Transgender Healthcare and Hormone Therapy

Question 1

What is meant by Transition?

• what does this involve?

Answer 1

• Social gender role change
  
  • Pronouns, clothes, name
• Hormone treatment
  
  • ~ follows sequence of pubertal development
  • 90% reversible
  • Less reversibility with breasts (trans-male) and hair (trans-female)
  • Discuss fertility / fertility preservation first
• Surgery
  
  • Various: not everyone has / wants to have / can have surgery

Question 2

What should being transgender not be confused with?

Answer 2

• Sexuality?
• Transvestites

Question 3

What specialities would be at a Gender Identity Clinic?

Answer 3

• Counselling / psychotherapy / psychological support
• Speech & language therapy (voice & communication therapy)
• Endocrinology (hormone therapy)
• Surgery (chest, hysterectomy/oophorectomy, gonadectomy, genital, ENT, facial etc.)

Question 4

What is the effect of Oestrogen treatment?

Answer 4

• Hair
  
  • Some effect on facial hair
    
    • Mechanical forms of hair removal often still required
  • More effect on body hair
  • No effect on ‘lost’ scalp hair, but prevents further loss
• Breasts
  
  • Expect one cup size < mother’s
  • Gradual oestrogen treatment for optimal breast development, otherwise fuse breast buds
• Maximum effect achieved after 2 years’ treatment

Question 5

What type of Oestrogen treatment is there?

Answer 5

• Oral or transdermal oestradiol (patch/gel)
  
  • Higher doses than post-menopausal HRT
  • Oestradiol safer than ethinylestradiol or conjugated equine oestrogens
• GnRH analogue to suppress testosterone
  
  • Depot IM injection 3-monthly
  • Not required after gonadectomy
• Venous thromboembolism risk increased
  
  • Multiplicative risks: smoking, obesity
• Life-long treatment
  
  • Do not stop at usual age of menopause

Question 6

What is the effect of Testosterone treatment?

• type of treatment

Answer 6

• Hair
  
  • Male-pattern hair growth
  • Scalp hair loss (depending on genetic factors)
• Intramuscular (depot, 3-monthly) or transdermal gel (daily) testosterone
  
  • Standard doses (depending on size)
• Do not need GnRH analogue
• Risk of polycythemia
  
  • Monitor haemoglobin and haematocrit
  • Increased risk in smokers
• Maximum effect achieved after 5 years’ treatment

Question 7

What needs to be considered for trans-male sexual health-wise?

Answer 7

• if they are a cis-trans male consider IUD or depot progesterone
  
  • testosterone treatment is teratogenic (not good for embryos)
• HIV screening is indicated as it is a relatively higher prevalence

Question 8

What screens need to be done for Trans-female?

Answer 8

• Mammography from age 50 once on hormone therapy for 5 years
• DEXA at 60
  
  • measures bone density
  • Sooner if other risk factors for osteoporosis or if inadequate hormone therapy post-gonadectomy

Question 9

What screens need to be done for Trans-males?

Answer 9

• Cervical and breast screening as for XX population unless surgically removed
  
  • Will not receive automated invitations for screening
  • Chest reconstruction is not a mastectomy: self-examination is recommended
• Consider 2-yearly USS endometrium unless surgically removed
  
  • Risk of hyperplasia?
• DEXA at 60
  
  • As for trans-females