transgender care Flashcards
(25 cards)
Testosterone treatment options
Sustanon 250mg IM 2-4 weekly
c/i in nut allergy
testosterone gel
Nebido 12 weekly injection
Normal T levels
1/52 post injection= 25-30nmol/l
day of sustanon injection= 8-12 nmol/L
Impact of Testosterone treatment
can take 2-5 years
amenorrhoea (2-3 injections) can used GnRH/MPA/NET if needed
facial/body hair
change to body shape
clitoromegaly (4-5cm at 12/12)
increased energy/libido
voice changes may take 3 years
may reduce fertility- consider gamate storage at time of referral
Risks of T treatment
polycythemia (increased stroke risk, may choose to decrease dose)
-venesection 4-6/52 as treatment
liver (mild changes, stop of 3xnormal)
cholesterol (nil increased IHD) increased TGs, decreased HDL
Cancer- T converted to E by aromatase- risk of hyperplasia. Annual USS/hysterectomy/POC
Initial investigations for T treatment
LH/FSH/T/E
SHBG/PL
LFTS/lipids
glucose
FBC
weight/BMI
Monitoring on T treatment
T
FBC
LFTs/lipids
weight/BMI
USS
smear/mammogram if needed
every 3-6/12 then annual when stable for 2 years
DEXA if nil hormonal rx/fracture/FHx
E1
E2
E3
E1= estrone
E2= estradiol
E3= estriol (predominant E in pregnancy)
Gender Recognition Act 2004
GRC+ birth certificate
needs- form, deed poll, birth certificate, proof lived in gender 2 years, 2 medical reports, £5, marriage certificate and permission from spouse
-unlawful to disclose or misgender or ask someone if they have applied for this
If need to verify identity=birth certificate or passport NOT GRC
Equality Act 2010
gender is a protected characteristic
Role of Gender Identity Clinic
voice/communications
psychological interventions
endocrine/pharmacological treatment
Refer for surgery
- 2 clinicians (1 lead at GIC, 1 independent)
-12/12 hormone rx and living in role
- 1 opinion if have GRC
Feminising treatment practicalities
Estradiol valerate 2mg OD
Increase by 2mg every 3 months until 8mg OD
bioidentical, level at 4-6hrs should be 400-600pmol/L (normal for a cis young F)
give slowly over 2 years for better breast formation
Gel/patch:
unsatisfactory levels
liver
bowel
testosterone in trans F
may reduce naturally
aim for 0-3nmol/L
can give GnRH (leuporelin/goserelin) every 12 weeks
-initial worsening then reduction- can give cyproterone acetate 50-100mg OD during this time
-metabolised in liver, blocks T by stopping binding and reduced PG production
Length of treatment for trans F
GnRH until orchidectomy
E lifelong (need some form of E/T)
Impact of E treatment
Hair:
finer on face, max response at 4 months
slowed male pattern balding
Breast:
takes 2-3/12, may 2 years
1 cup size less than mother, no augmentation on NHS
Body fat:
4kg weight gain, more on hip/bum
reduced bulk of muscle
Fertility:
reduce libido/erections (within a few months)
testes smaller/softer
reduced sperm (?gamete storage beforehand)
Risks of feminising treatment
-VTE- reduce smoking
highest in first two years of rx
-hyperprolactinaemia (E= +ve feedback on anterior pituitary= increased prolactin)
1 in 10 raised, GnRH can help
-Liver- 3 deranged, rarely abnormal enough to stop rx
-gallstones
-osteoporosis- give Vit D, E may help
Feminising treatment- initial investigations
LH, FSH, T, E
SHBG/PL
LFTs/lipids
glucose
PSA
BP
LFTs
Vit D
Weight/BP
Feminising treatment- monitoring
T/E
LFTs
PL
Weight/BP
Feminising treatment- screening
Mammogram
DEXA
AAA
What is dysphoria?
clinically significant distress
>six months
caused by mismatch between birth-assigned sex andgender identity
causing impairment in social, occupational or other important areas of functioning
ICD 10 diagnosis:
-desire to live and be accepted as a membe rof opposite sex, often accompanied by wish to make body congruent (surgery/hormonal rx)
-sexual identity being present >2 years
-not a symptom of mental health disorder or chromosomal abnormality
Finasteride
5 alpha reductase inhibitor
( 5ar converts testosterone into DHT)
not core component but can help with feminisation
Progesterone
Precursor to testosterone, may cause unwanted masculinisation
consider breast Ca risk (ie similar to cHRT v E only)
Breast Screening trans women
if on long term hormone rx should consider attending
Will be invited aged 50-70 if registered as female at GP
Breast Ca risk if lower than cis women but higher than cis men
Breast Screening trans men
indicated if any breast tissue still present
will only be invited if registered as F on GP system
Contraception trans men
Need if on testosterone
FSRH view is the combined should be avoided as can antagonise testosterone treatment
If wish for permanent=sterilisation as this will not interfere with hormonal rx
testosterone not thought to affect EHC
