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By: Connie Watkins Bales, PhD

• Professor in Medicine
• Senior Fellow in the Center for the Study of Aging and Human Development

https://medicine.duke.edu/faculty/connie-watkins-bales-phd

Since these medications block neither the production nor action of tes to mental illness vs demonic possession purchase mysoline 250 mg line sterone mental health zambia discount mysoline generic, their antiandrogen effect is less than that encountered with full blockade free mental therapy los angeles buy online mysoline. Antiandrogens � other approaches Antiandrogens can also be used alone to bring reduced masculinization and minimal breast development, or in those patients who wish to first explore reduced tes to sterone levels alone, or in those with contraindications to estrogen therapy. In the absence of estrogen replacement, some patients may have unpleasant symp to ms of hot flashes and low mood or energy. Long term full androgen blockade without hormone replacement in men who have undergone treatment for prostate cancer results in bone loss, and this effect would also be expected to occur in transgender individuals. In some patients, complete androgen blockade may be difficult or even impossible using standard regimens. In cases of persistent elevations of tes to sterone in the setting of maximal antiandrogen dosing with good medication adherance, au to nomous endogenous production. Orchiec to my may represent an ideal option in transgender women who do not desire to retain their gonads; this brief, inexpensive, outpatient procedure requires only several days for recovery and does not preclude future vaginoplasty. Progestagens: There have been no well-designed studies of the role of progestagens in feminizing hormone regimens. Many transgender women and providers alike report an anecdotal improved breast and/or areolar development, mood, or libido with the use of progestagens. In reality some patients may respond favorably to progestagens while others may find negative effects on mood. While progestagens have some anti-androgen effect through central blockade of gonadotropins, there is also a theoretical risk of a direct androgenizing effect of progestagens. This class includes micronized bioidentical progesterone (Prometrium) as well as a number of synthetic progestins. The most commonly used synthetic progestin in the context of transgender care is the oral medroxyprogesterone acetate (Provera). First, the transgender women may be at lower risk of breast cancer than non-transgender women. The study aimed to evaluate the role of menopausal hormone therapy in the prevention of chronic disease. The actual findings in the conjugated equine estrogen plus medroxyprogesterone group were an excess absolute risk per 10 000 person-years of 7 more cardiac events events, 8 more strokes, 8 more pulmonary emboli, and 8 more invasive breast cancers, with no change in overall mortality. Injected depo medroxyprogesterone acetate (Depo-Provera ) is less commonly used in transgender women. Other synthetic progestins may be used as necessitated by formulary limitations; some evidence suggests that norpregnane derived progestins (norethindrone, norgestrel) may have an increased risk of venous thromboembolism. Hormone preparations and dosing (Grading: T O M) b c Hormone Initial�low Initial Maximum Comments Estrogen Estradiol 1mg/day 2-4mg/day 8mg/day if > 2mg recommend divided bid oral/sublingual dosing Estradiol 50mcg 100mcg 100-400 Max single patch dose available transdermal mcg is 100mcg. Initial-low dosing for those who desire (or require due to medical his to ry) a low dose or slow upward titration. Maximal effect does not necessarily require maximal dosing; as such maximal doses do not necessarily represent a target or ideal dose. Many patients are eager to begin maximal feminizing hormone therapy and are opposed to the idea of a slow upward titration. Weak evidence suggests that initiation of estrogen therapy at lower doses and titrating up over time may result in enhanced breast development in transgender women. The estrogen recep to r agonist activity of spironolac to ne may play a role in reduced breast development due to premature breast bud fusion. As such an escalating regimen beginning with low dose estrogen only, and titrating up over several months, and then adding spironolac to ne may be an alternative approach,[17] consistent with management practices in children with delayed pubertal onset (Grading: T O W). Upward titration of spironolac to ne can also help minimize side effects such as orthostasis or polyuria. It is recommended that providers discuss these considerations with patients before initiation of hormones in order to make an informed decision. However, estrogen levels in non-transgender women may not be associated with specific secondary sex characteristics. Titration upwards of dose should be driven by patient goals, in the context of clinical response, hormone level moni to ring, and safety moni to ring.

Clinicians may add gender-affirming hormones after a multidisciplinary team has confirmed the persistence of gender dysphoria/gender incongruence and sufficient mental capacity to mental health youngstown ohio order 250 mg mysoline free shipping give informed consent to mental health america cheap mysoline 250mg with amex this partially irreversible treatment metabolic disorders of the brain part ii order 250mg mysoline overnight delivery. We recognize that there may be compelling reasons to initiate sex hormone treatment prior to age 16 years, although there is minimal published experience treating prior to 13. For the care of peripubertal youths and older adolescents, we recommend that an expert multidisciplinary team comprised of medical professionals and mental health professionals manage this treatment. The treating physician must confirm the criteria for treatment used by the referring mental health practitioner and collaborate with them in decisions about gender-affirming surgery in older adolescents. For adult gender-dysphoric/gender-incongruent persons, the treating clinicians (collectively) should have expertise in transgender-specific diagnostic criteria, mental health, primary care, hormone treatment, and surgery, as needed by the patient. We suggest maintaining physiologic levels of gender-appropriate hormones and moni to ring for known risks and complications. When high doses of sex steroids are required to suppress endogenous sex steroids and/or in advanced age, clinicians may consider surgically removing natal gonads along with reducing sex steroid treatment. Clinicians should moni to r both transgender males (female to male) and transgender females (male to female) for reproductive organ cancer risk when surgical removal is incomplete. Additionally, clinicians should persistently moni to r adverse effects of sex steroids. For gender-affirming surgeries in adults, the treating physician must collaborate with and confirm the criteria for treatment used by the referring physician. Clinicians should avoid harming individuals (via hormone treatment) who have conditions other than gender dysphoria/gender incongruence and who may not benefit from the physical changes associated with this treatment. We recommend against puberty blocking and the criteria for the endocrine phase of gender gender-affirming hormone treatment in pre transition before beginning treatment. We recommend that clinicians evaluate and ad (1 |EEss) dress medical conditions that can be exacerbated 1. We recommend that clinicians inform and by hormone depletion and treatment with sex counsel all individuals seeking gender-affirming hormones of the affirmed gender before begin medical treatment regarding options for fertility ning treatment. We suggest that clinicians measure hormone pression in adolescents and prior to treating with levels during treatment to ensure that endog hormonal therapy of the affirmed gender in both enous sex steroids are suppressed and admin adolescents and adults. In adolescents who request sex hormone treat 3 months during the first year of hormone ment (given this is a partly irreversible treatment), therapy for transgender males and females and we recommend initiating treatment using a then once or twice yearly. We suggest that clinicians evaluate transgender informed consent, which most adolescents have persons treated with hormones for cardiovas by age 16 years. We recognize that there may be compelling abetes screening, and/or other diagnostic to ols. We suggest that transgender females treated parameters every 6 to 12 months during sex with estrogens follow individualized screening hormone treatment. We recommend against puberty blocking necessary and would benefit the patient�s overall followed by gender-affirming hormone treatment of pre health and/or well-being. We advise that clinicians approve genital gender children, adolescents, and adults seeking gender affirming surgery only after completion of at least confirming treatment of their options for fertility preser 1 year of consistent and compliant hormone vation. Prior to treatment, clinicians should evaluate the treatment, unless hormone therapy is not desired presence of medical conditions that may be worsened or medically contraindicated. A multidis Practice Statement) ciplinary team, preferably composed of medical and 5. We advise that the clinician responsible for en mental health professionals, should moni to r treat docrine treatment and the primary care provider ments. Clinicians evaluating transgender adults for ensure appropriate medical clearance of trans endocrine treatment should confirm the diagnosis of gender individuals for genital gender-affirming persistent gender dysphoria/gender incongruence. We recommend that clinicians refer hormone hormone levels and metabolic parameters, as well as as treated transgender individuals for genital sur sessments of bone density and the impact upon prostate, gery when: (1) the individual has had a satisfac to ry gonads, and uterus. We also make recommendations for social role change, (2) the individual is satisfied transgender persons who plan genital gender-affirming about the hormonal effects, and (3) the individual surgery. The task force followed the approach recom mended by the Grading of Recommendations, Assessment, dividual. There is insufficient evidence to rec Development, and Evaluation group, an international group ommend a specific age requirement.

In fact mental disorders often go untreated because purchase 250mg mysoline visa, taking high-dose vitamin E is linked to list of mental disorders for ssi 250 mg mysoline for sale premature death degenerative disorders of the brain ppt generic 250mg mysoline fast delivery, underscoring that it is preferable to consume vitamins from food rather than in pill form. Food sources Vitamin A is found in beef liver and organ meats, but these are high in cholesterol, so limit their intake. Similar to vitamins and minerals, antioxidants from foods display stronger disease-fighting capacity than pill-based antioxidants. Glutathione and N-Acetyl Cysteine Glutathione is a powerful antioxidant, but its levels decline as we age. Glutathione is composed of three amino acids (building blocks of protein), so it is digested in the gastrointestinal tract (similar to proteins). This means it is not effective if taken in pill form, as most pills are digested in the s to mach. Despite this fact, glutathione is sometimes advertised in pill form, reminding us that supplements and their marketing are not strictly regulated. N-acetyl cysteine is an alternative pill option, since it is converted to glutathione in the body. At the same time, high uric acid levels can cause a painful form of arthritis called gout, as well as kidney s to nes and high blood pressure. Omega-3 Fatty Acids (Fish and Krill Oil) Diets high in omega-3 are associated with a lower risk of arthritis, stroke, depression, cognitive decline, and Alzheimer�s disease. Fish oil is derived from the tissues of oily fish, while krill oil is obtained from small sea living crustaceans. Food sources � Cold water oily fish such as salmon, mackerel, sardines, herring, halibut, and tuna are natural sources of omega-3 fatty acids. Curcumin Curcumin is a polyphenol with strong anti-inflamma to ry and antioxidant properties. It is found in the turmeric root, which is an important ingredient in Indian cooking (responsible for the yellow color of curries). Bioenergetics this category includes compounds that enhance cell energy production or serve as a brain or muscle energy source. This supplement is fat-soluble, so absorption can vary based on foods eaten, time of day taken, other supplements taken at the same time, and the type of CoQ10 used. Medium chain fatty acids are metabolized to ke to ne bodies, and the brain actually uses ke to nes preferentially and more efficiently than glucose. There is longstanding interest in diets high in medium-chain fatty acids for Alzheimer�s disease, and there have been some reports of improvement in measures of cognitive function. Creatine Creatine is a naturally occurring amino acid found in foods (especially meat); in the human body, its greatest concentration is in our muscles. Neurochemicals and Neuromodula to rs Some practitioners are attempting to help their patients by using drugs or supplements that are classified as either neuromodula to rs � which they believe will interact with our brain�s immune health and circadian body rhythms or neurochemicals � which activate or inhibit nerve cell activity. Mela to nin Mela to nin is a powerful antioxidant that is responsible for regulation of circadian rhythms, sleep, and wakefulness, so it is sometimes used to help people sleep. However, the safety of doses higher than 3mg is not established, so use with caution. Early morning sedation, depression, and vivid dreaming are experienced by some people who take mela to nin; it can also alter blood sugar levels in people with diabetes and influence the immune system. A recent study showed improved sleep, pain, tremor and bradykinesia (mo to r slowness) 30 minutes after smoking marijuana in clinic. Marijuana has psychoactive, behavioral, and mo to r effects, which can all impact tremor and movement. For example, tremor will increase with stress and improve with treatments known to enhance relaxation. Marijuana�s behavioral effects may lead to greater relaxation or euphoric mood, or may mitigate the stress response, and this alone could reduce tremor. As with any drug, there are pros and cons to using marijuana, and it is important to review these with your healthcare provider. In particular, the lack of regulation and the potential addictive and psychoactive consequences (including psychosis and apathy) are potential concerns. A small, controlled study comparing the effect of carbidopa/levodopa and mucuna pruriens in patients with mo to r fluctuations and dyskinesia showed faster and longer �on� time, without dyskinesia, after mucuna treatment. Mucuna pruriens contains levodopa and therefore carries the same potential risks and side effects of levodopa.

Evaluations of patient physical and psychological his to mental disorders in winnie the pooh 250mg mysoline amex ry can screen for risk fac to mental illness and the death penalty 250mg mysoline with visa rs and characterize pain to mental health therapy with horses mysoline 250mg mastercard inform treatment decisions. This includes screening for drug and alcohol use and the use of urine drug testing, when clinically indicated. Efective screening can include single questions, such as, �How many times in the past year have you used an illegal drug or used a prescription medication for nonmedical reasonsfi The agreement should be viewed as an opportunity for ongoing dialogue about the risks of opioids and what the patient and clinician can expect from each other. Clinicians should also screen for fac to rs that predict risk for poor outcomes and substance abuse, such as sleep disturbance, mood disorder, and stress, either by using a pain rating scale such as the Defense and Veterans Pain Rating Scale, which includes brief questions, or by routinely asking about these fac to rs on clinical examination. Lack of sufcient compensation for time and payment for services have contributed to barriers in best practices for opioid therapy. These are vital aspects of risk assessment and stratifcation for patients on opioids and other medications. Treatment agreements should include the responsibilities of both the patient and the provider. Studies suggest that patients who are receiving or who have previously received long-term opioid therapy for nonmalignant pain face both subtle and overt stigma from their family, friends, coworkers, the health care system, and society at large for their opioid treatment modality. I hate that I everyone assume the person was depressed am being treated like a drug abuser or anxious firstfi He yelled at My wife has Cervical Spinal me, shamed me, and Stenosis with Myelopathy. Within one month she was bed ridden and had talked to her September 2018 employer explaining why she may have to quit her accounting job. Stigma, combined with the enhanced time required to efectively evaluate and treat pain, leads to over-referral and patient abandonment. I ended up going to multiple doc to rs to fnd help for my pain � orthopedists, physiatrists, a neurologist, and four to p neurosurgeons. I was to ld that I was not a candidate for surgery, but few other solutions were given. This was also the most vulnerable time for my family, who were my caregivers, because they had no knowledge or understanding or to ols to deal with me and my pain. I had no prior psychiatric his to ry and had never been to a psychiatrist in my life. During one hospital stay, I was labeled chemically dependent and recommended for a 30-day drug-rehabilitation program. I refused to go because all I wanted was for the pain to s to p and to go back to my normal life. About two years later, I fnally ended up in a pain management clinic headed by fellowship-trained pain management anesthesiologists. Contributing to this stigmatization are the lack of objective biomarkers for pain, the invisible nature of the disease, and societal attitudes that equate acknowledging pain with weakness. This confusion has created a stigma that contributes to barriers to proper access to care. This is how my and necessary for optimizing patient outcomes, promoting appropriate use of pain medication, and reducing the risk nightmare began. I had no prior psychiatric his to ry and had Public Patient Provider Legistla to rs, never been to a psychiatrist in my life. Education Education Education Regula to rs Education Each time I would return home, but nothing had changed. My family didn�t know what to do to help me and the situation caused a lot of family stress. I refused + E ective, patient-centered care to go because all I wanted was for the pain to s to p and to go back to my normal life. About two years later, I fnally ended up in a pain management clinic headed by fellowship-trained + Optimize patient functional outcomes pain management anesthesiologists. I was treated with understanding and respect and given + Appropriate use of pain medication the medical care that I needed to help improve my quality of life + Eliminate stigma + Reduced risk through risk-benefit assessment Figure 19: Education Is Critical to the Delivery of E ective, Patient-Centered Pain Care and Reducing the Risk Associated With Prescription Opioids To begin to address the growing need for educational initiatives, multiple entities, including government agencies, nonproft organizations, pharmaceuticals manufacturers, academic institutions, and health systems, have developed and disseminated pain and opioid-related patient education programs, to olkits, pamphlets, and other interventions. Similarly, state-level continuing education requirements have been established for several provider types. Addressing multiple education gaps simultaneously will likely be necessary to optimize patient outcomes tied to public, patient, and provider education.

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