LGBTQIA+ Health Flashcards
Intersectionality
Having more than one social identity creates a whole
I.E: trans person of color vs cis person of color
Implicit bias
What to do if you have them?
Having an opinion or stereotype about a person or group of people without realizing it
Be aware of your own and reflect on them
Informed consent vs Standards of Care
Informed: patient decides what type of care is appropriate
Standards of care: mental health provider decides what tpye of care is appropriate
What to consider before starting hormone therapy for transitioning
- Think about the patient’s goals of treatment
- Research costs w/ and w/o insurance
- Don’t put off starting hormone therapy until other illnesses are under control
- Very few absolute contraindications to starting hormone therapy, only if the condition is extrememly unstable for the patient
- I.E: HIGH LFTs, breast cancer (estrogen therapy)
- Gender history: what hads it been like for you to think about your gender/gender identity?
- Managing expectations - BE REALISTIC
- Go over expected timeline/changes
- what hormones don’t do
- Does the patient have support?
Irreversible changes (testosterone therapy)
- Clitoris grows
- Body hair becomes darker and thicker
- Voice deepens
- Facial hair grows
- Head hair becomes thinner
- “Male pattern baldness”
Reversible changes (testosterone therapy)
- Body fat redistibutes - abd + waist
- Muscle mass increases
- Acne increases
- Skin becomes oiler
- Libido increases
- Menstruation stops 6 months in
- bleeding can get irregular or unusual when starting T
Three BIGGER things that testosterone DOES NOT DO
- Increase height (if puberty is complete)
- Shrink breasts
- Change vocal intonation - pronunciation (can practice changing)
- Change bone structure
Testosterone therapy risks
- Heme: Erythrocytosis → clot risk
- GI: liver inflammation → only check LFTs if have s/s
- CV: teach lifestyle modifications to decrease risk
- HTN, HLD, MI, stroke
- Endocrine: only check for insulin resistance if need to
- Reproductive: infertility, vaginal dryness/atrophy
- Psychosocial
- Destabilization of certain mood disorders: bipolar + schizophrenia losing stability when starting T → dose daily instead of weekly
- Social consequences: transphobic society
Causes of pelvic pain in transmasculine patients
- R/O other DXs first and treat
-
Vaginal atrophy - use smallest speculum for exam
- Low estrogen state - similar to menopause, post-partum lactation, cancer treatment
- Can cause pain on its own, or predispose to other diagnoses
- BV, UTI, cervicitis - TX
- Trauma from penetration or friction
Treatment for pelvic pain in transmasculine patients
Vaginal estrogen
* Localized dose
* Not systemically absorbed, short course
* Will not cancel out Testosterone therapy tx
* Creams > tablets
Treatment for cyclic pelvic pain in transmasculine patients
- Can be caused by T INJ and/or penetration/orgasm
- Switching from INJ → transdermal if correlated w/INJ timing
- Pelvic floor PT
- Hysterectomy/endometrial ablation
- General pelvic pain treament options (consider trauma/PTSD w/dysphoria)
Bleeding in transmasculine patients
Differentials
- Pregnancy
- Fibroids
- Endometrial polyps
- Cervicitis
- Malignancy
- PCOS
- Thyoid dysfunction
- Eating disorder
Delaying T if patient shows irregular bleeding?
- Depends, wait until full work-up is done to decide delaying
- Weight risks/benefits of delaying T
Diagnostic, dose work-up for persistent bleeding after 6-12 months on T
- Consider body physique for testosterone dosing
- Larger build → aromatizing testosterone → estrogen tissue (estradiol)
- May help to decrease T
- Missing/skipping INJs d/t financial cost
- Larger build → aromatizing testosterone → estrogen tissue (estradiol)
- Labs: Testosterone, FSH, LH
- If both WNL + testosterone in male range → further workup
- Endometrial polyps, endometrial hyperplasia, polyps, maligancy
- If both WNL + testosterone in male range → further workup
- Imaging: Pelvic U/S, endometrial biopsy, transabdominal U/S alone (less invasive)
Treatments for bleeding in transmasculine patients
- Adjust T
- Add progestin
- Hysterectomy
- Endometrial ablation
- Higher T
- BC, Depoprovera, IUD, etc.
Testosterone therapy medication forms and implications of each
-
INJ: T cypionate + T enthanate
- Qweekly or 2x dose Q2weeks
- IM, SQ (common - smaller needle)
- Compounded in oil - sesame - check allergy
- Gel: Avoid contact w/others after applying (Qday)
- Patch: may cause skin irritation or fall off (Qdaily)
-
Implant: Q3-6months (Testopel)
- In SQ fat of hip area
- Dissolves over time (do not need to be removed)
-
Other meds
- Topical estrogen cream or Estring for genital atrophy
-
Finasteride for male pattern baldness
- May cause external genitalia abnormalities in male fetuses (no crushed/broken tablets for ppl who might be pregnant)
Testosterone therapy monitoring
Timing
Labs
- At 3, 6, 12 mos: CBC + Total testosterone
- Erythrocytosis (gender marker in male range)
- TT: 200-800; ask when last shot was (peak/trough); know your lab’s reference ranges for cis-men
- Labs as needed /per USPSTF guidelines
- Estradiol (want < 50)
- LFTs → watch for gender marker
- Lipids
- Blood glucose
- BP
- CV RFs
Estrogen Therapy Timeline
Irreversible Changes
for M > W
- Sperm + semen production decrease
- Testicles shrink
- Breasts grow
Estrogen Therapy Timeline
Reversible Changes
- Body fat redistributes
- Muscle mass decreases
- Skin becomes softer
- Libido/erections decrease
- Body/facial hair becomes finer
- Head hair loss slows
Estrogen/Anti-androgen therapy risks
- Estrogen used in tx less likely to cause clots vs. estradiol
- GI : liver inflammation
- CV : HTN, MI, stroke, Venous thromboembolism
- Endocrine : Hyperprolactinemia
- Renal : Electrolyte imbalances (spironolactone)
- Reproductive : Infertility
Pts w/CV risks - nonmed and med options?
- Counsel pts about lifestyle modfications to lower risk, especially if they smoke or have FMHx of CVD
- Trasndermal E for pts w/higher VTE + CVD risk
- Baby aspirin for pts > 40 w/CV RF if smoking
Estrogen Therapy: Dosage forms + adjuvant meds
- INJ (estradiol valerate)
- Topical - (safest form for ppl w/existing clot risk)
- PO/ SBL (avoids 1st-pass effect → effective dosage)
- Dvided dosing recommended if > 2mg
- Other: Spironolactone (anti-androgen); Finasteride for hair loss, Cialis or Viagra
Estrogen/Anti-androgen Therapy Monitoring
- At baseline, at 3, 6, and 12 mos, then yearly:
- BUN/Cr/K+ (spironolactone)
- 3, 6, and 12 mos, then PRN:
- Estradiol (100-300) + Testosterone levels
- Total Testosterone: < 40 - don’t want 0 - lack o energy at 0
- PRN per USPSTF guidelines
- LFTs, Lipids, BG, BP, CV RFs, Prolactin
ACHEs stand for?
Blood clots
Abd pain
Chest pain
HA
Eye problems (vision changes)
Severe leg pain
+ Prolactinoma (visual changes, HA, galatorrhea)
Fertility considerations for Testosterone therapy
- Ovulation usually difficult, but not impossible to get pregnant
- Use Depo, IUD, POPs, Nexplanon, barrier methods
- Consider egg harvesting + storage; freezing embryos
Bottom line: Testosterone is not birth control, but might make it impossible to conceive a child
Fertility considerations for Estrogen/Anti-androgen Therapy
- Sperm count + motility decrease, BUT it’s difficult, not impossible, to get someone pregnant
- Consider banking sperm (better before hormone initiation), freezing embryos
Bottom line: estrogen is not birth control, but might make it impossible to conceive a child
Fertility visit follow-up frequency for patients taking hormone therapy
Every few months in 1st year
Then yearly
- More frequently with dose changes
Pap test considerations for transmasculine patients
What to use?
- Unsatisfactory paps more common d/t long time on T
- If unsastifactory test, need repeat in 2-4 mos
- HPV testing too
- Topical estrogen for repeat unsatisfactory Paps
- Consider self-colelction of vaginal swab for HPV if Pap removed
- T can make vagina atrophic + alter interpretation
Genital bleeding considerations for transmasculine patients
- Should stop after 3-6 mos on T
- T too low? → breakthrough bleeding
- T too high? → Aromatizing estrogen
Chest exams for transmasculine patients
- If no top surgery → cis women guidelines
- If s/p top surgery → clinical chest wall exam + pt education
- Not all breast tissue is removed
HIV prophylaxis for transmasculine pts?
PrEP
Mammogram considerations for transfeminine patients
- Recommended after age 50 if following present:
- Estrogen therapy for 5yrs ≤
- FMHx of breast cancer
- BMI > 35
Prostate exams + PSA testing for transfeminine patients?
YES - even after bottom surgery, prostate remains
Pap tests needed after bottom surgery?
Transfeminine
No - b/c no cervix
