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
Patient / Mental Health Provider Gatekeeper Model Hormone Provider Surgeons
In the past decade, there has been greater acceptance of transgender care within conventional medical circles
Background Potential factors determining gender identity: 1. Environment 2. Societal construct 3. Passive response to anatomy 4. Biological
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
If this biology what do we need to know?
Patient/PCP Medical model Endocrinology Specialist Mental Health Provider Surgeons other specialists
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.
Strategy: December 11, 2011
Male hormones Female hormones Testosterone Estradiol Testosterone Estradiol
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.
Primary Treatment Strategy Female to male: Titrate quickly to male serum testosterone levels But NB: I start at ½ dose --- 50-100 mg IM or SQ testosterone (enanthate or cypionate) q week; gel is fine; patches OK if tolerated Keep serum range 300-1000--
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.
Treatment Strategy Male to female: Anti-androgens usually essential: Spironolactone -- may require high doses (100-400 mg/day 200 usual) -- other anti-androgens OK: Leuprolide (Lupron) Cyproterone acetate (in Europe)
Medical Treatment Strategy
Medical Treatment Strategy spironolactone Androgen receptors
spironolactone Known mechanism Safety Known pitfalls (K, BP) + Unknown mechanism
Medical Treatment Strategy
Medical Treatment Strategy GnRH agonists Very clear mechanism Effective Safety? Cost
progestins -- is there the logic?
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
5 α reductase inhibitors
Medical Treatment Strategy DHT (in tissues)
Medical Treatment Strategy 5 alpha reductase inhib. DHT (in tissues)
Expectations Modestly protective of scalp hair with male level androgens
Medical Treatment Strategy estrogens
Estrogens oral ----- estradiol 2-6 mg/day. ----- conjugated estrogens 2.5-7.5 mg/day ease, cost, horses vs lab ----- ethinyl estradiol - thromboses. ----- other (e.g. bio-equivalent ) quality control
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
For M to F, follow T, estrogen sensitive indexes, and K Male to female: Follow - serum testosterone - estrogen level - K - lipid profile - prolactin
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).
Surgical Options Female to male: -- Chest Reconstruction * -- Genital Surgery (Phalloplasty) Male to female: -- Facial Feminization -- Genital Surgery (Vaginoplasty) * -- Breast Augmentation
Post-surgery (and aging) considerations Less estrogen Some estrogen Some testosterone
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.