Transgender Pharmacotherapy (L8)

transfeminine therapy

goals: promote development of female secondary sex characteristics and reduce endogenous effects of ___________

testosterone

transfeminine therapy: lab monitoring

_________ function and ___________: should be taken at baseline, q3mos, q6mos, q12mos, and prn for patients using Spironolactone

renal, potassium

transfeminine therapy: lab monitoring

renal function and potassium: should be taken at baseline, q3mos, q6mos, q12mos, and prn for patients using _______________

spironolactone

transfeminine therapy: lab monitoring

____________ (goal 100-200pg/mL): q3mos, q6mos, q12mos and prn

total ___________ (goal <50ng/mL): q3mos, q6mos, q12mos and prn

estradiol, testosterone

transfeminine therapy: lab monitoring

_________: should only be taken in pts experiencing symptoms of __________ while taking Leuprolide (GnRH agonist)

prolactin, prolactinoma (too much prolactin)

transfeminine therapy: lab monitoring

Prolactin: should only be taken in pts experiencing symptoms of prolactinoma while taking ___________ (GnRH agonist)

Leuprolide

transfeminine therapy: estrogen treatment

oral estradiol: can cause mood changes, migraines, hot flashes, weight gain, nausea, and _____________ events

thromboembolic (oral estradiol has the highest thromboembolic risk)

transfeminine therapy: estrogen treatment

________ estradiol: can cause mood changes, migraines, hot flashes, weight gain, nausea, and the highest risk for thromboembolic events

oral

transfeminine therapy: estrogen treatment

estradiol cypionate IM: can cause fluctuations in AEs; has _________ risk for thromboembolic events compared to oral estradiol

lower (not as low as transdermal tho)

transfeminine therapy: estrogen treatment

estradiol valerate IM: can cause fluctuations in AEs; has _________ risk for thromboembolic events compared to oral estradiol

lower (not as low as transdermal tho)

transfeminine therapy: estrogen treatment

transdermal estradiol: can cause skin reactions, has a slower onset; has _________ risk for thromboembolic events compared to oral or IM estradiol

lower (and the lowest of all formulations!! best for pts with CV-risk or DVT/VTE history)

transfeminine therapy: estrogen treatment

_________ estradiol: has the lowest risk for thromboembolic events and is preferred in patients with hx of DVT or VTE

transdermal

transfeminine therapy: other effects of estrogen

decreased __________ sensitivity, increase DVT/VTE risk with oral options, and these patients will now have the same ________ ________ risks as cisgender women

insulin, breast cancer

transfeminine therapy: effects of estrogen and anti-androgens

one of the permanent side effects (which is desired) is ____________

increased breast tissue

transfeminine therapy: effects of estrogen and anti-androgens

there is no change in facial bone structure, size of hands and feet, height, and most importantly to tell patients is no change in __________

voice

transfeminine therapy: anti-androgen therapy

__________: 100-400mg PO QD-BID; binds to androgen receptor and directly inhibits testosterone production

spironolactone

transfeminine therapy: anti-androgen therapy

Spironolactone side effects:

- hyper_________

- gynecomastia (desired for these patients)

- hypo________

kalemia, tension

transfeminine therapy: anti-androgen therapy

Spironolactone side effects:

- ________kalemia

- gynecomastia (desired for these patients)

- ______tension

hyper, hypo

transfeminine therapy: anti-androgen therapy

Spironolactone side effects:

- hyperkalemia

- ____________ (desired for these patients)

- hypotension

gynecomastia

transfeminine therapy: anti-androgen therapy

Finasteride or Dutasteride side effects:

- decreased _______________ (desired for these patients)

male pattern baldness

transfeminine therapy: anti-androgen therapy

____________ side effects:

- decreased male pattern baldness (desired for these patients)

Finasteride

transfeminine therapy: anti-androgen therapy

Leuprolide IM (GnRH agonist) side effects:

- injection site pain

- headaches

- hot flashes

- increased _________ (incidences are low, just monitor pts)

prolactin

transfeminine therapy: __________ therapy

may help with additional breast contouring and shaping, but there isn’t much data to show that it will significantly increase the breast size

progesterone

transfeminine therapy

which therapy is preferred for trans women >40 years old?

transdermal estradiol (less risk for VTE)

transfeminine therapy

what is a contraindication when initiating estrogen for gender affirmation in transfeminine persons?

an active estrogen-sensitive cancer (breast or pituitary)

transmasculine therapy: labs and monitoring

___________ (goal <50pg/mL): prn

___________ (goal 300-1000ng/mL): q3mos, q6mos, q12mos, and prn

estradiol, testosterone

transmasculine therapy

testosterone __________ or ____________ : given IM or subQ every week or every 2 weeks

AEs: acne, polycythemia (increased Hgb/Hct), sleep apnea, dyslipidemia, inj site reactions, pelvic pain, genital atrophy, hot flashes, and emotional changes

enanthate, cypionate

transmasculine therapy

testosterone __________ given IM or subQ one dose, then once at 4 weeks, then every 10 weeks (inj given in office)

rare cases of pulmonary micro embolism (POME) and anaphylaxis have occurred, so pts must be observed for 30 mins after injection

undecanoate

transmasculine therapy

testosterone gel (Androgel) is given every _________ (time of day) once daily

morning

transmasculine therapy

testosterone gel (Androgel) is given in the morning once ________

daily

transmasculine therapy

testosterone gel (Androgel) is given every morning

apply to __________ and _________ and keep area dry for >2 hours after

upper arms, shoulders

transmasculine therapy

testosterone gel (Androgel) is given every morning

apply to upper arms and shoulders and keep area dry for >___ _____ after

2 hours

transmasculine therapy

testosterone gel (Androgel) is given every morning

apply to upper arms and shoulders and keep area dry for >2 hours after

AEs: potential for __________ exposure, hypersensitivity, or a musky odor

secondary (can transfer from pts skin onto another persons skin)

transmasculine therapy: additional considerations

__________ cream to decrease vaginal atrophy, if desired

estrogen

transmasculine therapy: additional considerations

topical ________ or oral _________ for androgenic alopecia

minoxidil, finasteride

transmasculine therapy: additional considerations

use of _____________: may help cessation of menses (although usually the initiation of testosterone will stop them)

progesterone

transmasculine therapy: testosterone effects

permanent effects include an increased ___________ size (which is desired), increased face and body hair, increased androgenic alopecia of hair, and deeper voice

clitoral

transmasculine therapy: testosterone effects

permanent effects include an increased clitoral size (which is desired), increased ________ and ________ hair (desired), increased __________ ___________ of hair (not desired), and deeper voice

face and body, androgenic alopecia

transmasculine therapy: testosterone effects

does the patients voice change?

yes (deepens permanently)