Primary care of the transgender patient

OslerCast

Introduction

In this episode, I interview Jessica Rongitsch, an internist in Seattle specializing in primary care for the LGBTQ community, about hormone management (and other aspects of primary care) for the transgender patient. Although she specializes in trans* care, she believes it is well within the reach of any primary care provider.

Trans* people are at increased risk for depression and suicide, but gender-affirming hormone therapy improves psychological health.

Terminology

Jessica advises avoiding these terms: “transgendered“, “MTF”, and “FTM”. We should identify people based on their preference, not based on the sex they were designated at birth. If you mis-gender someone, apologize very briefly and then move on.

Developing a supportive clinic environment

Clinic staff should be trained in trans sensitivity and trans competency (CARDEA has resources for this). Evaluate and consider revising your clinic’s forms. Offer recommended cancer screening once you have developed a therapeutic relationship with the patient.

Treatment based on informed consent

Both major guidelines for trans* care, the WPATH and ICATH guidelines, now allow for informed consent as the basis for treatment. There is no longer a requirement for psychological evaluation or “lived experience” in the desired gender prior to the initiation of gender-affirming hormone therapy.

Absolute and relative contraindications to hormone treatment

Active steroid-responsive malignancies, pregnancy, and current VTE are considered contraindications to starting therapy. Patients with a history of VTE can be treated with the help of a hematologist and anticoagulation.

Effects of feminizing hormone therapy

Prescribing estradiol and spironolactone should suppress testosterone and raise estrogen levels to the normal female range. Patients at high risk for clotting problems should be targeted to the lower end of the normal female range. Expected changes include fat redistribution of the face and body to a more female pattern, breast tissue growth, testicular atrophy, erectile dysfunction, and infertility. Things that will not change include voice, laryngeal prominence (Adam’s apple), and the location of hair growth, although hair characteristics may change. Recommend sperm banking prior to starting treatment. Finasteride 1mg daily can help with alopecia in the early stages of treatment, until testosterone levels are suppressed.

Titrating feminizing hormone therapy

Start spironolactone at 50 mg PO daily (lower if there is baseline hypotension, or not at all if there is hyperkalemia or renal impairment) and estradiol 2 mg SL daily. Alternatively, estradiol can be written as a patch: 0.1 mg patch, changed twice weekly. Spironolactone can be uptitrated in 1-2 weeks if there are no problems with AKI, orthostatic hypotension, or hyperkalemia.

Gradually uptitrate spironolactone until toxicities limit the dosing, or the testosterone level is suppressed below 50 ng/dL, which usually occurs around 200 mg per day of spironolactone in divided doses.

Estradiol sublingual tablets can be uptitrated to 2 mg SL BID. Patches are the safest option in terms of VTE risk, but carry a higher risk of failing to reach normal female levels of estradiol (80-250 pg/mL).

A JAMA article on “Management of Transgenderism” recommends checking testosterone levels (goal < 55 ng/dL) and estradiol levels (100-200 pg/mL) every three months. Also, monitor electrolytes at least that frequently.

Effects of masculinizing hormone therapy

Effects of treatment include alopecia, deepening of voice, facial and body hair, acne, increased muscle mass, clitoral enlargement, cessation of menses, and a shift in body fat from the hips and thighs to the abdomen. Other effects can include polycythemia, weight gain, dyslipidemia, elevated transamonases, irritability, high risk sexual behavior, atrophic vaginitis, and permanent infertility. However, testosterone therapy is not an effective means of pregnancy prevention.

Titrating masculinizing hormone therapy

Testosterone cypionate is FDA approved for other indications as an IM injection, but has been used as a deep SQ injection with greater tolerability. Start with 40 mg injected weekly, and increase every 4-6 weeks to 60 mg and then 80 mg, with 80 mg being a typical dose achieving normal male levels of testosterone, and 100 mg weekly being considered the maximum dose. The target trough level is around 400 ng/dL.

The above JAMA article recommends checking testosterone levels every 2-3 months, CBC and LFT every three months for the first year and then at least annually, and estradiol levels during the first six months.

Surgical options

Many trans* patients don’t undergo surgery, because they don’t want it or can’t afford it. Although a year of hormone therapy is recommended prior to “top” surgery (breast augmentation or reduction), it is not strictly required. A psychological evaluation by two mental health providers, one being a PhD-level psychologist, is required prior to “bottom” surgery, and waitlists can be long. Options for “bottom” surgery include vaginoplasty, metoidoplasty, and phalloplasty.

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Image Credit

Image: Florence and Daniel, 2014, from The _________ High School Yearbook Project, by Evan Baden. Used with the artist’s generous permission. The work can be seen touring nationally in “The Outwin: Amerian Portraiture Today”

Audio Transcript

Transgender care episode transcript

References

Spack, Norman P. “Management of transgenderism” JAMA, 2013, V309, No5, 478-484.

Other Resources

Fenway Guide to LGBT Health (available at Amazon)

Clinical Care for Transgender and Gender Nonconforming Patients – Free eLearning Module (by CARDEA)

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