Transgender care Flashcards
Exam: use of estrogen and contraindications, screening for prostate ca in MtF persons
Exam: use of estrogen and contraindications, screening for prostate ca in MtF persons
Genderbread person
Exam: use of estrogen and contraindications, screening for prostate ca in MtF persons
Sex determination: brain vs physical anatomy and implication for gender identity
•Review of sex determination
–Brain vs. physical anatomy
–Chromosomes >> gonads >> phenotype
•Gender as a social construct
–Gender non-conforming
- Body develops one way, brain another Many consider the body as correct in this diagnosis whereas they would not consider the body as correct in HLD, DM, etc. In fact, the brain is correct.*
- Society adds objects to gender boxes. “Gender non-conforming” – we all are non-conforming*
Exam: use of estrogen and contraindications, screening for prostate ca in MtF persons
How is gender expressed & what happens when there is a disconnection?
•How is gender expressed?
–Anatomical
–Physical presentation
•What happens when there is a disconnection? happens esp at puberty - body change influences others’ reactions to you
–How to find congruency
–Social opportunities
–Medical/surgical options
Exam: use of estrogen and contraindications, screening for prostate ca in MtF persons
Transgender discrimination: rates of homelessness & poverty, suicide
•Homelessness and poverty
–Twice the rate of current homelessness
•Suicide
–41% vs 1.6% in the general population
Exam: use of estrogen and contraindications, screening for prostate ca in MtF persons
Transgenderism: barriers to care
–Postponement of care
–Lack of knowledgeable providers
–Insurance coverage
Exam: use of estrogen and contraindications, screening for prostate ca in MtF persons
Organizations that issue guidelines for transgender care
WPATH, The endocrine society, vancouver coastal health, community health centers, center of excellence for transgender health
many develop their own guidelines but tend to be very similar
Exam: use of estrogen and contraindications, screening for prostate ca in MtF persons
WPATH
Requirements for hormone therapy
- Persistent, well-documented gender dysphoria
- Capacity to make a fully informed decision and to consent for treatment
- Age of majority in the given country (18, but can start at 16 if parental agreement. Many doing sooner - though fear of litigation)
- If significant medical or mental health concerns are present, they must be reasonably well-controlled
Exam: use of estrogen and contraindications, screening for prostate ca in MtF persons
WPATH
Requirements for surgery
•Breast (1)
–hormones recommended for mammoplasty
–Living as preferred gender not required
•Hysterectomy/ovariectomy or orchiectomy (2)
–Hormones recommended but not required
–Gender role consistent with identity encouraged
•Metoidioplasty, phalloplasty, or vaginoplasty (2)
–12 months of hormone therapy recommended
– 12 months living in a gender role consistent with the gender identity required
- Same requirements as hormone therapy with additions*
- Hormone therapy is no longer a requirement except where it augments the success of the surgery; medical contraindication always an option*
- Sends in as safety issue — can’t look like man and have pendulous breasts. Usually approved.*
Exam: use of estrogen and contraindications, screening for prostate ca in MtF persons
WPATH
Key changes to guidelines
•Mental health care requirement
–Evaluation vs. psychotherapy (evaluation can now be done by medical provider - not need psychotherapy)
- Requirements for surgery
- Flexible clinical guidelines
- Less of a binary system (can take lower doses)
Exam: use of estrogen and contraindications, screening for prostate ca in MtF persons
Endocrine Society
2009 Guidelines - compare to WPATH
- Very similar to WPATH guidelines
- Real life experience required, consistent with the 6th WPATH standards
Exam: use of estrogen and contraindications, screening for prostate ca in MtF persons
Coding and documentation used in transgender care
•Informed consent documentation
–Risks and benefits to treatment
–Clear documentation (forms?)
•ICD-10 codes
–Gender dysphoria F64.9
–Hypogonadotropic hypogonadism E23.0
–Endocrine disorder not otherwise specified E34.9
- Always redoes education/side effects/adverse effects and document well*
- Gender dysphoria before surgical change. Then becomes hypogonadism*
- CTCare you use E34.9 b/c kicks back gender dysphoria as mental health*
Exam: use of estrogen and contraindications, screening for prostate ca in MtF persons
Secondary sex characteristic development: Male to Female treatment
- Block erectile response
- Attenuate growth spurt
- Prevent facial hair, voice change, skeletal/facial changes, male alopecia
- If Ided before tanner 2, wait until tanner 2 then put on blockers*
- Voice deepening – irreversible*
- Beauty is you can stop blockers at any time and will have nl puberty*
Exam: use of estrogen and contraindications, screening for prostate ca in MtF persons
Secondary sex characteristic development: Female to Male treatment
- Slow breast development
- Suppress menses
- Stimulate growth spurt
- FtM – growth plates open longer*
- Beauty is you can stop blockers at any time and will have nl puberty*
Exam: use of estrogen and contraindications, screening for prostate ca in MtF persons
Testosterone therapy: effects on expected onset in months
- Hair growth first on body/torso, 1-4 years for facial
- Deepening of voice is usually within 4 weeks
- Periods – usually one more then stops, but if BMI higher hang on longer
Exam: use of estrogen and contraindications, screening for prostate ca in MtF persons
FtM
Effects of hormone therapy - reversible
- Oiler skin / acne: increased sebaceous gland activity, if accutane, take UPT!
- Redistribution of fat / increased muscle mass
–Avoiding weight gain
- Irritability / depression: usually the opposite
- Increased libido
usuall 1-3 mths
Exam: use of estrogen and contraindications, screening for prostate ca in MtF persons
FtM
Effects of hormone therapy - irreversible
•Male pattern baldness (~10%)
–Treat with finasteride (– does not block testosterone, only blocks conversion of testosterone to active form at level of hair)
•Reproductive capability
–Testosterone is not a form of birth control (may be reversible)
•Clitoral growth
–Reported lengths of 3.5-6cm (may be reversible)
Exam: use of estrogen and contraindications, screening for prostate ca in MtF persons
FtM
Hormone therapy
•Testosterone cypionate or enanthate (if reaction to one, can try other)
–subcutaneous or IM injection
–200mg/mL in a 3cc 25G 5/8” needle
–50-100mg weekly or 100-200mg every 2 weeks
•Transdermal
–2.5-10g of testosterone per day
–Androgel 1.62% 1.25g per actuation
–Testim, Androgel 1% packet or pump
–Axiron 30mg in each actuation, 60mg per day
–Androderm 2mg, 2.5mg, 4mg, 5mg
–Fortesta 40mg daily (4 pumps)
–Compounded cream
Oral and depo not available in the US
Exam: use of estrogen and contraindications, screening for prostate ca in MtF persons
FtM
surgery options
- Mastectomy
- Hysterectomy/oopherectomy
- Metoidioplasty: releases the clitoris, thread w/urethra = micropenis and can stand to pee
- Phalloplasty: graft from arm, great results but about 2 years to heal
- Vaginectomy
- Scrotoplasty
- Major goal is to pee standing up*
- Covered by insurance (some caveats to watch out for – e.g., if no surgeons who do these take medicaid, can’t do it)*
Exam: use of estrogen and contraindications, screening for prostate ca in MtF persons
FtM
Preventative care
•Mammograms
–Follow natal guidelines until after surgery
–Mammogram not needed prior to surgery unless being done because of other risk factors
•Cervical
–Follow natal guidelines; tell pathologist about testo use
–No screening post-surgery unless history of high grade dysplasia or cancer
if bleeding, check testosterone - may be too low
•Pelvic exam
–Uterine/ovarian cancer
–Pelvic ultrasound if any vaginal bleeding
•CVD
–Unclear if change in risk on testosterone (risk shown at >60yo, decrease dose)
–Increased LDL on testosterone
- Follow NCEP guidelines
- Osteoporosis
–Screen with BMD at age >60 years
–Age >50 years if additional risk factors and on testosterone for more than 5 years
Exam: use of estrogen and contraindications, screening for prostate ca in MtF persons
FtM
Preventative care – lab monitoring of testosterone therapy
•CBC, LFTs, total/free testosterone, estradiol
–At baseline
–Every 3 months for the first year
–Every 6-12 months thereafter
–Goal estradiol
- Discontinue after no menstrual bleeding x 6 months
- Goal testosterone levels
–Upper quartile of normal, usually
–Total testosterone 320-1000 ng/dL
base on clinical response
- Timing of testosterone measuring
- Injections: midway if injections are >2 weeks apart
- Transdermal: after at least 1-2 weeks
Exam: use of estrogen and contraindications, screening for prostate ca in MtF persons
Risks to avoid if on testosterone therapy
- Testosterone is not a form of birth control
- Polycystic ovarian disease
–Weight gain
–Metabolic syndrome
- Liver dysfunction
- Vaginal atrophy
- Polycythemia
–Risk of clots
•Pain at the injection site
–Massage area after injection
Exam: use of estrogen and contraindications, screening for prostate ca in MtF persons
Estrogen therapy: expected effects and onset in months
***exam
Exam: use of estrogen and contraindications, screening for prostate ca in MtF persons
MtF
Effects of hormone therapy - reversible
***exam
- Softening of the skin
- Hair growth
–Arrests progression of balding
- Redistribution of fat
- Decreased muscle mass
- Decreased libido and spontaneous erections
Exam: use of estrogen and contraindications, screening for prostate ca in MtF persons
MtF
Effects of hormone therapy - irreversible
***exam
•Breast growth
–Initial in 3-6 months but won’t plateau until 2-3 years
- Testicular volume loss
- ? Fertility
Exam: use of estrogen and contraindications, screening for prostate ca in MtF persons
MtF
Surgery Options
- Breast augmentation: avoid until on HT >2years
- Penectomy
- Orchiectomy
- Vaginoplasty / clitoroplasty / vulvoplasty
–Dilation / intercourse
•Non-genital surgery
–Facial feminization, voice surgery, thyroid cartilage reduction, liposuction, lipofilling, hair reconstruction
Exam: use of estrogen and contraindications, screening for prostate ca in MtF persons
MtF
Hormone therapy options
***exam
•Estrogen
–Oral: estradiol 2-6mg daily, no more than 2mg post-op
–Transdermal: 0.1-0.4mg twice weekly
–Transdermal spray 1.53mg per spray
–Parenteral: estradiol valerate 5-20mg IM weekly
- Spironolactone 100mg twice daily
- Finasteride 5mg daily
- Progesterone
–Medroxyprogesterone
–Prometrium
–Depo-Provera
•All but estrogen is discontinued after surgery
Exam: use of estrogen and contraindications, screening for prostate ca in MtF persons
MtF
Preventative care
- Follow up every 3 months for the first year then every 6-12 months
- BMD: consider at baseline if other risk factors present or if post-gender affirming surgery and off estrogen for >5 years
–Vitamin D and calcium supplementation
•CVD
–Blood pressure and lipid control
•Mammogram
–After age 50 if on estrogen for >5 years
–Consider more aggressive screening for family history, BMI >35
Exam: use of estrogen and contraindications, screening for prostate ca in MtF persons
MtF
Preventative care – Lab monitoring
***exam
•Estradiol and testosterone every 3 months
–Estradiol target 200pg/mL
–Testosterone target –<55 ng/dL
•CMP/BMP
–At baseline and 4 weeks after spironolactone dose change
–Every 3 months for the first year then yearly
•PSA may show a false negative: blocked - can have ca and won’t show. See urology
–Testosterone deprivation
–Finasteride use
Exam: use of estrogen and contraindications, screening for prostate ca in MtF persons
Important education w/MtF HT
***exam
- Estrogen is not a form of birth control: can still make sperm
- Discontinue estrogen 2-4 weeks prior to surgery
- Dosing
–Pills
–Patches
•Remove for MRI
–Spray
•Avoid contact for at least 1 hour
–Injection
Exam: use of estrogen and contraindications, screening for prostate ca in MtF persons
Risks to avoid: MtF HT
***exam
- Pulmonary embolus / Deep vein thrombosis
- Gallstones
- Pituitary mass
- Breast cancer
- Migraines
- Metabolic disorders
–Diabetes
–Dyslipidemia
- Electrolyte disorders (spironolactone)
- Decreased libido (finasteride)
- Depression (progesterone)
Exam: use of estrogen and contraindications, screening for prostate ca in MtF persons
Effect of treatment on suicidality
significant decrease post treatment
Exam: use of estrogen and contraindications, screening for prostate ca in MtF persons
MtF: considerations regarding estrogen therapy and risks
***exam
- Oral ethinyl estradiol (used in OCPs) is used but associated w/increased VTE and CV death - recommend against. Instead use 17 beta estradiol which is not associated with VTE risk.
- Avoid oral estrogens if: FHx hypertriglyceridemia (Risk pancreatititis). Lipids prior to initiation.
- Breast ca in MtF: rare but monitor (mammo)
- Prostate ca MtF: rare, ? 2/2 estrogen, but monitor
