COVID-19 pandemic and hormone therapy – updated October 2020

Updated October 2020

In light of the ongoing Coronavirus pandemic, NHS services have adapted and most services are now able to provide a more normal service, including regular injections and blood tests in primary care and at GP practices. It is important that hormonal therapies are continued and maintained as per our recommendations and clinical guidelines. Delays and disruption to hormone therapy may affect psychological wellbeing and mental health. However, we recognise that in these challenging times, issues related to hormone therapy may arise. As such, we have put together the following, which covers:

  • Consequences of disruption and delays in treatment
  • Injections – options when there is difficulty in timely administration
  • Blood test monitoring
  • Managing complications of hormone therapy
  • Medication shortages and alternative formulations
  • Additional support services for patients
  • How to contact the Endocrine team

Consequences of disruption and delays in treatment

In general, we advise that hormonal therapies are continued as per our recommendations and clinical guidelines because disruption may affect psychological wellbeing and mental health. On the other hand, physical health is unlikely to be affected if there are small disruptions or minor delays in treatment. There may be some return of characteristics of birth assigned sex but these should revert when hormone therapy resumes. For patients who have had genital reconstructive surgery, physical health complications are unlikely unless they are off hormone therapy for more than two years.

Testosterone injections

Sustanon or Testosterone Enanthate: If it is difficult to provide timely administration of testosterone injections for a patient then it is possible to (a) teach the patient how to self-administer the injections or, (b) to switch them to a testosterone gel.

(a) Teaching to self-inject

Many of our patients have been taught to self-inject their Sustanon or Testosterone Enanthate injections if there are no risk issues and they are supported with this by their GP practice. This offers convenience and independence for patients, reduces visits to the practice and staff time. Blood test monitoring will still need to be done via the practice. Our advice is as follows:

  1. An appropriately qualified member of practice staff (usually a practice nurse), competent in intramuscular (IM) injection technique, should teach the patient how to inject safely. We suggest the vastus lateralis muscle of the thigh for self-injection, as other IM sites can be difficult to reach when self-injecting. The patient should then be supervised to ensure that they are injecting safely.
  2. Once satisfied the patient is competent to self-inject safely, the patient should be provided with the prescribed medication, as well as the following equipment:
    1. Skin cleansing wipes
    2. Needles for drawing up
    3. Needles for injecting (appropriate size for IM injections)
    4. Syringes (appropriate size for volume of medicine to be injected)
    5. A sharps bin for disposal of sharps and medicines waste
  3. Blood test monitoring will still need to be organised via the GP practice.

(b) Switching to testosterone gel

Another option is to switch the patient to a testosterone gel (to be self-administered by patient). Our advice on switching from injections to gels is as per the conversion leaflet: https://gic.nhs.uk/wp-content/uploads/2019/09/HRT-starting-doses-and-conversions.pdf

Nebido: Ideally, Nebido injections should be administered when they are due. However, patients already established on Nebido injections can be reassured that Nebido is a long-acting testosterone formulation and therefore, it is unlikely that testosterone levels will drop out of target range if an injection is delayed by a week or two. On the other hand, we do not recommend that the injections are administered early. Nebido should not be self-administered by patients.

Decapeptyl/GnRH injections and anti-androgens

Ideally, GnRH analogue injections should be administered when they are due. However, GnRH analogue injections may be safely delayed for a few weeks, with a very low risk of a resumption of testosterone or oestradiol release. Some patients worry about not having their injection at the usual time and may report symptoms suggesting a resumption of hormone release; however, because these medications are highly effective and reliable in suppressing this, the most likely cause for such symptoms is anxiety.

If it is difficult to provide timely administration of GnRH analogue injections, there are alternative options. Assuming that a patient is tolerating GnRH analogue therapy well, another option would be longer-acting formulations such as Decapeptyl 22.5mg IM every six months. You may also wish to consider alternative non-injectable preparations that patients can self-administer, such as Synarel (Nafarelin) 200 micrograms twice a day nasal spray (see BNF).

If it is not possible to offer injections in the near future, you can consider prescribing Finasteride 5mg a day as an anti-androgen until it is possible to resume GnRH analogue injections.

Monitoring hormone therapy

Blood tests: In line with a return to more normal NHS services, blood tests via primary care and GP practices have largely resumed with additional safety measures to ensure appropriate social distancing. These measures may lead to a reduction in capacity or slight delays, but there is no reason that monitoring blood tests for hormonal therapy should not be done, and they should be done as soon as is reasonably possible. If there are safety issues relating to hormone therapy then we would expect blood tests to be considered urgent.

Managing Complications of Testosterone therapy

Polycythaemia: actions for haematocrit levels

  • Haematocrit less than 0.52 is acceptable.
  • Haematocrit 0.52 – 0.55: Advise patient to drink 2L water, ensure they are not smoking. Repeat bloods just before next Sustanon or Nebido injection, or 8 weeks later if using gel. If still raised on repeat, GP to seek advice from GIC.
  • Haematocrit 55 – 0.60: GP to inform GIC urgently. Check FBC history to see if a pattern. Advise patient to drink 2L water, ensure they are not smoking. If it is an isolated episode, repeat bloods just before next Sustanon or Nebido injection, or 8 weeks later if using gel. If pattern of polycythaemia on injections, then we advise switching to testosterone gel (as above) and also assess for other potential causes such as Obstructive Sleep Apnoea.
  • Haematocrit 6 or above: GP to pause testosterone therapy and refer urgently to haematology for venesection, also inform GIC urgently. After haematology clearance then return to testosterone as topical therapy, with haematology plan for venesection.

Dyslipidaemia

Normal cardiovascular risk assessment and management applies. Seek advice if significant changes in lipids. Calculate the Q-risk score of the patient using the male gender to make intervention decisions.

Abnormal Liver Function Tests

For values less than 3x the upper limit of normal: check medicines and alcohol history, retest in 4-6 weeks. If LFTs are abnormal on repeat, then perform further investigations to determine the cause: Hepatitis B and C serology, HIV serology, Ferritin, Caeruloplasmin, liver auto-immune screen, ultrasound of the liver.

Values of greater than 3x the upper limit of normal: GP to suspend hormone therapy and refer to local hepatology.

Managing complications of oestrogen therapy

Thromboembolism

Stop oestrogen therapy until patient is anti-coagulated. When haematology advises that it is safe to do so, oestrogen therapy with topical formulations (gel or patch) can be resumed. Anti-coagulation should be lifelong to continue oestrogen therapy. Inform the GIC team.

Hyperprolactinaemia

Small transient rises in prolactin are often seen with oestrogen therapy.

  • If prolactin is higher than normal but less than 1000 then repeat the prolactin. If repeat prolactin level remains elevated then discuss with GIC endocrine team. Review medications for those that can cause hyperprolactinaemia.
  • If prolactin is higher than 1000 then refer to local endocrine service for assessment and MRI of pituitary.

Abnormal Liver Function Tests

For values less than 3x the upper limit of normal: check medicines and alcohol history, retest in 4-6 weeks. If LFTs are abnormal on repeat, then perform further investigations to determine the cause: Hepatitis B and C serology, HIV serology, Ferritin, Caeruloplasmin, liver auto-immune screen, ultrasound of the liver.

Values of greater than 3x the upper limit of normal: GP to suspend hormone therapy and refer to local hepatology.

Medication shortages and alternative formulations

If there are local supply issues with particular formulations of hormonal medications, there are alternatives. Please see the following link for our advice: https://gic.nhs.uk/gp-support/updates-on-physical-interventions/

Other sources of support

If a patient requires further support, we suggest that patients are directed to local third sector organisations and online community support groups during this time.https://gic.nhs.uk/info-support/support-groups-and-resources/

 

Contact with the GIC endocrine team:  

Please note we are not an emergency service.

 

We can only give advice on patients who are under, or who have been under, our care. For patients who have not been under our care we can only give general advice and it would be better for you to contact the service or practitioner that made the hormone recommendations for advice on monitoring or management of hormonal therapies.

 

Email: GPs and other healthcare professionals can email gic.endocrine@nhs.net with queries, or for advice and support regarding hormonal therapies. Patients should email gic.endo@nhs.net

Telephone: Our hormone advice telephone line for GPs and other healthcare professionals is now active again. If we do not answer the phone call, please leave a message. We aim to respond within 48 hours. The telephone number is: 020 8938 7369

 

***This phone number is not for patient queries, and we will not engage with or respond to patient queries made to this number. Instead, current or previous patients can email gic.endo@nhs.net with hormone specific queries. General patient queries can be emailed to gic.noreply@nhs.net.