ICL 17.5: Medical Management of Transgender Patients

Question 1

what is transgender?

Answer 1

a term for people whose gender identity, expression or behavior is different from those typically associated with their assigned sex at birth

Question 2

what is cisgender?

Answer 2

term for people whose gender identity, expression or behavior matches those typically associated with their assigned sex at birth

Question 3

what is gender non-conforming?

Answer 3

a term for individuals whose gender expression is different from societal expectations related to gender

Question 4

what is gender dysphoria in adult?

Answer 4

DSM5 diagnostic term used

a noticeable incongruence between the gender the patient believes they are, and what society perceives them to be

in DSM4 it was called gender identity disorder so do not use it!

Question 5

why has the demand for transgender health care increased?

Answer 5

1. increasing social acceptance
2. increasing economic access
3. increasing legal access

however the major limiting factor is a lack of available high quality care

Question 6

what are the common transgender disparities?

Answer 6

1. greater than 4 times the national average of HIV infection (2.6% vs. 0.6%).
2. 26% use or have used alcohol and drugs to cope with discrimination.
3. 41% reported attempting suicide compared to 1.6% of the general population.
4. 57% faced some rejection by their family.
5. family rejection significantly increased rates of homelessness, incarceration, sex work, HIV, suicide attempts, smoking, and use of drugs and alcohol

Question 7

what are the mental healthcare needs of transgender patients?

Answer 7

high rate of need

inpart in response to society’s reaction to who they are

Question 8

what do transgender people want from healthcare beyond routine needs?

Answer 8

1. hormonal transition to the gender of identity

transgender women need estrogen/anti-androgen and transgender men want testosterone

2. surgery

gender confirming/affirming surgery

transfender men want bilateral mastectomies/hysterectomy/BSO/vaginectomy/phalloplasty/scrotoplasty

transgender women might want orchiectomy/penectomy/vulvo-vaginoplasty

3. identity enhancing like facial feminization, vocal cord alteration, hair transplants, body contouring, implants, etc.

Question 9

what reproduction options are there for transgender people?

Answer 9

1. gamete cryopreservation/ART
2. counseling on recovery of reproductive capacity
3. contraception/STI prevention

Question 10

what behavioral modifications are available for transgender people?

Answer 10

1. vocal coaching for pitch and speech patterns

2. gender specific patterns of dress and behavior

Question 11

what is WPATH?

Answer 11

World Professional Association for Transgender Health

mission to promote evidence based care, education, research, advocacy, public policy, and respect in transgender health.

Question 12

what are the organization s in charge of standards of care for transgender people?

Answer 12

1. WPATH
2. Fenway Center in Boston
3. UCSF Center of Excellence for Transgender Health

Question 13

what is the role of a PCP in the care of transgender people?

Answer 13

1. trans-friendly optimal primary care

2. screening recomendations/provisions

Question 14

what screening recommendations/provisions are required for a transgender patient by their PCP?

Answer 14

1. cardiovascular/metabolic
2. STI, pregnancy and cervix care –> testosterone is not a reliable contraceptive!
3. breasts
4. prostate

Question 15

what are the trans-specific gynecologic health concerns?

Answer 15

1. abnormal bleeding in transgender men with a uterus is usually explained by hormone use….but work up if modifying the hormones doesn’t resolve it

long term risk of cancer with androgen use is unknown….

2. care of a neovagina/neovulva

frequently the initial surgery was done elsewhere…grafy sloughing/incisional breakdown are not uncommon and there is a need for long term dilation because structures are a pretty common problem – post neoclitoral/labial pain or hypersensitivity may require revision too

routine PAP is not recommended

Question 16

what are the trans-specific urologic health concerns?

Answer 16

care of neophalus/neoscrotum in transgender male

urethral structures and fistulas are common

Question 17

what are the male sex steroids that can be given for transgender hormonal therapy?

Answer 17

1. testosterone and derivatives
2. androstenedione; precursor only
3. dihydrotestosterone (DHT)

it’s a potent metabolite of T in skin so not used clinically systemically

compounded topical use before metoidioplasty

4. synthetic androgens especially for athletic enhancement but not used for transgender care

Question 18

what are the female sex steroids that can be given for transgender hormonal therapy?

Answer 18

1. estradiol and derivations
2. estrone
3. estriol
4. conjugated equine (CEE)
5. synthetic (not used for transgender women)

Question 19

where does testosterone come from?

Answer 19

gonads and adrenal glands

Question 20

what is the function of testosterone?

Answer 20

1. spermatogenesis
2. muscle density and mass
3. bone density and length, cartilage growth
4. libido
5. male secondary sex characteristics like organs, voice, hair, growth

Question 21

how much testosterone does it take to make things happen in transgender men?

Answer 21

men have ten-fold higher T levels than women

it circulates bound to SHBG and albumin because it’s lipophilic and hydrophobic and only the free fraction is what’s metabolically active

Question 22

where does estradiol come from?

Answer 22

gonads, fat and muscle

this is because aromatase is in fat mainly and converts testosterone to estrogen

Question 23

what is the function of estradiol?

Answer 23

1. menstrual cycle, endometrium
2. one, skin, hair, GI, lungs
3. clotting factors
4. lipids
5. female secondary sex characteristics like breast ductal development, vaginal growth, fat distribution

Question 24

how much estrogen does it take for estradiol does it take to make things happen in transgender woman?

Answer 24

it’s harder to estimate because cis women cycle and there’s a 10x change in estradiol depending on where they are in their cycle so when you ask how much estradiol you need, it’s hard to tell how much transgender females need…

so you shoot for 100-200 pg/nl

Question 25

what are the 2 primary goals of hormone therapy?

Answer 25

1. induce the desired secondary sex characteristics (‘mini-puberty’), a direct effect of the administered hormone transgender women: breast growth, body composition transgender men: voice deepening, terminal facial and body hair, body composition 2. cause regression of already induced characteristics, an indirect effect through suppression of the pituitary hormones that drive the gonads (FSH/LH) --> unnecessary after gonadectomy transgender men: amenorrhea, fat mass, some breast tissue transgender women: facial and body terminal hair, muscle mass, gonads, spontaneous erections

Question 26

what is the adjust goal of hormone therapy?

Answer 26

do no harm!! there are several studies of overall risk on short term hormone therapy but few data on long term risks patients don't consider hormones an elective option

Question 27

what are the effects of masculinizing hormones?

Answer 27

1. skil oiliness/acne 2. facial/body hair growth hair cycle can be up to 5 years so it can take up to 5 years for it to come in completely 3. scalp hair less 4. increased muscle mass/strength 5. body fat redistribution 6. cessation of menses 7. clitoral enlargement 8. vaginal atrophy 9. deepened voice

Question 28

what are the effects of feminizing hormones?

Answer 28

1. body fat redistribution 2. decreased muscle mass/strength 3. softening of skin/decreased oiliness 4. decreased labido 5. decreased spontaneous erections 6. male sexual dysfunction 7. breast growth 8. decreased testicular volume 9. decreased sperm production 10. thinning/slowed growth of body facial hair 11. male pattern baldness

Question 29

what are the risks of feminizing hormones?

Answer 29

1. VTE** 2. gallstones 3. elevated liver enzymes 4. weight gain 5. hypertriglyceridemia* possible increased risk of CVD, HTN, DMII but no increased risk of breast cancer

Question 30

what are the risks of masculinizing hormones?

Answer 30

1. polycythemia* 2. weight gain 3. acne 4. androgenic alopecia 5. sleep apnea possible increased risk of elevated liver enzymes, hyperlipidemia, destabilization of certain psych disorders, CVD, HTN, DMII but no increased risk for decreased bone density, breast cancer, cervical cancer, ovarian cancer, or uterine cancer

Question 31

how do you assess the patients response to hormone therapy?

Answer 31

short term: suppression of serum levels of the principal endogenous gonadal hormone(usually E2 /T, sometimes FSH/LH) long term: development of biological effects of the administered hormones, and suppression of the manifestations of the endogenous gonadal hormones

Question 32

what is the initial therapy in transgender women therapy?

Answer 32

estrogens if adequate suppression of testicular function is not achieved, consider adjunctive therapy, using anti-androgens and GnRH agonists

Question 33

what is the estrogen regimen used for transgender women?

Answer 33

oral dosage is typically 6-8 times that used in menopausal hormone therapy (reduced after orchiectomy, if GCS is performed). oral preparations, twice daily most commonly. avoid oral preparations of unknown bioavailability. non-oral options are increasingly requested, and may become the option of choice to minimize risk.

Question 34

what are the types of estrogen that can be given to TG women?

Answer 34

1. estradiol 2. conjugated estrogens USP 3. transdermal patches 4. IM depo-estradiol 5. buccal micronized estradiol

Question 35

which medications are adjunctive hormonal therapy for TG women?

Answer 35

1. anti-androgens ex. spironolactone, finasteride, flutamide, cyproterone acetate 2. progestins requested for breast growth like medroxyprogesterone or micronized progesterone but there's no evidence that this actually helps

Question 36

what surveillance regimen do you do for hormone therapy in TG women

Answer 36

baseline, 3, 6, 12, 18, 24 months, then annually for: 1. serum estradiol & testosterone E2 100-200 pg/mL; T< 0.9 ng/mL. 2. lood pressure 3. electrolytes if on spironolactone 4. lipids per usual female guidelines

Question 37

what is the initial therapy in transgender male therapy?

Answer 37

testosterone if adequate suppression of ovarian function is not achieved, consider adjunctive therapy, using anti-estrogen or GnRH agonist

Question 38

what is the dose of testosterone used for TG men?

Answer 38

1. dosage is typically 2-4 times that used as hormone replacement in male hypogonadism (reduced after oophorectomy, if GCS performed). 2. intramuscular administration is the standard 3. transdermal gel 4. transdermal patch 5. oral fluoxymesterone

Question 39

what adjunct therapy can you use for TG males?

Answer 39

anti estrogens but infrequently used 1. aromatase inhibitors (testosterone to estradiol): anastrozole, letrozole 2. estrogen receptor antagonists: tamoxiphene, toremifene, raloxifene

Question 40

how do you monitor TG male hormone therapy?

Answer 40

baseline, 3, 6, 12, 18, 24 months, then annually for: 1. serum testosteron and estradiol 2. Hb/Hct 3. liver function tests 4. serum lipid profile

Question 41

what are the adjunction hormone therapies in adolescents?

Answer 41

Inhibition of pituitary gonadotropins & thus gonadal steroidogenesis 1. Goserelin subcutaneous implant q 3-4 weeks 2. Leuprolide acetate depot suspension IM q 4 weeks 3. Nafarelin nasal spray

Question 42

what is gender confirming surgery?

Answer 42

1. irreversible and final 2. recommendation by an appropriate counselor WPATH: Two letters, one by an independent psychologist/psychiatrist 3. financial obstacles must be overcome 4. multidisciplinary surgeon teams. 5. may need several sessions of surgery.

Question 43

what is the WPATH readiness criteria for gender confirming surgery?

Answer 43

1. demonstrable progress in consolidating the evolving gender identity. 2. demonstrable progress in dealing with work, family, and interpersonal issues resulting in a significantly better state of mental health. 3. tolerating hormonal therapy and maintaining good health. 4. often a prerequisite for insurance coverage

Question 44

what is the gender confirming surgery for transgender women?

Answer 44

1. orchiectomy 2. vaginoplasty/clitoroplasty/labiaplasty can be done by: - inversion of penile/scrotal skin - penectomy and pedicled rectosigmoid transplant; or - penectomy and free skin graft to line a neovagina

Question 45

what is penile inversion vaginoplasty?

Answer 45

1. incise penis and scrotum, remove testes. 2. denude penile shaft. 3. remove erectile tissue, preserving the urethra and neurovascular bundle and glans. 4. create neovagina by inverting penile skin, shortening urethra, and trimming glans to form a clitoris. Form scrotal skin into labia.

Question 46

what cosmetic gender confirming surgery can be done for transgender women?

Answer 46

1. augmentation mammoplasty after achieving stable breast growth 2. reduction thyroid chondroplasty 3. suction lipoplasty/lipofilling 4. thinoplasty 5. facial bone reduction, face-lift, blepharoplasty 6. pectoral/gluteal implants 7. vocal cord reconstruction

Question 47

what are some of the post top problems associated with gender confirming surgery for transgender women?

Answer 47

1. graft failure 2. vaginal stenosis --> maintenance requires use of dilators/stents or regular intercourse 3. cosmetic appearance 4. hypersensitivity of reconstructed clitoris/vulva 5. anorgasmia

Question 48

what are the gender confirming surgery that can be done for transgender men?

Answer 48

1. reduction mammoplasty 2. hysterectomy +/- salpingo-oopherectomy 3. vaginectomy 4. phalloplasty --> metoidioplasty, flap, free vascular graft/urethroplasty 5. scrotoplasty with testicular implants

Question 49

what are the phalloplasty techniques?

Answer 49

both require subsequent scrotoplasty and testicular implants using labial skin erections will require placement of an erectile device.

Question 50

how is fertility effected in transgender males and females on hormone therapy?

Answer 50

hormone therapy suppresses gonadal function and fertility but it returns with cessation of therapy ovulatory cycles return immediately sperm recovery requires 3-6 months does not automatically cause gonadal failure

Question 51

how is fertility effected in transgender males and females who underwent gonadectomy?

Answer 51

sperm can be frozen and stored, but must be collected off of hormones egg freezing is now available, but requires stimulation and retrieval, and is expensive

Question 52

what is ambisexual hair?

Answer 52

becomes terminal (thick, dark) at T levels above the female range chin, neck, upper back, midline chest and upper abdomen has a 3-5 year growth cycle scalp hair with genetic predisposition will lose follicles in a male pattern with testosterone hormones

Question 53

how are vocal cords effected by testosterone?

Answer 53

they lengthen with testosterone which causes a longer and lower pitch they will not ever shorten even with testosterone