Pharmacology · chapter 37 · Transgender and Nonbinary Drugs
Feminizing Hormonal Therapy
The 14 things this section of the textbook says that you are most likely to be asked about — quoted word for word, not retold. Then 6 practice questions with the reasoning.
Key points
Cardiovascular risks of female hormones
The adverse effects of female hormone therapy are related to cardiovascular conditions such as myocardial infarction, stroke, and thromboembolic events.
How spironolactone feminizes
However, its action of blocking male sex hormone receptors, the androgen receptors, decreases the production of testosterone, the male hormone responsible for secondary sex characteristics (DailyMed Spironolactone, 2023; Deutsch, 2016; Hembree et al., 2017; Mayo Clinic, 2021a; Ramsay Safer, 2023; Unger, 2016).
Spironolactone contraindications
Contraindications include allergy to the drug, hyperkalemia, renal disease, and anuria (absent urine production and output).
Hyperkalemia is the main danger
The primary adverse effect is hyperkalemia, which could be life-threatening and must be monitored closely. Hyperkalemia may manifest as lethargy, confusion, ataxia, muscle cramps, cardiac dysrhythmias (irregular heart rhythms), or gastrointestinal symptoms (DailyMed, Spironolactone, 2023; Unger, 2016).
Monitor potassium, heart and kidneys
The nurse should monitor the client’s potassium levels and cardiac and renal function. Potassium may be found in intravenous fluids, salt substitutes, and some fruits and vegetables (including oranges, bananas, raisins and other dried fruits, and dark green and yellow vegetables).
How estrogen reduces androgens
Estrogen works through a negative feedback loop to suppress gonadotropin secretion from the pituitary gland and results in reduced androgen production. Usually, estrogen alone will not achieve sufficient androgen control.
When changes appear
These changes will usually begin 1–6 months after treatment starts. The full effect will take 2–3 years (Deutsch, 2016; Hembree et al., 2017; Mayo Clinic, 2021a; Ramsay Safer, 2023; T’Sjoen et al., 2019; Unger, 2016).
Blood clots contraindicate estrogen
A major contraindication for estrogen is a personal or family history of blood clots in the leg (deep vein thromboses) or lungs (pulmonary emboli).
Use estrogen cautiously in smokers
Estrogen should be used cautiously in clients who smoke, have obesity, or have hypertension (Mayo Clinic, 2021a; T’Sjoen et al., 2019; Unger, 2016).
Progesterone for breasts is not routine
However, because there is no evidence that this is effective and because this treatment involves risks, progesterone therapy is not routinely used in transgender treatment (Hembree et al., 2017; T’Sjoen et al., 2019).
GnRH analog changes are reversible
One of the primary benefits of GnRH analog therapy is that once therapy is discontinued, the sex characteristics of the sex assigned at birth return.
Adverse effects of GnRH analogs
Adverse effects that appear to be related to GnRH analog therapy include decreased bone density, diminished adult height, and impaired spatial memory (Hembree et al., 2017; Hruz, 2020).
Finasteride and pregnant handlers
Females of childbearing age, particularly those who are pregnant, should not handle finasteride, especially if the tablets are broken. The medication can be absorbed and negatively affect genital development in a male fetus.
Monitoring schedule
Monitor for feminizing and adverse effects every 3 months for the first year and then every 6–12 months and as needed for problems.
Terms to know
- Spironolactone
- Spironolactone is a nonspecific aldosterone blocker. Its primary use is as a potassium-sparing diuretic to manage hypertension.
- Gynecomastia
- Spironolactone can cause impotence and gynecomastia (breast tissue enlargement) in males, a desired effect for males transitioning to females.
- Anuria
- Contraindications include allergy to the drug, hyperkalemia, renal disease, and anuria (absent urine production and output).
Practice questions
Stuck on select-all-that-apply? How to take them one option at a time.
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Every question here, with the answer
A transgender female client taking spironolactone reports muscle cramps and feeling confused. Which laboratory value should the nurse check first?
- Serum triglycerides
- Serum prolactin
- Bone mineral density
- Serum potassium
Answer: Serum potassium
Spironolactone is potassium-sparing, and its primary adverse effect is hyperkalemia, which can present with confusion, muscle cramps and dysrhythmias. Prolactin, triglycerides and bone density are monitored for other reasons and do not explain these symptoms.
A client is starting spironolactone for male-to-female transition. Which teaching points about potassium should the nurse include? Select all that apply.
- Avoid salt substitutes that contain potassium.
- Keep appointments for potassium level checks.
- Eat extra dried fruit to prevent muscle cramps.
- Take a potassium supplement with each dose.
- Be aware that bananas and oranges contain potassium.
Answer: Avoid salt substitutes that contain potassium., Keep appointments for potassium level checks., Be aware that bananas and oranges contain potassium.
Spironolactone can cause hyperkalemia, so potassium levels are monitored and sources such as salt substitutes, oranges, bananas and dried fruits matter. Adding dried fruit or potassium supplements would raise potassium further.
A client asks to start estrogen for feminizing therapy. Which finding in the history is a major contraindication?
- A previous pulmonary embolism
- Seasonal allergies
- A history of acne
- Taking a daily multivitamin
Answer: A previous pulmonary embolism
A personal or family history of blood clots in the legs or lungs is a major contraindication for estrogen. The other findings are not listed as contraindications.
A client who started estradiol one week ago is upset that there are no visible changes yet. What should the nurse explain?
- Changes usually begin 1 to 6 months after starting, and the full effect takes 2 to 3 years.
- Estrogen works only when progesterone is added.
- Changes appear within days, so the drug is not working.
- The dose should be doubled if no changes appear in one week.
Answer: Changes usually begin 1 to 6 months after starting, and the full effect takes 2 to 3 years.
Feminizing changes usually begin 1–6 months after treatment starts and take 2–3 years for the full effect. Doubling the dose is not supported, and progesterone is not routinely used.
A client undergoing male-to-female transition asks for progesterone to enlarge her breasts. What is the best response?
- "Progesterone is the first-line drug for breast growth."
- "Progesterone has no risks, so it can be added anytime."
- "Progesterone replaces the need for estrogen."
- "Progesterone is not routinely used because there is no evidence it works and it carries risks."
Answer: "Progesterone is not routinely used because there is no evidence it works and it carries risks."
There is no evidence that progesterone enhances breast enlargement, and it carries risks, so it is not routinely used in transgender treatment. Its contraindications and adverse effects are similar to estrogen's, and it does not replace estrogen.
The nurse is planning monitoring for a client taking feminizing hormones. Which actions are part of the nursing implications? Select all that apply.
- Monitor prolactin and triglyceride levels.
- Monitor for feminizing and adverse effects every 3 months in the first year.
- Discuss family planning because of fertility-related effects.
- Monitor serum testosterone and estradiol levels at follow-up visits.
- Stop screening for prostate cancer once therapy starts.
Answer: Monitor prolactin and triglyceride levels., Monitor for feminizing and adverse effects every 3 months in the first year., Discuss family planning because of fertility-related effects., Monitor serum testosterone and estradiol levels at follow-up visits.
Nurses monitor effects every 3 months in the first year, check testosterone, estradiol, prolactin and triglycerides, and ensure the client understands fertility options. MTF clients should still be screened for breast and prostate cancer.
Where every quote comes from
Section 37.2 Feminizing Hormonal Therapy of Pharmacology for Nurses by Tina Barbour-Taylor, Leah Mueller (Sabato), Donna Paris, Dorie Weaver, OpenStax, 2024. Read the whole section free at openstax.org.
The textbook is licensed under CC BY-NC-SA 4.0. This page quotes it word for word and adds the headings, the order and the practice questions; references to the book's figures and stray spaces left by its formatting are removed. The page is shared under the same licence. Nothing here is sold.