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Thera 2 > Transgender > Flashcards

Transgender Flashcards

1
Q

What antiandrogen options are there for feminizing hormone therapy?

A

Cyproterone - progestin and androgen receptor antagonist
Spironolactone - diuretic (most commonly used)

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2
Q

Contraindications of Cyproterone

A
  • active liver disease and hepatic dysfunction,
  • Severe renal insufficiency,
  • Severe chronic, depression (caution in all patients with a history of depression),
  • Previous or existing liver tumours,
  • Presence or history of meningioma,
  • Existing thromboembolic process,
  • Avoid concomitant use of hepatotoxic medications
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3
Q

Contraindications of Spironolactone

A

renal insufficiency, addison’s disease, hyperkalemia. Avoid concomitant use of: ACEs/ARBs, other potassium-sparing diuretics, trimethoprim-sulfamethoxazole, potassium supplements, eplerenone, heparin

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4
Q

What is the criteria to start hormone therapy?

A
  • Persistent, well-documented gender dysphoria/gender incongruence
  • Capacity to make a well-informed decision
  • Relevant medical or mental health issues are well controlled
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5
Q

What is the diagnostic criteria for gender incongruence?

A
  • Persistent incongruence between gender identity and external sexual anatomy at birth
  • The absence of a confounding mental disorder or other abnormality
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6
Q

What is gender dysphoria?

A

The discomfort arising in some individuals from the incongruence between their gender identities and their external sexual anatomy at birth.

DSM-5 Criteria:
A. An incongruence between one’s experienced/ expressed gender and assigned gender, of at least six months duration, as manifested by at least 2 of the following:
- marked incongruence between one’s experiences/expressed gender and primary and/or secondary/anticipated sex characteristics
- strong desire to be rid of one’s primary and/or secondary sex characteristics because of a marked incongruence with one’s experienced/expressed gender.
- strong desire for the primary and/or secondary sex characteristics of the other gender.
- strong desire to be of the other/alternative gender
- strong desire to be treated as the other/alternative gender
- strong conviction that one has the typical feelings and reactions of the other/alternative gender
B. The condition is associated with clinically significant distress or impairment in social, occupational, or other important areas of functioning.

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7
Q

Why are anti-androgens needed for feminizing hormone therapy?

A

Administration of estrogens alone will suppress gonadotropin output and, therefore, androgen production, but dual therapy with one compound that suppresses androgen secretion or action and a second compound that supplies estrogen is more effective and may permit lower estrogen dosing

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8
Q

What routes of estrogen are available for transfeminine therapy? What is most commonly used?

A

Oral, transdermal patch and IM

Oral 17-beta-estradiol most common
Dosing: 2 to 4 mg/day, occasionally as high as 10 mg.

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9
Q

What is involved with Transfeminine hormone therapy?

A

Anti-androgen - cyproterone (start at 12.5mg daily) or spironolactone (start at 50mg PO bid)
+ Estrogen (17-estradiol) PO start at 1-2mg daily

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10
Q

What is involved with Masculinizing hormone therapy?

A

Testosterone therapy enanthate or cypionate (SC/IM) start at 20-50mg weekly (max dose 100mg qweekly)
- IM most common route
- enthate compounded in sesame oil
- cypionate compounded in cottonseed oil

Alternative gel or patch

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11
Q

What are some of the feminizing effects with Feminizing hormone therapy?

A

Redistribution of body fat
Decrease in muscle mass and strength
Softening of skin/decreased oiliness
Decreased sexual desire
Decreased spontaneous erections
Male sexual dysfunction
Breast growth
Decreased testicular volume
Decreased sperm production
Decreased terminal hair growth
Scalp hair
Voice changes

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12
Q

Which feminizing effects are irreversible?

A
  • breast growth irreversible (although minimal)
    variable reversibility: body fat distribution, reduced erections, decreased libido, decreased fertility, reduced prostatic size & testicular volume
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13
Q

What are you monitoring for feminizing therapy and how often?

A

BW taken at baseline, q4-6 wks post dose change and then post maintenance dose at 3, 6, and 12 month mark, then yearly thereafter.
- CBC, HbA1c or fasting glucose, lipids, testosterone, estradiol, prolactin, ALT, Creatinine, lytes

q3m in the first year
- serum testosterone and estradiol every three months. Serum testosterone levels should be <50 ng/dL.
Serum estradiol should not exceed the peak physiologic range: 100 to 200 pg/mL.
- For individuals on spironolactone, serum electrolytes (particularly potassium) should be monitored q3m in the first year and annually thereafter.
- Routine cancer screening is recommended, as in non-transgender individuals (all tissues present).
- Consider BMD testing at baseline. In individuals at low risk, screening for osteoporosis should be conducted at age 60 years or in those who are not compliant with hormone therapy.

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14
Q

AE of feminizing therapy

A
  • VTE
  • Cardiovascular disease
  • Elevated triglycerides
  • Mortality (higher for untreated dt suicide)
  • Hyperprolactinemia/prolactinoma for ethinyl estradiol 100 mcg/day as well as the progestin cytoproterone
  • Cancer - breast, prostate
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15
Q

Which masculinizing effects are irreversible?

A

Body & facial hair growth, scalp hair loss, deepend voice

Variable: fertility

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16
Q

Contraindications to Estrogen therapy?

A
  • Unstable ischemic cardiovascular disease,
  • estrogen-dependent cancer,
  • end-stage chronic liver disease,
  • psychiatric conditions which limit the ability to provide informed consent,
  • hypersensitivity
17
Q

Contraindications to Testosterone therapy?

A
  • Pregnancy or breast feeding,
  • Active known sex-hormone-sensitive cancer (breast, endometrial),
  • Unstable ischemic cardiovascular disease,
  • Poorly controlled psychosis or acute homicidality or psych conditions which limit the ability to provide informed consent,
  • Hypersensitivity to one of the components of the formulation
18
Q

What are some of the masculinizing effects with masculine hormone therapy?

A

Skin oiliness/acne
Facial/body hair growth
Scalp hair loss
Increased muscle mass/strength
Fat redistribution
Cessation of menses
Clitoral enlargement
Vaginal atrophy
Deepening of voice

19
Q

What are you monitoring for masculinizing therapy and how often?

A

BW taken at baseline, q4-6 wks post dose change and then post maintenance dose at 3, 6, and 12 month mark, then yearly thereafter.
- CBC, HbA1c or fasting glucose, lipids, testosterone, LH, ALT

q3m in the first year and then one to two times per year to monitor for appropriate signs of virilization and for development of adverse reactions.
- Measure serum testosterone q3m until levels are in the normal physiologic male range:
- For testosterone enanthate/cypionate injections, the testosterone level should be measured midway between injections. The target level is 400 to 700 ng/dL. Alternatively, measure peak and trough levels to ensure levels remain in the normal male range.
- For transdermal testosterone, the testosterone level can be measured no sooner than after one week of daily application (at least two hours after application).
- Measure hematocrit or hemoglobin at baseline and q3m for the first year and then one to two times a year. - Monitor weight, blood pressure, and lipids at regular intervals.
- Screening for osteoporosis should be conducted in those who stop testosterone treatment, are not compliant with hormone therapy, or who develop risks for bone loss.
- If cervical tissue is present, conduct Pap tests q3y
- Conduct sub- and periareolar annual breast examinations if mastectomy performed. If mastectomy is not performed, then consider mammograms as recommended

20
Q

AE of testosterone therapy

A
  • persistent bleeding: Menses usually stop within a few months of starting testosterone, but may continue.
  • metabolic: erythrocytosis.
  • heart disease
  • fertility: may limit fertility potential unless hormones are stopped.
21
Q

What are the options for young patients pre-puberty or are early into puberty?

A

puberty suppression through LEUPROLIDE ACETATE, a gonadotropin-releasing hormone analogue (GnRH). It is dosed by weight (range 7.5 mg to 15 mg) and is injected intramuscularly every four weeks. This is reversible and puberty will resume according to the assigned gender at birth when/if discontinued

22
Q

Is puberty suppression reversible

A

Yes, puberty will resume according to the assigned gender at birth when/if discontinued

23
Q

For patients >40yrs wanting transfeminine therapy what would be the preferred treatments?

A

Estrogen patch and spironolactone

Thera 2 (9 decks)

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