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Primary health care for transgenders
It has been widely reported that the quality primary health care for those identifying as transgender is currently hard to find in Australia.
This appears to be particularly the case if one looks at the broad spectrum of gender diversity and doesn’t focus just on referring pathways for gender reassignment.
My family GP, like many in Australia, does not claim familiarity with best practices for the management of transgender patients – so I searched on the internet to see if there was any creditable advice we could use as a basis.
I was surprised to find only one set of guidelines that were sufficiently general to embrace the wider gender diverse population. These guidelines for primary care were issued in 2006 in British Colombia.
http://scholar.google.com.au/scholar_url?hl=en&q=http://www.bgtransgender.com/Guidelines/guidelines-transgnder%2520primcare.pdf&sa=X&scisig=AAGBfm15802fUC8CxolibrPob6vC0W5i3Q&oi=scholarr&ei=KFm1UP_yKI6XiQfrkIGgAw&ved=0CC8QgAMoATAAIt leads to the question, why don’t we have a similar guidance in Australia….or do we?
I recommend the full article to everyone who wishes to have a more informed dialog with their GP. But would like to extract here the summary tables for primary prevention, screening and management selecting those most pertinent to Male to female transgenders who have NOT had surgical interventions.
Breast Cancer
MTF, no hormone use
[ul]• There is no evidence of increased risk of cancer compared to natal male patients, in the absence of other known risk factors (e.g., Klinefelter’s syndrome). Routine screening, either in the form of regular breast exams or mammography, is not indicated for these patients.
[/ul]MTF, past or current hormone use
[ul]• MTF patients who have taken feminizing hormones may be at increased risk of breast cancer compared to natal males, but likely have significantly decreased risk compared to natal females.
• The length of feminizing hormone exposure, family history, BMI >35 and use of progestins may further increase risk.
• Screening mammography for MTF patients receiving hormone therapy is not currently supported by the evidence, but screening mammography is advisable in patients over age 50 with additional risk factors (e.g., estrogen and progestin use > 5 years, positive family history, BMI >35).
• Annual clinical breast exam and periodic self-breast exam are not recommended.[/ul]Prostate Cancer
MTF, no current/past hormones, no surgery
[ul]• There is no evidence currently supporting PSA screening in any usual risk population. The risks and possible benefits of PSA screening should be discussed with all patients, and routine screening considered in high risk patients (African-Canadian, family history of prostate cancer) starting at age 45.
• Digital rectal exams should be performed as for natal males.[/ul]
MTF, past or current hormones, with or without surgery
[ul]• The prostate is not removed in male-to-female genital surgery.
• Feminizing hormone therapy appears to decrease the risk of prostate cancer, but the degree of reduction is unknown.
• PSA screening is not recommended as PSA levels may be falsely low in an androgen-deficient setting, even in the presence of prostate cancer. Consider screening in high risk patients only.
• Digital rectal exams should be performed as per natal males, along with education regarding the small but possible risk of prostate cancer.[/ul]Cardiovascular disease
All transgender patients
[ul]• Screening and treatment of known, modifiable cardiovascular risk factors is recommended for all transgender patients.
• It is recommended that cardiovascular risk factors be reasonably controlled before initiating feminizing/masculinizing hormone therapy.
• Consider stress testing among patients at very high risk or with any cardiovascular symptoms before initiating hormone therapy.
• Consider daily aspirin therapy in patients at high risk for CAD.[/ul]
MTF, currently taking feminizing hormones[ul]
• Close monitoring for cardiac events or symptoms is recommended for MTFs with risk factors, especially during the first 1-2 years of feminizing hormone therapy.
• In patients with pre-existing CAD, there is increased risk of future events using estrogen and/or progestin.
• It may be possible to reduce risks by using transdermal estrogen, reducing the estrogen dose, and omitting progestin from the regimen.[/ul]Hypertension
MTF, not currently taking estrogen
[ul]• Screen and treat hypertension as recommended in guidelines for non-transgender patients.
• Consider a systolic blood pressure goal of ≤ 130 mm Hg and a diastolic goal of ≤ 90 mm Hg if planning to begin feminizing hormone therapy within 1-3 years.[/ul]
MTF, currently taking estrogen
[ul]• Monitor blood pressure every 1-3 months.
• A systolic blood pressure goal of ≤ 130 mm Hg and a diastolic goal of ≤ 90 mm Hg is recommended.
• Consider using spironolactone (an anti-androgen) as part of an antihypertensive regimen.[/ul]Lipids (Cholesterol)
MTF, not currently taking estrogen
[ul]• Screen for and treat hyperlipidemia according to guidelines for non-transgender patients.
• Consider LDL goal
.5 mmol/L if planning to start feminizing hormones within 1-3 years.[/ul]
MTF, currently taking estrogen
[ul]• An annual fasting lipid profile is recommended.
• Transdermal estrogen is recommended for patients with hyperlipidemia, particularly hypertriglyceridemia.
• Treat high cholesterol to an LDL goal of.5 mmol/L for low-moderate risk patients and <2.5 mmol/L for high risk patients.[/ul]Diabetes Mellitus
MTF, not taking estrogen
[ul]• Follow diabetes screening and management guidelines as for the non-transgender population.[/ul]
MTF, currently taking estrogen
[ul]• Patients taking estrogen may be at increased risk for Type 2 diabetes, particularly those with family history of diabetes or other risk factors.
• Recommend annual fasting glucose test in patients with family history of diabetes and/or greater than 5 kg weight gain. Consider glucose tolerance testing (or A1c in patients unable to perform a GTT) in patients with evidence of impaired glucose tolerance without diabetes.
• Diabetes should be managed according to guidelines for non-transgender patients, but insulin sensitizing agents are recommended if medications are indicated.
• Decrease in estrogen dose may be indicated if glucose is difficult to control or the patient is unable to lose weight.[/ul]Mental health
All transgender patients
[ul]• All transgender patients should be screened for depression.
• Refer patients, if needed, to a trans-competent mental health provider.[/ul]Musculoskeletal health
All transgender patients
[ul]• Exercise may help MTFs taking feminizing hormones to maintain muscle tone.[/ul]Osteoporosis
MTF, no hormone use, no surgery
[ul]• There is no evidence of increased risk of osteoporosis. No screening is recommended except as indicated by additional risk factors.[/ul]
MTF, past or present feminizing hormones, pre-orchiectomy
[ul]• There is no current evidence that feminizing therapy increases risk of osteoporosis, but long-term prospective studies have not been done.
• No screening is recommended except as indicated by additional risk factors.
• Calcium and Vitamin D supplementation is recommended.[/ul]Venous thrombosis/thromboembolism and feminizing hormones
MTF patients, considering or currently taking estrogen
[ul]• Estrogen therapy is contraindicated in MTF patients with a history of venous thromboembolic events (VTE) or underlying thrombophilia (e.g. anticardiolipin syndrome, Factor V Leiden, etc).
• MTF patients over age 40, smokers, and highly sedentary patients are at particular risk and may benefit from lifestyle change, transdermal estrogen and lower estrogen doses.
• Consider daily aspirin therapy in patients with risk factors for VTE who are taking estrogen.[/ul]I should stress that the above information is a brief and incomplete selection from a document intended for medical practitioners. The information I have provided is not a substitute for qualified medical advice. I also recommend reading, in full, the guidance paper.
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