Transcript General Medical Care and Hormone Therapy for Transgender Patients Oregon Society of Physician Assistants Spring Medical Update Embassy Suites Tigard, Oregon April 27-29, 2007 11/6/2015 Sara Becker MD Northwest.

General Medical Care and
Hormone Therapy for
Transgender Patients
Oregon Society of Physician Assistants
Spring Medical Update
Embassy Suites
Tigard, Oregon
April 27-29, 2007
11/6/2015
Sara Becker MD Northwest Primary
Care Group, PC
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Sara Becker MD Northwest Primary
Care Group, PC
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The Difference Between Sex
and Gender
Sex is the physical expression of
genes.
Gender identity is the concept of
how one relates to others in
society (masculine vs feminine)
and self perception.
The organic basis of gender
identity may be a reflection of
hormonal effects in utero
**John Money 1955
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Cases in Point
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Transsexual
Transsexuals are Human Beings that have the brain of one gender and the
body of the other gender
They seek to become the gender of their mind
They have known all their lives that they are different but try to fit in
The inability to do so produces a Dysphoria or depression that is often
overwhelming
Gender is how an individual relates to others in society masculine vs. feminine
It is not about who you love. It is about who you are
Since the mind cannot be changed, the body must be changed by hormones
and surgery
There is no other cure for being a transsexual other than to “transition” and
be able to live as the opposite sex
The health professionals role is to help that transition to occur safely and to
exhibit compassion and competence
Estimated incidence is one in five thousand
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Standards of Care
The
World Professional Association For Transgender Health,
Inc.
Formerly Known AS HBIGDA
The World Professional Association for Transgender Health
(WPATH, formerly known as the Harry Benjamin International
Gender Dysphoria Association, Inc. (HBIGDA)) is a professional
organization devoted to the understanding and treatment of
gender identity disorders. There are approximately 500
members from around the world, in fields such as medicine,
psychology, law, social work, counseling, psychotherapy,
family studies, sociology, anthropology, and sexology.
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Transsexual
Individuals seeking medical therapy should have a
letter from a therapist recommending hormonal
treatment
To qualify for Gender Reassignment Surgery the
transsexual needs to live as the opposite gender
for one year and be employed. This is known as
“The Real Life Test”
To have surgery the transsexual must have
completed the Real Life Test and have letter
from a masters level therapist and an MD or
PhD Level professional recommending surgery
Not all transsexuals have surgery
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Transsexual
Gender Reassignment Surgery in Males to
Females (MTF) is the construction of a
vagina from the male genitals.
Gender Reassignment Surgery in Females
to Males (FTM) is usually reconstruction of
the chest to appear as a male. Genital
surgery is much more problematic
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What are some of the
obstacles for patients seeking
medical care
Patient issues
– Ambivalence, “coming out” issues, fears of violence, fears of
rejection, discrimination, social stigmatization
– Not transsexual or not intensely transsexual
– Access to health care
Distance
Cost (high rate of unemployment, insurance)
– Mistrust of medical establishment (prior mistreatment)
– Ability to have sustained follow-up and monitoring
– Medical/behavioral contraindications
Underlying disease states
Unfavorable family history
Unfavorable lifestyle (tobacco, alcohol, substance abuse)
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What are some of the
obstacles to transitioning?
Social and economic marginalization
– Relationship changes with family members,
friends, and employers
– Job discrimination and lack of societal
protections
– Loss of employment
– Divorce and marriage decisions
– Restriction or loss of visitation rights for
children.
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What are some of the
obstacles to obtaining medical
care
– Health care provider issues
Lack of education
Lack of clinical experience
Problems with partners and cross coverage
Relative paucity of studies
Unanswered questions
Personal discomfort or religious belief
Serious complications
Fear of litigation
Off-label administration of medications
Lack of reimbursement
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Some general principles for
Patients
Stay informed (the internet has list of
professionals who are knowledgeable)
Bring questions
Educate your health care provider
Follow directions—don’t “double dose”
Keep all members of medical team
informed
Keep family/significant others informed
Don’t be sneaky
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Questions the Health Professional
may ask at the First Visit
Current medications (including prescription
meds, OTC’s, and herbals
Most recent examinations (testicular,
prostate, breast, mammograms)
Current habits
– Tobacco
– Alcohol
– “Recreational drugs”
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Questions The Health Professional
may ask
Past hospitalizations (medical and psychiatric)
Past surgery
Family history
–
–
–
–
–
–
Clotting disorders (very important)
Cardiovascular disease
Hypertension
Diabetes
Mental illness
Breast, prostate cancer
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Questions The Health Professional
may ask
Sexual history
– Sexual orientation
– Risk behaviors related to STD’s
– Sexual function
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Questions The Health Professional
may ask
Social environment—can be sources
of support or stress
– Significant others
– Living situation
– Occupation
– Financial challenges
Ongoing support groups or
psychiatrist/psychotherapist
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Questions The Health Professional
may ask
Participation in a real-life test
– Cons
HRT can cause permanent changes including sterility
and gynecomastia. RLT may confirm that transitioning
is the right choice
– Pros
HRT makes it easier to pass and easier to attempt RLT
Most people who would consider hormones are pretty
sure of what they want by that time
HRT is “diagnostic” itself—true transsexuals will feel
calmer and relieved upon starting HRT; if not truly
transsexual, changes will cause worsening anxiety
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Questions The Health Professional
may ask
History of hormone use
– Estrogen
– Progesterone
– Anti-androgens
– Testosterone (needles)
Side effects
Phytoestrogens and other herbals
Points of acquisition of hormones (25%)
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Questions The Health Professional
may ask
Prior feminizing surgery
– Genital reassignment surgery
– Facial feminization surgery
– Breast augmentation
– Tracheal shave
– Voice surgery
– Abdominoplasty
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Questions The Health Professional
may ask
Prior masculinizing surgery
– Genital reassignment surgery (phalloplasty,
metoidioplasty)
– Chest Reconstruction
– Abdominoplasty
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Questions The Health Professional
may ask
Future feminizing/masculiniation
plans
– Surgeries
Additional needs
– Clothing
– Hair removal
– Hair transplant
– Guidance in mannerisms
– Make-Up
– Voice therapy
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The physical
examination
Wear clothing that is easily
removable
Routine blood pressure, pulse,
respiratory rate,
weight
Scalp, facial, and body hair*
Skin
Prostate exam*
Pelvic exam in FTM
Hernia exam (especially in those who practice “tucking”)*
Breast examination*
– Presence of masses
– Presence of galactorrhea
Examination of genitalia in pre- and post-op ’s*
*May be deferred until a strong clinician-patient relationship is established
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Hormone Therapy
The time machine
Allows genetic males to appear feminine
Allows genetic females to appear
masculine
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Hormones
It is the human sex hormones which shape
the clay that becomes the being.
Human beings are not fixed permanently
into one gender or another.
To a great degree, feminization and
masculinization can occur in the same
body at different stages of life.
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Hormones
We all go through this process once.
It is called puberty.
It takes five to seven years the first time.
It is not any faster the second time.
To transition one must reverse the effects
of the first puberty as well as let the
second occur.
Higher hormone doses do not speed the
process but do increase risks and side
effects.
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Typical Hormone Levels
of Estrogen in Adults
• Estradiol male 0.30-0.90 pg. /Ml. (Total)
• Free Estradiol (1.66-2.11%) .10-.50 pg./Ml
• Estradiol female 20-450 pg./Ml. (Total)
• Free Estradiol (1.49-2.85%) or .60-4.10
pg./Ml
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Typical Hormone Levels
of Testosterone in Adults
• Testosterone male 260-1000 ng./Ml.
(Total)
• Free testosterone % (1.0-2.7%) or 50-210
pg./Ml
• Testosterone female 15-70 ng./Ml. (Total)
• Free testosterone % (0.5-1.8%) or 1.0-8.5
pg./Ml
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Effects of Estrogen on Genetic
Males
Skin Changes—finer skin, thin nails
Female fat distribution Abdomen to breasts and
hips
Muscle changes-loss of 30% muscle mass
Breast development max in two years (2/3
mothers size at age 21, older less development)
Face changes five years (not all need surgery)
Nails become brittle (lack of sebaceous oil)
Decrease hair loss, sometimes regrowth scalp
hair
Decreased body hair in two years (between
breasts)
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Effects of Estrogen on Genetic
Males
Alteration of clotting system
Decrease in Hematocrit from 44% to 35%
Elevation of liver test
Decrease in basal metabolic rate –FAT!!
Alteration of bone
Decrease in total chol, increase HDL
(good) decrease LDL (bad)
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Psychological Effects of
Estrogen on Genetic Males
Increased emotional lability
Increased sensitivity to opinions of others
Decreased aggression
Heightened sensitivity to smell and color
Small study in group of violent prisoners
showed estrogen worked as well as major
tranquilizers in reducing violence and
aggressive behavior (however lots of
fighting over soap operas)
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Side Effects of Estrogen on
Genetic Males
Will not reduce size of penis.
Testicles will shrink
Voice does not change
Skeletal size does not change
Facial hair reduces growth rate after about
six months but does not disappear
All effects except breast enlargement and
infertility are reversible
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Antiandrogens
in M2F
Block the production and effects of testosterone.
Testosterone is much more powerful than
estrogen and is the true chemical difference
between the sexes. Must be blocked for
estrogen to work
Use allows a lower dose of estrogen to produce
the same feminization but reduce the risks of
estrogen.
Many different kinds but many are expensive.
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Antiandrogens
in M2F
Goserelin (gnrh inhibitor)
Leuprolide (gnrh inhibitor
Ketoconazole
Cytopyrone
Spironolactone
bicalutamide
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Common Regimes for M2F
Spironolactone (Aldactone) 100-400 mg plus
Conj estrogens 2.5 to 7.5 (Premarin) or
Estradiol (Estrace) 1mg to 6 mg or
Ethiny Estradiol (Estinyl) .02 to 2.0 mg or
Estradiol (Vivelle Microdot) two .1 mg patches
a week or
Estradiol Valerate 20 to 40 mg every two weeks
Mixture of oral estrogen and Injectable estrogen
(one study showed this simulated female levels
the most closely)—small (11) number of patients
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Care Group, PC
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Postoperative SRS or
Orchiectomy
No need for spironolactone
CEE 0.625 to 2.5 mg
Estradiol 0.5 mg to 2.0 mg.
Estradiol patch 0.25 to 1.0 mg per week
Estradiol 20 to 40 IM mg a month
Lesser is better if more than two years on
hormones
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Testosterone in Postop MTF
Testosterone patch 300ug in 51 women for 12 months
called intrinsa by Proctor and Gamble
Increased bone density in hip 1%
Increased muscle mass 7%
Increased libido
Skin irritation
Karen Miller et al. "Effects of testosterone replacement in
androgen-deficient women with hypopituitarism: a
randomized, double-blind, placebo-controlled study. The
Journal of Clinical Endocrinology & Metabolism 2006;
91:1683-1690.
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Postoperative SRS
in M2F
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Female to Male
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Testosterone in F2M
Oral testosterone is metabolized in the gut
and quickly inactivated in the liver. 400mg
oral T for effective dose
Methytestosterone less easily broken
down by liver and inactivated
Intramuscular testosterone absorbed
slowly during storage in the fat less liver
toxicity
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Care Group, PC
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Testosterone in F2M
Extremely powerful.
“Difference between the sexes” Time
Magazine
Usually given as an intramuscular
injection.
Testosterone Enanthate 250-400 mg IM q
2 weeks.
Testosterone Cyprionate 250-400 mg. IM q
2 weeks.
Must not be mixed
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Intramuscular Testosterone in F2M
Least expensive
Causes supraphysiologic doses for 1-3
days then levels fall to lower normal levels
“Rollercoaster effect”
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Care Group, PC
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Testosterone in F2M
Probably better to give 100mg IM every
week
Less variation in effect
Less mood fluctuation
Less acne (T Stat)
Less risk of spotting
Some may do well on 50mg every week
One patient transitioned on 100 mg /month
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Care Group, PC
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Compounded Testosterone Cream
Produced by Stroheckers in Portland,
Oregon
5% cream applied to shoulder daily
5 Grams a day used
Takes about six months to work
Cost $60 per month ($360)
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Care Group, PC
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Physiological Changes on
Testosterone in FTM
Increase in red cell mass (blood volume)
Increase stamina
Increase caloric requirements (muscle
mass)
Increase strength (30%)
? Change in stature 2 documented cases
1” growth
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Changes on Testosterone in
FTM
Increase sexual motivation (libido)
Increases arousal
Increase orgasm, pleasure and
satisfaction
Ejaculation
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Side Effects of Testosterone
On Genetic Females
Water and sodium retention, sugar
intolerances,edema
Change in lipid status -Increase cholesterol, LDL,
VLDL and lowered HDL (good cholesterol)
Liver, heart disease, osteoporosis
Acne
Weight and muscle gain (change in nitrogen balance)
Sleep apnea (size 16 neck)
Increased libido
Psychiatric illness (steroid rages, anger)
Endometrial Hyperplasia (uterine and cervical cancer)
Bacterial Vaginosis
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Care Group, PC
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Steps Before Initiating Hormone
Therapy
Informed consent
Higdba guidelines recommend written
Consent
Vancouver recommendations are for
extensive PARQ
Risk of leaving something out
All drugs are used “off label”
True long term effects are unknown
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The Harry S Benjamin
Standards of Care (ages less
than
18)
Initial phase- biological males should be administered an
A.
B.
C.
a.
a.
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antiandrogen (which neutralize testosterone effects only) or an
LHRH agonist (which stops the production of testosterone only)
Biological females should be administered sufficient
androgens, progestins, or LHRH agonists (which stops the
production of estradiol, estrone, and progesterone) to stop
menstruation.
Second phase treatments--after these changes have occurred
and the adolescent's mental health remains stable
Biologic males may be given estrogenic agents
Biologic females may be given higher masculinizing doses of
androgens
Second phase medications produce irreversible changes
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Care Group, PC
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Under Age 18
Initial phase
5 patients MTF ages 14 to 17
1 patient age 11 FTM being treated by Peds Endo at
Kaiser
2 emancipated
Letters from Therapist and/ or Psychiatrist
Spironolactone 200-500 mg in MTF
If spironolactone contraindicated can use GNRH
inhibitors
Oral progesterone 60 mg orally daily in FTM FE 1.52 N
1.66-2.11
Well tolerated
Reversible
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Common laboratory monitoring
Normal values for transsexuals in
transition or post-transition have not been
established
Doctors should request “genetic ”
reference ranges in pre-op TG’s and “new
gender ” reference ranges in post-op TG’s
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Laboratory tests during
transition
Initial tests may include:
–
–
–
–
–
–
–
–
–
Free testosterone
Prolactin
Fasting blood sugar
Basic metabolic panel (sodium, potassium,
tests of kidney function)
Liver panel
Karyotyping
Complete blood count
Coagulation studies*
Lipid profile
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Sara Becker MD Northwest Primary
*optional
Care Group, PC
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Laboratory tests during
transition
Early follow-up
– Basic metabolic panel, 1 wk; 1, 3, 6, 12, 18
mo. etc
– Liver enzymes, fasting glucose 1, 3, 6, 12,
18 mo. etc.
– Free testosterone 3, 6, 9 mo and every 3
months until at target
– Prolactin 6, 12, 24, and 36 months
– Lipid profile 6, 18, 30 months, etc.
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Vaccinations
Hepatitis B vaccine
– Health care workers
– More than one sexual partner in past six
months
– Recent sexually transmitted disease
– Sharing needles
– Traveling to endemic areas
Hepatitis A, Meningococcal C
– Transgenders having sex with men
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Cancer prevention and
detection
Breast cancer
– No hormones—no increased risk
– Feminizing hormones—increased risk of
breast cancer, but less risk than GG’s
– Risk increases with obesity, length of
hormone exposure (> 5 years), family
history, and use of progestins
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Who should get mammograms
Annual mammogram after age 50 if there
are risk factors:
– Family history
– Estrogen and progestin use >5 years
– Obesity (body mass index >35)
– If female to male may still need chest exam as
some breast tissue may remain
Implants do not increase cancer risk, but
may lessen the accuracy of mammograms
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Cancer prevention and
detection
Annual breast exam to screen for cancer and
breast self exam
– Of limited use except in high risk patients
– Much more likely to find benign lumps, waste money,
and cause unnecessary emotional distress
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Cancer prevention and
detection
Cancer of the neocervix has been reported
Vaginal cancer in MTF’s is rare
Pap smears
– If the glans penis has
been used to create a
neocervix
– MTF’s with history of
exposure to human
papillomavirus (HPV),
especially if immune
compromised
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Vaginal Neoplasia in a Male-to-Female Transsexual:
Case Report, Review of the Literature, and
Recommendations for Cytological Screening, Int. J.
Transgenderism, 5:1 (2001)
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Cancer prevention and
detection
Prostate cancer
– MTF’s always have a prostate gland, even
post-op
– Routine digital rectal examinations are
needed
– HRT reduces, but does not eliminate the risk
of prostate cancer
– PSA screening is falsely low with hormones or
post-op
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Cancer prevention and
detection
Gyn exam in FTM
– FTM may still have uterus and / or vagina.
– Pap smear is important particularly if they
have had vaginal intercourse with a male
– Routine digital rectal examinations are
needed
– If a hysterectomy and oophorectomy have
been performed no pap smear is needed
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Cancer prevention and
detection
In summary, this randomized trial showed that
the use of estrogen plus progestin was associated
with a decreased risk of colorectal cancer. However,
the cancers diagnosed in women who were using estrogen
and progestin had greater lymph-node involvement
and a more advanced stage than the cancers
in the placebo group. These findings support
wider implementation of bowel screening among
postmenopausal women who are using hormone
therapy. Current data are insufficient to support the
use of estrogen plus progestin to reduce the risk of
colorectal cancer in any population.
Sara Becker MD Northwest Primary
New
England Journal of Medicine, 350: 991-1004,
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CareMarch
Group, 4,
PC2004
62
Cancer prevention and
detection
Screening that is important, independent
of gender
– Colon cancer (colonoscopy if age 50 or older)
– Lung cancer
– Anal cancer
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The transgendered
heart
Many FTM’s have cardiac risk factors
Testosterone alters lipid status
Increases total cholesterol, LDL, decreases HDL
– Younger Age
Hypertension
Diabetes
Hyperlipidemia
– Smoking
– Hormonal therapy
– HRT increases risk of future events in those with established
coronary artery disease
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The transgendered
heart
Many MTF’s have cardiac risk factors
– Older age (often > 40)
Hypertension
Diabetes
Hyperlipidemia
– Smoking
– Hormonal therapy
– HRT increases risk of future events in those with established
coronary artery disease
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The cardiac risks of feminizing
hormones
Most studies have and are being done in biologic
women
Much evidence suggests that estrogen lowers
cholesterol levels, and raises HDL (good
cholesterol)
Increases triglycerides, blood pressure,
subcutaneous and visceral fat
Decreased LDL particle size (bad)
Decreased insulin sensitivity (bad)
Increases blood pressure through fluid and salt
retention
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Estrogens and the heart
Current studies
– Women’s Health Initiative
27,500 enrollees without CAD to test
estrogen or estrogen plus progestin posthysterectomy
– Women’s Angiographic Vitamin and
Estrogen
– Women’s Estrogen/Progestin and Lipid
Lowering Hormone Atherosclerosis
Regression Trial (WELL-HART)
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Hormones and the heart
JAMA: July 17, 2002
– “Risks and Benefits of Estrogen Plus Progestin in
Healthy Postmenopausal Women”
16,608, ages 50-79 studied
Received placebo or Premarin® plus Provera®
Study stopped after 5.2 years because of
significantly increased risk of cancer in
treatment group
Reduced risk of colorectal cancer and hip
fractures
Increased risk of coronary artery disease,
pulmonary embolism, stroke
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Hormones and the heart
Archives of Internal Medicine, February 13,
2006 “Conjugated Equine Estrogens and
Coronary Heart Disease The Women's Health
Initiative”
– Unopposed conjugated equine estrogens
(Premarin® without progestins) “provided no
overall protection against myocardial infarction or
coronary death in generally healthy postmenopausal women during a 7-year period of use.
There was a suggestion of lower coronary heart
disease risk with CEE among women 50 to 59
years of age at baseline.”
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National Institute of Health WHI Study-Estrogen Only
7.1 years
Outcome
No
HRT
On ET
Per 10,000 women; ave age
63.3
Strokes
33
45
12 more Strokes
Clots Legs
22
30
6 more clots
Hip Fracture
17
11
6 fewer hip fractures
Colon CA
16
17
No statistical difference
Heart Attacks
56
53
No statistical difference
Breast CA
34
28
No statistical difference
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The Nurses Health Study
Began 1976, with 121,700 female nurses
aged 30-55
Lasted 22 years
30% decrease in coronary heart disease in
both estrogen and estrogen +
progesterone
Used variety of estrogens not just CEE
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Heart Disease and Estrogen
What is missing, is an explanation for sex differences in
heart disease.
Throughout life, women have less heart disease than
men, and the difference is especially pronounced at
younger ages.
Possible that estradiol, the estrogen women naturally
produce and that goes directly to their bloodstream is
protective.
The estrogen in pills, metabolized by the liver before
entering the blood, may be harmful. Neither the nurses'
study nor the Women's Health Initiative addressed that
question .
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Hormones and the heart
What is the risk-benefit ratio
in post-menopausal women?
– Decreased hot flashes
How does the risk-benefit
ratio differ in transgenders?
– Physical feminization
– Reduced emotional stress
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Care Group, PC
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Reducing chances of heart
problems
If there’s a history or strong family history of
heart attack, coronary artery disease, or stroke
– Close supervision by a cardiologist, stress test
– Blood pressure, lipid control, blood thinners
Estradiol (Estrace® 1 or 2 mg), a naturally
occurring estrogen, is preferred to Premarin®
– Usual dose is 4 mg daily pre-op, 2 mg daily post-op
Consider daily administration of aspirin 81 mg
daily
Folic acid
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Reducing cardiac risk factors
No smoking
Watch weight
Watch blood sugar
Monitor lipid profile and treat
hyperlipidemia, consider transdermal
estrogen especially in
hypertriglyceridemia
Monitor blood pressure and treat
hypertension
Glueck, C. J., Lang, J., Hamer, T., & Tracy, T. (1994). Severe hypertriglyceridemia and
pancreatitis when estrogen replacement therapy is given to hypertriglyceridemic women.
Sara Becker MD Northwest Primary
Journal
of
Laboratory
and
Clinical
Medicine,
123,Group,
59-64.
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Care
PC
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Risks of blood clots
on Estrogen
Blood clots—
– 12% over age 40
– Usually start in the veins of
the legs
– Can break off and block
blood supply to the lungs—a
FATAL complication
(pulmonary embolism)
– 20-fold increased risk in
MTF’s
– Risk increased with oral vs.
transdermal estrogens
– Central retinal vein
occlusion has been reported
Mortality and morbidity in transsexual subjects treated with
cross-sex hormones, Clinical Endocrinology, 47: 37-342
(1997)
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Risk factors for Venous
Thromboembolism
Surgery
Trauma (major or lower
extremity)
Immobility, paresis
Malignancy
Cancer therapy (hormonal,
chemotherapy, or radiotherapy)
Previous venous
thromboembolism
Increasing age
Pregnancy and postpartum
period
Estrogen therapies
Selective estrogen receptor
modulators
Acute medical illness
Heart or respiratory failure
Inflammatory bowel disease
Nephrotic syndrome
Myeloproliferative disorders
Paroxysmal nocturnal
hemoglobinuria
Obesity
Central venous catheterization
Inherited or acquired
thrombophilia
Varicose veins
Smoking
Geerts et al. CHEST 2004:338S-400S.
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Reducing the Risk of Blood
Clots
Smoking cessation
– Pharmacologic support
– Relaxation therapy
– Behavioral therapy
Discontinue HRT for 3-6 weeks prior to any
major surgery, including SRS
Review HRT with surgeon and anesthesiologist
prior to minor surgery
Discontinue HRT in injuries which result in
immobilization
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MTF’s and Diabetes
Estrogen increases the risk for Type 2 diabetes
Risk factors:
– Obesity
– Family history
– Concurrent corticosteroids
Sometimes, the estrogen dose may need to be
reduced to achieve glucose control
Blood sugar should be checked at least annually
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FTM’s and Diabetes
Testosterone increases the risk for Type 2
diabetes (acts through growth hormone)
Risk factors:
– Obesity
– Family history
– Concurrent corticosteroids
Sometimes, the testosterone dose may need to
be reduced to achieve glucose control
Blood sugar should be checked at least annually
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Effects of HRT on
metabolism in FTM’s
Metabolism increases
Increased blood cell mass
Increased muscle mass
– Given a caloric intake and exercise regimen
consistent with pre-hormonal treatment
Weight loss
Increased energy
Decreased need for sleep
Increased Stamina
Risk of Sleep apnea (size 16 neck)
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Effects of HRT on
metabolism in MTF’s
Metabolism decreases
– Given a caloric intake and exercise
regimen consistent with pre-hormonal
treatment
Weight gain
Decreased energy
Increased need for sleep
Cold intolerance
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HIV, hepatitis, and MTF’s
Estimated prevalence of HIV: 25-30%
Hepatitis B/C often are co-infections
Risk factors:
– Using street drugs
– Sharing needles
Psychologic co-factors for unsafe sex:
–
–
–
–
Poor self-esteem
Compulsive sex (to confirm identity)
Lack of safety in a romantic relationship
Substance abuse
Reducing risk:
– Education and behavioral changes
– HIV and Hepatitis B/C testing every 6 months with ongoing risk
behavior
– HIV and Hepatitis B/C testing at least one in life in other patients
Kellog, T. A., Clements-Nolle, K., Dilley, J., Katz, M. H., & McFarland, W. (2001). Incidence of
human immunodeficiency virus among male-to-female transgendered persons in San Francisco.
Journal of Acquired Immune Deficiency Syndrome, 28, 380-4.
Clements-Nolle, K., Marx, R., Guzman, R., & Katz, M. (2001). HIV prevalence, risk behaviors,
health care use, and mental health status of transgender persons: Implications for public health
intervention. American Journal of Public Health, 91, 915-921.
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Other sexually transmitted
diseases
Other sexually transmitted infections
– Gonorrhea
– Chlamydia
– Syphillis
– Herpes
– Trichomonas
– HPV
– Gardnerella
Practice safe sex, care in genital touching, sharing
sex toys
Get tested
Treat partners
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Ts and Mental Health
Depression is not unusual(30-40% in one study)
32% prior suicide attempts
42% in recent study reported need for mental
health assistance
Ask physician for appropriate counseling and
referrals for symptoms of depression
Goldberg, J. M., Matte, N., MacMillan, M., & Hudspith, M. (2003). Community survey:
Transition/crossdressing services in BC – Final report. Vancouver, BC: Vancouver Coastal
Health and Transcend Transgender Support & Education Society.
Clements-Nolle, K., Marx, R., Guzman, R., & Katz, M. (2001). HIV prevalence, risk behaviors, health
care use, and mental health status of transgender persons: Implications for public health
intervention. American Journal of Public Health, 91, 915-921.
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Reproductive
options
To give opportunity
to obtain children who are
genetically “their own”
Sperm banking prior to
HRT for MTF
Embryo banking
Gender reassignment and assisted reproduction, Human
Reproduction 16: 612-614 (2001)
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Osteoporosis
prevention
No increased risk without hormones
in pre-ops MTFs
Pre-op with estrogen, risk is unclear,
probably minimal
Calcium 1200 mg daily with Vitamin D 600 units
daily is recommended
Post-op (risk seems higher)
– Bone densitometry
– Calcium and Vitamin D
– Estrogen therapy/ small dose testosterone therapy
Schlatterer, K., Auer, D. P., Yassouridis, A., von Werder, K., & Stalla, G. K. (1998). Transsexualism
and osteoporosis. Experimental and Clinical Endocrinology and Diabetes, 106, 365-368.
van Kesteren, P. J. M., Lips, P., Gooren, L. J. G., Asscheman, H., & Megens, J. A. J. (1998). Longterm follow-up of bone mineral density and bone metabolism in transsexuals treated with cross-sex
hormones. Clinical Endocrinology, 48, 347-354.
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Osteoporosis
prevention
No increased risk without hormones
in pre-ops FTMs
Calcium 1200 mg daily with Vitamin D 600 units
daily is recommended
Post-op
– Bone densitometry
– Calcium and Vitamin D
Schlatterer, K., Auer, D. P., Yassouridis, A., von Werder, K., & Stalla, G. K. (1998). Transsexualism
and osteoporosis. Experimental and Clinical Endocrinology and Diabetes, 106, 365-368.
van Kesteren, P. J. M., Lips, P., Gooren, L. J. G., Asscheman, H., & Megens, J. A. J. (1998). Longterm follow-up of bone mineral density and bone metabolism in transsexuals treated with cross-sex
hormones. Clinical Endocrinology, 48, 347-354.
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Failure to respond to HRT in MTFs
In no changes are
seen (including
“tender nipples”)
within 2-3 months
or
Feminization is very
limited over a longer
period of time (2-5
years)
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

Serum
testosterone,
DHEAS levels
to rule out
overproduction
of androgens
Referral to an
endocrinologist
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601 Patients in Milwaukie, OR.
Followed Up To Seven and a Half
Years
215 Female to Male ages 20 to 76
76 Chest reconstructions, 2 Bottom surgery (35%)
Postops FTM ages 21 to 76 Preops ages 12-74
Cross dressers 6
1MTFTM (SRS, BI>RBI) living as male (counted as
MTF)
386 Males to Females ages 12 to 78 (includes
MTFTM and 6 CD)
82 postops MTF GRS (21%)
6 orchiectomies
Postop MTF ages 21-77 Preop ages 12 to 78
Less than age 18 at inception of treatment 5
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Male to Female to Male
50 year old genetic male
SRS, Breast implants, facial surgery
Eight years as a female on estrogen
Breast implants removed
Therapy note
Testosterone therapy now with full beard
Living as a male engaged to be married
“There and Back Again” by Bilbo Bagins
Ability to change in humans
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Complications FTM
215 Females to males 2 treated with T Cream, rest
IM
2 cases of liver disease alcoholic suspect in one
No need to stop hormones
Increase in red cell mass in all test from HCT of
about 38 to 50-52 three patients reduce T because
of HCT (>52)
No strokes, heart attacks or breast cancer
Frequent vaginitis
Acne
Three cases of sleep apnea (size 16 neck)
2 hypertension, 2 diabetic (NIDM) 3 hypothyroid
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Complications MTF
386 patients followed up to 7.5
years
All patients are treated with Vivelle microdot,
estradiol injection or sublingual estradiol
No estinyl estradiol
No (CEE) “Premarin”
No progesterone
All are strongly encouraged at each visit to take
aspirin 81 mg, 2 are on comadin, Multivits with folic
acid, 800 u Vit D, and 1200 mg of calcium and not to
smoke
Attempted aggressive risk stratification and control
of coincident disease in consultation with specialists
and primary care MD
5 on replacement testosterone 2.5 mg troche
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Complications MTF
386 Males to Females ages 16 to 79 (pre
and post)
3 cases mild liver disease
6 cases of detected osteoporosis in
MTFPO age 35-52
1 case of pulmonary embolus antithrombin
3 defect
1 case PE 2 days on CEE traveled Maine to
Tx by car, no asa
1 case DVT IM estradiol, ASA NS, FH
clotting dis
1 case of death, MI, 1 wk after srs,
smoker, ASA, patch age 42
1 case of death myocardial infarction age
49 smoker no aspirin
1 case of myocardial infarction age 52 non
fatal during hair transplant nonsmoker, no
ASA
case Sudden death age 49 smoker not
started HRT
1 case during SRS age 52 Thailand prev
smoker, no ASA
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Complications MTF
1 case of prolactin secreting tumor (no
treatment)
4 cases of carcinoma of the throat (2 deaths)
1 case of small cell carcinoma lung met
1 case adenocarcinoma of the lung
1 case of malignant Melanoma met
1 case of invasive prostate cancer –10 years
on 10 mg of CEE
2.1 % incidence
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Complications MTF
Cancers 2.1 %
Myocardial Infarction 1.2%
Osteoporosis 1.5% (note 5 of 7 tested)
Total Serious complications 3.8%
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Complications MTF
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How long Does it Take
Range is 2 to 5 years
Real answer is at least 5 years
Probably a lifetime
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Insights
3 MTF patients with Dx of Schizophrenia
referred by psychiatrists with formal letter
for hormone therapy
1 patient discontinued antipsychotic after
one year on oral estradiol
2 patients reduced or eliminated
medications for schizophrenia
2 FTM with documented Aspergers
Syndrome reported improved by families
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Some Caveats
The process can only move so fast. Higher
doses of hormones beyond a certain point only
increases risk and cost.
Changes in dosage up or down suddenly can
cause significant depression and mental
impairment.
Although hormones are available without
prescription, ask yourself if you would do dental
work or brain surgery on yourself before starting
on your own.
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Alternative Therapies
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Home Remedies
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The Future of Hormone Therapy
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The Future of Hormone Therapy
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The Real Future of Hormone
Therapy?
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Some Caveats
Time never reveals the best answers, only
the wrong ones.
Courage is when you have a choice.
When the airplane is going down, the crew
saves themselves first.
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Resources
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Resources
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[email protected]/t/index.htm
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[email protected]
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Moving Beyond Trans-Sensitivity: Developing Clinical
Competence
in Transgender Care
(the Trans Care Project)
Project Summary and Analysis
Joshua Mira Goldberg
Research Coordinator, Trans Care Project
Donna Lindenberg
Administrative Coordinator, Trans Care Project
a collaboration between Transcend Transgender Support &
Education Society and Vancouver Coastal Health’s Transgender
Health Program, with funding from the Canadian Rainbow Health
Coalition’s Rainbow Health – Improving Access to Care init
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Web Resources
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Questions?
He who asks a question is a fool for five
minutes
He who fails to ask a question is a fool for
life
Old Chinese Proverb
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