Preventative care for transgender and gender non-conforming patients

– [Narrator] Welcome to the CREOG modules on caring for transgender and
gender non-conforming patients for the obstetrician-gynecologist. This module is the
second of several modules that will introduce you to the role of the obstetrician-gynecologist in providing care for
this patient population. These modules were
created with the support of the CREOG Empower Award, and with the support of
the University of Michigan. In this module, we will
discuss preventative care for transgender and gender
non-conforming patients. As obstetrician-gynecologists,
we may see transgender men, people who are assigned female at birth, transgender women, people who
are assigned male at birth, as well as gender non-conforming, or gender non-binary people. For all of these patients, we should adjust preventative care needs, including vaccinations, STI
screening, cancer screening, and screening for metabolic
and cardiovascular disease. When considering preventative measures for transgender people a general principle is
to be guided by anatomy and hormonal status. Does your patient have a cervix? They should have regular pap tests. Do they have a prostate? They should be screened
for prostate cancer according to the regular
screening guidelines. There are no differences between vaccine recommendations guidelines for cisgender and transgender people. If a transgender man, or gender non-conforming
person with a uterus, is considering or planning a pregnancy, they should be offered
MMR prior to pregnancy. Routine HPV vaccination is recommended by the Centers for Disease
Control and Prevention, CDC, and the American College of
Obstetricians and Gynecologist, ACOG, regardless of sex
at ages nine to 26 years. The target age for HPV
vaccination is 11 to 12 years, regardless of sex, but the HPV vaccine can
be given to all people through 26 years of age. In addition to standard
adult immunizations, Hepatitis A and B vaccination
should be discussed with transgender and gender
non-conforming patients. The CDC recommends offering
Hepatitis A and B vaccines to men who have sex with men. Although this categorization
may not fit well for transgender and gender
non-conforming people, they may also be at increased risk, and Hepatitis A and B
vaccination should be considered. For many transmasculine
people, transgender men, or non-binary and gender
non-conforming people assigned female at birth, genital exams in general, and
speculum exams in particular, can be emotionally and
physically difficult, at times triggering dysphoria. Be mindful, as in any
pelvic exam for any patient, of the possibility that your patient may have a history of
sexual abuse or trauma, and that a pelvic exam may be stressful. For people receiving
testosterone for masculinization, pelvic exams can also be
painful due to vaginal atrophy. Using a small or pediatric
speculum and exam gel is usually sufficient
to alleviate discomfort. Application of lidocaine
gel can also be helpful. Prior vaginal estrogen treatment may also help alleviate discomfort. Under certain circumstances, consideration for an exam
under sedation or anesthesia may be warranted. A greater than average
proportion of pap tests will come back inadequate for
patients who take testosterone and may require repeat exams. It is a good idea to let
your patients know in advance that they may need to come
back for a repeat pap test. Having your patient’s trust and making sure they’re comfortable is more important than
them getting a pap test. Under most circumstances,
a pelvic exam with pap test can be differed to a follow up appointment so that you can gain the patient’s trust and they can feel prepared for the exam. If a patient is very reluctant
to have a pelvic exam certain information such as
gonorrhea and chlamydia testing can be sent from the urine. There is no evidence to
suggest that transgender men are at increased risk for any
gynecological malignancies, including ovarian, tubal,
uterine, or breast cancer. For transgender men who have
not undergone mastectomy screening should be done according to the usual recommendations
for cisgender women. Following masculinizing chest surgery, some residual breast
tissue is usually present, however it is typically insufficient for mammography screening. While there is no evidence
to show the effectiveness of any particular
approach, annual chest exam or chest self-awareness can be considered and discussed with patients, and ultrasound or MRI can be used to assess any suspicious or new findings. Data on breast cancer in
transgender women is limited. Using extrapolated data, it is recommended to start mammography
screening in transgender women every two years after at
least five to 10 years of exposure to estrogen,
and after the age of 50 using screening guidelines
for cisgender women. It is also useful to know that most transgender
women will have a prostate. It is typically not removed in male to female bottom
surgeries, or vulvovaginoplasties. While as obstetrician-gynecologists, we may not be familiar
with more recent guidelines for prostate cancer screening, as we typically do not see
patients with prostates, we can recommend screening according to the regular screening
guidelines for prostate cancer. Discussion of sexual
health is an important part of a gynecologist’s
care for their patients. It is also an integral part
of assessing for sexual risk, STI screening, and
contraceptive counseling. As with all our patients,
when discussing sexual health it is important to be
respectful, nonjudgmental, and avoid making assumptions. Transgender may be straight,
gay, lesbian, bisexual, or define their sexuality differently. Additionally, sexual practices may vary. A survey of transmasculine individuals noted that top-rated health concerns were desirability, sex drive, sexual assault or coercion, and pregnancy. Keep in mind that terms
we are used to using in the context of cisgender people may fall short with transgender patients. For example, if you want
to know if a trans man is having receptive vaginal sex, you’ll likely need to
ask that exact question instead of only asking if he is having sex with men or women. Some transgender people may
use different terminology to speak about their genitalia. You can follow your patient’s cues and use the same language they use to describe their anatomy. For example, if a patient
talks about their front when referring to their
vagina, use the same word. One can also ask patients what terms they are comfortable with you using. A survey of transmasculine
individuals reported that they majority, 78%, wanted a provider to ask their preferred
language for their body, although a majority, greater than 60%, also prefer that their provider
use medical terminology, although this percentage was lower following gender affirming surgeries. Using gender neutral
language is a good way to open up a nonjudgmental,
non assumptive conversation about your patient’s sexual
partners and practices. For example, what parts do
your partner or partners have? How do you use your parts in sex? Do you have any front
or vaginal penetration with a penis, fingers, or toys? While testosterone levels
within the male range usually suppress menstruation, there is insufficient
data currently regarding its suppression of ovulation. Testosterone use is not
considered adequate contraception for transgender men who have
insertive vaginal intercourse with anyone who produces sperm. Additionally, testosterone is a teratogen and can cause reduced birth
weight and masculinization of a developing female fetus. It is hence recommended
that transgender men who have not had a hysterectomy and are not trying to get pregnant either use barrier contraception, or an alternative contraceptive method such as progesterone-based contraception that will not interfere
with masculinization, such as progesterone-only
pills, or an LNG-IUD. We will learn more about transgender men and pregnancy in module four. The CDC comments on
transgender men and women with regard to sexually
transmitted diseases, but with few specific screening recommendations or intervals. Transgender women, particularly
black transgender women, bear a disproportionate burden of HIV, with HIV prevalence estimates of 22 to 28% for all transgender women, and 56% for black transgender women. Based on anatomy and sexual behaviors of transgender and gender
non-conforming people, clinicians should assess
STI and HIV related risks. For individuals at high risk,
who have multiple partners, condomless sex, transactional
sex, or sex while intoxicated, screening is recommended
every three months. Additionally, for HIV negative individuals with elevated risk for HIV acquisition, pre-exposure prophylaxis, or
PrEP, should be discussed. Although not specific to
the transgender population, the CDC screening recommendations for men who have sex with men include at least annually HIV
serology, syphillis serology, urine test, Nucleic Acid
Amplification test, or NAT, for urethral infection
if insertive intercourse, rectal test, rectal specimen NAT if receptive anal intercourse
for gonorrhea and chlamydia, pharyngeal specimen test NAT if receptive oral intercourse
for gonorrhea only, as well as HCV screening for
HIV positive individuals. Given the differing
effects of steroid hormones on the risk for cardiovascular disease, one should take both
past and current exposure to steroid hormones, as
well as other risk factors, such as family history and
personal medical history, into account when making
decisions regarding screening for cardiovascular disease. When using cardiovascular risk calculators consider using natal sex, affirm
gender, or an average risk depending on the length of time since initiation of hormone therapy. Additionally, data about the
effects of hormones on lipids and blood pressure in
transgender people is limited. Estrogen exposure in transgender women has been associated with increased HDL, decreased LDL, increased weight,
increased blood pressure, and increased markers
of insulin resistance. Evidence regarding cardiovascular risk for transgender women compared
to cisgender men is mixed. Whereas evidence more
consistently suggests unchanged cardiovascular
risk among transgender men compared to cisgender women. For transgender women with elevated risk for cardiovascular thromboembolic disease, transdermal estrogen
administration may be preferable to oral, sublingual, or
intramuscular administration. Similarly, given some data
suggesting an increase in insulin resistance secondary
to testosterone exposure, screening for diabetes
may be warranted earlier in transgender men receiving testosterone. Other cardiovascular related
risks related to testosterone may include polycythemia,
elevated LDL and decreased HDL, elevated total cholesterol
and triglycerides, and possible hypertension. Mixed data exists regarding bone health, but bone mineral density
is likely affected in transgender women and men by the length of exposure to
testosterone and estrogen. Use an individualized
approach and take into account all other risk factors,
paying particular attention to prolonged periods of hypogonadism. Additional risk factors
include race, age, BMI, family and personal history,
smoking, alcohol intake, chronic corticosteroid use,
and chronic risk conditions such as rheumatoid
arthritis, HIV, immobility, and vitamin D deficiency. In summary, many preventative
services are the same in transgender and gender
non-conforming individuals as compared to cisgender individuals. Screening should be based
on anatomy, hormonal status, and other personal risk factors such as behavior and family history. Thank you for viewing module
two about preventative care for transgender and gender
non-conforming patients.

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