People have asked for a #tweetorial# on gender-affirming hormone therapy ( #GAHT). I’m by no means an expert but here are some basics! Please respond with any tips of your own; we’re all learning! #tweetorial #gaymedtwitter #familymedtwitter

1/ GAHT refers to use of hormones and hormone blockers to help trans and non-confirming folx transition or affirm their gender. For a brief primer on the term folx, check this out: https://forfolxsake.com/what-does-the-term-folx-mean/

2/ Most of the medicines used for GAHT are relatively familiar. All of these medicines are well-studied in a variety of contexts even though there aren’t as many data in trans and non-confirming folx.

3/ GAHT is a life-saving intervention. Lots of studies support its efficacy for improving a number of conditions that disproportionately affect trans folx including anxiety, depressions and even suicidality.

4/ Many studies specifically show that GAHT is an effective intervention across the lifespan. This includes using medicines to suppress or slow puberty in trans and non-conforming youth.

5/ So who is a candidate for GAHT? Since GAHT is elective and not something that all trans folx want, it’s important to closely weigh the risks and benefits of the medicine with the patient in an informed consent process.

6/ Using informed consent to begin GAHT is supported by many professional societies and university groups including @WPATH, @TheEndoSociety, and @UCSF, all of whom help to set guidelines for using GAHT safely and effectively.

7/ During the informed consent process, we work with our patients to explore any pre-existing medical problems that could make GAHT riskier. If such a risk exists, we work hard to come up with a safe plan that also meets our patient’s goals for their transition.

8/ Previously, physicians would ask trans folx to get a “clearance letter” from a mental health professional before starting GAHT. That expectation was a barrier to care and also implied that trans folx have a mental illness. Most of us consider that process antiquated.

9/ The medicines we use for GAHT are simple. For trans men or patients desiring a masculinizing transition, we use testosterone. Testosterone is often given as a SQ injection every week or every other week. Many patients are able to do this injection themselves.

10/ There are other formulations of testosterone available. Topical formulations (gels, pumps) are less popular. Long-acting formulations are popular and include an IM injection every 10-12 weeks (Aveed) as well as implantable pellets every 12-16 weeks (Testopel).

11/ Patients who take testosterone for masculinization are able to pick a formulation of medicine that is convenient for them. Some patients may switch between formulations at different periods in life depending on what works best for them.

12/ Testosterone is a safe medicine when appropriately monitored and dosed. Two notable adverse effects include polycythemia and worsening of sleep apnea. We review particular risks with each patient in depth before starting the medicine to make sure it’s as safe as possible.

13/ For trans women or patients desiring a feminizing transition, we use a combination of estradiol and an androgen blocker. The most common androgen blocker in the US is spironolactone though many medicines can be used to block androgens.

14/ Most patients who take estradiol for feminization take it as a sublingual tablet once or twice a day. There is also a topical formulation (a patch) and an IM injection. Those are less common but some patients may choose one for convenience.

15/ Estradiol and the androgen blockers are very safe medicines when appropriately monitored and dosed. We pay close attention to risk of blood clots (DVT/PE) as well as cardiovascular disease in patients on estradiol.

16/ For patients with cardiovascular disease or a history of a DVT/PE, there are a number of strategies to keep the patient safe while also offering effective GAHT for their transition.

17/ We personalize GAHT for every patient according to their needs. That can be particularly important for non-binary folx. We check in throughout treatment to make sure that the medicines are working to the patient’s satisfaction.

18/ Since I work in Massachusetts, GAHT is covered by insurance. Most insurances allow you to prescribe the best formulation for your patient with minimal headache and paperwork. It’s much harder in other states.

19/ So if GAHT is so simple, why doesn’t everybody prescribe it? In addition to prejudice, most medical schools and residencies don’t offer much teaching about GAHT. Lots of the clinicians who prescribe GAHT learned to do so after training.

20/ I started to learn about GAHT in residency and continue to learn more about it. Prescribing GAHT to trans and non-conforming folx is absolutely one of the best parts of my job.

21/ Organizations like @WPATH and universities offer online and in-person courses to teach the ins and outs of GAHT. Check one of them out and learn to start prescribing these medicines yourself!