Care of the Transgender Patient

Today we sit down with Dr. Beth Cronin, clinical associate professor and assistant program director at Brown / Women and Infants of Rhode Island. Dr. Cronin has become a national expert in the care of LGBTQ patients, and is a fixture at ACOG and other venues, and we are lucky enough today to have her break down the need-to-know essentials for the OB/Gyn.

Definitions are an excellent place to start, and set the stage for this conversation:

  • Sex is what we do in the delivery room - defining “male” or “female” based on the presence of external genitalia.

  • Gender is a social construct, comprising attitudes, feelings, or behaviors associated to “male” or “female” by a culture.

  • Gender identity is a person’s internal sense of their gender:

    • Cisgender the biological sex and gender identity align

    • Transgender the biological sex and gender identity are opposite:

      • Transgender woman biological sex male, identity female

      • Transgender man biological sex female, identify male

    • Gender should be viewed along a spectrum, with varying definitions for terms such as gender fluid, gender queer, or nonbinary.

About 1.4 million adults and 150,000 youth aged 13-17 are estimated to identify as transgender or gender non-binary in the United States. This population has much higher risks of experiencing discrimination, violence, and sexual assault. Additionally, these patients are likely to have poor experiences in healthcare settings. These patients really need access to care, and OB/Gyns are in perfect position to be safe and welcoming environments for the transgender/gender non-binary community.

For your office and daily practice, it is important to be inclusive, and there are myriad resources to get this started. Staff training and education to promote inclusivity is also important. Inclusive forms and medical record systems that elicit gender identity are important to make available, including documentation of preferred pronouns.

Dr. Cronin also took time today to discuss some clinical care aspects. UCSF and WPATH each have excellent protocols and guidelines for clinical care, including for initiating or maintaining transition care. Modifications of usual care, and care in the midst of hormonal transition, is discussed in great detail at these resources. ACOG also has excellent online modules for OB/Gyns for transgender healthcare, in addition to more primary reading at CO 512, CO 685, and additional ACOG-approved resources for clinicians.

Dr. Cronin easily explains it as “screen the parts that are present” per usual care guidelines, including with respect to things such as breast and cervical cancer screening, contraceptive methods, and pregnancy and abortion care.

Intimate Partner Violence and Gun Violence

Today we are spending some time on IPV/DV and gun violence. These are topics every OB/GYN should be familiar with; IPV accounts for 250,000 hospital visits, 2,000 deaths, and $8 billion in direct care costs annually on a conservative estimate. 1 in 3 American women is victimized by IPV during their lifetimes, and 1 in 5 report being the victim of sexual assault.

ACOG CO 518 serves as essential reading for our conversation today. Important points from the reading and today’s episode include:

Finally, check out ACOG’s stance and legislative priority list surrounding gun violence. Be active and get involved today — this is our lane!

Breastfeeding Part II: Facts and Myth-busting

Today we (finally!) sit down with Part II of our breastfeeding special with Dr. Erin Cleary to cover myths, facts, and advantages of breastfeeding.

There are only three main contraindications to breastfeeding:
1. In infants with galactosemia.
2. In mothers who are HIV+ in high-resource settings.
3. In mothers with human T-cell lymphoma virus.

There are a number of relative contraindications to breastfeeding:

  • In a mother with Hepatitis A until she receives gamma globulin.

  • In a mother with Hepatitis B until the infant receives HBIG and HepB vaccine.

  • In a mother with Hepatitis C if coinfections present, such as HIV.

  • In a mother with Varicella zoster (Chicken pox) while mother is infectious.

  • In a mother with Active TB until mother has received 2+ weeks treatment

  • In a mother with influenza

    • if the mother has been afebrile without antipyretics for >24 hours, and the mother is able to control her cough and respiratory secretions.

    • Oseltamivir or Tamiflu is poorly excreted in breastmilk

  • In patients abusing IV drugs.

  • In patients using marijuana:

    • (THC), the main compound in marijuana, is present in human milk up to eight times that of maternal plasma levels, and metabolites are found in infant feces, indicating that THC is absorbed and metabolized by the infant

    • Several preclinical studies highlight how even low to moderate doses during particular periods of brain development can have profound consequences for brain maturation, potentially leading to long-lasting alterations in cognitive functions and emotional behaviors

    • Breastfeeding mothers should be counseled to reduce or eliminate their use of marijuana to avoid exposing their infants to this substance and advised of the possible long-term neurobehavioral effects from continued use

Common Breastfeeding Myths/Misconceptions:

Infectious:

  • You should breastfeed if you have mastitis, emptying the breast prevents stasis of milk

You can breastfeed in setting of acute respiratory, urinary, GU infections, continuation of BF acceptable

Imaging Sudies

  • You can breastfeed if… You need medical imaging.

    • XRays do not affect milk

    • Mammograms may be harder to interpret when a patient is lactating, but this should not be a reason to defer recommended diagnostic imaging

    • CT/MRI with or without contrast do not impact breastmilk

    • XRays with contrast dye or imaging with radioactive material are also OK

    • Exception: thyroid scan using I-131

      • I-131 concentrates in breastmilk and at high levels can suppress baby’s thyroid function (or even destroy the thyroid) and increase risk of thyroid cancer.

      • Therefore it is important that breastfeeding be discontinued until breastmilk levels are safe (this depends upon the dose and ranges from 8 days to 106+ days). The half-life for I-131 is 8.1 days.

      • Hale recommends that when I-131 is used, breastmilk samples should be tested with a gamma (radiation) counter before breastfeeding is resumed to ensure that radiation in the milk has returned to safe levels.

  • You can breastfeed if… You are pregnant!  

    • Increasing progesterone will decrease supply and cause breast/nipple sensitivity.  

    • Mature milk will be replaced by colostrum in the 2nd trimester.

    • Tandem feeding includes breastfeeding a newborn and toddler

  • You can breastfeed if… You’ve had general anesthesia.  As soon as you are awake enough to hold the baby, the medication has metabolized and breastfeeding is safe.

  • You can breastfeed if… You are on maintenance medications such as methadone and buprenorphine

    • There is a reduction in severity and duration of treatment of NAS when mothers on these medications breastfeed

  • You can breastfeed if… You have an occasional alcoholic beverage

    • Alcohol concentration in the blood is in steady state with the milk, so delaying nursing or pumping until more alcohol is metabolized can limit exposure

  • If direct breastfeeding is interrupted due to temporary separation of mother and child for any reason, the breastfeeding mother should be encouraged and supported to regularly express her milk.

    • Expression and storage of milk allows the infant to continue to receive milk if appropriate, and prevents stasis of milk and mastitis

In the setting of infection, prior to expressing breast milk, mothers should wash their hands well with soap and water and, if using a pump, follow recommendations for proper cleaning.

Vaccines II: MMR, Varicella, and HPV

Let’s tackle the second part of our vaccinations series with some of the more common live-virus vaccines: MMR, Varicella, and HPV. Check out the CDC vaccine guides linked here.

MMR

  • Measles, mumps, and rubella - all are live attenuated strains of the virus

  • Should NOT be given during pregnancy

  • Immunity is about 97% against measles and rubella after 2 doses, and 88% against mumps after 2 dose

  • Given ideally before pregnancy to protect against congenital rubella

    • Otherwise, after pregnancy and not during

    • This is because during pregnancy, the adaptive immune system is not as robust as when one is not pregnant and higher risk of the live attenuated virus actually causing disease.

      • If an adult is not immune to MMR (and we screen for rubella during pregnancy), at least one dose should be given postpartum.

  • Ingredients

    • Chicken embryo cell culture - medium

    • Human diploid lung fibroblasts - medium

    • Vitamins, amino acids, sucrose, glutamate, human albumin, sorbitol, gelatin, sodium phosphate, sodium chloride

    • Fetal bovine serum - medium

    • Neomycin - antibiotic

  • Side effects

    • Can get rash, temperature, loss of appetite 2-3 days

    • Can get a VERY mild form of measles or mumps

    • Extremely rare: severe allergic reaction

Varicella

  • Protects against chickenpox and shingles

    • 88-98% effective at preventing varicella after two doses, and 85% effective after 1 dose.

    • Ideally given before pregnancy to protect against chickenpox complications during pregnancy (ie. pneumonia) and congenital varicella syndrome or neonatal varicella.

    • Don’t give it during pregnancy.

  • Ingredients

    • Human diploid cells with DNA and protein

    • Sucrose, gelatin

    • Sodium chloride, monosodium-glutamate, sodium phosphate, potassium phosphate, potassium chloride, EDTA

    • Neoomycin

    • Fetal bovine serum

  • Side effects

    • Common: sore arm, fever, mild rash, temporary pain and stiffness

    • Severe: (very uncommon) - severe infection, pneumonia

HPV

  • Gardasil 9 protects against human papilloma virus 16, 18 (causes 80% of cervical cancer cases), 6, 11 (90% of genital wart cases), and another 5 types (31,33,45, 52, 58) that can lead to cervical cancer.

    • 3 separate shots for people aged 15-45 - high efficacy, with close to 100% prevention of HPV virus

    • If 9-14, 2 shots are sufficient

    • Not currently recommended during pregnancy

      • Good time to give it: immediately pp in hospital (dose 1), then 6 weeks pp  

  • Ingredients

    • Vitamins, amino acids, mineral salts, carbohydrates

    • Amorphous aluminum hydroxyphosphate sulfate

    • Sodium chloride

    • Polysorbate 20

    • Neomycin, yeast protein

  • Side effects

    • Common: pain, redness, swelling of arm where shot was given

    • Less likely: fever, headache, feeling tired, nausea, muscle or joint pain.

Vaccines I: Tdap and Influenza

Today we get a little political to arm you with the most up-to-date information on vaccines. We’ll start with the two vaccines recommended in pregnancy: Tdap and Flu. We summarize some of the salient details below:

(C) CREOGs Over Coffee


Now onto some of these controversial ingredients:

  • Formaldehyde - this is used to inactivate viruses and detoxify bacterial toxins

    • Why are people concerned? Because they hear that formaldehyde is used in glues and adhesives, used in preserving dead bodies,  used in insulation materials. In high levels and long-term exposure, formaldehyde IS linked to cancer development.

    • But it is safe! There is always a small amount  of formaldehyde in humans at all times as a normal part of our metabolism (it’s in the air and all around us). In a normal two-month old, there is around 1.1mg of formaldehyde circulating in the body, which is 50-70x more formaldehyde than is present in one dose of vaccine.

  • Octylphenol ethoxylate (Triton X-100) - basically a detergent. Present in trace amounts

  • Sodium phosphate-buffered isotonic sodium chloride solution - this is salt water, it’s used as a buffer

  • Thimerosol - mercury containing ingredient that acts as a preservative.

    • Why are people concerned? The word mercury. Large amounts can be harmful

    • In vaccines this is ethylmercury, which is different from methylmercury, which is the mercury compound that is harmful. Ethylmercury is much more quickly metabolized and removed from your body.

      1. It’s like being afraid of sodium.  Sodium on it’s own will explode if you put it on water. Sodium chloride is salt that you eat.

      2. Even now… only multi-dose flu vaccines have thimerosol, and thimerosal-free vaccines are widely available.

  • 1,2-phenoxyethanol - preservative; it is metabolized and excreted.

  • Aluminium phosphate - used as an adjuvant in vaccines. Makes it more effective by strengthening immune system response, so people need fewer doses of the vaccine to build immunity.

    • Why are people concerned? There has been concern that long-term exposure to high amounts of aluminum can contribute to brain and bone disease

    • Why are we not concerned? There are trace amounts of aluminum in water, food, breast milk

      • A breast-fed patient will ingest about 7 mg of aluminum in 6 months of life . The standard vaccine administered over the first six months of life averages to just 4.4 mg. The amount in a single vaccine is so small that there is no noticeable raise in the base amount found in the blood even immediately after injection.