Gender Affirming Care for Transfeminine Patients/media/Images/Swedish/CME1/SyllabusPDF… · LGBTQ...

LGBTQ Health 101 4/7/2017

1

Gender Affirming Care for Transfeminine Patients

Jessica Rongitsch, MDSimon Adriane Ellis, CNMMarch 2017


2

CO

NTE

NTS

01.

02.

03.

Feminizing hormone therapy

Gender affirming surgery

Q&A


3

GENDER AFFIRMING HORMONE THERAPY

01.


4

HORMONE INITIATION

Informed consent from the prescriber:

- Risks, benefits, side effects

- Physical and emotional changes

- Expectations

- Social impact

- Fertility

- Goals and alternatives


5

PREPARING FOR TRANSITION

Realistic expectations

Assessing support resources and planning for potential social consequences

- Family of origin

- Partners

- Children

- Friends

- Work/school

- Transphobia and harassment


6

CONTRAINDICATIONS

Hormone-responsive cancer

Untreated venous/arterial thromboembolism

History suggesting untreated hypercoagulable state

Consider avoiding spironolactone if on ACE I/diuretics, renal dysfunction, low blood pressure


7

POTENTIAL RISKS

VTE: 1-2% of MTF patients, risk greatest 1st year of therapy, tobacco abuse, peri-operative period

Breast cancer: no increased risk compared to general population

CAD risk: increased in MTF but associated with ethinylestradiol use and other CV risk factors


8

COMMON SIDE EFFECTS

Orthostatic hypotension/dizziness

Mood issues: depression, increased emotional range, mood swings, anxiety

Weight gain

Fatigue

Sexual dysfunction

Renal dysfunction/hyperkalemia


9

TIMELINE OF PHYSICAL CHANGES

Effect Onset (months) Maximum (years)

Redistribution of body fat 3-6 2-3

Decrease in muscle mass 3-6 1-2

Softening skin 3-6 unknown

Decreased libido 1-3 3-6

Decreased erections 1-3 3-6

Breast growth 3-6 2-3

Decreased testicular volume 3-6 2-3

Decreased sperm production

unknown > 3 years

Decreased hair growth 6-12 >3 years

Scalp hair No regrowth

Voice changes none


10

Comp/CMP

CBC

+/- lipid

+/- HIV/STI screen

+/- testosterone

+/- prolactin if on anti-psychotics

BASELINE LABS


11

REGIMEN: ANDROGEN BLOCKERS

Name Starting dose Standard dose range

Spironolactone 50 mg qd, 50 mg BID after 7 days

50 mg BID – 150 mg BID

Finasteride 5 mg 0.25 tab – 1 tab qd 5 mg 0.25 tab – 1 tab qd

Prometrium (progesterone-no consensus on use)

100 mg – 200 mg qd 100 mg – 200 mg qd


12

REGIMEN: ESTRADIOL

Name Starting dose Standard dose range

Estradiol patch 0.1 mg once or twice a week depending on formulation

0.1 mg – 0.4 mg once or twice a week depending on formulation

Oral estradiol 2 mg qd sublingual 4 mg – 8 mg qd usually divided into BID doses

Injectable: estradiol valerate40 mg/ml

0.15 ml – 0.25 ml weekly 0.15 ml – 0.25 ml weekly


13

Q 6-8 weeks if spironolactone dose increased, q 3 months x 1 year then q 6 months

Effects? Side effects?

Social transition

Suicide risk assessment

Documentation needs

Risk HIV/STI

Surgical affirmation procedure/hair removal

Labs: BUN/Cr, K, testosterone level, estradiol level

MONITORING PARAMETERS


14

CASE ONE

45 yo trans woman establishes careto start feminizing regimen.


15

Psychosocial history:

- Gender issues since early childhood

- Punished for cross-dressing as child

- Bullied as child for gender nonconformity

- Unsupportive spouse

- First language: Spanish, from Mexico

- Employment: fast food restaurant

CASE 1


16

PMH

- DMII

- HTN

- Hyperlipidemia

- Obesity

Meds

- Losartan 50 mg qd

- Atorvastatin 20 mg

- Metformin 500 mg BID

CASE 1


17

Physical exam

- BP 158/98

- BMI 34

- Significant male-pattern hair loss

Labs:

- A1C 8.5%

- LDL 82 mg/dl

- ALT 59

- Testosterone 242 ng/dl

CASE 1


18

Assessment:

- Longstanding gender dysphoria

- CV risk factors and poorly controlled DMII and HTN

- On an ARB so spironolactone not a good option

- Psychosocial:

• Lack of support

• Limited resources

• Limited employment options

CASE 1


19

Treatment plan

- Mental health:

• Referral to therapist

• Recommendation for support groups

- CV risk management:

• Diabetes control, metformin increased

• BP control, losartan increased

- Feminizing regimen:

• Low dose estradiol patch

• ASA 81 mg

• Finasteride 5 mg 0.25 tab qd, no spironolactone

CASE 1


20

CASE TWO

25 yo transgender woman on hormone regimen x 2 years establishes care:

“My breasts are very small.” “My friends have had better results.”


21

Meds: Spironolactone 300 mg qd, estradiol 4 mg qd

PMH: healthy and nonsmoker

ROS: dizziness

Physical exam:

- BP 92/52 Pulse 80

- Breasts: Tanner II

- Minimal fat redistribution

Labs: Testosterone 520 ng/dl (goal <50 ng/dl) Estradiol 53 pg/ml (goal 120-250 pg/ml)

CASE 2


22

Suboptimal hormone levels/Testosterone level difficult to suppress

? Adherence

? Timing of labs relative to dose

CASE 2


23

Options:

1. Increase estradiol dose

2. Add micronized progesterone

3. Injectable estradiol

4. Orchiectomy

5. Add finasteride

CASE 2


24

CASE THREE

38 yo trans woman, African-American, transitioned 10 years ago, establishes care

with goal help with “detransition.”


25

“It’s been 10 years and I keep waiting for it to get easier and it never does.”

Plan:

- Stay on estradiol valerate 40 mg/ml 0.2ml IM weekly

- Androgynous gender presentation

- Using they/them pronouns “for now”

- Still has female gender identity

CASE 3


26

GENDER AFFIRMING SURGERY

02.


27

COMMON SURGICAL PROCEDURES

“Top” – breast augmentation

“Bottom” – vaginoplasty

Orchiectomy (no vaginoplasty)

Feminizing facial surgeries: nose, brow, lip, cheek, etc.

Tracheal shave


28

Before surgery

- Discuss goals and options

- Guidance on insurance issues and limitations

- Guidance on what healing looks like

- Referrals to transgender competent surgeons

- Letters and paperwork for insurance

- Maximize health prior to surgery

ROLE OF PRIMARY CARE PROVIDER


29

After surgery

- Follow up upon return to local area

- Depression and suicide risk assessment

- Manage minor complications

- Point of contact with out of state surgeon

ROLE OF PRIMARY CARE PROVIDER


30

QUESTIONS??03.

Gender Affirming Care for Transfeminine Patients/media/Images/Swedish/CME1/SyllabusPDF… · LGBTQ...

Documents

Transcript of Gender Affirming Care for Transfeminine Patients/media/Images/Swedish/CME1/SyllabusPDF… · LGBTQ...