Transgender 201: Case Discussion Group Melissa Davis, MD Maria Barnett, DO October 19, 2017 Maria Barnett, DO, Date
Welcome! Disclosures Introductions Discussion The total time of this workshop will depend on the character of the discussion and the group participants needs. 2
Disclosures: Melissa Davis and Maria Barnett have no financial disclosures to report and have no current or past pharmaceutical or industry relationships.
Introductions: Maria Barnett, DO, is a family physician at Upper Arlington Preventative Primary Care and at the OSU Transgender Primary Care Clinic (TPC) which she started with Dr. Andrew Keaster, then an Internal Medicine resident, in 2014. Melissa Davis, MD is a family physician at OSU Carepoint East and Nationwide Children s Teen Clinics. She began to take care of transgender patients at OSU s TPC and to provide HRT in 2015. TPC has undergone expansion from 1 half day session per month to 1-2 full day sessions per week and now has 4 physicians. TPC has its home at the Ohio State University Carepoint East location in the Near East Side and provides both primary care and consulting. TPC has a role within the larger university community to educate and train internal medicine and family medicine residents, NPs, medical students, and other health professionals to prepare them to provide excellent care to gender non-conforming patients. We also communicate with other departments within the university to improve the experience of transgender individuals. 4
Introductions: Who are you? Name Where are you currently working? How many years have you been in practice? How many years providing HRT or other medical services to transgender patients? How did you develop an interest in transgender medicine? What do you hope to get out of this experience? 5
Case Discussions: To be compliant with HIPAA, please remove all patient identifiers and speak in general terms while discussing cases. 6
OSU TPC Case #1: A 29yo transgender male patient with a history of anxiety comes in to follow up on his hormone replacement therapy. He has been on IM testosterone cypionate for several years. The shots are administered by his roommate, an RN, because he has significant anxiety about the injection process. He is about to move to another state. 7
OSU TPC Case #1: He will not use topical androgens because of concern about transference to his girlfriend Testopel, patches are cost prohibitive He is asking about subcutaneous use of testosterone cypionate. 8
OSU TPC Case #1: What do you think about subcutaneous use of testosterone cypionate? How would you instruct this patient? 9
2014 study by Olson et al at the Department of Adolescent Medicine associated with Keck School of Medicine 35 cross sex hormone naive patients were started at 25mg every 14 days and titrated to effect most ended up on 50mg weekly. 85% of transgender male youth had cessation of menses at 6 months and 91.4% achieved physiologic T levels (mean 521 ng/dl) Injections were given via 25-gauge, 5/8 inch needles on alternating sides into subcutaneous fat tissue in the midsection of the torso. Injections initially given by a nurse Patients were taught to give own injections and most self injected by 3-6 months. LGBT Health. 2014 Sep;1(3):165-7. doi: 10.1089/lgbt.2014.0018. Epub 2014 Jun 26. 10
2014 study by Olson et al at the Department of Adolescent Medicine associated with Keck School of Medicine 2 injection site reactions mild, resolved after switching from sesame oil to cottonseed oil suspension No dissatisfaction with the method. 11
2017 retrospective cohort study of patients choosing subq at Maine Medical Center 63 transgender male patients over 18 A 25-gauge, 5/8-inch needle used to inject into the SC tissue of the abdomen or thigh Patients were administered Testosterone cypionate or enanthate weekly at an initial dose of 50 mg. Dose was adjusted if needed to achieve serum total T levels within the normal male range. Serum T levels within the normal male range were achieved in all 63 patients with doses of 50 to 150 mg (median, 75/80 mg). Therapy was effective across a wide range of body mass index (19.0 to 49.9 kg/m2). The Journal of Clinical Endocrinology & Metabolism, Volume 102, Issue 7, 1 July 2017, Pages 2349 2355, https://doi-org.proxy.lib.ohio-state.edu/10.1210/jc.2017-00359 12
2017 retrospective cohort study of patients choosing subcutaneous administration at Maine Medical Center Minor and transient local reactions were reported in 9 out of 63 patients (subcutaneous nodules lasting 1-2 days, local urticaria 2-3 days, cellulitis in one patient). Patients expressed a marked preference for SC administration. When provided with options of IM, SC, topical, and transdermal T administration for initial therapy, almost all chose SC injections. Furthermore, all patients who experienced both IM and SC injections voiced a preference for SC injections. The Journal of Clinical Endocrinology & Metabolism, Volume 102, Issue 7, 1 July 2017, Pages 2349 2355, https://doi-org.proxy.lib.ohio-state.edu/10.1210/jc.2017-00359 13
OSU TPC Case #2: 35 year transgender male on testosterone cypionate 100mg IM weekly. Testosterone levels are therapeutic at 500 (has been on HRT for about 1 year). Hematocrit comes back at 54%. How would you manage this patient? 14
OSU TPC Case #2: ask about smoking lower dose? blood donation? How frequently? leeches? 15
Thank You melissa.davis@osumc.edu maria.barnett@osumc.edu 16