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Even after fve years had passed spasms stomach area order pletal 50mg without prescription, and the listed on page 8 along with some practical tips from other women women were no longer taking any hormone therapies spasms near ovary buy pletal 100mg overnight delivery, the women and health professionals on how to spasms pain rib cage order pletal 100 mg with visa manage them spasms esophageal buy pletal 100mg without a prescription. This means that the benefcial efects of hormone therapy are ongoing and will last well beyond the fve years you take them. Recent clinical trials have also shown that, for some women, taking tamoxifen for 10 years provides even further protection against breast cancer recurring. Your medical oncologist will be able to talk to you about whether taking tamoxifen for more than fve years could be of beneft to you. Research is currently underway to see whether taking an aromatase inhibitor for 10 years is also better than fve years. If the thought of another fve years of hormone therapy is distressing for you, you may like to talk to your medical oncologist about the possibility of taking a three-month break from treatment for each of those fve years. A recent clinical trial found that women who were post-menopausal and who had taken tamoxifen, an aromatase inhibitor or both (one after the other) continuously for fve years could safely take a three-month break from treatment each year for the next fve years. The side efects were less severe in some women sweating, a rapid heartbeat, and anxiety or nausea. Hot fushes can be very uncomfortable and frustrating as they Despite these promising results, it’s important not to stop taking can interfere with your sleep and compromise your quality of life. Hot fushes can also afect your mood and can leave you feeling Your doctor will be able to give you the best advice on what is irritable and tired. Side efects of hormone therapy We don’t need menopause symptoms again, but we don’t the hot fushes were a challenge for a while, but by layering my need the alternative – cancer – either! Thankfully, I now only experience them very Many women experience menopausal-like symptoms when taking occasionally. If you are experiencing hot fushes, some helpful suggestions include: If you do experience side efects and are fnding it difcult to cope, there are ways you can manage them. If the practical strategies • Wear loose cotton clothing to allow your skin to breathe. Turn the pillow appointment with you, or you can seek a second opinion from over during a hot fush to cool your face. I took tamoxifen for fve years and then Femara for another • Avoid anything that triggers your hot fushes, such as hot spicy fve. These include a low-dose antidepressant such as venlafaxine (Efexor) or other similar antidepressants, or other drugs including clonidine (Catapress) and gabapentin (Neurontin, Pendine). Clonidine is generally Complementary medicines used to treat high blood pressure, but can be used to reduce There are a number of complementary medicines, health menopause-related hot fushes after breast cancer. Gabapentin is supplements and foods that are promoted as useful in managing used to treat chronic pain. Let your doctor know if you are taking tamoxifen as some in clinical trials, and some may interfere with your breast cancer antidepressants, especially paroxetine (Aropax) and fuoxetine treatments. If you have private health insurance, your fund may provide you Bio-identical hormones are lozenges, troches or creams prepared with a rebate so it’s worth checking with them. As they are classifed as foodstufs they are as Replens (a low-pH gel), which is available from pharmacies, not covered by drug regulations or clinical trials. When breast cancer is not known and their efectiveness in reducing hot applied directly to the vagina, vaginal moisturisers help replenish fushes has not been proven. Vaginal moisturisers are designed Herbal therapies such as ginseng, passionfower, valerian, chaste to be applied twice a week, but can be used more or less tree, St John’s Wort, black cohosh and gingko are also used by frequently as necessary. Opinion is It’s important to be aware that while vaginal moisturisers can divided as to whether they are safe to use after breast cancer. They are likely to take around six to Some, such as St John’s Wort, can reduce the efectiveness of eight weeks to be fully efective. Vaginal oestrogens are commonly prescribed to treat vaginal dryness in women who have not had breast cancer. However, Before taking any herbal therapy or over-the-counter herbal doctors are cautious about prescribing vaginal oestrogens to product, it is important to speak to your medical oncologist as women who have had breast cancer, particularly those women some products can interfere with breast cancer treatments. These creams You can fnd more information about potential interactions or vaginal tablets contain low doses of oestrogen, which may be between herbs and cancer medicines at the Memorial Sloan absorbed into the body at low levels. You may like to discuss with Kettering Cancer Centre’s About Herbs website, mskcc. While some studies have shown the therapy improves In recent clinical trials, cognitive behaviour therapy has been symptoms, further research is needed to determine its benefts and shown to reduce the impact of hot fushes, reduce anxiety and whether it is safe. You might like to talk to your cancer specialist if improve sleep after breast cancer. Vaginal lubricants can be used in sexual foreplay immediately before and during sex to provide lubrication, and to Alternative therapies reduce pain and discomfort from dryness. If you are prone to vaginal thrush, use water-based Vaginal symptoms lubricants as lubricants with high levels of glycerine or silicone may Hormone therapies may cause vaginal dryness, discharge, itch cause recurring vaginal thrush. Many women may also experience some of these symptoms as they go through menopause. Although it may be a Ospemifene is an oral drug sometimes used to treat painful difcult topic to discuss openly with your doctor, in most cases intercourse. Details on how to order a copy are at the back of this the menopausal symptoms do settle down after a while. Thinning hair and nails Some women who take hormone therapy fnd that their hair and/ Sure, my joints are a bit stif when I start to move. It is often difcult to know for sure whether But once I’m up and moving they feel so much better. If If you are taking an aromatase inhibitor, you may fnd that you you experience hair and/or nail thinning, you may like to try some experience some joint stifness and/or pain. Over-the-counter of these suggestions from women who found them helpful: drugs such as paracetamol, ibuprofen or Voltaren may help you. If you are undergoing chemotherapy, seek the • Dry your hair naturally or use a cool setting on the hair dryer. Joint stifness most commonly occurs in the morning, but it does • Protect your head and scalp from the sun. Some of the common exercises women fnd helpful include • If you colour your hair, ask your hairdresser to use/recommend hydrotherapy (exercise in a heated pool), swimming, tai chi and a vegetable hair colour rather than a chemical dye. If exercise is new to you, the good news is you can begin at any • Apply a nail strengthener, such as Revitanail, regularly. It’s important to start exercising slowly, and gradually build • Use nail polish remover that does not contain acetone. There may be times when you don’t feel like exercising, and during these times it is okay to give yourself a break. If you are feeling fatigued, it can help to make sure you: Aromatase inhibitors • stay hydrated by drinking plenty of water Aromatase inhibitors can cause loss of bone density, or thinning • incorporate some exercise into your day of the bones, which may increase your risk of bone fractures • eat a healthy, well-balanced diet and developing osteoporosis. Your doctor may want to assess your bone mineral density (strength and thickness) with a scan, • take some time to rest between activities. Your bone nights: breast cancer and sleep provides a range of tips and mineral density may also be re-checked around every two years strategies if you are having trouble sleeping. Details on how to while you are taking an aromatase inhibitor, but this will depend on order a copy are at the back of this booklet. Long-term side efects of hormone therapy I knew that osteoporosis was a risk factor when I made the decision to take an aromatase inhibitor. I do what I can to As with many drugs, there are some long-term side efects of minimise the risk, such as walking, watching my weight, eating hormone therapies that you may like to keep in mind. You can calcium-rich foods and having regular checks for my vitamin D discuss them with your doctor if you have concerns. Tamoxifen If you are concerned about bone thinning, it can help to make Tamoxifen can very slightly increase your risk of blood clotting. The If you have had blood clots before, or think you are at risk of amount of sun needed to maintain adequate vitamin D levels will developing them, it is important to let your doctor know about vary according to your location, the season and the time of day. You may also like to take simple precautions, such as wearing Generally, you can get enough vitamin D by exposing your arms to compression stockings (available from pharmacies) if you are the sun for fve to seven minutes mid-morning or mid-afternoon in going to be immobile for a long period of time, for example, when the warmer months and fve to 30 minutes at noon in the cooler travelling on long-haul fights. Good sources of vitamin D are fresh and tinned fsh (tuna, salmon, sardines, herring and mackerel). There are also some foods There is also a very small risk that tamoxifen will afect the lining that have vitamin D added to them, such as margarine and some of the uterus. While types of milk, cheese and yoghurt, however, the amounts are not this may sound scary, the benefts of taking tamoxifen far exceed high enough to meet daily requirements. If you have unexpected vaginal bleeding while Calcium is found in dairy products such as milk, yogurt and taking tamoxifen, let your doctor know.

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The following guide is designed to muscle relaxant reversals order 50 mg pletal amex help readers find the sections that will be most this guideline summarizes the specific approaches to muscle relaxant potency pletal 100mg discount useful to spasms that cause coughing generic pletal 50 mg on-line them muscle relaxant zanaflex order pletal 50 mg mastercard. The treatment recommendations that tion and implementation of a treatment plan for the follow may also have some relevance for patients who individual patient. Psychiatric management Psychiatric management consists of a broad array of interc. Management of the therapeutic allibehavior; delineation of current stressors and potential ance should include awareness of transference and counterprotective factors. In addition to assessing suiliance or nonadherence to treatment may be caused by the cide risk per se, it is important to assess the patient’s level depressive symptoms themselves or may represent psyof self-care, hydration, and nutrition, each of which can be chological conflicts or psychopathology for which psychocompromised by severe depressive symptoms [I]. An evaluation of the impact of the depression der, identify other psychiatric or general medical conditions on the patient’s ability to care for dependents is an importhat may require attention, and develop a comprehensive tant component of the safety evaluation [I]. This evaluation generally includes a risk of harm to himor herself and to others should also be history of the present illness and current symptoms; a psymonitored as treatment proceeds [I]. Establish the appropriate setting for treatment uation has been done [I], either by the psychiatrist or by the psychiatrist should determine the least restrictive another health care professional. Monitor the patient’s psychiatric status sideration of the patient’s symptom severity, co-occurring the patient’s response to treatment should be carefully psychiatric or general medical conditions, available support monitored [I]. Integrate measurements into psychiatric management Measures such as hospitalization should be considered for Tailoring the treatment plan to match the needs of the patients who pose a serious threat of harm to themselves particular patient requires a careful and systematic assessor others [I]. Education about the symptoms and treatment of major depressive disorder should be provided in language that is f. Coordinate the patient’s care with other clinicians readily understandable to the patient [I]. If more than one tion about the illness, its effects on functioning (including clinician is involved in providing the care, all treating clifamily and other interpersonal relationships), and its treatnicians should have sufficient ongoing contact with the ment [I]. In addition, nated, relevant information is available to guide treatment education about major depressive disorder should address decisions, and treatments are synchronized [I]. Practice Guideline for the Treatment of Patients With Major Depressive Disorder, Third Edition 17 of complications or a full-blown episode of major depresto patients who do not respond to other treatments [I], sion [I]. Patients should also be told about the need to given the necessity for dietary restrictions with these medtaper antidepressants, rather than discontinuing them ications and the potential for deleterious drug-drug interprecipitously, to minimize the risk of withdrawal sympactions. Choice of an initial treatment modality carefully and systematically monitored on a regular basis Treatment in the acute phase should be aimed at inducing to assess their response to pharmacotherapy, identify the remission of the major depressive episode and achieving a emergence of side effects. Selection of an initial treatment motion with treatment, availability of social supports, and the dality should be influenced by clinical features. If antidepressant side effects do occur, an initial or psychosocial stressors) as well as other factors. Pharmacotherapy tients with severe major depressive disorder that is not reAn antidepressant medication is recommended as an inisponsive to psychotherapeutic and/or pharmacological tial treatment choice for patients with mild to moderate interventions, particularly in those who have significant major depressive disorder [I] and definitely should be profunctional impairment or have not responded to numervided for those with severe major depressive disorder unous medication trials [I]. Because the effectiveness of antiindividuals with major depressive disorder who have assodepressant medications is generally comparable between ciated psychotic or catatonic features [I], for those with an classes and within classes of medications, the initial selecurgent need for response. Considertreatment is often associated with poor functional outations in the choice of a specific type of psychotherapy incomes. For patients in psycarefully and systematically monitored on a regular basis to chotherapy, additional factors to be assessed include the assess their response to treatment and assess patient safety frequency of sessions and whether the specific approach [I]. Psychotherapy plus antidepressant medication A number of strategies are available when a change in the combination of psychotherapy and antidepressant the treatment plan seems necessary. For patients treated medication may be used as an initial treatment for patients with an antidepressant, optimizing the medication dose is with moderate to severe major depressive disorder [I]. To prevent a relapse of Due to the risk of recurrence, patients should be mondepression in the continuation phase, depression-focused itored systematically and at regular intervals during the psychotherapy is recommended [I], with the best evidence maintenance phase [I]. Discontinuation of treatment sis, turning to reduce risks of decubitus ulcers, and passive When pharmacotherapy is being discontinued, it is best range of motion to reduce risk of contractures [I]. Bencontinuing antidepressants or reducing antidepressant zodiazepines may be used adjunctively in individuals with doses. Factors that suggest a need for antidevance of the final session [I], although the exact process by pressant treatment soon after cessation of substance use which this occurs will vary with the type of therapy. Because the symptoms of some of a co-occurring substance use disorder, and past and famwomen may fluctuate with gonadal hormone levels, the ily history of suicidal behavior [I]. Family history of a response therapy, or for those with a prior positive response to to a particular antidepressant may sometimes help in psychotherapy [I]. ElectroFor patients who have experienced a recent bereaveconvulsive therapy may be considered for the treatment of ment, psychotherapy or antidepressant treatment should depression during pregnancy in patients who have psybe used when the reaction to a loss is particularly prochotic or catatonic features, whose symptoms are severe longed or accompanied by significant psychopathology or have not responded to medications, or who prefer treatand functional impairment [I]. The evaluation should also assess parenting skills cians who are providing treatment for general medical for the newborn and for other children in the patient’s conditions is recommended [I]. In other respects, treatment for depression should parpsychiatric condition [I]. In patients with preexisting hypertension or cardiac the assessment and treatment of major depressive disconditions, treatment with specific antidepressant agents order should consider the impact of language barriers, as may suggest a need for monitoring of vital signs or carwell as cultural variables that may influence symptom prediac rhythm. In cations should be cautioned about drug-drug interactions treating the depressive syndrome that commonly occurs with St. In patients with hepatitis C infection, potential for interactions between antidepressants and interferon can exacerbate depressive symptoms, making anticoagulating (including antiplatelet) medications [I]. In addition, the psyric management includes a broad array of possible interchiatrist must determine the treatment setting that will be ventions and activities. Essential components include most likely to enhance the patient’s safety as well as proeducating the patient and when appropriate the family mote improvement in the patient’s condition. These eleabout depression, discussing treatment options and interments of psychiatric management are described in more ventions, and enhancing adherence to treatment. The general principles and regardless of the treatment modalities ultimately selected. To establish and maintain a therapeutic alhistory of the present illness and current symptoms, inliance, it is important for the psychiatrist to be sensitive to cluding vegetative symptoms and symptoms of mania or the patient’s concerns. They notes current treatments, responses to previous treatmay feel unworthy of help, embarrassed or ashamed of ments, past hospitalizations or suicide attempts, and the having an illness, guilty about placing burdens on family presence of co-occurring psychiatric disorders. Such issues require open discussion to educate Many individuals with depression attempt to alleviate the patient about the goals and framework of treatment symptoms through the use of alternative or complemenand to provide an empathic and trusting environment in tary treatments, over-the-counter or prescription medicawhich the patient feels comfortable expressing his or her tions or dietary regimens, or through use of caffeine, self-doubts, fears, and other concerns. Consequently, sive illness, his or her receptiveness to psychiatric treatment, each of these factors should be carefully assessed. Management of the therapeutic alliance ing physical, sexual, or emotional abuse or neglect; detershould also include awareness of transference and countermination of responses to life transitions, major life events, transference issues, even if these are not directly addressed or significant traumas; a social history; and an occupational in treatment. Co-occurBecause patients frequently have strong preferences ring general medical conditions are common and can inabout treatment options, the psychiatrist should identify fluence the diagnosis of major depressive disorder as well the patient’s wishes for treatment and collaborate with the as choices of treatment. Thus, a general medical history is patient in choosing among effective treatments. They may status examination is crucial in identifying signs of depresalso represent psychological conflicts or a psychopathosion, associated psychosis, cognitive deficits, and factors logical condition for which psychotherapy should be coninfluencing suicide risk. Complete the psychiatric assessment in order to determine the impact of the patient’s condition Patients with symptoms of depression should receive a on his or her family. Following a stressor, depressive sympvolves the collection of the family pedigree including partoms that do not reach sufficient number or severity to be ents, grandparents, and number and sex of siblings and classified as a major depressive episode may be better dechildren. Despite the possible on their symptom state may be useful because of the high presence of antecedent stressors, psychiatrists should not possibility of psychiatric problems in the offspring of a dedismiss potentially disabling depressive symptoms as “norpressed parent (11, 12). Major depressive disunusual behaviors in the patient’s relatives along with any order may be associated with mood-congruent and moodassociated impairments. Depressive symptoms that would otherwise be All patients who present for treatment for a major dediagnosable as major depressive disorder are diagnosed pressive episode should be screened for a past history of instead as a mood disorder due to a general medical conmanic or hypomanic episodes and for past adverse reacdition if the mood disturbance is judged to be the direct tions to antidepressants that might be consistent with a physiological consequence of a specific general medical con“switch” into hypomania or mania. Clinical assessment should also include whether or pressive symptoms, should be explored in the course of a not the patient is experiencing a mixed episode, which is psychiatric assessment. Factors to Consider in Assessing Suicide Risk “double depression” (dysthymic disorder and major deLifetime history, nature, seriousness, and number of pressive disorder), and major depressive disorder with the previous attempts and aborted attempts “chronic” specifier—are all depressions with a duration of Presence, history, and lethality of suicidal ideation, at least 2 years. However, despite a smaller response rate self-esteem, narcissistic vulnerability and slower response, it is important to recognize that Presence of severe anxiety, panic attacks, agitation, chronic depression is not treatment refractory (20). Nature of cognition, such as loss of executive function, the presence of a family history of a mood disorder thought constriction (tunnel vision), polarized should also be determined. The psychiatrist should evaluate the presence of suicidal ideation and behaviors, the extent Demographic features, such as age, race, marital status, to which the patient has made plans for or begun to prepare sexual orientation for suicide, the availability and lethality of the means for Presence of acute or chronic psychosocial stressors, which suicide, and the degree to which the patient intends to act may include actual or perceived interpersonal losses, on suicidal plans. A suicide risk assessment should be individualized History of childhood traumas, particularly sexual and to the particular circumstances of the patient by including physical abuse an evaluation of the patient’s strengths, motivation to seek Family history of or recent exposure to suicide help, social support systems, and physical health. The assessment of suicide risk is complicated should also include consideration of the patient’s ability to by the fact that suicidal individuals often conceal their adequately care for himor herself, provide reliable feedthoughts and plans or act impulsively on short-lived suiback to the psychiatrist, and cooperate with treatment of cidal thoughts, making their response to direct questions the major depressive disorder. For this Patients with suicidal or homicidal ideation, intention, reason, in addition to using direct questioning, the psychior plans require close monitoring.

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June 17 spasms the movie pletal 50mg line, 2016 48 Guidelines for the Primary and Gender-Affirming Care of Transgender and Gender Nonbinary People 8 spasms medication pletal 50 mg amex. General effects include the development of facial hair muscle relaxant 10mg purchase 100mg pletal fast delivery, virilizing changes in voice muscle relaxant non prescription buy pletal 50mg mastercard, a redistribution of facial and body subcutaneous fat, increased muscle mass, increased body hair, change in sweat and odor patterns, frontal and temporal hairline recession, and possibly male pattern baldness. Sexual and gonadal effects include an increase in libido, clitoral growth, vaginal dryness, and cessation of menses. An ovulatory state is common, though not absolute and long-term fertility may be affected, though some transgender men are able to discontinue testosterone and achieve successful pregnancy. The general approach involves the use of one of several forms of parenteral testosterone. Prior use of oral methyltestosterone and other synthetics commonly encountered in bodybuilding communities has resulted in unsubstantiated concerns about negative hepatic effects of testosterone use in transgender men. Testosterone is available in a number of injected and topical preparations, which have been designed for use in non-transgender men with low androgen levels (see table). Since the label dosing (not included in table) for these medications are based on the treatment of men with low, but not no, testosterone, higher dosing may be needed in transgender men (see table) than are commonly used in non-transgender men. Furthermore, these dosage ranges do not necessarily represent a target or ideal dose. Dose increases should be based on patient response and/or monitored hormone levels. Specific absorption and activity varies and consultation with the individual compounding pharmacist is recommended. Testosterone undecanoate has been used extensively for transgender care outside of the U. Testosterone undecanoate has been associated with rare cases of pulmonary oil microembolism and anaphylaxis. All injections must be administered in an office or hospital setting by a trained and registered health care provider and monitored for 30 minutes afterwards for adverse reactions. Benefits of subcutaneous administration include a smaller and less painful needle, and may avoid scarring or fibrosis from long term (possibly > 50 years) intramuscular therapy (Grading: T O M). After application, the testosterone moves into the dermis, where it slowly releases over the course of the day. Care should be taken to avoid any contact of the gel with others, especially women and June 17, 2016 50 Guidelines for the Primary and Gender-Affirming Care of Transgender and Gender Nonbinary People children. It is also recommended that the application site be washed at a later time if close skin-skin contact with another person is expected. Clinical response can be measured objectively by the presence of amenorrhea by 6 months. Lab reference ranges for total testosterone levels are generally very wide (roughly 350-1100ng/dl); if men have testosterone levels at the lower end of the normal male range and are either concerned about slow progress or are having symptoms of low June 17, 2016 51 Guidelines for the Primary and Gender-Affirming Care of Transgender and Gender Nonbinary People energy, libido, or mood, it is reasonable to slowly increase the dose while monitoring for side effects. Once total testosterone is greater than the midpoint value in the lab reported reference range, it is unclear if an increase in dose will have any positive effect on perceived slow progress, or on mood symptoms or other side effects. While some providers choose to omit hormone level monitoring, and only monitor for clinical progress or changes, this approach runs the risk of a suboptimal degree of virilization if testosterone levels have not reached the target range. A prospective study of 31 transgender men newly started on either subcutaneous 50-60mg/week testosterone cypionate, 5g/day 1% testosterone gel, or 4mg/day testosterone patch found that after 6 months only 21 (68%) achieved male range testosterone levels and 5 (16%) had persistent menses, with only 9 (29%) achieving physiologic male-range estradiol levels. Regardless of initial dosing scheme chosen, titrate upwards based on testosterone levels measured at 3 and 6 months. Once hormone levels have reached the target range for a specific patient, it is reasonable to monitor levels yearly. As with testosterone replacement in nontransgender men, annual visits and lab monitoring are sufficient for transgender men on a stable hormone regimen. Endocrine Society guidelines recommend monitoring of hormone levels every 3 months. Such patients may also require more frequent office visits to manage coexisting conditions. General comments on hormone level interpretation Interpretation of laboratory results requires special attention in the context of transgender care. Numerous sources publish target ranges for serum estradiol, total estrogens, free, total and bioidentical testosterone, and sex hormone binding globulin. However, these specific ranges may vary between different laboratories and techniques. For example, a transgender man who is still registered as female will result in lab reference ranges reported for a female; clearly these ranges are not applicable for a transgender man using virilizing hormone therapy. Providers are encouraged to consult with their local lab to obtain hormone level reference ranges for both “male” and “female” norms, and then apply the correct range when interpreting results based on the current hormonal sex, rather than the sex of registration. Testosterone levels must also be interpreted in the context of knowing whether the specimen was drawn at the peak, trough or mid-cycle of the dosing interval, as values can vary widely (and if so may cause symptoms, see below and pelvic pain and bleeding guidelines) June 17, 2016 52 Guidelines for the Primary and Gender-Affirming Care of Transgender and Gender Nonbinary People Monitoring testosterone levels Testosterone levels can be difficult to measure in non-transgender men due to rapid fluctuations in levels, relating to pulsatile release of gonadotropins. In transgender men who are receiving exogenous testosterone, levels may lack these rapid fluctuations (though they may vary over the dosing interval). Bioavailable testosterone is free testosterone plus testosterone weakly bound to albumin. For transgender care, the Endocrine Society recommends monitoring of the total testosterone level. Peak (1-2 days post injection) and trough levels of testosterone may reveal wide fluctuations in hormone levels over the dosing cycle; in these cases, consider changing to a transdermal preparation, or reducing the injection interval (with concomitant reduction in dose, to maintain the same total dose administered over time). Estradiol may play a role in pelvic pain or symptoms, persistent menses, or mood symptoms. An in-depth discussion of pelvic pain and persistent menses is covered elsewhere in these guidelines. Interpreting sex-specific, non-hormone labs Alkaline phosphatase, hemoglobin and hematocrit, and creatinine may vary depending on the patient’s current sex hormone configuration. Several factors contribute to these differences, bone mass, muscle mass, number of myocytes, presence or lack of menstruation, and erythropoetic effect of testosterone. Many transgender men do not menstruate, and those with male-range testosterone levels will experience an erythropoetic effect. As such an amenorrheic transgender June 17, 2016 53 Guidelines for the Primary and Gender-Affirming Care of Transgender and Gender Nonbinary People man taking testosterone, registered as female and with hemoglobin/hematocrit in the range between the male and female lower limits of normal, may be considered to have anemia, even though the lab report may not indicate so. Conversely, the lack of menstruation, and presence of exogenous testosterone make it reasonable to use the male-range upper limit of normal for hemoglobin/hematocrit. Using the male-range upper limit of normal for alkaline phosphatase and creatinine may also be appropriate for transgender men due to increased bone and muscle mass, respectively. In these cases the provider should reference the male normal ranges for their lab. Lower and upper limits of normal to use when interpreting selected lab tests in transgender men using masculinizing hormone therapy Lab measure Lower Limit of normal Upper Limit of normal Creatinine Not defined Male value Hemoglobin/Hematocrit Male value if menorrheic* Male value Alkaline Phosphatase Not defined Male value * If menstruating regularly, consider using female lower limit of normal. Individualized dosing based on patient centered goals Some patients may desire limited hormone effects or a mix of masculine and feminine sex characteristics. Examples include deepening of voice or growth of a beard (both irreversible), with retention of breasts or female body habitus. Some patients may choose to undergo testosterone therapy for a period of time to develop such irreversible changes, and then discontinue testosterone and revert to their endogenous estrogen hormonal milieu. While manipulation of dosing regimens and choice of medication can allow patients to achieve individual goals, it is important to have a clear discussion with patients regarding expectations and unknowns. Specifically, it is not possible to prospectively choose a regimen that will predictably allow patients to arrive at a specified configuration of sex characteristics. Furthermore, individual genetic and physiologic variation can result in wide variations in blood levels and response to therapy between different individuals using the same route and dose. At the same time, response to hormone therapy is also individualized and measures such as beard growth or voice changes are variable in both degree and time course. Likely predictive factors of speed and degree of virilization include genetics and particulars of body habitus; younger age at start also likely contributes to faster progress and a greater degree of virilization once an endpoint is reached. Patients beginning hormone therapy later in life may experience more limited results. Patients should be counseled on setting reasonable expectations based on these factors, and avoid making comparisons to the experiences of others. Post-gonadectomy: Since testosterone dosing should be based on physiologic male replacement levels, no reduction in testosterone dosing is required after gonadectomy.

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