What to Know a 21 st Century Approach to Transgender Medical Care

Transcription

1 What to Know a 21 st Century Approach to Transgender Medical Care Joshua Safer, MD Transgender Medicine Research Group Center for Transgender Medicine and Surgery

2 Patient / Mental Health Provider Gatekeeper Model Hormone Provider Surgeons

3 In the past decade, there has been greater acceptance of transgender care within conventional medical circles

4 Background Potential factors determining gender identity: 1. Environment 2. Societal construct 3. Passive response to anatomy 4. Biological

5 Evidence for the biological nature of gender identity Historical attempts to manipulate gender identity Twin studies Attempts to find brain anatomy associations with gender identity

6 If this biology what do we need to know?

7 Patient/PCP Medical model Endocrinology Specialist Mental Health Provider Surgeons other specialists

8 Presentation of Transgender Individuals presentation in adulthood is common and late adolescence more the norm than the exception. Articulation? Awareness? Not known. Fertility is addressed in an ad hoc fashion.

9 Strategy: December 11, 2011

10 Male hormones Female hormones Testosterone Estradiol Testosterone Estradiol

11 Current Approach to Therapy Adolescents: GnRH agonists at Tanner 2 Adult Transmen: androgen supplementation can be lifelong. Adult Transwomen: blockade to some degree of androgen production or action along with some degree of estrogen supplementation thrombosis concerns.

12 Primary Treatment Strategy Female to male: Titrate quickly to male serum testosterone levels But NB: I start at ½ dose mg IM or SQ testosterone (enanthate or cypionate) q week; gel is fine; patches OK if tolerated Keep serum range

13 For F to M, follow T and androgen sensitive indexes Female to male: Follow - serum testosterone - CBC - lipid profile Don t neglect Pap smears, mammograms etc.

14 Treatment Strategy Male to female: Anti-androgens usually essential: Spironolactone -- may require high doses ( mg/day 200 usual) -- other anti-androgens OK: Leuprolide (Lupron) Cyproterone acetate (in Europe)

15 Medical Treatment Strategy

16 Medical Treatment Strategy spironolactone Androgen receptors

17 spironolactone Known mechanism Safety Known pitfalls (K, BP) + Unknown mechanism

18 Medical Treatment Strategy

19 Medical Treatment Strategy GnRH agonists Very clear mechanism Effective Safety? Cost

20 progestins -- is there the logic?

21 progestins -- is there the logic? Lowers testosterone Anecdotal reference to areola Some data support modest virilization; most recent data suggest INCREASED prolactin Logic woman w/ uterus Concern for post-menopausal woman

22 5 α reductase inhibitors

23 Medical Treatment Strategy DHT (in tissues)

24 Medical Treatment Strategy 5 alpha reductase inhib. DHT (in tissues)

25 Expectations Modestly protective of scalp hair with male level androgens

26 Medical Treatment Strategy estrogens

27 Estrogens oral estradiol 2-6 mg/day conjugated estrogens mg/day ease, cost, horses vs lab ethinyl estradiol - thromboses other (e.g. bio-equivalent ) quality control

28 estrogens injectable estradiol valerate 5-20 mg IM every 1-2 weeks. estrogens other transdermal (gel or patch) every day. (may have role for trans-men) implantable

29 For M to F, follow T, estrogen sensitive indexes, and K Male to female: Follow - serum testosterone - estrogen level - K - lipid profile - prolactin

30 Health concerns long term? The only pitfalls known are HYPOGONADISM (osteoporosis and perhaps metabolic concerns) and SUPRA-PHYSIOLOGIC levels which may expose individuals to harm without known benefit (e.g. erythrocytosis with testosterone and thrombosis risk with estrogen).

31 Surgical Options Female to male: -- Chest Reconstruction * -- Genital Surgery (Phalloplasty) Male to female: -- Facial Feminization -- Genital Surgery (Vaginoplasty) * -- Breast Augmentation

32 Post-surgery (and aging) considerations Less estrogen Some estrogen Some testosterone

33 Only a minority of transgender individuals have surgery Increased acceptance of transgender people has 2 potentially competing results: 1. Access to surgery increased with more providers and better insurance coverage 2. Interest in surgery may decrease with greater societal acceptance.