Hormone Replacement: Case Studies For Your Gender Diverse Population Allison Fox, MSN, FNP
Lecture Objectives • Overview of medications used • Overview of lab testing needed • Jump into case studies!
Hormones: Readiness, Informed Consent, Initiation and Monitoring
Initiating Hormones • Endocrine Society, 2017
Assessing Readiness • Gender Dysphoria replaces gender identity disorder in DSM V • To diagnose GD- there must be: – gender identity is not congruent with gender assigned at birth – desire to live or be treated as the other gender – strong conviction that one has feelings and reactions typical of the other gender – must be present for at least 6 months • DSM notes GD is not in itself a mental disorder
Informed Consent • Fenway Health • Email me: foxal@ohsu.edu • take time to read them over- they can be long • reiterate important topics, things that can’t be changed, fertility, T doesn’t prevent pregnancy, estrogen can carry higher risk for blood clot
Initiating Hormones • Know your resources! –UCSF Transgender guidelines
Initiating Hormones: UCSF, feminizing
Endocrine Society, 2017
Monitoring Hormones: UCSF Goal Estrogen level: 100- 200 pg/ml Goal Testosterone level: <55 ng/dl
Endocrine Society, 2017
Initiating Hormones: UCSF, masculizing
Endocrine Society, 2017
Monitoring Hormones: UCSF Goal Testosterone Level: no higher than 700
Endocrine Society, 2017
Case Studies
Feminizing 40 year old MtF patient who has been on hormones for 2 years and had an orchiectomy 4 months ago. Currently on estrace 2 mg po daily, provera 10 mg Labs this week returned: Estradiol 151 pg/mL Testosterone 29 ng/dL Potassium 4.2 mmol/L Any change needed?
Masculizing Jay is a 22 yr old transmale who has been on T for >2 years. He is taking 0.4 ml of testosterone IM weekly, down from 0.5 ml the first year he was on T. He presents to your office and is overdue for labs. His last level was in 2016 and was 103. Previously levels were: 631 and 930 What do you want to do?
Feminizing Sarah is a 44 year old transfemale you inherited from a colleague who left your practice. She’s been on a few regimens of oral medication and patches but prefers patches in the colder months. She is a little anxious and likes her labs to be checked frequently. How often would you check her labs? Currently taking: estradiol 0.1mg/24 hr patch, using 2 patches twice weekly, spiro 150 mg bid, progesterone 200 mg qhs Estradiol levels (T levels): 189 (93), 183 (13), 122 (71), 554 (113), 69 (237), 146 (70), 157 (53), 157 (86)
Feminizing Grace is a 25 yo MtF patient who suffers from depression and admits during your visit that she forgets to take her meds sometimes. Her current medications are: estrace 3 mg bid, zoloft 100 mg, zyrtec 10 mg daily, spiro 100 mg bid Labs: estradiol (T): 70 (535), 120 (142), 316 (129), 147 (132), 83 (132), 91 (243) Her potassium is consistently between 4.0-4.6
Cervical Cancer Cervical cancer screening for transmen follows recommendations for ciswomen as endorsed by the ACS, WHO, and USPSTF. • Transmen have lower rates of screening • Inadequate screening is linked to the barriers trans patients face in accessing culturally sensitive care – Trauma-informed approach to exam – Use non-gendered, culturally sensitive language – Remember testosterone effects on vaginal tissue (atrophy-use extra lube, smaller speculum) (UCSF Primary Care Protocol, 2016) • Some evidence to support self-collection – Review of 18 studies with 5441 participants found self-swab to be as sensitive as provider collected sample (Petignat, Faltin, Bruchim, Tramèr, Franco, & Coutlée, 2007)
Resources & Conferences
Trans* Healthcare Resources Prescribing Guidelines & Support UCSF Center of Excellence for Transgender Health Primary Care Protocol http://transhealth.ucsf.edu/trans?page=protocol-00-00 International Endocrine Society Guideline http://press.endocrine.org/doi/pdf/10.1210/jc.2009-0345 OHP Provider Tool Kit http://www.healthshareoregon.org/for-providers/provider- resources/Provider%20tool%20kit%20v4.pdf Project Health: Transline http://project-health.org/transline/ WPATH Standards of Care http://www.org/site_home.cfm Trans* Education and Advocacy National LGBT Health Education Center (a lot of free webinars on working with trans* patients) http://www.lgbthealtheducation.org/training/on-demand-webinars/ TransActive Gender Center (Youth Organization) http://www.transactiveonline.org/index.php Gay & Lesbian Alliance Against Defamation (GLAAD) An Ally’s Guide to Terminology http://www.glaad.org/2011/07/28/an-allys-guide-to-terminology-talking-about-lgbt-people- equality National Center for Transgender Equality (has IDs Document Center and more) http://www.transequality.org
Conferences LGBTQ Meaningful Care Conference—Portland, OR – Biannual spring conference http://oregonlgbtqhealth.org/mcc National Transgender Health Summit—Oakland, CA – Biannual conference (2019) http://transhealth.ucsf.edu/summit National Transgender HIV Testing Day: June 27th – Toolkit Available Philadelphia Trans Health Conference—Philadelphia, PA – Annual Conference August 2-4 2018 (free) https://www.mazzonicenter.org/trans-health WPATH (World Professional Association for Transgender Health) Biannual conference, November 2-6 2018 Buenos Aires
References Coleman, E., Bockting, W., Botzer, M., Cohen-Kettenis, P., DeCuypere, G., Feldman, J., ... & Monstrey, S. (2012). Standards of care for the health of transsexual, transgender, and gender- nonconforming people, version 7. International Journal of Transgenderism , 13 (4), 165-232. Retrieved from http://www.tandfonline.com/doi/abs/10.1080/15532739.2011.700873 Deutsch, M. B., Green, J., Keatley, J., Mayer, G., Hastings, J., Hall, A. M., ... & Fennie, K. (2013). Electronic medical records and the transgender patient: recommendations from the World Professional Association for Transgender Health EMR Working Group. Journal of the American Medical Informatics Association , 20 (4), 700-703. FamilyCare Health. (2015). Trans health provider tool kit. [pdf]. Retrieved from https://www.familycareinc.org/images/uploads/entries/Trans_Health_Provider_Tool_Kit.pdf Hall, W. J., Chapman, M. V., Lee, K. M., Merino, Y. M., Thomas, T. W., Payne, B. K., ... & Coyne-Beasley, T. (2015). Implicit racial/ethnic bias among health care professionals and its influence on health care outcomes: a systematic review. American journal of public health , 105 (12), e60-e76. Retrieved from http://eds.b.ebscohost.com.liboff.ohsu.edu/ehost/pdfviewer/pdfviewer?sid=f8a0818e-3179- 47e1-b296-ddb35fe29027%40sessionmgr112&vid=0&hid=108 Hembree, W. C., Cohen-Kettenis, P., Delemarre-van de Waal, H. A., Gooren, L. J., Meyer III, W. J., Spack, N. P., ... & Montori, V. M. (2009). Endocrine treatment of transsexual
References, cont’d Legacy Health. (n.d.) Transgender clinic. Retrieved from http://www.legacyhealth.org/health- services-and-information/health-services/for-children-a-z/diabetes-and-endocrine/transgender- clinic.aspx Oregon Department of Consumer and Business Services. (2012, December 19). Oregon insurance division bulletin ins 2012-1 . Retrieved from http://www.oregon.gov/DCBS/Insurance/legal/bulletins/Documents/bulletin2012-01.pdf Oregon Health & Science University. (n.d.) Transgender health program. Retrieved from https://www.ohsu.edu/xd/health/services/diversity-and-inclusion/culture-specific- services/transgender-program/index.cfm Petignat, P., Faltin, D. L., Bruchim, I., Tramèr, M. R., Franco, E. L., & Coutlée, F. (2007). Are self-collected samples comparable to physician-collected cervical specimens for human papillomavirus DNA testing? A systematic review and meta-analysis. Gynecologic oncology, 105(2), 530-535. Transgender Law Center. (n.d.). Healthcare laws and policies. Retrieved on May 16, 2016 from http://transgenderlawcenter.org/equalitymap Transline. (2012). Summary tables—labs and hormone doses. [pdf]. Retrieved from https://transline.zendesk.com/entries/21714071-Summary-Tables-Labs-and-Hormone-Doses University of California, San Francisco. (2016). Center of excellence for transgender h lth i t l f t d ti t R t i d f
THANK YOU! Contact Us: Allison Fox, FNP foxal@ohsu.edu 503-880-9160
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