Care of Trans Patients Flashcards
(20 cards)
Indications for mammography screening in trans women
screen if:
- > 50yo + hormone tx hx
- additional risks: fhx, obesity, estrogen and progestin use > 5 yrs
Osteoporosis screening rx for transmen
- Bone density at age 60 or earlier based on risk factors - Consider in those not compliant with hormone therapy
Osteoporosis screening rx for transwomen
- Bone density at age 60 or earlier based on risk factors - Consider in those not compliant with hormone therapy
Breast cancer screening @ transmen
-Perform chest wall examination after chest surgery -otherwise mammography as recommended for cisgender women
Main principles for gender-affirming hormone therapy
- reduce endogenous
hormone levels and their associated sex characteristics - replace with hormones of the preferred sex
Risks with estrogen therapy
- thromboembolic disease (~2-6%); decreased w/transdermal
- coronary artery disease
- cerebrovascular disease
- severe migraine headaches
- liver dysfunction
- macroprolactinoma
- increased insulin resist/Fast BG
- increased triglyceride
Risks with testosterone
- erythrocytosis (HCT > 50%)
- increased insulin resist/Fast BG
Goal hormone levels for transwomen
-estrogen @ normal range for
cisgender women of reproductive age (< 200
pg/mL)
-testosterone levels should be suppressed < 55 ng/dL
Goal hormone levels for transmen
-Goal testosterone =
320 - 1,000 ng/dL measured
at intervals specific to the preparation used
(ie, midway between injections for tx w/ Test cypionate).
-Estradiol levels < 50ng/dL
Lab monitoring for transwomen
- estradiol/testosterone q3mo x 1 yr, then q6-12 mo after goal
- serum prolactin prn sx of prolactinoma
- serum electrolytes w/spironolactone
Lab monitoring for transmen
- estradiol/testosterone, +/- SHBG/albumin (for testosterone bioavailability) q3mo x 1 yr, then q6-12 mo after goal
- CBC, LFTs q3mo x 1yr, then q6-12 months
Physical changes timeline for transwomen on hormones
- decreased libido/spontaneous erections for first 3 mo
- breast growth @ 3-6mo
Physical changes timeline for transmen on hormones
- fat redistribution first 6 mo
- facial/body hair slow x up to 4-5 yrs
- amenorrhea @ 1-6 mo
Types of hormones used in gender-affirming therapy for transwomen
- estrogens (estradiol or 17-beta-estradiol)
- progesterone
- androgen blockers (sprio, 5-alpha-reductase inhibitors e.g. finasteride, dustasteride)
Estrogen formulations
- oral/SL (daily, TDD>2mg = BID dosing)
- transdermal (patch) - frequency depends on formulation
- injection (estradiol valerate IM, estradiol cypionate IM) q2wk dosing (can go weekly if cyclical sx)
Progesterone formulations
- oral, QHS dosing
- medroxyprogesterone acetate (provera)
- micronized progesterone
Anti-androgen medication classes
- spironolactone (main SE is hyperK, can have diuresis, orthostasis)
- 5-alpha-reductase: finasteride, dustasteride
- other anti-androgens not used in US: cyproterone acetate (assoc w/fulminant hepatitis), bicalutamide (risk to liver, fulminant hepatitis)
- (if unable to suppress/work-up negative): GnRH analogs = leuporelin (Lupron), triptorelin (Decapeptyl)
Work-up for persistently elevated testosterone in transwomen
- adherence/access
- exogenous testosterone use
- eval for testicular neoplasm: scrotal exam, hcg, LDH, AFP, +/- scrotal imaging
Management of persistently elevated testosterone in transwomen
- work-up for exogenous testosterone source
- GnRH analogs
- orchiectomy
Lab monitoring to ensure adequate bone density maintenance
LH/FSH suppression can be used as a surrogate marker (in addition to clinical effect/testosterone levels) that indicates adequate sex hormone levels for maintaining bone density
