Menopause, Bio Identical Hormones, Sexual Health, Lack of Libido, Erection Problems, Gender Issues, Prostate Cancer, Psychiatry, Cancer

Definitions

Transsexualism is the desire to live and be accepted as a member of the opposite sex, usually accompanied by the wish to make her or his body as congruent as possible with the preferred sex through surgery and hormone treatment. The transsexual identity has been present persistently for at least two years.

1993, International Classification of Disease (ICD) 10

Gender dysphoria refers to the experience of dissonance between the physical appearance and the personal sense of being a man or woman.

The terms trans women (for a male to female T/S person) and trans man (for a female to male T/S person) are used in these guidelines.

Overview of Procedure

Introduction

My qualifications for working in this field are a higher degree in internal medicine FCP(SA); training and work as Lecturer in Sexual Medicine and Psychiatrist with a Diploma in Psychological Medicine (DPM); several year’s experience at the Gender Identity Clinic at Charing Cross Hospital in the 1980’s and my current membership of the Gender Recognition Panel. I participate in peer group discussion and have access to supervision as necessary.

The approach of my clinic is holistic and my preference is to work with Transsexual (T/S) individuals as part of a multidisciplinary team including the T/S persons General Practitioner (GP), a psychotherapist and with the involvement of a specialist endocrinologist and psychiatrist where appropriate, along with ancillary service providers, for example for laser hair removal and voice modulation. Typically liaison with the GP is on a ‘shared care’ basis and will mean hormonal treatment is initiated and monitored under the direction of the clinic but prescribed by their GP who will also carry out the necessary blood tests and monitor physical health.

The clinic is often asked by trans gendered individuals to help with the process of their transition. We think it important to allow plenty of time for discussion of gender status and how gender change may be best managed. We agree with the view that there is a continuum as regards gender identity and that the task of the gender specialist is to assist the individual to place themselves within the gender continuum and find its best expression in the particular circumstances of their life.

In practice patients at our clinic typically fall into one of three categories: those who come at the start of the transition process, those who have completed transition and want confirmation of their status before certification by the Gender Recognition Panel (GRP), and those who want a second opinion from a specialist in the field before undertaking gender re-assignment surgery (GRS).

Initial Assessment

We record the T/S person’s full history including a developmental and psychosexual history with mental state evaluation; we offer a routine general and sexual health screen, physical examination and genital examination.

The gender history will include early memories of gender related behaviour with or without cross-dressing plus any erotic accompaniments; attempts at conformity and peer relationships; sexual behaviour in adolescent and adult relationships, and details of relationships within marriage and the extended family. Discussion will include the choices that relate to the future management of their transition. The patient will receive copies of all correspondence relating to their care.

Baseline measurement for trans women includes blood pressure (BP), a full blood count (FBC), urea and electrolytes, liver function tests (LFT’s), fasting blood sugar, lipids, thyroid hormones (TSH and T4), testosterone, estradiol (< 100pmol/l), and prolactin (<400mU/L).

Baseline measurement for trans men includes BP, FBC, urea and electrolytes, LFT’s, fasting glucose, lipids, serum T4, TSH, prolactin (<400mU/L), serum oestradiol and testosterone.

Further Management

In principle reversible steps are taken before irreversible steps. Hormonal therapy will usually be started following the commencement of full time real life experience (RLE) in the chosen gender and will be for a duration of one year minimum before referral for gender re-assignment surgery (GRS). Hormonal therapy may otherwise be initiated after commencement of psychotherapy (which advisedly would be at least once every two weeks over a three month period). The quality of RLE will be reviewed: taking account of attendance in role at work (voluntary or paid) and the stability of the individual’s domestic and social lifestyle. Verifiable evidence of gender role change is required.

A decision to start hormonal therapy will often be made by doctor and patient jointly within the clinic; the decision may require discussion with colleagues. Before GRS is undertaken a second opinion will be required from a specialist in the field.

Guidelines for hormonal feminisation of Trans Women

As described by Professor Mike Besser, Consultant Endocrinologist, 2011

Feminisation is achieved by combined therapy giving the female sex hormone Estradiol whilst suppressing androgenic male sex hormones.

Estradiol Therapy:

Estradiol (E2), as tablet, 1-6 mg orally per day, for example with Progynova, to achieve levels in the upper half of the normal follicular range between 300-400 pmol/l.

The blood plasma level is best monitored 24 hours after ingestion. Blood levels higher than 400pmol are associated with an increasing risk of thrombo-embolism, hypertension and myocardial infarction.

Alternatively, Estradiol (E2), is prescribed as a transcutaneous patch, 50-150mcg two to three times per week, and aimed to achieve physiological blood levels between 300-400pmol/l. The blood plasma level of E2 is best monitored 48 hours after the application of a patch.

Suppression of androgen secretion:

Gonadotrophin Releasing Hormone (GRH) Therapy with an analogue (a synthetic equivalent hormone), goserelin 3.6mg, is given as a s/c depot implant every 4 weeks (or in a higher dose, 10.8mg as s/c implant every 3 months).

Goserelin’s mode of action is by super-stimulation of the pituitary as a result of which it becomes unresponsive, GRH receptors on it are down regulated, levels of the pituitary hormones, LH and FSH, fall to hypopituitary levels and target androgens produced from the testes fall to post-gonadectomy levels. If treatment with goserelin is stopped the process is reversed and gonadotrophin and androgen secretion will resume.

NB. GRH and analogue hormones such as goserelin have no action on the adrenal gland’s production of androgens and Tabs finasteride 2.5-5.0mg may be added to block masculinising actions of dihydrotestosterone (DHT) which arise from conversion of androstenedione and DHEA secreted by the adrenal glands .

Alternatively, as a supplement to goserelin treatment with Tabs cyproterone (Androcur) 50-100mg/d blocks androgen receptors (but has long-term side-effects, see below). Similarly Tabs spironolactone 100-400mg/d will block androgen receptors (but may increase potassium levels and liver dysfunction).

Cyproterone may be used as an alternative treatment to goserelin, given in doses of 50-100mg daily by mouth. Its action is to block androgen receptors, limiting the androgenic effects of circulating testosterone, DHT and DHEA . However, it has glucocorticoid (diabetic inducing) effects and may be toxic to the liver. Flattening of mood and depression may also occur. For these reasons cyproterone is less frequently recommended for long term use.

Hormonal feminisation should be stopped 4 weeks before Gender Re-assignment Surgery (GRS) and a single dose of s/c goserelin 3.6mg is given at that time.

Routine Monitoring for trans women will usually be 6 monthly for 3 years and thereafter annually. Tests to include:

Blood pressure, FBC, urea and electrolytes, LFT’s, fasting glucose, lipids, testosterone, serum oestradiol 24 hours after a tablet or 48 hours after application of a patch (300-400pmol/L), and prolactin.

Guidelines for Hormonal Masculinisation of Trans Men

As described by Professor Mike Besser, Consultant Endocrinologist, 2011

Hormonal masculinisation is achieved with a regime that combines the suppression of estrogenic sex hormone production with androgenic sex hormones by i/m injection, by mouth or with a skin patch:

The use of a synthetic analogue of Gonadotrohin Releasing Hormone (GRH), goserelin, 3.6mg monthly or 10.8mg 3 monthly, given as a s/c implant, will rapidly suppress LH and FSH production and stop ovarian function.

Testosterone therapy should be started at the same time as ovarian function is suppressed with the aim of achieving testosterone levels at the lower end of the normal adult male range. It may be given as a depot preparation, for example as i/m testosterone enantate (Sustanon 250) 250-500mg every 2-4 weeks. A check to confirm adequate plasma testosterone levels is best done just prior to injection.

Alternative regimes are: a transdermal gel (Testogel 5g/d applied to shoulders or loins in the morning); a patch (testosterone 100-150 micrograms twice a week); oral, as testosterone undecanoate (Restandol 40mg) tabs 120-160mg /d in divided doses; or by intramuscular injection, testosterone as Nebido 1g, every 10-12 weeks.

NB Testosterone taken as a patch may induce a local skin reaction to the medication, while Testosterone taken by mouth cannot be accurately measured from a blood sample as absorption takes place through the gut wall prior to reaching the liver’s portal system. Conversion in the gut wall by the enzyme 5-alpha-reductase produces dihydrotestosterone (DHT), a more active androgen than testosterone, and blood levels of this, rather than testosterone itself, should be measured 3-4 hours after ingestion. DHT will be above usual male physiological levels while plasma testosterone will remain at the normal or low level of a biological male. Trans men on testosterone may over time get a raised level of haemoglobin in the blood.

Routine Monitoring for trans men

Monitoring should be 6 monthly for 3 years and then usually on an annual basis:

BP, FBC, urea and electrolytes, LFT’s, fasting glucose., lipids, serum oestradiol (<70pmol/l), testosterone (<10nmol/L with test just prior to injection if i/m route of administration) and prolactin (<400mu/l). DHT should also be measured (3-4 hours after a dose) if oral testosterone is prescribed.

Post-operative care

Hormone therapy should recommence 4 weeks after surgery. For trans women an anti-androgen is not usually required but hair growth due to adrenal androgens can be countered with finasteride 5mg/d if necessary.

General medical care post-operatively for trans women will include advice on breast awareness (5 yearly monitoring for breast cancer is recommended) and prostate problems (in accordance with ‘good medical practice’ guidelines), and for trans men will include cervical screening (if the cervix is present). Longer term trans men will be advised to consider hysterectomy. Measurement of bone density is advised due to an increased risk of osteoporosis.

General health guidelines apply: encouragement is given not to smoke, to take regular exercise, to have of a balanced diet and to consume no more than 14 units of alcohol per week.

Please note these guidelines may change from time to time according to the prevailing views on ‘best medical \practice’.

For further details of Optimal Health please see www.optimalhealth.org.uk or contact the practice Manage, Christine, on 020 74367713

Please address emails to mikeperring@optimalhealth.org.uk

These guidelines are made with reference to the following: RCP: T/S Standards of Care July, 2011 (draft version); WPATH SoC Guidelines, 2001; Gooren L J. Care of Transsexual Persons. N Eng J Med 2011; 364 (13):1251-1257.