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Repro Week 4 > ICL 17.5: Medical Management of Transgender Patients > Flashcards

ICL 17.5: Medical Management of Transgender Patients Flashcards

1
Q

what is transgender?

A

a term for people whose gender identity, expression or behavior is different from those typically associated with their assigned sex at birth

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2
Q

what is cisgender?

A

term for people whose gender identity, expression or behavior matches those typically associated with their assigned sex at birth

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3
Q

what is gender non-conforming?

A

a term for individuals whose gender expression is different from societal expectations related to gender

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4
Q

what is gender dysphoria in adult?

A

DSM5 diagnostic term used

a noticeable incongruence between the gender the patient believes they are, and what society perceives them to be

in DSM4 it was called gender identity disorder so do not use it!

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5
Q

why has the demand for transgender health care increased?

A
  1. increasing social acceptance
  2. increasing economic access
  3. increasing legal access

however the major limiting factor is a lack of available high quality care

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6
Q

what are the common transgender disparities?

A
  1. greater than 4 times the national average of HIV infection (2.6% vs. 0.6%).
  2. 26% use or have used alcohol and drugs to cope with discrimination.
  3. 41% reported attempting suicide compared to 1.6% of the general population.
  4. 57% faced some rejection by their family.
  5. family rejection significantly increased rates of homelessness, incarceration, sex work, HIV, suicide attempts, smoking, and use of drugs and alcohol
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7
Q

what are the mental healthcare needs of transgender patients?

A

high rate of need

inpart in response to society’s reaction to who they are

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8
Q

what do transgender people want from healthcare beyond routine needs?

A
  1. hormonal transition to the gender of identity

transgender women need estrogen/anti-androgen and transgender men want testosterone

  1. surgery

gender confirming/affirming surgery

transfender men want bilateral mastectomies/hysterectomy/BSO/vaginectomy/phalloplasty/scrotoplasty

transgender women might want orchiectomy/penectomy/vulvo-vaginoplasty

  1. identity enhancing like facial feminization, vocal cord alteration, hair transplants, body contouring, implants, etc.
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9
Q

what reproduction options are there for transgender people?

A
  1. gamete cryopreservation/ART
  2. counseling on recovery of reproductive capacity
  3. contraception/STI prevention
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10
Q

what behavioral modifications are available for transgender people?

A
  1. vocal coaching for pitch and speech patterns

2. gender specific patterns of dress and behavior

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11
Q

what is WPATH?

A

World Professional Association for Transgender Health

mission to promote evidence based care, education, research, advocacy, public policy, and respect in transgender health.

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12
Q

what are the organization s in charge of standards of care for transgender people?

A
  1. WPATH
  2. Fenway Center in Boston
  3. UCSF Center of Excellence for Transgender Health
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13
Q

what is the role of a PCP in the care of transgender people?

A
  1. trans-friendly optimal primary care

2. screening recomendations/provisions

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14
Q

what screening recommendations/provisions are required for a transgender patient by their PCP?

A
  1. cardiovascular/metabolic
  2. STI, pregnancy and cervix care –> testosterone is not a reliable contraceptive!
  3. breasts
  4. prostate
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15
Q

what are the trans-specific gynecologic health concerns?

A
  1. abnormal bleeding in transgender men with a uterus is usually explained by hormone use….but work up if modifying the hormones doesn’t resolve it

long term risk of cancer with androgen use is unknown….

  1. care of a neovagina/neovulva

frequently the initial surgery was done elsewhere…grafy sloughing/incisional breakdown are not uncommon and there is a need for long term dilation because structures are a pretty common problem – post neoclitoral/labial pain or hypersensitivity may require revision too

routine PAP is not recommended

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16
Q

what are the trans-specific urologic health concerns?

A

care of neophalus/neoscrotum in transgender male

urethral structures and fistulas are common

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17
Q

what are the male sex steroids that can be given for transgender hormonal therapy?

A
  1. testosterone and derivatives
  2. androstenedione; precursor only
  3. dihydrotestosterone (DHT)

it’s a potent metabolite of T in skin so not used clinically systemically

compounded topical use before metoidioplasty

  1. synthetic androgens especially for athletic enhancement but not used for transgender care
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18
Q

what are the female sex steroids that can be given for transgender hormonal therapy?

A
  1. estradiol and derivations
  2. estrone
  3. estriol
  4. conjugated equine (CEE)
  5. synthetic (not used for transgender women)
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19
Q

where does testosterone come from?

A

gonads and adrenal glands

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20
Q

what is the function of testosterone?

A
  1. spermatogenesis
  2. muscle density and mass
  3. bone density and length, cartilage growth
  4. libido
  5. male secondary sex characteristics like organs, voice, hair, growth
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21
Q

how much testosterone does it take to make things happen in transgender men?

A

men have ten-fold higher T levels than women

it circulates bound to SHBG and albumin because it’s lipophilic and hydrophobic and only the free fraction is what’s metabolically active

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22
Q

where does estradiol come from?

A

gonads, fat and muscle

this is because aromatase is in fat mainly and converts testosterone to estrogen

23
Q

what is the function of estradiol?

A
  1. menstrual cycle, endometrium
  2. one, skin, hair, GI, lungs
  3. clotting factors
  4. lipids
  5. female secondary sex characteristics like breast ductal development, vaginal growth, fat distribution
24
Q

how much estrogen does it take for estradiol does it take to make things happen in transgender woman?

A

it’s harder to estimate because cis women cycle and there’s a 10x change in estradiol depending on where they are in their cycle so when you ask how much estradiol you need, it’s hard to tell how much transgender females need…

so you shoot for 100-200 pg/nl

25
Q

what are the 2 primary goals of hormone therapy?

A
  1. induce the desired secondary sex characteristics (‘mini-puberty’), a direct effect of the administered hormone

transgender women: breast growth, body composition

transgender men: voice deepening, terminal facial and body hair, body composition

  1. cause regression of already induced characteristics, an indirect effect through suppression of the pituitary hormones that drive the gonads (FSH/LH) –> unnecessary after gonadectomy

transgender men: amenorrhea, fat mass, some breast tissue

transgender women: facial and body terminal hair, muscle mass, gonads, spontaneous erections

26
Q

what is the adjust goal of hormone therapy?

A

do no harm!!

there are several studies of overall risk on short term hormone therapy but few data on long term risks

patients don’t consider hormones an elective option

27
Q

what are the effects of masculinizing hormones?

A
  1. skil oiliness/acne
  2. facial/body hair growth

hair cycle can be up to 5 years so it can take up to 5 years for it to come in completely

  1. scalp hair less
  2. increased muscle mass/strength
  3. body fat redistribution
  4. cessation of menses
  5. clitoral enlargement
  6. vaginal atrophy
  7. deepened voice
28
Q

what are the effects of feminizing hormones?

A
  1. body fat redistribution
  2. decreased muscle mass/strength
  3. softening of skin/decreased oiliness
  4. decreased labido
  5. decreased spontaneous erections
  6. male sexual dysfunction
  7. breast growth
  8. decreased testicular volume
  9. decreased sperm production
  10. thinning/slowed growth of body facial hair
  11. male pattern baldness
29
Q

what are the risks of feminizing hormones?

A
  1. VTE**
  2. gallstones
  3. elevated liver enzymes
  4. weight gain
  5. hypertriglyceridemia*

possible increased risk of CVD, HTN, DMII but no increased risk of breast cancer

30
Q

what are the risks of masculinizing hormones?

A
  1. polycythemia*
  2. weight gain
  3. acne
  4. androgenic alopecia
  5. sleep apnea

possible increased risk of elevated liver enzymes, hyperlipidemia, destabilization of certain psych disorders, CVD, HTN, DMII but no increased risk for decreased bone density, breast cancer, cervical cancer, ovarian cancer, or uterine cancer

31
Q

how do you assess the patients response to hormone therapy?

A

short term: suppression of serum levels of the principal endogenous gonadal hormone(usually E2 /T, sometimes FSH/LH)

long term: development of biological effects of the administered hormones, and suppression of the manifestations of the endogenous gonadal hormones

32
Q

what is the initial therapy in transgender women therapy?

A

estrogens

if adequate suppression of testicular function is not achieved, consider adjunctive therapy, using anti-androgens and GnRH agonists

33
Q

what is the estrogen regimen used for transgender women?

A

oral dosage is typically 6-8 times that used in menopausal hormone therapy (reduced after orchiectomy, if GCS is performed).

oral preparations, twice daily most commonly.

avoid oral preparations of unknown bioavailability.

non-oral options are increasingly requested, and may become the option of choice to minimize risk.

34
Q

what are the types of estrogen that can be given to TG women?

A
  1. estradiol
  2. conjugated estrogens USP
  3. transdermal patches
  4. IM depo-estradiol
  5. buccal micronized estradiol
35
Q

which medications are adjunctive hormonal therapy for TG women?

A
  1. anti-androgens
    ex. spironolactone, finasteride, flutamide, cyproterone acetate
  2. progestins

requested for breast growth like medroxyprogesterone or micronized progesterone but there’s no evidence that this actually helps

36
Q

what surveillance regimen do you do for hormone therapy in TG women

A

baseline, 3, 6, 12, 18, 24 months, then annually for:

  1. serum estradiol & testosterone
    E2 100-200 pg/mL; T< 0.9 ng/mL.
  2. lood pressure
  3. electrolytes if on spironolactone
  4. lipids per usual female guidelines
37
Q

what is the initial therapy in transgender male therapy?

A

testosterone

if adequate suppression of ovarian function is not achieved, consider adjunctive therapy, using anti-estrogen or GnRH agonist

38
Q

what is the dose of testosterone used for TG men?

A
  1. dosage is typically 2-4 times that used as hormone replacement in male hypogonadism (reduced after oophorectomy, if GCS performed).
  2. intramuscular administration is the standard
  3. transdermal gel
  4. transdermal patch
  5. oral fluoxymesterone
39
Q

what adjunct therapy can you use for TG males?

A

anti estrogens but infrequently used

  1. aromatase inhibitors (testosterone to estradiol): anastrozole, letrozole
  2. estrogen receptor antagonists: tamoxiphene, toremifene, raloxifene
40
Q

how do you monitor TG male hormone therapy?

A

baseline, 3, 6, 12, 18, 24 months, then annually for:
1. serum testosteron and estradiol

  1. Hb/Hct
  2. liver function tests
  3. serum lipid profile
41
Q

what are the adjunction hormone therapies in adolescents?

A

Inhibition of pituitary gonadotropins & thus gonadal steroidogenesis

  1. Goserelin subcutaneous implant q 3-4 weeks
  2. Leuprolide acetate depot suspension IM q 4 weeks
  3. Nafarelin nasal spray
42
Q

what is gender confirming surgery?

A
  1. irreversible and final
  2. recommendation by an appropriate counselor

WPATH: Two letters, one by an independent psychologist/psychiatrist

  1. financial obstacles must be overcome
  2. multidisciplinary surgeon teams.
  3. may need several sessions of surgery.
43
Q

what is the WPATH readiness criteria for gender confirming surgery?

A
  1. demonstrable progress in consolidating the evolving gender identity.
  2. demonstrable progress in dealing with work, family, and interpersonal issues resulting in a significantly better state of mental health.
  3. tolerating hormonal therapy and maintaining good health.
  4. often a prerequisite for insurance coverage
44
Q

what is the gender confirming surgery for transgender women?

A
  1. orchiectomy
  2. vaginoplasty/clitoroplasty/labiaplasty can be done by:
    - inversion of penile/scrotal skin
    - penectomy and pedicled rectosigmoid transplant; or
    - penectomy and free skin graft to line a neovagina
45
Q

what is penile inversion vaginoplasty?

A
  1. incise penis and scrotum, remove testes.
  2. denude penile shaft.
  3. remove erectile tissue, preserving the urethra and neurovascular bundle and glans.
  4. create neovagina by inverting penile skin, shortening urethra, and trimming glans to form a clitoris. Form scrotal skin into labia.
46
Q

what cosmetic gender confirming surgery can be done for transgender women?

A
  1. augmentation mammoplasty after achieving stable breast growth
  2. reduction thyroid chondroplasty
  3. suction lipoplasty/lipofilling
  4. thinoplasty
  5. facial bone reduction, face-lift, blepharoplasty
  6. pectoral/gluteal implants
  7. vocal cord reconstruction
47
Q

what are some of the post top problems associated with gender confirming surgery for transgender women?

A
  1. graft failure
  2. vaginal stenosis –> maintenance requires use of dilators/stents or regular intercourse
  3. cosmetic appearance
  4. hypersensitivity of reconstructed clitoris/vulva
  5. anorgasmia
48
Q

what are the gender confirming surgery that can be done for transgender men?

A
  1. reduction mammoplasty
  2. hysterectomy +/- salpingo-oopherectomy
  3. vaginectomy
  4. phalloplasty –> metoidioplasty, flap, free vascular graft/urethroplasty
  5. scrotoplasty with testicular implants
49
Q

what are the phalloplasty techniques?

A

both require subsequent scrotoplasty and testicular implants using labial skin

erections will require placement of an erectile device.

50
Q

how is fertility effected in transgender males and females on hormone therapy?

A

hormone therapy suppresses gonadal function and fertility but it returns with cessation of therapy

ovulatory cycles return immediately

sperm recovery requires 3-6 months

does not automatically cause gonadal failure

51
Q

how is fertility effected in transgender males and females who underwent gonadectomy?

A

sperm can be frozen and stored, but must be collected off of hormones

egg freezing is now available, but requires stimulation and retrieval, and is expensive

52
Q

what is ambisexual hair?

A

becomes terminal (thick, dark) at T levels above the female range

chin, neck, upper back, midline chest and upper abdomen

has a 3-5 year growth cycle

scalp hair with genetic predisposition will lose follicles in a male pattern with testosterone hormones

53
Q

how are vocal cords effected by testosterone?

A

they lengthen with testosterone which causes a longer and lower pitch

they will not ever shorten even with testosterone

Repro Week 4 (16 decks)

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