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The risk of this approach is that if hormone levels (particularly testosterone) have not reached the target range erectile dysfunction injection therapy cost order 80 mg top avana amex, but progress is judged as appropriate based on clinical exam erectile dysfunction latest medicine purchase top avana in india, a suboptimal degree of feminization is possible erectile dysfunction 19 top avana 80mg without prescription, and the presence of supraphysiologic levels would also be obscured erectile dysfunction jason generic top avana 80mg otc. Conversely, Endocrine Society guidelines recommend monitoring of hormone levels every 3 months. A prospective study of transgender women taking 4mg/day divided dose oral estradiol or 100mcg transdermal estradiol, plus 100-200mg/day divided dose spironolactone found that all women achieved physiologic estradiol levels, though only 2/3 of the women achieved female range testosterone levels. Regardless of initial dosing scheme chosen, dosing may be titrated upwards over 3-6 months. Check estradiol and June 17, 2016 31 Guidelines for the Primary and Gender-Affirming Care of Transgender and Gender Nonbinary People testosterone levels at 3 and 6 months and titrate dose accordingly. For those patients using spironolactone, check renal function and K+ at 3 months and 6 months, then q 6-12 months. While laboratory monitoring of hormone levels may seem complex, it is of similar difficulty to the monitoring of other similarly complex lab-monitored conditions managed by primary care providers, such as thyroid disorders, anticoagulation, or diabetes. Once hormone levels have reached the target range for a specific patient, it is reasonable to monitor levels yearly, or only as needed as described below. As with other situations involving maintenance of hormone therapy (menopause, contraception), annual visits are sufficient for transgender women on a stable hormone regimen. Other reasons for measuring hormone levels in the maintenance phase include significant metabolic shifts such as the onset of diabetes or a thyroid disorder, substantial weight changes, subjective or objective evidence of virilization, or new symptoms potentially precipitated or exacerbated by hormone imbalances such as hot flashes or migraines. Increased frequency of office visits may also be useful for patients with complex psychosocial situations to allow for the provision of ancillary or wraparound services. Current Endocrine Society recommendations include the measurement of only total testosterone and estradiol. This is consistent with Endocrine Society recommendations that only total testosterone be monitored in non-transgender men being managed for testosterone deficiency, except in cases of borderline testosterone levels. However, since testosterone is of particular concern is insuring maximal feminization, the calculation of bioavailable testosterone in transgender women may still be of value. As such in cases of patient concern or persistent virilized features in the presence of a female-range total testosterone, calculation of the bioavailable testosterone may help fine tune hormone regimens for optimal effect. Interpretation of laboratory results requires special attention in the context of transgender care. However, these specific ranges may vary between different laboratories and techniques. Furthermore, the interpretation of reference ranges supplied with lab result reports may not be applicable if the patient is registered under a gender that differs from their intended hormonal sex. For example, a transgender woman who is still registered as male will result in lab reference ranges reported for a male; clearly these ranges are not applicable for a transgender woman using feminizing hormone therapy. Hormone levels for genderqueer or gender nonconforming/nonbinary patients may intentionally lie in the mid-range between male and female norms. Providers are encouraged to consult with their local lab(s) 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. Monitoring estradiol levels Historically estrogen levels have been monitored using the total serum estradiol. The 2009 Endocrine Society Guidelines recommend monitoring serum estradiol and maintaining levels at the June 17, 2016 32 Guidelines for the Primary and Gender-Affirming Care of Transgender and Gender Nonbinary People mid-cycle range for non-transgender women. There is no evidence that higher estradiol levels in patients with adequate androgen suppression results in additional feminization or breast development. Maintaining estrogen levels in the physiologic range for menstruating non-transgender women minimizes risks and side effects, and makes sense clinically. Note that the use of conjugated estrogens (Premarin®) or ethinyl estradiol (found in most combined oral contraceptives) are not accurately measured by estradiol assays and will typically result in low measured levels. In patients who have been using self-administered conjugated estrogens, or ethinyl estradiol, it is reasonable to check a total estrogens level, which may provide a more accurate estimate in these cases. There is some evidence that the use of oral estradiol results in higher serum levels of estrone due to first pass hepatic metabolism, as compared to parenteral forms. 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, with higher levels in the morning hours. Monitoring hormone levels in patients using injected estrogen Pharmacokinetic studies of injected estrogen have been limited. Two earlier studies only examined single-dose pharmacokinetics and are therefore unable to be applied to steady-state dosing. When measuring hormone levels in patients using injected forms of estradiol, a mid-cycle level is often sufficient, however if the patient is experiencing cyclic symptoms such as migraines or mood swings, peak (1-2 days post injection) and trough levels of both estradiol and testosterone may reveal wide fluctuations in hormone levels over the dosing cycle; in these cases, consider changing to an oral or transdermal preparation, or reducing the injection interval (with concomitant reduction in dose, to maintain the same total dose administered over time). A single study suggests similar pharmacokinetics when estradiol is injected subcutaneously, rather than intramuscular. Several factors contribute to these differences, bone mass, muscle mass, number of myocytes, presence or lack of menstruation, and the erythropoetic effect of testosterone. While transgender women do not menstruate, those with female-range hormone levels will lack the erythropoetic effects of male-range testosterone, and it may be reasonable to use the female-range lower limit of normal when interpreting H&H. Conversely, the lack of menstruation, and potential for pulsatile undetected androgen activity in those with retained gonads make it reasonable to use the male-range upper limit of normal for H&H. Using the male-range upper limit of normal for alkaline phosphatase and creatinine may also be appropriate for transgender women due to retained bone and muscle mass or myocyte counts, respectively. This is of particular importance in transgender women using spironolactone who are registered as female, and may have a lab result flag showing an abnormal elevated creatinine. Lower and upper limits of normal to use when interpreting selected lab tests in transgender women using feminizing hormone therapy Lab measure Lower Limit of normal Upper Limit of normal Creatinine Not defined Male value Hemoglobin/Hematocrit Female value Male value Alkaline Phosphatase Not defined Male value 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 retention of erectile function with otherwise maximum feminization, or minimal feminizing effects with the exception of body or facial hair elimination or breast growth. While manipulation of dosing regimens and choice of medication can allow patients June 17, 2016 34 Guidelines for the Primary and Gender-Affirming Care of Transgender and Gender Nonbinary People to achieve this goal, it is important to have a clear discussion with patients regarding expectations and unknowns. Specifically, it is not possible to select in advance an exact hormone 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 both 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 breast growth are variable in both degree and time course. Likely predictive factors of speed and degree of feminization include genetics, age at initiation of therapy, and body habitus. All transgender women who smoke should be counselled on tobacco risks and cessation options at every visit. Many transgender women may be unable or unwilling to quit smoking; this should not represent an absolute contraindication to estrogen therapy. After an in depth and careful informed consent discussion, it is reasonable to prescribe estrogen using a harm reduction approach, with a preferred route of transdermal estrogen. Loss of erectile function: Sildenafil (Viagra) and tadalafil (Cialis) can be used for preservation of erectile function at any stage or with any feminizing hormone regimen, in consideration of the typical contraindications and precautions when using this class of medication. It is reasonable check both total and bioavailable testosterone levels, and consider reduction of androgen blockade to allow an increase in testosterone, depending on patient goals. This study found no correlation between sexual desire and testosterone levels in the transgender women, though a significant correlation was found between hormones and desire in non-transgender women. Post-gonadectomy: Since estrogen dosing should be based on physiologic female levels, no reduction in estrogen dosing is required after gonadectomy. Some patients may choose to use a lower dose, which is appropriate as long as dosing is adequate to maintain bone density. Due to higher levels of co-occurring conditions in older individuals, there may also be higher risk of adverse effects. Nevertheless a large number of women have started hormones at advanced ages and safety and satisfaction have been reported as acceptable. Expected effects of this may be similar to non-transgender women experiencing menopause. Transgender women who retain their gonads but withdraw hormone therapy may experience return of virilization. A discussion of the pros and cons of this approach, with individualized and shared decision making is recommended. Pituitary adenoma (prolactinoma) and galactorrhea: Prolactin elevations and growth of pituitary prolactinomas are theoretical risks associated with estrogen therapy; several cases have been reported.
The effect of vardenafil, a potent and highly selective phosphodiesterase-5 inhibitor for the Tzivoni D, Klein J, Hisdai D et al. The Israel Heart treatment of erectile dysfunction, on the cardiovascular response Society expert consensus document: the cardiac to exercise in patients with coronary artery disease. J Am Coll patient and sexual activity in the era of sildenafil Cardiol 2002;40(11):2006-2012. Intracavernous self-injection pharmacotherapy program: analysis of results and Wagner G, Rabkin J, Rabkin R. The new 2000;356(9224):169 injection treatment for impotence: Medical and psychological aspects. Br J Urol vasoactive substances administered into the human corpus 2005;173(1):167-170. Histopathologic prostaglandin E1 in the management of erectile effect of chronic use of sildenafil citrate on the choroid & retina dysfunction. Am J Ophthalmol 2006;141(3):598 controlled study on erectile dysfunction treated by trazodone. Erectile dysfunction in the patient on sleep and sleep-related penile tumescence in with diabetes mellitus. Sildenafil citrate potentiates the hypotensive effects of nitric Virag R, Floresco J, Richard C. Impairment of shear-stress oxide donor drugs in male patients with stable angina. No clinically among men with diabetes mellitus: Comprehensive review, important effects on intraocular pressure after short- methodological critique, and suggestions for future research. Vascular endothelial growth factor restores erectile function Wespes E, Rammal A, Garbar C. Sildenafil non-responders: through inhibition of apoptosis in diabetic rat penile haemodynamic and morphometric studies. Synthetic melanotropic Sildenafil and Yohimbine for the treatment of erectile peptide initiates erections in men with psychogenic erectile dysfunction. Chinese Journal of Andrology dysfunction: double-blind, placebo controlled crossover study. Treatment of sexual dysfunction of hypogonadal patients with long-acting testosterone Wheatley D. A erectile function recovery after radiotherapy and long-term case report and review of literature. Andrologia androgen deprivation with luteinizing hormone-releasing 2006;38(1):34-37. Tadalafil in the embolization for impotent patients with venous treatment of erectile dysfunction. J Fam alprostadil cream applied topically to the glans meatus Pract 1998;46(4):282-283. Clinical observation on the therapeutic effects of heavy moxibustion plus point-injection in treatment of impotence. Sexual behavior of men with isolated hypogonadotropic hypogonadism or prepubertal anterior panhypopituitarism. Effect of sildenafil citrate on blood pressure and heart rate in men with erectile dysfunction taking concomitant antihypertensive medication. H-2 1 = Very dissatisfied 2 = Moderately dissatisfied 3 = About equally satisfied and dissatisfied 4 = Moderately satisfied 5 = Very satisfied Q15: How do you rate your confidence that you could get and keep an erection? When you had erections with sexual stimulation, Much less Much more Almost Almost never About half how often were your erections hard enough for than half the than half the always or or never the time penetration? Much less Much more Almost When you attempted sexual intercourse, how often Almost never About half than half the than half the always or was it satisfactory for you? Prescrire Int 2002; response to sildenafil in patients with erectile 11(59):76-79. Medico-Legal Update 1998; 3(1- administration of sildenafil citrate in 30 patients 2):67-78. Erectile prostaglandin E1 for the treatment of erectile dysfunction and sildenafil citrate. Clinical and prostaglandin E1 gel applications for experience with intraurethral alprostadil impotence. Erratum: Efficacy and tolerability of sildenafil in Indian males with erectile McMahon C. Methods & Findings in dysfunction secondary to selective serotonin re- Experimental & Clinical Pharmacology 2004; uptake inhibitors. Be ready to answer a number of questions Some of these questions will be personal and may seem embarrassing • Do you smoke or vape? What do you smoke, and how Honest answers will help fnd the cause and best treatment much? Questionnaires are often used by health experts to rate • If you do have erections, how frm are they? The physical exam is a way to check your total health For This is called performance anxiety. The good news is that you don’t have to give up on your ? Can you check my heart and blood health? The condition can be caused by vascular, neurologic, psychological, and hormonal factors. Tobacco cessation, regular exercise, weight loss, and improved control of diabetes, hypertension, and hyperlipidemia are recommended initial lifestyle interventions. Surgically implanted penile prostheses are an option when other treatments have been ineffective. Association Source: For more information on the Choosing Wisely Campaign, Laboratory Evaluation see http://www. For supporting citations and to the A1C or fasting glucose level can be used to assess for search Choosing Wisely recommendations relevant to primary care, see http://www. A thyroid-stimulating hormone level is recommended for men with signs or symptoms of hypothyroidism. Single-Question Assessment for assessing cardiovascular risk, particularly in younger of Erectile Dysfunction men and minorities, for whom global risk assessment calculators may underestimate actual risk. Minimally impotent: usually able to get and keep an erection good enough for sexual intercourse. Moderately impotent: sometimes able to get and keep an erection good enough for sexual intercourse. Completely impotent: never able to get and keep an cations and other substances, and an assessment of psy- erection good enough for sexual intercourse. Erectile Dysfunction: Related Conditions and Approaches to Evaluation Related condition Approach to evaluation Routine measurement of testoster- Cardiovascular disease History and physical examination one levels is controversial. As part of the Diabetes mellitus A1C or fasting glucose level Choosing Wisely campaign, the Ameri- Endocrine disorders (e. A diagnosis of hypo- Hypertension Blood pressure gonadism must be based on more than just an abnormal laboratory test result. However, depression, guilt, history of sexual when hypogonadism is clinically sus- abuse, marital or relationship pected but the morning total testosterone problems, stress) level is repeatedly normal, bioavailable Sedentary lifestyle History testosterone or free testosterone may Tobacco use History account for the effects of sex hormone– Trauma History binding globulin levels on testosterone Venous leakage History and physical examination; activity. Levels of follicle-stimulating if venous leakage is suspected, hormone, luteinizing hormone, sex hor- consider urology consultation for venous fow testing mone–binding globulin, estradiol, and prolactin can help differentiate between Information from references 6 through 8. Medications and Substances That May Cause or Contribute to Erectile Dysfunction Alcohol, nicotine, and illicit drugs (e. These treatments can or overweight men, and improved control of diabetes, hypertension, and hyperlipid- emia are recommended. Compared Perform a focused history and physical examination: medical and surgical history, sexual history, use of medications and substances, psychological and relationship with men who have never smoked, the risk health. Consider morning total testosterone level and other laboratory tests if clinically indicated. Table 4 Metabolic syndrome Nocturnal penile tumescence testing summarizes these medications. The effects may be delayed or decreased if the patient has recently eaten a fatty meal, 69 First-line therapies: particularly for sildenafl and vardenafl. Oral phosphodiesterase-5 inhibitor (if not contraindicated) Headache, fushing, and dyspepsia are com- mon adverse effects. Tadalafl has a Vacuum device longer half-life, which gives men the option of taking it up to 12 hours before sex or as a lower-dose, once-daily medication; however, Consider urology consultation for possible penile prosthesis implantation. Lower doses should be used in patients with chronic kidney disease or moderate liver impairment.
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