transgender care Flashcards
Testosterone treatment options
Sustanon 250mg IM 2-4 weekly
c/i in nut allergy
testosterone gel
Nebido 12 weekly injection
Normal T levels
1/52 post injection= 25-30nmol/l
day of sustanon injection= 8-12 nmol/L
Impact of Testosterone treatment
can take 2-5 years
amenorrhoea (2-3 injections) can used GnRH/MPA/NET if needed
facial/body hair
change to body shape
clitoromegaly (4-5cm at 12/12)
increased energy/libido
voice changes may take 3 years
may reduce fertility- consider gamater storage at time of referral
Risks of T treatment
polycythemia (increased stroke risk, may choose to decrease dose)
-venesection 4-6/52 as treatment
liver (mild changes, stop of 3xnormal)
cholesterol (nil increased IHD) increased TGs, decreased HDL
Cancer- T converted to E by aromatase- risk of hyperplasia. Annual USS/hysterectomy/POC
Initial investigations for T treatment
LH/FSH/T/E
SHBG/PL
LFTS/lipis
glucose
FBC
weight/BMI
Monitoring on T treatment
T
FBC
LFTs/lipids
weight/BMI
USS
smear/mammogram if needed
every 3-6/12 then annual when stable for 2 years
DEXA if nil hormonal rx/fracture/FHx
E1
E2
E3
E1= estrone
E2= estradiol
E3= estriol (predominant E in pregnancy)
Gender Recognition Act 2004
GRC+ birth certificate
needs- form, deed poll, birth certificate, proof lived in gender 2 years, 2 medical reports, £5, marriage certificate and permission from spouse
-unlawful to disclose or misgender
Equality Act 2010
gender is a protected characteristic
Role of Gender Identity Clinic
voice/communications
psychological interventions
endocrine/pharmacological treatment
Refer for surgery
- 2 clinicians (1 lead at GIC, 1 independent)
-12/12 hormone rx and living in role
- 1 opinion if have GRC
Feminising treatment practicalities
Estradiol valerate 2mg OD
Increase by 2mg every 3 months until 8mg OD
bioidentical, level at 4-6hrs should be 400-600pmol/L (normal for a cis young F)
give slowly over 2 years for better breast formation
Gel/patch:
unsatisfactory levels
liver
bowel
testosterone in trans F
may reduce naturally
aim for 0-3nmol/L
can give GnRH (leuporelin/goserelin) every 12 weeks
-initial worsening then reduction- can give cyproterone acetate 50-100m OD during tis time
-metabolised in lover, blocks T by stopping bindings and reduced PG production
Length of treatment for trans F
GnRH until orchidectomy
E lifelong (need some form of E/T)
Impact of E treatment
Hair:
finer on face, max response at 4 months
slowed male pattern balding
Breast:
takes 2-3/12, may 2 years
1 cup size less than mother, no augmentation on NHS
Body fat:
4kg weight gain, more on hip/bum
reduced bulk of muscle
Fertility:
reduce libido/erections
testes smaller/softer
reduced sperm (?gamete storage beforehand)
Risks of feminising treatment
-VTE- reduce smoking
-hyperprolactinaemia (E= +ve feedback on anterior pituitary= increased prolactin)
1 in 10 raised, GnRH can help
-Liver- 3 deranged, rarely abnormal enough to stop rx
-gallstones
-osteoporosis- give Vit D, E may help
Feminising treatment- initial investigations
LH, FSH, T, E
SHBG/PL
LFTs/lipids
glucose
PSA
BP
LFTs
Vit D
Weight/BP
Feminising treatment- monitoring
T/E
LFTs
PL
Weight/BP
Feminising treatment- screening
Mammogram
DEXA
AAA
