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- 02:54 Hormone therapy contraindications
- 07:09 Time course for hormone changes
- 10:21 Hormone risks
- 19:09 Hormone treatment options
- 25:22 Preventative Care Screening
Pearl 1: Are there absolute contraindications to hormone therapy?
- When considering initiating hormone therapy, there are usually two absolute contraindications:
- Sex-specific cancer (e.g. hormone sensitive breast cancer)
- Being actively pregnant while starting testosterone
- Some things that aren’t contraindications, but are commonly perceived as such:
- A history suggestive of elevated clot risk (e.g. a prior clot or a coagulopathy)
- While likelihood of clot does increase while on exogenous estrogen, the risk is modest.
- In these situations, consider checking out the UCSF guidelines, which provide an approach on which estrogen formulation is most appropriate.
- Mental health history
- If your patient has a prior psych history, they can still be started on hormone therapy. Remember that initiation of gender affirming care, such as therapy, has been shown to improve mental health outcomes!
- Nevertheless, it’s always a good idea to encourage your patients to plug into mental health. After all, there are many big life changes associated with hormone therapy, and having a strong support system can help.
- A history suggestive of elevated clot risk (e.g. a prior clot or a coagulopathy)
Pearl 2: What expectations should you set upfront when initiating hormone therapy?
- Treat hormone therapy like any other medication and perform an informed consent – walk through the pros and cons, the benefits and risks.
- Setting expectations around the hormone-induced changes is a key part of this process. Three big things to set expectations on:
- Hormone changes will be gradual and will come into full effect over several years. Think of it as analogous to puberty.
- There is no magic wand, it’s a process!
- What the end result will be:
- The outcome won’t be exaggeratedly feminine/masculine. Encourage the patients to look at their family members to see what they can expect.
What are the physical changes they can expect?
- Transmasculine: male pattern baldness, clitoromegaly, deepening of voice
- Transfeminine: fertility (irreversible effects on sperm motility and viability – however still possible to conceive!), breast development.
- Within the first 3-6 months: cessation of menses, pelvic pain, oiliness of skin (possible acne)
- 6-12 months+: change in hair growth, voice deepening, increased muscle mass/body fat distribution
- Longer term: clitoral growth, vaginal atrophy
- Early on: smoothing of skin
- 6-12 months+: testicular atrophy, decreased muscle mass
- Longer term: libido decrease and decreased ability to have an erection (if have a penis)
- Also, estrogen will not make facial hair fall out, but may see some decrease in facial/body hair growth
Pearl 3: What are the major risks associated with hormone therapy in transgender patients, and what can we do to mitigate them?
- Clot in transfeminine individuals
- There is a slight increased risk of any thromboembolic event in trans individuals who are receiving estrogens.
- Counsel patients that there is a potential 1 to 2% incidence over 8 years
- Formulation is a key way to attenuate risk: transdermal formulations of estrogen lower clot risk than do oral formulations.
- Despite the risk of clot, there is no evidence to support the practice of stopping estrogens during times of critical illness (e.g. perioperatively, or when a patient is inpatient). Consider that stopping hormones can be very distressing for trans patients.
- There is a slight increased risk of any thromboembolic event in trans individuals who are receiving estrogens.
- Cardiovascular risk
- Transfeminine individuals: the data on this is still emerging, but may suggest an increased risk of MI or stroke after decades of use.
- Transmasculine individuals
- Testosterone does worsen a few cardiovascular risk factors
- However: the evidence does not point to increased MIs or stroke
- What to make of the data
- These numbers are still very small. The research needs to be fleshed out as to whether this is an absolute correlation rather than a speciation of the data.
- Fortunately, we can counter these risk factors by promoting lifestyle changes (as well as using other primary care interventions)!
- Other likely increased risks of feminizing hormones (source: WPATH)
- Gallstones (clinically significant)
- Weight gain
- Hypertriglyceridemia (clinically significant)
- Other likely increased risks of masculinizing hormones (source: WPATH)
- Polycythemia (clinically significant)
- Weight gain
- Male-pattern baldness
- Sleep apnea
Pearl 4: What options are available for feminizing and masculinizing medications, and how should we monitor hormone therapy?
- Formulations of testosterone
- Dosing and frequency:
- ~50 milligrams every week or every other week depending on the patient’s preferences
- Biweekly dosing lessens the number of injections. However, weekly dosing avoids the fatigue and irritability that can sometimes occur at the end of the injection cycle.
- IM or SubQ Route:
- Should go into a tissue that there will be a slow release
- Make sure to prescribe needles (and a sharps container)! Bigger is better since you can inject more volume faster and reduce discomfort. A minimum of 22G.
- Harder to guarantee steady levels via this modality
- However, may be an option for patients who are very uncomfortable with needles
- Dosing and frequency:
- Testosterone: initial labs and when to follow up
- CBC for erythrocytosis: q3-6 months in first year, then yearly
- Estradiol levels, free testosterone levels (to track changes over time): shooting for testosterone levels between 300 to 1000 mid-injection cycle
- Lipids and LFTs
- Feminizing hormones
- Oral (often the easiest or simplest option)
- Patches (recommended if someone has clotting risk factors, as transdermal poses much lower risk)
- IM injections
- Testosterone blocker
- Only indicated if the patient is still producing testosterone (i.e. still have testes). This is why an organ inventory is important!
- Spironolactone is a preferred first-line agent – and often safe even in younger patients with low or normal blood pressures (expert experience).
- If your patient has a contraindication to spironolactone, such as kidney disease, finasteride is also an option.
- Initial labs to order
- Hormone levels of estrogen and testosterone (to trend)
- BMP or a CMP (if patient will be starting spironolactone)
- What to monitor
- Levels of estrogen and testosterone
- Goal is to see the estrogen rise and the testosterone fall, since the latter has a virilizing effect regardless of how much estrogen the patient has.
Pearl 5: How do you approach preventative care – such as cancer screening – for transgender patients?
- Chest screening for breast cancer
- Transmasculine people who have had chest masculinization (i.e. top surgery or mastectomy) may still have some breast tissue, so a discussion of breast cancer screening may be needed.
- In these situations, mammograms may be difficult to perform, and a risk benefit conversation about manual physical exam, ultrasound or MRI should be discussed depending on family history, though no clear guidelines are available for this.
- Cervical cancer screening
- In transgender men who have a uterus with a cervix and ovaries, screen for cervical cancer at the same intervals as we do with cisgender women.
- Using vaginal estrogen creams for 1 week prior to the exam can help decrease discomfort, though transgender men may decline this intervention as estrogens can be a charged topic for these patients.
- Prostate cancer screening
- Transfeminine patients will often have prostates as these are not typically removed during vaginoplasty procedures.
- However, there are no clear guidelines (as is the case with cisgender patients.)
- When considering patient risk factors, remember that testosterone blockers can reduce the risk of prostate cancer.
- Breast cancer screening
- Who: transfeminine people over 50 on estrogen > 5 years (with breast development)
- How often: every two years (same as with cisgender women)
Nathan: I used to work at Callen-Lorde community health center, which is an LGBT health center in Chelsea, in New York. And I had my first hormone education visit and the person came to me and said, I said, what are, uh, what are your goals? Are hormones, what are the changes you think are going to happen? And as a trans guy going on testosterone and he said, I’m going to start testosterone about one to two weeks later, I’m going to feel really great about my body and my family is going to accept me. I’m going to like be able to go out dating again, go out to the bars, I’m going to feel so comfortable, I’m going to get a beard. It just like kept going. I’m going to have a deep voice. And so it was a great moment for me to realize like you need to set expectations for patients.
S: That’s Nathan Levitt FNP-BC, a clinician and advocate for the transgender community as well as a transgender man himself. And just to clarify for those new to this subject, which was a teaching point for me too, his patient had an unrealistic timeline in mind. We will get into why that was today!
M: Welcome back to the Core IM 5 pearls podcast, this is Dr. Marty Fried, a primary care doc at The Ohio State Wexner Medical Center, and Dr. Shreya Trivedi, population health fellow at NYU. Today we are finishing up a two-part series on comprehensive transgender care.
S: We hope you listened to the previous transgender health episode, which really set the stage with gender affirming care and now we want to hit the road with hormones. But some caveats before we start – we wanna be clear we are targeting adult medicine clinicians – some of what we talk about can be applied to adolescent medicine but as heads up, we don’t specifically address pediatrics. The hope of this episode is to give a good foundation and dispel hesitation with starting hormone therapy
M: So with that, let’s jump into our pearls.
S: Remember, the more you test yourself the deeper your learning gains.
- Are there absolute contraindications before starting hormone therapy?
- What are the expectations you should be setting upfront for your patients when starting hormone therapy to avoid the misconception that Nathan described in the intro quote
- Hormone Risks
- What are the major risks associated with hormone therapy in transgender patients, and what can we do to mitigate them?
- Medications and maintenance (care)
- What options are available for feminizing and masculinizing hormones, and what do we monitor when on hormone therapy?
- Preventative Screening
- How do you approach preventative care, such as cancer screening, for transgender patients?
Pearl 1: Contraindications
M: So before we start we just wanted to give a quick heads up that in this pearl we are going to outline a few rare contraindications for gender affirming hormone therapy, so while we cover these, and other risks later on in this episode, we absolutely do not want to give the impression that any of these represent reasons to withhold life saving gender-affirming hormone therapy for our trans and nonbinary patients.
S: So let’s dive in – say a patient comes into your office wanting help with their transition and asks you if you can prescribe hormones. How do you even begin this conversation?
M: Yeah this can certainly feel overwhelming. After speaking with all of our experts and reviewers what I’ve come away with is to treat hormone therapy like any other procedure in medicine, and that is starting with a good detailed informed consent.
S: So before we get into the informed part, we need to remember that patients come in with different experiences, thoughts or questions about hormone therapy.
Richard: Often trans and non-binary people who are walking in have done a lot of research and know a lot about this, but some people don’t. And there’s some misinformation out in the community.
M: That’s Dr. Greene who you might remember from our first Transgender Care episode on gender-affirming care.Dr. Greene is an NYU internist and runs the Pride Center at Bellevue Hospital in New York City.
S: As we are learning about what patients are bringing to the table, step 1 is to keep in mind any absolute contraindications for starting hormone therapy that you might want to address sooner rather than later.
Richard: I think there are very few things that stopped me from starting hormones. I think the things that I would think about personally sex specific cancers. So like a hormone sensitive breast cancer is a really good reason to not start hormones in this moment. And active pregnancy is a really good reason to not start testosterone because it’s a known teratogen. Other than that, there aren’t absolute contraindications to starting hormones.
S: Ok so do not pass go if they have those two contraindications: hormone sensitive CA (which is extremely rare) and pregnancy. And one last thing before getting into further discussion is thinking about fertility. Hormones can affect ability to conceive and sometimes infertility can be permanent – especially for transwomen. Because of this, the UCSF guidelines specifically recommend discussing future fertility with all patients and offer sperm or oocyte banking if that is desired
M: But the interesting cavet I learned was that we still need to discuss contraception in those patients who are engaging in sexual activity that could lead to pregnancy. The teaching point being hormones may affect fertility but we don’t want our patients to think they are on birth control.
Carl: There’s only really these two main contraindications for starting hormone therapy at that moment. And clot is not one of them.
M: That voice you heard there was Dr. Carl Streed, also heard in part I, who is the research lead Transgender Medicine and Surgery at Boston University. Wait, did he just say history of clots – like blood clots – like DVTs and PEs – are NOT a contraindication for hormone therapy? Did he JUST say that?
S: He did say that! We will get more into that in pearl 3. And get this – cigarette smoking a risk factor for DVT in this population is also not an absolute contraindication. Neither are mental health issues like severe depression and prior suicidality in starting hormone therapy.
M: There is a misconception that you can’t start hormone therapy in patients who have had prior mental health issues – that is suuupes false, though sometimes it’s worth getting behavioral health on board because of the high prevalence of mental health issues in this population. The point here is that hormone therapy can actually be therapeutic in transgender patients with mental health issues.
Carl: In fact, they are, for me, often a motivated for like, great, let’s get this going because anxiety and depression and suicidality have been found time and time again to go down with starting gender affirming care of any kind.
S: Alright, so major take-home points from this pearl is that the only widely agreed upon absolute contraindication against hormone therapy is current pregnancy and current hormone sensitive- cancer. So there is not much that should be stopping you if your patient wants hormone therapy! And don’t forget to talk to your patient about future fertility and sperm or oocyte banking if genetic offspring are important … [Marty:] but keeping in mind there are other ways to build families.
S: Right that is a good point!
Pearl 2: Hormone Expectations
M: Now that the patient doesn’t have any absolute contraindications we should prep our patients with the time course of expected hormone changes. At the start of this episode you heard Nathan discuss one patient’s impression about the timing of changes once masculinizing hormones start. Here’s the rest of that clip:
Nathan: So I just stopped him and said this, thank you for sharing what you think is going to happen here or that. And then I go over what are the expected changes. But in that, I say it’s different for every person. Like for myself. I’ve been on hormone, on testosterone, for 15 years and I get ma’amed on the phone all the time. So I didn’t get the deep booming voice that some people do. And then I got hair I didn’t want like back hair. I didn’t ask for that. So I just feel like you don’t, you can’t always choose where things happen. So I try to say to patients, these are the expected changes. The course of when it can happen can be short term or longterm.
S: It sounds like unfortunately body changes from hormones isn’t quite a menu where patients can pick from, but we can guide what patient can possibly expect to see after the start of hormones.
Richard: The analogy that we talk about frequently is think about puberty. How long did puberty take to go through the first time? Certainly there’s a gen a genetic component to what kinds of changes people will see. If the, if the body shape in your family of people of the affirm gender is one thing, but you’re hoping to look like somebody else that may or may not be possible with hormones.
M: So on average for a trans man, the first 3-6 months is characterized by oiliness of skin – maybe some acne – cessation of menses. Between 6-12 months the voice will typically deepen, muscle mass increase and people will notice changes in hair growth – that’s the back hair Nathan was referring to. Some of these changes are reversible if testosterone is stopped, and others are not.
Richard: So in terms of thinking about some of the, um, the irreversible changes of hormones, so for trans masculine people, for people who are using testosterone, male pattern baldness does, uh, tend to be permanent. Um, clitoromegally. Um, so an enlargement of the clitoris is permanent and also deepening of the voice as the voice deepens even with the stopping of testosterone, it does not tend to go back up again.
S: Good to know! I can imagine my patients would wanna get a heads up on male pattern hair that is going to be permanent and especially if baldness is a possibility. What about time-scale for transfeminine patients?
M: Trans women will probably notice skin being smoother early on followed by testicular atrophy and decreased muscle mass between 6-12 months. The development of breast tissue is typically irreversible. Oh, and don’t shouldn’t forget to warn patients about some possible irritability:
Carl: I do remind people that you’re going to have some mood changes as well. Remember how fun puberty was the first time. This is the second round.
S: Oh man, you have to respect the strength of these patients…
M: Amen sister. So to summarize, the timing of these changes follows a general pattern and usually takes months to years, but the changes can’t be predicted and any specific change unfortunately can’t be guaranteed.
Pearl 3: Hormone Risks
S: Ok so we just talked about the informed part of that informed consent giving our patients a heads up about what to expect with hormone therapy, but understanding the risks is also key.
M: For sure – but real quick Shrey, before we dive into all the potential bad stuff let’s keep in mind the benefits of hormone therapy. I think Nathan said this particularly well.
Nathan: Hormones can be incredibly lifesaving. I mean, it’s just from my own life to other people I’ve worked with. When people have access to hormones, they literally want to live their lives, right? They feel better about who they are. They see themselves on the outside match who they feel on the inside. And I’ve seen people who were previously, you know, suicidal ideations who have said, now that they have access to hormones and affirming care, they want to live their lives right. And they want to take care of themselves and their bodies.
S: Wow. Quite powerful. So the general idea around risks, most of the time with estrogen we worry about clots and cardiovascular disease. Then in terms of testosterone, people worry about worsening of cardiovascular risk factors – but let’s see if it holds true in terms of evidence. Maybe we can myth bust some of these dogmas.
M: Starting with the elephant in the room…what did our experts have to say about estrogen and risk of venous thromboembolism? Also, are we cool if we just say VTE for now on?
S: Hah yes, I’ll allow it Marty.
Richard: One of the things that I like to remind people is that one of the older estrogens that we don’t use anymore. For gender affirmation, ethinyl estradiol, was one of the big culprits and it’s not something that we use commonly.
S: So there is lots of outdated studies but its really data since 2010 that is look at current estrogen formulation and so the current data, what are we telling our patients about the risk of clot on estrogen?
Carl: There is a slight increase in potential thromboembolism based on estrogens. However, this risk is much lower than I think a lot of people think it is to be perfectly honest. There is a change in the risk. We’re not talking about everybody’s going to get a clot. We’re not even talking about like one in 10 people are going to get a clot. We’re talking about much lower numbers here.
S: More specifically there was a 2018 Annals paper that showed approximately 1% incident rate of clot in cismen over 8 years and that increases to about a 5% incident rate of clot in transwomen on estrogen, again over 8 years … still quite low.
M: Right but the conversation changes a bit if the patient who wants to start estrogen smokes cigarettes- the risk of clot is certainly higher in smokers.
S: Which is a great way to motivate patients to stop smoking! What if the patient has had a history of clot in the past?
Carl: The main thing here is to remember is that having had a clot in the past is not a reason not to start hormone therapy. There are ways of walking through this.
Richard: And so one of the things that can be really helpful is really selecting what kind of estrogen using and really selecting the, uh, the form that the estrogen takes, whether it’s, uh, enteral or parenteral, um, I think is incredibly helpful.
M: Great so let’s say we are dealing with a patient who is at increased risk for VTE – like those with family history or current smokers, for example – then we should reach for the transdermal formulation like estrogen patches.
S: Nice its good to have options to decrease the risk of VTE as you say in our patients. We will link in our transcript the UCSF has a really great algorithm (pg. 36-40) that walks you through step by step if you are worried about a clot in a transfeminine individual.
M: Ok, we covered the risk of clot of estrogen therapy, let’s move on from risk of VTE to overall cardiovascular risk from feminizing hormones.
Carl: So there seems to be, um, as far as we can tell in terms of some of the larger population studies, a potential increase in the risk of M.I and or stroke, I say and or possibly because the data keeps on changing depending on which study you’re looking at, um, as to whether there is an increased risk or not. Um, I generally explained to my patients that there is the likelihood that there is an increased risk for MI and stroke based on estrogens over the longterm, and we’re talking about decades of use at this point, but again, talking about routine primary care, we are going to be monitoring all the other classic risk factors, um, and really kind of addressing that as we provide their gender affirming care for over the course of their life.
M: Can I tell you how much I love how he frames this? So Dr. Streed acknowledges the uncertainty in the data but reaffirms that we’re in this for the long haul. Like, “listen, I can’t promise this won’t happen to you, but I promise I’ll be here for you if it does” we will do our best to prevent this.
S: Did you steal that line from Dr. Greene?
M: I definitely stole that line from Dr. Greene.
S: Haha It’s a good one! Ok, so not ready to say Myth Busted on cardiovascular disease risk from estrogen, but the data keeps changes
M: Love it, let’s move on to testosterone risks:
Carl: And all trans masculine individuals who use testosterone, we’re not seeing any kind of change in the clot burden in this population in the current studies that we have available. I mean case closed and not really worried about testosterone causing clots at this point. I haven’t, honestly, I have not seen a trans masculine individual get a clot unless they have a predisposing clotting disorder already. That testosterone is not the cause here friends.
S: Myth Busted! So we busted testosterone and clots but what about effect of testosterone on cardiovascular health?
Carl: We do know within transgender men and trans masculine individuals receiving testosterone, testosterone does worse than some of the classic risk factors for cardiovascular events. So it will increase systolic and diastolic blood pressures (table 3). The research really shows it’s probably no more than like one to two millimeters of mercury, a change. That being said, it is still, it’s still, it was statistically significant and it is moving towards the direction we really don’t want it to move towards. Um, it will lead to a less protective lipid profile. So a slight increase in LDL lowering of HDL, worsening of cholesterol and triglycerides actually. It can lead to a slight decrease in insulin sensitivity or essentially increasing insulin resistance among transmasculine individuals.
M: So you hear that and sort of take a pause, right, like, am I just going to be giving all of my transmasculine patients the metabolic syndrome with this therapy? And then Dr. Streed drops this bomb:
Carl: Is this leading to more heart attacks and stroke in trans masculine individuals and current data really doesn’t support that this is so, to be perfectly honest.
S: Right so testosterone may make numbers look a little worse – we are talking mostly not clinically significant numbers like maybe 1-2 mm Hg in BP – and more importantly, we are not seeing these small bumps in numbers translate into worse outcomes like a heart attack and stroke for transmasculine patients. But if we think about this in terms of harm reduction model, we can work as good primary care clinicians to engage them in care and intensifying their anti-hypertensive regimen as needed
M: Perfect. So I’m about to let you summarize this section but before I do I want to direct our listeners’ attention to an amazing table in the WPATH guildelines – that is World Professional Association for Transgender Health (page 40). There are other, less publicized risks that we should at least mention. Feminizing hormones likely increase the risk of gallstones, weight gain and hypertriglyceridemia. Masculinizing hormones likely increase the risk of polycythemia, weight gain, acne, male-pattern baldness and sleep apnea. The full list, broken down in order of descending likelihood, will be included in our show notes.
S: But wanna emphasize… Marty threw those in to be through but all those risks are quite uncommon! So to summarize what I learned from this pearl – when discussing the risks of hormone therapy, for our transfeminine patients we are telling them about there is slight 1-2% potential risk for clot over years but we can modify that risk if we go with the transdermal estrogen options. The second risk – heart attack and stroke – the data seems to be not as clear cut here and if we do see a small increased risk its also over YEARS with estrogen.
For our patients who want to start testosterone, there is NOT increase clot risk [yay one myth busted] – but we might see a slight bump in their lipids, fingers or that blood pressure – without solid evidence that manifests into heart attack or stroke in transmasculine patients.
Pearl 4: Medications and maintenance (care)
M: Alright Shrey, so at this point we’ve really reviewed the first visit with a patient who comes to us asking about gender affirming hormone therapy including the informed consent for treatment. Let’s focus in on the medications themselves.
S: So masculinizing medications is fairly straightforward, right – we’re talking testosterone here.
M: Yeah – the two groups of delivery methods are either intramuscular/subcutaneous vs. topical. Dr. Streed had some thoughts on these:
Carl: I’m a bigger fan of intramuscular or subQ here versus doing creams and ointments. The creams and ointments, it’s a little bit harder to ensure that they’re going to get an adequate dose. Um, every time they do it. And again, it’s gonna come down to preference. Some people feel like the creams arguments are always oily, it’s a mess. They have a hard time cleaning up afterwards. But the flip side is some people are terrified of needles naturally. We’re not gonna do IM injections if they don’t feel they can do it safely and comfortably.
S: Well that certainly seems reasonable, and nice to have options. The injections are either weekly or every other week, right?
M: Yep, exactly. The weekly dosing option provides a more level dosing and avoids fatigue and irritability that can sometimes occur at the end of the injection cycle. Obviously that’s twice as many injections as biweekly so you can give patients options here.
S: What should we watch out for and monitor for when our patients are on testosterone injections or creams?
M: So we’re getting baseline CBC to monitor hemoglobin/hematocrit monitoring every 3-6 months in the first year and then yearly after that since testosterone can cause erythrocytosis. The recommendation is also to check baseline lipids and LFTs, as well as baseline free testosterone and estradiol levels for comparison purposes later on.
Carl: I want to see that estrogen has come down and that testosterone has come up and I’m aiming for testosterone. Depending on which lab you’re using, aiming for it, testosterone that matches cisgender, a cisgender men, for the most part, I don’t want somebody hovering in a testosterone that’s only like around a hundred, because that’s really not providing any kind of added benefit for them.
M: And each lab is different but in general we are shooting for over 300 to 1000 during the middle of the injection cycle.
S: Okay, moving on. What about for transfeminine patients – what’s the strategy here?
M: So transfeminine patients will all get some form of estrogen as well as an androgen blocker – which is typically spironolactone or finasteride.
Carl: Looking at estrogen for the main part here, in terms of labs, we think about same as before. Hormone levels- I want to know what estrogen and testosterone we’re looking at, uh, at baseline, again, aiming for it testosterone and that is very low, to almost undetectable. And then I make sure that we order a BMP and or CMP, cause if somebody is being started on an anti androgen like spironolactone, I really need to know their renal function here. Um, and I need to know their electrolytes at baseline. I have, by doing this screening, I’ve actually identified with kidney disease who would not be a good candidate for spironolactone. So then we actually try a five alpha reductase inhibitor like finasteride, which can be used as an antiandrogen.
S: Great so for feminizing hormones, we are checking hormone levels and a basic but I’m curious when starting spironolactone – most of these patients are young with relatively lower BPs. Curious how the experts go about this.
Carl: Most of my patients, even with low normal blood pressures, their blood pressure really doesn’t take a big dive. Um, when they’re on the spironolactone the main thing they always bring up as is not surprising with a diuretic is how often they have to go pee. Uh, so I do, if I, when I’m doing twice a day dosing, I remind them to really aim for morning and early afternoon for their spironolactone rather than later in the day.
And also I would point out that we are talking about the medical side of gender affirming care here. People once they, if they go down the route, if they so choose to have a um, orchiectomy you no longer need the test, uh, no longer need antiandrogens at that point.
S: Right I had to wrap my brain around that for a second. Once those testicles are out, you don’t have that source of testosterone and you don’t need that androgen blocker! So what about formulations of estrogen?
M: Here we have a lot more options – tablets, patches and injections. It sounded like Drs. Streed and Greene had almost all of their patients on oral estrogen because it’s so much easier. Remember that those patients with elevated risks of VTE – remember smoking or family hx of clots – should probably be on a patch.
S: Great, and what about lab monitoring that are on estrogen?
Carl: Um, for my trans feminine individuals, again, I really need to see that testosterone come down. Since testosterone has such a strong virilizing effect that we really, I really do want to see that that is coming down. Even if they have an estrogen level that’s appropriate, which is a much wider range. Um, the testosterone really needs to be pretty low and that’s the main reason I want to know where they’re coming from.
M: Right so again arguing for baseline testosterone in transfeminine patients. Shrey – do you want to summarize this section?
S: Yeah I’d love to. So masculinizing hormone regimens really center around testosterone which can be administered sub-Q or IM OR topically -tho those creams can get a bit messy it seems. We monitor testosterone levels aiming for normal cisgender range based on your lab and we are monitoring CBCs for erythrocytosis and lipids as well as A1c and will try to minimize the cardiovascular risk we talked about in pearl 2.
Feminizing regimens include estrogen – available in pill, topical or injection form – as well as an androgen-blocker typically spironolactone or finasteride. We’re monitoring free testosterone here mainly to see it drop as well as keeping an eye on renal function and electrolytes especially if they are on spironolactone.
M: And I will just make another plug for the UCSF guidelines that lays out a very clear follow-up chart (page 51) about what labs to check and when to check them!
Pearl 5: Preventative Health
S: Alright so let’s change gears a bit and put ourselves a few months into the care of our transgender patients. hopefully we have built a level of trust, addressed any pertinent medical and psychosocial issues our patient has and we are starting to think about not only their acute issues but how can we keep this individual healthy for their whole life. This is the beauty of primary care – What do we need to do now to prevent illness in the future?!?
Richard: I actually really enjoy talking to my trans nonbinary patients about preventative screening because I think it’s, uh, really at the core of what we do as primary care providers.
So often in primary care we think about gender based care, like women need mammograms and men need perhaps a conversation about prostate cancer screening or something. But rather than thinking about it in terms of gender, thinking about it as anatomy based care. So what organs do you have? And if so, do they have to be screened for cancer?
M: Love this paradigm shift from gender-based screening to organ-based screening. We spent some time in the first podcast discussing the organ inventory – which gives us a chance to learn about how our patients describe their body parts and also learn about any gender-affirming surgeries they’ve had in the past.
Richard: So what organs do you have? And if so, do they have to be screened for cancer? Right? If you have a cervix, regardless of what you call it, if it’s at risk for cancer, we should screen it. So the phrase I use with my patients is if you have it, check it. And most of my patients are okay with that as long as we come up with affirming ways to do that.
S: “If you have it, check it”. Perfect. Ok so let’s start with transgender men and chest screening – (M: which is usually the preferred term for breast cancer screening) – should follow current guidelines for cis-gender women, and thats the case UNLESS theyhve had a bilateral mastectomy. This is why a detailed surgical history is really important because we want to know if our patients had chest surgery was it mastectomy vs breast reduction.
M: Ok, so I’m guessing things get complicated if there is breast tissue left…
S: Yeah – the bottom line is as follows: if they’ve undergone breast reduction and there may be some breast tissue left then we just don’t know the optimal modality for cancer screening so in these cases it’s important to acknowledge the uncertainty and make a shared decision. Mammogram is probably not technically feasible so if there is a family history you’re reaching for MRI or ultrasound and unfortunately we don’t have good guidelines to steer us in any particular direction.
M: Right – the old evidence-free zone. I’m becoming comfortable in that space. Ok, and what about cervical cancer screening in transgender men who have a cervix?
S: In general the screening intervals follow the recommendations for cigender women. Remember from episode 1 can be dysphoric that process for some patients. But there is a lot that we can to make it somewhat easier for patients including discussing the exam months in advance, using a pediatric speculum, and some pre-medication that Dr. Greene describes:
Richard: If you’re planning on doing a cervical exam, it can be helpful for people to use vaginal estrogen creams for a week or two prior to the procedure only because it can make things more comfortable. You might get a better sample- all of those things are possible. And so I’ll have this conversation well in advance with my trans men about the idea of using an estrogen for them is often very uncomfortable. But the exam itself will also be uncomfortable. So some of my trans men and trans men will use the estrogen creams and some won’t. I absolutely respect both decisions.
M: Wow I never thought about estrogen being a triggering topic for transmen but it totally makes sense. Let’s move on to cancer screening in transgender women.
S: So a few important organs to consider screening in transgender women – namely breast and prostate.
M: Wait breast cancer screening in transgender women?!? This is a thing?
S: It IS a thing. So in general the guidelines sort of follow the same for cis-gender women – that we should be screening transgender women over 50 who have been on feminizing hormones for at least 5 years get screened every two years for breast cancer
M: Ok, perfect. Tell me about prostate screening in transgender women. I’m not even sure what I’m doing with prostate cancer screening in my cisgender men…
S: Oof I feel the same way! And with prostate screening in transgender women, there’s no clear guidelines here either – but Dr. Greene reminds us that long term estrogen and antiandrogen therapy may actually decrease the risk for prostate cancer in these women.
Richard: If you imagine that someone who has been on testosterone blockade and estrogen for a very long period of time, is that very low risk for prostate cancer. But just in case to remember that they have this body part and discuss screening, particularly in people who are high risk is very important.
M: Also makes sense…. So dealer’s choice huh?
S: Yeah – shared decision-making here prevails!
M: Alright, so to summarize this section in terms of cancer screening transgender patients remember Dr. Greene’s famous words – If you got it, check it! Transmasculine patients should undergo cervical cancer screening according to the timeline in the cis-gender guidelines if they still have a cervix. Also, consider chest screening for transmasculine men who have either not had mastectomy or underwent breast reduction. Transfeminine patients also should get breast cancer screening but only if they are older than 50 AND have been on hormones for greater than 5 years. And like for cis-gender men, prostate cancer screening for transwomen should be individualized based on their own risk and preferences.
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Tags: 5 Pearls, CME, endocrinology, primary care