Gender Affirming Care for Transfeminine Patients/media/Images/Swedish/CME1/SyllabusPDF… · LGBTQ...
Transcript of Gender Affirming Care for Transfeminine Patients/media/Images/Swedish/CME1/SyllabusPDF… · LGBTQ...
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Gender Affirming Care for Transfeminine Patients
Jessica Rongitsch, MDSimon Adriane Ellis, CNMMarch 2017
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CO
NTE
NTS
01.
02.
03.
Feminizing hormone therapy
Gender affirming surgery
Q&A
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GENDER AFFIRMING HORMONE THERAPY
01.
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HORMONE INITIATION
Informed consent from the prescriber:
- Risks, benefits, side effects
- Physical and emotional changes
- Expectations
- Social impact
- Fertility
- Goals and alternatives
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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
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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
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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
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COMMON SIDE EFFECTS
Orthostatic hypotension/dizziness
Mood issues: depression, increased emotional range, mood swings, anxiety
Weight gain
Fatigue
Sexual dysfunction
Renal dysfunction/hyperkalemia
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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
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Comp/CMP
CBC
+/- lipid
+/- HIV/STI screen
+/- testosterone
+/- prolactin if on anti-psychotics
BASELINE LABS
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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
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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
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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
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CASE ONE
45 yo trans woman establishes careto start feminizing regimen.
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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
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PMH
- DMII
- HTN
- Hyperlipidemia
- Obesity
Meds
- Losartan 50 mg qd
- Atorvastatin 20 mg
- Metformin 500 mg BID
CASE 1
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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
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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
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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
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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.”
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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
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Suboptimal hormone levels/Testosterone level difficult to suppress
? Adherence
? Timing of labs relative to dose
CASE 2
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Options:
1. Increase estradiol dose
2. Add micronized progesterone
3. Injectable estradiol
4. Orchiectomy
5. Add finasteride
CASE 2
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CASE THREE
38 yo trans woman, African-American, transitioned 10 years ago, establishes care
with goal help with “detransition.”
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“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
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GENDER AFFIRMING SURGERY
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COMMON SURGICAL PROCEDURES
“Top” – breast augmentation
“Bottom” – vaginoplasty
Orchiectomy (no vaginoplasty)
Feminizing facial surgeries: nose, brow, lip, cheek, etc.
Tracheal shave
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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
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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
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QUESTIONS??03.