Hormone Therapy for Transgender Individuals

Introduction to Hormone Therapy

• The standard regimen for transgender hormone therapy includes gender-affirming hormones tailored to the individual's gender identity, with regular laboratory monitoring at 3-6 months initially and then annually thereafter, according to the American Society of Anesthesia 1

Testosterone Therapy for Transgender Men

• Testosterone therapy aims to achieve serum testosterone concentrations in the typical cisgender male reference range, resulting in effects such as voice deepening, facial and body hair growth, menstrual suppression, increased libido, clitoral growth, increased muscle mass, and decreased fat mass, with potential risks including polycythemia, reduced HDL cholesterol, androgenic alopecia, acne, and potential increased risk of myocardial infarction 1

Estrogen Therapy for Transgender Women

• Transdermal estradiol may be preferred for hypertensive patients or those with higher thrombosis risk, and no routine laboratory monitoring is required once established on therapy unless prompted by specific symptoms or concerns, according to the European Society of Human Reproduction and Embryology 2
• Estradiol therapy should be initiated at 1-2 mg daily (oral) or equivalent transdermal dose, with the goal of bringing testosterone levels to <50 ng/dL while maintaining estradiol in the female range, as recommended by the American College of Physicians and the Endocrine Society 3
• For women with an intact uterus, progesterone must be added to estrogen therapy to prevent endometrial hyperplasia, with recommended options including micronized progesterone (100-200 mg/day for 12-14 days of the month) and dydrogesterone (5-10 mg/day for 12-14 days of the month), as recommended by the American College of Obstetricians and Gynecologists 2

Anti-Androgen Options and Contraindications

• Anti-androgen options, such as spironolactone, cyproterone acetate, GnRH analogues, bicalutamide, and finasteride, can be used for those who have not had orchiectomy, with potential risks including venous thromboembolism, weight gain, and potential cardiovascular disease risk 1
• Contraindications for hormone replacement therapy include history of breast cancer, active thromboembolic disorders, history of arterial thrombotic disease, undiagnosed vaginal bleeding, and liver problems, as stated by the American Heart Association 2, the American College of Obstetricians and Gynecologists 4, 5, 6

Important Considerations and Potential Risks

• Using oral ethinylestradiol increases thrombosis risk compared to 17β-estradiol, and neglecting to add progesterone for transgender women with intact uterus can lead to endometrial hyperplasia, according to the European Society of Human Reproduction and Embryology 2
• Potential risks of hormone replacement therapy include endometrial cancer, venous thromboembolism, and stroke, which can be minimized by using transdermal estradiol and progesterone, as recommended by the American Heart Association 2
• Early estrogen replacement is crucial for bone mass accrual, with 90% of peak bone mass achieved by age 18 7
• Hormone replacement therapy reduces risk of ischemic heart disease, hypertension, and stroke in women, according to the American Heart Association 8

Monitoring and Follow-up

• Initial evaluation should be done at 3-6 months after starting therapy, with annual clinical review thereafter, monitoring for symptom control, compliance, blood pressure, and weight, and no routine laboratory monitoring required unless prompted by specific symptoms, as stated by the American College of Obstetricians and Gynecologists 2
• Annual cardiovascular risk assessment (including blood pressure, smoking, weight, lipid profile, fasting glucose, and HbA1c) is recommended for women with Turner's syndrome, as stated by the American Heart Association 2
• The following dosage regimen is recommended for adolescents with premature ovarian insufficiency: