Family Medicine Vital Signs

By: Robin Brown, MD

Earlier this month I had a sun-filled weekend in the Bay Area attending the National Transgender Health Summit hosted by UCSF. In between my hunt for the best burrito and rapid consumption of fancy coffee, I attended three days of conference. The content was widespread, addressing current practices as well as cutting edge research. The audience ranged from community advocates to medical students to surgeons. I primarily attended clinically-focused lectures and below are some of the take-home ideas I jotted down. Use this link if you have questions about terminology related to transgender care:

• For patient’s receiving feminizing therapy with estradiol, there is mixed evidence regarding the increased risk of thromboembolic events. While some studies show no risk as compared to cisgender women, others show up to a 4-fold increased risk. One presentation put this risk in perspective: while the relative risk appears to be a dramatic 400%, the absolute risk goes from 1 in 1,000-10,000 in cisgender women to 4 in 1,000-10,000 in transgender women. Thus the number needed to harm remains reassuringly large, a point I will now incorporate in my consent process.¹
• It’s difficult to apply cancer screening guidelines to transgender patients since the current guidelines do not differentiate gender from sex assigned at birth. At minimum, you can assume that if a patient has an organ or body part and meets cancer screening criteria then screening should be recommend. Unfortunately, there is a lack of consensus when it comes to more complex decisions regarding preventative screening.
• Cervical cancer screening may cause discomfort or have an associated trauma experience for transgender men. In discussing screening recommendations, consider factors that increase or decrease their likelihood of HPV infections. For instance, there is a 5-fold increase in HPV if the patient has receptive vaginal-penile sex. So for a transgender man in a monogamous relationship with a cisgender woman, his risk of cervical cancer may be arguably low. This illustrates a great opportunity to practice shared decision making with your patients.¹
• On the topic of what type of sex patients are having, one presenter addressed how to ask clearly about pregnancy risk in transgender and nonbinary patients. If you find yourself confused, simply ask “are you having sex that could result in pregnancy?” and thus skip any incorrect inferences about their partner.
• When considering breast cancer screening, you should take a detailed surgical history for transgender men whom have undergone mastectomy. If they have not had a radical mastectomy or have only had a breast reduction, then they do have residual breast tissue. This has the potential to become cancerous, therefore you should discuss breast cancer screening with these patients. Mammography may not be feasible due to the limited breast tissue, so screening may include chest wall examinations, ultrasound, or MRI.¹
• Bone health screening is another quandary. At minimum, most providers agree with starting at age 65 for all transgender patients regardless of sex assigned at birth or hormone use. You may start earlier if there are risk factors for osteoporosis, such as removal of gonads or the use of puberty blockers. Once you’ve received DEXA results consider basing treatment recommendations on an average between the male and female FRAX^R scores.¹
• I really enjoyed a presentation on what the PCP needs to know about “bottom surgery”. While I do not expect to retain the intricacies of the surgical process, I encourage you all to take a moment to read a summary of what these surgeries entail. The Center of Excellence for Transgender Health at UCSF provides an overview including postoperative considerations for both vaginoplasty and phalloplasty. I now recognize that for patients whom have had a vaginoplasty, the neovagina is created from inverted penile skin. Therefore, it does not have a mucosal lining and is not colonized with lactobacillus or candida. Now as PCP, when a patient whom has had a vaginoplasty arrives to clinic with the complaint of vaginal discharge, it would be more appropriate for me to consider infections that involve skin flora than to reach for a vaginal pathogen swab.²
• Last but not least, I learned about the complications of silicone fillers. Up to 50% of transgender women have injected fillers for the purpose of rapid feminization. “Silicone fillers” can be any number of substances, ranging from mineral oil to window caulk, and are often bought off the street and injected by non licensed individuals. Studies are now showing serious complications including hypercalcemia, necrotizing granulomas, and pneumonitis. Consider adding routine questions about filler use when taking your history or at least keep these considerations on your differential. This patient brochure provides information on safer silicone use.⁴

That’s all for now. The next National Transgender Health Summit will be in 2021, for more information check this link out. 

References:

1. Maddie Deutsch. (2019, April) “Cancer Screening, Cardiovascular Considerations, Fertility, Common Postoperative Complications” Presented via PowerPoint at NTHS
2. Toby Meltzer. (2019, April) “Overview of Surgical Techniques and Post Op Complications” Presented via PowerPoint at NTHS
3. Zil Goldstein. (2019, April) “Trauma Informed Approaches and Behavioral Health Considerations” Presented via PowerPoint at NTHS
4. Asa Radix. (2019, April) “Bone Health, Managing HIV in Transgender Populations, Silicone, Informed Consent Approaches” Presented via PowerPoint at NTHS

Robin Brown, MD, is a second-year resident in the Division of Family Medicine in the Department of Family and Preventive Medicine at the University of Utah in Salt Lake City, UT. Her medical areas of interest include child and adolescent medicine, women’s gynecologic care, sports medicine, medical education, and quality improvement.