Hormone Therapy in Adults: Suggested Revisions to the Sixth Version of the Standards of Care

ABSTRACT

Often viewed as the definitive professional document on transgender care, the current Standards of Care for Gender Identity Disorders—Sixth Version provides a general overview of the risks and effects of adult hormone therapy, but at present offers limited guidance for the medical provider as to how best to execute this critical intervention. Newer versions need to present a comprehensive approach to transgender hormone therapy, including preventive health care, by incorporating the following key elements: the prescribing physician's responsibilities, clinical situations for hormone therapy, effects and risks of hormone therapy, assessment for initiating hormone therapy, monitoring hormone therapy, and suggested hormone regimens.

KEYWORDS:

• Hormone therapy
• gender identity disorder
• adults

The authors would like to acknowledge Dr. Vin Tangpricha, Emory University, for his contributions to this paper.

Notes

¹Estimates represent published clinical observations.

∗Prevention and treatment as recommended for biological men.

∗∗Menorrhagia requires diagnosis and treatment by a gynecologist.

∗Risk elevated in patients with additional risk factors (including age).

∗ Laboratory monitoring should be based on the risks of hormone therapy, the patient's individual co-morbidities and risk factors, and the specific hormone regimen itself. In the face of limited resources, and in the absence of other indications , we advocate prioritizing monitoring for risks that are either likely to be increased by hormone therapy or possibly increased by hormone therapy but clinically serious in nature.

∗If 0 to 1 major cardiac risk factors (excluding male gender) and not using progestin agents, can consider monitoring fasting triglycerides only.

∗∗If not using cyproterone, and no risk of other hepatic conditions, can consider monitoring every 6 to 12 months only.

∗∗∗If on spironolactone and no other renal conditions, can consider monitoring K+ per the above schedule, with BUN, creatinine and other electrolytes every 6 to12 months. If not using spironolactone, renal monitoring may be optional in healthy patients.

∗For testosterone enanthate/cypionate injections, measure the level midway between injections.

∗∗Not available in the USA.

∗∗∗1000 mg initially followed by an injection at 6 weeks then at 12-week intervals.

1. In one arm of the WHI trial, women with uteruses received estrogen/progestin or a placebo. In the other women without uteruses received estrogen only or a placebo.

2. One method measures breasts with the patient in a standing position (a) vertically from the midclavicular line to the inframammary fold, across the largest portion of the breast and (b) from the anterior axillary line to the midsternum, across the largest portion of the breast.

3. There are varying clinical opinions on the accuracy and reliability of testosterone assays. While free or bioavailable testosterone levels provide a more accurate assessment of hormonal status, these tests may not be available in all clinical settings. Total testosterone levels, supplemented by clinical findings, can be used as an alternative.

4. In an effort to eliminate menses quickly, patients may wish to achieve adequate testosterone levels as soon as possible. More frequent monitoring can assist with this goal.