Transgender Health

management, distribution, calculations

what is gender/gender identity

• a persons self-declared identity usually based on internal sense of being a male, female, neither, both, or somewhere else along the gender

• some people may feel more feminine or masculine or not on be on the spectrum at all

sex/sex assigned at birth (SAAB)

• category assigned/designated at birth based mainly on healthcare provider’s exam of external genitalia (male, female, intersex)

gender expression

• how one shows their gender identity (hair style/length, clothing, makeup, body language, voice, pronouns, etc) may or may not correlate with gender identity or SAAB

gender incongruence

• marked and persistent experience of incompatibility between a persons gender identity and their SAAB

transgender and gender-diverse (TGD)

umbrella term used to describe persons whose gender identity or gender expression is not aligned with their SAAB and includes

• transgender

• gender diverse individuals

transgender

when gender identity is different from SAAB

gender diverse individuals

people who’s gender identity or expression doesn’t conform to traditional binary normals of male or female

transgender man/transmasculine

person with masculine gender identity who was recorded/designated female sex at birth

transgender women/transfeminine

person with feminine gender identity who was recorded/designated male sex at birth

non-binary

a person who does not identify exclusively as a man nor a woman, may be in combination, something outside these two roles, nonexistent, or fluid

2-spirit/two spirit

terms used by some indigenous peoples identifying as diverse gender, sexual, and or spiritual identities

gender dysphoria

distress experienced by a person whose gender identity is not aligned with their SAAB

not all TGD individuals experience gender dysphoria

gender affirming care

• a range of social, psychological, and medical services designed to support and affirm a persons gender identity, especially when it differs from the sex they were assigned at birth

cis and cisgender

describes a person with a gender identity that aligns with their SAAB

non-binary individual may use what pronouns

gender neutral

they, them, their

gender-affirming care includes

social interventions

medical/surgical interventions

examples of social interventions

• name, pronouns (he, she, they, ze, or a mix of these)

• voice training

• gender-inclusive language (body parts, medical procedures)

• gender presentation changes (clothing, mannerisms, expressions, nonsurgical body modifications such as tucking, padding, packing, binding)

medical/surgical interventions

chest surgery (breast augmentation or mastectomy)

genital surgery (vaginoplasty or phalloplasty)

hysterectomy

orchiectomy

feminizing or masculinizing facial surgery

laryngeal surgery

puberty suppression

use in TGD youth before undergoing hormone-based therapy

benefits and risks should be discussed with provider

not routinely done

hormone based therapy (estrogen-based or testosterone based)

• lower endogenous sex hormone levels and/or add exogenous sex hormones to match individuals gender identity

• non-binary patients may also use hormone-based therapies to better align with their gender identity, though the dosing may be lower

estrogen-based therapy

• reduce endogenous effects of testosterone, induce feminine secondary sex characteristics

testosterone based therapy

develop androgenic sex characteristics

the decision to start puberty blockers in youth is made by who

• parental, physician/or psychologist approval

• lack of high-quality evidence for safety in youth

• future areas of research include potential impact on bone density, fertility, and long term effects on cognitive, emotional, and psychosocial development during adolescence

pharmacist roles in gender affirming care

1. create a safe and inclusive pharmacy environment

2. medication management and monitoring

3. education and counselling

what does creating a safe and inclusive pharmacy environment include for patients

• create a welcoming space for transgender patients including using inclusive language, respecting pronouns and names, and displaying signs that signal support for 2SLGBTQIA + community

• maintain confidentiality and treat every individual with respect

• do no impose your own beliefs

medication management and monitoring

• advise prescribers of optimal therapy

• dispense medication

• identify and prevent potential drug interactions between hormonal therapy and other medications

• monitor patients for the effects and adverse effects of hormone therapy, in collaboration with other healthcare providers, this may involve reviewing labs

education and counselling

• counsel patients about their medications, including expected effects, potential risks, and how to manage adverse effects

• address patient’s concerns and questions about their treatment in a safe and confidential manner

• promote adherence through education and ongoing support

which drug is used for puberty suppresion

GnRH analogs

• down regulate response to endogenous GnRH and suppress LH and FSH - prevent puberty

• leuprolide (lupron depot)

AE leuprolide

• injection site reactions, weight gain, depression/anxiety/mood changes, headache, visual changes, hot flashes

is puberty suppression reversible

once stopping leuprolide, puberty typically resumes within 6 months of discontinuation

may impact fertility potential, and bone mineral density

when is leuprolide injected

IM or SC at either 1,3,6 month intervals

what is included in estrogen based therapy for gender affirming care

anti-androgens

estrogen

anti-androgens used include

spironolactone

cyproterone acetate

AE spironolactone

hyperkalemia, increased urination, hypotension, orthostatic hypotension, increased skin sensitivity to sunlight

when can spironolactone be stopped after orchiectomy (testicle removal)

can be stopped or tapered over 4-6 weeks

AE cyprotereone

• fatigue, lethargy, dose-related risks for acute liver damage, meningiomas

• may be associated with hyperprolactinemia and prolactinemia, monitor prolactin if hyperprolactinemia symptoms are present

when can cyprotereone be stopped after orchiectomy

can be stopped immediately

which estrogen options are used in gender affirming care

oral/sublingual 17-beta estradiol

transdermal 17-beta estradiol

injectable estradiol valerate

AE oral/sublingual 17-beta estradiol

• headache, migraine, hot flashes, VTE, weigh gain, mood changes

• reduced thrombogenicity compared to synthetic/conjugated estrogens (consider monitoring estrogen levels)

AE transdermal 17-beta estradiol

• application site irritation, headache, migraine, hot flashes, VTE, weight gain, mood changes

• transdermal formulations avoid first pass metabolism and may be less thrombogenic than oral therapy, considered to have better safety profile than oral/sublingual

• patch or gel

injectable estradiol valerate AE

injection site irritation/pain, headache, migraine, hot flashes, VTE, weight gain, mood changes

no commercially avaialble product can be compounded

which gender affirming effects of estrogen are irreversible

breast growth

onset of most gender affirming effects of estrogen happen in what time frame

3 months

is testosterone sufficient contraception

no

patient must be counselled to use additional contraceptives, if needed

testosterone therapies include

injectable testosterone

testosterone gel

testosterone cypionate is compounded in what oil

cottonseed oil

testosterone enanthate is compounded in what oil

sesame oil

AE of injectable testosterone

• acne, alopecia, insomnia, N/V/D, hypertension, change in libido, injection site inflammation, bladder irritability, weight gain, depression/anxiety

• weekly injection

transdermal testosterone gel AE

application site irritation, acne, alopecia, headache, hypertension, depression

applied once daily to clean, dry, intact skin (shoulders, upper arms, or abdomen) depending on product

counselling testosterone gel

• should be used same time each day, avoid showering (approximately 5-6 hours) after application, avoid intimacy until the gel dries (may expose partner to testosterone), wash hands thoroughly after use

which effects of testosterone are irreversible in gender affirming care

• increase in facial and body hair

• scalp hair loss

• clitoral growth

the max effect of testosterone therapy can take how long

up to 5 years

pharmacists can offer what for transgender patients

recommended cancer screenings

recommended vaccinations across lifespan (shingles, pneumonia, flu, COVID-19)

minor ailments (UTIs, acne)

recommended laboratory testing (monitoring drug therapy or hormone levels)

transfeminine cancer screenings

prostate: beginning at age 50

testicular: annually only if did not undergo orchiectomy

breast: over the age of 50 who have been on gender-affirming therapy for 5-10 years should receive mammogram every 2 years

neovaginal: those who undergone vaginoplasty should get annual digital and speculum exams on the neovagina

colorectal: all individuals 50 or older should get routine screening

transmasculine cancer screening

breast: follow guidelines for cisgender woman if no bilateral mastectomy

endometrial/uterine: those who have undergone hysterectomy should report abnormal sxs

cervical: annual pap smears after 21 in those with a cervix

ovarian: not routine but if have symptoms and had a oophorectomy

colorectal: all individuals 50 or older

patients who have undergone genital surgery can have increased risk of what infections

UTI

genital surgery considered a major alteration to the GU anatomy making UTIs in these patients complicated

how does TGD affect STIs

anatomy of patient will determine which testing and treatments should be completed

patients that have undergone genital surgery may have different organisms that cause infection compared to those who do not

TGD patients may have mental health concerns associated with

gender dysphoria

risk factor for suicide

testosterone can cause what issues in TGD patients

testosterone associated acne

testosterone increases sebum which may be exacerbated by changes in clothing, binders,

follow general cystic acne guidelines. patient doesn’t need to stop GAHT

is contraception required on testosterone therapy in transmasculine men

yes

testosterone is not an adequate contraception for this purpose

patients receiving hormone therapy have an increased risk of what

CVD

estrogen increases the risk of what

stroke and other clots

changes to blood pressure and lipids

testosterone affects on health

increased hemoglobin, changes to blood pressure and lipids

testosterone or estrogen levels should be maintained in a

efficacious but safe range

what should be monitored for patients on GAHT

blood pressure, lipids, CV risk factors: throughout duration of therapy

surgical complications (UTI, bleeding): during and post surgery