2021-10-28-transgender-medicine.md (5600B)
1 # Transgender medicine 2 3 ["academic half day", "transgender", "primary care"] 4 5 Shayne Taylor, MD 6 7 ## Disparities 8 9 - insurance 10 - knowledge 11 - bad care 12 - disease burden 13 - trauma-informed care 14 15 ### insurance 16 17 Insurance often won't cover the visit if the primary dx is e.g. "Gender Dysphoria," 18 have to bill it as "HTN", "Endocrine Disorder NOS", "Therapeutic Monitoring," etc. 19 20 Insurance problems even problematic for procedures. 21 22 Also, transgender people need 23 two letters of mental health support 24 for any procedures below the belly-button (e.g. TVH). 25 Also, wtf. 26 27 ### knowledge 28 29 Knowledge gaps for patients, providers, insurance as above. 30 Even if well-meaning, physicians typically know too little or are uncomfortable. 31 32 ### bad care 33 34 1/2 trans women in the South is HIV+, and of those, 35 outcomes are worse compared with the cis population. 36 37 ## language 38 39 ### pronouns 40 41 Introducing ourselves with pronouns normalizes the process. 42 43 Ask directly, 44 "Hi Emily, nice to meet you, what pronouns do you use?" 45 46 Documentation in Epic is getting better, 47 will hopefully be part of the standard intake soon. 48 49 ### anatomy 50 51 Use functional terms that have medical meaning - 52 53 "people who menstruate," 54 "people with a cervix," 55 56 ### intimacy 57 58 Regarding the act of sex, think about: 59 60 1. do we need to modify the chances of getting pregnant? 61 2. do we need to mitigate the risk of HIV? 62 3. do you feel safe? 63 64 ## medications 65 66 Bottom line is medical therapy for gender dysphoria is life-saving. 67 68 Secondarily, 69 regarding risk reduction, 70 many people will buy hormones online if no provider will rx, 71 so better part of valor is to have open conversation, 72 rx meds with appropriate mitigations as possible, 73 monitor closely. 74 75 ### Transgender men 76 77 (assigned female at birth, identifies as male) 78 79 Essentially, one drug: testosterone. 80 81 - CBC, CMP, A1c, lipids, bHCG (if they have sex with penis people). 82 - Consent is in MedEx (risk of HTN, increased blood glucose, increased lipids, ?increased risk ASCVD/CVA [contested]) 83 - permanent changes: facial hair, body hair, male pattern baldness, voice lowering, clitoral growth 84 - temporary changes: acne, irritability, sex drive, secondary amenorrhea, lab changes, male pattern fat deposition 85 86 Forms: Testosterone cypionate/enanthate 87 88 Overall strategy: 89 90 - q14d 0.25mL (50mg) starting 91 - in 2-3mo, get HCT, total T (goal 400-700 mid-injection) 92 - will likely be low, move to q7d (i.e. double dose) 93 - then go to q7d 0.4mL (80mg) (some do 100mg, but seems to have more adverse effects) 94 - some folks like q14d dosing instead, some folks like IM injections - accommodate! 95 96 Reassess every few years to see if the permanent changes are where they'd like, 97 if they're ok with the temporary changes reverting, would like hysterectomy, etc. 98 99 Generally FDA approved for MSK injection, 100 but subQ works and is easier for pts 101 (may have to talk to pharm about getting the right needles). 102 103 Main issue with gel is the expense, coupons exist (good for needlephobes). 104 Secondary concern is transfer to close contacts. 105 106 Birth control: prefer progesterone-only, IUD, Nexplanon 107 108 (for unknown reasons, 109 IUDs in people who are on T therapy are associated with pelvic pain, 110 pain w orgasm, 111 so Nexplanon is a great option) 112 113 ### Transgender women 114 115 (assigned male at birth, identifies as female) 116 117 Two goals: block T, add E2 118 119 Block T: 120 - spironolactone @ 100mg daily typically, can go to BID (keep an eye on K, etc.) 121 - bicalutamide @ 50mg - designed for metastatic prostate cancer, monitor CMP 122 - goal T < 50 (may have higher goal if still wants to have sex) 123 124 Add E2: 125 - estradiol, prefer patches d/t lowest risk of CVA 126 - patch: vivelle dot (0.05 2x/wk, 0.1 2x/wk, 2x0.1 2x/wk, can go higher but becomes logistically difficult) 127 - pills: 2mg, 4mg, 6mg, 8mg max. Can take SL, but will have to take more often. Careful with lab checking, variability is high. 128 - injections: estradiol valerate/cypionate, q7d 0.2-0.3mL (3-6mg) 129 - level: society guidelines 100-200, practical 200-300 may be more effective, but overall go by symptoms 130 131 ?progesterone 132 - expert opinion varies 133 - online opinion is pro 134 - may help w breast development 135 - 200mg (PO vs PR) qHS (causes some somnolence) 136 - try for 6mo, reassess (cont if good, d/c if equivocal) 137 138 Cancer screening: 139 pap smears (atrophic, let the pathologist know this is a transgender pt), 140 get HPV co-test, 141 mammograms as indicated 142 143 Also consider sperm banking (expensive, not always desired, but worth discussing). 144 145 ## surgeries 146 147 ### Transgender men 148 149 Breast removal, very helpful. 150 Usually requires 1 letter from mental health specialist. 151 Cash price is $8500 at VUMC if insurance won't cover. 152 153 TVH: prefer keeping ovaries for long-term bone protection, etc. 154 155 Metoidioplasty - release the clitoris enlarged by T therapy, 156 can reroute urethra (frequent complications, but can urinate standing up), 157 not large enough for penetrative sex. 158 159 Phalloplasty - TVH first, graft from forearm skin, 160 urethral lengthening (also frequent complications, 161 e.g. require I/O cath, SPC), penile implants possible for penetrative sex. 162 163 164 ### Transgender women 165 166 Breast augmentation - well-tolerated, few downsides 167 168 Orchiectomy - well tolerated, will also need lifelong HRT 169 170 Vaginoplasty 171 - shallow depth, cosmetic but no penetrative depth, few downsides 172 - 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) 173 174 175 ## Inpatient care 176 177 Unless clear indication to stop, 178 which would be rare 179 (?estrogen iso CVA, but even then probably ok to continue), 180 continue their hormones inpatient.