming hormones without a prior assessment or referral from a mental health provider
who can prescribe hormone affirming therapy?
- PCP
- OB/GYN
- endocrinologists
- advance practice provides though many do not
how does HRT vary by age?
prepubescent, pubertal or adult
what do you do if the patient has comorbid conditions and wants HRT?
the most important step in the initiation of hormonal therapy is to ensure that patients do not have comorbid conditions that could be exacerbated by hormonal treatments.
when is gender identity fixed?
usually in early adolescence and beyond
what do you give to adolescents that want to change?
once gender dysphoria is confirmed, pubertal suppression may be accomplished in male and female adolescents with use of a gonadotropin-releasing hormone analogue
this treatment is reversible
what are the evaluations you have to do in an adolescent before initing HRT?
- menstrual history (if born a female)
- tanner staging
- height
- hormone labs: serum luteinizing hormone, follicle stimulating hormone, estradiol levels, testosterone levels
- other labs: CMP, Lipid, HgA1c, bone age and bone density
what followup evaluation do you need to do for adolescents on HRT?
followup about every 3-6 months and look at:
- menstrual cycles (if born a female)
- pubertal development/advancement
- height
4 hormone labs: serum luteinizing hormone, follicle stimulating hormone, estradiol levels, testosterone levels
- other labs: CMP, Lipid, HgA1c, bone age and bone density
what’s the difference between initiating HRT in adults vs. adolescents?
in adults, hormones are irreversible!!!
HRT results in physiologic changes that irreversible so you need to talk about:
- assess readiness
- infertility; consider oocyte or sperm cryopreservation
- social consequences
which HRT do you use for male to female?
estrogen and anti-androgen medication
what are the risk assoacited with estrogen HRT?1.
- thromboembolic disease
- prolactinoma
significant liver disease - breast cancer
- coronary artery disease
- migraine headaches with aura
- HTN
- liver disease
what is the target goal with male to female HRT?
- decrease testosterone to female range (<55 ng/dL)
- maintain an estradiol level similar to premenopausal women (<200 pg/dL)
tell the patient that results that are often noted within 3 months!! they’ll notice:
1. fat redistribution, breast growth, voice and skin changes
- decrease in erections, libido, and sperm production
what are the estrogen medications give for HRT?
estradiol
PO. IM or transdermal
what anti-androgen medications can you give for TG females?
- progesterone or medroxy-progesterone acetate
- spironolactone
- finasteride
- cyproterone
- GnRH agonists (ex: leuprolide, histrelin implant)
the transdermal route of estrogen administration is highly recommended, as therapeutic effects are achieved at lower peak doses since first-pass hepatic metabolism is avoided, plasma hormone levels remain constant, and the sustained drug delivery reduces the need for frequent self- administration, which improves patient compliance.
what are the risk associated with androgen blockers?
- hypokalemia
2. hypotension
what HRT do you use for TG males?
testosterone
can
what are the risk associated with testosterone HRT in TG males?
patients are at risk for exacerbation of breast or endometrial cancer and significant liver disease while on testosterone therapy
this is because testosterone can be converted into estrogen by aromatase
what are the effects of testosterone in TG males? what is the target goal for testosterone HRT?
objective of hormonal therapy is to induce virilization with exogenous androgens
testosterone enanthate and testosterone undecanoate are most commonly used = PO, IM, subQ, transdermal
target goal:
1. increase serum testosterone to male range (goal 350-700 ng/dL)
- decrease serum estradiol (goal <50 pg per mL)
what are the physical results of testosterone in TG males?
- increased muscle mass
- decreased fat mass
- increased facial hair and body hair
- acne
- clitoromegaly
- vaginal atrophy
- voice deepening
- male pattern baldness
- increased libido
- amenorrhea, especially if it is administered intramuscularly
if this is not achieved, especially in the case of transdermal testosterone administration, progesterone therapy can be used concomitantly to stop menstrual flow
what are the risks of testosterone HRT in TG males?
- polycythemia
- hyperlipidemia
- HTN
- osteoporosis
monitor liver enzymes, Hct lipid levels and screen for DM
must do estradiol monitoring once uterine bleeding ceases
how often do you monitor adults that are on HRT?
monitor patients every 3 months during the first year of therapy then once or twice yearly thereafter
at these visits, patients are monitored for metabolic alterations resulting from therapy as well as changes in their quality of life
documented side effects from these formulations include depression and increased risk of suicidal thoughts, mood swings, hyperprolactinemia, elevated liver enzymes, migraines, and decreased insulin sensitivity
all of these changes are important to monitor as they can significantly impair the health of these patients
