Primary and Preventive Care for Transgender and Non-Binary People Madeline B. Deutsch, MD, MPH Associate Professor of Clinical Family & Community Medicine Medical Director, UCSF Transgender Care University of California – San Francisco November 2, 2019 Disclosures . Nothing relevant to disclose . Will discuss off-label use of FDA approved medications 46 y/o transgender man wants to begin testosterone therapy . BMI 32 . Hx oligomenorrhea . Taking escitalopram for anxiety . In a monogamous relationship with non-transgender (cisgender) male partner . Has been living full time as a male for 3 years . Interested in chest surgery 35 year old transgender woman wants to begin estrogen therapy . History of borderline hyperlipidemia according to her prior physician . ½ ppd smoker x 10 years, unwilling to quit . Has been cross-dressing for many years in secret . Married to a heterosexual woman who is not accepting of pt desires, they have a 3 y/o son . Has not yet spoken with coworkers/boss 19 year old person presents seeking primary care . Name: Chase . Gender ID: Non-binary . Pronouns: They/Them . Birth-assigned sex: Male . Housing: Couch surfing . Income: Occasional sex work, food stamps . Substance abuse: Tobacco 2-3 cig/day, marijuana . Polyamorous, some condomless receptive and insertive sex Tobacco . Smoking in the setting of any estrogen use is a risk factor for venous thromboembolism (VTE) . What if unwilling or unable to quit? . Harm reduction approach . Transdermal estradiol (lower VTE risk) . Aspirin 81mg/day . Risk/benefit ratio for gastrointestinal hemorrhage is unknown Pituitary adenoma . Several cases have been reported in transgender women(19) . However, Endocrine Society guidelines recommend watchful waiting only in cases of assymptomatic prolactinomas (20) . Therefore in the absence of visual disturbances, galactorrhea, or headache syndromes, routine monitoring of prolactin not likely of clinical value Migraines . Migraines have a clear hormonal component . Patients with hx of complex/severe migraines should begin at low dose and titrate slowly . Oral or transdermal routes may be preferred to avoid cyclic levels seen with injected estrogen (24) . Unclear if the known increased risk of stroke in patients using oral contraceptives with a history of aura applies to transgender patients using 17- beta estradiol Use of estrogens in the perioperative period . No clear evidence that transgender women at average risk of VTE should stop estrogen in the perioperative period . Lowering dose or changing to transdermal route may be advisable (27) . Studies of risks of perioperative oral contraceptives (ethinyl estradiol) have mixed results and methodological limitations (28) . Stopping hormones abruptly in the setting of major surgery and gonadectomy can have negative impact Venous thromboembolism – data from menopause literature . Menopausal studies suggest no increased risk when transdermal estradiol used (29) . Menopausal data on oral 17-beta estradiol is mixed, with risks as high as 2.5-4x increase (10,29) . With a background rate of 1:1,000 to 1:10,000 in general population, absolute increase is small (4) Venous thromboembolism – data in transgender women . Studies > 10 years old showing 20 to 40 fold increase involved use of up to 200mcg/day of ethinyl estradiol, and did not control for tobacco use (30,31) . These studies are not applicable to modern 17-beta estradiol regimens used in an average risk, non-smoking population . No increased risk has been observed in a large retrospective sample of Dutch transgender women using 17-beta estradiol (5) Primary and secondary prevention of VTE . Insufficient evidence to guide the use of estrogen therapy, anticoagulation, or antiplatelet therapy in transgender women with risk factors or personal history of DVT . Case series of 11 transgender women with activated protein C resistance using transdermal estradiol without anticoagulation or antiplatelet therapy found no VTE after mean 64 months (32) Coexisting metabolic disorders . Metabolic syndrome . Obesity . Hyperlipidemia . Impaired glucose tolerance . Polycystic ovarian syndrome (PCOS) Coexisting metabolic disorders . PCOS is not a contraindication to testosterone therapy . Do maintain higher index of suspicion for hyperlipidemia and diabetes . Amenorrhea in the presence of testosterone generally indicates endometrial atrophy (18,19) rather than hyperplasia Coexisting metabolic disorders . Psychosocial benefits of testosterone may include positive lifestyle changes which can reduce obesity and glucose and lipid disorders . These benefits likely outweigh any potential increased metabolic risks Acne . Approach is similar to that in non-transgender people . Acne tends to peak in 1st year of therapy, then declines (20) . Avoiding supraphysiologic levels, and avoiding excessive peaks associated with prolong (2-4 week) dosing intervals may help minimize acne Coronary artery disease screening . 48 y/o transgender person seeking to begin hormone therapy . Father died at age 59 of heart attack . BMI 29 . They want to know about their cardiac risk . Should they have their cholesterol checked before starting treatment? Coronary artery disease screening Considerations . Any additional/specific screening recommendations? . What does the evidence say . Baseline risk, contributions of minority stress . Any added risk from hormone therapy? . What gender to use when calculating risk? . Primary prevention? . Any specific hormone therapy considerations to reduce risk? Cis Cis Cis Cis Cis Cis Vaginal Flora in the Neovagina . Lack of lactobacilli and presence of BV . No association between symptoms and a particular species STI screening after vaginoplasty? . Penile inversion technique – skin lined vagina . ? Urethral mucosa used . Sigmoid colon vaginoplasty . Less common . Mucosa Breast Cancer Breast Cancer – Transgender Women Mean age @ start of tx 29 +/- 13 yrs Mean follow-up period 21 +/- 9 yrs Estimated 4.1 cases / 100k person-years (95% CI = 0.8 to 13) Rates in the cis Dutch population 1.1/100k men and 155/100k women Breast Cancer – Transgender Men . Estrogen levels persist when on testosterone (aromatase activity) . Role of testosterone in breast cancer pathogenesis . How do you screen someone post-mastectomy? Breast Cancer – Transgender Men Mean age @ start of tx 23 +/- 7 yrs Mean follow-up period 20 +/- 7 yrs Estimated 5.9 cases / 100k person-years (95% CI = 0.5 to 27.4) Rates in the cis Dutch population 1.1/100k men and 155/100k women ? Study Limitations . Retrospective cohort - this was not a screened population . Outcome of breast cancer was only based on clinical presentation / diagnosis . Did not stratify by mastectomy status . Use of hormones not clear . How were transgender subjects identified? Female >90% endorsed preference for self-collection over provider collection 47 Cancer Screening Potpourri . Trans women . Breast CA if > 5 yrs lifetime estrogen AND > 50 y/o . Prostate CA ? (tx for prostate CA is E + anti-andr) . Trans men . Breast CA as with non-trans women if no surg . Chest wall exam/MRI/UTZ if post-surg? . No evidence of risk of Ovarian/Uterine CA . Trans men require routine cervical screening Cancer & Osteoporosis Potpourri . Trans women . Breast CA if > 5 yrs lifetime estrogen AND > 50 y/o . Prostate CA ? (tx for prostate CA is E + anti-andr) . Osteoporosis as with non-trans or sooner if prolonged period without hormones < age 50 . Trans men . Breast CA as with non-trans women if no surg . Chest wall exam/MRI/UTZ if post-surg? . No evidence of risk of Ov/Ut CA . Trans men require routine cervical screening . Osteoporosis as with non-trans or sooner if prolonged period without hormones < age 50 Fertility Fertility . Transgender women . Sperm storage . Surgical sperm extraction . Removes need for orgasm . Invasive procedure . Transgender men . Oocyte / embryo / tissue preservation Fertility - Options . Post-hormones . Sperm preservation…. Stop hormones? HCG? . Impact of T on ovarian structure/function . Cumulative T exposure? . Time since d/c T? . Role of contraception Pregnancy and Transgender Men . 41 FTM, mean age 28 . 20% conceived while still amenorrheic . 11/13 “at risk” wanted to avoid pregnancy . 4 of 11 on T . 3 of 4 w/ amenorrhea . 3 of 11 not using contraception . 2 of 3 on T . 1 of 2 amenorrheic.