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0830 Hatfield.Pdf Masculinizing Options Swedish Hospital LGBTQ Symposium 4/13/2018 Kevin Hatfield MD The Polyclinic - Seattle WA 1 Laith Ashley Benjamin Melzer Gena Rocero 2 GOALS & OBJECTIVES Getting Started with patients Introduction, First visits and discussion points Medications to consider Androgens 5a-reductase Inhibitors, Aromatase Inhibitors Estrogen SERMS (selective estrogen receptor modulators) Progestin-only contraceptives PrEP (Pre Exposure Prophylaxis against HIV) Cases 3 Getting Started Meet the patient, Clarify Name, Pronouns, Gender Terminology Take full histories – Past and Current Medical, Surgical, Psychosocial, Sexual, Family, Medications Physical Exam “Tell me about your gender journey?” When did you first feel your gender was different than how others labeled you? When did you first discover a name for what you were experiencing? Where are you now in the process? What terms feel comfortable to describe your gender? What are your goals for today? Are you working with a skilled therapist? Patient role – “Captain of your own ship.”- Captain Kirk My Role – “safety monitor - fixer,” - Scotty 4 Approach to Masculinization What to Choose? Cross Hormone Protocol? Testosterones Aromatase inhibitors 5a-reductase inhibitors Estrogens Progestins 5 • Anastrazole (Arimidex) • Letrozole (Femara) • Finasteride (Proscar) • Exemastane • Dutasteride (Avodart) (Aromasin) 6 7 8 • Anastrazole (Arimidex) • Letrozole (Femara) • Finasteride (Proscar) • Exemastane • Dutasteride (Avodart) (Aromasin) 9 Timeline for Medicines Medicine When to Start Timeline Notes Testosterone (T) Immediately Every 3-6 months Acne, Weight gain, Mood changes Aromatase inhibitors If ongoing menses/ Titrate to effect 0.5 mg BIW/TIW? High E with slow D 5-a Reductase If androgenic alopecia Set by patient Reduced phallus inhibitor is notable, growth Contraceptives ASAP if penetration by Set by patient Choose non-hormonal sex partner with penis or progestin only method Estrogen (E) Excessive dryness/skin Set by patient Therapy discussion weakness/coital with patient, go over topicals/orals spotting options. ASAP if sexual activity Set by patient, based Q3 month BMP, HIV, RPR, increases risk of HIV on personal risk Oral/Front & Back Hole PrEP* GC/CT-NAAT if exposure. activities applicable * Pre Exposure Prophylaxis Against HIV exposure 10 Testosterone Options Oral – Striant BID adhesive trans-buccal tabs Topical - Patch and Gel – Androgel, Testoderm, Testim, Axiron etc Topical compounds – Customized - creams, ointments, gels Injectable Testosterone - Enanthate, Cypionate, Undecanoate Implantable – Testopel Topical – (Europe only) - Andractim gel (DHT) 11 Testosterone Promotes Drop in vocal pitch Cartilage thickening Frontalis muscle hypertrophy Change in body odor Amenorrhea within first 3-6 months Acne – face and back Muscle development: encourage routine exercise & stretching Increased appetite/weight gain Increase in body hair Facial hair – often much later Scalp hair loss and balding Clitoromegaly Increased libido Mood changes: Irritability is possible BUT most feel Contentment Lab changes: Hct, lipids, sCr, AlkPhos 12 Testosterone Options “T” Type Low Usual Dose Max Cost Dosing Notes Transbuccal 15 mg BID 30 mg BID 60 mg BID >$650/m BID Buccal adhesive Patch 1-2 mg 4 mg 8 mg >$530/m Daily Peel-off, linty halo Gel 1% or 1.62% 12.5 mg 50 mg 100 mg >$120/m Daily Pump or packet Transfer to partner? 2% Axillary Gel 30 mg 60 mg 120 mg $600/m Daily Messy/Sticky Custom Cream 2.5 % 5 % 20% $15-$80/m Daily Specialty Pharmacy (vehicle matters!!!) Cypionate or 20 mg 60 mg 200 mg $5-$20/ Weekly Home SQ Injection Enanthate SQ month Undecanoate 750 mg 750 mg 750 mg $800/10w Q10 Weeks One size fits all IM Injection OFFICE ONLY - IM injection Testo/Stearic 75 mg 375 mg 1125 mg $800-$1200 Q3-4 Office ONLY- Trochar acid pellets /3-4months Months Assisted Insertion 13 Testosterone ½ Life by Type Bio Enanthate Cypionate Undecanoate Type of Half-Life Dose LFT Cancer Risk Lab / Mood Testosterone Frequency D Changes Bio-identical 4-6 hours N/A Rare NOT Observed N/A Enanthate 4.5 days Q7 Days Rare NOT Observed Likely/Possible Cypionate 8 days Q7 Days Rare NOT Observed Likely/Possible Undecanoate 20 days Q70 Days Rare NOT Observed Likely/Possible 14 Testosterone Level by Decade 15 Timeline of Testosterone Changes Site of Change Time of Onset Completion Time Reversible? Skin Oiliness/Acne 1-6 months 1-2 years YES Voice Deepening 2-4 months 1-2 years NO Facial Hair/Body Hair 3-6 months 3-5 years NO Muscle Mass Increase 6-12 months 2-5 years YES Amenorrhea 2-6 months N/A YES Fat Redistribution 3-6 months 2-5 years YES Libido Increase 1-3 months 1-2 years YES Vaginal Atrophy/Dryness 3-6 months 1-2 years YES Clitoral Enlargement 3-6 months 1-2 years NO Androgenic Alopecia 6-12 months 3-5 years NO Fertility Reduction 3-6 months N/A PROBABLY 16 Other Medication Half Life (Consider Flexible Dosing) Medication / Half-Life Dose/ Cash Cost Purpose Action strength Frequency #90 tablets Finasteride 5-7 hours 1 - 2.5 mg $14-$20 Prevent 5a-Reductase 1 mg, 5 mg Daily Alopecia Inhibitor tab (Block DHT) Dutasteride 28 days 0.5 mg $35 Prevent 5a-Reductase 0.5 mg cap Daily - Alopecia Inhibitor Weekly (Block DHT) Anastrazole 2 days 0.5 mg TIW $21 Lower E2 if Blocks T 1 mg tab too high conversion to E Letrozole 2 days Daily $22 Lower E2 if Blocks T 2.5 mg tab too high conversion to E Exemestane 1 day Daily $350 Lower E2 if Blocks T 25 mg tab too high conversion to E 17 Other Medications ( for particular needs ) Medication / Half-Life Dose/ Cash Cost Purpose Action strength Frequency #90 tablets Prasterone / 38 minutes 6.5 mg $540 Reduces Local conversion DHEA 6.5 mg (DHEAS 15 Inserted Daily dryness / into Estrogens/ insert hours) fragility Androgens Ospemifene 26 hours 60 mg daily $620 Reduces SERM acivity on 60 mg oral tab dryness / mucosal tissue fragility Estrogen ring n/a 2 mg Q 90 days $450 Reduces Local release of 2 mg insert dryness / Estrogen to fragility mucosa Etonorgestrel n/a 1 implant Q 3 $900 Contraception Prevents 68 mg implant years Ovulation IUD options n/a Q 3 or more $900+ Contraception Prevents progestin/Cu years Conception 18 Testosterone Induced Lab Value and Risk Changes Probability Observation / Possible Risks Likely Increase of these Lab Values Higher LDL & Triglycerides (Lower HDL) Hematocrit Creatinine Alkaline Phosphatase Possible Increased Risk Polycythemia (Sleep Apnea induced Hypoxemia) Possible Increased Risk if Other Heart Disease Factors Present Type 2 Diabetes (weight gain) No increase Breast/Uterine/Ovarian Cancer 19 20 Typical SQ Testosterone Injection Supplies Testosterone Cypionate 200mg/ml 10 ml vial $45 3-5 month supply 18G 21G 1mL Slip Tip Luer-Lok Syringe 25G 30G 21 Testosterone Dosing and Escalation Treat Patient NOT Protocol Use patient’s age & desired rate of change Consider body habitus and menstrual regularity/dysphoria Start with 20-60 mg SQ weekly (0.1 mL – 0.3 mL of 200mg/mL T Cypionate) Check Total Testosterone and Estradiol at nadir in 5-6+ weeks Look for T nadir between 450-650 and Estradiol <50 IF T <650 consider increase by 20 mg and recheck T in 3-6 months Maintain high range T nadir for 3-5 years to complete changes If Estradiol >60 AND Pelvic complaints, ongoing menses or slow observed changes add 0.5 mg Anastrazole BIW-TIW and look for Estradiol to fall back to normal male range 22 Remember to discuss Sexually Transmitted Infections Some patients may ask about precautions but … Please be proactive – inform and educate, offer 3 site testing “An ounce of prevention…” My mantra – “Leave no ‘active’ orifice untested!” 23 Case 1 - Martin - February 2017 Martin, 18 yo AFAB headed to WSU in Fall. “100% guy” ; he/him pronouns. “I have known since 3rd grade.” Medical history; Vaccine Hx, Surg Hx. Social history – “parents not on board” Working part time for college money (-)Tobacco, (+)THC, (+)Dating No prior HPV vaccine (#1 today) Dates only vagina-bodied people Would like to get a counselor Binder is effective but rigidly inelastic Baseline labs Total T 39 ng/dL, E 215 pg/mL, HCT 35.6% What can we do for him? 24 Martin – April 2017 ; 2 month follow up/lab visit Prior labs T 39 ng/dL E 215 pg/mL Nadir labs prior to visit Total T 270, E 142, HCT 37 HCT 35.6% Medication started – decided to pay cash, ongoing counseling to improve parental relationship Needle phobia is improving (great! HPV#2 today!) Noting some changes from T New binder is “ok, but not great” Dating life is “busier”, Still using THC – “but less than before” Wants Male gender in EPIC & Driver License form Surgical consult information (top surgery) 25 Martin – August 2017, 4 month follow up/lab visit Prior Labs T 270 Nadir Labs done a week prior to visit E 142 Total Testosterone 490, Estradiol 46, HCT 45.6 HCT 37% Physical exam Voice deeper Facial hair Acne – manageable No bleeding for 7 weeks – “very happy” Sexual activity – “Still dating and doing fine” Joint counseling sessions with parents went well! Wants all legal gender forms prior to college (in 2 weeks) HPV #3 today Outline next visits during college breaks Then you get Email in November 2017 about changes in his dating life… 26 Case #2 – Max - July 2016 32 yo Max has known about personal gender nonconformity since gradeschool. Came out to parents & friends as Bisexual in 9th grade. Parent’s voiced “concerns about sexuality” Married to cis-female partner, has 2 yo child. Gender talk with spouse earlier this year – “Went pretty well” They/them pronouns; Identifies as “Non-binary - Transmasculine” PMHx : Obesity, Asthma, Elevated Triglycerides SurgHx : C-section FamHx: Dad HTN, OSA; Mom Obesity, DM2 @44; Brother OSA SocHx: Moved to Seattle 2 months ago from Ames Iowa; Works at Big tech company with wife; 7-10 drinks per week, (-) Tobacco, (-) THC, Committed non-monogamous.
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