Transgender Flashcards
What antiandrogen options are there for feminizing hormone therapy?
Cyproterone - progestin and androgen receptor antagonist
Spironolactone - diuretic (most commonly used)
Contraindications of Cyproterone
- active liver disease and hepatic dysfunction,
- Severe renal insufficiency,
- Severe chronic, depression (caution in all patients with a history of depression),
- Previous or existing liver tumours,
- Presence or history of meningioma,
- Existing thromboembolic process,
- Avoid concomitant use of hepatotoxic medications
Contraindications of Spironolactone
renal insufficiency, addison’s disease, hyperkalemia. Avoid concomitant use of: ACEs/ARBs, other potassium-sparing diuretics, trimethoprim-sulfamethoxazole, potassium supplements, eplerenone, heparin
What is the criteria to start hormone therapy?
- Persistent, well-documented gender dysphoria/gender incongruence
- Capacity to make a well-informed decision
- Relevant medical or mental health issues are well controlled
What is the diagnostic criteria for gender incongruence?
- Persistent incongruence between gender identity and external sexual anatomy at birth
- The absence of a confounding mental disorder or other abnormality
What is gender dysphoria?
The discomfort arising in some individuals from the incongruence between their gender identities and their external sexual anatomy at birth.
DSM-5 Criteria:
A. An incongruence between one’s experienced/ expressed gender and assigned gender, of at least six months duration, as manifested by at least 2 of the following:
- marked incongruence between one’s experiences/expressed gender and primary and/or secondary/anticipated sex characteristics
- strong desire to be rid of one’s primary and/or secondary sex characteristics because of a marked incongruence with one’s experienced/expressed gender.
- strong desire for the primary and/or secondary sex characteristics of the other gender.
- strong desire to be of the other/alternative gender
- strong desire to be treated as the other/alternative gender
- strong conviction that one has the typical feelings and reactions of the other/alternative gender
B. The condition is associated with clinically significant distress or impairment in social, occupational, or other important areas of functioning.
Why are anti-androgens needed for feminizing hormone therapy?
Administration of estrogens alone will suppress gonadotropin output and, therefore, androgen production, but dual therapy with one compound that suppresses androgen secretion or action and a second compound that supplies estrogen is more effective and may permit lower estrogen dosing
What routes of estrogen are available for transfeminine therapy? What is most commonly used?
Oral, transdermal patch and IM
Oral 17-beta-estradiol most common
Dosing: 2 to 4 mg/day, occasionally as high as 10 mg.
What is involved with Transfeminine hormone therapy?
Anti-androgen - cyproterone (start at 12.5mg daily) or spironolactone (start at 50mg PO bid)
+ Estrogen (17-estradiol) PO start at 1-2mg daily
What is involved with Masculinizing hormone therapy?
Testosterone therapy enanthate or cypionate (SC/IM) start at 20-50mg weekly (max dose 100mg qweekly)
- IM most common route
- enthate compounded in sesame oil
- cypionate compounded in cottonseed oil
Alternative gel or patch
What are some of the feminizing effects with Feminizing hormone therapy?
Redistribution of body fat
Decrease in muscle mass and strength
Softening of skin/decreased oiliness
Decreased sexual desire
Decreased spontaneous erections
Male sexual dysfunction
Breast growth
Decreased testicular volume
Decreased sperm production
Decreased terminal hair growth
Scalp hair
Voice changes
Which feminizing effects are irreversible?
- breast growth irreversible (although minimal)
variable reversibility: body fat distribution, reduced erections, decreased libido, decreased fertility, reduced prostatic size & testicular volume
What are you monitoring for feminizing therapy and how often?
BW taken at baseline, q4-6 wks post dose change and then post maintenance dose at 3, 6, and 12 month mark, then yearly thereafter.
- CBC, HbA1c or fasting glucose, lipids, testosterone, estradiol, prolactin, ALT, Creatinine, lytes
q3m in the first year
- serum testosterone and estradiol every three months. Serum testosterone levels should be <50 ng/dL.
Serum estradiol should not exceed the peak physiologic range: 100 to 200 pg/mL.
- For individuals on spironolactone, serum electrolytes (particularly potassium) should be monitored q3m in the first year and annually thereafter.
- Routine cancer screening is recommended, as in non-transgender individuals (all tissues present).
- Consider BMD testing at baseline. In individuals at low risk, screening for osteoporosis should be conducted at age 60 years or in those who are not compliant with hormone therapy.
AE of feminizing therapy
- VTE
- Cardiovascular disease
- Elevated triglycerides
- Mortality (higher for untreated dt suicide)
- Hyperprolactinemia/prolactinoma for ethinyl estradiol 100 mcg/day as well as the progestin cytoproterone
- Cancer - breast, prostate
Which masculinizing effects are irreversible?
Body & facial hair growth, scalp hair loss, deepend voice
Variable: fertility
