Transgender health problems Flashcards
Surgical terms Female -> Male:
Colpectomy -removal of some or all of the vagina
Colpoclesis -closure of the vaginal opening
Metoidioplasty -construction of an artificial penis from a clitoris
Phalloplasty -construction of an artificial penis from skin flaps
Scrotoplasty -construction of an artificial scrotum from the labia majora
Urethroplasty -construction of a urethra within artificial penis
Surgical terms Male -> female
Orchiectomy: removal of testes
Vaginoplasty – creation of a vagina which can be done via penile inversion
Allows for penetrative frontal sex
Vulvoplasty – creation of superficial/external female genitalia and short vaginal pouch
Not generally able to have penetrative frontal sex
Puberty blockers
NOT commissioned/ used within NHS practice due to concerns of lacking evidence of safety for use but can be obtained privately
Concerns if used at a very early age –> irreversible effects on sexual functioning / bone development
GnRH agonists can be used to ‘arrest puberty’ in people considering/ intending for gender transition
»Initial SURGE in LH and FSH release
»Continuous stimulation -> desensitisation of anterior pituitary to respond to GnRH -> less LH/FSH: Takes several weeks for this to occur
»Sex steroid hormone levels (usually produced in response to LH/FSH) fall
»No further secondary sexual characteristic development
This process is generally considered to be reversible; if GnRH agonist treatment withdrawn the hypothalamic-pituitary gonadal axis reactivates and pubertal development will resume
(used for precious puberty)
Trans-masc gender affirming hormonal therapy
Testosterone
Menstrual suppression
Testosterone: medicinal form IM/TD/PO
Most commonly given IM
Short acting (Sustanon/enantate)
Contains peanut oil
Long acting (Nebido/undecanoate) formulations
Start with short acting and increase to long acting at later stage (more cost-effective once stable as less GP visits required)
Transdermal route can be considered but generally #2
Oral testosterone NOT generally favoured:
Gut wall contains 5a-reductase enzymes which convert testosterone –> dihydrotestosterone
Very challenging to reliably monitor testosterone levels
Effect of testosterone - time based
1-6 months
Increased muscle mass/ sex desire/ oiliness of skin/ face and body hair.
Redistribution of fat mass.
Cessation of menses.
6-12 months
Deepening of voice, cliteromegaly, male-pattern hair loss.
1-2 years
Voice cont to deepen - full effect by 2 years.
3-5 years
Can take up to 5 years for full effect of body hair growth
Testosterone levels
values
when to take
Aiming for within normal range for cis-males
> 300 – 1000ng/dl
OR
> 10-35 nmol/L
FOR IM INJECTIONS:
Trough levels should be at the low-normal end of the male reference range (10-12mol/L) - taken just before given.
If checking peak levels too (for shorter acting IM formulations) aim for these to be at the high-normal end of male reference range (25-30nmol/L) - taken 1 week post given/ midpoint between AND trough
> > Levels should be taken at ‘steady state’ – after 4th IM dose
To titrate the trough value adjust the injection dosing intervals (adjust in weeks)
To titrate the peak value adjust the dose in 50mg increments
FOR TRANSDERMAL
preparations levels should be within middle 1/3 of normal adult male reference range (15-20nmol/L) reflective of their more consistent release – take level 2-6 hours AFTER application
Oral formulations (not commonly used) – take DIHYDROTESTOSTERONE level 3-4 hours post dose
Blood tests for people on testosterone
Check every 3 months for the first year -> annually thereafter, once stable on regime
FBC (polycythaemia risk)
Fasting lipids (increased CVD risk)
LFTS (evidence less clear)
Testosterone: side effects (androgenic)
Acne (most common)
Increased CVD risk (weight gain, hypertension and type 2 diabetes risk increases; monitor lipids)
Increased VTE / thrombotic stroke risk (Mechanism: increases blood heamatocrit -> increases viscosity)
Atrophy, irritation and skin thinning in vaginal canal -> dyspareunia with penetrative frontal sex
Hot flushes may be experienced, similar to menopausal women (declining effects of oestrogen)
Changed experience of orgasm as the clitoris enlarges and becomes more sensitive
Can cause polycythaemia with elevated Hb and haematocrit; FBC monitoring is recommended
(more common with injectable and at higher doses) (Usually reversible by reducing dose but if not might need reg venesection to reduce heamatocrit levels)
Male pattern baldness
Sleep apnoea exacerbation
Risk of infertility with long term use (but not contraceptive) - egg freezing before sometimes
BMN espec if taking around puberty (prior to peak BMD attainment)
Testosterone and endometrial hyperplasia
Some studies suggest that testosterone can cause endometrial hyperplasia in those with a uterus
Suspected mechanism is via aromatisation of testosterone -> oestrogen
Vigilance for unusual frontal bleeding recommended -> low threshold for pelvic ultrasound
Tavistock centre recommend routine ultrasound endometrial assessment on 2 yearly basis
Testosterone and breast tissue
Testosterone does not decrease breast size (though does decrease activity of glandular breast tissue)
Testosterone and teratogenicity
Patient’s should use highly reliable contraception as per teratogenic medicines guideline
LNG-IUD likely most desirable given most would hope to cease menses
Cu-IUD and implant also suitable options (less likely to confer reliable bleeding control)
Depot alone is not deemed effective enough for contraception with teratogen
Additional precautions advised (condoms as well)
Menstrual suppression
Menses expected to cease for majority within first 6 months of testosterone therapy
If they do not, additional progestins OR GnRH analogues can be used
Medroxyprogesterone acetate (Provera) 10mg BD-TDS
Variety of GnRH analogue regimes that could be used
Vit d and transgender people
All transgender and non-binary people should take over the counter vitamin D- 400 IU (10mcg)
Ix prior to starting female hormones if >40
PSA level checked prior
PSA value become uninterpretable after starting female hormones
Existing asymptomatic malignancy of prostate can be exacerbated by oestrogen therapy
Although prostate ca risk acc lower in trans-women than cis-men
Trans-feminine gender affirming treatment
Oestrogen
Progesterone
Cyproterone acetate
Spironolactone
Trans fem Oestrogen
Bioidentical oestrogens (oestradiol) recommended
Oestradiol valerate or oestradiol hemihydrate, with once daily oral dosing
Target oestrogen level should be upper ½ of female follicular phase physiological range
Why use Bioidentical oestrogens as oppose to synthetic
Higher risks associated with synthetic oestrogen (ethinylestradiol / EE)
Not detected on serum oestradiol monitoring levels either so monitoring/ adjustments challenging
Oestrogen levels
What to aim for
When to take
Target oestrogen level should be upper ½ of female follicular phase physiological range
Aiming for plasma oestradiol level of 400 – 600pmol/L 4-6 hours post-dose for oral or gel forms
If using oestrogen patches, level should be checked 48 hours after patch applied
Adjust dose every 3 months until this is achieved
Investigations for person on oestogen therapy:
Monitoring should be done every 3 months for the first year –> annually thereafter, once stabilised:
Oestradiol (aiming for 400 – 600 pmol/L – upper ½ of female follicular phase range)
Testosterone (aiming for 0 – 3 nmol/L – normal female physiological range)
Prolactin (oestrogen therapy can -> pituitary hypertrophy and hyperprolactinaemia)
LFTs (less evidence, can cause LFT elevation however usually only mild and not impacting treatment)
BMI
Blood pressure
Serum Testosterone and oestogen therapy
If plasma testosterone not suppressed into female range of 0 - 3nmol/L with oestrogen therapy –> can add GnRH analogues
Should be used with cyproterone acetate (androgen receptor antagonist) for first 2 weeks to prevent initial testosterone ‘flare’
Effects of oestrogen therapy
1-3 months
Reduced libido, reduced spontaneous erections
3-6 months
Breast tissue development begins (completes /matures by ~2 years), reduction in muscle mass, testicular atrophy, body fat redistribution
6-12 months
Slower facial and body hair growth
Variable
Impaired spermatogenesis and fertility
Oestrogen therapy: risks
(1) VTE risk
» Greatest within first 2 years of commencing treatment, then plateaus
> > Lowest if using transdermal preparations (however these are more expensive)
> > Same rules/guidance applies around surgical interventions as with CHC: stop at least 4 weeks prior if anticipated major surgery with immobility due to VTE risk, and do not resume until 2 weeks post recovery of full mobility
(2) Impaired spermatogenesis
» Variable time taken for this to occur, person-person
» Not enough to achieve sterility and contraception (condoms) still advised
CVD and oestrogen
Rates of myocardial infarction are reduced by 2/3 in trans women compared to cis-men
BMD and oestrogen
Oestrogen is protective on BMD and there is no evidence on routine BMD monitoring for trans women
Cyproterone acetate is sometimes used in trans women and non-binary patients
Cyproterone acetate is a synthetic progesterone derivative with antiandrogenic and progesterone-like activity
Up to 100mg daily
Mechanism:
Androgen receptor antagonist -> blocks binding of testosterone and its metabolite (dihydrotestosterone) to tissue receptors
Also supresses LH -> Leydig cells in testes stimulated less -> lower testosterone level
USED (FOR FIRST 2 WEEKS) TO PREVENT INITIAL FLARE OF TESTOSTERONE IF USING GNRH AGENTS
associated with small but significant increased risk of meningioma (benign)
Sprionolactone
Primary mode of action is as a potent “anti-mineralocorticoid” (potassium sparing diuretic and aldosterone antagonist)
It can sometimes be used as gender affirming therapy for trans women due to it’s weak-moderate anti-androgenic effects
Often started prior to oestrogen therapy, to first reduce naturally circulating testosterone levels/ activity
Mechanism:
1. Competitive binding of receptors at the aldosterone-dependent Na-K+ exchange in renal DCT
» Promotes water and sodium excretion (–>diuresis)
» Promotes potassium retention (-> risk of hyperkalaemia)
- Inhibits 17- α hydroxylase enzyme necessary for synthesis of testosterone
» Decreases testosterone production - Also binds to and occupies androgen receptors -> displaces testosterone/DHT (reduces activity)
- Also acts as a weak oestrogen receptor agonist
Up to 400mg daily; start at low dose and increase gradually with K+ monitoring due to risk of hyperkalaemia
Finasteride in transwomen/ non binary
Inhibits conversion of testosterone into more potent dihydrotestosterone (DHT)
Mechanism: inhibition of 5-alpha reductase enzyme
Effective anti-androgen effects when used in this context
Can help with hirsutism
Note – some finasteride is excreted in semen; condom recommended if sexually active with partner who could become pregnant however no evidence to confirm any link to fetal abnormalities
Breast screening in trans and non binary pop
Breast screening is required for all those aged 50 – 70 years with breast tissue
» Either naturally occurring (including trans-men without top surgery to remove breast tissue)
» Or due to oestrogen therapy (trans women/ non-binary patients on oestrogen >5 years)
Trans women have a higher risk of breast cancer than cisgender men
Trans women have a lower risk of breast cancer than cisgender women
It is recommended that trans women >70 years old should continue to access breast screening if they are continuing to use exogenous oestrogen therapy
Trans men who are registered as male with their GP would not automatically be invited for screening
» Can be referred by their GP at request
Trans men who have had a mastectomy (top surgery) would be unable to have a mammogram as they would not have sufficient breast tissue, but they should still be vigilant for symptoms as malignancy can still occur on the chest wall/ very small amount of tissue that would be left behind
Symptoms include: new lumps, skin change, nipple discharge
Contraception and transgender populations
AFAB (trans-males or non-binary)
If using testosterone
» IUC or implant recommended options for teratogen use
» All other methods (including depot!) need extra precautions on top!
» PO as O can counteract T effects.
» Testosterone is not thought to affect either form of oral emergency contraception; both can be used
AMAB (trans women or non binary people)
» Contraception (condoms) would be required to prevent pregnancy if having IVI with AFAB person
