Hello, I am Leslie Greenberg. I am a family physician in Reno, Nevada. I attended Northwestern University in Chicago, then University of Nevada School of Medicine. I relocated back to my hometown in 2015. I trained and practiced medicine in the Midwest (Indiana and Kansas) for 20 years before moving back West. I consider myself a teacher and educator. I have taught 400 + family medicine residents (and countless medical students), over nearly 25 years. I currently teach at the family medicine residency program in Reno and also see private patients. I care for newborns through elderly patients in both the hospital and office. I love to do procedures: skin biopsies, circumcisions, IUD insertion/removals, paps, colposocopies, and toenail removals. I invite you to read my blog. If you would like to become a patient, please call 775-982-1000.
Please remember that medical information provided by myself, in the absence of a visit with a health care professional, must be considered an educational service only. This blog should not be relied upon as a medical judgement and does not replace a physician’s independent judgement about the appropriateness or risks of a procedure or condition for a given patient. I will do my best to provide you with information that may help you make your own health care decisions.
I recently attended a transgender medical lecture. Excellent resources abounded. Here are the ones I thought may be most helpful.
https://Jackturban.com Dr. Turban is a UCSF child and adolescent psychiatrist. He has a fabulous website regarding adolescent care. He reviews media articles on transgender issues. He has copious research showing benefit of offering adolescents gender-affirming care.
When transgender issues occur in adolescents, your primary care may do your primary care AND you will often be referred to pediatric endocrinology. Pediatric endocrinology physicians can help with medication management and watch their growth. This portion of their care can be done by telehealth if needed.
Real Mama Bears is a fabulous website to help families address transgender issues.
TrevorLifeline 1-866-488-7386 is a hotline 24/7 to help decrease suicide in transgender youth.
Want to know about how to bind? Which bras to buy? Look at Fenway Health.
Transcare.ucsf.edu has guidelines for the primary care and gender-affirming care of transgender and gender nonbinary people. This done by Dr. Deutsch.
WPATH World Professional Association for Transgender Health website has excellent resources and a link to their society guidelines
I am in Kansas City learning with 1000 other family medicine academic physicians how to LEAD family medicine residency programs. It is refreshing to hear new educational curriculum: how family physicians can meet the needs of our current patients. Because I have taught at three medical schools over 25 years this meeting allows for reconnecting with cherished friends at this meeting.
University of Nevada Reno Family Medicine Residency Program has existed for over 30 years. We currently mentor 28 family medicine residents over three years and have two one-year fellowships: one wilderness medicine fellow and 2 sports medicine fellows.
In the US, there are 745 family medicine residency programs who graduate 5,000 family physicians a year.
On average, resident physicians learn over 3 years on HOW to be a family physician. Each resident physician sees over 1600 physicians (both in the hospital and the office) and do 150 telehealth visits before graduation. There are also requirements for residents to see nursing home patients and do home visits.
Family physicians are diverse with the goal being that the physicians look like the patients:
9 % Black
The personal care of patients is our core goal. Family physicians want to care for patients longitudinally, over time. My friend has a license plate holder that reads “Everyone deserves a family physician.” I could not agree more.
I recently attended a medical conference and listened to a fabulous transgender care lecture. Here are the pearls that I learned…
Goal of testosterone is 300 – 1000. There is large range for testosterone. Testosterone level over 1000 causes problem with increased red blood cell mass.
The masculinizing change takes upwards of 3-5 years for masculinization to take effect. Usually within 6 months, the voice has completely changed and this is an irreversible effect of testosterone.
Testosterone cypionate is usually given under the skin (and does not need to be injected into the muscle). Gel is a popular option, but these are expensive and often not covered by insurance. Testosterone pellets (Testepell) is used as a subdermal implant that is inserted every 3 months.
Labs: testosterone level.
Estradiol level does not matter much.
Goal for testosterone is within the male-range. Monitor red blood cell mass. Hematocrit less than 55 is the goal. Be sure to hydrate with water with blood work drawn.
Removal of uterus and ovaries. Ob/gyn perform this surgery.
After 2 years of testosterone the clitoris can be formed into a phallus. Metoidioplasty (done at many sites) and phalloplasty (staged surgeries over a year or two. Complicated. Only done at a few centers around the country) may be considered.
Patients still need primary care!
Physician should take organ-inventory to make sure that all organs are screened for.
For example, transgender men who have a cervix need pap smears to screen for cervical cancer).
If transmen miss a testosterone dose (and have vaginal intercourse with men) they can get pregnant. What is the contraception method?
Mammogram. If breasts were mostly removed and chest contouring was performed, there is still some breast tissue present. Consider breast u/s or MRI may be needed (there may not be enough breast tissue to squeeze in a mammogram machine).
I recently attended a medical lecture on transgender medical care. Here were some take-home points about transgender women.
3 commonly prescribed feminizing medications:
Here is an excellent checklist and consent regarding starting feminizing medications.
1. Estradiol (oral/transdermal/intramuscularly). Oral and transdermal are the most common. Estradiol is often used for postmenopausal females. Most physicians are accustomed to giving this. The effects of these medications are both reversible and irreversible.
Reversible (loss of muscle mass, weight gain, skin changes, erectile dysfunction, mood, nausea, increased risk of blood clots, diabetes and hypertension).
Irreversible effects (breast growth, testicle size reduction, infertility). Because of infertility, discuss fertility plans with the patient. Estradiol 2 mg by mouth daily may help the patient inch up. If the patient wants to shut down male attributes, a therapeutic dose may be estradiol 6 mg. Transdermal estrogen decreases clot risk.
2. Antiandrogen. Spironolactone is often used. This may cause premature breast bud fusion in adolescents. Many physicians start with estrogen and then add spironolactone later and the dose of spironolactone can be titrated up. Bicalutamide is an old drug that (was originally used for prostate cancer) is also used for antiandrogen effects. It has had case report of liver failure and this should be discussed with patients. Patients may learn of bicalutamide on Youtube. The physician and patient should used shared decision making when this drug is used.
3. Progestagens. They promote breast growth. Synthetic type is Depo Provera (injected subcutaneous or intramuscular every 3 months) or bio identical oral tablets of micronized progesterone. Usual dose of micronized progesterone is 100 mg po taken nightly.
Within 3 months blood lab work is done.
The treatment goal is to manipulate testosterone in all patients. Estradiol goal is around 100. But if the testosterone is less than 55, the medication is therapeutic. Sex hormone binding globulin lab does not need to be obtained as it does not give us much information.
Two labs: testosterone and estradiol levels are important and will change care.
Medications often cause increased breast formation. Many plastic surgeons perform breast augmentation for transgender women.
Orchiectomy (removal of testicles) is often performed by urologists.
Gender-affirming vaginoplasty. This is done at tertiary care centers who specialize in this. The surgeries make a neo-vagina with the penis and scrotum. The nerve bundle at the glans penis are placed to make a clitoris. 80% of patients after this surgery have orgasms with genital stimulation. THE PROSTATE IS PRESERVED. The prostate is kept in place to help suspend the bladder to maintain continence. Because the prostate is still present, this needs appropriate screening for prostate cancer.
Be sure your primary care physician knows which organs you have. This will let us know which health screenings you need.
Prostate cancer screening is needed in transwomen that still have a prostate. Rectal exam does not feel the prostate after a neovaginal surgery was performed. The prostate is felt through a vaginal exam. Your physician should consider PSA per guidelines and shared guidelines with the patient are done. Prostate cancer is thought to be low, but we do not know.Let us help you appropriately.
I recently attended a medical meeting and heard a fascinating talk about transgender care for primary care physicians.
Physicians often fear that we are going to do harm if we offer gender affirming medication or surgery. We are concerned that they will have regrets down the road. Studies have shown that 95% are happy with their changes. Within the 5% who are unhappy, most say that they regret changing because it was hard and disruptive (family/friends/cost of treatment/time-intensity of treatment).
Gender affirming care is a spectrum.
It starts with using the pronouns and names that they request.
Patients can change their dress.
Tucking, packing and binding to have the profile that fits their gender identity.
Physicians should invite openness into their exam space. Consider that we all are on a gender spectrum: (Do I prefer to wear pants? Am I the breadwinner in the family?) and that if we are aware of our privilege this would be helpful. Here’s a great privilege checklist to appreciate what is YOUR privilege?
See my future blog posts on more information about transgender medical care…
Chlamydia and Gonorrhea infections. Who should be screened? What is the current treatment?
Chlamydia and gonorrhea infections are the most common sexually transmitted infections in the US. These bacteria often infect the mouth, urogenital and anorectal areas. If unknown or not treated they can cause spread to other organ systems, scar fallopian tubes, increase the chance of ectopic pregnancy, infertility, and pain with intercourse and defecation. Ouch!
Best treatment plan…. Have both members of the couple get STI testing before oral or genital intercourse. Have your partner wear a condom from start to finish. Routinely get screened for infections so an infection can be adequately treated.
ALL sexually active individuals less than age 25
Men who have sex with men
Transgender and gender-diverse people
Having multiple sexual partners
Personal history of sexually transmitted infection
Screening guidelines (per USPSTF and CDC)
Annual screening for chlamydia and gonorrhea in any sexually active people under age 25 AND anyone (of any age) with risk factors. Screening should test all the “parts” used for sex (mouth, genitals, anus).
–Gonorrhea, if uncomplicated, is routinely treated with a single antibiotic dose injected into the muscle.
–Chlamydia treatment requires a 7-day oral course of doxycycline.
When to test to confirm the infection is gone?
If pregnant, a test of cure should be obtained 4 weeks after treatment.
If not pregnant, testing 3 months after will confirm no reinfection. I urge those infected to tell those who they have had intimate contact with.
If they are a couple, I educate them both about the infection that they share, treatment regimens they both should take, and the LOW risk of getting re-infected after treatment…. Unless one of them has another partner.
Who gets oral yeast infections? How to treat them?
Most healthy people’s mouths are colonized with yeast, Candida albicans. When the yeast count is at a routine level, this should have no symptoms.
Who is at risk for symptomatic oral yeast infection?
People on oral or inhaled steroids *for asthma or sinus issues)
Recent antibiotic use
What does oral candida look like? White plaques (on inside of cheeks, palate or tongue)that can’t be wiped off and are often on the sides of the tongue or white plaques that when wiped off show redness at their base. Patients may have no symptoms, complain of “cotton-mouth” or oral burning, or have a metallic taste in their mouth.
Dentures may be colonized with yeast. Removing the appliance overnight and soaking in 0.1% sodium hypochlorite or 4% chlorhexidine will help decrease colonization. Brushing dentures with toothpaste can cause scratching on the denture surface.
Treatment usually consists of oral antifungal lozenge or tablets for 1-2 weeks. If the white plaque does not resolve with treatment with an antifungal, a biopsy is needed to rule out cancer.
Ugh. Canker sores are the most common ulcerative condition in the mouth.
Peak age is in the teen years.
There’s a genetic predisposition to getting canker sores.
It is unknown why some people get them.
Most ulcers are considered mild with lesions less than 1 cm in diameter. These lesions are usually present for 1-2 weeks and heal without scarring.
Ulcers more than 1 cm in diameter represent less than 10% of cases. They may persist for 6 weeks and heal with mucosal scarring. Major ulcers are associated with HIV infection.
Treatment: Topical corticosteroid gels or rinses are the most common therapy but most heal without any treatment. Major ulcers may require oral steroids. Peridex rinse may decrease pain and severity, but may stain teeth. Avoidance of toothpaste with sodium lauryn sulfate may decrease recurrences of canker sores.
What is the prognosis of onychomycosis (fungal infection of your toenails)? And, how to prevent recurrence? There is effective treatment to rid the majority of patients of onychomycosis. But the relapse rate is nearly 25% within 2 years (even AFTER successful treatment).
Who is most at risk to have a relapse (or a recurrence) of their onychomycosis?
Patients older than 70 years,
those with a history of nail trauma, and
How to prevent recurrence?
Avoid walking barefoot in public places.
Disinfect shoes and socks.
Keep feet dry and cool.
See your physician if a nail seems to be getting infected again.
Twice weekly application of topical antifungal on the toes can help decrease the chance your skin will be infected and serve as a reservoir of infection.
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