The Very Basics of Transgender Health Care · • We follow—or try to follow—Harry Benjamin...
Transcript of The Very Basics of Transgender Health Care · • We follow—or try to follow—Harry Benjamin...
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Transgender Medicine: The Basics and More Complex Problems
© Linda Gromko, MD
WAPA Spring Conference, April 2017
www.QueenAnneMedicalAssociates.com
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“We do sensitive medicine well.”
• Practice started in
1989—one Pap at a time
• Initially women’s health care
and strong OB focus
• Transgender care
• Electrolysis and Laser
• Broad Range of Family
Medicine
Queen Anne Medical
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Another Passion:
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My New Book
• For Trans & Gender
Non-Conforming Youth
(and parents, etc.)
• Blunt, honest
• Jacqui Beck’s Amazing
Art/Medical Illustrations
• “The Puberty Book
You Never Had”
Rated ‘R’ for ‘Realistic!’
And I can get you a deal…
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In 1998, a caller asked:
“Does your clinic treat
transgender women?”
My answer:
“Not yet…”
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No Trans Training in med school or nursing
school back then…
• I attended Ingersoll’s
Open Groups every week
for many months
• Read WPATH SOC
• Talked to the few medical
people around with trans
experience
• Listened to hundreds of
trans stories over past
19 years
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Now, Everybody Wants/Needs Information!
June 14, 2013
Gender Justice League Health
Insurance Forum January 2015
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Objectives for Today:
• What is the “Gender Continuum?”
• Basic Definitions
• Whom do we treat?
• Basic MTF (feminizing) care: consent, medications,
presentation, surgical options
• Basic FTM (masculinizing) care: consent, meds, presentation,
surgical options
• Briefly, what about kids and teens?
• General pointers throughout for creating a
trans-friendly practice
• And then, a quiz!
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A Different Understanding
• Gender Dysphoria* is characterized by a long-held and/or clear understanding of self as being of the other gender— and feeling distress related to that.
• Often aware of GD well before age 5.
• Puberty is often a crisis time.
• Gender orientation and sexual orientation are independent. (“who we are vs. who we love”)
*Gender Identity Disorder (GID) is outdated term.
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Stop being so “Binary!”
• Think of gender as a
continuum—like we think
of sexual orientation as
being a continuum
• You may want to use terms
like “masculinizing” or
“feminizing.”
• Some define selves as
agender and/or asexual.
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Terminology changes continually!
We do our best to keep up…
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Basic Vocabulary
• MTF = male to female
• FTM = female to male
• GG = genetic girl (“community term”)
• “Cis” male or female – as opposed to trans
• Genotype = what your chromosomes say, i.e., XX, XY, etc.
• Phenotype = what your appearance says
(in this context, genital appearance)
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And now, we have…
“Assigned Male at Birth” = AMAB
– Natal Male/Genetic Male
“Assigned Female at Birth” = AFAB
– Natal Female/Genetic Female (assumptions!)
Remember, correct terms today will likely be offensive tomorrow!
“How would you like to be addressed?
What pronouns do you use?”
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More Acronyms
• SRS = Sexual Reassignment Surgery
• GRS = Genital Reassignment Surgery
• FFS = Facial Feminization Surgery
• “Top” Surgery = FTM Breast Reduction
• All referred to as “gender affirming” or “gender
confirming” surgeries
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Whom do we treat?
• We follow—or try to follow—Harry Benjamin Standards,
now called WPATH Standards of Care
• All patients who receive hormones from us
“require” a letter from a therapist trained in Gender Issues
(traditional 3 month therapy or ICATH)—but we are getting
more flexible
• There is a provision for “harm reduction,” which we use
occasionally when people are self-prescribing via Internet, etc.
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To Get Started…
First Visit:
• “Tell me your story” or “What are your gender goals?”
• Medical History
• Consent Form
• Initial Blood Work (CBC, Comprehensive Metabolic Panel,
TSH, Vitamin D, Estradiol, Free &/or Total Testosterone,
+/- Lipid Panel)
Second Visit:
• Physical Examination
• Prescription of appropriate medications
(We provide total primary care for most clients.)
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What about Reproductive Options?
• Cryopreservation:
- Banking sperm
- Harvesting eggs
• This is done before hormones
or testosterone blockers
• May be huge relief for parents
of trans person!
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Starting MTF Treatment
• H&P, labs, consent spread over two visits
• I start with testosterone “blocker,” usually spironolactone
(Aldactone) titrated up weekly from 25 mg bid to 100 mg bid
over 4 weeks (Caution: spiro plus ACE or ARB can cause
hyperkalemia and renal failure!)
• Pts may notice decreased libido, decreased erectile function,
breast & skin changes—and diuretic effect
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Starting Estrogen
• Estrogen comes in several forms:
1. Oral (pill is swallowed)
2. Sublingual (pill is dissolved under tongue)
3. Patches
4. Injectable estrogen
5. Pellets
• Typical oral dose: estradiol 2mg qd – 6 mg qd;
often starting with 1 mg qd
• TG dose will be at least four times the dose used
for HRT in post-menopausal genetic female
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Injectable Estrogen
• Typical injection: delestrogen 20-40 mg IM/month
• Divided as q wk, q 10 days, qo wk; q month
• I measure blood levels at nadir after fifth dose
• Injection is thick; generally injected into thigh
• Most people ultimately learn to do their own injections.
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What do people notice on estrogen?
• Sense of calm!
• Change in body odor
• Softer skin
• Decrease in overall body hair
• Breast development: starts with sensitivity, a breast “bud”
under the areola (highly individual; may see a surge after SRS)
• Decreased libido
• Fewer morning and/or spontaneous erections
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More changes:
• Decrease in physical strength
• Decreased testicular size
• Decreased prostate size
• Estrogen has no effect on vocal pitch; that comes from
coaching and practice
• Estrogen generally has no effect on hair thinning or balding
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What about Progesterone?
• The word “on the street” is that it helps with breast development
• At WPATH 2/14, experts said that progesterone has no role in
TG breast development
• However, we have anecdotal experience to suggest it may
• Consider Micronized Progesterone (Prometrium) at
100-200 mg/day.
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Thromboembolic Events (MTF)
• Estrogen increases risk
of blood clots (DVTs)…
• …especially in smokers
• and especially if person
has a “thrombophilia”
• Be mindful of periods of
immobility, e.g., long flights,
surgery.
• KNOW WARNINGS!
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What can happen with a DVT?
• A clot forms—usually in the
deep veins of legs or pelvis
• Clot travels north
• Veins get larger until…
They reach the lungs!
• There, vessels are tiny—and
get blocked by clot
• Outcome depends on size,
but can be fatal.
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Warnings for DVT/PE
DVT (Deep Vein Thrombosis)
• Swelling in leg
• Tender lump in leg
• Tender “cord” in leg
• Tightness in one leg
• Pain with walking because
of above
• Think history!
PE (Pulmonary Embolism)
• Pain at the “peak” of each
breath
• Chest pain, arrhythmia
• Upper abdominal pain*
• Shortness of breath
• Hemoptysis, cough
• Dizziness/agitation/loss
of consciousness
*Think gall bladder also!
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Learning to “present” female
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Give appearance advice only if asked!
• BLENDABLE = DEPENDABLE!
• Many people start with “Androgynous look”
• Seattle women tend to be more casual (REI, Eddie Bauer)
• Go to a personal shopper for higher end wardrobe assistance
• How do you create the appearance of breasts?
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The Old-Fashioned Way
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What about Facial Hair?
• Enormous roadblock for
trans women!
• Laser works well…if you have
darker hair (not on white,
blond, red, gray)
• Electrolysis takes years,
works for any hair color
• Can be painful, so we use
medications!
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MTF Surgeries
• FFS = Facial Feminization Surgery
• Breast Augmentation
• SRS = Sexual Reassignment Surgery or “Bottom Surgery”
• Bilateral Orchiectomy
• (Hormone dose may be reduced after SRS/orchiectomy)
• If presentation is main objective, FFS and
Breast Augmentation may be satisfactory
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Facial Feminization Surgery
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Male vs. Female Skull (FFS-Ousterhout)
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Male vs. Female Skull (FFS-Ousterhout)
Notice the differences in basic contour and the fullness on the sides of the male chin.
Notice the difference in vertical height of the chin between the male and female.
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Transformation
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Transformation: 2/17/2012
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Transformation: 3/29/2012
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MTF “Bottom” Surgery
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Sexual Reassignment Surgery
• Testicles removed
• Urethra is dissected out
and redirected
• Glans penis becomes
a functioning clitoris
• Neovagina is formed
from inverted phallus
& scrotal tissue.
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GRS Techniques in MTF (Dr. Bowers)
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“Normal” Early Post-op GRS Result
11 days Post-op 6 weeks Post-op
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You Must Dilate the Neovagina Regularly
or It Will Quickly Close!
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And Now, for Masculinization
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Beginning FTM Treatment
• H&P, Labs, Consent over two weeks
• Start with Depotestosterone IM/SQ
• General dose is 200-400 mg q mo, titrated up.
• Often start with 100 mg IM qo wk, and work up
• Also available as patches or gel (lotions/pellets, too)
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Giving Testosterone
• Typical injection: depotestosterone 200-400 mg IM
or SQ/month
• May be divided as weekly, q 2weeks, q month
(SQ usually weekly)
• Blood levels drawn at nadir after 5th dose
• Thick preparation
• We teach many people self-inject
• Some people learn on You Tube
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What people notice on “T”
• Drop in vocal pitch
• Change in body odor
• Amenorrhea within first 3-6 months
• Acne—face and back
• Muscle development: encourage people to work out,
but remember that tendons/ligaments have to catch up
• Increased appetite/weight gain
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More Testosterone Effects
• Increase in body hair
• Facial hair—often much later
• Scalp hair loss and balding
• Clitoromegaly
• Increased libido
• Mood changes: watch for “testosterone rage,”
but most clients feel more content
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Learning to “present male”
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Common Helps for FTM folks
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Sign of the Times
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Refuge Restrooms App
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Bathroom Difficulties
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What about Contraception?
If you are a trans man, be
alert that sex with partners
who make sperm could result
in an unplanned pregnancy.
Consider non-estrogen
contraception:
Nexplanon, IUDs,
and always latex barriers.
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Protection from HIV
Have you heard about PrEP?
(Pre-Exposure Prophylaxis)
Taken daily—and correctly,
PrEP greatly reduces the risk
of contracting HIV.
(www.cdc.gov)
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Transformation
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Transformation
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Are hysterectomy and oophorectomy
necessary?
• Robert Eads (FTM)
assimilated to life in
the deep South
• Was refused care
for a GYN cancer by
multiple MDs out of
concern that other
patients would be
embarrassed by his
presence in their
waiting rooms!
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FTM Genital Surgery
• What is important to the client? (If standing to urinate is
important, more extensive procedures are appropriate)
• Testosterone-produced clitoromegaly can be significant
• A “clitoral release” elongates appearance of phallus and
may be well accepted by client. This is called metoidioplasty,
but there are further refinements…
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Metoidioplasty (Plus)
• Creates 4-6 cm phallus
• Urethral elongation from
labia minora or buccal tissue
• Scrotoplasty with testicular
implants
• Standing to urinate may
be possible unless patient
is obese. (Crane Photo)
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More Photos of Metoidioplasty from
Dr. Curtis Crane’s Website
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What is Phalloplasty?
• More extensive surgery creates larger phallus (15 cm)
where standing to void and penetration are priorities
• Multiple stage procedure
• May start with hysterectomy, bilateral oophorectomy,
and vaginectomy
• Urethral lengthening is done using labia minora or
buccal mucosa
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And then…
• Phallus is constructed from full-thickness graft from lateral thigh,
forearm or back – microsurgical technique
• Glansplasty creates more authentic appearance
• Erection possible by implanted inflatable pump
(in scrotum (Meltzer) or by malleable implant placed
approximately 9 months later (Crane))
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Standing to Urinate 3 weeks After Surgery
(Dr. Crane’s Website)
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Free Flap is Dissected as Full-thickness
Skin Graft: Good Blood Supply (Crane)
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Phalloplasty & Glansplasty (Crane Website)
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Phalloplasty—One Month Post-Op
• Notice the “burn” scar on thigh
• Malleable Implants would
be placed nine months
later—consider the risk of
placing an implant in phallus
without full sensation! (Crane)
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General Post-Op Tips
• See patients soon if you are the PCP
• Expect them to tell you things they may not tell their surgeon
• Focus on rest, nutrition (protein and fluids!)
• Depression isn’t uncommon; ask about it
• ALL surgeries carry risk of infection, bleeding, damage to tissue
• Some surgeries are characteristically exhausting, e.g., FFS.
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So, what about kids and teens?
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We know that….
• Children may have very early understanding of
gender asynchrony
• Delaying puberty may give kids and families more time
to be sure—sometimes, for parents to “catch up”
• Puberty blockers can be given by IM injection (DepoLupron),
or by implants under the skin of the upper arm (Histrelin)
• Genetic puberty resumes on course if blocker stopped
or removed.
• Start blockers at Tanner 2 or 3.
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Puberty Blockers (Tanner 2-3)
• For genetic females,
Tanner 2 = breast
bud formation
• For genetic males,
testicles are equal
to or greater than
one inch in long axis.
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Puberty Blockers have been used for years
in Precocious Puberty
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Puberty is rugged for anyone…
…but it’s especially hard
when you’re going through
the wrong puberty!
Cross hormones may be
started in gradual doses to
mimic a “normal” puberty.
I have started kids as early
as 14-15 with good results.
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Hard to pass as female at 6’5”!
• Earlier transition may
eliminate the need for
extensive surgeries
• Get off to a more authentic
start in life
• When gender “fits,” everything
seems to work better.
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The most compelling consideration:
• Transgender teens attempt
suicide in disproportionately
high numbers: close to half!
• Is delay of puberty a suicide
prevention strategy?
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So, how about some training?
• Professional schools—not
just as an elective!
• Join WPATH
• Ingersoll has a Professional
Group
• Attend Ingersoll’s Open Group
on Wednesdays
• Gender Odyssey
• Films
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What to remember? Respect!
• While routine for us, remember that
this patient visit carries enormous
importance
• Remember that your patient may
have never told anyone before
• Ask your patient: “What would
you like to be called?”
• Let your forms help you:
Gender M___ F___ Other:______
• Your EMR may allow a window
where you can say: “goes by____”
What should
you do if you
“misgender”
someone?
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What I want you to know…
• Gender Transition can present
enormous complexities for our
patients and their families.
• Most health care providers
have not received training in
Trans Medicine.
• The words we
choose—and all our
forms of communication
are potent tools that can
help or harm people.
• We can and do make a
difference in our patient’s
lives, often by showing
simple respect.
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Closing thoughts:
• Our TG population is generally very happy and relieved to
receive thorough, respectful care.
• Our underlying theme is safety: “I don’t want to see you through
an elegant transition only to lose you to a technicality.”
• “Your transgender patients are survivors. They are the ones who have
lived in spite of steep odds. They are resilient!”
• “Hasten slowly.”
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Trans Medicine Questions
© Linda Gromko, MD
WAPA Spring Conference April, 2017
www.QueenAnneMedicalAssociates.com
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1. Your 19-year-old TG patient says they are
depressed. How concerned should you be?
• Very, because the suicide attempt rate is close to half.
• Assess them as you would any depressed patient,
• But be especially alert to support systems, self-harm
behaviors, prior suicide attempts, psychiatric admissions, etc.
• Ask about suicidal thinking, plans, availability (and lethality)
of methods considered.
• Know local hot-line resources.
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2. True or False: Estrogen will substantially
reduce facial hair in most MTF patients.
• FALSE
• Estrogen will not significantly reduce facial hair in most
patients.
• Laser and electrolysis are most commonly used.
• Estrogen will not prevent male-pattern hair loss either.
• Finasteride, FFS, and hair transplants are often used.
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3. A 45-year-old trans woman presents to
the ER with RUQ pain, stating “I’m having
a gall bladder attack.” What do you do?
• Be careful here.
• Pulmonary emboli can mimic gall bladder sxs and vice versa.
• Ask about other PE related sxs, i.e., dyspnea, pleuritic pain,
leg sxs, hemoptysis, dizziness, etc.
• Check pulse oximetry.
• Consider d-Dimer, and if positive, get a pulmonary
CT angiogram.
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4. Your 28-year-old trans female patient has
been on sublingual estradiol for one year.
Estradiol level is low at 58, and total
testosterone is 10. What to do?
• Considering that cis-female estradiol levels range from 11-500
over a given cycle, we might consider a more stable higher
level, i.e., 200-300.
• Remember that if a patient has both inadequate estradiol
AND testosterone, osteoporosis is a risk.
• Mood, energy level, and libido can also be impacted by
low levels.
• Check adherence, and consider another route of
administration.
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5. Your 30-year-old trans female patient is
taking spironolactone, and asks, if it’s
okay to eat a banana every day.
What do you think? • People worry that spironolactone will elevate potassium levels.
• In a patient with healthy kidney function, no dietary adjustment
is needed – but no potassium supplements either!
• Be careful with ACE inhibitors or ARBs; these plus
spironolactone can precipitate a drop in renal function.
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6. Your trans male patient has a hematocrit
of 50%, where it was 43% before starting
testosterone. What is the likely explanation?
• Testosterone stimulates the kidneys to produce more
erythropoietin, which acts on the bone marrow to increase
RBC production.
• RBCs, Hb, Hct can all rise in response.
• Sometimes, the hematocrit can rise to the level of
polycythemia, and phlebotomy is recommended.
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7. Your 20-year-old trans male client has
been on IM testosterone for 7 months.
He stopped having periods 3 months ago,
but has started again. Now what?
• On therapeutic testosterone doses, periods usually end
within 3-6 months.
• If periods restart, check adherence and check trough
testosterone dose.
• Your patient may be forgetting T – or may need a higher dose
to prevent bleeding.
• Warning: could your patient be pregnant? Is there any
other cause for bleeding, e.g., STD, malignancy?
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8. A 50-year-old trans woman presents to
you with a concern about a breast lump.
What are your concerns??
• As in any patient, a breast lump in a trans woman should
be evaluated with diagnostic mammogram (mammogram +
ultrasound) to rule out malignancy.
• Breast cancers are not likely to occur in trans women,
but they can.
• Be especially alert for patients with a family history of breast,
ovarian, colon cancers.
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9. A 78-year-old patient presents saying
he has known he was female all his life.
His wife died a couple of years ago; he
asks your help in transitioning. Where
do you start?
• While such scenarios are not common, they do occur.
• Ask the patient what their “gender goals” are.
• Assess overall medical history to rule out contraindications
to medications and/or surgeries.
• In my opinion, do your best to assist the patient meet goals
within reasonable bounds of safety.
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Thank you for your attention!
Linda Gromko MD
Queen Anne Medical Associates PLLC
200 W. Mercer #104
Seattle, WA 98119
www.QueenAnneMedicalAssociates.com
www.LindaGromkoMD.com