How To Keep Estradiol Patch On Transgender

Feminizing Hormone Therapy

The goal of hormone therapy in trans women is to reduce the endogenous furnishings of testosterone such every bit coarse body hair and facial hair; and to induce female person secondary sex characteristics such every bit breast and hip evolution. Physiologically, this requires a suppression of endogenous androgens and the improver of estrogen.

Hormonal agents

Anti-androgens

Spironolactone has traditionally been used preferentially every bit it was thought to take a superior safe profile. This exercise has recently come up into question every bit it has been noted that adequate anti-androgen effects are achievable at lower doses of cyproterone at which adverse furnishings are less likely. Thus the choice of anti-androgen should be made individually for each client based on their medical history and preference regarding respective side issue profiles.

Following orchiectomy (+/- vaginoplasty), most trans women volition not require androgen suppression. The androgen-blocker can be tapered over the course of 4-6 weeks.

Estrogen

Estrogen acts directly on estrogen receptors to initiate feminization. It is unremarkably the focus of hormonal transition for trans women. The starting dose of estrogen tin be maintained for one-2 months, after which a dose increase tin be considered barring any apropos effects. In clients over 50 years old who have been on estrogen for several years, doses may be reduced to those administered to post-menopausal cis women (ie. 0.025 – 0.05 mg patch).

Expected effects

What to await from a regimen consisting of an anti-androgen and estrogen

The degree and rate of physical effects is dependent on the dose and road of administration, besides every bit client-specific factors such as historic period, genetics, body habitus and lifestyle.

Physical changes related to androgen occludent and estrogen may take months to announced and are generally considered to exist complete afterwards 2-iii years on hormone therapy. Feminizing therapy does not bear on the pitch of the vox in trans women. Some clients may obtain benefit from voice therapy with a qualified and supportive speech and language therapist who can work with the client to modify their song characteristics.

Effects and expected time course Download

Risk mitigation

Absolute contraindications

Unstable ischemic cardiovascular illness
Estrogen-dependent cancer
End stage chronic liver disease
Psychiatric weather condition which limit the ability to provide informed consent
Hypersensitivity to one of the components of the formulation

Precautions and risk mitigation Download

Several pre-existing medical weather and risk factors may increase the risks associated with estrogen assistants. When these are present, a careful evaluation of risks and benefits should be completed and fully discussed with the client.

Precautions in cherry-red impart moderate to loftier risk of an adverse outcome without take chances mitigation.

Select area of concern beneath

Neurologic

More data on seizure disorders and anticonvulsant therapy on page 17 of the full Protocols

Take a chance factors	How to minimize risks
Cerebrovascular affliction	Consider referral to neurology, ensure optimal medical management (including safety anticoagulation) and ambitious risk gene optimization, use transdermal route of assistants +/- lower dose
Severe refractory or focal migraine	Consider referral to neurology, consider daily migraine prophylaxis, ensure all other cerebrovascular take chances factors are optimized, consider transdermal route of administration
Seizure disorders	Consider referral to neurology, consult with a pharmacist re: impact of estrogen interaction with anticonvulsant medication
History of benign intracranial hypertension	Consider referral to neurology/neurosurgery

Endocrine

Risk factors	How to minimize risks
Hyperprolactinemia	Refer to endocrinology, defer initiation until etiology determined, manage based on etiology. More information on hyperprolactinemia/Prolacinoma on page 17 of the full Protocols
Marked hypertriglyceridemia	Identify and address barriers to optimal lipid control, refer to dietician, minimize alcohol consumption, consider anti-lipemic pharmacologic therapy, consider endocrinology referral, encourage deferral of estrogen until controlled, consider transdermal route of assistants
Uncontrolled diabetes	Identify and address barriers to optimal glycemic control, refer to dietician, encourage lifestyle modification, initiate antiglycemic agent(s), encourage deferral of estrogen until controlled, consider cardiac stress test, consider transdermal road of administration.
Metabolic syndrome	Dietary and medical direction of component disorders, encourage deferral until components adequately managed, consider cardiac stress examination, consider transdermal route of administration

Cardiovascular

More information on cardiovascular and cerebrovascular disease on page 17 of the full Protocols

Gamble factors	How to minimize risks
Stable ischemic cardiovascular disease	Consider referral to cardiology, ensure optimal medical (including prophylactic anticoagulation) and/or surgical management as indicated, aggressive chance gene optimization, use transdermal road of assistants +/- lower dose
Other cardiac diseases	Consider referral to cardiology
Uncontrolled high blood pressure	Place and address barriers to optimal BP command, use spironolactone as antiandrogen, add together additional antihypertensives as needed (avoid ACEs/ARBs with spironolactone), encourage deferral of estrogen until controlled, consider cardiac stress examination, consider transdermal road of administration

Hepatic

More information on liver/gallbladder effects on page 17 of the full Protocols

Risk factor	How to minimize risks
Hepatic dysfunction	Dependent on etiology, eg. minimize alcohol consumption, weight loss in NAFLD, consider referral to hepatology/GI, use transdermal or injectable route of assistants

Oncologic

More than information on breast cancer on page 17 of the full Protocols

Risk factors	How to minimize risks
Strong family history of breast cancer	Refer to genetics/familial chest cancer program for farther risk stratification and BRCA1/2 testing as indicated

Hematologic

Chance factors	How to minimize risks
Personal or family unit history of porphyria (rare)	Consider referral to porphyria clinic or internist with experience in porphyria
Personal history of deep vein thrombosis (DVT) or pulmonary embolism (PE)	Identify and minimize co-existent chance factors, consider prophylactic anti-coagulation, consider referral to hematology, use transdermal route of administration +/- lower dose
Family history of abnormal clotting	Consider referral to hematology, rule out genetic clotting disorder, consider condom anticoagulation, utilise transdermal route of assistants

Respiratory

Risk/Precaution	How to minimize risks
Smoker	Encourage and support smoking cessation, offer NRT and/or bupropion/varenacline, or negotiate a decrease in smoking, consider lower dose, consider cardiac stress test, use transdermal route of administration

Monitoring strategies

Standard monitoring of estrogen administration should be employed at baseline, 1, 3, 6, and 12 months. This should include a functional inquiry, targeted physical exam, bloodwork, and wellness promotion/ illness prevention counselling.

Testosterone level may be the near useful test for monitoring in trans women; for many clients, the goal will be to achieve the suppression of testosterone into the female range. That said, the client may have clinically relevant results without total suppression of testosterone because of androgen blockade, which is not easily measured. Estradiol levels are of variable utility in monitoring feminizing therapy given the wide cyclical variation in cis women. Most clients reach considerable feminization at estradiol levels between 200-500 pmol/L. According to the Endocrine Society Guidelines, serum estradiol levels should not exceed the mean daily level for cis women (approximately 700 pmol/L).

Long-term preventive care

Trans women maintained on feminizing hormone therapy take unique preventive intendance needs and recommendations.

Long-term care of trans women on feminizing hormone therapy should involve (at least) annual preventive care visits. An Adaptive Preventive Care Checklist with accompanying explanations for trans-specific recommendations can be accessed beneath.

Preventive care screening procedures

Physical examinations that involve intimate body parts are discomforting to anyone. While many trans people are comfortable with their bodies others may feel body dysphoria. Some may be very uncomfortable with concrete examinations or be reluctant to acknowledge or touch on their own genitals.

Provide intendance based on organs present

It is best to base routine screening on the presence or absenteeism of body parts. Sex assigned at birth and gender identity are divide things. Some women have pensises, some men accept vaginas. Refrain from calling torso parts 'male' or female'. Instead use technical terms or enquire customer what they prefer to call their body parts. Organs nowadays should receive routine and preventive care.

Click on i of the tabs to find out routine care and screening suggestions.

Osteoporosis and Os Mineral Density Screening

Indications for BMD screening

Clients over 65 years old
Clients over 50 years quondam and with higher chance for osteoporosis
Clients with any other risk factors for osteoporosis or bone loss (glucocorticoid therapy, previous fractures, family history of osteoporosis)
Agonadal clients with eleveated LH levels
Clients at whatever age having undergone orchiectomy and having been off exogenous hormones for any pregnant length of time
Clients on anti-androgen therapy for a significant length of time without co-administration of exogenous estrogen

Chest exam

Employ the diagram below to discover out whether your client needs breast cancer screening.

Colon cancer screening

Utilise the diagram below to find out when and what type of colon cancer screening is recommended.

Cervical cancer screening

Utilise the diagram beneath to find out what type of cervical cancer screening is recommended.

Prostate exam

The risk of prostate cancer is not increased past estrogen use, in fact it is reasonable to assume that the risk is significantly decreased by the associated androgen impecuniousness. Although rare, there have been cases of prostate cancer reported in trans women, generally occurring in those who started hormone therapy after the age of l.^{1, two} It is important to note that estrogen will lower PSA values fifty-fifty in the presence of prostate cancer, thus impacting its utility in this population. Routine PSA screening is non recommended in trans women in the absence of pregnant adventure factors. There is little testify to support a role for annual DRE in prostate cancer screening; still, it may be considered according to a provider's routine practice with cis men. In clients who have undergone vaginoplasty, the prostate remains in situ and may be palpated anteriorly via digital vaginal exam in a gender affirming lithotomy position.

Sources

Gooren LJ, Giltay EJ, Bunck MC. Long term treatment of transsexuals with cross-sex hormones: extensive personal experience. J Clin Endocrinol Metab. 2008; 93(1):19-25.
Mueller A, Gooren L. Hormone-related tumors in transsexuals receiving treatment with cross-sex hormones. Eur J Endocrinol. 2008; 159(3):197-202.

Source: https://bmc1.utm.utoronto.ca/~kelly/transprimarycare/gp-femht.html

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