Post-Test Multi choice questions
1. Recommended HRT for trans women, include:
Elleste Duet (estradiol + norethisterone)
A and C
A and D
Estradiol valerate and hemihydrate as estrogen-only HRT are recommended in the UK as feminising endocrine therapy in this context.
2. At menopausal age, trans women:
should aim to discontinue their HRT regime
could reduce their HRT dose to maintain serum estradiol approx. 200pmol/l
If HRT dose reduction is requested or required, it is broadly accepted that maintaining a serum estradiol level of approximately 200pmol/L should be sufficient to maintain feminisation and bone health. Ageing can present a challenge for gender diverse people, particularly with regard to losing control over appearance, dress and identity should they become reliant on others for self-care. 20 Living with dementia can cause some people confusion between their gender preference and their birth assignation.21
could reduce their HRT dose to maintain serum estradiol approx. 650pmol/l
should consider combination HRT
3. Regarding gender diverse people accessing the National Breast Screening programme:
this is required by all
this is not usually required for people on testosterone therapy
this is not usually required for people who have undergone chest surgery
Routine breast screening is required by all trans people who have breasts, including people who have undergone mammoplasty. For those who have a small amount of breast tissue following bilateral mastectomy with chest reconstruction surgery, routine breast screening is not usually required, but self-examination for lumps should be encouraged.
this is only required for those trans women with a significant genetic risk
none of the above
4. A person with a non-binary gender identity might affirm their gender through:
chest surgery only
low dose estradiol or testosterone
all of the above
A person’s affirmed gender describes the gender status achieved after transition. This usually involves bringing their general appearance, name and pronouns into line with their gender identity.11 Validity does not depend on any given transition process, and indeed not all gender diverse people require medical or surgical intervention in order to achieve it. Social transition usually involves a change of name and dressing/behaving in an affirmative way, and for some this can be sufficient. People with a non-binary gender identity (an identity that is neither exclusively male or female) may require a bespoke medical transition pathway, for example, low dose hormone or anti-androgen therapy, in order to achieve psychological and physical congruence.
A, and D
5. GnRH agonist injection in trans women using estradiol can be associated with:
initial menopausal symptoms including hot flushes
transient reduction in bone density
hypoactive sexual desire disorder
Hypoactive sexual desire disorder is characterised by the loss of sexual fantasies and the desire for sexual intimacy. Due to the relative potency of GnRH agonist with regard to androgen suppression, this is occasionally reported. Treatment with add-back testosterone therapy can be offered with specialist guidance.
all of the above
6. Max is 39 and was assigned female at birth. He identifies as a trans man and wishes to medically transition having recently been endorsed for hormone therapy by a NHS Gender Identity Clinic. Considering options for initiation of testosterone treatment:
Nebido is most commonly used
Sustanon has the highest rate of associated polycythaemia but could be considered as short-term starter therapy
Nebido is the most commonly used long-term testosterone but is not recommended for the initiation of treatment. Sustanon is short-acting and therefore an appropriate starter therapy, but it does confer the highest rate of polycythaemia and mood variability. Testosterone gel is an alternative, offering more control and less of an impact on mood. Smoking cessation should have occurred for at least 3 months before treatment begins, and in this context NRT is considered a safe alternative to combusting tobacco.
Nicotine replacement therapy is contraindicated
Testosterone gel applied daily can be associated with wide variation in mood
B, and D
7. Polycythaemia associated with exogenous testosterone use:
is caused by testosterone inhibiting erythropoietin production
is compounded by smoking
is usually defined as haemoglobin >185 g/L and/or HCt >0.52
requires cessation of testosterone treatment until resolution
B and C
Exogenous testosterone stimulates erythropoetin. Smoking is an independent risk factor for secondary polycythaemia. This is usually defined as haemoglobin >185g/L and HCt >0.52. Resolution can usually be achieved by improving hydration and through smoking cessation and does always require testosterone treatment to be stopped. Specialist guidance should however be sought.
8. Charlotte changed her name using a Deed Poll and lives as a woman in all aspects of her life. She has been on the waiting list for some time, and in the past 6 months decided to start self-medicating. She was using ProgynovaÒ 4mg and Spironolactone 100mg daily, purchased on the black market. She found the feminising effects extremely positive.
During the Summer break from University she developed a DVT and is now anti-coagulated. She has a good understanding of the risks involved and now buys estradiol patches.
You agreed to prescribe Finasteride as a safer oral anti-androgen alternative to Spironolactone. Looking at her treatments:
Spironolactone may have contributed to the thrombotic event
Finasteride reduces serum testosterone but has no impact on DHT (dihydrotestosterone)
topical estradiol is not associated with a significantly increased risk of DVT
all of the above
A, and C
Through its diuretic action, Spironolactone could under certain circumstances be a factor in the development of a DVT. Topical estradiol is not associated with a significantly increased risk of DVT.22 Finasteride lowers serum DHT (dihydrotestosterone) and for this reason helps protect against scalp hair loss.
9. If a trans woman who has undergone vaginoplasty develops symptoms of STI, a vulvo-vaginal swab is sufficient for detection of Chlamydia and Gonorrhoea:
A vulvo-vaginal swab might miss the focus of a mucosal infection, particularly if the vagina has been constructed from penile skin. In this scenario, a urine NAAT (urine nucleic acid amplification) test would be more likely to detect Chlamydia and Gonorrohoea.
10. Pertaining to bilateral mastectomy with chest reconstruction surgery:
this is a gender affirming intervention available on the NHS exclusively to trans masculine people using testosterone therapy
smoking is associated with higher risk of free graft nipple loss
Bilateral mastectomy with chest reconstruction surgery can be deployed as a gender affirmative intervention for people who do not use testosterone therapy. For people who do, treatment for a minimum period of 6-9 months is usually recommended in order for changes in the shape of the chest wall to have taken place, thus offering the best cosmetic result. The double-incision technique is most commonly used and usually leaves scarring along the contour of the pectoralis. Less dramatic is the peri-areolar technique, the incision limited to the areolar complex. However, this is only a possibility for candidates with a small breast volume. Surgery of any kind is not a requirement for a Gender Recognition Certificate. Smoking affects the integrity of micro-capillaries and is therefore associated with a higher rate of failure of free graft, including the nipples.
it is a requirement for a Gender Recognition Certificate under the Gender Recognition Act 2014
the peri-areolar technique is most commonly used
at least two years of testosterone therapy is a pre-requisite
none of the above
all of the above