- [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.