Message

From: Apple, Dionne [/O=EXCHANGELABS/OU=EXCHANGE ADMINISTRATIVE GROUP

(FYDIBOHF23SPDLT)/CN=RECIPIENTS/CN=67799012E36842DBA8F8341D404E8F4C-TIFFANY DIO]
Sent: 3/27/2023 7:32:19 PM
To: Fammed Faculty [/o=ExchangeLabs/ou=Exchange Administrative Group
(FYDIBOHF23SPDLT)/cn=Recipients/cn=el9abac5ea4f4e51a07a5abc8d8225de-Fammed_Facu]
Subject: Education Meeting Slides and Link
Attachments: GAC for Faculty.pdf

Good afternoon everyone,

Attached are the slides from Riley and Rupal's session on "Updates in Gender Affirming Care" from last Wednesday's
education meeting.

The recording can be viewed by using the link below.

Itttlps;:; uttcch.hosted.panopto.cp!xt Partopto/Paged-!Vi e.r.aspx'?id:-d29592 466-4c.l.l-bO2a-afcdOI054f1l.

Best regards,
Dionne
(She/heUhers)
Executive .Assistant to Margaret R. Helton, MID
Chair, Department of Family Medicine
Direct Line: 984-974-4990
UNC-Chapel Hill I.)epartment of Family Medicine
1
1
1
1
1
1

pq
1
1

pq
1
Patient meets at least two of tlx: following criteria for Gender Dysphoria, with distress with an impact on important
reas of their life, (Yes/No 11203)
Noticeable incongruence between gender that the patient sees themselves as and their sex characlenstics.
An intense need to do away with (or prevent) primary,secondary sex features
An intense desire to have the primary andror secondary sex features of the other gender
A deep desire to transform into another gender
A profound need for society to treat them as someone of the other gender
A powerful assurance of having the characteristic feelings and responses of the other gender
T ULC 1A: EFFMrS AND E%RECYtt) Yt b CCk1RSE 3F MMASC::ttiirlp*G HOtM3P1tS'
Efred Expected onset Expected matt4tyt{{Yn effect
Effect Expected onset Expected maximum effect
Body fat reds;r:bulor 3-6 mnnths
l:ii oil:ness/acne I-6 months 1 2 yeers: . Decreased muscle mass;
6 months
stterglh
Facial/bod? hair growth 3-6 months, 3-.3 years Softening orskir.deceased
3 6 months
olitness
Scalp hair loss >12 months ix rahTe' Decreased lit•ido 1-3 months

Inrreasad muffle rnaesestrengtl; 6-12 months w2 ;Syg;1t>' Decreased sporraneous

1-3 months
erections
Body r t redistribution 3-6 months 2- ,ears Male sexual dysfi:nctior: Variable

Cessation of rnenses 2-6 months ttPa Breast growth 3-6 murrthr•

Clitoral enla gement 3-6 months -2 years Decreased testiraiar volume 3-6 months

Decreased sperm produn cn Va}table

Vagtrai.:trophy 3-15 months 1:2;c&rs
fhimmng and slowed growth of
Y? nwrths
Deepened voice 3-12 months €€ 1 x vexes body and faoal stair
—.........—............... _...... ..._...
i
No eegrorrth, lass
Male pattern baldness
Mapted vmh pmaesbn from H4r.:xe Qt ai.;71NH1. C.4 i5i.; 1M),'! ha Eadavine S+n .tr
stone 1._3 months
a Esbmans opnnentpabtaheda:d arrsbrishnd Inca: Wsave,er.
' Ae.puedwdr pvmessb: dcm.I:eo.Yee a al iXlN!. tmrag+r 2X5• T`e txee nr .en.,.
` H:ghlr deaendent oe ade and Irwdtwur: r. ,Y be nxrxrc.d
eone p4 itblsr; us:.::~J.4 1 .4 emw} ebsonrc::,.
r' S-gdEcrr.H/ drperd.nt on tine m l t.i one: if:
. ,r+nr rermst 4 ,,,.ge fsn> aei'mt, kpr , !'rx aby : iy(:..Inn t«sr.:arvr ^r .VP
 1

Table 2. Risks associated with gender affirming hormone

therapy (bolded items are clinically significant) (Updated
from SOC-7)
Testosterone-based
RISK LEVEL Estrogen-based regimens regimens
Likely increased Venous Polycythemia
risk Thromboembolism Infertility
Infertility Acne
hyperkalemia' Androgenic Alopecia
Hypertrigyceridemia Hypertension
Weight Gain Sleep Apnea
Weight Gain
Decreased HDL Cholesterol
and increased LDL
Cholesterol
Likely increased Cardiovascular Disease Cardiovascular Disease
risk with Cerebrovascular Disease Hypertriglyceridemia
presence of Meningioma`
additional Polyur€a/Dehydration'
risk factors Cholelithiasis
Possible Hypertension
increased risk Erectile Dysfunction
Possible Type 2 Diabetes Type 2 Diabetes
Increased Low Bone Mass/ Cardiovascular Disease
risk with Osteoporosis
presence of Hyperprolactinemia
additional
risk factors
No increased Breast and Prostate Low Bone Mass/
risk or Cancer Osteoporosis
inconclusive Breast, Cervical, Ovarian,
Uterine Cancer
ccyproterone-based regimen
Sspironolactone-based regimen
1
 kiUNTLOGC
UNC F ltyinewdne

scusslon Guide for Gander Affirming Estrogen and Androgen Blockers

What is informed consent?

Before starting hormone treatrrrent, it is important to understand the possible benefits, risks, warning signs,
and :alternatives. Agreeing to start hormone treatment once you know all of the benefits; risks, warning
,signs; and alternatives, and have had all of your questions answered, is called informed consent.

Wilaf medications can feminize physical appearance?

Pad of transition for many t€ansgenrder and gender diverse people involves taking hormones. Most people who
were assigned male at birth who desire fen inizing medication take estrogen (;feminizing hormone) and androgen
blockers to prevent their body from producing or utilizing testosterone (rrmsculinedng hormone). You may want to
take these medications to feminize your body, to appear more androgynous, or to feel more comfortable in your
lived gender.

What Is esregen and how is It taken?

Estrogen is a sex hormone that found is almost all bodies. Different forms of the hormone estrogen are used to
change your appearance and how you feet. Estrogen can be given as a patch (which is changed once or twice
a week)_ an in ection (weekly or every other week), or as a pill (daily or twice a day. Estradiol is the form of
estrogen horntone that is prescribed for gender affirming care. Some trans and gender diverse people choose
to take esiradiol and others do not. The choice is based on personal preference and the desired benefits of the
hormone.

What are androgen Mockers and how they taken?

Medications that block the production or effects of testosterone are called androgen Mockers. Androgen is
another term for masculine sex hormones like testosterone. Spironolactone is the androgen blacker that is most
commonly used in the US. it s a pill that you swallow oncee or to ce a day. Other medicines are sometimes
used, but because spironolaclore is relatively safe, inexpensive, and effective, it is the primary androgen
blacker.
@ASSESSMENTPL.ANBEGIN
@PREFERREDNAME@ is a @AGE@@SEX@ who presents to discuss initiation of gender-affirming care.

Attending: Dr. ***

# Gender-affirming care
Preferred name PREFERREDFIRSTNAME@, pronouns: ***, It is my assessment that
@PREFERREDFIRSTNAME@ meets DSM criteria for gender dysphoria. Reviewed risks, complications and side
effects associated with the use of hormone therapy including, but not limited to effects of feminizing hormones and
changes in fertility, and provided written handout with further information. "*Patient has reviewed this and consents
to proceed with feminizing hormone therapy. Informed that their insurance may require prior authorization. Labs
drawn today for baseline levels and will review prior to hormone initiation.
- Baseline labs today:
- BIM prior to Spironolactone
- ***Plan to send feminizing hormone therapy if baseline labs appropriate:.
- Estradiol ***
- Spironolactone *** mg
- Resources provided in AVS
1
1
 .. ......_
" ~ 'JMiatSRY{un Sf RVltY-

Gender Affirming
Hormone Therapy
... ...
T Guidelines
... ._ ... . _. _._...._
T RA J SL E ........... ... ....

aesxsw :
M.wfa
~e.:m xszx ct.

Ei 'r ..
.. . . . +n.V w ewe
•

E.

o ..... ....... ......

..... ..... q
i iii ::q ....«
as :r •:::« i~roR4: wareVesd ... K I

•~. rw~maro
?IGd s'pi11p5eii ww y<m _ .y
-.v eeN.wu +̀iA +Rp
'.: »<xwp rry xxracwwr ~'°.W
Si di!

EE.f<dlX.~;M+. •x '.. '.. ...

~vsg ......:::';y??Nw :::... :::.... .:::Rhw r+a
iiiil!!!R+,@ :::::::::::::::: ::::::::::r• :: ..............w •:::iiii: ::::::::::m:::: ::::::::::::::::: iiii i:::_::'}n iwa

mRi xb~i<.~•m:u~.•~w«+av~eeMwtwan~mwar..vear~ i..e~ex~en.n~Ma'

` s àve~i :iaea.aroa~M'aimli a:.ww:.tre->s n.~iF~i.~iwer~x~~ena ~~oewr.z»ne ~wr
L.
1
 1

# Gender-affirming care - nrasculinizing hormone therapy

Preferred name @PR.EFERR.EDFIRSTNAi 1E@: pronoun<: I "- Pt has been doing well on current dose, and is
satisfied with changes. Physical changes since last visit indude """. Ert~.ntiondllsacial changes include "". Medical
concerns include """. Denies' chest pain, shortness of breath, headache, vision changes, or any other new
symptoms.
Current testosterone regimen:
Labs: tt&H or CPC, total testosterone at 3, 6, and 12 months, then annually thereafter
Add CMP or lipids if cli=nical concern for liver disease or hypertipids a
Aim for testosterone in mid-physiologic range fords mole (300_;00)
Goal hematocrit <55. If elevated, will ensure patient is well hydrated and recheck If persistently elevated,
will evaluate for pulmonary disease (OSA, tobacco use), would then consider lower dosing, more frequent dosing,
and,'ar transderar:,al administration
Follow-up in three months, repeat labs at that time
Injection supplies 13 gauge needle to draw, 1-5 mL syringe; 23 gauge for IM, 25 for SQ- (muse GAC order set In
Vi nay's preference list)
.. PrEP eligibility: >sh (it patient is eligible)inlerested in PrEP, add this as a separate problem below, and use dotphrase
FMCPREPSTART)
- G traception: """`
1
1
1
 1

• • •
w • .• fit` ~•" • • # • ~►

"Anyone with a cervix should have a pap smear every 3-5 years" or "Guys who have a cervix should still
,"
be screened for cervical cancer instead o "You still have your cervix, so you need pap smears regularly"
 1

General Chosen name Pregnancy Documentation of pregnancy r€sk/contraception status

Information (AFAB)
Pronouns De~avment in Epic or note. consr~tentin notr
Prescriptions Estrogen not above max: 8mg Pit tally, 400mcg transdermal,
"Gender story" first visit only 2Cmg IM weeldy (EV) 2.5ma IM weeidy (EC) or documented w/
appropriate fobs
Diagnosis Note clearly states patient meets criteria for Gender
Dysphoria first visit only Spironolactone not above max 200mg BID

Consent Consent documented verbalorwhiten

Stop Spiro post-orchiectomy
Labs For Testosterone:
• Baseline CBC Testosterone not above max: 100c wk
• Testosterone and CSC q3 months for first year,
after dose changes Health Pap (AFAB) Or documented
• Annual CBC Maintenance Mammography (AFAi )ordoeumented
• HCT (55 orpfan documented Mammography (AIAB) ordocumiented
• Testosterone 200.1000 or plan documiented
Follow up Every 3 months for first year (appt scheduled, documnentedin
For Estradiol/spiro: note, or in A's)
• Baseline SMP prior to spiro
• Test, Estradiol, BMP q3 months for first year.
after dose changes
• Annual BIM while on spiro
• K < 5,0 or plan documented
• Estrogen 50-400 or plan documented
1
1
1
1
Figure 1. Approach to management of estrogen in patients with a personal history
of VTE

This figure outlines the estrogen management approaches for patients with a personal
history of VTE.
1