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into consideration the capacity of the patient to make an informed decision and the significant harm that can come from withholding treatment. Care providers may use eCase or call the RACE Line at 604-696-2131 or toll free at 1-877-696-2131 and request the “Transgender Health” option to consult an experienced clinician. Dose Titration: Titrate dose q 4-6 weeks until maintenance dose is achieved (e.g. 25 mg x 4-6 weeks, then 50 mg x 4-6 weeks, then 75 mg, etc.) A slower titration rate may be preferred by some patients or may be chosen based on clinical indication. Goal of therapy: To maintain mid-injection cycle levels in the mid - high end of male range, minimize side effects and maintain expected rates of physical change (degree of change is influenced in part by patient preference). Lab monitoring: Request the lab to report male reference ranges Baseline and annually thereafter ● Testosterone, CBC, ALT, fasting glucose, lipids Following dose changes and 4-6 weeks after gonadectomy ● Mid-injection cycle testosterone, CBC, ALT ● Trough testosterone if amenorrhea is delayed >6 months Areas for review in follow up visits: Subjective Objective ■ Effects of hormones: physical, emotional ■ Current dose/desire for dose change ■ Side effects/concerns ■ Mental health: mood, body image, libido ■ Social: significant others, support, acceptance, safety, housing, finances ■ Lifestyle: exercise, nutrition, smoking, substance use ■ Blood pressure ■ Weight (baseline and q 6 months prn) ■ Mental status (brief assessment) ■ Cardiovascular and abdominal exam (baseline and yearly) ■ Labs ■ Other investigations as indicated 8 Managing side effects of testosterone, screening & health promotion Trans Care BC Primary Care Toolkit Managing side effects of testosterone, screening & health promotion Managing side effects of testosterone & other common concerns Acne Typically most problematic in the first year of hormone therapy Treat as per usual, consider lower dose or switching testosterone type if persistent Scalp hair loss Minoxidil – will not impact facial hair growth Finasteride – will inhibit facial hair growth Polycythemia Usually a misinterpretation due to lab using “female” ranges. Ensure the hemoglobin and hematocrit are being interpreted based on male laboratory ranges. If hemoglobin > 175 g/L or hematocrit > 0.52 or if symptomatic (headaches, facial flushing) increase frequency of dosing to weekly, reduce dose, or switch to a patch or gel to minimize peak/trough variation Elevated transaminases Usually transient unless another cause of hepatic dysfunction is identified Unexpected (menstrual/cyclical) bleeding Bleeding is typically suppressed within 6 months of starting testosterone. Evaluate for missed, inconsistent or excessive testosterone dosing (missed or inconsistent doses can cause spotting, excess testosterone can convert to estrogen with theoretical risk of endometrial proliferation) Check trough testosterone levels, estradiol, LH, FSH. Consider more frequent dosing (weekly at half the q 2 week dose) or dose adjustment. Persistent, unexplained bleeding should be evaluated with pelvic ultrasound +/- endometrial biopsy Internal genital (vaginal) dryness Internal genital atrophy is fairly common for those on long-term testosterone. It can be treated with over-the-counter internal genital moisturizers or topical estrogen: estradiol cream 0.5-1 g daily for 2 weeks then twice weekly or estradiol tablet 10 mcg daily for 2 weeks then twice weekly. It can be helpful to advise patients that product names may not be affirming. Screening Cardiovascular risk Testosterone use does not appear to significantly increase cardiovascular risk. If using a risk calculator, use male scores if hormones were started early in life, female scores if hormones were started later (or both to estimate range) Chest/Breast cancer If the client has not had chest surgery, screen as per BC Cancer guidelines. The risk of cancer related to residual tissue after chest construction (double mastectomy) is unknown. If high risk or patient concern, consider physical exam and diagnostic ultrasound or other modality when appropriate. Cervical cancer Screen as per BC Cancer Cervical Screening guidelines On the requisition, use “T” for the gender marker, in the notes section indicate testosterone use, including dose and duration. See Appendix E - Sexual Health Screening Sexual health Some trans people may be at higher risk for sexually transmitted infections (STIs) including HIV and syphilis. Screen for STIs and consider HIV pre-exposure prohylaxis based on patient-specific risk factors. See Appendix E - Sexual Health Screening Osteoporosis Screen as per national guidelines (ages 65 and up) or earlier if higher risk (for example, longterm low levels of testosterone post-oophorectomy). Encourage vitamin D and calcium intake and weight bearing exercise. Maintain hormone therapy post-gonadectomy. Colon cancer Screen as per BC Cancer Colon Screening guidelines Trans Care BC Primary Care Toolkit Overview of estrogen-based hormone therapy 9 Overview of estrogen-based hormone therapy Estrogen in combination with a testosterone blocking medication is used to reduce testosterone-related features, induce estrogen-related features and relieve distress related to gender. Medication Dose Androgen Blockers Spironolactone First-line due to
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