Transgender health Flashcards
Gender diverse epidemiology and fertility desires
~1 in 200 (0.6%), higher in younger age group - 0.7% in 13-24 yo.
95% think fertility preservation should be offered and discussed prior to GAHT
68% were not offered FPT
Gender affirming healthcare
Gender affirming hormone thearpy (GAHT)
Gender affirming surgery
Fertility preservation options transwomen
Spermache occurs at Tanner stage 4 - 15-20ml testicular volume or 4.1-4.5cm testicular length.
TTC in prepubertal boys in experimental, requires autotransplantation into scrotum/testicle and as yet no reported live births from this.
Effects of feminising GAHT on spermatogenesis
Puberty blockers - GnRH agonists
* will suppress HPO, can still conceive so contraception required.
* Fertility will return (may be delayed resumption) on discontinuing.
Feminising (oestrogen and antiandrogens - cyproterone acetate/sprinolactone)
* Stops the testicle from producing testosterone.
* Can cause shrinkage of testicle – up to 50% reduction in volume.
* Eventually may stop spermatogenesis.
* This is some will be permanent.
Effects of masculinising GAHT on fertility in those PFAB
Puberty blockers - GnRH agonists
* will suppress HPO, some PFAB patients can still conceive so contraception required.
* Fertility will return (may be delayed resumption) on discontinuing.
Testosterone:
* Long term effects of T on fertility is unknown.
* Growing evidence that stopping T can resume menses and fertility returns.
* Likely harder to conceive the longer they have been on T.
* Can’t take T during a pregnancy – can cause virilisation of XX fetus.
* Even once amenorrhoea still a possibility of pregnancy so contraception discussion needed.
Options for fertility preservation in transmen
If T discontinued 80% will commence menses within 6 months
Principles of GA healthcare
- The principle of non-discrimination
- The principles of bodily integrity, bodily autonomy and informed consent
- The principle of freedom from torture and degrading and inhuman treatment
- The principle of free self-determination of gender
- The principles of quality, specialised and decentralised care
- The principles of the right to decide on number and spacing of own children
- The principle of the best interest of the child
Models of hormone provision
The two main models of hormonal affirmation are the
1. Informed consent (or affirmation enablement) model,
* Medical practitioners seeing patients under the age of 18 are unable to initiate GAHT without first ascertaining whether or not a child’s parents or legal guardians consent to the proposed treatment.
* If there is a dispute about consent or treatment, a doctor should not administer treatment, need to establish in over 16yo whether they have capacity - Gillick competency utilised.
* Informed consent places the experiences, expertise and needs of the trans patient first, while ensuring they work with a doctor who can help them navigate potential risks.
2. Approval letter model,
* Trans person sees a mental health professional for endorsement prior to starting hormones. While this model is beginning to fade from standard clinical practice, if a patient wants to use the approval letter model, that should be supported.
Puberty blockers - types dose etc, what hx/ex/inv needed prior to starting
Most effective if intiated in Tanner stage 2-3
Often not used in transmen in NZ as by the time seen often puberty is complete and minimal additional benefit - menstrual suppresion through Depot may be option.
Puberty blockers:
- Lucrin (leuprorelin acetate) - 12weekly 11.25mg IM
- Zoladex (goserelin acetate) 12 weekly 10.8mg SC implant
- Triptorelin (every 5-6months - not available in NZ)
If evidence of insufficient pubertal suppression - LH>2, pubertal progression, continued menses can shorten interval.
Full history, informed consent (parental/Gillick), safety, mental health screen.
Exam - every 3-6months, height, weight, BP, tanner stage to ensure complete suppression.
Blood tests - 6-12months, LH, E2 or T. Consider Vit D or treat.
Left hand bone age on xray if clinically indicated.
Consider DEXA if additional risk factors.
Informed consent points for blockers
Transmen
If started Tanner 2/3 - usually stop significant breast growth, widening of hips, menses. If started later in puberty - may soften but not change the size of the breasts, blockers can stop periods but often take up to 3-6months to do so.
Side effects:
Hot flushes, mood swings, fatigue, vaginal dryness
Risks:
Increased height (unlikely if already through puberty), decrease future bone density, fertility - (likely to be affected, not permanent, need contraception if having penile/vaginal intercourse), vaginal dryness increases risk of STI transmission, libido may lower.
Risks of withholding blockers - anxiety, depression, worsening dysphoria, permanent unwanted physical changes.
Transwomen:
If started Tanner 2/3 - halt voice change, facial hair growth, enlargement of penis and testicles. Later in puberty - prevent further hair growth, facial coarsening, broadening of shoulders, decrease muscle development.
Side effects:
Hot flushes, mood swings, possible fatigue
Risks:
Increased height (unlikely if through puberty), decreased future bone density, fertility - likely to affect ability to get someone pregnant but not definite so contraception needed. Can store sperm in later stage pubertal development prior to starting puberty blockers. Can lower libido, can stop erections, decreases size of testicles.
Risks of withholding blockers - anxiety, depression, worsening dysphoria, permanent unwanted physical changes.
Informed consent for GAHT - feminising
Progynova (oestradial valerate) or Estradot (oestradial hemihydrate). Antiandrogens required unless gender affirming surgery has occured.
- Gradual increase in breast size over 2-3 years
- Dose increased slowly for best breast development
- Unknown if increases risk of breast cancer - likely does due to increased breast tissue
- soften skin, decreases muscle mass, less body hair, more fat on buttock, hips and thighs
Things that don’t change much
- facial hair slows but doesn’t completely stop
- voice unchanged
- bone structure of face and laryngeal protruberance doesn’t change
Fertility
- Testicles shrink 50%
- May eventually stop sperm production
Sex
- lower libido
- erections less often and less hard
Mental health
- Variable response with mood
Side effects
- nausea, headaches, breast tenderness, weight gain
Risks:
- DVT, PE, stroke, heart attack (transdermal will likely reduce)
- cholesterol changes
- gallstones
Possible increased risks:
- HTN, liver derangement, increased prolactin and other benign pituitary tumours, diabetes, heart disease
Informed consent for GAHT - transmen
Permanent changes:
Deeper voice, increased growth of hair, gradual growth of beard hair/moustache, hair loss at temples, genital changes - clitoral growth - 1-3cm, vaginal dryness
Nonpermanent:
Skin changes - acne and oil, changes in body shape (less fat on buttock, hip, thighs), increased muscle mass and upper body strength, increased sex drive, periods usually stop after 1-6months.
Not much change:
Breast tissue
Fertility
Likely harder to get pregnant older you are and the longer you’ve been on testosterone but unclear.
Testosterone is dangerous in pregnancy - virilising so must not be on it when you’re ttc.
Increased risk of STIs including HIV.
Mental health - increased frustration, anger, irritation.
Risks:
Likely increased risk - polycythemia, sleep apnoea
POssible - cholesterol changes, liver problems, diabetes, HTN
Masculinising hormones
testosterone undecanoate (reandron)- 1000mg 12 weekly with loading dose at 6 weeks.
Transdermal testosterone (androderm) - 5mg patch/24hours - can cause skin irritation
Aiming for a total testosterone of 10-15nmol/L.
Usually checked baseline, 3-4monthly for first year then annually.
FBC, renal and liver function, blood pressure and lipids, BSLs.
Feminising hormones
Estrogen -
* The following regimen is recommended for full-dose estrogen hormonal therapy.
o Oral estradiol or estradiol valerate 2–6 mg daily, increasing to up to 8mg as needed; or
o Transdermal estradiol patches 100–150 μg/24 hours changed twice weekly
(start low and slow for optimal breast growth and shape) aim for max dose at 2-3years.
Prescribe estrogen based on how a patient responds to treatment and alongside risk factors, rather than based solely on specifically targeted levels.
Does recommend targeting estradiol levels of 250–600 pmol/L and total testosterone levels < 2 nmol/L (ie, to the pre-menopausal cis female reference range).
Anti-androgen
Cyproterone acetate - (12.5–25 mg daily)
Spironolactone (100–200 mg daily)
Suppress T and block it’s effects on the body.
NZ regulations
Managed by youth health in Auckland
Provincially by gen paed, endocrinologist, social worker.
MDT approach - nurse, SW, doctor, psychologist.
Up until 18yo primary caregiver consent required,
<18 can use Gillick compentence to determine capacity for informed consent.
“Consent requires the cognitive capacity to understand the risks and benefits of a treatment and the potential negative and positive outcomes. It also requires the ability to retain that information for the purposes of making the decision (using aids as necessary) as well as the cognitive ability to use that understanding to make an informed decision”
Follow a harm reduction model
