Healthcare Basics of Transgender Medicine Presented by Nick Gorton MD The presentation will begin shortly This webinar will be recorded and used for future presentations Funds for this webinar were provided by the US Department of Health and Human Services HHS Health Resources a ID: 919536
Download Presentation The PPT/PDF document "Welcome to TRANSitioning" is the property of its rightful owner. Permission is granted to download and print the materials on this web site for personal, non-commercial use only, and to display it on your personal computer provided you do not modify the materials and that you retain all copyright notices contained in the materials. By downloading content from our website, you accept the terms of this agreement.
Slide1
Welcome to TRANSitioning Healthcare: Basics of Transgender MedicinePresented by Nick Gorton, MD
The presentation will begin shortly.This webinar will be recorded and used for future presentations.Funds for this webinar were provided by the U.S. Department of Health and Human Services (HHS), Health Resources and Services Administration (HRSA) with the American Recovery and Reinvestment Act (ARRA) funding for the Retention and Evaluation Activities (REA) Initiative.This webinar is offered by San Francisco Community Clinic Consortium and the California Statewide AHEC program in partnership with the Office of Statewide Health Planning and Development (OSHPD), designated as the California Primary Care Office (PCO).
Slide2Primary Care and Hormonal Treatments for Transgender Patients
Nick Gorton, MD, DABEMnick@lyon-martin.org
Slide3Slide4Primary Care and Hormone TherapyYou already know 90% of what you need to know
Most medical care of transgender patients has nothing to do with being transgender100% of the medical treatments and most of the surgeries are used in cisgender patientsResources….
Slide5Slide6Transline.zendesk.com
Slide7Transhealth.ucsf.edu
Slide8Transhealth.vch.ca
Slide9How does this work?Typical Narrative...Accept your own trans identity and seek help
Internet, local groups, organizationsFind a therapist and receive a dx (and letter)3 month 'Real Life Experience' ORPsychotherapy (duration TBD, usually 3+months)
Find a medical provider
Start hormone therapy
Non-genital surgery (same time as HRT
)
1 year successful – genital surgery
Slide10Typical Narrative (following SOC)Does everyone do it this way?
If they don't should you still treat them?
Slide11Harm ReductionWPATH-SOC explicitly endorse harm reduction
Slide12Medical Treatments: FundamentalsSet realistic goals
What will, might, and won't happenEmphasize primary and preventative careUse the simplest hormonal program that will achieve goalsEvery option doesn't work for every patient
Cost, ease of use, safety
Slide13Medical Treatments: FundamentalsPatience is a virtue
Puberty comparisonSide effects are in the eye of the beholder Baldness
Slide14Medical Treatments: FundamentalsHormone treatments are one of the easiest parts
FTM – Testosterone up to normal male dose Dose that masculinizes and stops menses is enoughMTF – More difficult because must suppress testosterone production to get best resultsAnti-androgen(s)
Estrogens
Slide15Medical Treatments: MTFEstrogens at high dose
3-5x normal replacement doses Estrogen Supresses Testosterone!Anti-AndrogenSpironolactone and others
Orchiectomy
Results variable
Age
at starting is
important
Genetics
plays a big part
Slide16Hormones: MTF - EstrogensOral - $
$$$ Premarin 1.25 – 10mg/d (usual 5-6.25)$ Estradiol 1-5mg/d (usual 2-4)Estradiol marginally safer
IM – Delestrogen $$10-40mg q2weeks (usual 20)Can't
easily 'stop' in an emergency when patient immobilizedTransdermal – Estradiol patch
$$$
0.1-0.3mg/day
(1-3 patches/week –
overlapped)
Probably
the safest for
transwomen
predisposed to
thrombo
- embolic
dz
(age>40, smoking, FH, etc
.)
Patient's
often wary
at start
but some prefer
after trying
Slide17Hormones: MTF - EstrogensBeneficial effects
Breast growthSuppress androgen productionChange of body habitus (muscle and fat)
Softening of skin
Contraindications/PrecautionsSame
as in cisgender
women
Individual
risk/benefits (MTF get greater benefits r/t mental health than menopausal cisgender women
.)
In women w/
absolute CI – at least suppress
T
fully
Slide18Hormones: Estrogens Adverse EffectsTHROMBOEMBOLIC DISEASE
Hepatotoxicity (especially ORAL) – incr TA, adenomasProlactinoma (if dose is too high)Decreased glucose tolerance
Lipid profile
Gallbladder DiseaseWorsening migraine/seizure control
Breast Cancer
Mood
Decreased libido
Slide19Hormones: MTF - Anti-AndrogensAntiandrogens - All
Decrease T production or activitySlow/stop MPB, and decrease unwanted hair growthDecrease erections/libidoImprove BPH
Spironolactone 50-300 mg/d divided bid
Cheap, reasonably safe
Hyper-K+, diuresis, changes in BP, 'just don't like it'
Decreased H/H (T
erythropoetin
)
Flutamide
– Inhibits androgen receptor binding
Cyproterone
Slide20Hormones: MTF - Anti-Androgens5-α-reductase inhibitors
Finasteride, dutasteride, saw palmettoFinasteride (Proscar/Propecia)Stops conversion of T DHT5mg tabs = $20 for 30 at Costco1mg tabs = $74 for 30 at Costco
Slide21Hormones: MTF - MonitoringEvery Visit
BP, Weight, BMISafetyMental healthGeneral screening based on age, organ, gender, and sex appropriate normsPatient education
S/Sx of TEDz
Healthy Habits
Vision changes or lactation
Slide22Hormones: MTF - MonitoringClinical monitoring most important
Same adverse events in cisgender pts w/ same meds (use what you know!)Labs0, 2, & 6 mo initially then (semi)annual or p changes
CBC, CMP, Lipids
PL and T
Cr
K
+
Glucose
AST
/
ALT
PL
Slide23Hormones: MTF - EfficacyWhat is adequate treatment?
Pt outcomes – breast growth (peak 2-3 yrs), changes in skin, hair, fat/muscle, libidoThe floor – testosterone levels (female range)The roof – prolactin
level>20
possibly too much (ask @ 'extra' E use or other meds)
>
25 probably too
much
>30
definitely too
much
>50
worry a great deal about PL-
oma
Slide24Hormones: MTF – Adverse effectsElevated PL: Stop Estrogens (not anti-androgen)
If levels normalize, resume E at lower doseConsider changing meds that cause increase in PLIf levels remain high MRI to r/o PL-oma
Elevated LFTs
Look for other cause!
If
due to E, lower dose or
stop until
LFT normal
Slide25Medical Treatments: FTM
Slide26Hormones: FTMTestosterone Injected Esters (cheapest)
Cypionate200mg/ml: 1-10ml vialsCheapest - $60-100 for 10ml (~4mos supply)
Enanthate
Biggest vial is 5ml
Slightly
more expensive
Slide27Hormones: FTM
Steady State post 3-5 T½
T½ 8-10 days
~2 months
Side effects happen at peak and trough
Slide28Hormones: FTMTransdermal
Expensive: $7 day retail, $1/day compoundedLess variable levelsDaily administration
Risk of inadvertent transfer to others
5%, 1g QD
1%, 5g QD
Slide29Hormones: FTM - MonitoringEvery Visit
BP, Weight, BMISafetyMental healthGeneral screening based on age, organ, gender, and sex appropriate normsPatient education
Vaginal bleeding
Healthy habits
Tx available for acne, MPB
Slide30Medical Treatments: Fundamentals
ALTClinical monitoring most importantSame adverse events in cisgender pts w/ same meds (use what you know!)Labs
0, 2, & 6 mo initially then (semi)annual or p changes
CBC, CMP, Lipids
T
(trough) in FTM
Cr
Glucose
T
Hgb
Hct
Slide31Treatment Effects (any delivery...)First 6 months
Increased sebum and resultant acneIncreased sex driveVoice change starts – parallels adolescenceHair growth (and loss) begins: parallels adolescence*
Clitoromegaly starts
Most amenorrhea (but E only decreases modestly)*
Metabolic including fat
and muscle distribution changes
*
Gooren
, et al. 2008. “Review of studies of androgen treatment of FTM transsexuals: Effects and risks of administration of androgens to females”.
Slide32Treatment Effects1-5 Years
Voice settles Final fat and muscle redistributionClitoromegaly maxesLength average 4-5cm (3-7 cm range)1
Volume increases 4-8x2
Greater change in younger patients2
1 Meyer W, et al. 1986 “Physical and hormonal evaluation of transsexual patients: a longitudinal study.”
2 Gooren, et al. 2008. “Review of studies of androgen treatment of FTM transsexuals: Effects and risks of administration of androgens to females”.
Slide33Treatment Effects5-10 years
Final hair growthAndrogenic alopecia can happen at any age – and does in 50% of FTMs by 13 years** Gooren, et al. 2008. “Review of studies of androgen treatment of FTM transsexuals: Effects and risks of administration of androgens to females”.
Slide34Hormones: FTM – Adverse effectsAcne – MC side effect (chest/back)
CV - worsening of surrogate endpoints - lipids, glucose metabolism, BPPolycythemia (normals for males)Unmask or worsen OSAEnhanced Libido
Androgenic alopecia
'Other' hair growth
Slide35Hormonal Treatments: Is this safe?Van Kesteren P, et al. “Mortality and morbidity in TS subjects treated with cross-sex hormones.” Clin Endo (Oxf). 47(3):337-42.1997.
DESIGN: Retrospective, descriptive study @ univ. teaching hospital that is the national referral center for the Netherlands (serving 16 million people)SUBJECTS: 816 MTF & 293 FTM on HRT for total of 10,152 pt-yearsOUTCOMES: Mortality
& morbidity incidence ratios c/w general Dutch population (age & gender-adjusted)
Slide36Hormonal Treatments: Is this safe?Van Kesteren P, et al. “Mortality and morbidity in TS subjects treated with cross-sex hormones.” Clin Endo (Oxf). 47(3):337-42.1997.
293 FTMs816 MTFs
10,152pt years
????
????
c/w
♂
c/w
♀
Slide37Hormonal Treatments: Is this safe?Van Kesteren P, et al. “Mortality and morbidity in TS subjects treated with cross-sex hormones.” Clin Endo (Oxf). 47(3):337-42.1997.
MTF/FTM total mortality no higher than general popl'nLargely, observed mortality not r/t hormone treatmentVTE was the major complication in MTFs. Fewer cases after the introduction of transdermal E in MTFs over 40
In MTFs increased morbidity from VTE and HIV and increased proportion of mortality due to HIV
HIV
VTE
Slide38Hormonal Treatments: Is this safe?Van Kesteren P, et al. “Mortality and morbidity in TS subjects treated with cross-sex hormones.” Clin Endo (Oxf). 47(3):337-42.1997.
293 FTMs816 MTFs
10,152pt years
c/w
♂
c/w
♀
No Increase Morbidity
or Mortality
No Increase Mortality
Increase morbidity r/t HIV/VTE
Slide39Hormonal Treatments: Is this safe?Asscheman H, et al. “A long-term follow-up study of mortality in transsexuals receiving treatment with cross-sex hormones.” Eur J Endo. 164:635-642. 2011.
DESIGN: CohortSUBJECTS: 966 MTF & 365 FTM on HRT for median 18.5 yearsOUTCOMES: MTF mortality increased – almost all due to suicide and HIV. FTM mortality unchanged.
Slide40Hormonal Treatments: Is this safe?Gooren L, et al. “Long term treatment of TSs with hormones: Extensive personal experience.” J Clin Endo & Metab. 93(1):19-25. 2008.
Same clinic group as 1997 Dutch Van Kesteren paper but now 2236 MTF, 876 FTM (1975-2006)Outcome M&M Data, data assessing risks of osteoporosis and cardiovascular disease, cases of hormone sensitive tumors and potential risks
Slide41Hormonal Treatments: Is this safe?Gooren L, et al. Cardiovascular Risks
Analyzed studies of surrogate markers for CVDz in MTF/FTM: Body composition, lipids, insulin sensitivity, vasc function, hemostasis/fibrinolysis, others (HC CRP)Some worsen, some improve, some are unchanged – much of the worsening seems likely d/t weightMTF do worse than FTM
Hard clinical endpoints show no difference
Counsel patients @ modifying CV risk
Slide42Hormonal Treatments: Is this safe?Elamin MB, et al. “Effect of sex steroid use on cardiovascular risk in transsexual individuals: a systematic review and meta-analyses.” Clin Endo (Oxf). 71(1):1-10. 2010.
Both MTF and FTM had increased TGsMinor effect on FTM BPNo hard clinical endpoints
Most CV events were in MTFs
Study quality poor
Slide43Hormonal Treatments: Is this safe?Gooren L, et al. Hormone Dependent Tumors
Lactotroph AdenomaRareCheck PL!Prostate Cancer
Prostatectomy is not a part of SRS
Screen based on the organs present
Withdrawal
of testosterone
may decrease
but doesn't eliminate the risk
of
BPH and
malignancy
May
falsely lower PSA
Slide44Hormonal Treatments: Is this safe?Gooren L, et al. - Breast cancer
MTF - Estrogen exposure: dose and durationConservative: screen as cisgender women of same age/riskProgesterone increases risk (esp if cyclic)
Other risk factors: obese, FH, HRT>5 years, Chest radiation
FTM
Reported
in 1 case 10 years after
mastectomy
Mastectomy
reduces but doesn't eliminate
risk
Some
injected T is aromatized to
estrogen
Family
history
Slide45Hormonal Treatments: Is this safe?Gooren L, et al. Gynecologic Tumors
CervicalOvarianEndometrial
Slide46Gynecologic Cancer risks in FTMs6 + ???
???
Slide47Gynecologic Cancer risks in FTMs
Normal
Hyperplasia
Dysplasia
Cancer
F
T
M
P
C
O
S
???
If
infrequent
periods
ENDOMETRIAL CANCER
Slide48Gynecologic Cancer risks in FTMs
Grynberg et al Histology of genital tract and breast tissue after long-term testosterone administration in a female-to-male transsexual population. Reproductive BioMedicine (2010) 20, 553-558104 Hysterectomies: Atrophy in 50, 54 Proliferative, 4 polyps, 8 hyperplasia, 1 with dysplasia with a small foci of carcinoma in situ.
Slide49Gynecologic Cancer risks in FTMs
Slide50Gynecologic Cancer risks in FTMs
IARC Working Group on Evaluation of Cervical Cancer Screening Programmes. Screening for squamous cervical cancer: duration of low risk after negative results of cervical cytology and its implication for screening policies. Br Med J. 1986;293:659-664.
Slide51Gynecologic Cancer risks in FTMs
Slide52Gynecologic Cancer risks in FTMs
Slide53Is it effective?
Slide54Is it effective?Of 28 studies 23 included Psych/HRT/Surgery
Five were Psych/HRT onlyPre-tx suicidality 30%, 8% post treatmentSignificant improvements in SCL-90 and MMPI and in measures of gender dysphoriaOne study of Psych/HRT/Surgery showed long term SCL-90 scores were in non-clinical rangeFive studies assessed employment and financial status and all improved
Slide55What about regret ???Pfäfflin, F., & Junge, A. (1998). Sex reassignment – Thirty years of international follow-up studies; SRS: A comprehensive review, 1961-1991 Düsseldorf , Germany: Symposion Publishing.
74 f/u studies and 8 reviews published b/w 1961-1991Less than 1% long term regret in over 400 FTMs1.5% regret in over 1000 MTFsCompare with regret rates for gastric bypass, breast recon after mastectomy, surgical sterilization
Studies after 1991 show lower rates of regret (and found risk of regret correlates well with surgical success.)
Slide56Making Things Official
Slide57Identity Document ChangesPart of the medical treatment for GID
Lack of appropriate IDVulnerability to interpersonal violenceInability toGet a job
Make a purchase with a credit card
Board a planeEnter a federal building
Voluntary withdrawal from activities
Slide58What can you get in CA w/o SRS?Drivers License/State ID - DL328
PassportCourt Ordered Name and Gender ChangeCA Birth Certificate (possibly other states as well)Social Security NAMESocial Security GENDER MARKER
Slide59Supportive LettersThere are no gender cops
Its not your job to enforce bad policyYour jobAdvocate for your patients needsDon't lieGive your true medical opinion
Don't write something if you don't have experience
Slide60Supportive Letters: a thought experimentYou are a doctor in NC in 1950. An 18 year old young man who is your patient asks you for help. He is white, but his great grandfather was African American. He was accepted to attend UNC-CH, but an anonymous letter to the school revealed his heritage. He was told he must provide a letter from a teacher, doctor, or minister verifying he is white to be allowed to enter UNC.
You're pretty advanced for the 50's and understand race as a social construct and believe he really is 'white'.... but know that UNCs policies and understanding of race would exclude him.Do you write the letter?
Slide61Supportive LettersThere are no gender cops
Its not your job to enforce bad policyYour jobAdvocate for your patients needsDon't lieGive your true medical opinion
Don't write something if you don't have experience
Slide62I am a physician licensed to practice medicine and surgery in the state of California.John Smith is a patient in my care at LMHS
In my medical opinion Mr Smith is a transsexual man.I have determined that his male gender predominates and have provided him with appropriate and irreversible sex reassignment treatments.(In addition, he has undergone irreversible sex reassignment surgery that I have verified by my own examination.) As a result Mr Smith has completed all necessary medical (and surgical) procedures to fully transition from female to male.
He should be considered male for all legal and documentation purposes – including drivers license, birth certificate, passport, and social security records
.
Slide63ResourcesTwo page clinical protocol
Informed consent formsThis talkproject-health.org/translineanand@transgenderlawcenter.org