Transgender Medicine: The Basics and More Complex Problems

© Linda Gromko, MD

WAPA Spring Conference, April 2017

www.QueenAnneMedicalAssociates.com

“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

Another Passion:

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…

In 1998, a caller asked:

“Does your clinic treat

transgender women?”

My answer:

“Not yet…”

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

Now, Everybody Wants/Needs Information!

June 14, 2013

Gender Justice League Health

Insurance Forum January 2015

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!

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*Gender Identity Disorder (GID) is outdated term.

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.

Terminology changes continually!

We do our best to keep up…

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)

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?”

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

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.

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.)

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!

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

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

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.

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

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

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.

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!

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.

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!

Learning to “present” female

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?

The Old-Fashioned Way

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!

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

Facial Feminization Surgery

Male vs. Female Skull (FFS-Ousterhout)

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.

Transformation

Transformation: 2/17/2012

Transformation: 3/29/2012

MTF “Bottom” Surgery

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.

GRS Techniques in MTF (Dr. Bowers)

“Normal” Early Post-op GRS Result

11 days Post-op 6 weeks Post-op

You Must Dilate the Neovagina Regularly

or It Will Quickly Close!

And Now, for Masculinization

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)

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

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

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

Learning to “present male”

Common Helps for FTM folks

Sign of the Times

Refuge Restrooms App

Bathroom Difficulties

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.

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)

Transformation

Transformation

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!

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…

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)

More Photos of Metoidioplasty from

Dr. Curtis Crane’s Website

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

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))

Standing to Urinate 3 weeks After Surgery

(Dr. Crane’s Website)

Free Flap is Dissected as Full-thickness

Skin Graft: Good Blood Supply (Crane)

Phalloplasty & Glansplasty (Crane Website)

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)

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.

So, what about kids and teens?

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.

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.

Puberty Blockers have been used for years

in Precocious Puberty

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.

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.

The most compelling consideration:

• Transgender teens attempt

suicide in disproportionately

high numbers: close to half!

• Is delay of puberty a suicide

prevention strategy?

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

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?

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.

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.”

Trans Medicine Questions

© Linda Gromko, MD

WAPA Spring Conference April, 2017

www.QueenAnneMedicalAssociates.com

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.

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.

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.

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.

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.

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.

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?

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.

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.

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

ljgromko@msn.com