28 - Trans - 22 Months Hrt - Just Your Average...
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Many patients are eager to begin maximal feminizing hormone therapy and are opposed to the idea of a slow upward titration. Weak evidence suggests that initiation of estrogen therapy at lower doses and titrating up over time may result in enhanced breast development in transgender women. The estrogen receptor agonist activity of spironolactone may play a role in reduced breast development due to premature breast bud fusion. As such an escalating regimen beginning with low dose estrogen only, and titrating up over several months, and then adding spironolactone may be an alternative approach, consistent with management practices in children with delayed pubertal onset (Grading: T O W). Upward titration of spironolactone can also help minimize side effects such as orthostasis or polyuria. It is recommended that providers discuss these considerations with patients before initiation of hormones in order to make an informed decision.
Some providers choose to omit the use of hormone level testing and only monitor for clinical progress or changes. The risk of this approach is that if hormone levels (particularly testosterone) have not reached the target range, but progress is judged as appropriate based on clinical exam, a suboptimal degree of feminization is possible, and the presence of supraphysiologic levels would also be obscured. Conversely, Endocrine Society guidelines recommend monitoring of hormone levels every 3 months. In practice this is not realistic and not likely to add value once a stable dosing has been achieved. A prospective study of transgender women taking 4mg/day divided dose oral estradiol or 100mcg transdermal estradiol, plus 100-200mg/day divided dose spironolactone found that all women achieved physiologic estradiol levels, though only 2/3 of the women achieved female range testosterone levels. Some gender-nonconforming/nonbinary patients may prefer to maintain estradiol or testosterone levels in an intermediate range. Regardless of initial dosing scheme chosen, dosing may be titrated upwards over 3-6 months. Check estradiol and testosterone levels at 3 and 6 months and titrate dose accordingly. For those patients using spironolactone, check renal function and K+ at 3 months and 6 months, then q 6-12 months. While laboratory monitoring of hormone levels may seem complex, it is of similar difficulty to the monitoring of other similarly complex lab-monitored conditions managed by primary care providers, such as thyroid disorders, anticoagulation, or diabetes.
Insufficient evidence exists to definitively guide estrogen therapy in transgender women with risk factors or with a personal history of prior VTE, either on or off estrogen. A report of 11 transgender women with a history of activated protein C resistance (the mechanism of action implicated in the hypercoagulable state associated with the Factor-V Lieden mutation) using transdermal estradiol without anticoagulation found no clotting events after a mean of 64 months of therapy.
Within three months of initiating testosterone therapy, the following can be expected: cessation of menses (amenorrhea), increased facial and body hair, skin changes and increased acne, changes in fat distribution and increases in muscle mass, and increased libido (11,16). Later effects include deepening of the voice, atrophy of the vaginal epithelium, and increased clitoral size. Male pattern hair loss also can occur over time as a result of androgenic interaction with pilosebaceous units in the skin (17). Some patients find this favorable as it may be considered masculinizing. For those who do not find it favorable, 5α-reductase inhibitors can be used as adjuncts to combat alopecia. However, patients should be made aware of the potential side effects on sexual functioning that can be associated with these medications, and they should be counseled that no data exist on the use of these medications in transgender men (18). In most female-to-male patients (unless testosterone is administered during the peri-pubertal period), there is some degree of feminization that has taken place that cannot be reversed with exogenous testosterone. As a result, many transgender men are shorter, have some degree of feminine subcutaneous fat distribution, and often have broader hips than biologic males (19).
While some providers choose to omit hormone level monitoring, and only monitor for clinical progress or changes, this approach runs the risk of a suboptimal degree of virilization if testosterone levels have not reached the target range. A prospective study of 31 transgender men newly started on either subcutaneous 50-60mg/week testosterone cypionate, 5g/day 1% testosterone gel, or 4mg/day testosterone patch found that after 6 months only 21 (68%) achieved male range testosterone levels and 5 (16%) had persistent menses, with only 9 (29%) achieving physiologic male-range estradiol levels. Some genderqueer and gender-nonconforming/nonbinary patients may prefer to maintain testosterone levels in an intermediate range. Regardless of initial dosing scheme chosen, titrate upwards based on testosterone levels measured at 3 and 6 months. Once hormone levels have reached the target range for a specific patient, it is reasonable to monitor levels yearly. As with testosterone replacement in non-transgender men, annual visits and lab monitoring are sufficient for transgender men on a stable hormone regimen. Endocrine Society guidelines recommend monitoring of hormone levels every 3 months. In practice this is not realistic and not likely to add value once a stable dosing has been achieved. Other reasons for measuring hormone levels in the maintenance phase include significant metabolic shifts such as the onset of diabetes or a thyroid disorder, substantial weight changes, subjective or objective evidence of regression of virilization, or new symptoms potentially precipitated or exacerbated by hormone imbalances such as hot flashes, pelvic cramping or bleeding, or migraines. Such patients may also require more frequent office visits to manage coexisting conditions. Increased frequency of office visits may also be useful for patients with complex psychosocial situations to allow for the provision of ancillary or wraparound services.
Erythrocytosis/polycythemia: Hemoglobin and hematocrit (H&H) values in transgender men should be interpreted in the context of the dose of testosterone used and menstruation status. Transgender men with physiologic male testosterone levels and who are amenorrheic would be expected to have H&H values in the male normal range. Note this may differ from the normal female range listed on the lab report if the patient is registered in the lab system as a female. Providers should reference their lab(s)' normal male range H&H, and disregard reported high flags if an amenorrheic transgender man on testosterone has an H&H above the female upper limit, but below the male upper limit. Similarly in this same patient, an H&H below the male lower limit but above the female lower limit may not be flagged as abnormal, but in reality may represent a true anemia. Patients with persistent menses or on lower doses of testosterone should have their H&H interpreted accordingly. Transgender men with true polycythemia should first have their testosterone levels checked, including a peak level, and have dose adjusted accordingly. Changing to a more frequent injection schedule (maintaining the same total amount of testosterone over time) or transdermal preparations may limit the risk of polycythemia. Phlebotomy or blood donation may be an appropriate short term solution depending on the level of elevation; in all cases other pathologic causes of polycythemia should be excluded. In addition to neoplasms and cardiopulmonary disease, specific conditions of concern in transgender men include obesity-related obstructive sleep apnea, and tobacco use.
If your cancer has spread to the area just outside the prostate (locally advanced prostate cancer), you may have hormone therapy before, during and after radiotherapy. Hormone therapy can help shrink the prostate and any cancer that has spread, and make the treatment more effective.
You will have the injections or implants at your GP surgery or local hospital. How often you have them will vary, depending on the type you are having. Some men have an injection or implant once a month, while others have an injection every three or six months.
There are ways to reduce your risk of breast swelling and tenderness, or help treat it. These include treating the breast area with a single dose of radiotherapy during your first six months on hormone therapy, taking tablets (such as tamoxifen), or sometimes having surgery to remove some of the breast tissue.
This blog will describe some of the changes you might experience to your weight, body composition or body fat, and muscle strength when taking testosterone as a transgender man, transmasculine person, or nonbinary person who wants to experience hormone therapy as part of their transition.
The first twelve months of gender-affirming hormone therapy (GAHT, which some people also call HRT or hormone replacement therapy) are exciting. As you get ready to start your testosterone medication with Plume, you might wonder what is ahead. Will testosterone affect your weight, body fat, or BMI How will higher testosterone levels change your body composition Can testosterone increase your strength or endurance Knowing what to expect can help you prepare for this milestone in your gender journey.
While few scientific studies focus on transgender people, there is some interesting information out there that reflects our lived experience. If you have additional questions, you can always reach out to your trans-led care team of medical experts at Plume. We are also working on creating spaces where you can connect with other trans and genderqueer folks who are prescribed testosterone. Our blog, social media, and newsletter are all packed with free, accessible resources that you can use any time to learn about GAHT, too! 59ce067264