Gender Affirming Treatment & Transition Related Care

– [Instructor] Welcome
to the third CREOG module on caring for transgender and
gender non-conforming patients for the obstetrician/gynecologist. These modules were
created with the support of the CREOG Empower Award and with the support of
University of Michigan Medicine. Module three, gender affirming care. Gender affirming treatment also known as transition related
care or medical transition is the process of assisting
transgender people with medical treatments
to physically express their gender identities. These treatments can
include hormonal treatments, which affect the secondary
sex characteristics of an individual and surgical treatments to change body contours or genitalia. Gender affirming treatment
has been shown to improve mental health outcomes
including depression and suicidal ideation amongst
transgender individuals. However, it is important
to note that one does not have to undergo any medical
treatment to be transgender and that many people will
decide to only undergo some or none of these treatments. There is no one way to transition. Different people need different things. Hormonal management for transgender and gender non-conforming individuals. Transmasculine people
may use testosterone or T to gain masculine secondary
sex characteristics. Transfeminine people may use estrogen along with androgen blockers to gain female secondary
sex characteristics. While some transgender
women have advocated for the use of progesterone treatment, there is no evidence for any benefit and there may increased
risk of breast cancer. The major goals of hormone therapy are to reduce endogenous
sex hormone levels and to replace them with
exogenous sex hormones. Hormone therapy follows
the same principles of hormone replacement treatment
in hypogonadal patients, allowing for the development of secondary sex characteristics congruent with the
individual’s gender identity. Initiating hormone therapy. The initiation of hormone
therapy should follow an extensive discussion with
the patient about goals, expectations, and risks and side effects, acknowledging the limitations
of currently available data. Most guidelines currently recommend a documented prior evaluation and counseling by a
mental health provider. This evaluation assesses the appropriateness of hormonal care for the treatment of the
individual’s gender dysphoria. However, many providers
and patients advocate for the use of an informed consent model. This model seeks to
acknowledge and better support the patient’s right to and capability for personal autonomy in choosing care. According to WPATH or the World Professional Association
for Transgender Health, the criteria for gender
affirming hormone therapy in adults are persistent, well
documented gender dysphoria or gender incongruence, the capacity to make a
fully informed decision and to consent for treatment, mental health concerns if present must be reasonably well controlled. There are multiple options
for prescribing testosterone. The most common form of
prescribed testosterone available in the US is either testosterone cypionate or
testosterone enanthate, which can be given either
intramuscularly or subcutaneously, typically in a weekly dosage. Typical doses range from 40
to 120 milligrams a week. One should aim for mid male
range of both testosterone and estradiol and for a
hematocrit of less than 50%. One should adjust clinically for example, some patients may get mood changes in the days before injection. A small increase in
dose can eliminate this. When initiating testosterone therapy, aim for the therapeutic
dose from the start to avoid intermittent
bleeding and spotting that can be seen when using
low doses of testosterone. It is worthwhile alerting the patient to expect the puberty like process. Facial hair growth for transgender men or breast development for trans women can take up to two years for full effect. Transdermal administration
using gel is an alternative for those who want to avoid injections. It does require daily
administration, is more expensive, and requires care when coming
into skin to skin contact with other individuals or
sharing a hot tub or pool. It also tends to have slower, more subtle masculinizing effect and might cause bleeding or
spotting in some individuals. Effects of testosterone
include the following, permanent changes include voice deepening, clitoral enlargement,
and male pattern baldness depending on the genetics
of the individual. Increase in terminal
facial hair and body hair can take up to five years to stabilize and an equal timeframe to resolve as testosterone is discontinued. Reversible changes include
body fat redistribution, increase in muscle mass,
increase in skin thickness, acne and cessation of menstrual bleeding. Most transgender men
will achieve amenorrhea within a few months of
testosterone treatment. Ongoing bleeding or
spotting in the presence of male range testosterone levels with adequate estrogen suppression may require further investigation. This may include ultrasound to
assess endometrial thickness or an endometrial biopsy. In the first year of treatment, one should monitor total testosterone and hematocrit every three months. After the first year, annual
monitoring is sufficient. In complex cases, it may be
helpful to monitor albumin and SHBG every three
months in the first year. In some cases, testosterone
use may be associated with the following, erythrocytosis, or a hematocrit greater than
50%, severe liver dysfunction, transaminitis greater than three times the upper limit of normal, hypertension, increase in LDL and
decrease in HDL levels, increased visceral fat and
decrease in fasting glucose, which indirectly contribute to the risk of cardiovascular disease. However, there is currently
no evidence for an increase in cardiovascular events
in transgender men. If your patient presents with symptoms, reduction in dosage may be warranted. Keep in mind that many
transgender people are wary of being cutoff from
hormone therapy entirely, so it is essential to
discuss risks and benefits of any dosage change with your patients where problems arise in order
to keep them retained in care. Monitoring testosterone therapy. Various protocols have been suggested for the monitoring of
masculinizing therapy. The goal of monitoring is to ensure safety and that the therapy is adequate for maintenance of
hormones in the male range. Monitoring should include a CBC to ensure that the hematocrit is
not excessively elevated, a comprehensive metabolic profile, and testosterone and estradiol levels. While initial testing may be more frequent such as at the three month interval, with a stabilization of dosage
the frequency of testing can be gradually reduced to once annually. For an example of a protocol, see the UCSF Center of Excellence website. Hormone therapy for transgender women. Obstetrician gynecologists
are well positioned to provide gender affirming
care to trans women. OBGYNs have experience and
knowledge of prescribing estrogen in many different contexts
including suppression of androgenic hormones such
as in treatment for PCOS. Additionally obstetrician
gynecologists can be vital to increasing transgender women’s access to receiving affirming care. Hormone therapy for transgender
women will usually include an androgen blocker and estrogen. In this case too the aim is
for physiologic female levels of testosterone and estrogen. Available routes of estrogen
administration will include oral, sublingual,
intramuscular, and transdermal. Here are some hormone regiments
for transgender women. In most cases we will prescribe an antiandrogen along with estrogen. Effects of estrogen include
decreased body and facial hair, a decrease in libido and loss
of spontaneous erections, a reduction in muscle mass
and fat redistribution. Breast development can be expected within three to six months and
usually peaks by two years. Adverse effects of estrogen. The major concerns with use
of high doses of estrogen are for an increase in
cardiovascular disease, thromboembolic disease, and stroke. There is no evidence for
increased risk of breast cancer. Transdermally administered
estrogen is associated with lower rates of
venous thromboembolism. It may hence be the preferred
option for transgender women with cardiovascular risk factors or established cardiovascular disease. If using spironolactone
as an antiandrogen, keep in mind that this medication is a potassium sparing diuretic and patients should be counseled about symptoms of
hypotension and dehydration. Antiandrogens can be discontinued
following gonadectomy and estrogen doses can be reduced. Monitoring feminizing hormone therapy. As with masculinizing
therapy for transgender men, various protocols have been suggested for the monitoring of feminizing therapy with gradually increasing
intervals of testing. For an example of a protocol, see the UCSF Center of Excellence website. Sexual function and fertility. Hormone therapy can impact
sex drive and arousal. Testosterone may increase
libido among transgender men. Both androgen blockers and estrogen use among transgender women will lead to decrease in spontaneous erections and may affect sex drive and
ability to sustain an erection. These issues should be
discussed with patients. Prior to initiating hormone
therapy providers and patients should discuss fertility
and family planning issues. Please refer to module four on the gynecological
care for further detail. For transgender men
testosterone is not adequate birth control even with
cessation of menses and has teratogenic potential. Options for contraception if engaging in penetrative intercourse
with pregnancy potential include progesterone only
pills, subdermal implants, IUDs, injectable progesterone or condoms. There are currently limited
data on the longterm effects of testosterone on ovarian
function, reserve and fertility. Anecdotal data report transgender men who have conceived spontaneously following cessation of
testosterone treatment. However it is not known whether
transmasculine individuals can routinely expect to be
able to carry pregnancies or harvest gametes following
testosterone treatment. For transgender women androgen blockers and estrogen therapy will
decrease sperm counts. These effects are reversible, however it may require
three to six months. It is important that providers discuss fertility preservation with patients prior to initiation of hormone treatment and prior to surgical removal of gonads. Transgender and gender
non-conforming youth GnRH agonists. In transgender adolescents
endogenous puberty can cause significant distress. Additionally some
physical changes affected by endogenous hormones
are either permanent or difficult to reverse when a person transitions after puberty. GnRH agonists can be useful in
those cases to delay puberty. These are usually started
when the adolescent is at Tanner stage two enabling the delay of endogenous puberty until the adolescent and their family are ready to initiate gender affirming sex steroid treatment. For further information on care for transgender children and adolescents, please refer to the
Endocrine Society guidelines and to the UCSF Center of Excellence for Transgender Health guidelines. Surgical options. Many transgender individuals will seek surgery as part of aligning their physical body to
their affirmed gender. The World Professional Association for Transgender Health Standards of Care require mental health provider referral letters for surgical options. One referral letter is required for breast/chest surgery
such as mastectomy, chest reconstruction and
augmentation mammoplasty. Two referral letters and
usually 12 continuous months of hormone treatment are
required for genital surgeries such as hysterectomy,
salpingo-oophorectomy, orchiectomy and genital
reconstructive surgery. Additionally per WPATH, genital
reconstructive surgeries including metoidioplasty,
phalloplasty and vaginoplasty require 12 months of
living in the gender role congruent with one’s gender identity. It is important to stress that these guidelines
are general principles and treatment should
always be individualized. Some providers are moving toward
an informed consent model. At this point however,
most insurance companies do still require letters prior
to authorization of coverage. So for patients with insurance coverage, letters will likely be needed. Options for gender affirming surgery for transmasculine people
include top surgery, bilateral mastectomy, and bottom surgery. Bottom surgery may include a hysterectomy, with or without gonads and
tubes, colpectomy or vaginectomy, phalloplasty, which is the
creation of a neo phallus from a flap usually forearm or thigh. This can be done with or
without a penile implant, scrotal implants or a urethral hookup. Lastly there is metoidioplasty
also known as meta or meto, in which the cruor of an enlarged clitoris are released to increase length. For trans women options
include top surgery, breast reconstruction including
implants, bottom surgeries, vaginoplasty, penectomy or orchiectomy, and other ancillary procedures such as electrolysis or hair
removal, facial reconstruction, and chondrolaryngoplasty, which is commonly known
as a tracheal shave. Effects of body contour practices. There are several practices
that transgender people may use to alter their body contours
which may affect their health or be notable upon physical exams. These include binding. This is the flattening of
the transmasculine chest using tape, ace bandages, tight
fitting or layered garments, or a specially designed binder. While there is no evidence that binding is itself a harmful practice, depending on the tightness and
material or technique used, it may restrict breathing, increase acne underneath the binder, or cause skin irritation
or fungal skin infections. Trans men should be advised
to avoid overnight binding. Longterm binding may
result in muscle imbalances or weaknesses in the chest and back. Tucking, this entails
pushing the testicles upward in the inguinal canal
allowing one to flatten the penis and scrotum
backward toward the perineum. This is done in order to achieve
a flat crotch appearance. Anecdotally this may lead
to urinary tract infections and local pain, especially if prolonged. Silicone and other fillers. This is often injected
by transgender women to achieve rapid and
significant augmentation to breasts, hips and buttocks. These injections are often performed in unsupervised non-sterile settings and may include a variety of substances. Risks include embolization,
which can lead to ARDS, infection, local inflammation,
erosion and necrosis, migration and deformation,
and granuloma formation. When treating transgender
women for otherwise unexplained inflammatory or embolic conditions, remember to consider
complications of filler injections either recent or remote in
your differential diagnosis. Gender affirming treatment
is medically necessary and at times lifesaving
for appropriate candidates. Treatment can include
hormones, surgeries or both. It is important to review
expected changes, risks, alternatives and regiment options as well as contraception and
fertility preservation options with patients prior to
initiation of treatment. Thank you for listening,
this concludes module three.

One comment

  1. thank you for uploading this video! surprisingly i searched all over youtube for a scientific breakdown for the whole process with no clue ! and here comes heros like you who does this and throw it out there helping people like me thanks again

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