Practical Guidelines for Transgender Hormone Treatment

Adapted from: Gardner, Ivy and Safer, Joshua D. 2013 Progress on the road to better medical care for transgender patients. Current Opinion in Endocrinology, Diabetes and Obesity 20(6): 553-558.


  • In order to improve transgender individuals’ access to health care, the approach to transgender medicine needs to be generalized and accessible to physicians in multiple specialties.
  • A practical target for hormone therapy for transgender men (FTM) is to increase testosterone levels to the normal male physiological range (300–1000 ng/dl) by administering testosterone.
  • A practical target for hormone therapy for transgender women (MTF) is to decrease testosterone levels to the normal female range (30–100 ng/dl) without supra- physiological levels of estradiol (<200 pg/ml) by administering an antiandrogen and estrogen.
  • Transgender adolescents usually have stable gender identities and can be given GnRH analogs to suppress puberty until they can proceed with hormone therapy as early as age 16.

Hormone regimes for transgender men (female to men, FTM)

   1. Oral

  • Testosterone undecanoate*     160–240mg/day

   2. Parenterally (i.m. or subcutaneous)

  • Testosterone enanthate or cypionate     50–200mg/week or 100–200mg/2 weeks
  • Testosterone undecanoate     1000 mg/12 weeks

   3. Transdermal

  • Testosterone 1% gel     2.5 – 10 g/day
  • Testosterone patch      2.5 – 7.5 mg/day 

i.m., intramuscular.
*Not available in the USA.

Monitoring for transgender men (FTM) on hormone therapy:

  1. Monitor for virilizing and adverse effects every 3 months for first year and then every 6 – 12 months.
  2. Monitor serum testosterone at follow-up visits with a practical target in the male range (300 – 1000 ng/dl). Peak levels for patients taking parenteral testosterone can be measured 24 – 48 h after injection. Trough levels can be measured immediately before injection.
  3. Monitor hematocrit and lipid profile before starting hormones and at follow-up visits.
  4. Bone mineral density (BMD) screening before starting hormones for patients at risk for osteo- porosis. Otherwise, screening can start at age 60 or earlier if sex hormone levels are consistently low.
  5. FTM patients with cervixes or breasts should be screened appropriately.

Hormone regimes for transgender women (male to women, MTF) 

     1. Anti-androgen

  • Spironolactone   100 – 200 mg/day (up to 400 mg)
  • Cyproterone acetatea   50–100mg/day
  • GnRH agonists   3.75 mg subcutaneous monthly

    2. Oral estrogen

  • Oral conjugated estrogens   2.5–7.5mg/day
  • Oral 17-beta estradiol   2–6mg/day

    3. Parenteral estrogen

  • Estradiol valerate   5–20mg i.m./2 weeks  or cypionate  2–10mg i.m./week

    4. Transdermal estrogen

  • Estradiol patch    0.1–0.4mg/2X week

i.m., Intramuscular; MTF, male to female. aNot available in the USA.

Monitoring for transgender women (MTF) on hormone therapy:

  1. Monitor for feminizing and adverse effects every 3 months for first year and then every 6– 12 months.
  2. Monitor serum testosterone and estradiol at follow-up visits with a practical target in the female range (testosterone 30 – 100 ng/dl; E2 <200 pg/ml).
  3. Monitor prolactin and triglycerides before start- ing hormones and at follow-up visits.
  4. Monitor potassium levels if the patient is taking spironolactone.
  5. BMD screening before starting hormones for patients at risk for osteoporosis. Otherwise, start screening at age 60 or earlier if sex hormone levels are consistently low.
  6. MTF patients should be screened for breast and prostate cancer appropriately.


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