Transcare

Question 1

What are the masculinizing agents for female -> male

Answer 1

Testosterone 20-50 mg Qweekly IM/SC

GnRH analogues -> typically only reserved for adolescents

Question 2

What are the irreversible changes once you start testosterone

Answer 2

voice changes
clitoral growth are irreversible
scalp hair loss
facial/body hair growth

Question 3

When does deepened voice occur?

Answer 3

6-12 months onset

Expected max time 1-2 years

Question 4

When do you except cessation of menses once testosterone started ?

Answer 4

1-6 months

Question 5

CI to testosterone?

Answer 5

PPPHAU

P-pregnancy / BF
P- poorly controlled psychosis or acute HI
P-psych conditions that limit consent
H-hypersensitivity
A- active or known hormone sensitive cancers (breast, endometrial)
U-unstable ischemic CVD

Question 6

is cessation of menses reversible?

Answer 6

yes

Question 7

Monitoring timeline for pt on testosterone

Answer 7

baseline, 3 months, 6 months and 12 months

Question 8

What are baseline labs for those on testosterone ?

Answer 8

CBC (transient elevation of RBC can occur with testosteron)
ALT (transient elevation of LFTs and resolve unless cause identified)
AST
A1C
Glucose fasting
Lipid
Total Testosterone

Question 9

What labs do you monitor at 3 months, 6 months and 12 months with testosterone

Answer 9

3-6 months -> CBC, total testosterone

12 months -> same as baseline

Question 10

What if your transman patient complains of sudden vaginal bleeding

Answer 10

increase risk of endometrial cancer with testosterone > should investigate for vaginal bleeding without explanation warrants follow up

Question 11

Atrophic changes to vagina with testosterone use, what are options for the pt?

Answer 11

use local lubricants and moisturizers

Question 12

Osteoporosis risk and testosterone use, what are prevention options for pt?

Answer 12

vit D 1000 u
calcium 1200 mg
moderate gradual weight bearing exercises

BMD testing >65 years but if they have been on testosterone for >2 years, they can start at 50.

Question 13

What are the feminimizing hormones (male -> female)

Answer 13

1. Anti-androgens
   -Spironolactone 50 mg daily
   -Cyproterone 12.5 mg- 25 mg
2. Estrogens
   need to wait 1-3 months after anti-androgens to start estrogen
   transfermal > oral (fewer side effects) ; recommended for patients >40 with CVS, thromboembolic or liver disease

AJUNCT ONLY
3. Progestins (not routinely recommended)
-only use if androgen suppression inadequate

AE= increased risk of breast cancer, heart disease, stroke and VTE (when combined with estrogen)

Question 14

What are the SE of spironolactone

Answer 14

Hyperkalemia
renal impair
polyuria
polydipsia
hypotension
rash

Question 15

what are the SE of cyproterone

Answer 15

increased liver enzymes
hepatotoxic
depression
VTE risk
CBC changes

Question 16

CI to starting estrogen?

Answer 16

CLPHAU
unstable ischemic cardiovascular disease
cardiovascular disease
estrogen dependent cancer
end stage liver disease
psych conditions that limit ability to provide consent
hypersensitivity to component

Question 17

Monitoring timeline for those on feminizing therapy

Answer 17

baseline, 3 months, 6 months and 12 months and q yearly after that

Question 18

What are the baseline blood work?
3 months, 6 months and 12 month blood work?

For male -> female

Answer 18

Baseline:
CBC
ALT (estrogen causes transient increase in LFTs)
Cr
Lytes
A1C
Total testosterone
Estradiol
Prolactin (increased risk: s/s visual disturb, galactorhea, new onset headache -> most common with cyproterone.)

Month 3-6: (only estradiol and testosterone, * if indicated)
CBC*
ALT*
Cr * (not the same for female-male)
Lytes * (don’t measure this for f-m)
Total testostone
Estradiol

Month 12:
Same as baseline

Goal: checking to see the degree of androgen suppression

Question 19

What is the estradiol target ?

Answer 19

200-500 pmol/L

Question 20

If your patient is on spironolactone, what do you monitor in terms of bw? how often?

Answer 20

Lytes q4-6 weeks following initiation (can cause hyperkalemia)

Question 21

What are the irreversible effects of feminizing hormones?

Answer 21

breast growth

Question 22

When should you expect to see breast growth in estrogen therapy?

Answer 22

3-6 months
expected max effect 1-2 years

Question 23

What are the recommendations for osteoporosis guidelines for male->female transitioners

Answer 23

*increased risk
usually >65 years you start
screen at 50 if >2 years on hormone therapy

Prevention:
Take 1000 units/ day Vitamin D
1200 mg/day of Calcium
wt bearing exercises (higher reps, lighter weights)

Question 24

How do you mitigate risk of breast cancer with estrogen therapy

Answer 24

CI- if you have a family hx of

Mammo Q2 years if >50 years AND on estrogen for >5 years.

Question 25

If your pt is on estrogen hormone therapy and has a seizure disorder, what is the best course of action?

Answer 25

hormones increase risk for seizures
-consult with neurologist prior to hormone therapy
-Lamotrigine, valproic acid, gaba dont seem to interact with estrogen

Question 26

Your patient has sexual dysfunction as a result of estrogen therapy, what is the best course of action?

Answer 26

this is part of the anti-androgen treatment
-can order PDE5i (sildenafil or tadalafil)

Question 27

Note:
Letter of support is required to attest to the fact that a change in sex designation is appropriate

Question 28

When should you consider discontinuing hormone therapy?

Answer 28

fertility preservation
pregnancy
surgery
older age
health issues
financial issues
retransition

Question 29

What is involved in the planning period of hormone therapy treatment

Answer 29

review medical history
explore gender identity and expression
review lifestyle and mental health consideration
ensuring capacity to consent

** Psych eval is not required prior ** -> strongly encouraged to discuss with someone tho.

Question 30

What if Carmen asked about fertility preservation before starting hormone therapy? What would be the NP’s next steps?

Answer 30

-Have discussion as to what Carmen’s wishes are
-Some patients may wish to conceive in the near future and delay medical transition to allow for harvesting, storage and/ or advanced reproductive technologies
-Some costs associated with fertility preservation are covered by Ontario Ministry of Health at certain clinics
Refer Carmen to fertility clinic that specializes in trans persons seeking fertility preservation to allow for the best care possible
-Also possible to conceive once hormone therapy is discontinued (usually 3-6 months for function to recover)
-To help speed up the process NP can also have patient complete STI screening which is required before banking sperm

Question 31

Transman is sexually active with boyfriend. What advice can the NP give him?

Answer 31

Although fertility is reduced with testosterone therapy it is not a adequate method of contraception
**Testosterone is teratogenic and therefore Justin should be counselled on risk of pregnancy and should be offered contraceptive options
Options include: progesterone only contraception or IUD device
IUD placement is easier to place prior to initiating testosterone due to atrophic changes that occur to the vaginal and cervical tissues

Question 32

Androgenic alopecia which starting testosterone, what are the therapeutic options for the NP to provide?

Answer 32

Finasteride may be used to treat
It blocks the conversion of testosterone to dihydrotestosterone (DHT)
If using this option patients need to be made aware if can impact facial hair growth and negative impact on other aspects of masculinization
Minoxidil can be used as a topical agent to the scalp