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Part 1 MFSRH 2024 > Transgender Health > Flashcards

Transgender Health Flashcards

- Anatomy of transgender phenotypes - Pharmacology of puberty blockers and hormonal agents used in therapy

1
Q

Can testosterone treatment be relied upon for contraception?

A

No

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2
Q

Can GnRH analogues (used to suppress ovarian function) be relied upon for contraception?

A

No

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3
Q

Why is testosterone treatment an absolute contraindication in pregnancy?

A

Because of teratogenicity to the fetus - i.e. masculinisation of a female fetus

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4
Q

Why is CHC not recommended in those undergoing testosterone treatment?

A

Because the estrogen component will counteract the masculinising effect of the testosterone

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5
Q

Does testosterone treatment effect the efficacy of EC?

A

It is not thought to

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6
Q

Is estradiol treatment an effective contraception?

A

Although estradiol does result in impaired spermatogenesis, it should not be relied upon for contraception

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7
Q

What is a serious side effect of testosterone therapy?

A

Polycythaemia - this increases the risk of VTE and arterial thrombotic events

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8
Q

What haematocrit/haemoglobin is normal in the trans-men, using testosterone therapy as gender affirming therapy?

A

Should be within the normal cisgender male range

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9
Q

If the haemoglobin/haematocrit is raised on testosterone therapy, what should happen?

A

The level needs to be reduced, this might be by extending the interval between injections, or reducing the dose where transdermal therapy is used

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10
Q

How often should haemoglobin/haematocrit be measured on testosterone therapy?

A

Every 3 months for the first year, annually after the first year if stable

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11
Q

How can spironolactone be used in gender-affirming therapy for trans-women?

A

Primarily a potent anti-mineralocorticoid, however, also exhibits weak to moderate anti-androgen activity, resulting in feminising side effects such as gynaecomastia and reduced male pattern hair loss

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12
Q

What types of drugs are ‘puberty-blockers’?

A

GnRH analogues

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13
Q

How do GnRH analogues work?

A
  • GnRH analogues initially cause a surge in LH and FSH release
  • Continuous stimulation causes desensitisation of GnRH receptors resulting in a fall in LH and FSH release. This takes several weeks to take effect
  • This results in falling sex steroid levels, arresting further development of secondary sexual characteristics
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14
Q

How does finasteride work?

A

It is a 5-alpha-reductase inhibitor which is the enzyme responsible for converting testosterone into dihydrotestosterone (DHT)

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15
Q

How often is IM testosterone given?

A

Every 2-20 weeks depending on preparation

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16
Q

What are the common side effects of testosterone?

A
  1. Hot flushes
  2. Hypertension
  3. Hypertriglyceridaemia
  4. Polycythaemia
  5. Skin reactions
  6. Weight gain
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17
Q

What are the target trough serum testosterone levels in transmen using IM testosterone?

A

Lower third of the cisgender male physiological reference range (10-12nmol/L)

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18
Q

What are the target trough serum testosterone levels in transmen using transdermal testosterone?

A

Middle third of the cisgender male physiological reference range (15-20nmol/L) - level should be measured 4-6 hours after gel application

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19
Q

When is breast screening indicated in transmen?

A
  1. Indicated if breast tissue present
  2. Patients registered as women are invited for routine screening
  3. Patients registered as men can be referred for screening by their GP if required
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20
Q

What is the relative risk of breast cancer in transmen?

A

Breast cancer risk is lower than cisgender women but higher than cisgender men

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21
Q

When is breast screening indicated in transwomen?

A
  1. Indicated if using long term hormone therapy
  2. Patients registered as women are invited for routine screening
  3. Patients registered as men can be referred for screening by their GP if required
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22
Q

What is the relative risk of breast cancer in transwomen?

A

Breast cancer risk is lower than cisgender women but higher than cisgender men

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23
Q

When should you expect decreased spontaneous erections and reduced libido after starting oestrogen therapy?

A

1-3 months later

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24
Q

When should you expect breast tissue development after starting oestrogen therapy?

A

3-6 months later

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25
Q

When should you expect reduced muscle mass/body fat redistribution after starting oestrogen therapy?

A

3-6 months later

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26
Q

When should you expect testicular atrophy after starting oestrogen therapy?

A

3-6 months

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27
Q

When should you expect skin softening after starting oestrogen therapy?

A

3-6 months

28
Q

When should you expect slower facial and body hair growth after starting oestrogen therapy?

A

6-12 months

29
Q

When should you expect reduced spermatogenesis and impaired fertility after starting oestrogen therapy?

A

Variable

30
Q

What changes can you expect to see 3-6 months after starting oestrogen therapy?

A
  1. Reduced muscle mass
  2. Breast tissue development
  3. Testicular atrophy
  4. Skin softening/dryness
  5. Body fat redistribution
31
Q

What changes can you expect to see 3-6 months after starting testosterone therapy?

A
  1. Amenorrhoea
  2. Vaginal atrophy
  3. Body fat redistribution
  4. Facial/body hair growth
32
Q

When should you expect clitoral hypertrophy after starting testosterone therapy?

A

1-6 months

33
Q

When should you expect facial/body hair growth after starting testosterone therapy?

A

3-6 months

34
Q

When should you expect amenorrhoea and vaginal atrophy after starting testosterone therapy?

A

3-6 months

35
Q

When should you expect voice deepening after starting testosterone therapy?

A

3-12 months

36
Q

When should you expect male pattern baldness after starting testosterone therapy?

A

> 12 months

37
Q

When should you expect increased muscle mass after starting testosterone therapy?

A

3-12 months

38
Q

Why are bioidentical oestrogens, such as oestradiol, recommended over synthetic oestrogens, such as ethinylestradiol for gender-affirming therapy?

A

Because synthetic forms have a higher risk of adverse effects

39
Q

What is main risk associated with oestrogen therapy?

A

VTE - highest in the first two years of therapy. Transdermal preparations have a lower thrombosis/hepatic risk

40
Q

What is the target serum oestrodiol level on oestroegn therapy?

A

Upper half of physiological oestrogen levels during the follicular phase

41
Q

How quickly do serum oestrodiol levels normally plateau?

A

Within a week of a dosage change

42
Q

How can synthetic oestrodiol affect serum oestrodiol levels?

A

Tests for serum oestrodiol will only detect bioidentical oestrogens; if synthetic formulations are being used results may be falsely low

43
Q

After a minimum of how many initial assessments my hormonal therapy be recommended at a GIC?

A

2

44
Q

What are the first line oestrogen options to bring about feminisation?

A

Estradiol valerate or Estradiol hemihydrate initiated at a dose of 2mg OD orally

45
Q

What range of Estradiol valerate/Estradiol hemihydrate may be used in feminsisation?

A

2-8mg, adjusted by 2mg every 3 months until specific plasma oestradiol level achieved?

46
Q

What plasma oestradiol are you aiming for with oestrogen therapy for feminisation?

A

400-600 pmol/l, 4-6 hours after taking the tablets

47
Q

When should topical oestrogens be considered in feminisation?

A

If estradiol tablets not tolerated or inadequate levels achieved

48
Q

Which tends to achieve better oestrogen levels - gels or patches?

A

Gels

49
Q

What are the topical oestrogen options for feminisation?

A

Topical oestrogen gel (Sandrena 0.5-5mg/day):
Initiated at a dose of 0.5mg a day, dose adjusted by 0.5-1mg every 3/12

Estradiol patches 50 –200micrograms/24hr, applied x2/week, dose adjusted by 50micrograms every 3/12

50
Q

When can a GnRH analogue be added to oestrogen therapy for feminisation?

A

If oral oestrogen at 4mg OD (or equivalent topical dose) does not suppress the plasma testosterone into the female range of 0-3nmol/l

51
Q

What are the GnRH analogue of choice in feminisation?

A

Decapeptyl (triptorelin) SR 11.25mg (IM) every 12/52 (most cost-effective option)
or
Zoladex (goserelin) 10.8mg (sub cut) every 12/52

52
Q

What can be used to prevent the testosterone flare on initiation of GnRH analogues?

A

Cyproterone Acetate 50mg OD orally, co-administered for 2/52 with the first dose of a GnRH analogue

53
Q

How long should GnRH analogues be continued?

A

Until orchidectomy or gender reassignment surgery (whilst oestrogen therapy should be lifelong)

54
Q

What 3/12 bloods should be taken in the first year of oestrogen therapy (and then annually thereafter)?

A

Oestradiol (unless taking ethinyloestradiol) (range 400-600 pmol/l)
Testosterone (range 0-3 nmol/l)
Prolactin
LFTs
BMIs
BP

55
Q

What is the DVT risk with oestrogen therapy for feminisation?

A

0.4% over 5 years (80% of cases occurring within the first 2 years of starting therapy)

56
Q

What is the first-line testosterone for masculisation?

A

Sustanon 250mg (IM) 4 weekly (not in those with nut allergy)

57
Q

What is the target level for peak testosterone one week after testosterone injection?

A

High normal male range (25-30 nmol/l)

58
Q

How should titration of IM testosterone be carried out?

A

50mg change with each testosterone injection

59
Q

What is the 2nd line option for testosterone for masulisation?

A

Testosterone gel 20-100mg

The usual starting dose is 40 mg daily:
2 squirts of Testogel 16.2 mg/g (= 40.5 mg)
4 squirts of Tostran 2% (= 40 mg)
2 squirts of Testavan 20 mg/g (= 46 mg)

60
Q

When may long acting injectable testosterone be considered for masculisation?

A

Where the short-acting injection causes side effects (e.g. mood swings or injection site reactions), and gel preparations are not suitable (i.e. do not give reliable levels, the client is very hirsute, or there is a significant risk of transfer of the testosterone gel to others), the long acting Testosterone Undecanoate (Nebido) may be used

61
Q

What may be used for menstrual suppression in those using testosterone for masculisation?

A

Medroxyprogesterone acetate 10 mg BD or TDS
or
GnRH analogues

Used until genital surgery or oophorectomy (unlike testosterone which is used lifelong)

62
Q

What 3/12 bloods should be taken in the first year of testosterone therapy (and then annually thereafter)?

A

Testosterone
FBC
LFTs
Fasting lipids
BMI

63
Q

What screening should transwomen have?

A

Breast screening
Abdominal aortic screening
Bowel screening

64
Q

What screening should transmen have?

A

Breast screeng (if breast tissue present)
Cervical screening (if cervix present)
Bowel screening

65
Q

What samples should be taken from those with a neovagina, in relation to testing for GC?

A

In transgender women at risk of GC should include
swabs from the neovagina and first-pass urine

66
Q

What samples should be taken from those with a neopenis, in relation to testing for GC?

A

First-pass urine as the specimen of
choice from people with a neopenis

Part 1 MFSRH 2024 (20 decks)

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