Medical Management of Adult Transsexual Persons

Emily L. Knezevich, Pharm.D; Laura K. Viereck, Pharm.D; Andjela T. Drincic, M.D.


Pharmacotherapy. 2012;32(1):54-66. 

In This Article

Pharmacist Involvement

The medical management of transsexual patients provides ample opportunity for pharmacist-physician collaboration in ensuring that patients reach and maintain the goals of therapy. Pharmacists should be involved initially in the discussion of potential therapies and their risks for patients transitioning. In addition, pharmacists should assess the use of herbal or complementary agents commonly used in this patient population and determine how their use will impact the patient's clinical course. Many drug-drug interactions exist with the use of cross-sex hormone therapy, and pharmacists must be able to identify these potential interactions to avoid complications of therapy. Because the drugs used in the transition of transsexual individuals commonly impose adverse effects on patients, a pharmacist may be able to suggest ways to avoid or ameliorate the reactions. For example, to limit skin reactions that occur from a transdermal patch, sites may be rotated or the use of an alternative dosage form may be recommended. In addition, because the use of oral estradiol in patients who smoke is not recommended due to the increased risk for thromboembolic events, a pharmacist could offer smoking cessation counseling and management of pharmacotherapy aimed at helping divert the patient from tobacco use.

It is well known that hormone therapies can be quite expensive and often are not covered by a patient's insurance plan. A pharmacist can help identify the most cost-effective therapy and facilitate patient enrollment into a drug assistance program if the patient qualifies.

Pharmacists should evaluate the risk:benefit ratio of each formulation of therapy based on each patient's individual risk factors. Commonly prescribed drugs among providers who may not be familiar with current guidelines include conjugated estrogens or oral contraceptives. A pharmacist knowledgeable of cardiovascular risks and poor monitoring capabilities of these formulations should intervene to recommend a product containing 17β-estradiol. In addition, after therapy is selected, pharmacists can optimize patient administration. For example, if injectable agents are used, pharmacists should evaluate the suspension vehicle, keeping in mind patient allergies, to avoid hypersensitivity. Common vehicles for injectable estradiol and testosterone include cottonseed oil, castor oil, and sesame oil. In addition, when self-injection is chosen, pharmacists are well equipped to educate patients on appropriate injection technique. Pharmacists should also be aware of potential errors in dosing related to the confusion that may occur with the availability of multiple concentrations of injectable hormones and be able to counsel patients on measuring and administering the appropriate dose. Conversely, if topical gels or transdermal patches are used, pharmacists should educate patients on proper use and pitfalls to avoid.

Finally, pharmacist involvement could occur in laboratory monitoring after initiation of therapy as well as in titration of hormone therapy based on results of that monitoring and the patient's description of physical changes or adverse drug reactions. Protocols can be established with providers to guide the decision-making process with regard to drug titration based on laboratory values and clinical presentation.


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