commit 75cb65f38a386cbecee2ce195e92bf0e71e46956
parent 9a9fe0aa3b4617cfcef8e96ae86b0fbed0b3706a
Author: Beau <cbeauhilton@gmail.com>
Date: Thu, 28 Oct 2021 10:10:11 -0500
add transgender lecture
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1 file changed, 180 insertions(+), 0 deletions(-)
diff --git a/learn/2021-10-28-transgender-medicine.md b/learn/2021-10-28-transgender-medicine.md
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+# Transgender medicine
+
+["academic half day", "transgender", "primary care"]
+
+Shayne Taylor, MD
+
+## Disparities
+
+- insurance
+- knowledge
+- bad care
+- disease burden
+ - trauma-informed care
+
+### insurance
+
+Insurance often won't cover the visit if the primary dx is e.g. "Gender Dysphoria,"
+have to bill it as "HTN", "Endocrine Disorder NOS", "Therapeutic Monitoring," etc.
+
+Insurance problems even problematic for procedures.
+
+Also, transgender people need
+two letters of mental health support
+for any procedures below the belly-button (e.g. TVH).
+Also, wtf.
+
+### knowledge
+
+Knowledge gaps for patients, providers, insurance as above.
+Even if well-meaning, physicians typically know too little or are uncomfortable.
+
+### bad care
+
+1/2 trans women in the South is HIV+, and of those,
+outcomes are worse compared with the cis population.
+
+## language
+
+### pronouns
+
+Introducing ourselves with pronouns normalizes the process.
+
+Ask directly,
+"Hi Emily, nice to meet you, what pronouns do you use?"
+
+Documentation in Epic is getting better,
+will hopefully be part of the standard intake soon.
+
+### anatomy
+
+Use functional terms that have medical meaning -
+
+"people who menstruate,"
+"people with a cervix,"
+
+### intimacy
+
+Regarding the act of sex, think about:
+
+1. do we need to modify the chances of getting pregnant?
+2. do we need to mitigate the risk of HIV?
+3. do you feel safe?
+
+## medications
+
+Bottom line is medical therapy for gender dysphoria is life-saving.
+
+Secondarily,
+regarding risk reduction,
+many people will buy hormones online if no provider will rx,
+so better part of valor is to have open conversation,
+rx meds with appropriate mitigations as possible,
+monitor closely.
+
+### Transgender men
+
+(assigned female at birth, identifies as male)
+
+Essentially, one drug: testosterone.
+
+- CBC, CMP, A1c, lipids, bHCG (if they have sex with penis people).
+- Consent is in MedEx (risk of HTN, increased blood glucose, increased lipids, ?increased risk ASCVD/CVA [contested])
+- permanent changes: facial hair, body hair, male pattern baldness, voice lowering, clitoral growth
+- temporary changes: acne, irritability, sex drive, secondary amenorrhea, lab changes, male pattern fat deposition
+
+Forms: Testosterone cypionate/enanthate
+
+Overall strategy:
+
+- q14d 0.25mL (50mg) starting
+- in 2-3mo, get HCT, total T (goal 400-700 mid-injection)
+- will likely be low, move to q7d (i.e. double dose)
+- then go to q7d 0.4mL (80mg) (some do 100mg, but seems to have more adverse effects)
+- some folks like q14d dosing instead, some folks like IM injections - accommodate!
+
+Reassess every few years to see if the permanent changes are where they'd like,
+if they're ok with the temporary changes reverting, would like hysterectomy, etc.
+
+Generally FDA approved for MSK injection,
+but subQ works and is easier for pts
+(may have to talk to pharm about getting the right needles).
+
+Main issue with gel is the expense, coupons exist (good for needlephobes).
+Secondary concern is transfer to close contacts.
+
+Birth control: prefer progesterone-only, IUD, Nexplanon
+
+(for unknown reasons,
+IUDs in people who are on T therapy are associated with pelvic pain,
+pain w orgasm,
+so Nexplanon is a great option)
+
+### Transgender women
+
+(assigned male at birth, identifies as female)
+
+Two goals: block T, add E2
+
+Block T:
+- spironolactone @ 100mg daily typically, can go to BID (keep an eye on K, etc.)
+- bicalutamide @ 50mg - designed for metastatic prostate cancer, monitor CMP
+- goal T < 50 (may have higher goal if still wants to have sex)
+
+Add E2:
+- estradiol, prefer patches d/t lowest risk of CVA
+ - patch: vivelle dot (0.05 2x/wk, 0.1 2x/wk, 2x0.1 2x/wk, can go higher but becomes logistically difficult)
+ - pills: 2mg, 4mg, 6mg, 8mg max. Can take SL, but will have to take more often. Careful with lab checking, variability is high.
+ - injections: estradiol valerate/cypionate, q7d 0.2-0.3mL (3-6mg)
+- level: society guidelines 100-200, practical 200-300 may be more effective, but overall go by symptoms
+
+?progesterone
+- expert opinion varies
+- online opinion is pro
+- may help w breast development
+- 200mg (PO vs PR) qHS (causes some somnolence)
+- try for 6mo, reassess (cont if good, d/c if equivocal)
+
+Cancer screening:
+pap smears (atrophic, let the pathologist know this is a transgender pt),
+get HPV co-test,
+mammograms as indicated
+
+Also consider sperm banking (expensive, not always desired, but worth discussing).
+
+## surgeries
+
+### Transgender men
+
+Breast removal, very helpful.
+Usually requires 1 letter from mental health specialist.
+Cash price is $8500 at VUMC if insurance won't cover.
+
+TVH: prefer keeping ovaries for long-term bone protection, etc.
+
+Metoidioplasty - release the clitoris enlarged by T therapy,
+can reroute urethra (frequent complications, but can urinate standing up),
+not large enough for penetrative sex.
+
+Phalloplasty - TVH first, graft from forearm skin,
+urethral lengthening (also frequent complications,
+e.g. require I/O cath, SPC), penile implants possible for penetrative sex.
+
+
+### Transgender women
+
+Breast augmentation - well-tolerated, few downsides
+
+Orchiectomy - well tolerated, will also need lifelong HRT
+
+Vaginoplasty
+- shallow depth, cosmetic but no penetrative depth, few downsides
+- full depth, needs full electrolysis of scrotum to create vaginal shaft, then needs dilation forever (prevent spontaneous closure, immediately post-op 3-4x/day for 30-45 minutes)
+
+
+## Inpatient care
+
+Unless clear indication to stop,
+which would be rare
+(?estrogen iso CVA, but even then probably ok to continue),
+continue their hormones inpatient.
