Medical Management of the Transgender Patient: for MHPs Vin Tangpricha M.D. Ph.D. Associate Professor of Medicine Emory University School of Medicine, Division of Endocrinology, Diabetes & Lipids, Department of Medicine WPATH SoCal Kaiser Training April 13, 2013

At the conclusion of this presentation, attendees should be able to 1.To list the roles and responsibilities of the mental health provider and the hormone prescriber 2.To list available resources for hormone prescribers 3.To describe common hormone regimens used in transgender individuals 4.To identify some potential adverse events and pitfalls in cross hormone therapy Learning Objectives

1. Persistent, well-documented gender dysphoria; 2. Capacity to make a fully informed decision and to consent for treatment; 3. Age of majority in a given country (if younger, follow the Standards of Care outlined in section VI); 4. If significant medical or mental health concerns are present, they must be reasonably well controlled. Major Changes: No longer requiring a letter. More emphasis on informed consent. No real life experience. Age cut-off removed. Documentation for Hormone Therapy: SOC7 in a nutshell

Mental Health Provider Should: -Assist clients be psychologically prepared and practically prepared for hormones -Discuss reproductive options -Refer the patient to a qualified health care provider who can appropriate assess relative and absolute contraindications to cross sex hormones and monitor for long term complications -Provide a letter of referral to a hormone provider that patient meets eligibility and readiness criteria for hormones according to SOC7 upon request* SOC7: The role of the mental health and hormone provider

Hormone Provider Should: -Obtain informed consent for hormone therapy (discuss risks and benefits) and document that the patient understands and accepts risks -Perform history, physical examination and laboratory tests to assess and modify risks prior to initiation of hormone therapy -Document reproductive options have been discussed -Provide ongoing monitoring of potential risks of therapy -Communicate with other health professionals as necessary to ensure a safe transition SOC7: The role of the mental health and hormone provider

SOC7: Bridging Clinicians who may not be experienced in hormone therapy or who have not fully assessed patients may provide limited (1-6 months) prescription of cross hormone therapy for patients who have been treated by other clinicians or obtained hormones from other means in order to allow for the proper referrals to mental and medical health

Copyright © 2013 World Professional Association for Transgender Health Male to Female Estrogen Anti-Androgens

Copyright © 2013 World Professional Association for Transgender Health Estrogens Inhibit LH secretion at the pituitary to decrease testosterone secretion Also may directly inhibit gonadal production of testosterone* Has steroid hormone effects at target organs *Leinonen P. JCEM 1981; 53(3):

Copyright © 2013 World Professional Association for Transgender Health Estrogens Conjugated Estrogens –Premarin mg daily Synthetic Estrogens (NO LONGER RECOMMENDED) –Ethinyl Estradiol to mg daily Steroidal Estrogens –Estradiol (2 to 6 mg daily) –Estradiol transdermal patches 0.1 – 0.4 mg/day –Estradiol valerate IM mg/month Tangpricha et al. Endocrine Pract 2002, Hembree et al 2009

Copyright © 2013 World Professional Association for Transgender Health Anti-Androgens Spironolactone mg/day Anti-androgen at the androgen receptor and decreases androgen production Often required to reduce testosterone levels Cyproterone Not available in US Some progestin activity Tangpricha et al. Endocrine Pract 2002, Hembree et al 2009

Copyright © 2013 World Professional Association for Transgender Health Initial Evaluation Male to Female Transsexual Complete physical examination Blood pressure, height, weight Extent of masculinization/feminization Palpation of liver and breasts for tumors Examination of venous system for thromboembolism Examination and measurement of genitalia (glans penis, testes) Tangpricha et al. Endocrine Pract 2002, Hembree et al 2009

Copyright © 2013 World Professional Association for Transgender Health Initial laboratory tests Electrolytes, BUN/creatinine Liver function tests Fasting glucose and lipid profile Estradiol and free or total testosterone Serum Prolactin* Tangpricha et al. Endocrine Pract 2002, Hembree et al 2009

Copyright © 2013 World Professional Association for Transgender Health Estrogen Contraindications Very High Risk History of Thrombosis Moderate High Risk Macroprolactinoma Hepatic dysfunction Breast Ca Coronary artery disease Cerebrovascular disease Migraine headaches Endocrine Society Guidelines 2009

Copyright © 2013 World Professional Association for Transgender Health Morbidity and Mortality Observed mortality in 816 M to F’s incidence vs. nl Suicide 9 fold AIDS 6 fold van Kesteren PJM 1997 Clinical Endocrinol 47:

Copyright © 2013 World Professional Association for Transgender Health Morbidity and Mortality Observed morbidity in 816 M to F’s incidence vs. nl Venous thrombosis 20 fold Prolactin elevation 82 fold Hepatitis B 44 fold van Kesteren PJM 1997 Clinical Endocrinol 47:

Copyright © 2013 World Professional Association for Transgender Health Effects of Hormonal Feminization

Copyright © 2013 World Professional Association for Transgender Health Monitoring of Estrogen Therapy Patients should be seen every 2-3 months initially Aim for castrate levels of T (<75 ng/dl) Estradiol level should be approximately pg/ml Screening for complications at every visit Depression/suicide screen Tangpricha et al. Endocrine Pract 2002, Hembree et al 2009

Copyright © 2013 World Professional Association for Transgender Health Lab Monitoring Estradiol Testosterone Liver function Potassium Fasting Lipids Prolactin yearly* After two years, semi-annually hold estrogen 1 month prior and after surgery Reduce estrogen by 50% after surgery Tangpricha et al. Endocrine Pract 2002, Hembree et al 2009

Testosterone Female to Male

Testosterone Esters Testosterone enanthate 100 to 200 mg IM q2 wk Testosterone cypionate 100 to 200 mg IM q2 wk Transdermal patches mg/day transdermally Oral Testosterone (not 17  ) Testosterone undecanoate 40mg QID Testosterone gel (AndroGel or Testim) g packet daily Tangpricha et al. Endocrine Pract 2002, Hembree et al 2009 Testosterone Regimens

Testosterone Contraindications Very high risk Pregnancy Breast or Uterine Cancer Erythrocytosis (HCT>50) Moderate High Risk Hepatic Endocrine Society Guidelines 2009

Effects of Hormonal Masculinization

Initiation of Testosterone Therapy Complete history and physical CBC, LFTs, fasting glucose and lipids, estradiol and free or total testosterone ?  -HCG ?Bone mineral density ? Sleep study if sx of OSA Start IM testosterone mg q2weeks Tangpricha et al. Endocrine Pract 2002

Monitoring Testosterone Therapy

Testosterone Complications Abnormal liver function Tests (15%) Hepatic adenomas, peliosis hepatitis (rare) Increase in visceral fat Elevation of total cholesterol, triglycerides and LDL and lowering of HDL cholesterol Endometrial hyperplasia Tangpricha et al. Endocrine Pract 2002

Copyright © 2013 World Professional Association for Transgender Health Conclusions The initiation of hormone therapy requires cooperation between the MHP and hormone provider The hormone provider should complete a comprehensive evaluation to avoid risks with hormone therapy Detailed published regimens are available by the Endocrine Society Monitoring for potential complications are important at least initially for the first 2 years and then at least annually thereafter

Thank you for your attention! Vin Tangpricha M.D. Ph.D. Associate Professor Emory University Division of Endocrinology 101 Woodruff Circle NE- WMRB 1301 Atlanta GA