Welcome to TRANSitioning 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 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).
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Welcome to TRANSitioning 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 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).
WELCOME EVERYONE!
Thank you for joining us today
Raising your hand to ask a question
Sending Notes
Muting your phone
Primary Care and Hormonal Treatments for Transgender Patients
Stops conversion of T DHT 5mg tabs = $20 for 30 at Costco 1mg tabs = $74 for 30 at Costco
Hormones: MTF - Monitoring Every Visit
BP, Weight, BMI Safety Mental health General screening based on age, organ, gender,
and sex appropriate norms Patient education
S/Sx of TEDz Healthy Habits Vision changes or lactation
Hormones: MTF - Monitoring
Clinical monitoring most important Same 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 PL and T
CrK+Glucose
AST/ALT
PL
Hormones: MTF - Efficacy
What is adequate treatment? Pt outcomes – breast growth (peak 2-3 yrs), changes
in skin, hair, fat/muscle, libido The 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
Hormones: MTF – Adverse effects
Elevated PL: Stop Estrogens (not anti-androgen) If levels normalize, resume E at lower dose Consider changing meds that cause increase in PL If levels remain high MRI to r/o PL-oma
Elevated LFTs Look for other cause! If due to E, lower dose or
Enanthate Biggest vial is 5ml Slightly more expensive
Hormones: FTM
Steady State post 3-5 T½ T½ 8-10 days ~2 months
Side effects happen at peak and trough
Hormones: FTM
Transdermal Expensive: $7 day retail, $1/day compounded Less variable levels Daily administration Risk of inadvertent transfer to others
5%, 1g QD1%, 5g QD
Hormones: FTM - Monitoring Every Visit
BP, Weight, BMI Safety Mental health General screening based on age, organ, gender,
and sex appropriate norms Patient education
Vaginal bleeding Healthy habits Tx available for acne, MPB
Medical Treatments: Fundamentals
ALT
Clinical monitoring most important Same 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
CrGlucose
T HgbHct
Treatment Effects (any delivery...)
First 6 months Increased sebum and resultant acne Increased sex drive Voice change starts – parallels adolescence Hair 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”.
Treatment Effects
1-5 Years Voice settles Final fat and muscle redistribution Clitoromegaly maxes
Length 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”.
Treatment 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. 2008. “Review of studies of androgen treatment of FTM transsexuals: Effects and risks of administration of androgens to females”.
Hormones: FTM – Adverse effects
Acne – MC side effect (chest/back) CV - worsening of surrogate endpoints - lipids,
glucose metabolism, BP Polycythemia (normals for males) Unmask or worsen OSA Enhanced Libido Androgenic alopecia 'Other' hair growth
Hormonal 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-years
OUTCOMES: Mortality & morbidity incidence ratios c/w general Dutch population (age & gender-adjusted)
Hormonal 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 FTMs
816 MTFs
10,152pt years
????
????c/w ♂
c/w ♀
Hormonal 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'n Largely, observed mortality not r/t hormone treatment VTE 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
Hormonal 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 FTMs
816 MTFs
10,152pt years
c/w ♂
c/w ♀ No Increase Morbidityor Mortality
No Increase MortalityIncrease morbidity r/t HIV/VTE
Hormonal 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: Cohort SUBJECTS: 966 MTF & 365 FTM on HRT for median 18.5
years OUTCOMES: MTF mortality increased – almost all due to
suicide and HIV. FTM mortality unchanged.
Hormonal 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
Hormonal Treatments: Is this safe?
Gooren L, et al. Cardiovascular Risks Analyzed studies of surrogate markers for CVDz in
Some worsen, some improve, some are unchanged – much of the worsening seems likely d/t weight
MTF do worse than FTM Hard clinical endpoints show no difference Counsel patients @ modifying CV risk
Hormonal 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 TGs Minor effect on FTM BP No hard clinical endpoints Most CV events were in MTFs Study quality poor
Hormonal Treatments: Is this safe?
Gooren L, et al. Hormone Dependent Tumors Lactotroph Adenoma
Rare Check 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
Hormonal Treatments: Is this safe?
Gooren L, et al. - Breast cancer MTF - Estrogen exposure: dose and duration
Conservative: screen as cisgender women of same age/risk Progesterone 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
Hormonal Treatments: Is this safe?
Gooren L, et al. Gynecologic Tumors Cervical Ovarian Endometrial
Gynecologic Cancer risks in FTMs
6 + ???
???
Gynecologic Cancer risks in FTMs
Normal
Hyperplasia
Dysplasia
Cancer
FTM
PCOS
???
Ifinfrequentperiods
ENDOMETRIAL CANCER
Gynecologic 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, 553-558
104 Hysterectomies: Atrophy in 50, 54 Proliferative, 4 polyps, 8 hyperplasia, 1 with dysplasia with a small foci of carcinoma in situ.
Gynecologic Cancer risks in FTMs
Gynecologic Cancer risks in FTMs
Never Every 10 yr Every 5 yr Every 3 yr Every 2 yr Every year0
10
20
30
40
50
60
70
80
90
100
Cervical Cancer Risk Reduction from Pap Smears
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.
Gynecologic Cancer risks in FTMs
Gynecologic Cancer risks in FTMs
Is it effective?
Is it effective?
Of 28 studies 23 included Psych/HRT/Surgery Five were Psych/HRT only Pre-tx suicidality 30%, 8% post treatment Significant improvements in SCL-90 and MMPI
and in measures of gender dysphoria One study of Psych/HRT/Surgery showed long
term SCL-90 scores were in non-clinical range Five studies assessed employment and financial
status and all improved
What 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 1961-1991 Less than 1% long term regret in over 400 FTMs 1.5% regret in over 1000 MTFs
Compare 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.)
Making Things Official
Identity Document Changes
Part of the medical treatment for GID Lack of appropriate ID
Vulnerability to interpersonal violence Inability to
Get a job Make a purchase with a credit card Board a plane Enter a federal building
Voluntary withdrawal from activities
What can you get in CA w/o SRS? Drivers License/State ID - DL328 Passport Court Ordered Name and Gender Change CA Birth Certificate (possibly other states as well) Social Security NAME Social Security GENDER MARKER
Supportive Letters
There are no gender cops Its not your job to enforce bad policy Your job
Advocate for your patients needs Don't lie Give your true medical opinion Don't write something if you don't have experience
Supportive Letters: a thought experiment
You 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?
Supportive Letters
There are no gender cops Its not your job to enforce bad policy Your job
Advocate for your patients needs Don't lie Give your true medical opinion Don't write something if you don't have experience
I 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.
Resources
Two page clinical protocol Informed consent forms This talk project-health.org/transline [email protected]