A good number of transgender men and women include hormone therapy as a component of the transition procedure. Transgender men for instance, use exogenous testosterone in order to stimulate virilization and overcome feminizing characteristics. Meanwhile, transgender women, begin to take exogenous estrogen as part of their hormone therapy in order to promote feminization, and add anti-androgens to aid in the suppression of masculinizing characteristics. Presently, there are guidelines to assist hormone specialists for selecting suitable beneficial hormone therapy for transgender patients.
Transgender patient hormone therapy has clearly demonstrated positive physical and psychological effects for those transgender patients that are in transition, and is regarded as necessary treatment for most transitioning transgender patients. Although there are many health concerns which should be closely monitored for transgender patients undergoing long-term hormone therapy, especially bone and cardiovascular health.
One of the most common issues experienced by transgender persons is the disconnection that occurs between their biological sex and the gender they identify with. Those persons who were born as females but identify themselves as men are transgender men. Conversely, persons born as males but identify themselves as women are transgendered women. Current evidence shows that transgenderism is most likely the result of the individuals biology, and transgenderism in a most recent study, has been reported to be about half a percent in the United States alone.
Today the number of transgender patients getting hormone therapy has increased dramatically. Exogenous hormones for the majority of transgender patients is deemed as medically necessary. The Endocrine Society as well as the World Professional Association for Transgender Health, have created specialized procedures for medical providers providing care for transgender patients. The specialized guidelines are based on established experts with vast clinical experience in transgender patient care. Moreover, the hormone therapy procedures for transgender males are based on the present treatment of hypogonadal natal men, while the hormone therapy procedure for transgender females are similar to treatments for postmenopausal women.
Previously, the hormone therapy protocol suggested that transgender patients prior to receiving hormones, spend 12-months living as their personal affirmed gender. The purpose of the guideline was to assist transgender patients in their social transition. Today, this recommendation has been shown to be unreasonable for the majority of transgender patients due to the dissimilarity between the transgender patient’s self-affirmed gender and their actual appearance. Furthermore, today the current guidelines have abandoned this aspect of the protocol and instead advocate that transgender patients begin hormone therapy and social transitioning at the same time.
Currently, the World Professional Association for Transgender Health, suggests the initiation of hormone therapy immediately after psychosocial assessment and the transgender patient has been approved for hormone therapy and has given informed consent upon disclosure and review of benefits and risks associated with hormone therapy. Moreover, the World Professional Association for Transgender Health has made it a requirement to get a referral by a licensed mental health professional, unless the hormone therapy provider is authorized to complete these assessments.
There are several requirements that must be met prior to transgender patients receiving hormones:
The comorbidity/concurrent condition requirement is usually the most difficult to understand. Although a number of transgender patients exhibit concurrent disorders associated with mood associated with the patients particular gender dysphoria, experienced hormone providers have a relatively high success rate in countering the mood symptoms early in the hormone therapy process.
Testosterone therapy for transgender patients is used for the purpose of limiting the secondary sex female characteristics and masculinizing transgender men. Testosterone therapy for transgender patients is substantially similar to testosterone replacement therapy for treating natal men with low testosterone production.
Presently, the most common form of testosterone used for transgender patients undergoing hormone therapy are the injectable forms. Injectable testosterone is available in two forms, enanthate and cypionate. Generally, the injectable testosterone is done via intramuscular or subcutaneous. Although generally, injections are recommended weekly, if there is a requirement for a higher dose, your provider can make the necessary adjustments. Alternatively, the injection dose intervals can be spread over a two week period. The most recently approved form of testosterone is the undecanoate form, which is longer acting and only requires to be administered once every 12 weeks.
Prior to a transgender patient starting testosterone therapy, a blood test is given in order to see hematocrit baseline and a lipid profile. A bone mineral density baseline should be taken in the event that a transgender patient is at risk for osteoporosis. The target testosterone levels in the male range for transgender patients are between 300 to 1,000 ng/dl, with testosterone doses able to be rapidly titrated in order to attain proper levels. During the initial stages of testosterone therapy, testosterone levels are dose dependent, however after 6 months of therapy, higher doses do not produce better results over lower doses. While higher dosage will achieve the desired testosterone levels quicker, there are risks with titrating too quickly and should be assessed and transgender patients should be mindful of the fact that their testosterone levels will eventually become the same once they have reached the 6 month mark.
Estrogen is used as part of hormone therapy for transgender female patients. The goal of transgender female hormone therapy is to feminize the transgender patient by altering fat distribution, induction of breast formation and minimizing male pattern hair growth. The foundation of hormone therapy for transgender female patients are estrogens. Exogenous hormones via a negative feedback look, are used to suppress the secretion of gonadotropin from the pituitary gland, which results in reduced production of androgen. Generally, only using estrogen to reach ideal androgen suppression for transgender female patients is insufficient, so an anti-androgenic will be added to the therapy.
There are four types of estrogen formulas that are used today for transgender patients, oral, estradiol, parenteral estradiol valerate, and transdermal. For patients over 40 years of age, transdermal estrogen is the most advocated in hormone therapy due to the fact that the transdermal formula is linked to better metabolic rates.
While there isn’t a preferred anti-androgen formulation, spironolactone is probably the most used on transgender female patients for suppressing endogenous testosterone. The most serious risk that has been reported for spironolactone is hyperkalemia, while it is rare, your provider will monitor for this. Another option which is less popular is finasteride, but has potential for liver toxicity and often not as effective as spironolactone.
A number of transgender men are looking to maximize their development of male characteristics, while some prefer to only suppress their natal secondary sex characteristics. Therefore, transgender patients hormone therapy can be customized to the patients exact transition objectives, as well as consider their individual medical comorbidities so that risks can be assessed prior to starting therapy.
Usually in the early stages of testosterone hormone therapy for transgender patients (about 3 months), several things can be anticipated:
Subsequent changes as a result of testosterone hormone therapy for transgender patients include:
For the majority of female to male patients, a certain amount of feminization occurs which is not reversable with exogenous testosterone, unless testosterone was used in the peri-pubertal period. Consequently, a large number of transgender men are shorter, maintain a certain degree of feminine subcutaneous fat distribution, and typically have broader hips over biological males.
Body changes associated with estrogen hormone therapy include:
The time that is generally required for these changes to reach their peak is between 1.5 to 2 years after starting estrogen hormone therapy.
The general consensus in the medical community is there is ample proof that hormone therapy increases a transgender patients quality of life. Additionally, studies show that hormone therapy offers positive effects on mood and sexual function as well as reduction in serotonin reuptake transporter expression for both trans men and women with major depression.
Transgender patients also gain benefits from hormone therapy on physiological stress. Studies have shown that after starting exogenous hormones, transgender patients exhibit greatly reduced cortisol levels as well as perceived stress.