It has now been recognised that there has been a rapid increase in demand for clinical services in this area and Lothian GPs have previously received guidance on safe approaches from the Lothian GP Sub-Committee. This is available on the intranet.
Lothian Gender Dysphoria / Incongruence Endocrine Treatment Shared Care Agreements (SCAs).
There are now two Lothian SCAs for gender dysphoria/incongruence on the East Formulary website, and the Chalmers arrangements to support these will start on 11th November 2024. They refer to prescribing after assessment at the Gender Identity Clinic (GIC) for those aged over 18:
- Feminising Endocrine Treatment (Estradiol and GnRHa)
- Masculinising Endocrine Treatment (Testosterone).
In summary, the GIC undertakes full assessment and treatment counselling / consent, and, where appropriate, will then ask GPs to prescribe endocrine treatment. The GIC will recall patients in line with the SCA protocol and undertake any tests or other monitoring required. The exception, agreed with the GP Sub-Committee, is bloods for those on testosterone injections, where these have to be taken immediately pre-dose. Those on hormonal treatment will also be offered a review at GIC: for suitable low risk patients, that may be through Patient Initiated Followup (PIFU). Chalmers GIC will then write to the GP to advise about ongoing prescribing.
GPs do not need to refer patients already on treatment and known to the service but should refer those wanting to be assessed for their gender identity, or on treatment newly moving into Lothian. There is a SCI Gateway e-advice option, too.
ADDITIONAL MEDICATION SAFETY WARNINGS
Topical testosterone safety warning.
Premature puberty and genital enlargement have been reported in children who were in close physical contact with an adult using topical testosterone and who were repeatedly accidentally exposed to this medicine. To reduce these risks, advise patients to wash their hands after application of topical testosterone, cover the application site with clothing once the product has dried, and wash the application site before physical contact with another adult or child.
Further information can be found on the MHRA Jan 2023 update (page 6).
Testosterone and avoiding conception.
Testosterone is not contraceptive and is teratogenic. Therefore, transmen and non-binary people using testosterone should be using effective contraception if they are sexually active. Apart from combined hormonal contraception, all methods of hormonal and non-hormonal contraception can be used whilst someone is taking testosterone.
Please see the FSRH Clinical effectiveness Unit guidelines on contraceptive choices and sexual health for transgender and non-binary people.
Cyproterone acetate and risk of meningioma
Some patients prefer cyproterone acetate as an antiandrogen and some private providers may recommend using it. There is a dose-dependent association with cyproterone acetate and meningioma. The risk increases with increasing cumulative dose. It is contraindicated in patients with a meningioma or a history of meningioma. If someone treated with cyproterone acetate develops a meningioma it must be permanently stopped.
GPs are not expected to undertake any monitoring.
Further information can be found at: Cyproterone acetate: new advice to minimise risk of meningioma.
Medication Shortages
There are occasional shortages of hormone treatments. Any shortages and recommended substitutions are posted on the GIC section of Lothian sexual health website.
Frequently Asked Questions:
The service is always happy to provide advice and can be contacted via Chalmers Gender Identity SCI Gateway advice.
Will the NHS provide fertility preservation for patients who have obtained treatment privately?
Patients are entitled to NHS fertility preservation once they have been assessed by the clinic as suitable for hormone treatment. The specialist service can make a referral after discussion with patients. If people want to preserve their fertility before being seen at the gender clinic they need to do it privately.
It is helpful to give patients the link to information about fertility preservation for trans and non-binary people.
My patient is self-prescribing; how can I support them?
It is well-established that at their first gender clinic visit, a significant number of transgender people will already be taking hormones bought online or from someone else. In the UK surveys suggest that the main reason for doing so is the long wait for assessment and treatment. The dangers of DIY hormones range from minor to serious. Even buying hormones from an online pharmacy is risky.
We recommend that you explore your patients understanding of hormone use and the safety issues round them.
Should I prescribe progesterone as requested by my patient who is a trans woman?
Chalmers GIC follows the guidance from NHS National services Scotland ‘Endocrine and fertility preservation guidance’. This states that progesterone is not recommended for transwomen. There is only anecdotal evidence and a few opinion pieces recommending it. There are risks including possible increased risk of breast cancer and cardiovascular disease and side effects including mood changes.
How do I stop periods in transmen and non-binary people before they start testosterone?
Often transmen are distressed by their periods and may require medical intervention to reduce or stop menstruation whilst they are awaiting their initial assessment. The investigation and management of abnormal uterine bleeding in transmen not on testosterone is the same as for cis females. However, transmen may find pelvic examinations and transvaginal ultrasound scans distressing and clinicians should be sensitive to this. Although combined hormonal contraception can be effective at managing bleeding problems, some transmen may not wish to use this method as it contains oestrogen.
The progesterone only pill is often used (desogestrel 75 micrograms once daily) but there is a risk of unpredictable bleeding. Depot or implant progestogens (usual contraceptive doses) and the IUS are also options, but bleeding may take 3 – 6 months to settle down.
Once someone is established on testosterone, periods should stop, usually within 6 -12 months.
C.M. & F.C. 06-11-24
