Download Objectives

Objectives
ƒ Understand the importance of safe, accessible, high
quality healthcare for the transgender community
ƒ Plan specific ways to improve the practice
environment for transgender patients
ƒ Review guidelines for initiating and managing
hormone therapy
MedicalIssuesofTransgenderAdults
ƒ Discuss considerations for billing/coding/prescribing
February10,2016
CarolBlenning,MD
ƒ I have nothing to disclose
Professionaluseofthisslidedeckoranyduplicationofitscontentswithouttheexplicitpermissionofthepresentersisprohibited.
Initiatinghormonetherapy
TimelineofExpectedEffects
• BaselineLabs,H&P
ͲFemaleAffirming:CBC,CMP,Testosterone,Estradiol,Prolactin,
Lipids,TSH
ͲMaleAffirming:CBC,CMP,Testosterone,Estradiol,Lipids,TSH
• RelativeContraindicationspriortotreatment:
FemaleAffirming:H/ohypercoaguability,estrogensensitiveneoplasm(esp
pituitaryadenoma),ESLD
MaleAffirming:UnstableCAD,untreatedPolycythemia
• Considerations:activeTobaccouse,activepyschosis,active
SubstanceUse
• Addressirreversibleandreversibleeffectsthroughconsenting
process(seehandout)
• Addresstimelineofexpectedchanges
Testosteronerisks
Testosteronerisks(cont)
• Inc’d Hyperlipidemia/loweredHDL
• Polycythemia(usemalereferencerangesforevaluatingRBCindices!)
• Metabolicsyndromerisks
• Hypertension
• Aggression
• Excessivelibido
• Acne
• Malepatternbaldness(androgenicalopecia)
• Infertility(considereggstorage)
•
•
•
•
•
•
•
•
•
Headaches
Boneloss(ifnotonadequatetestosterone,esp postoophorectomy)
Worsensbreast/uterinecancer
Liverdysfunction
Pelvicpainorcramping
Spotting(atrophicendometriumtypical)
Injectionsiteissues(pain,lumps,allergicrash,infection)
RisktocisͲfemalepartnerwithexposuretotopicalgelsorcreams
NOT anreliableformofCONTRACEPTIVE!
EstrogenRisks
SpironolactoneRisks
• Venousthromboembolism(withoralestrogen,ethinyl estradiol,
smokers,hypertension)
• Mayworsen:CAD,cerebrovasculardisease,macroprolactinoma,
migraines,hypertension,hypertriglyceridemia,gallstones,liver
dysfunction(transaminases>3x)
• Infertility
• Fewreportedcasesofbreast,prostatecancerbutnoincreased
overallcancermortality
• Renaldysfunction,especiallyinolderpatients
(monitorBUN,creatinine,urinealbumin)
• Hyperkalemia
• Hyponatremia
• DruginteractionswithACEinhibitorsandARB’s(hyperkalemia)
• Hypotension
• Erectiledysfunction
• Infertility
ExampleDosingChart:
Example DosingChart:
Managingandmonitoringhormonetherapy
• FollowͲupin1,3,6,12months
• ReviewBP,sideeffects,emotional/physicalchanges,sexuality,weight,
andqualityoflife(riskbehaviorsifindicated)
• Surveillancelabsperguidelines
• Titratemedicationsperguidelines
• ContinueHCMcarerelevanttonatalgender
•
Managingandmonitoringhormonetherapy:Example
FeminizingHormones:
• SerumTestosteroneassessment:GoalistosuppressTotal
Testosteroneto<55ng/dL
• SerumEstradiol assessment:Goalistomaintainlevelsin
“healthyfemalerange”but<200pg/mL
• RecommendedManagement:OralEstradiol:titrateupor
downby0.1mg/week,maxdose0.6mg/day,dividedintoBID
doses.OralSpironolactone:titrateupordownby50mg/week,
maxdose400mg/day.
• RepeatLab:q4Ͳ6weeksuntilstableinrange
Managingandmonitoringhormonetherapy:Example
Masculinizing Hormones:
• SerumTestosteroneassessment:Goalrange270Ͳ1200
ng/dL;cantestmidͲdoseor trough;amenorrheaiscritical
formostpatients
• SerumEstradiol assessment:Goalistosuppressestradiol
to<50pg/mL and/ortoachieveamenorrheic state
• RecommendedManagement:Injectable:titrateupor
downby10mg/week
• RepeatLab:q4Ͳ6weeksuntilstableinrange
Page 1 of 5
Sample Consent Form #2
You are considering taking testosterone, so you should learn about some of the risks,
expectations, long term considerations, and medications associated with transition from
female to male.
It is very important to remember that everyone is different, and that the extent of, and rate
at which your changes take place depend on many factors. These factors include your
genetics, the age at which you start taking hormones, and your overall state of health.
It is also important to remember that because everyone is different, your medicines or
dosages may vary widely from those of your friends, or what you may have read in books
or online. Many people are eager for changes to take place rapidly; please remember that
you are going through a second puberty, and puberty normally takes several years for the
full effects to be seen. Taking higher doses of hormones will not necessarily make things
move more quickly—it may, however, endanger your health.
There are four areas where you can expect changes to occur as your hormone therapy
progresses.
1) Physical
The first changes you will probably notice are that your skin will become a bit thicker
and more oily. Your pores will become larger, and there will be more oil production.
You may develop acne, which in some cases can be bothersome or severe. Acne can be
managed with good skin care technique as well as typical acne treatments such as lotions.
You may notice that you perceive pain or temperature differently, or that things just “feel
different” when you touch them. You will probably notice skin changes within a few
weeks. In these first few weeks you will notice that the odors of your sweat and urine
will change, and that you may sweat more overall.
Your breasts will not change much during transition, though you may notice some breast
pain, or a slight decrease in size. For this reason, many breast surgeons recommend
waiting for at least six months after beginning testosterone therapy before having chest
reconstruction surgery.
Weight will begin to redistribute around your body. Fat will diminish somewhat around
your hips and thighs, and the fat under your skin throughout your body will become a bit
thinner, giving your arms and legs more muscle definition and a slightly rougher
appearance. Testosterone may cause you to gain fat around your abdomen (otherwise
known as your “gut”). Your muscle mass will increase significantly, as will your
strength. However, in order to maximize your development and maintain your health you
should exercise 4-5 times a week with 30 minutes/day of cardio/aerobics, as well as at
least mild weight training. Depending on your diet, lifestyle, genetics, and starting
weight and muscle mass, you may gain or lose weight once you begin HRT.
The fat under the skin in your face will decrease and shift around to give your eyes and
face in general a more angular, male appearance. Please note that your bone structure
Page 2 of 5
Sample Consent Form #2
will likely not change, though some people in their late teens or early twenties may see
some subtle bone changes. The facial changes can take up to 2 years or more to see the
final result.
The hair on your body, such as your chest, back and arms will increase in thickness,
become darker and will grow at a faster rate. You may expect to develop a pattern of
body hair similar to other men in your family. However, again please remember that
everyone is different, and that it can take up to 5 years or longer to see the final results.
Most transmen notice some degree of frontal scalp balding, mostly in the area of your
temples. Depending on your age and family history, you may develop thinning or even
complete hair loss in a male pattern baldness pattern.
Beards vary from person to person. Some people develop a thick beard quite rapidly,
others make take several years to do so, while others may never develop a full and thick
beard. This is a result of genetics and the age at which you start testosterone therapy.
You might notice that non-transgender men also have a varying degree of facial hair
thickness, and a varying age at which their beard fully developed.
2) Emotional
Your overall emotional state may or may not change, this varies from person to person.
Puberty is a roller coaster of emotions, and the second puberty that you will experience
during your transition is no exception. You may find that you have access to a narrower
range of emotions or feelings, or have different interests, tastes or pastimes, or behave
differently in relationships with other people. While psychotherapy is not for everyone,
most people would benefit from a course of supportive psychotherapy while in transition
to help you explore these new thoughts and feelings, and get to know your new self.
3) Sexual
Soon after beginning hormone treatment, you will likely notice a change in your libido.
Quite rapidly, your clitoris will begin to grow, and will become larger when you are
aroused. You may find that there are different sex acts or different parts of your body
that bring you erotic pleasure. Your orgasms will feel different, with perhaps more peak
intensity, and more focused on your genitals, as opposed to a whole body experience. It
is recommended that you explore and experiment with your new sexuality through
masturbation, using sex toys, and involve your sexual partner.
4) Reproductive
You may notice at first that your periods become lighter, arrive later, or are shorter in
duration than previously. Some people will actually notice heavier or longer lasting
periods for a few cycles before they stop altogether.
Testosterone greatly reduces your ability to become pregnant. However, it does not
eliminate the risk of pregnancy completely. If you are on testosterone and remaining
Page 3 of 5
Sample Consent Form #2
sexually active with a non-transgender man, you should always continue to use a birth
control method to prevent unwanted pregnancy.
It is possible for transgender men to become pregnant while on testosterone. If you
suspect you may be pregnant, have a pregnancy test as soon as possible, so that your
doctor can stop your testosterone treatment, which may be dangerous to the fetus. If you
want to become pregnant, you must first stop your testosterone treatment and wait until
your doctor tells you that it is okay to begin trying to conceive. Your doctor may check
your testosterone levels before clearing you to begin efforts of conception.
Testosterone therapy may change the shape of your ovaries and make it more difficult for
them to release eggs. If this happens, you may need to use fertility drugs, or use
techniques such as in vitro fertilization in order to become pregnant. It is possible that
after taking testosterone, you may completely lose the ability to become pregnant.
“Freezing” eggs is not yet a realistic alternative for preserving your fertility.
After being on testosterone for some time, you may experience a small amount of
spotting or bleeding. This may occur if you miss a dose, or change your dosage. You
should report any bleeding or spotting to the doctor; in some cases, it must be followed
up with an ultrasound to be sure that you do not have a precancerous condition called
“hyperplasia”.
The risk of developing hyperplasia while taking testosterone is not clear. It is usually
recommended that as long as you have a uterus, you are screened for hyperplasia once
every two years, even if you have not had any bleeding. There are two ways to do this.
One is to have an ultrasound performed. Another way is to take a hormone called
progesterone for 10 days, after which you will have small period. This helps to “reset”
your uterus and help prevent hyperplasia. If you take 10 days of progesterone and do not
have a period, you will need an ultrasound as this may indicate that hyperplasia has
developed.
Your risk of cervical cancer relates to your past and current sexual practices. Please note
that even people who have never had a penis in contact with their genitals may still
contract HPV infections. The HPV vaccine (Gardasil) can greatly reduce your risk of
cervical cancer, depending on the age at which you get the vaccine, and how many sexual
partners you have had before receiving the vaccine. Pap smears are generally
recommended every two years; more or less frequent pap smears may be recommended
by the doctor, depending on your sexual history and the results of your prior pap smears.
The risk of cancer of the ovaries may be slightly increased while on testosterone
treatment. Ovarian cancer is difficult to screen for, and most cases of ovarian cancer are
discovered after it is too late to be treated. A pelvic examination, where your doctor uses
a gloved hand to examine your vagina, uterus and ovaries is recommended every 1-2
years to help detect this condition. Many experts recommend a full hysterectomy and
bilateral salpingo-oopherectomy (removal of the uterus, ovaries, and fallopian tubes)
within 5-10 years of beginning testosterone treatment in order to minimize your cancer
Page 4 of 5
Sample Consent Form #2
risk.
The risk of breast cancer while on testosterone treatment is not significantly increased.
However, there has not been enough research on this topic to be certain of the actual risk.
It is still important to receive periodic mammograms or other screening procedures as
recommended by your doctor. After breast removal surgery, there is still a small amount
of breast tissue left behind. It may be difficult to screen this small amount of tissue for
breast cancer, though there are almost no cases of breast cancer in transgender men after
chest reconstruction surgery.
Testosterone will change your overall health risk profile to that of a man. Your risk of
heart disease, diabetes, high blood pressure, and high cholesterol may go up, though these
risks may be less than a non-transgender man’s risks. Since men on average live about 5
years less than women, you may be shortening your lifespan by several years by taking
testosterone. Since you do not have a prostate, you have no risk of prostate cancer and
there is no need to screen for this condition.
Testsosterone can make your blood become too thick, which can cause a stroke, heart
attack or other conditions. Testosterone can cause your liver to work too hard, causing
damage. Your doctor will perform periodic tests of your blood count, cholesterol, kidney
functions, and liver functions, and a diabetes screening test in order to closely monitor
your therapy. Testosterone levels do not need to be routinely checked as they are
expensive; however, your doctor may choose to check them for a variety of reasons.
Some of the effects of hormone therapy are reversible if you stop taking testosterone.
The degree to which the effects can be reversed depends on how long you have been
taking the testosterone. Clitoral growth, facial hair growth, and male-pattern baldness are
not reversible.
If you have had your ovaries removed, it is important to remain on at least a low dose of
hormones post-op until at least age 50 years old (and perhaps beyond), to prevent a
weakening of the bones, otherwise known as osteoporosis.
Testosterone comes in several forms. Most transgender men begin using an injectible
form of testosterone, which is safe and effective. Some men chose to begin on a lower
dose and increase slowly, while others chose to begin at a standard dose. Both
approaches have their pros and cons, and you can discuss this with the doctor.
Testosterone levels tend to be most even when the injections are given weekly. There are
also trandermal forms (patches, gels, and creams) available. Most men will need to start
with injections in order to see significant changes, some may then change to one of the
transdermal forms.
Taking more testosterone will not make your changes progress more quickly and can be
unsafe. Excess testosterone can be converted to estrogen, which can then increase your
risks of hyperplasia or cancer, as well as make you feel anxious or agitated, can harm
Page 5 of 5
Sample Consent Form #2
your liver, and can cause your cholesterol or blood count to get too high. It is important
to be patient and remember that puberty can take years to develop all of its changes.
I understand the foregoing information about testosterone usage, and I hereby consent to
the prescription use of testosterone.
Patient__________________________________
Date_____________________
Physician________________________________
Date_____________________
You are considering taking feminizing hormones, so you should learn about some of the
risks, expectations, long term considerations, and medications associated with transition
from male to female.
It is very important to remember that everyone is different, and that the extent of, and rate
at which your changes take place depend on many factors. These factors include your
genetics, the age at which you start taking hormones, and your overall state of health.
It is also important to remember that because everyone is different, your medicines or
dosages may vary widely from those of your friends, or what you may have read in books
or online. Many people are eager for changes to take place rapidly: Please remember that
you are going through a second puberty, and puberty normally takes several years for the
full effects to be seen. Taking higher doses of hormones will not necessarily make things
move more quickly; it may, however, endanger your health.
There are four areas where you can expect changes to occur as your hormone therapy
progresses.
1) Physical
The first changes you will probably notice are that your skin will become a bit drier and
thinner. Your pores will become smaller, and there will be less oil production. You may
become more prone to bruising or cuts. You may notice that you perceive pain or
temperature differently, or that things just “feel different” when you touch them. You
will probably notice skin changes within a few weeks. In these first few weeks you will
notice that the odors of your sweat and urine will change, and that you may sweat less
overall.
You will also notice small “buds” developing beneath your nipples within a few weeks of
starting your treatment. These may be slightly painful (especially to the touch) and
uneven between the right and left side. This is normal, and is the normal course of breast
development. The pain will diminish somewhat over the course of several months.
Breast development is quite variable from person to person. Not everyone develops at
the same rate, and most transgender women can only expect to develop an “A” cup or
perhaps a small “B” cup, sometimes only after many years of hormone therapy. Like
non-transgender women, the breasts of transgender women vary in shape and size, and
are sometimes different sizes or shapes between the right and the left.
Weight will begin to redistribute around your body. Fat will begin to collect around your
hips and thighs, and the fat under your skin throughout your body will become a bit
thicker, giving your arms and legs less muscle definition and a smoother appearance.
Hormones will not have a significant effect on the fat in your abdomen (otherwise known
as your “gut”. Your muscle mass will decrease significantly, as will your strength
(thought you should continue to exercise to maintain your muscle tone as well as your
general health). Depending on your diet, lifestyle, genetics, and starting weight and
muscle mass, you may gain or lose weight once you begin HRT.
The fat under the skin in your face will increase and shift around to give your eyes and
face in general a more female appearance. Please note that your bone structure
(including your hips, arms, hands, legs and feet) will not change. The facial changes can
take up to 2 years or more to see the final result; It is usually a good idea to wait at least 2
years after beginning HRT before considering any drastic facial feminization procedures.
The hair on your body, such as your chest, back and arms will decrease in thickness and
will grow at a slower rate. It may not all go away, however, and some people may need
electrolysis or laser to help reduce unwanted body hair. Your beard may thin a bit and
grow a bit slower; however, it will rarely go away completely without electrolysis or
laser treatments. If you have had any scalp balding, this should slow or stop, though the
amount that will grow back is variable.
Some people may notice minor changes in shoe size or height. This is not due to bony
changes, but due to changes in the ligaments and muscles of your feet.
2) Emotional.
Your overall emotional state may or may not change, this varies from person to person.
Puberty is a roller coaster of emotions, and the second puberty that you will experience
during your transition is no exception. You may find that you have access to a wider
range of emotions or feelings, or have different interests, tastes or pastimes, or behave
differently in relationships with other people. While psychotherapy is not for everyone,
most people would benefit from a course of supportive psychotherapy while in transition
to help you explore these new thoughts and feelings, and get to know your new self.
3) Sexual.
Soon after beginning hormone treatment, you will notice a decrease the number of
erections that you have. When you do have an erection, it will be less firm, and will not
last as long. You may lose the ability to penetrate. You will still have erotic sensation,
and will still be able to orgasm. However, when you do orgasm, it may be “dry”. You
may find that there are different sex acts or different parts of your body that bring you
erotic pleasure. Your orgasms will feel different, with more of a “whole body”
experience, less peak intensity, and longer duration. It is recommended that you explore
and experiment with your new sexuality through masturbation, using sex toys such as
dildos or vibrators, and involve your sexual partner.
Your testicles will shrink to less than half their original size, or less. In nearly all cases,
this does not affect the amount of scrotal skin available for future genital surgery.
4) Reproductive.
You must assume that within a few months of beginning hormone therapy, you will
become permanently and irreversibly sterile. While some people may be able to maintain
a sperm count on hormone therapy, or have their sperm count return after stopping
hormone therapy, you must assume that this will not be the case for you. If you think that
there might be any chance that you may in the future want to parent a child using your
own sperm, you should speak to the doctor about preserving your sperm in a sperm bank.
This process generally takes 2-4 weeks and costs between roughly $2000-$3000. You
should store your sperm before beginning any hormone therapy.
Also, if you are on hormones but remaining sexually active with a woman who is able to
become pregnant, you should always continue to use a birth control method to prevent
unwanted pregnancy.
Many of the effects of hormone therapy are reversible, if you stop taking them. The
degree to which they can be reversed depend on how long you have been taking them.
Breast growth, and possibly sterility are not reversible. If you have an orchiectomy
(which is removal of the testicles) or genital reassignment surgery, you will be able to
take a lower dose of hormones. However, it is important to remain on at least a low dose
of hormones post-op until at least age 50 years old, to prevent a weakening of the bones,
otherwise known as osteoporosis.
Cross-gender hormone therapy for transwomen may include three different kinds of
medicines. Estrogen, testosterone blockers, and progesterones.
1) Estrogen
Estrogen is the hormone responsible for most female characteristics. It causes the
physical changes of transition, as well as many of the emotional changes. Estrogen may
be given as a pill, by injection, or by a number of preparations applied to the skin, such as
a cream, a gel, a spray or a patch.
Pills are convenient, cheap and effective, but they are hard on your liver and are less safe
after age 35 or if you smoke. Patches can be very effective and safe, they may cost a
little more than pills, and they require that you wear them at all times. Sometimes, they
may irritate your skin. Creams, sprays and gels are very effective and safe, and absorb
quickly into your skin. These do tend to be a bit more expensive, and may not work as
well for people who still have testicles.
Risks associated with estrogen include high blood pressure, blood clots, liver problems,
stroke, and perhaps diabetes. Also, there are potential unknown risks since we have not
done a lot of research on the use of estrogen in transwomen. It is possible that in the
future we may learn about more risks or side effects, particularly when using estrogen for
many years. Contrary to what many may believe, a very small amount of estrogen is
needed to deliver the maximum effect. Taking very high doses of estrogen does not
necessarily make changes happen more quickly, but it can be dangerous and harmful to
your health.
There is not much scientific evidence about the risks of cancer in transgender women.
We believe that your risk of prostate cancer will go down, but we are not sure, and
therefore you will still need to be tested for that cancer when appropriate. Your risk of
breast cancer may increase slightly, though it will still be less than a non-transgender
female. Breast cancer screening with mammograms is recommended to begin between
ages 40 and 50, for people who have been on hormones for more than 2-3 years.
Many transwomen are interested in taking estrogen injections. Estrogen injections may
be appropriate for some people in some cases. When you take estrogen injections, you
will have the same amount of estrogen as a pregnant woman. This can make you
nauseous, tired, or cause you to gain weight or have mood swings. In people who smoke,
or people over 35-40 years old, this high level of estrogen can be dangerous and increase
your risk of stroke, blood clots, diabetes, or other disorders. If the doctor does start you
on estrogen injections, you should expect to stop them after 1-2 years, since the body is
not designed to be constantly exposed to such high levels of estrogen. When you stop the
injections and switch to another form of estrogen, you may feel sick for a while, with
mood swings, anxiety, and other symptoms as your body re-adjusts to the lower and
healthier levels of estrogen.
After you have had genital surgery or orchiectomy (removal of the testicles), your
estrogen dose will be lowered, and estrogen injections will be stopped. Once you have
have your testicles removed, you need very little estrogen to maintain your feminine
characteristics.
Estrogen can make your liver work too hard, causing damage. Your doctor will
periodically check your liver functions, cholesterol, and perform a diabetes screening test
to monitor your health while on testosterone therapy.
2) Testosterone blockers.
There are a number of medicines which can be used to block testosterone. Some of these
drugs block the action of testosterone in your body, and some of them also prevent the
production of testosterone. Most of the testosterone blockers are very safe. The one
most commonly used, spironolactone, does have some side effects. It can make you
urinate excessively, especially when you first start taking it, which can make you feel
dizzy or lightheaded. It is important to drink plenty of fluids when taking this medicine.
Also, spironolactone can interact with some blood pressure medicines and can be
dangerous in people with kidney problems. It is important to share your full medical
history and medication list with the doctor so that they can be sure there will be no
interactions. People taking spironolactone must have their potassium levels checked
periodically, as it can rarely get dangerously high, which can cause your heart to stop.
3) Progesterone.
Progesterone is a source of constant debate among both transwomen and providers.
Progesterone has a number of reported benefits, such as improved mood, energy or libido,
better breast development, or better body fat redistribution and “curves”. There is very
little scientific evidence to support these claims. However, some transwomen do prefer
to take progesterone and have seen some of these benefits. When you take a natural form
of progesterone, your risk of things like blood clots, stroke, or cancer are minimized, but
still may be increased; There simply is not enough research in this area to make an
accurate prediction of you risk.
Progesterone may be given by a pill or by a cream. The pill is easy and relatively safe,
the cream is also quite easy and safe. Both are about the same price.
I understand the foregoing information about feminizing hormone usage, and I hereby
consent to the prescription use of feminizing hormones.
Patient__________________________________
Date_____________________
Physician________________________________
Date_____________________