The role of pharmacists in transgender therapy

As awareness of transgender people grows, so does the need for healthcare professionals to be educated in the area of transgender health. A recent article in Australian Prescriber draws on ‘decades of experience’ to give practitioners fresh insight into gender-affirming hormone therapy.

The article, authored by sexual health physician Dr Louise Tomlins, noted that, while not all transgender individuals chose to undergo gender-affirming therapy, interest in the therapy has increased. This makes it vital that educated healthcare professionals are available to provide support, both clinical and psychosocial.¹

As awareness increases, the role of pharmacists in multidisciplinary healthcare teams supporting individuals undergoing gender confirmation therapy has been a topic of renewed discussion. In the UK, Caroline Dada is the medication safety officer and lead pharmacist for community mental health services and gender identity for the Leeds and York Partnership Foundation Trust. She believes she is the only pharmacist specialising in gender identity in the UK.

‘Community pharmacists and GP-based pharmacists are in a great position to support patients with gender identity issues,’ she said. ‘The service users for whom I prescribe will be on lifelong therapy, so community pharmacists will need to have a greater understanding of their health requirements and therapy.’²

The Australian Prescriber article outlines the different therapy options for individuals undergoing gender transition from male to female, and from female to male.

Transwomen

Estrogens in combination with an anti-androgen are the standard first-line gender-affirming hormone treatments for patients transitioning from male to female (transwomen).

Estrogen is the preferred treatment as it most closely resembles the hormone produced by the ovaries. The dose of estradiol valerate tablets starts at 2–4 mg daily, increasing up to 8 mg daily. Tablets can be given in divided doses if nausea occurs in higher doses. Patches or implants are preferred for transwomen over 40 years of age (although can be used in younger women) to minimise the risk of venous thromboembolism. Patches start at 100 microgram/24 hours. Implants of 50 mg and 100 mg are available from compounding pharmacies. Their duration of drug delivery is on average 6–12 months, but this needs to be monitored. Tachyphylaxis can develop with long-term implant use.¹

Ethinylestradiol and conjugated equine estrogens are generally avoided because of an increased risk of venous thromboembolism. Also, blood levels may be inaccurate.

Anti-androgens suppress the production and effect of endogenous androgens, thereby reducing masculine characteristics. Cyproterone and spironolactone are the most commonly used agents. In combination with estrogen, they reduce the dose of estrogen required to achieve feminising effects.

Cyproterone is a synthetic progestogen with a potent anti-androgenic effect. The starting dose is usually 25–50 mg daily, which can be increased to 100 mg daily. Cyproterone has been associated with rare cases of fulminant hepatotoxicity when used for metastatic prostate cancer.

Spironolactone is a potassium-sparing diuretic, which in higher doses directly inhibits testosterone production and blocks androgen receptors. The usual starting dose is 100 mg daily in one or two doses, up to a maximum of 400 mg daily. Monitoring of blood pressure and potassium concentrations is required. Possible adverse effects include hyperkalaemia, polyuria, polydipsia and postural hypotension, particularly at higher doses.

Some clinicians add progesterone to improve breast development. However, evidence is limited, and adverse effects are possible e.g. depression, weight gain and higher lipid levels.

The impact of hormone therapy is variable in transwomen, ranging from breast growth and changes in the body fat distribution, to emotional changes and a decline in libido.

Transmen

Testosterone is the standard masculinising treatment for patients transitioning from female to male (transmen). Usually injections are used. Other formulations are available (tablets, gels and creams), but are generally unsuitable. Tablets don’t achieve adequate concentrations.

Testosterone enantate is given by intramuscular injection every two to three weeks. Some patients can self-inject. A starting dose of 125 mg is titrated up to 250 mg to achieve male physiological concentrations. Transmen may experience cyclical effects of aggression at the beginning of the hormone cycle and fatigue and irritability at the end, in addition to desirable outcomes of deepening of the voice, increased muscle mass and the cessation of menstruation.¹

Alternatively, testosterone undecanoate injections are given in a dose of 1000 mg every 10–12 weeks. Cyclical effects occur, but less frequently. This formulation is associated with a risk of pulmonary microembolism, making it unsuitable for self-injection.

The impacts

In both transmen and transwomen, hormone concentrations are monitored at three month intervals throughout the first year of therapy, and at 6–12 month intervals thereafter. Patients can expect to see changes in the first few months of treatment, and reach a maximum after 3–5 years.

It is recommended that transmen, who still have female reproductive organs and breast tissue, continue to undergo cervical and breast screenings. Similarly, prostate cancer screenings should be discussed with transwomen.¹

Starting treatment after puberty will reverse or regress many primary and secondary sexual characteristics. However some will persist to the extent that reassignment surgery might be sought by some individuals. These therapies are believed to be relatively straightforward and safe, and resemble therapies used for postmenopausal women or hypogonadal men.¹

However, Bryan Bishop, a community pharmacist who has worked extensively with transgender patients, told Pharmacy Today that an understanding of the mechanics of hormone therapy is only one part of the role that healthcare professionals play in supporting transgender patients. Being open to communication with these patients is also an important part of delivering optimal healthcare outcomes.

‘You don’t have to shy away from communicating with a patient. Ask them their preferred name and if they have any preferred pronouns,’ he said.³ 

References:

1. Tomlins L, Prescribing for transgender patients. Aust Presc 2019; 42(1). At: https://www.nps.org.au/australian-prescriber/articles/prescribing-for-transgender-patients#article  
2. Dada C, The gender identity guru. The Pharmaceutical Journal. Epub 2016 Jan 13. At: https://www.pharmaceutical-journal.com/careers-and-jobs/careers-and-jobs/career-qa/how-i-deliver-a-pharmacy-service-for-patients-undergoing-gender-reassignment/20200322.article?firstPass=false  
3. Bonner L. Pharmacists can be accessible trusted providers for transgender patients. Pharm Today 2016;22(3):57. At: https://www.pharmacytoday.org/article/S1042-0991(16)00356-X/fulltext