Continuing Education

This article was inspired by the National LGBTQIA+ Health Education Center. I completed their webinar titled, Testosterone Therapy, which is one of the many videos accessible on their website for continuing education. Did I mention it’s free? They offer 1 contact hour of Continuing Medication Education which they report is accepted as 1 CE by the American Nurses Credentialing Center. Always check with your Board of Nursing to find out what is acceptable.

The webinar is taught by Julie Thompson, PA-C (she/her), the Medical Director of Trans Health at Fenway Health, faculty at the National LGBTQIA+ Health Education Center, faculty for TransECHO and TransLine for gender affirming medical consultative services for healthcare providers, and she was appointed to serve on the Board of Directors for the US Professional Association of Transgender Health (USPATH). She did an excellent job not only delivering the information, but role modeling inclusive language. Here’s a list of a few words she used that I will incorporate in my practice.

-bottom growth

-freezing gametes

-instead of using the words birth control, just call the medication by its name, discuss the indications and mechanisms of action

The webinar was initially presented November 7, 2022.

Call-to-Action

I’ve heard more about T therapy in the last 8 months than I ever heard about it in acute care, clinical rotation, or nursing school. One thing I’ve learned about it is that most patients who would qualify, are not being recommended hormone replacement therapy often enough, and thus are under-treated. A growing number of nurse practitioner entrepreneurs have added T therapy as a service line to help address this gap in care. For our LGBTQIA+ patients, it affirms how they feel on the inside and desire to look on the outside. It’s a medication that sells itself, lends well to attracting a repeat customer, requires very little time to administer and follow-up, yet can yield amazing results in terms of satisfaction, lifestyle, and even mental health outcomes. I heard a therapist say she was able to discontinue psych medications for some of her male patients once they started T therapy and it reached therapeutic levels. In short, it’s been a game changer for patients.

I recently posted an article about Treating Acne in Patients Who Desire Gender-affirming Hormone Therapy for Aspiring Dermatology NPs. In the article, I reference a study where the authors, Radi et al., (2022), delivered a call-to-action for dermatology providers to play a bigger role when it comes to testosterone-induced acne as we are perfectly positioned to do so, especially considering the frequency at which we may see patients. While we become experts in acne, it would behoove us to also become more familiar with T therapy as we are likely to encounter it more in clinical practice.

Testosterone (T) Therapy

Treatment Considerations:

 Go low and slow with dosing to allow the patient to see if T therapy is right for them

 Find out if the patient desires more (injectables and topicals) or less (pellets) control over dosing

 Keep in mind, results are unpredictable, and some results may not be reversible

 Not all patients will want or need T therapy for life

 There is not enough clinical evidence to suggest that therapeutic levels beyond what is seen in cisgendered men is beneficial or effective

 Discuss family planning

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Formulations

Injectables. T therapy injectables can be administered intramuscularly or subcutaneously. Injectables can be dosed daily or every two weeks, ranging from 50 mg per week to 200 mg every 2 weeks. Patients can administer injections themselves or have them injected in clinic if they choose. While biweekly dosing can be more convenient, it also can lead to wider fluctuations in therapeutic levels and symptoms. Fortunately, that peak tapers over two weeks and thus patients who are experiencing fluctuations can expect their symptoms to improve around that time. Weekly dosing is more common and more tolerable.

Transdermal. Transdermal formulations are available via patches, and topical gel packets and pumps. The patch is applied daily with dosing ranging from 2-8mg/day (available as 2 and 4 mg patches). The patch covers the testosterone which reduces the worry patients have about transferring the medication to others. The patch is quite large and can cause skin irritation. The most common sites for placement are the upper arm (where it was formulated to be placed), the abdomen, or thigh.

The topical gels (40-50 mg/day) are more affordable, administered via two pumps per day or 1 packet per day (25 or 50 mg) to the upper arm (where they were formulated), upper chest, abdomen, and inner thigh. Note, the skin of the abdomen and thigh may be thicker, which can decrease absorption.

Axillary application is not generally covered by insurance. However, this location decreases the worry about transferring the medication to others. The gel is available in a pump and 1 pump (30 mg) is applied to each axilla daily.

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Long-acting Affirming Medications

Pellets. Pellets are sold by a company called Testopel. About 8 to 12 pellets are implanted every three to four months. Pellets may become a good option for patients who no longer respond to or desire injectable therapy. Pellets are surgically implanted under sterile precautions where the incision is covered with steri-strips. The pellets eventually dissolve and thus it’s important for patients to know a few things. One, there is a rare, but small chance a pellet will fall out. Two, because it’s implanted there’s less control over dosing and symptoms (fatigue and irritability).

Injection. Outside of the US, testosterone undecanoate is the most commonly administered testosterone replacement. It’s available in the US as AVEED, costs about $900 per injection. The first administration is a loading dose. Patients return the following month for the subsequent dose (750mg/3mL) and every ten weeks thereafter. Patients have to be monitored for 30 minutes after administration for potential yet, rare adverse effects including micro pulmonary embolisms and anaphylaxis. It requires a special certification to administer it.

Oral. Jatenzo is a gel cap that is prescribed twice daily with food which unfortunately, decreases its uptake by patients who find those requirements are not convenient. There are multiple dosing options, but 237mg BID with food is preferred. It was specifically designed for oral administration and avoids first-pass metabolism by the liver, but still requires monitoring of liver function tests (risk of hepatotoxicity is low). There is a black box warning for blood pressure elevation with a number of patients developing high blood pressure while on the medication.

Estrogen. Estrogen may be administered to treat atrophy, dryness, and bleeding induced by T therapy.  It can even be recommended about two weeks before a pap tests to improve comfort level during the exam and allow the patient to be comfortable long enough for you to perform a thorough exam. As a topical treatment, it will not have systemic effects which is important for LGBTQIA+ patients who would not find that gender-affirming.

Hair Loss. Patients receiving T therapy are at risk for androgenic hair loss. This can be treated with minoxidil (not covered by insurance) or finasteride (5-alpha reductase inhibitors) (more affordable).

Progesterone. Progesterone can be administered to thin the uterine lining, decrease or cease menses making it an ideal option for patients who do not find testosterone or its effects gender-affirming. Examples of long-acting reversible contraception (LARC) options include intrauterine devices (IUD), Nexplanon, Depo, or oral progesterone.

Testosterone cream/DHT cream. While many patients may inquire or even try to apply testosterone cream to the genitals, this is really an area that calls for more education. Testosterone works by being systemically absorbed. In other words, the gender-affirming changes that take place are a result of the medication being absorbed in the blood stream, not by applying it externally. For patients who report it makes them feel better, consider prescribing testosterone compounded with petrolatum (which is more expensive and without evidence of effectiveness) instead of the commercial version that is alcohol based and would be uncomfortable. Patients who express interest in applying testosterone cream to the genitals for bottom growth are good candidates to talk with about the risk and benefits of pumping, and how to do it safely.

At the time of the recording, DHT cream was not available or allowed in the US or approved by the FDA.

Skin and Hair Changes. T therapy can cause the skin to be oilier or develop acne, either may resolve or persist over time. I previously discussed one study found some transgender patients may continue to experience mild acne ten years after testosterone therapy. Additional effects include fat redistribution (from lower body and hips to the abdomen), clitoral enlargement (this can be undesirable and dysmorphic for some patients), vaginal atrophy, facial and body hair growth, scalp hair loss, coarser skin texture, and increased sweating.

Primary Care Considerations for Dermatology Providers. It’s good to know patients receiving T therapy for gender-affirming care do not experience higher rates of cardiovascular disease (as seen in cisgendered men). However, lipid levels, BMI levels, and smoking risks do need to be monitored, especially for transmasculine patients. These modifiable risk factors are great teaching points to consider.

Other areas of interests are family planning, mental health, bone health, and sexual health. Studies have shown patients were able to successfully conceive even after ten years of T therapy.  T therapy leads to improved mental health and assists patients in achieving the life they desire. Keep in mind, mental health is a social determinant of health (SDOH) that must be considered a top priority as our LGBTQI+ patients are still at high risk for harassment, discrimination, and harm where they live, work, play, and age.  The evidence shows only 10-20% of medical interventions influence health outcomes. The remaining 80-90% is directly tied to SDOH. When we step outside of dermatology and find where what we provide intersects with what our patients need, then we can begin to expect to see real change in our patients’ lives.

Testosterone therapy improves bone density, muscle mass, and may aid in increasing libido.  Gender-affirming therapy changes the way our patients look, feel, and are received in the world. This can alter the way they navigate the world, access health care, and how healthcare professionals treat them (which can be worse, especially for our transgender patients who may also access healthcare less frequently). This highlights how imperative it is to remember the key components of culturally competent and holistic care.

My Recommendation

I highly recommend this free, 1-hour webinar for dermatology nurse practitioners and physician assistants who desire to provide more comprehensive care for their LGBTQIA+ patients. Every so often I attend a dermatology webinar in the company of primary care providers who inquire about dermatology pearls so they can improve care and better prepare their patients for referrals to dermatology. The opposite should also be true. I recommend dermatology providers find the niche areas in healthcare that intersect with dermatology where you can improve care. Perhaps it’s for LGBTQIA patients, veterans, older adults, or rural communities. Visit National LGBTQIA+ Health Education Center’s website to see all the resources they have available to help you build a more inclusive practice and adopt the language that will lead to better health outcomes and relationships with our patients. Here are a few more courses I have my eyes on:

 Foundations of LGBTQIA+ Health Part I

 Foundations in LGBTQIA+ Health Part II

 LGBTQIA+ Older Adults

 LGBTQIA+ People of Color

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Reference

Radi, R., Gold, S., Acosta, J., Barron, J., & Yeung, H. (2022). Treating acne in transgender persons receiving testosterone: A practical guide. American Journal of Clinical Dermatology, 23, 219-229. https://doi.org/10.1007/s40257-021-00665-w

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Kimberly Madison, DNP, AGPCNP-BC

Kimberly Madison is a new dermatology nurse practitioner with a passion for writing, entrepreneurship, financial literacy, and mentorship. I created this blog to share my journey as I become a dermatology nurse practitioner and entrepreneur. Most importantly, I’m looking forward to helping nurse practitioners and aspiring students to better understand the business of dermatology and their role in improving access to care, providing culturally competent care, and advancing education.

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