Transgender Medicine: Essentials for the Primary Care Provider BENJAMIN J. BOH, DO, MS ASSISTANT PROFESSOR OF MEDICINE SECTION OF ENDOCRINOLOGY GEISEL SCHOOL OF MEDICINE AT DARTMOUTH
Disclosure I will be discussing off-label use of testosterone, estradiol, leuprolide and histrelin No financial interest in any pharmaceutical product
Transgender umbrella page from the GENDER book. (cc) www.thegenderbook.com Transgender men = Female Male Transgender women = Male Female
Transgender history 1929-1939 Era of sex steroid discovery 1940 Dr Harry Benjamin 1966 Transsexual Phenomenon 1990s Amsterdam adolescent Gender Clinic 2016 1939 Micheal Dillon starts testosterone 1952 Christine Jorgensen 1987 DSM Gender Identity Disorder 2013 DSM V Gender Dysphoria
World Professional Association for Transgender Health The Endocrine Society Pediatric Endocrine Society European Society of Endocrinology European Society for Paediatric Endocrinology Contains 157 references from medical literature JCEM September 2009
Gay Committee on Lesbian, Board on the Health of Select Populations, and Institute of Medicine. Health of Lesbian, Gay, Bisexual, and Transgender People: Building a Foundation for Better Understanding. National Academies Press, 2014. Evidence based care? Institute of Medicine issued report outlining need for research in LGBT population Need more data Improved methods for collecting data Increased LGBT participation in clinical research
Database Academic medical centers and large community health centers 500+ transgender patients
Meeting the needs of TG patients Honor patient s affirmed gender identity Transgender inclusivity (EMR, intake forms, bathrooms) Office staff education (clerical and nursing staff) Advocating for insurance coverage and providing documents for legal gender change Educating families and allies Privacy and confidentiality
Goals of primary care STD screening Family planning Preventive healthcare Screen for depression, anxiety, suicide, and bullying Screen for substance abuse
Snyder, Barbara K., Gail D. Burack, and Anna Petrova. "LGBTQ Youth s Perceptions of Primary Care." Clinical Pediatrics (2016): 0009922816673306. Patient perceptions of primary care Many youth do not feel that their needs are being met Lack of discussion of important topics (sexual and emotional health) Physicians/ providers often uncomfortable with transgender patients Inappropriate comments Adolescents need time alone with provider Providers often focus visit towards parent Contraception/family planning not discussed with TG patients
Hormone therapy Testosterone cypionate/ enanthate Androgen gels Beta estradiol (oral or sublingual) Transdermal estradiol Estradiol valerate (injectable) Anti-androgen: spironolactone, leuprolide depot Finasteride (early on)
2016 Meet-The-Professor Endocrine Case Management. State-of-the-Art: Use of Hormones in Transgender Individuals. Benjamin Boh, DO, MS and Joshua Safer, MD, FACP. Monitoring of transgender women on hormone therapy - Target serum testosterone levels should be <100 ng/dl - Serum estradiol should not exceed the peak physiological range for young healthy females, with ideal levels <200 pg/ml - Doses of estrogen should be adjusted according to the serum levels of estradiol - For individuals on spironolactone, potassium should be monitored with dose changes - Consider BMD testing at baseline if risk factors for osteoporotic fracture - In individuals at low risk, screening for osteoporosis should be conducted at age 60 and in those who are not compliant with hormone therapy
Monitoring of transgender men on hormone therapy 2016 Meet-The-Professor Endocrine Case Management. State-of-the-Art: Use of Hormones in Transgender Individuals. Benjamin Boh, DO, MS and Joshua Safer, MD, FACP. - Measure serum testosterone every 3 months until levels are in the normal physiological male range - For testosterone injections, some measure peaks and troughs and some measure midway between injections - Measure hematocrit at baseline and every 3 months for the first year; then 1 2 times a year - Monitor weight, blood pressure, lipids, fasting blood sugar, and/or hemoglobin A1c at regular visits as needed - Consider BMD testing at baseline if risk factors for osteoporotic fracture are present - If cervix present, pap smears as indicated for other population groups - If breast tissue is present, mammograms as indicated for other populations
Preventive health screening No established guidelines for TG individuals Screen based on natal sex PSA Mammography Pap tests
Endocrine Treatment of Transsexual Persons: Endocrine Society Practice Guidelines 2009.
VTE Risk in Transwomen Asscheman et al. (2014) 1% incidence of VTE among 1076 transwomen (5.4 years) Gooren et al. (2008), no increase in VTE among 2236 transwomen on estradiol from 1975 to 2000 (ethinyl estradiol = 6 8% incidence) Wierckx et al. (2013) 5% of 214 transwomen developed VTE within the first three years of estrogen therapy 10 out of 11 of these women had at least one VTE risk factor (smoking, immobilization/ surgery, or thrombophilia)
A long-term follow-up study of mortality in transsexuals receiving treatment with cross-sex hormones Asscheman H, et al. A long-term follow-up study of mortality in transsexuals receiving treatment with cross-sex hormones. Eur Society of Endocrinology. 2011;164: 635-642.
Asscheman H, et al. A long-term follow-up study of mortality in transsexuals receiving treatment with cross-sex hormones. Eur Society of Endocrinology. 2011;164: 635-642.
Asscheman H, et al. A long-term follow-up study of mortality in transsexuals receiving treatment with cross-sex hormones. Eur Society of Endocrinology. 2011;164: 635-642. M F: 966 F M: 365 Cause of death number SMR number SMR Malignancy 28 0.98 5 0.99 Lung malignancy Hematologic malignancy 13 1.35 (1.14-1.58) 1 1.06 6 2.58 (2-3.3) 1 2.86 (0.69-8.57) CAD 18 1.64 (1.4-1.9) 1 1.19 (0.39-2.74) HIV 16 30 0 - Illicit drug use 5 13.2 1 25 Suicide 17 15.7 1 2.2 Unknown 21 4 2 2 Total 122 1.51 12 1.12
Case 1 An 18 year old patient assigned female at birth Dressing in male attire for several years Academic performance has been deteriorating and pt is withdrawing socially and at home Deepening of voice and worsening of acne How do you address this patient and what are you goals for the first office visit?
Case 1 Establish rapport Affirm gender identity PCP often is first point of contact The primary medical concern in this case is illicit testosterone use Arduous process of qualifying for hormone therapy or lack of access to providers
Case 2 A 26 year old transgender male has been treated with testosterone therapy for 1 year He is successfully living as a male Current dose of testosterone cypionate: 200 mg IM every 2 weeks He complains of pruritus during warm showers and frequently feels flushed Hematocrit of 56% What treatment related condition has he experienced and what changes do you recommend?
Case 2 Testosterone stimulates erythropoiesis Androgen therapy is likely to raise hemoglobin (2gm/dL) Tobacco use and sleep apnea should be excluded as contributors The elevated hematocrit can be mitigated with lower doses of testosterone Androgens can unmask polycythemia Hematological evaluation may be required for polycythemia unresponsive to dose lowering (JAK mutation)
Case 3 36 year old natal female with a male gender identity (transgender male) Duration of testosterone therapy: 17 years Patient and female partner present to discuss options for fertility
Labs and Imaging Estradiol 38 pg/ml FSH 7.5 LH 6 Progesterone 0.56 ng/ml Testosterone 0.47 ng/ml Anti-Mullerian hormone 3.56 ng/ml Antral follicle count= >15
Discussion What are this couple s options for fertility? Donor sperm Pregnancy Controlled ovarian stimulation (IVF) with gestational carrier Long term androgen use does not appear to deplete primordial follicle pool Extremely limited data on fertility preservation
Fertility in Transgender Men 54% desired children 38.5% would have considered oocyte/embryo cryopreservation Costs Donor sperm $500-1,000/vial Sperm cryopreservation $1,000-1,500 (with FDA testing) IVF $15,000/cycle Gestational carrier $50,000+ Wierckx, K. Human Reproduction, 2012.
Fertility in Transgender Women Sperm cryopreservation Ideally performed prior to hormonal transition Total cost ~1,500 (+ yearly storage fees)
Thank you for your attention I welcome your questions / comments