medical management of the transgender patient: for mhps vin tangpricha m.d. ph.d. associate...

Medical Management of the Transgender Patient: for MHPs

Vin Tangpricha M.D. Ph.D. Associate Professor of Medicine

Emory University School of Medicine,

Division of Endocrinology, Diabetes & Lipids, Department of Medicine

WPATH SoCal Kaiser TrainingApril 13, 2013

At the conclusion of this presentation, attendees should be able to

1.To list the roles and responsibilities of the mental health provider and the hormone prescriber

2.To list available resources for hormone prescribers

3.To describe common hormone regimens used in transgender individuals

4.To identify some potential adverse events and pitfalls in cross hormone therapy

Learning Objectives

1. Persistent, well-documented gender dysphoria;2. Capacity to make a fully informed decision and to

consent for treatment;3. Age of majority in a given country (if younger,

follow the Standards of Care outlined in section VI);4. If significant medical or mental health concerns are

present, they must be reasonably well controlled.

Major Changes: No longer requiring a letter. More emphasis on informed consent. No real life experience. Age cut-off removed.

Documentation for Hormone Therapy: SOC7 in a nutshell

Mental Health Provider Should:

- Assist clients be psychologically prepared and practically prepared for hormones

- Discuss reproductive options- Refer the patient to a qualified health care

provider who can appropriate assess relative and absolute contraindications to cross sex hormones and monitor for long term complications

- Provide a letter of referral to a hormone provider that patient meets eligibility and readiness criteria for hormones according to SOC7 upon request*

SOC7: The role of the mental health and hormone provider

Hormone Provider Should:

- Obtain informed consent for hormone therapy (discuss risks and benefits) and document that the patient understands and accepts risks

- Perform history, physical examination and laboratory tests to assess and modify risks prior to initiation of hormone therapy

- Document reproductive options have been discussed- Provide ongoing monitoring of potential risks of therapy- Communicate with other health professionals as necessary

to ensure a safe transition

SOC7: The role of the mental health and hormone provider

SOC7: Bridging

Clinicians who may not be experienced in hormone therapy or who have not fully assessed patients may provide limited (1-6 months) prescription of cross hormone therapy for patients who have been treated by other clinicians or obtained hormones from other means in order to allow for the proper referrals to mental and medical health

Copyright © 2013 World Professional Association for Transgender Health

Male to Female

Estrogen

Anti-Androgens


Estrogens

Inhibit LH secretion at the pituitary to decrease testosterone secretion

Also may directly inhibit gonadal production of testosterone*

Has steroid hormone effects at target organs

*Leinonen P. JCEM 1981; 53(3):569-73.


Estrogens

Conjugated Estrogens–Premarin 2.5 - 5.0 mg daily

Synthetic Estrogens (NO LONGER RECOMMENDED)–Ethinyl Estradiol 0.100 to 0.300 mg daily

Steroidal Estrogens–Estradiol (2 to 6 mg daily)–Estradiol transdermal patches 0.1 – 0.4 mg/day–Estradiol valerate IM 40-80 mg/month

Tangpricha et al. Endocrine Pract 2002, Hembree et al 2009


Anti-Androgens

Spironolactone

100-400mg/dayAnti-androgen at the androgen receptor and decreases androgen production

Often required to reduce testosterone levels

Cyproterone

Not available in USSome progestin activity



Initial Evaluation

Male to Female TranssexualComplete physical examination Blood pressure, height, weightExtent of masculinization/feminizationPalpation of liver and breasts for tumorsExamination of venous system for

thromboembolismExamination and measurement of genitalia

(glans penis, testes)



Initial laboratory tests

Electrolytes, BUN/creatinineLiver function testsFasting glucose and lipid profileEstradiol and free or total testosteroneSerum Prolactin*



Estrogen Contraindications

Very High RiskHistory of Thrombosis

Moderate High RiskMacroprolactinomaHepatic dysfunctionBreast CaCoronary artery diseaseCerebrovascular diseaseMigraine headaches

Endocrine Society Guidelines 2009


Morbidity and Mortality

Observed mortality in 816 M to F’s

incidence vs. nl

Suicide 9 fold

AIDS 6 fold

van Kesteren PJM 1997 Clinical Endocrinol 47:337-342


Morbidity and Mortality

Observed morbidity in 816 M to F’s

incidence vs. nl

Venous thrombosis 20 fold

Prolactin elevation 82 fold

Hepatitis B 44 fold

van Kesteren PJM 1997 Clinical Endocrinol 47:337-342


Effects of Hormonal Feminization


Monitoring of Estrogen Therapy

Patients should be seen every 2-3 months initially

Aim for castrate levels of T (<75 ng/dl)

Estradiol level should be approximately 200-400 pg/ml

Screening for complications at every visit

Depression/suicide screen



Lab Monitoring

EstradiolTestosteroneLiver functionPotassium

Fasting LipidsProlactin yearly*

After two years, semi-annually

hold estrogen 1 month prior and after surgery

Reduce estrogen by 50% after surgery


Testosterone

Female to Male

Testosterone Esters Testosterone enanthate 100 to 200 mg IM q2 wkTestosterone cypionate 100 to 200 mg IM q2 wk

Transdermal patches2.5 - 5 mg/day transdermally

Oral Testosterone (not 17)Testosterone undecanoate 40mg QID

Testosterone gel (AndroGel or Testim)2.5 -5 g packet daily


Testosterone Regimens

Testosterone Contraindications

Very high riskPregnancyBreast or Uterine Cancer

Erythrocytosis (HCT>50)

Moderate High RiskHepatic

Endocrine Society Guidelines 2009

Effects of Hormonal Masculinization

Initiation of Testosterone Therapy

Complete history and physical

CBC, LFTs, fasting glucose and lipids, estradiol and free or total testosterone

? -HCG

?Bone mineral density? Sleep study if sx of

OSA

Start IM testosterone 50- 75 mg q2weeks

Tangpricha et al. Endocrine Pract 2002

Monitoring Testosterone Therapy

Testosterone Complications

Abnormal liver function Tests (15%)

Hepatic adenomas, peliosis hepatitis (rare)

Increase in visceral fatElevation of total

cholesterol, triglycerides and LDL and lowering of HDL cholesterol

Endometrial hyperplasia

Tangpricha et al. Endocrine Pract 2002


Conclusions

The initiation of hormone therapy requires cooperation between the MHP and hormone provider

The hormone provider should complete a comprehensive evaluation to avoid risks with hormone therapy

Detailed published regimens are available by the Endocrine Society

Monitoring for potential complications are important at least initially for the first 2 years and then at least annually thereafter

Thank you for your attention!

Vin Tangpricha M.D. Ph.D.

Associate Professor

Emory University

Division of Endocrinology

101 Woodruff Circle NE- WMRB 1301

Atlanta GA 30322

[email protected]

medical management of the transgender patient: for mhps vin tangpricha m.d. ph.d. associate...

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