Testosterone Effects in Transmen

Transcription

1 Transmen

2 Testosterone Effects in Transmen EFFECT Skin oiliness/acne Facial/body hair growth Scalp hair loss Increased muscle mass/strength Fat redistribution Cessation of menses Clitoral enlargement Vaginal atrophy Deepening of voice ONSET (months) MAXIMUM (years) Hembree JCEM 2009, 94(9):

3 Effect of Testosterone in Transmen (FtM) Increased facial and body hair Male pattern baldness Voice change Increased libido Increased social drive and arousability Cliteromegally Increased muscular strength Redistribution and decrease of body fat Breast atrophy

4 Charing Cross Regimen Standard male HRT doses and regimens are used INTRAMUSCULAR Sustanon (250mg im 2-4 weekly) Nebido (1000mg 12 weekly) TRANSDERMAL Gel (50-100mg) SUBCUTANEOUS IMPLANTS mg

5 Contraindications Breast cancer Pregnancy Breast feeding Primary liver tumour Hypercalcaemia Ischaemic Heart disease

6 Morbidity in 293 Transmen Myocardial Infarction (6 fatal) Angina Pectoris Hypertension (>160/95mmHg) Elevation of Liver Enzymes Transient (<6 months) Persistent (>6 months) Alcohol related Others Acne Venous thrombosis Postoperative Oedema No. Observed SIR (95% CI) 0.34 [ ] NA 1. 2[ ] NA 9.09 [ ] NA Van Kesteren Clin Endo

7 Morbididty: Female to male No excess mortality No excess morbidity ACNE MI rate one third expected

8 Haematological Effects of Androgen Therapy Testosterone increases erythropoietin Hematocrit increases with androgen therapy 12-25%. 3-5% require phlebotomy or stop therapy Immune function not effected

9 Effects of Testosterone on Lipid Parameters in Transmen Elamin Clinical Endocrinology (2010) 72, 1 10

10 Effects of Testosterone on Lipid Parameters in Transmen Total Cholesterol mmol/l Triglyceride mmo/l LDL Cholesterol mmol/l HDL Cholesterol mmol/l Elamin Clinical Endocrinology (2010) 72, 1 10

11 Total Cholestrol 8 cholesterol (mmol/l) ** *** Baseline Polycythaemic After Natal male Transmen

12 Triglyceride Triglyceridse (mmol/l) Baseline Polycythaemic After Natal male Transmen

13 HDL ** *** HDL (mmol/l) Baseline Polycythaemic After 0 Natal male Transmen

14 LDL ** *** 3.5 LDL (mmol/l) Baseline Polycythaemic After Natal male Transmen

15 Cardiovascular Risk Cardiovascular Risk and testosterone treatment Normal range Plasma Testosterone

16 Testosterone and Endometrial Hyperplasia Endometrial hyperplasia occurs in 15% Recommend hysterectomy and salpingoopherectomy after 2 years of treatment If uterus is retained USS scan every 2 years Futterweit 1998 Arch Sex Behav

17 BMD in Transmen Turner 2004 Clin Endocrinol 61 (5),

18 MtF FtM Van Kesteren 1998 Clinical Endocrinology 48 (3),

19 Monitoring Preparation Dose Frequency Monitoring Method Testosterone Injections (monthly) Sustanon or Testosterone Enantate 250mgs Injection (Dose can be from mgs) 4, 3 or 2 weekly Trough on day of injection prior to injection and Peak 7 days later Testosterone Values Trough level 8 12nmol/ls Peak level 25 30nmol/ls Maximum Dose 250mg every 10days Longer Acting Testosterone Injection Nebido (has a loading phase) 1,000mg 10 to 15 weekly Trough on day of injection prior to injection prior to injection 15 20nmol/Ls 1000mg every 9 weeks Topical Testosterone gel Testogel Testim 50mg/5gm Daily Ensure no gel on arms and 4 6 hours after application of gel nmol/Ls 2 packets (100mg) daily

20 Monitoring Initial frequency depends on preparation When dose stablised 6 Monthly monitoring for 2 year then annual monitioring Testosterone, FBC, LFTs Lipids Sustanon/Testosterone Enantate Day 4 th injection plus testosterone 7 days after injection Nebido: annual monitoring on the day of injection Testim/Testogel 4-6 after the gel is applied take the blood from the arm that the gel was NOT applied to

21 Monitoring Cervical Smears As per national guidelines Endometrial USS every 2 years Brest cancer risk is same a male breast caner risk after male chest reconstruction

22 Non Binary

23 Non Binary Clinical Approach Advice should only be given where the clinician can give a clear indication to the person what physical changes will occur on hormone therapy and whether the desired mix of male and female features they desire is feasible with hormone therapy It is also important to advise the individual that none of the hormone regimens used in this field have been examined by randomised controlled clinical trials. The approach to hormone therapy also needs to be individualised In those that desire gender neutrality GnRH analogues alone may be appropriate The other approach is to allow natal hormone production to continue and attempt to suppress this sufficiently with antiandrogen therapy in a male-bodied person, or progestin or combined oestrogen/progestin treatment in a female-bodied person

24 Non Binary Clinical Approach This is Specialist Gender Medicine Decisions are made in the context of a multidisciplinary approach. degree of fluidity ;a clear formulation of the mix of male, female, and neutral physical features is made; significant psychological co-morbidities are excluded or managed. In all people it is important to discuss the fact that hormone therapy will impact on reproductive potential It is also good practice for the individual to be reviewed regularly by the members of the multidisciplinary team. It is important to have psychological input to the care of the individual, as the impact of the physical changes in the person on the psychological function

25 Long term outcome in gender dysphoria

26 Figure 1. Death from any cause as a function of time after sex reassignment among 324 transsexual persons in Sweden (male-tofemale: N = 191, female-to-male: N = 133), and population controls matched on birth year. Dhejne C, Lichtenstein P, Boman M, Johansson ALV, et al. (2011) Long-Term Follow-Up of Transsexual Persons Undergoing Sex Reassignment Surgery: Cohort Study in Sweden. PLoS ONE 6(2): e doi: /journal.pone

27 Risk of various outcomes among sex-reassigned subjects in Sweden (N = 324) compared to population controls matched for birth year and birth sex. Dhejne C, Lichtenstein P, Boman M, Johansson ALV, et al. (2011) Long-Term Follow-Up of Transsexual Persons Undergoing Sex Reassignment Surgery: Cohort Study in Sweden. PLoS ONE 6(2): e doi: /journal.pone

28 SMR adjusted for age and period of follow-up on hormone treatment by biological sex in 1331 transsexual subjects Asscheman Eu J Endo (2011)

29 Hazard ratios (95% CIs) of mortality according to the use of ethinyl estradiol in 964 Transwomen (median follow up of 18.6 years) Asscheman Eu J Endo (2011)

30 Long Term Outcome in Gender Dysphoria There is no difference in SMR for transmen There may be an increase in SMR for transwomen Suicide (x5.7) AIDS (x30) Cardiovascular Death (1.64) (EE users only) However Studies are confounded by changes in therapy over the last 10 years

31 In Summary Gender dysphoria requires hormonal therapy to achieve the secondary sexual characteristics of the desired gender Hormonal therapy carries physical risks provides psychological benefit Careful monitoring is required to prevent complications occurring Hormonal therapy in gender dysphoria is Effective Safe