8Primary Care and Hormone Therapy You already know 90% of what you need to knowMost 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 patients
13How does this work? Typical Narrative... Accept your own trans identity and seek helpInternet, 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 providerStart hormone therapyNon-genital surgery (same time as HRT)1 year successful – genital surgery
14Typical Narrative (following SOC) Does everyone do it this way?If they don't should you still treat them?
16Medical Treatments: Fundamentals Set realistic goalsWhat will, might, and won't happenEmphasize primary and preventative careUse the simplest hormonal program that will achieve goalsEvery option doesn't work for every patientCost, ease of use, safety
17Medical Treatments: Fundamentals Patience is a virtuePuberty comparisonSide effects are in the eye of the beholderBaldness
18Medical Treatments: Fundamentals Hormone treatments are one of the easiest partsFTM – Testosterone up to normal male doseDose that masculinizes and stops menses is enoughMTF – More difficult because must suppress testosterone production to get best resultsAnti-androgen(s)Estrogens
19Medical Treatments: MTF Estrogens at high dose3-5x normal replacement dosesEstrogen Supresses Testosterone!Anti-AndrogenSpironolactone and othersOrchiectomyResults variableAge at starting is importantGenetics plays a big part
22Hormones: MTF - Estrogens Oral - $$$$ Premarin 1.25 – 10mg/d (usual )$ Estradiol 1-5mg/d (usual 2-4)IM – Delestrogen $$10-40mg q2weeks (usual 20)Can't easily 'stop' in an emergency when patient immobilizedTransdermal – Estradiol patch $$$mg/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 of starting but some prefer after trying it
23Hormones: MTF - Estrogens Beneficial effectsBreast growthSuppress androgen productionChange of body habitus (muscle and fat)Softening of skinContraindications/PrecautionsSame as in cisgender womenIndividual risk/benefits (MTF get greater benefits r/t mental health than menopausal cisgender women.)In transwomen with absolute CI – at least suppress testosterone fully
24Hormones: Estrogens Adverse Effects THROMBOEMBOLIC DISEASEHepatotoxicity (especially ORAL) – incr TA, adenomasMedi-Cal will cover IM/TD (with TAR) if other Liver dzProlactinoma (if dose is too high)Decreased glucose toleranceLipid profileGallbladder DiseaseWorsening migraine/seizure controlBreast CancerMoodDecreased libido
25Hormones: MTF - Anti-Androgens Antiandrogens - AllDecrease T production or activitySlow/stop MPB, and decrease unwanted hair growthDecrease erections/libidoImprove BPHSpironolactone mg/d divided bidCheap, reasonably safeHyper-K+, diuresis, changes in BP, 'just don't like it'Decreased H/H (T erythropoetin)Cyproterone
26Hormones: MTF - Anti-Androgens 5-α-reductase inhibitorsFinasteride, dutasteride, saw palmettoFinasteride (Proscar/Propecia)Stops conversion of T DHT5mg tabs = $20 for 30 at Costco1mg tabs = $74 for 30 at Costco
28Hormones: MTF - Monitoring Every VisitBP, Weight, BMISafetyMental healthGeneral screening based on age, organ, gender, and sex appropriate normsPatient educationS/Sx of TEDzHealthy HabitsVision changes or lactation
29Hormones: MTF - Monitoring Clinical monitoring most importantSame adverse events in cisgender pts w/ same meds (use what you know!)Labs0, 2, & 6 mo initially then (semi)annual or p changesCBC, CMP, LipidsPL and TGlucosePLK+CrAST/ALT
30Hormones: MTF - Efficacy What 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 'extra' E use or other meds)>25 probably too much>30 definitely too much>50 worry a great deal about PL-oma
32Hormones: MTF – Adverse effects Elevated 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-omaElevated LFTsLook for other cause!If due to E, lower dose or stop until LFT normal
36Steady State Usually achieved after 3-5 T½ T ½ of esters = 8-10 days TherapeuticRange
37Hormones: FTM Transdermal Expensive: $7 day retail, $1/day compounded Less variable levelsDaily administrationRisk of inadvertent transfer to others1%, 5g QD5%, 1g QD
38Hormones: FTM - Monitoring Every VisitBP, Weight, BMISafetyMental healthGeneral screening based on age, organ, gender, and sex appropriate normsPatient educationVaginal bleedingHealthy habitsTx available for acne, MPB
39Medical Treatments: Fundamentals Clinical monitoring most importantSame adverse events in cisgender pts w/ same meds (use what you know!)Labs0, 2, & 6 mo initially then (semi)annual or p changesCBC, CMP, LipidsT (trough) in FTMGlucoseCrALTTHgbHct
40Treatment Effects (any delivery...) Nearly immediateIncreased sebum and resultant acneIncreased sex driveSometimes – amenorrheaMetabolic changes start
41Treatment Effects 1-6 months Voice change starts – parallels adolescenceHair growth (and loss) begins: parallels adolescence*Clitoromegaly startsMost amenorrhea (but E only decreases modestly)*Fat and muscle distribution changesMetabolic changes* Gooren, et al “Review of studies of androgen treatment of FTM transsexuals: Effects and risks of administration of androgens to females”.
42Treatment Effects 1-5 Years Voice settles Final fat and muscle redistributionClitoromegaly maxesLength average 4-5cm (3-7 cm range)1Volume increases 4-8x2Greater change in younger patients21 Meyer W, et al “Physical and hormonal evaluation of transsexual patients: a longitudinal study.”2 Gooren, et al “Review of studies of androgen treatment of FTM transsexuals: Effects and risks of administration of androgens to females”.
43Treatment Effects 5-10 years Final hair growth Androgenic alopecia can happen at any age – and does in 50% of FTMs by 13 years** Gooren, et al “Review of studies of androgen treatment of FTM transsexuals: Effects and risks of administration of androgens to females”.
44Androgenic Alopecia T DHT E 5-α-reductase aromatase aromatase not very Finasteridearomatasearomatasenot veryactive stuffE
45Hormones: FTM – Adverse effects Acne – MC side effect (chest/back)CV - worsening of surrogate endpoints - lipids, glucose metabolism, BPPolycythemia (normals for males)Unmask or worsen OSAEnhanced LibidoAndrogenic alopecia'Other' hair growth
46Hormonal 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):DESIGN: Retrospective, descriptive university 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 and morbidity incidence ratios calculated from the general Dutch population (age and gender-adjusted)
47Hormonal 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):293 FTMsc/w ♀????10,152pt years816 MTFs????c/w ♂
48Hormonal 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):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 40In MTFs increased morbidity from VTE and HIV and increased proportion of mortality due to HIVHIVVTE
49Hormonal 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):293 FTMsc/w ♀No Increase Morbidityor Mortality10,152pt years816 MTFsNo Increase MortalityIncrease morbidity r/t HIV/VTEc/w ♂
50Hormonal 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):The absence ofevidence is notevidence of absence
51Hormonal Treatments: Is this safe? Gooren L, et al. “Long term treatment of TSs with hormones: Extensive personal experience.” J Clin Endo & Metab. 93(1):Same clinic group as 1997 paper – now 2236 MTF, 876 FTM ( )Outcome M&M Data, data assessing risks of osteoporosis and cardiovascular disease, cases of hormone sensitive tumors and potential risks
52Hormonal Treatments: Is this safe? Gooren L, et al. Cardiovascular RisksAnalyzed 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 FTMHard clinical endpoints show no differenceCounsel patients about modifying CV risk
53Hormonal Treatments: Is this safe? Gooren L, et al. Hormone Dependent TumorsLactotroph AdenomaRareCheck PL!Prostate CancerProstatectomy is not a part of SRSScreen based on the organs presentWithdrawal of testosterone may decrease but doesn't eliminate the risk of BPH and malignancyMay falsely lower PSA
54Hormonal Treatments: Is this safe? DRE is a little different
55Hormonal Treatments: Is this safe? Gooren L, et al. Hormone Dependent TumorsBreast cancerMTF - Estrogen exposure: dose and durationConservative: screen as cisgender women of same age/riskProgesterone increases risk (esp if cyclic)Other risk factors: obesity, FH, HRT >5 yearsFTMReported in 1 case 10 years after mastectomyMastectomy reduces but doesn't eliminate riskSome injected T is aromatized to estrogenFamily history
56Hormonal Treatments: Is this safe? Gooren L, et al. Gynecologic TumorsGynecologic TumorsCervicalOvarianEndometrial
58Gynecologic Cancer risks in FTMs NormalFTMPCOS???HyperplasiaIfinfrequentperiodsDysplasiaCancerENDOMETRIAL CANCER
59Gynecologic 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) 20,104 Hysterectomies: Atrophy in 50, 54 Proliferative, 4 polyps, 8 hyperplasia, 1 with dysplasia with a small foci of carcinoma in situ.
61Gynecologic 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:
65Is 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
66What about regret ???Pfäfflin, F., & Junge, A. (1998). Sex reassignment – Thirty years of international follow-up studies; SRS: A comprehensive review, Düsseldorf , Germany: Symposion Publishing.74 f/u studies and 8 reviews published b/wLess 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 sterilizationStudies after 1991 show lower rates of regret (and found risk of regret correlates well with surgical success.)
68Identity Document Changes Part of the medical treatment for GIDLack of appropriate IDVulnerability to interpersonal violenceInability toGet a jobMake a purchase with a credit cardBoard a planeEnter a federal buildingVoluntary withdrawal from activities
69Identity Document Changes Differing StandardsSurgicalAny treatmentExamplesCA DMV: Physician approval (restricted Psychologist)US Dept of State: Physician approvalUS Social Security Administration: SurgicalTX (Birth Cert): Any state court orderAK (BC): Letter from a surgeonNY (BC): Letter from a surgeon and specific surgeriesOH, ID, MS, SC, TN (BC): Screw offPhysician approvalPatient request
70What can you get in CA w/o SRS? Drivers License/State ID - DL328PassportCourt Ordered Name and Gender ChangeCA Birth Certificate (possibly other states as well)Social Security NAMESocial Security GENDER MARKER
71Supportive Letters There are no gender cops Its not your job to enforce bad policyYour jobAdvocate for your patients needsDon't lieGive your true medical opinionDon't write something if you don't have experience
72Supportive Letters: a thought experiment You are a doctor in NC in 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.
73Supportive Letters: a thought experiment You are a doctor in NC in 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?
74Supportive Letters There are no gender cops Its not your job to enforce bad policyYour jobAdvocate for your patients needsDon't lieGive your true medical opinionDon't write something if you don't have experience
75Supportive LettersI am a physician licensed to practice medicine and surgery in the state of California.John Smith is a patient in my care at LMHSIn 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.)
76Supportive LettersAs 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.Indicating his gender as male is accurate and will eliminate the considerable confusion and bias Mr Smith encounters when using identification that does not reflect his current true gender.