Ask the Doc: Transgender Health, Hormones and HIV
Q: I am 23 years old and recently came out as a transgender man. I've been in therapy for a while and now want to start hormones (testosterone) but I am not sure how to choose a doctor. Do I need to see an endocrinologist? What should I expect at the visit?
A: You will want to look for a provider (usually either a primary care provider or endocrinologist) who has experience working with transgender clients. If you live in a large metropolitan area, you can visit an LGBT health center e.g., Callen-Lorde Community Health Center in New York, Fenway Health in Boston or Howard Brown Health Center in Chicago. You can also search the provider directories on WPATH.org (World Professional Association for Transgender Health) or GLMA.org (Gay and Lesbian Medical Association) to find a provider close to you with experience in transition care.
During the initial evaluation you should expect to answer questions about your medical and transition history, as well as have a physical examination and laboratory tests. Some providers may want a letter from your therapist or psychiatrist before initiating hormones, while others may do the evaluation themselves and have you sign an "informed consent" form that reviews the risks and benefits of treatment.
Once you begin hormones, you will also need to have periodic laboratory tests and office visits to monitor for side effects. It is also important that you continue to have routine medical care and screenings for preventable health issues. For example, it is important for transgender men to continue cervical cancer screening and breast/chest cancer screening and for transgender women to have testicular exams and evaluations for prostate disease. "If you have it, check it."
For more information, you can visit the resource pages at GLMA http://www.glma.org/index.cfm?fuseaction=Page.viewPage&pageId=948&grandparentID=534&parentID=938&nodeID=1 and UCSF http://transhealth.ucsf.edu/trans?page=lib-community
Q: I heard that taking hormones may not be safe when you are on HIV-medicines. I'm a transgender woman and recently tested HIV-positive. Will I need to stop my estrogen when I start HIV treatment?
A: HIV has had a big impact on transgender communities, with recent studies showing that one-in-five transgender women in the United States is HIV-positive. Getting tested was very important to ensuring that you get the care that you need.
To answer your question -- no, you do not need to stop hormones. Luckily there do not appear to be any serious drug-drug interactions between antiretroviral medicines and estrogens, although your medical provider may make small adjustments in the dose or type of estrogen. In addition, certain antiretroviral medicines (e.g., unboosted fosamprenavir) are usually avoided due to potential drops in drug levels when given with estrogen.
Although there aren't serious drug interactions between estrogen and antiretrovirals, there are other concerns you should be aware of. Cardiovascular disease (e.g., heart attacks and strokes) appear to be more common among people living with HIV as well as among transgender women receiving hormones. This means that it is very important to reduce risk factors for heart disease by not smoking, staying a healthy weight and ensuring that issues like high cholesterol and hypertension are controlled. Your HIV specialist can provide advice on smoking cessation and additional treatment if needed.
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Anita Radix, MD MPH, is the Director of Research and Education and internist/HIV specialist at The Callen Lorde Community Health Center in New York City, providing care to LGBT clients and those living with HIV. She completed her residency in internal medicine and fellowship in infectious disease at the University of Connecticut. Dr. Radix' current research interests involve studying the impact of transphobia and homophobia on access to HIV services. She is a consultant for the Pan American Health Organization/World Health Organization on HIV issues and health disparities related to sexual and gender minority status, and a technical advisor for the Blueprint for provision of care to transgender persons in the Americas.