Disclosures. Endocrine Care of the Transgender Patient. Objectives. Start where you are. Use what you have. Do what you can. Vocabulary.

Transcription

1 Disclosures Endocrine Care of the Transgender Patient Kathryn Tierney, MSN, APRN, FNP-BC Medical Director, Middlesex Hospital Transgender Medicine Program Middlesex Multispecialty Group Division of Endocrinology November 8, 2018 Speaker has no relationships to disclose Objectives Participant will be able to understand and use appropriate vocabulary to address transgender patients Participant will be able to list common doses, routes and side effects for both masculinizing and feminizing therapy Participant will be able to identify potential unwanted side effects of hormone therapy and list prevention strategies. Start where you are. Use what you have. Do what you can. - Arthur Ashe Sex Gender Sexual orientation Vocabulary Vocabulary Transgender Gender non-conforming Gender dysphoria Trans man/trans woman Passing Stealth 1

2 The Binary Population data De-pathologizing gender Gender diversity pathology Experiencing gender Through body Through cultural and social interaction Gender is pervasive in our culture Treating the human What organs are present Using preferred name and preferred pronoun Williams Institute (2016): 0.6% or 1.4 million people Likely an underestimate Flores et al, June ,715 respondents in 2015 Included all 50 states and DC, Guam, Puerto Rico and US military bases 40% attempted suicide in their lifetime 33% had at least one negative interaction with a healthcare provider 23% did not seek healthcare that they needed 46% were verbally harassed in the year before 47% sexually assaulted in their lifetime 57% did not feel comfortable asking the police for help 59% avoided using a public restroom 32% limited food or drink intake 8% had a UTI or kidney infection Health discrimination 19% refused care outright Microagressions and minority stress 28% verbally harrassed in a medical setting 50% had to teach their medical provider Name Gender pronoun EHR Billing Documentation I would have never known you used to be a girl/boy What s your real name? But you re so pretty! Did you have the surgery? I would never have known that you were trans! I have a cousin who is trans! 2

3 Coding and documentation Informed consent documentation Risks and benefits to treatment Clear documentation (forms?) ICD-10 codes Gender dysphoria F64.9 Hypogonadotropic hypogonadism E23.0 Endocrine disorder not otherwise specified E34.9 DSM 5 WPATH 28 years old I ve known since I was a kid that I was a boy. I fought my mom all the time telling her I wasn t a girl. I wouldn t wear dresses. I made her cut my hair short. It got worse when I was a teenager. I didn t know there was a word for what I am until I got to college. No therapist currently History of suicidal ideation and inpatient treatment followed by intensive outpatient two years ago. WPATH, 2011 Goals Effects Masculinize Suppress (or prevent) secondary sex characteristics from natal organs Maintain emotional stability Irreversible Voice deepening Facial hair growth Balding Clitoral enlargement Reversible Oiler skin / acne Redistribution of fat / increased muscle mass Irritability / depression Increased libido Vaginal atrophy Amenorrhea Infertility 3

4 History Labs CMP, CBC, lipids, TSH, Vitamin D Informed consent Hormone initiation Testosterone Testosterone cypionate or enanthate subcutaneous or IM injection 200mg/mL in a 1cc syringe, 18G to draw up, 25G 5/8 to inject mg weekly or mg every 2 weeks Implanted Testopel Transdermal g of testosterone per day Androgel 1.62% 1.25g per actuation Testim, Androgel 1% packet or pump Axiron 30mg in each actuation, 60mg per day Androderm 2mg, 2.5mg, 4mg, 5mg Fortesta 40mg daily (4 pumps) Compounded cream Risks Polycythemia Testosterone is not a form of birth control Liver dysfunction Increased risk of metabolic disorders Dyslipidemia, insulin resistance, weight gain Stroke risk Surgery Mastectomy Hysterectomy/oopherectomy Metoidioplasty with or without cavity closure Phalloplasty Scrotoplasty Restart psychotherapy Initiate testosterone cypionate 200mg/mL 0.3cc IM weekly Review labwork and order medications Check state-wide data system Follow up in 3 months with labs CMP, CBC, total testosterone 23 years old I was always very feminine. I assumed I was just gay. On Saturday s I work as a drag queen. I found that every Saturday I didn t want to take the dress off. Every night I would sleep in the dress and be sorry to take it off Sunday morning. Therapist referral BMI >30 but no other significant medical issues 4

5 Goals Effects Feminize Maximize breast tissue growth Suppress testosterone Irreversible Breast tissue growth Decreased testicular volume Reversible Softening of the skin Arrests progression of balding Redistribution of fat Decreased muscle mass Decreased libido (?) and spontaneous erections Infertility History Labs CMP, lipids, TSH, Vitamin D +/- testosterone, prolactin Informed consent Hormone initiation Estrogen Oral estradiol tablets (2mg) Up to 6mg daily in divided doses Use sublingually or orally Parenteral estradiol valerate 10mg/mL, 20mg/mL, 40mg/mL 5-10mg IM or subcutaneously weekly Use 18G to draw up, inject with 1cc syringe 25G 5/8 needle Transdermal patches 0.1mg/24 hour Up to 0.4mg once or twice weekly Ancillary medications Spironolactone 100mg twice daily Up to 300mg per day Finasteride 2.5-5mg daily Progesterone Medroxyprogesterone 5mg daily Prometrium 100mg daily Depo-Provera All but estrogen is discontinued after surgery Risks Pulmonary embolus / Deep vein thrombosis Gallstones Pituitary mass Breast cancer Migraines Dyslipidemia (particularly triglycerides) Electrolyte disorders, hypotension (spironolactone) Decreased libido (finasteride) Depression (progesterone) 5

6 Surgery Breast augmentation Penectomy Orchiectomy Vaginoplasty / clitoroplasty / vulvoplasty Dilation / intercourse Non-genital surgery Facial feminization, voice surgery, thyroid cartilage reduction, liposuction, lipofilling, hair reconstruction Initiate hormone therapy Estradiol 2mg tablets twice daily Can take orally or sublingually Spironolactone 50mg twice daily Consider deferring spironolactone for 3 months Anticipatory guidance Follow up in 3 months with labwork CMP, estradiol, total testosterone Community health Exercise Smoking Safer sex Not all is lost! Global philosophy Being transgender is not a disease It takes a team There is no such thing as binary Come as you are You are an expert in compassion References Center of Excellence for Transgender Health. (2011). Primary Care Protocol for Transgender Patient Care. University of California, San Francisco, Department of Family and Community Medicine. Hembree, W.C., Cohen-Kettenis, P.T., Gooren,L., Hannema, S.E., Meyer, W.J., Murad, M.H., Rosenthal, S.M., Safer, J.D., Tangpricha, V., T Sjoen, G.G. (2017) Endocrine Treatment of Gender-Dysphoric/Gender- Incongruent Persons: An Endocrine Society Clinical Practice Guideline, The Journal of Clinical Endocrinology & Metabolism, Volume 102, Issue 11, 1 November 2017, Pages James, S. E., Herman, J. L., Rankin, S., Keisling, M., Mottet, L., & Anafi, M. (2016). The Report of the 2015 U.S. Transgender Survey. Washington, DC: National Center for Transgender Equality. World Professional Association for Transgender Health. (2011). Standards of Care for the Health of Transsexual, Transgender, and Gender- Noncomforming People 6

7 THANK YOU Middlesex Hospital Division of Endocrinology 7