Guidelines for Initiating and Monitoring Gender-Affirming Hormone Therapy

Initial Assessment and Monitoring

A comprehensive baseline assessment should include complete blood count, liver function tests, lipid profile, glucose levels, and baseline hormone levels (estradiol and testosterone) 1
Mental health evaluation is important as transgender individuals have higher rates of psychiatric disorders including anxiety, depression, and autism compared to cisgender individuals 2
Fertility preservation counseling should be provided before starting hormone therapy, as both feminizing and masculinizing treatments may affect fertility 2

Estradiol is the cornerstone of feminizing hormone therapy, available in oral, transdermal, or injectable forms 1
Anti-androgens are typically added to enable lower doses of estrogen while achieving adequate testosterone suppression 1
Common anti-androgen options include spironolactone, cyproterone acetate, GnRH agonists, bicalutamide, and finasteride 1
Breast development and decreased muscle mass are expected physical changes, with variable results 1
Softening of skin, decreased body/facial hair, decreased libido, and reduced erectile function are also expected 3

Testosterone therapy is used to induce virilization and suppress feminizing characteristics, with target testosterone levels maintained in the typical physiological range for cisgender men (300-1,000 ng/dL) 4
Increased muscle mass and decreased fat mass are expected physical changes 4
Deepening of voice, body and facial hair growth, menstrual suppression, and increased libido are also expected 3

Check estradiol and testosterone levels at 3 months after initiating therapy, and monitor every 3-6 months during the first year of hormone therapy 1
Annual monitoring of hormone levels is recommended once stable, along with regular cardiovascular risk assessment 1
Monitor hematocrit in transgender men, as testosterone therapy can cause erythrocytosis 4

Feminizing hormone therapy may increase the risk of venous thromboembolism, weight gain, compromised bone structure, and cardiovascular disease risk 1, 3
Masculinizing hormone therapy may cause erythrocytosis, increased blood pressure, elevated triglycerides and LDL cholesterol, decreased HDL cholesterol, acne, androgenic alopecia, and pelvic pain 3, 4

For transgender individuals with pre-existing cardiovascular conditions, more frequent monitoring may be necessary 4
Laboratory values should generally be interpreted based on affirmed gender for individuals on hormone therapy for more than 1 year 4
Cystatin C may be preferred over creatinine for evaluating kidney function in transgender individuals on hormone therapy 4