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.
Goal for first visit: “Starting T Today since… I’ve wanted to start T since 10th grade” Data from Visit: BP 134/86, BMI 32.2 TChol 178, LDL 87, HDL 42, TG 245 Total T 28 ng/dL, E 310 pg/dL, HCT 38.2 %
What should we do for Max?
27 Items for Max
More health history discussed, Medical record request for more detail… Vaccines?
Physical exam: Vitals, Affect, HEENT, Heart, Lungs, Abd, etc.
Need for healthful food choices and routine exercise on T and preparing for pregnancy
Fertility discussion, They desire pregnancy in next 18 months – Timing of Testosterone and preconception planning. Ob/Gyn referral given.
Testosterone consent forms given, DOL paperwork given. STI/PrEP discussed
Importance of counseling and support during transition reviewed.
Agenda setting and their timeline reviewed “voice deeper & more hair ASAP”
Testosterone injection education materials, Youtube video, Rx (cost coaching)
First 60 mg Testosterone training session – able to self inject with coaching only!
Lab value recheck planned at 10-12 week nadir (they are traveling) with next day office visit.
28 Prior Labs Max – October 2016, 3 month f/u & lab visit T 28 E 310 Vitals BP 130/89, BMI 33.1 HCT 38.2 Nadir Labs done a day prior to visit LDL 87 HDL 42 Total Testosterone 320 ng/dL, Estradiol 156 pg/mL, HCT 47.6%, TG 245 T Chol 192, LDL 84, HDL 35, TG 365
Still having monthly cycle – “tiny bit shorter and lighter” BP 134/86 BMI 32.2 Physical exam
Voice is a little deeper, minimal hair on face. “Changes seem too slow Doc, How much can we raise the dose?”
What do you do?
29 Prior Labs Max – February 2018, 20 month f/u visit T 320 E 156 Have been back on SQ T for 6 months since delivery of 2nd child. HCT 47.6 Bottle feeding. LDL 84 Exercising routinely and committed to healthy food choices HDL 35 Vitals BP 123/82, BMI 28.7 TG 365 Nadir Labs Total Testosterone 580 ng/dL, Estradiol 18 pg/mL, HCT 50.6%, TChol 208 LDL 112, HDL 49, TG 235 BP 130/89 BMI 33.1 Physical exam – deeper voice, some facial hair, androgenic alopecia noted
No bleeding for 3 months
Complaints today: “Dryness and bleeding with sex and the wife says, ‘You snore too much.’”
How can we help Max now?
30 Thank you!
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