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5 Pearls on Transgender Health: Hormone Therapy and Preventive Screening Episode 2

Core IM

This episode gives a good foundation and dispels hesitation with starting hormone therapy. 

First, listen to the podcast. After listening, ACP members can take the CME/MOC quiz for free.

CME/MOC:

Up to 0.75 AMA PRA Category 1 Credits ™ and MOC Points
Expires April 1, 2023   active

Cost:

Free to Members

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Podcasts and Audio Content

Product:

Core IM

Welcome to Core IM, a virtual medical community! Core IM strives to empower its colleagues of all levels and backgrounds with clinically applicable information as well as inspire curiosity and critical thinking. Core IM promotes its mission through podcasts and other multimodal dialogues. ACP has teamed up with Core IM to offer continuing medical education, available exclusively to ACP members by completing the CME/MOC quiz.

Pearl 1: Contraindications 

Are there absolute contraindications to hormone therapy?  

  • When we talk about hormone therapy, there are usually two absolute contraindications:
    • Sex-specific cancer  (e.g. hormone sensitive breast cancer)
    • Being actively pregnant while starting testosterone
  • Some things that aren’t contraindications, but are commonly perceived as such:
    •  A history suggestive of elevated clot risk (e.g.  a prior clot or a coagulopathy)
      • While clot risk does increase while on exogenous estrogen, the difference is modest. 
      • In these situations, consider checking out the USCF guidelines, which provide an approach which type of estrogen (transdermal patch).
    • Mental health history
      • If your patient has a prior psych history, they can still be started on hormone therapy. Remember that initiation of gender affirming care such as therapy has been shown to improve mental health outcomes!
      • Nevertheless: always a good idea to encourage your patients to plug into mental health – after all, there are many big life changes associated with hormone therapy, and having a strong support system can help.

Pearl 2: Expectations

What expectations should you set upfront when initiating hormone therapy?

  • Treat hormone therapy like any other medication and perform an informed consent – walk through the pros and cons, the benefits and risks. 
  • Setting expectations around the hormone-induced changes is a key part of this process. Three big things to set expectations on:
  1. Timing:
    • Hormone changes will be gradual and will come into full effect over several years. Think of it as analogous to puberty.
    • There is no magic wand, it’s a process!
  2. What the end result will be: Likely, the outcome won’t be exaggeratedly or stereotypically feminine/masculine. Encourage the patients to look at their family members to see what they can expect. 
  • What are the physical changes they can expect?
    • Irreversible
      • Transmasculine: male pattern baldness, clitoromegaly and deepening of voice
      • Transfeminine: fertility (irreversible effects on sperm motility and viability – however still possible to conceive!), breast development.
    • Reversible/non-permanent
      • Transmasculine
        • Within the first 3-6 months: cessation of menses, pelvic pain, oiliness of skin (possible acne)
        • 6-12 months: change in hair growth, voice deepening, increased muscle mass/body fat distribution
        • Longer term: clitoral growth, vaginal atrophy
      • Transfeminine
        • Early on: smoothing of skin
        • 6-12 months: testicular atrophy, decreased muscle mass
        • Longer term: libido decrease and decreased ability to have an erection (if have a penis)
        • Also, E will not make facial hair fall out, but may see some decrease in facial/body hair growth

Pearl 3: Hormone Risks

What are the major risks associated with hormone therapy in transgender patients, and what can we do to mitigate them?

  • Clot in transfeminine individuals
    • There is a slight increased risk of any thromboembolic event in trans individuals who are receiving estrogens.  
    • Formulation is a key way to attenuate risk: transdermal formulations of estrogen lower clot risk than do oral formulations.
    • Despite the risk of clot, there is no evidence to support the practice of stopping estrogens during times of critical illness (e.g. perioperatively, or when a patient is inpatient). Consider that stopping hormones can be very distressing for trans patients.
  • Cardiovascular risk
    • Transfeminine individuals: the data on this is still emerging, but may suggest an increased risk of MI or stroke after decades of use.
    • Transmasculine individuals
      • Testosterone does worsen a few cardiovascular risk factors 
        • Increase systolic and diastolic blood pressure by few mmHg
        • Less protective lipid profile 
        • Decreases insulin sensitivity 
      • However: the evidence does not point to increased MIs or stroke
    • What to make of the data
      • These numbers are still very small. The research needs to be fleshed out as to whether this is an absolute correlation rather than a speciation of the data. 
      •  We can work to improve these risk factors with lifestyle changes and other interventions in primary care
  • Other risks of feminizing hormones
    • Gallstones 
    • Weight gain
    • Hypertriglyceridemia
  • Other risks of masculinizing hormones
    • Polycythemia
    • Weight gain
    • Acne
    • Male-pattern baldness 
    • Sleep apnea

Pearl 4: Medications and maintenance (care)

What options are available for feminizing and masculinizing medications, and how should we monitor hormone therapy?

  • Formulations of testosterone
    • IM 
      • Dosing and frequency: 
        • ~50 milligrams every week or every other week depending on the patient’s preferences
        • Biweekly dosing lessens the number of injections. However, weekly dosing avoids the fatigue and irritability that can sometimes occur at the end of the injection cycle.
      • IM or SubQ Route: 
        • Should go  into a tissue that there will be a slow release 
        • Make sure to prescribe needles (and a sharps container)! Bigger is better since you can inject more volume faster and reduce discomfort. A minimum of 22G. 
      • Cream
        • Harder to guarantee steady levels via this modality
        • However, may be an option for patients who are very uncomfortable with needles
  • Testosterone: initial labs and when to follow up
    • CBC for erythrocytosis: q3-6 months in first year, then yearly
    • Estradiol levels, free testosterone levels (to track changes over time): shooting for testosterone levels between 300 to 1000 mid-injection cycle
    • Lipids and LFTs
  • Feminizing hormones
    • Formulations
      • Oral (often the easiest or simplest option)
      • Patches (recommended if someone has cardiovascular or clotting risk factors, as transdermal poses much lower risk)
      • IM injections
    • Testosterone blocker
      • Only indicated if the patient is still producing testosterone (i.e. still have testes). This is why an organ inventory is important!
      • Spironolactone is a preferred first-line agent – and often safe even in younger patients with low or normal blood pressures (expert experience).
      • If your patient has a contraindication to spironolactone, such as kidney disease, finasteride is also an option.
    • Initial labs to order
      • Hormone levels of estrogen and testosterone (to trend)
      • BMP or a CMP (if patient will be starting spironolactone)
    • What to monitor
      • Levels of estrogen and testosterone 
      • Goal is to see the estrogen rise and the testosterone fall, since the latter has a virilizing effect regardless of how much estrogen the patient has.

Pearl 5: Preventative Screening

How do you approach preventative care – such as cancer screening – for transgender patients? 

  • Transmasculine-identifying people
    • Chest screening for breast cancer
      • Transmasculine people who have had chest masculinization (i.e. top surgery or mastectomy) may still have some breast tissue, so a discussion of breast cancer screening may be needed.  
      • In these situations, mammograms may be difficult to perform, and a risk benefit conversation about manual physical exam, ultrasound or MRI should be discussed depending on family history, though no clear guidelines are available for this.
    • Cervical cancer screening
      • In transgender men who have a uterus with a cervix and ovaries, screen for cervical cancer at the same intervals as we do with cisgender women.
      • Using vaginal estrogen creams for 1 week prior to the exam and help decrease discomfort, though transgender men may decline this intervention as estrogens can be a charged topic for these patients.
  • Transfeminine-identifying people
    • Prostate cancer screening
      • Transfeminine patients will often have prostates as these are not typically removed during vaginoplasty procedures.
      • However, there are no clear guidelines (as is the case with cisgender patients.)
      • When considering patient risk factors, remember that testosterone blockers can reduce the risk of prostate cancer.
    • Breast cancer screening
      • Who: transfeminine people over 50 on estrogen > 5 years (with breast development)
      • How often:  every two years (same as with cisgender women)

Contributors

Shreya Trivedi, MD - Host, Editor

Marty Fried, MD - Host, CME questions

Carl Streed, MD - Guest

Richard Greene, MD - Guest

Gaby Mayer - Show Notes

Reviewers

Michelle Forcier, MD, MPH

Brandon Pollack, MD

Those named above unless otherwise indicated have no relationships with any entity producing, marketing, reselling, or distributing health care goods or services consumed by, or used on, patients.

Release Date: March 25, 2020

Expiration Date: March 25, 2023

CME Credit

This activity has been planned and implemented in accordance with the accreditation requirements and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint providership of the American College of Physicians and the Core IM.  The American College of Physicians is accredited by the ACCME to provide continuing medical education for physicians.

The American College of Physicians designates each enduring material (podcast) for 0.75 AMA PRA Category 1 Credit™.  Physicians should claim only the credit commensurate with the extent of their participation in the activity.

ABIM Maintenance of Certification (MOC) Points

Successful completion of this CME activity, which includes participation in the evaluation component, enables the participant to earn up to 0.75 medical knowledge MOC Point in the American Board of Internal Medicine’s (ABIM) Maintenance of Certification (MOC) program.  Participants will earn MOC points equivalent to the amount of CME credits claimed for the activity. It is the CME activity provider’s responsibility to submit participant completion information to ACCME for the purpose of granting ABIM MOC credit.

How to Claim CME Credit and MOC Points

After listening to the podcast, complete a brief multiple-choice question quiz. To claim CME credit and MOC points you must achieve a minimum passing score of 66%. You may take the quiz multiple times to achieve a passing score.