Handout - tg care.pdf

Oral estradiol (e.g., Estrace®), 6 - 8 mg PO or sublingual qD in divided doses; orOral conjugated estrogens (e.g., Premarin®), 5 mg PO qD in divided doses; orTransdermal estradiol (e.g., Vivelle-Dot®), two - 0.1 mg patches changed twice weekly; and Spironolactone (e.g., Aldactone®), 200 - 400 mg PO qD in divided doses.
Typically I start with an “average” dosage of oral estradiol (e.g., 2 mg TID). Six to eight weeks later,I add spironolactone, 100 mg BID. Subsequently I add more estrogen or spironolactone as needed toachieve desired feminization, to eliminate spontaneous erections (a useful index of free testosterone),and to achieve measured serum free testosterone levels in the normal female range. Ordinarily I don’tcheck serum estradiol levels; if obtained, I like to see levels approximately one-third to one-half ofthe normal female midcycle peak.
Most of my patients receive oral estradiol. I typically prescribe transdermal estradiol for patients overage 40, for smokers, and for those with other cardiovascular risk factors. I do not ordinarily prescribeinjectable estrogen, progesterone, or synthetic progestins for my male-to-female patients.
After orchiectomy or sex reassignment surgery, anti-androgens can be discontinued and estrogen canbe decreased to one quarter to one half of the preoperative dosage.
Testosterone enanthate (e.g., Delatestryl®) or cypionate (Depo-Testosterone®), 75 - 100 mg IM q week or 150-200 mg IM q 2 weeks; orTransdermal testosterone patch (Androderm®), 5 – 7.5 mg, changed daily; orTransdermal testosterone gel (Androgel®), 5 – 10 mg, applied daily.
Injecting smaller doses of testosterone weekly often results in better subjective satisfaction. Cessationof menses and masculinization are much slower with transdermal testosterone and transdermaltestosterone is much more expensive.
After ovariectomy, androgen can often be decreased to one-half or less of the pre-op dosage.
Free testosterone, fasting glucose, liver function tests, and complete blood count – pretreatment, at 6and 12 months, and yearly thereafter. An estradiol level may occasionally be helpful if feminizationappears to be inadequate. Prolactin levels are obtained pretreatment and at 1, 2, and 3 years. Ifhyperprolactinemia does not occur during this time, no further measurements are necessary.
Fasting lipid profile, liver function tests, and complete blood count – pretreatment, at 6 and 12months, and yearly thereafter. Trough testosterone levels may occasionally be useful, but normalmale levels of testosterone vary widely. Patients who have not had hysterectomy need periodic Papsmears and possibly ultrasound examinations to detect endometrial hyperplasia. Hysterectomy andovariectomy are recommended after satisfaction with testosterone therapy has been demonstrated.
Anne A. Lawrence, M.D., Ph.D. December 2004

Source: http://www.annelawrence.com/tgcare.pdf

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