{"id":414,"date":"2013-12-21T11:53:16","date_gmt":"2013-12-21T16:53:16","guid":{"rendered":"https:\/\/www.bumc.bu.edu\/endo\/?page_id=414"},"modified":"2014-05-13T18:45:29","modified_gmt":"2014-05-13T22:45:29","slug":"guidelines","status":"publish","type":"page","link":"https:\/\/www.bumc.bu.edu\/endo\/clinics\/transgender-medicine\/guidelines\/","title":{"rendered":"Practical Guidelines for Transgender Hormone Treatment"},"content":{"rendered":"
\n

Adapted from:<\/span>\u00a0Gardner,<\/strong>\u00a0Ivy\u00a0<\/strong>and\u00a0Safer, Joshua D<\/strong>. 2013\u00a0<\/strong>Progress on the road to better medical care for transgender patients. Current Opinion in Endocrinology, Diabetes and Obesity 20(6): 553-558.<\/p>\n

\n

KEY POINTS<\/strong><\/p>\n

    \n
  • In order to improve transgender individuals\u2019 access to health care, the approach to transgender medicine needs to be generalized and accessible to physicians in multiple specialties.<\/li>\n
  • A practical target for hormone therapy for transgender men (FTM) is to increase testosterone levels to the normal male physiological range (300\u20131000 ng\/dl) by administering testosterone.<\/li>\n
  • A practical target for hormone therapy for transgender women (MTF) is to decrease testosterone levels to the normal female range (30\u2013100 ng\/dl) without supra- physiological levels of estradiol (<200 pg\/ml) by administering an antiandrogen and estrogen.<\/li>\n
  • 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.<\/li>\n<\/ul>\n
    \n
    \n

    Hormone regimes for transgender men (female to men, FTM)<\/strong><\/p>\n

    <\/strong>\u00a0 \u00a0<\/strong><\/em>1. Oral<\/strong><\/p>\n

      \n
    • Testosterone undecanoate* \u00a0 \u00a0\u00a0160\u2013240mg\/day<\/em><\/li>\n<\/ul>\n
      \n
      \n

      \u00a0 \u00a02. Parenterally (i.m. or subcutaneous)<\/strong><\/p>\n

        \n
      • Testosterone enanthate or cypionate \u00a0 \u00a0\u00a050\u2013200mg\/week or 100\u2013200mg\/2 weeks<\/em><\/li>\n
      • Testosterone undecanoate\u00a0\u00a0\u00a0\u00a0\u00a01000 mg\/12 weeks<\/em><\/li>\n<\/ul>\n

        \u00a0 \u00a03. Transdermal<\/strong><\/p>\n

          \n
        • Testosterone 1% gel \u00a0 \u00a0\u00a02.5 \u2013 10 g\/day<\/em><\/li>\n
        • Testosterone patch \u00a0 \u00a0 \u00a02.5 \u2013 7.5 mg\/day\u00a0<\/em><\/li>\n<\/ul>\n

          i.m., intramuscular.
          \n*Not available in the USA.<\/p>\n<\/div>\n

          \n
          \n
          \n
          \n

          Monitoring for transgender men (FTM) on hormone therapy:<\/strong><\/p>\n

            \n
          1. Monitor for virilizing and adverse effects every 3 months for first year and then every 6 \u2013 12 months.<\/li>\n
          2. Monitor serum testosterone at follow-up visits with a practical target in the male range (300 \u2013 1000 ng\/dl). Peak levels for patients taking parenteral testosterone can be measured 24 \u2013 48 h after injection. Trough levels can be measured immediately before injection.<\/li>\n
          3. Monitor hematocrit and lipid profile before starting hormones and at follow-up visits.<\/li>\n
          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.<\/li>\n
          5. FTM patients with cervixes or breasts should be screened appropriately.<\/li>\n<\/ol>\n<\/div>\n<\/div>\n<\/div>\n
            \n
            \n

            Hormone regimes for transgender women (male to women, MTF)<\/strong>\u00a0<\/strong><\/p>\n

            \u00a0 \u00a0 \u00a01. Anti-androgen<\/strong><\/p>\n

              \n
            • Spironolactone \u00a0\u00a0100 \u2013 200 mg\/day (up to 400 mg)<\/em><\/li>\n
            • Cyproterone acetatea \u00a0\u00a050\u2013100mg\/day<\/em><\/li>\n
            • GnRH agonists \u00a0\u00a03.75 mg subcutaneous monthly<\/em><\/li>\n<\/ul>\n

              \u00a0 \u00a0 2. Oral estrogen<\/strong><\/p>\n

                \n
              • Oral conjugated estrogens \u00a0\u00a02.5\u20137.5mg\/day<\/em><\/li>\n
              • Oral 17-beta estradiol \u00a0\u00a02\u20136mg\/day<\/em><\/li>\n<\/ul>\n

                \u00a0 \u00a0 3. Parenteral estrogen<\/strong><\/p>\n

                  \n
                • Estradiol valerate \u00a0 5\u201320mg i.m.\/2 weeks<\/em>\u00a0 or cypionate \u00a02\u201310mg i.m.\/week<\/em><\/li>\n<\/ul>\n

                  \u00a0 \u00a0 4.\u00a0Transdermal estrogen<\/strong><\/p>\n

                    \n
                  • Estradiol patch \u00a0 \u00a00.1\u20130.4mg\/2X week<\/em><\/li>\n<\/ul>\n

                    i.m., Intramuscular; MTF, male to female. aNot available in the USA.<\/p>\n<\/div>\n

                    Monitoring for transgender women (MTF) on hormone therapy:<\/strong><\/p>\n

                      \n
                    1. Monitor for feminizing and adverse effects every 3 months for first year and then every 6\u2013 12 months.<\/li>\n
                    2. Monitor serum testosterone and estradiol at follow-up visits with a practical target in the\u00a0female range (testosterone 30 \u2013 100 ng\/dl; E2 <200 pg\/ml).<\/li>\n
                    3. Monitor prolactin and triglycerides before start- ing hormones and at follow-up visits.<\/li>\n
                    4. Monitor potassium levels if the patient is taking spironolactone.<\/li>\n
                    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.<\/li>\n
                    6. MTF patients should be screened for breast and prostate cancer appropriately.<\/li>\n<\/ol>\n

                       <\/p>\n

                      REFERENCES AND RECOMMENDED\u00a0READING (from Gardner & Safer, 2013)<\/strong><\/span><\/span><\/span><\/div>\n
                      <\/div>\n
                      <\/div>\n
                      <\/em>1.Gates GJ. How many people are lesbian, gay, bisexual, and transgender? The Williams Institute; 2011.<\/div>\n
                      <\/div>\n
                      2. Sanchez NF, Sanchez JP, Danoff A. Healthcare utilization, barriers to care, and hormone usage among male-to-female transgender persons in New York City.\u00a0Am J Public Health 2009; 99:713 \u2013 719.<\/div>\n
                      \n

                      3. Leinung MC, Urizar MF, Patel N, Sood SC. Endocrine treatment of transsexual\u00a0*<\/strong> persons: extensive personal experience. Endocr Pract 2013; 19:644 \u2013 650.<\/p>\n

                      4. Gorin-Lazard A, Baumstarck K, Boyer L, et al. Is hormonal therapy associated *with better quality of life in transsexuals? A cross-sectional study. J Sex Med\u00a02012; 9:531\u2013541.<\/p>\n

                      5. Obedin-Maliver J, Goldsmith ES, Stewart L, et al. Lesbian, gay, bisexual, and transgender-related content in undergraduate medical education. J Am Med Assoc 2011; 306:971 \u2013 977.<\/p>\n

                      6. Safer JD, Tangpricha V. Out of the shadows: it is time to mainstream treatment for transgender patients. Endocrine Pract 2008; 14:248 \u2013 250.<\/p>\n

                      7. Reiner WG, Gearhart JP. Discordant sexual identity in some genetic males with cloacal exstrophy assigned to female sex at birth. N Engl J Med 2004; 350:333 \u2013 341.<\/p>\n

                      8. Meyer-Bahlburg HFL. Gender identity outcome in female-raised 46,XY per- sons with penile agenesis, cloacal exstrophy of the bladder, or penile ablation.\u00a0Arch Sex Behav 2005; 34:423 \u2013 438.<\/p>\n

                      9. Zhou J-N, Hofman MA, Gooren LJG, Swaab DF. A sex difference in the human brain and its relation to transsexuality. Nature 1995; 378:68 \u2013 70.<\/p>\n

                      10. Kruijver FP, Zhou JN, Pool CW, et al. Male-to-female transsexuals have female neuron numbers in a limbic nucleus. J Clin Endocrinol Metab 2000; 85:2034 \u2013 204z<\/p>\n

                      11. Berglund H, Lindstro \u0308 m P, Dhejne-Helmy C, Savic I. Male-to-female transsex- uals show sex-atypical hypothalamus activation when smelling odorous steroids. Cerebr Cortex 2008; 18:1900 \u2013 1908.<\/p>\n

                      12. Rametti G, Carrillo B, Go \u0301mez-Gil E, et al. White matter microstructure in female to male transsexuals before cross-sex hormonal treatment. A diffusion tensor imaging study. J Psychiatr Res 2011; 45:199 \u2013 204.<\/p>\n<\/div>\n<\/div>\n

                      \n

                      13. RamettiG,CarrilloB,Go \u0301mez-GilE,etal.Themicrostructureofwhitematterin male to female transsexuals before cross-sex hormonal treatment. A DTI study. J Psychiatr Res 2011; 45:949\u2013954.<\/p>\n

                      14. GreenR,NewmanL,StollerR.Treatmentofboyhood\u2018transsexualism\u2019.Arch Gen Psychiatry 1972; 26:213\u2013217.<\/p>\n

                      15. Liao L-M, Audi L, Magritte E, et al. Determinant factors of gender identity: a commentary. J Pediatr Urol 2012; 8:597\u2013601.<\/p>\n

                      16. World Professional Association for Transgender Health. Standards of care for the health of transsexual, transgender, and gender nonconforming people. 7th ed.; 2011. http:\/\/www.wpath.org\/documents\/Standards%20of%20Care% 20V7%20-%202011%20WPATH.pdf (Accessed on 24 December 2012)<\/p>\n

                      17. Hembree WC, Cohen-Kettenis P, Delemarre-van de Waal HA, et al. Endo- crine treatment of transsexual persons: an Endocrine Society clinical practice guideline. J Clin Endocrinol Metab 2009; 94:3132 \u2013 3154.<\/p>\n

                      18. Gooren LJ. Care of transsexual persons. N Engl J Med 2011; 364:2559\u2013 2560.<\/p>\n

                      19. BhasinS,SaferJ,TangprichaV.Thehormonefoundation\u2019spatientguideto the endocrine treatment of transsexual persons. J Clin Endocrinol Metab 2009; 94:.<\/p>\n

                      20. Bockting WO, Miner MH, Swinburne Romine RE, et al. Stigma, mental health, *<\/strong>\u00a0and resilience in an online sample of the US transgender population. Am J\u00a0Public Health 2013; 103:943 \u2013 951.<\/p>\n

                      21. Olshan JS, Spack NP, Eimicke T, et al. Evaluation of the efficacy of sub-cutaneous administration of testosterone in female to male transexuals and hypogonadal males. Endocr Rev 2013; 34:(03_MeetingAbstracts): MON- 594.<\/p>\n

                      22. Nagarajan V, Chamsi-Pasha M, Tang WHW. The role of aldosterone receptor antagonists in the management of heart failure: an update. Cleve Clin J Med 2012; 79:631 \u2013 639.<\/p>\n

                      23. Asscheman H, Giltay EJ, Megens JAJ, et al. A long-term follow-up study of mortality in transsexuals receiving treatment with cross-sex hormones. Eur J Endocrinol 2011; 164:635 \u2013 642.<\/p>\n

                      24. Wierckx K, Mueller S, Weyers S, et al. Long-term evaluation of cross-sex *<\/strong> hormone treatment in transsexual persons. J Sex Med 2012; 9:2641\u20132651.<\/p>\n

                      25. Wallien MSC, Cohen-Kettenis PT. Psychosexual outcome of gender-dysphoric children. J Am Acad Child Adolesc Psychiatry 2008; 47:1413 \u2013 1423. 26. Cohen-Kettenis PT, Delemarre-van de Waal HA, Gooren LJG. The treatment of adolescent transsexuals: changing insights. J Sex Med 2008; 5:1892\u20131897.<\/p>\n

                      27. De Vries ALC, Steensma TD, Doreleijers TAH, Cohen-Kettenis PT. Puberty\u00a0suppression in adolescents with gender identity disorder: a prospective\u00a0follow-up study. J Sex Med 2011; 8:2276 \u2013 2283.<\/p>\n

                      28. Safer JD, Pearce EN. A simple curriculum content change increased medical & student comfort with transgender medicine. Endocrine Pract 2013; 33:39\u201344.<\/p>\n

                      \u00a0<\/strong><\/p>\n<\/div>\n<\/div>\n<\/div>\n<\/div>\n<\/div>\n<\/div>\n<\/div>\n","protected":false},"excerpt":{"rendered":"

                      Adapted from:\u00a0Gardner,\u00a0Ivy\u00a0and\u00a0Safer, Joshua D. 2013\u00a0Progress on the road to better medical care for transgender patients. Current Opinion in Endocrinology, Diabetes and Obesity 20(6): 553-558. KEY POINTS In order to improve transgender individuals\u2019 access to health care, the approach to transgender medicine needs to be generalized and accessible to physicians in multiple specialties. A practical target […]<\/p>\n","protected":false},"author":8077,"featured_media":0,"parent":45,"menu_order":2,"comment_status":"closed","ping_status":"closed","template":"","meta":[],"_links":{"self":[{"href":"https:\/\/www.bumc.bu.edu\/endo\/wp-json\/wp\/v2\/pages\/414"}],"collection":[{"href":"https:\/\/www.bumc.bu.edu\/endo\/wp-json\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/www.bumc.bu.edu\/endo\/wp-json\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/www.bumc.bu.edu\/endo\/wp-json\/wp\/v2\/users\/8077"}],"replies":[{"embeddable":true,"href":"https:\/\/www.bumc.bu.edu\/endo\/wp-json\/wp\/v2\/comments?post=414"}],"version-history":[{"count":16,"href":"https:\/\/www.bumc.bu.edu\/endo\/wp-json\/wp\/v2\/pages\/414\/revisions"}],"predecessor-version":[{"id":518,"href":"https:\/\/www.bumc.bu.edu\/endo\/wp-json\/wp\/v2\/pages\/414\/revisions\/518"}],"up":[{"embeddable":true,"href":"https:\/\/www.bumc.bu.edu\/endo\/wp-json\/wp\/v2\/pages\/45"}],"wp:attachment":[{"href":"https:\/\/www.bumc.bu.edu\/endo\/wp-json\/wp\/v2\/media?parent=414"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}