Szociológia | Tanulmányok, esszék » Transgender Medicine, Essentials for the Primary Care Provider

Source: http://www.doksinet Transgender Medicine: Essentials for the Primary Care Provider B E N JA MIN J. B O H , D O, M S A S S I STA NT PRO F ES S O R O F M E D I CINE S EC TION O F E N D OCRI NOLOGY GE I S E L S C H O O L O F M E D IC INE AT DA RTMOU TH Source: http://www.doksinet Disclosure I will be discussing “off-label” use of testosterone, estradiol, leuprolide and histrelin No financial interest in any pharmaceutical product Source: http://www.doksinet Transgender men = Female Male Transgender women = Male Female Transgender umbrella page from the GENDER book. (cc) www.thegenderbookcom Source: http://www.doksinet Transgender history 1929-1939 1990s 1940 Era of sex steroid discovery 1966 Dr Harry Amsterdam adolescent Gender Clinic “Transsexual Phenomenon” Benjamin 2016 1939 1952 1987 2013 Micheal Dillon starts testosterone Christine Jorgensen DSM Gender Identity Disorder Gender Dysphoria DSM V Source: http://www.doksinet • World

Professional Association for Transgender Health • The Endocrine Society • Pediatric Endocrine Society • European Society of Endocrinology • European Society for Paediatric Endocrinology • Contains 157 references from medical literature JCEM September 2009 Source: http://www.doksinet Evidence based care? • Institute of Medicine issued report outlining need for research in LGBT population • “Need more data” • Improved methods for collecting data • Increased LGBT participation in clinical research Gay Committee on Lesbian, Board on the Health of Select Populations, and Institute of Medicine. Health of Lesbian, Gay, Bisexual, and Transgender People: Building a Foundation for Better Understanding. National Academies Press, 2014 Source: http://www.doksinet Database • Academic medical centers and large community health centers • 500+ transgender patients Source: http://www.doksinet Meeting the needs of TG patients • Honor patient’s affirmed gender

identity • Transgender inclusivity (EMR, intake forms, bathrooms) • Office staff education (clerical and nursing staff) • Advocating for insurance coverage and providing documents for legal gender change • Educating families and allies • Privacy and confidentiality Source: http://www.doksinet Goals of primary care • STD screening • Family planning • Preventive healthcare • Screen for depression, anxiety, suicide, and bullying • Screen for substance abuse Source: http://www.doksinet Patient perceptions of primary care • Many youth do not feel that their needs are being met • Lack of discussion of important topics (sexual and emotional health) • Physicians/ providers often uncomfortable with transgender patients • Inappropriate comments • Adolescents need time alone with provider • Providers often focus visit towards parent • Contraception/family planning not discussed with TG patients Snyder, Barbara K., Gail D Burack, and Anna Petrova

"LGBTQ Youth’s Perceptions of Primary Care" Clinical Pediatrics (2016): 0009922816673306. Source: http://www.doksinet Hormone therapy • Testosterone cypionate/ enanthate • Androgen gels • Beta estradiol (oral or sublingual) • Transdermal estradiol • Estradiol valerate (injectable) • Anti-androgen: spironolactone, leuprolide depot • Finasteride (early on) Source: http://www.doksinet Monitoring of transgender women on hormone therapy - Target serum testosterone levels should be <100 ng/dl - Serum estradiol should not exceed the peak physiological range for young healthy females, with ideal levels <200 pg/ml - Doses of estrogen should be adjusted according to the serum levels of estradiol - For individuals on spironolactone, potassium should be monitored with dose changes - Consider BMD testing at baseline if risk factors for osteoporotic fracture - In individuals at low risk, screening for osteoporosis should be conducted at age 60 and in those who

are not compliant with hormone therapy 2016 Meet-The-Professor Endocrine Case Management. State-of-the-Art: Use of Hormones in Transgender Individuals. Benjamin Boh, DO, MS and Joshua Safer, MD, FACP Source: http://www.doksinet Monitoring of transgender men on hormone therapy - Measure serum testosterone every 3 months until levels are in the normal physiological male range - For testosterone injections, some measure peaks and troughs and some measure midway between injections - Measure hematocrit at baseline and every 3 months for the first year; then 1–2 times a year - Monitor weight, blood pressure, lipids, fasting blood sugar, and/or hemoglobin A1c at regular visits as needed - Consider BMD testing at baseline if risk factors for osteoporotic fracture are present - If cervix present, pap smears as indicated for other population groups - If breast tissue is present, mammograms as indicated for other populations 2016 Meet-The-Professor Endocrine Case Management.

State-of-the-Art: Use of Hormones in Transgender Individuals. Benjamin Boh, DO, MS and Joshua Safer, MD, FACP Source: http://www.doksinet Preventive health screening • No established guidelines for TG individuals • Screen based on natal sex • PSA • Mammography • Pap tests Source: http://www.doksinet Endocrine Treatment of Transsexual Persons: Endocrine Society Practice Guidelines 2009. Source: http://www.doksinet VTE Risk in Transwomen • Asscheman et al. (2014) 1% incidence of VTE among 1076 transwomen (5.4 years) • Gooren et al. (2008), no increase in VTE among 2236 transwomen on estradiol from 1975 to 2000 (ethinyl estradiol = 6–8% incidence) • Wierckx et al. (2013) 5% of 214 transwomen developed VTE within the first three years of estrogen therapy • 10 out of 11 of these women had at least one VTE risk factor (smoking, immobilization/ surgery, or thrombophilia) Source: http://www.doksinet A long-term follow-up study of mortality in transsexuals

receiving treatment with cross-sex hormones Asscheman H, et al. A long-term follow-up study of mortality in transsexuals receiving treatment with cross-sex hormones. Eur Society of Endocrinology 2011;164: 635-642 Source: http://www.doksinet Asscheman H, et al. A long-term follow-up study of mortality in transsexuals receiving treatment with cross-sex hormones. Eur Society of Endocrinology 2011;164: 635-642 Source: http://www.doksinet MF: 966 FM: 365 Cause of death number SMR number SMR Malignancy 28 0.98 5 0.99 Lung malignancy 13 1.35 (114-158) 1 1.06 Hematologic malignancy 6 2.58 (2-33) 1 2.86 (069-857) CAD 18 1.64 (14-19) 1 1.19 (039-274) HIV 16 30 0 - Illicit drug use 5 13.2 1 25 Suicide 17 15.7 1 2.2 Unknown 21 4 2 2 Total 122 1.51 12 1.12 Asscheman H, et al. A long-term follow-up study of mortality in transsexuals receiving treatment with cross-sex hormones. Eur Society of Endocrinology 2011;164: 635-642 Source:

http://www.doksinet Case 1 An 18 year old patient assigned female at birth • Dressing in male attire for several years • Academic performance has been deteriorating and pt is withdrawing socially and at home • Deepening of voice and worsening of acne • How do you address this patient and what are you goals for the first office visit? Source: http://www.doksinet Case 1 • Establish rapport • Affirm gender identity • PCP often is first point of contact • The primary medical concern in this case is illicit testosterone use • Arduous process of qualifying for hormone therapy or lack of access to providers Source: http://www.doksinet Case 2 A 26 year old transgender male has been treated with testosterone therapy for 1 year He is successfully living as a male Current dose of testosterone cypionate: 200 mg IM every 2 weeks He complains of pruritus during warm showers and frequently feels flushed Hematocrit of 56% What treatment related condition has he

experienced and what changes do you recommend? Source: http://www.doksinet Case 2 Testosterone stimulates erythropoiesis Androgen therapy is likely to raise hemoglobin (2gm/dL) Tobacco use and sleep apnea should be excluded as contributors The elevated hematocrit can be mitigated with lower doses of testosterone Androgens can unmask polycythemia Hematological evaluation may be required for polycythemia unresponsive to dose lowering (JAK mutation) Source: http://www.doksinet Case 3 36 year old natal female with a male gender identity (transgender male) • Duration of testosterone therapy: 17 years • Patient and female partner present to discuss options for fertility Source: http://www.doksinet Labs and Imaging • Estradiol 38 pg/ml • FSH 7.5 • LH 6 • Progesterone 0.56 ng/ml • Testosterone 0.47 ng/ml • Anti-Mullerian hormone 3.56 ng/ml • Antral follicle count= >15 Source: http://www.doksinet Discussion What are this couple’s options for fertility? •

Donor sperm • Pregnancy • Controlled ovarian stimulation (IVF) with gestational carrier • Long term androgen use does not appear to deplete primordial follicle pool • Extremely limited data on fertility preservation Source: http://www.doksinet Fertility in Transgender Men • 54% desired children • 38.5% would have considered oocyte/embryo cryopreservation • Costs • Donor sperm $500-1,000/vial • Sperm cryopreservation $1,000-1,500 (with FDA testing) • IVF $15,000/cycle • Gestational carrier $50,000+ Wierckx, K. Human Reproduction, 2012 Source: http://www.doksinet Fertility in Transgender Women • Sperm cryopreservation • Ideally performed prior to hormonal transition • Total cost ~1,500 (+ yearly storage fees) Source: http://www.doksinet Thank you for your attention I welcome your questions / comments