5.3 Hormone Therapy Care - Horace

What does the code _____ indicate in guideline recommendations for gender affirming care?

1. T

2. NT

3. X

1. at least some data in the trans pop

2. no data in the trans pop, but data is in other pop

3. no data available (expert opinion only)

What does the code _____ represent for strength of evidence for gender affirming care?

1. M

2. R

3. O

4. C

1. meta analysis, cautionary evidence

2. randomized controlled studies, most reliable

3. observational studies, weaker evidence

4. consensus expert opinion

What does the code ____ indicate for overall strength of recommendation for gender affirming care?

1. S

2. M

3. W

1. strong

2. medium

3. weak

gender identity definition

A person’s internal sense of self and how they fit into the world from the perspective of gender

sex definition

sex assigned at birth based on external genitalia, chromosomes, and gonads

T or F:
sex is the same thing as gender

F

gender expression definition

outward way a person expresses or displays their gender

T or F:

gender identity and gender expression can differ

T

transgender person definition

person whose gender identity differs from their assigned sex at birth

transgender man definition

Male gender identity with female sex assigned at birth

cisgender definition

person identifies with the sex they were assigned at birth

transgender woman definition

Female gender identity with male sex assigned at birth

gender nonconforming / genderqueer definition

Gender identity differs from assigned sex at birth and may be more complex, fluid, or less clearly defined

nonbinary definition

A transgender or gender nonconforming person who identifies as neither male nor female

trans-masculine definition

A person with a masculine spectrum gender identity and female sex listed at birth

(specifically for people who are genderqueer or nonbinary based on the directionality of their identity)

trans-feminine definition

A person with a feminine spectrum gender identity and male sex listed at birth

(specifically for people who are genderqueer or nonbinary based on the directionality of their identity)

they/them/their pronouns definition

Neutral pronouns used by some individuals with nonbinary or nonconforming gender identity

transsexual definition

A clinical term for transgender individuals who sought medical intervention (hormones or surgery) for gender affirmation

cross dresser / drag queen / drag king definition

People who wear clothing of a gender different from their assigned sex for entertainment, self-expression, or sexual pleasure

What is cultural humility in transgender care?

Recognizing that one’s own experiences/identities may not apply to others and approaching each patient without preconceptions

Which staff should receive transgender care training?

all of em

What is the purpose of inclusive waiting areas?

To show commitment to serving the transgender community

What are recommended bathroom policies in transgender care settings?

gender neutral bathrooms or allow patients to choose a bathroom based on preference

What does fluency of terminology mean in transgender care?

Providers should be familiar with basic terminology used by the transgender community

just dont offend people

What types of interventions are considered gender-affirming treatments?

Hormone therapy, surgery, facial hair removal, speech/communication modification, and behavioral adaptations (e.g., tucking, packing, chest binding)

How does the World Professional Association for Transgender Health (WPATH) classify gender-affirming treatments?

Medically necessary

What outcomes have been observed after gender-affirming treatments?

Improvements in psychosocial measures

What is the primary estrogen used for feminizing therapy?

17-beta estradiol

(bioidentical)

What is meant by “bioidentical” estradiol?

Chemically identical to human ovarian estrogen

What are common routes of administration for estradiol in transgender women?

Transdermal patch, oral tablet, injection

What is the most commonly used androgen blocker in the U.S.?

Spironolactone

What is a typical safe dose range of spironolactone for gender affirming care?

Up to 200 mg/day commonly; up to 400 mg/day reported

What is the most serious adverse effect of spironolactone?

Hyperkalemia

When is hyperkalemia risk increased with spironolactone?

Renal insufficiency or use with ACE inhibitors/ARBs

What common side effects may occur due to spironolactone’s diuretic effect?

Polyuria, polydipsia, orthostasis

T or F:

evidence suggests that progestogens have the best effects for gender affirming care

F

(no evidence for or against)

dosing of estradiol oral

1. initial low dose

2. initial dose

3. maximum dose

1. 1 mg / day

2. 2-4 mg/day

3. 8 mg/ day

How should oral estradiol be dosed if >2 mg/day?

divide into BID dosing

dosing of estradiol transdermal

1. initial low dose

2. initial dose

3. maximum dose

1. 50 mcg

2. 100 mcg

3. 100-400 mcg

What is the maximum single patch dose available for estradiol?

100 mcg

What is important about estradiol patch frequency?

Depends on brand/product

dosing of spironolactone

1. initial low dose

2. initial dose

3. maximum dose

1. 25 mg qd

2. 50 mg bid

3. 200 mg bid

counseling for spironolactone in gender care

give K every time dose is increased and every 2-4 weeks

When should BUN/Cr/K+ be monitored in gender care?

only if the pt is on spironolactone

How often should BUN/Cr/K+ be monitored if on spironolactone?

Baseline, 3 months, 6 months, 12 months, and yearly

When should estradiol levels be monitored for gender care?

At 3 months, 6 months, and yearly

When should total testosterone levels be monitored for gender care?

At 3 months, 6 months, 12 months, and yearly

dose of testosterone cypionatea

1.initial low dose

2. maximum dose

1. 20 mg / week IM or SQ

2. 100 mg / week IM or SQ

Is there evidence supporting routine lipid monitoring in masculinizing hormone therapy?

no

When should total testosterone be monitored in masculinizing therapy?

At 3 months, 6 months, and 12 months

A general reference range for bioavailable testosterone is_______

> 72ng/dl