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Basics of Hormone Therapy for Transgender Patients Julie K

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Basics of Hormone Therapy for Transgender Patients Julie K Basics of Hormone Therapy for Transgender Patients Julie K. Prussack, MD Northern Michigan Family Medicine Update June 27, 2019 Disclosures None Disclaimer: No medications are currently FDA-approved for gender alteration or affirmation. Discussion of treatment is based on expert opinion. Objectives 1. Understand the difference between informed consent and referral letter models for initiating hormone therapy. 2. Access UCSF Guidelines for the Primary and Gender- Affirming Care of Transgender and Gender Nonbinary People. 3. Understand the medications, routes, and doses typically used for feminizing and masculinizing therapy. 4. Understand typical expectations and monitoring for patients on feminizing or masculinizing therapy. Hormone Therapy • Goal to suppress endogenous hormones by providing exogenous hormones • Affects secondary sex characteristics • Masculinizing: testosterone • Feminizing: estrogen, anti-androgen, ?progesterone • Patients may desire surgery of body contours and genitalia • Referral letter vs. informed consent models Stroumsa et al. Gender affirming treatment ant transition-related care. URL: https://www.youtube.com/watch?v=3ixr0YgB0As WPATH • Incorporated in 1979 as the Harry Benjamin International Gender Dysphoria Association, changed name to World Professional Association for Transgender Health in 2007 • 7th version of Standards of Care (SOC) published in 2012 • Mission to promote evidence based care, education, research, advocacy, public policy, and respect in transgender health. World Professional Association for Transgender Health, 2016. URL: www.wpath.org WPATH Criteria for Hormone Therapy 1. Persistent, well-documented gender dysphoria 2. Capacity to make a fully informed decision and to consent for treatment 3. Age of majority in a given country (if younger, follow SOC for Puberty-Suppressing Hormones) 4. If significant medical or mental health concerns are present, they must be reasonably well-controlled. Coleman et al. Standards of Care for the Health of Transsexual, Transgender, and Gender Nonconforming People, 7th version. The World Professional Organization for Transgender Health, 2012. URL: www.wpath.org Gender dysphoria (F64.0) • Discomfort or distress that is caused by a discrepancy between a person’s gender identity and that person’s sex assigned at birth (and the associated gender role and/or primary and secondary sex characteristics) • DSM-V diagnosis, adapted from “sexual identity disorder” (DSM-IV) • Alternatively can use Endocrine disorder, NOS (E34.9) • Different from gender nonconformity (“a person’s gender identity, role, or expression differs from the cultural norms prescribed for people of a particular sex”) Coleman et al. Standards of Care for the Health of Transsexual, Transgender, and Gender Nonconforming People, 7th version. The World Professional Organization for Transgender Health, 2012. URL: www.wpath.org Gender dysphoria (DSM-V) Lasts at least six months and is shown by at least two of the following: • A marked incongruence between one’s experienced/expressed gender and primary and/or secondary sex characteristics • A strong desire to be rid of one’s primary and/or secondary sex characteristics • A strong desire for the primary and/or secondary sex characteristics of the other gender • A strong desire to be of the other gender • A strong desire to be treated as the other gender • A strong conviction that one has the typical feelings and reactions of the other gender Parekh, R. What is gender dysphoria? American Psychiatric Association, Feb 2016. URL: https://www.psychiatry.org/patients- families/gender-dysphoria/what-is-gender-dysphoria Referral letter 1. The client’s general identifying characteristics; 2. Results of the client’s psychosocial assessment, including any diagnoses; 3. The duration of the referring health professional’s relationship with the client, including the type of evaluation and therapy or counseling to date; 4. An explanation that the criteria for hormone therapy have been met, and a brief description of the clinical rationale for supporting the client’s request for hormone therapy; 5. A statement that informed consent has been obtained from the patient; 6. A statement that the referring health professional is available for coordination of care and welcomes a phone call to establish this. Coleman et al. Standards of Care for the Health of Transsexual, Transgender, and Gender Nonconforming People, 7th version. The World Professional Organization for Transgender Health, 2012. URL: www.wpath.org Referral letter • Hormone therapy (?) and breast/chest surgery require one referral letter from a qualified mental health professional • Genital surgery requires two referral letters from qualified mental health professionals Coleman et al. Standards of Care for the Health of Transsexual, Transgender, and Gender Nonconforming People, 7th version. The World Professional Organization for Transgender Health, 2012. URL: www.wpath.org Informed Consent - WPATH “Initiation of hormone therapy may be undertaken after a psychosocial assessment has been conducted and informed consent has been obtained by a qualified health professional... A referral is required from the mental health professional who performed the assessment, unless the assessment was done by a hormone provider who is also qualified in this area.” Coleman et al. Standards of Care for the Health of Transsexual, Transgender, and Gender Nonconforming People, 7th version. The World Professional Organization for Transgender Health, 2012. URL: www.wpath.org Informed Consent – Fenway Health “The prescribing provider must make an assessment of each patient’s competency and ability to understand these risks and benefits and make an informed decision. We respect the individual’s sense of self and agency, and will provide cross sex hormone therapy (CSHT) under an informed consent model. However, informed consent does not mean ‘hormones on demand,’ but requires that the prescribing provider, along with the patient, assess for and manage physical and mental conditions which might impact the safety and success of hormone therapy and surgical interventions.” The Medical Care of Transgender Persons. Fenway Health Transgender Health Program. Fall 2015. URL: https://www.lgbthealtheducation.org/wp-content/uploads/COM-2245-The-Medical-Care-of-Transgender-Persons-v31816.pdf https://fenwayhealth.org/documents/medical/transgender- resources/Fenway_Health_Consent_Form_for_Feminizing_Therapy.pdf https://fenwayhealth.org/documents/medical/transgender- resources/Fenway_Health_Consent_Form_for_Feminizing_Therapy.pdf Coleman et al. Standards of Care for the Health of Transsexual, Transgender, and Gender Nonconforming People, 7th version. The World Professional Organization for Transgender Health, 2012. URL: www.wpath.org Feminizing Hormone Therapy Contraindications to estrogen: • previous venous thrombotic events related to an underlying hypercoagulable condition • history of estrogen- sensitive neoplasm • end-stage chronic liver disease Start at low doses and increase gradually at 3-6 months intervals Permanent Coleman et al. WPATH SOC. Feminizing Hormone Therapy (T O M) Hormone Initial-lowb Initial Maximum Comments Estrogen If >2mg recommend dividing Estradiol PO/SL 1mg/day 2-4mg/day 8mg/day bid. Max single patch dose available Estradiol transdermal 50mcg 100mcg 100-400 mcg is 100mcg. Frequency of change is product dependent. Estradiol valerate IMa <20mg IM q2 wk 20mg IM q2wk 40mg IM q2wk May divide dose to weekly. Estradiol cypionate <2mg q 2wk 2mg IM q2wk 5mg IM q2wk May divide dose to weekly. IM Androgen blocker Spironolactone 25mg qd 50mg bid 200mg bid Finasteride 1mg qd 5mg qd Dutasteride 0.5mg qd Center of Excellence for Transgender Health, Department of Family and Community Medicine, University of California San Francisco. Guidelines for the Primary and Gender-Affirming Care of Transgender and Gender Nonbinary People; 2nd edition. Deutsch MB, ed. June 2016. Feminizing Hormone Lab Monitoring Test Baseline 3 mo. 6 mo. 12 mo.Yearly PRN Comments BUN/Cr/K+ X X X X X X Only w/spironolactone Lipids Per USPSTF X Otherwise no evidence A1c or glucose Per USPSTF X Otherwise no evidence Estradiol XX X Total Testosterone XXX X Sex Hormone Optional to calculate XXX X Binding Globulin bioavailable testosterone Albumin XXX X“ Only if symptoms of Prolactin X prolactinoma Center of Excellence for Transgender Health, Department of Family and Community Medicine, University of California San Francisco. Guidelines for the Primary and Gender-Affirming Care of Transgender and Gender Nonbinary People; 2nd edition. Deutsch MB, ed. June 2016. Feminizing Hormone Lab Monitoring • Titrate to clinical response • Use hormone levels as a guide • Goal levels: • Testosterone below physiological female range (<55ng/dL) • Estrogen in physiologic pre-menopausal range and below supraphysiologic level Center of Excellence for Transgender Health, Department of Family and Community Medicine, University of California San Francisco. Guidelines for the Primary and Gender-Affirming Care of Transgender and Gender Nonbinary People; 2nd edition. Deutsch MB, ed. June 2016. Progesterone • No evidence for or against • Anecdotes of improved breast development, mood and libido • ?Risk of breast cancer, cardiovascular disease • Medroxyprogesterone acetate (Provera) 2.5mg-10mg qHS • Micronized progesterone (Prometrium) 100-200mg qHS (theoretical risk of direct androgenizing effect) Center of Excellence for Transgender Health, Department of Family and Community Medicine, University
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