413.3 🩺 內科專科考前版

413.3.0.1 📌 䞀頁重點

  • 22E:
    • WPATH SOC 8 (2022) updated standards
    • Lenacapavir (Sunlenca) SC Q6 mo PrEP — long-acting (FDA 2024)
    • Cabotegravir (Apretude) IM Q2 mo PrEP (FDA 2021)
    • Mpox vaccine (Jynneos) for high-risk MSM
    • Adolescent gender care evolving + politically variable
    • Affirming language + practice
  • Taiwan: 健保 estradiol + spironolactone for MTF (條件); 健保 testosterone for FTM (條件); 健保 GnRH agonist (條件); 健保 PrEP (TDF/FTC) limited; 健保 mpox vaccine (高 risk MSM); cabotegravir + lenacapavir 自費 倚; 健保 gender-confirming surgery 限制 + 自費 倚 (健保 涵蓋限制); WPATH-Taiwan 對照

413.3.0.2 🌟 Pearls (10)

  1. WPATH SOC 8 (2022) removes lengthy psychiatric assessment requirement; informed consent model
  2. Endocrine Society Gender-Affirming Care Guideline 2017 + updates
  3. Adolescent guidelines politically contentious globally: clinical evidence + international variation
  4. Cabotegravir IM PrEP discontinuation: gradual decline; risk of acquiring resistant HIV if exposed during decline period
  5. Lenacapavir SC Q6 mo: newest long-acting; capsid inhibitor; PURPOSE trials
  6. Mpox vaccine 2-dose Jynneos: high-risk MSM (multiple partners, recent STI, PrEP)
  7. Cervical CA in trans men 䞍 routine screening trans status alone: still need Pap if cervix present
  8. Breast CA in trans women on long-term estrogen: mammography starting age 50 if 5+ yr estrogen (some guidelines)
  9. Trans-specific cancer registries emerging
  10. Doxycycline post-exposure prophylaxis (DoxyPEP): emerging for STI prevention in MSM

413.3.0.3 📍 Taiwan + 健保

413.3.0.3.1 Drugs
  • 健保 estradiol oral + transdermal (條件)
  • 健保 spironolactone (off-label for MTF)
  • 健保 testosterone IM/gel (條件)
  • 健保 GnRH agonist (leuprolide) — 條件 + 自費 倚
  • 健保 cyproterone acetate — 郚分 / 自費
  • TDF/FTC (Truvada) 健保 limited (HIV+ care; PrEP 郚分自費)
  • Cabotegravir + lenacapavir 自費 倚
  • Mpox vaccine (Jynneos) 健保 (高 risk; 郚分自費)
  • 健保 STI screening + treatment
413.3.0.3.2 Surgery
  • 健保 mastectomy (top surgery) 限制 (cosmetic; 郚分自費)
  • 健保 hysterectomy + oophorectomy (條件)
  • 健保 phalloplasty / vaginoplasty 限制 + 自費 倚
413.3.0.3.3 孞會 + 指匕
  • WPATH-Taiwan 對照
  • Endocrine Society Gender-Affirming Care 2017+
  • 國健眲 LGBTQIA+ health initiative limited

413.3.0.4 🎓 內專必懂 (10)

  1. LGBTQIA+ inclusive medicine + affirming language
  2. Gender-affirming hormone therapy (MTF + FTM)
  3. WPATH SOC 8 (2022)
  4. Trans health long-term monitoring (CV, bone, cancer)
  5. MSM PrEP (TDF/FTC, cabotegravir, lenacapavir 22E)
  6. DoxyPEP for STI prevention
  7. Mpox vaccine + risk reduction
  8. Anatomy-based cancer screening
  9. Mental health disparities + affirming care
  10. 22E: lenacapavir, WPATH 8, cabotegravir PrEP, mpox vaccine

413.3.0.5 ⚙ MTF Hormonal Therapy Detailed

Goals:
- Feminize: breast development, fat redistribution, skin softening, ↓ body hair, voice (limited)
- Suppress masculinization: ↓ T, ↓ libido erections

Estrogen Options:
- Estradiol oral 2-6 mg/d (multiple doses)
- Estradiol transdermal patch 50-200 ÎŒg twice weekly (less DVT risk)
- Estradiol injectable (cypionate IM weekly or valerate biweekly)
- Sublingual estradiol 1-4 mg twice daily
- Avoid: ethinyl estradiol (high DVT risk), conjugated equine estrogen

Anti-androgen:
- Spironolactone 100-200 mg/d (most common)
- Cyproterone acetate (Europe)
- Bicalutamide (rare; hepatotoxicity)
- GnRH agonist (e.g., leuprolide; expensive but effective)

Progestogen (controversial):
- Some advocate for breast development, mood
- Micronized progesterone or medroxyprogesterone

Monitoring:
- Estradiol level (target 100-200 pg/mL with patch; oral lower)
- Total T (target < 50 ng/dL)
- LFT
- K (if spironolactone)
- Lipid + glucose (E increases risk metabolic syndrome)
- Prolactin (rare prolactinoma)
- BMD (if puberty blocker before)

Side Effects:
- DVT/PE (2-3x; smoker + age + oral E)
- Breast CA (long-term)
- Gallstones
- Mood changes
- Erectile dysfunction (intentional)
- Reduced libido + spontaneous erection

413.3.0.6 ⚙ FTM Hormonal Therapy Detailed

Goals:
- Masculinize: voice deeper, muscle, body hair, fat redistribution, amenorrhea, clitoral enlargement, ↑ libido

Testosterone Options:
- Cypionate IM 50-100 mg q1-2 wk
- Enanthate IM similar
- Undecanoate IM Q10-14 wk (depot)
- Gel 50-100 mg/d topical
- Patch 4-8 mg/d
- Oral undecanoate (Jatenzo)

Effects (timeline):
- Acne (1-3 mo)
- Voice change (3-12 mo, irreversible)
- Body hair (3-12 mo)
- Muscle increase (6-12 mo)
- Fat redistribution (6-12 mo)
- Amenorrhea (1-6 mo)
- Clitoral enlargement (3-6 mo, irreversible)
- Vaginal atrophy (6-12 mo)

Monitoring:
- Testosterone level (mid-cycle for IM, target mid-normal male range)
- Hct (target < 54%; avoid erythrocytosis)
- Lipid panel
- LFT
- BMD if pre-puberty blocker
- Sleep apnea (clinical)

Side Effects:
- Erythrocytosis (24%; phlebotomy if Hct > 54%)
- Acne (mostly improve)
- Alopecia (male-pattern baldness)
- Mood changes (initial; usually settles)
- Sleep apnea (worsen if predisposed)
- Lipid changes (HDL ↓, LDL ↑)
- Possible CV risk long-term (uncertain)

Special Considerations:
- Pregnancy risk: continue contraception unless wanting (testosterone alone not contraception)
- Cervical screening (if cervix): continue Pap
- Endometrial atrophy with T (rare hyperplasia)

⚠ AI 草皿。