Transgender

Question 1

List the biochemical goals of hormone therapy in transgender care

Answer 1

1. Suppress endogenous sex hormone production
2. Maintain sex hormone levels within the normal range for the person’s affirmed gender

Question 2

What tanner stage should you start treatment of transgender patients with Lupron?

Answer 2

Tanner 2

Question 3

When should you start treatment of transgender patients with gender affirming hormones?

Answer 3

When a multidisciplinary team has confirmed the persistence of gender dysphoria AND sufficient mental capacity to give informed consent (typically age 16, minimal published studies in age 13.5-14)

Question 4

How often should transgender patients be monitored clinically and with lab evaluation while on pubertal suppression?

Answer 4

• Every 3-6 months: height, weight, sitting height, blood pressure, Tanner staging
• Every 6-12 months: lab tests (LH, FSH, estradiol/testosterone, 25 OH vitamin D)
• Every 1-2 years: DEXA scan, bone age x-ray

Question 5

When should gender-affirming surgery be considered?

Answer 5

After at least 1 year of consistent and compliant hormone treatment (unless hormone therapy is contraindicated or not desired)

Question 6

At what age can you consider gender-affirming surgery with gonadectomy/hysterectomy in transgender patients?

Answer 6

• Age 18 or the age of majority in the patient’s country

Question 7

Define gender dysphoria

Answer 7

Persons who are not satisfied with their designated gender (APA definition)

Question 8

The prevalence of gender dysphoria in individuals with 46,XX CYP21A2 CAH is ______ than the baseline population prevalnce

Answer 8

higher

This supports the concept that gender identity is impacted by androgen exposure in-utero

Question 9

What percentage of pre-pubertal children with gender dysphria persist into adolescence?

Answer 9

15%

More likely to persist if it is extreme dysphoria or if they have socially transitioned

Question 10

What are the DSM5 criteria for GD in adolescents and adults?

Answer 10

A) Marked incongruence between one’s experienced vs. natal gender of at least 6 months, manifested by 2+ of:

• incongruence between experienced gender and primary/secondary sex characteristics
• desire to be rid of primary/secondary sex characteristics
• desire for sex characteristics of the other gender
• desire to be of the other gender
• desire to be treated as the other gender
• conviction that one has typical feelings/reactions of the other gender

B) Condition is associated with distress or impairment in functioning

Specify if: associated with DSD, or post-transition

Question 11

What factors may contribute to post-operative regret in transgender patients?

Answer 11

• Poor quality of surgery
• Severe psychiatric comorbidity
• Lack of support

Question 12

List the eligibility criteria for transgender adolescents to proceed with gender-affirming hormone therapy

Answer 12

• Qualified MPH has confirmed (1) the persistence of GD (2) Any coexisting psychological, medical or social problems have been addressed and (3) Adolescent has sufficient mental capacity to consent to this potentially irreversible treatment
• Adolescent (1) has been informed of effects of treatment and (2) has given informed consent
• Endocrinologist (1) agrees with the indication and (2) has confirmed no medical contraindications

Question 13

When should counselling about fertility preservation be done in transgender patients?

Answer 13

• Before pubertal suppression (adolescents) or before cross-sex hormone therapy (adolescents and adults)

Question 14

List 2 advantages to starting puberty-blocking early (T2) in transgender adolescents

Answer 14

• Improved physical outcome (prevent undesirable secondary sexual characteristics)
• Improved psychological experience

Question 15

Which secondary sex characteristics are irreversible after pubertal progression in males and females?

Answer 15

• Males: Adam’s apple, low voice, male bone configuration (large jaw, big feet and hands), tall stature
• Females: breasts, female body habitus, relatively short stature

Question 16

What are the risks of pubertal suppresion in adolescents with gender dysphoria?

Answer 16

• Poor bone mineralization (decreased BMD Z scores)
• Hot flashes, fatigue, mood alterations
• Compromised fertility IF subsequently treated with sex hormones
• Unknown effects on brain development
• Possibly increased fat mass/decreased lean body mass
• Arterial hypertension (reported in precocious puberty)

Question 17

What can you do to improve bone health in transgender adolescents on Lupron?

Answer 17

• Calcium suppplement
• Vitamin D supplement
• Physical activity

Question 18

List 3 adverse effects from excess testosterone therapy

Answer 18

• Erythrocytosis
• Sleep apnea
• Lipid changes
• Hypertension
• Excessive weight gain
• Salt retention
• Excessive/cystic acne

Question 19

How often should transgender patients be monitored clinically and with lab evaluation while on gender-affirming hormone therapy?

Answer 19

• Every 3-6 months: height, weight, sitting height, blood pressure, Tanner staging
• Every 6-12 months: lab tests (TG males = hemoglobin/hematocrit, lipids, testosterone, 25 OH vitamin D, TG females = prolactin, estradiol, 25 OH vitamin D)
• Every 1-2 years: DEXA scan, bone age x-ray

Question 20

What physical changes can you expect in the first 6 months of testosterone therapy in transgender males? 1 year?

Answer 20

• 6 MONTHS:
  
  • Cessation of menses
  • Increased sexual desire
  • Increased facial and body hair
  • Increased oiliness of skin
  • Increase muscle
  • Restribution of body fat
• 1 YEAR:
  
  • Deepening of voice
  • Clitoromegaly
  • Male pattern hair loss (if genetically predisposed)

Question 21

What physical changes can you expect in the first 12 months of estrogen/antiandrogen therapy in transgender females? 2 years?

Answer 21

• 1 YEAR:
  
  • Decreased sexual desire
  • Decreased spontaneous erections
  • Decreased facial and body hair
  • Decreased oiliness of skin
  • Increased breast tissue growth
  • Redistribution of fat mass
• 2 YEARS:
  
  • Maximal breast development
  • Prostate and testicular atrophy (after prolonged treatment)

Question 22

List 3 adverse effects from excess estrogen therapy

Answer 22

• Thromboembolic disease (20-fold increase)
• Liver dysfunction
• Hypertension