Hormone Therapy Overview for the Behavioral Health Provider Julie Thompson, PA Fenway Health
Continuing Medical Education Disclosure Program Faculty: Julie Thompson, PA Current Position: Physician s Assistant, Fenway Health Disclosures: No relevant financial relationships. All hormone therapy for transgender people is off-label. It is the policy of The National LGBT Health Education Center, Fenway Health that all CME planning committee/faculty/authors/editors/staff disclose relationships with commercial entities upon nomination/invitation of participation. Disclosure documents are reviewed for potential conflicts of interest and, if identified, they are resolved prior to confirmation of participation. Only participants who have no conflict of interest or who agree to an identified resolution process prior to their participation were involved in this CME activity.
Hormone Readiness
WPATH Criteria for Initiating Hormone Therapy Persistent, well-documented gender dysphoria Capacity to make a fully informed decision and consent to treatment Age of majority in a given country If significant medical or mental health concerns are present, they must be reasonably well-controlled
Informed Consent Model Effectively communicate benefits, risks and alternatives of treatment to patient Judge that the patient is able to understand and consent to the treatment Informed consent model does not preclude mental health care Based on clinical judgment Lack of contraindications Pt. capacity to give informed consent Pt with clear understanding of information they are consenting to expectations, knowns, unknowns
Initial Visits Reviewing implications and obtaining consent: Reproductive Rights - freezing sperm/eggs, ability to get pregnant despite testosterone therapy Permanent vs transient changes Goals of short-term and long-term Short and long-term risks, screenings unknowns! Social implications supports job/career sex
Hormone Therapy
FTM Hormone Therapy
Female to Male Treatment Options Injectable Testosterone Testosterone Enanthate or Cypionate Transdermal Testosterone Androderm Topical testosterone Gels in packets and pumps, multiple formulations (Testim, Androgel) Axiron 2% pump gel for axillary application 1 pump to each axilla daily Testosterone Pellet Testopel- implant q 3 to 6 months
Female to Male Treatment Options
Masculinizing Effects of Testosterone Effect Onset (months) Maximum (years) Skin oiliness/acne 1-6 1-2 Fat redistribution 1-6 2-5 Cessation of Menses 2-6 Clitoral enlargement 3-6 1-2 Vaginal atrophy 3-6 1-2 Emotional changes Increased sex drive
Masculinizing Effects of Testosterone Effect Onset (months) Maximum (years) Deepening of voice 3-12 1-2 Facial/Body Hair Growth 6-12 4-5 Scalp Hair Loss 6-12 Increased Muscle Mass & Strength Coarser Skin/ Increased Sweating Weight Gain/Fluid Retention Mild Breast Atrophy Weakening of Tendons 6-12 2-5
Other Treatment Therapies for FTM Testosterone cream in Aquaphor for clitoral enlargement Estrogen vaginal cream for atrophy Rogaine or Finasteride for male pattern baldness Use of Progesterone aid in cessation of menses before or after starting testosterone therapy LARC for cessation of menses/birth control
MTF Hormone Therapy
Male to Female Treatment Options Antiandrogens Spironolactone (aldactone) Finasteride (Proscar) Oral Estrogens Estradiol (estrace) Premarin (conjugated estrogens) Transdermal Estrogens Estradiol patch, twice weekly Injectable Estrogens Estradiol valerate 5-20mg IM q2 weeks Estradiol cypionate 2-10mg IM weekly
Feminizing Effects of Estrogens and Anti-Androgens Effect Onset (months) Maximum (months) Decreased Libido 1-3 3-6 Decreased Spontaneous Erections Breast Growth 3-6 24-36 Decreased Testicular Volume 3-6 24-36 Decreased Sperm Production Unknown Unknown Redistribution of Body Fat 3-6 24-36 Decrease in Muscle Mass 3-6 12-24 Softening of Skin 3-6 Unknown Decreased Terminal Hair 6-12 >36
Cosmetic Therapies Hydroquinone Topical treatment for pigmentation caused by estrogen therapy Hair Removal Eflornithine (Vaniqa) cream Electrolysis Laser hair removal
Physical Implications and Risks
Risks of Estrogen Therapy Venous thrombosis/thromboembolism Weight gain Decreased libido Increased triglycerides Elevated blood pressure Decreased glucose tolerance /risk of diabetes Gallbladder disease Benign pituitary prolactinoma Breast cancer(?) Infertility
Health Considerations for the Trans Feminine Spectrum Thrombosis/Blood clots Rates of 1 to 6% reported Associated with cigarette smoking and immobility (surgery) Type of anti-androgen and estrogen used (ethinyl estradiol)
Health Considerations for the Trans Feminine Spectrum Cardiovascular disease About 50 to 60% higher risk in transwomen Associated with smoking and higher baseline cholesterol levels Higher rates of diabetes may play a role Type of estrogen used
Risks of Testosterone Therapy Lower HDL Elevated triglycerides Increased homocysteine levels Hepatotoxicity? Polycythemia Unknown effects on breast, endometrial, ovarian tissues Increased risk of sleep apnea (Insulin resistance) Infertility
Health Considerations for Trans Masculine Spectrum Polycythemia/ increase in red blood cells?risk of blood clots, heart attacks and strokes Dosage and form of testosterone used
Good News No increase in the incidence of cancers in transwomen or transmen.
Risks of Hormone Therapy 2011 review of Dutch patient cohort 966 transwomen and 365 transmen 50% higher mortality rate in MTF patients compared to general population Most of the increase in mortality was due to higher rates of suicide, drug-related deaths, and AIDS The mortality rate for trans men was similar to the general population
Mental Health Implications
Mental Health Issues Estrogens can potentially worsen depression Testosterone may destabilize bipolar disorder, schizophrenia, impulse control disorders
Mental Health Benefit Access to cross-sex hormone therapy has been reported in a number of studies to be associated with better functioning in terms of : gender dysphoria relief quality of life improvement psychological functioning decrease in suicide attempts improve body image
Depression and Suicide Weighing risks and benefits: Well-controlled BH issues vs Harm Reduction and Baseline functioning Suicide rates: In some surveys, up to 40% of transgender/gender variant individuals report having ATTEMPTED suicide. Suicidal ideation rates as high as 64% A 2009 NYC Metro survey of 571 transwomen found a lifetime history of suicidal thinking of approximately 53%, suicidal planning of approximately 35%, and attempted suicide rate of 28 35%
Depression and Suicide A 2009 study of 515 transgender individuals in San Francisco found that depression approaches 62% in trans women and 55% in trans men NYC metropolitan area survey found that 52 54% of trans women have a lifetime history of major depression
Depression and Suicide ** But, suicide rates remain higher than in the general population even after hormones or surgery. Minority Stress Discrimination Expectations not met
Additional Topics in Hormone Therapy
Options for Non-binary Identified People Lower doses? Shorter courses? Testosterone blockers alone? What are the risks of stopping hormone therapy?
Questions?
Resources UCSF Center of Excellence for Transgender Health Guidelines http://transhealth.ucsf.edu/trans?page=lib-00-00 Vancouver Coastal Health Guidelines http://transhealth.vch.ca/resources/careguidelines.html The Endocrine Society Guidelines (First published September, 2009) http://www.endo-society.org/guidelines/final/upload/endocrine-treatment-of- Transsexual-Persons.pdf Transline http://project-health.org/transline/ Surgical options: http://www.surgery.ubc.ca/presentarch/srs.pdf http://ai.eecs.umich.edu/people/conway/ts/srs.html#anchor66325 http://ai.eecs.umich.edu/~mirror/ffs/lynnsffs.html http://ai.eecs.umich.edu/people/conway/tssuccesses/tssuccesses.html http://www.thetransitionalmale.com/