Gender dysphoria (Virilising and Feminising hormonal treatments)

Posted in Gender Dysphoria .

Virilising Treatment (Female to Male)

Testosterone

GnRH analoguese

Decapeptyl SR (Triptorelin)

Goserelin (Zoladex) Implant

Leuprorelin (Prostap) Less cost-effectiv

if they are on feminising HRT then need to check oestrogen, progesterone, LFTs and lipids, add FSH/LH if on a blocker
Medication	Formulation	Additional Notes	Dose	Monitoring
Nebido (First line)	IM Testosterone Depot injection	First Line	Day 0 then week 6 then every 12 weeks Adjust dosage frequency rather than dose to achieve treatment goal	Before initiation (ususally done by specialist) oestradiol, testosterone, prolactin, FSH, LH, LFT, FBC, lipids and HbA1c 4 weeks after initiation haematocrit 3 months after initiation haematocrit Immediately before 4th dose serum testosterone level, haematocrit, LFT, HbA1c & lipids immediately before fourth dose Annually testosterone, haematocrit, LFT, HbA1c, FBC, FSH/LH, lipids, weight, BP immediately before administration of a scheduled injection Action on abnormal results Prolactin > 400 mU/l - redo and refer to specialist if still high oestradiol - FBC - we are monitoring for polycythaemia (just check haematocrit and hamoglobin) LH + FSH can be used to help determine whether to increase or decrease dosage Serum testosterone level trough pre-injection target 12-20 peak target 14-28 Patients with a cervix should be offered screening - this is usually arranged by specilaist team Monitor menstruation (see below)
Tostran (First Line - Recommended for patients with high haematocrit at baseline assessment (>0.50))	2% testosterone gel Each metered dose delivers 10mg	First Line	Typical starting dose is 5 pumps daily as a single dose (range between1-8) Adjust pumps to achieve testostroen target around 18	Before initiating (ususally done by specialist) Perform a blood test to obtain baseline figures for oestradiol, testosterone, prolactin, FSH, LH, LFT, FBC, lipids and HbA1c Prolactin < 400 mU/l (if raised redo and refer tospecialist if still high) LH + FSH can be used to help determine whether to increase or decrease dosage During treatment Check testosterone & Haematocrit four weeks and three months after initiation of treatment Testosterone target range is 14-28 (ideally around 18) Once target has been achieved, testosterone, haematocrit, LFT, HbA1c, lipids, FBC, FSH/LH every 3 months for first year then every 6 months for two years then annually SHBG level just indicates amount of unbound testosterone avaiable in blood stream - can be overlooked for this monitoring Blood sample must be drawn 2-4 hours after gel application On the day of this blood test, gel should be applied to thigh, not arms to avoid inaccurate results Monitor menstruation (see below) Patients with a cervix should be offered screening - this is usually arranged by specilaist team
Triptotelin	Decapeptyl IM injection GnRH analogue	Additional treatment with GnRH analogues is rarely neccessary May be required if amenorrheoa not achived after three months of commencing testosterone therapy Prefered over cyproterone After gonadectomy, GnRH analogue is discontinued	11.25mg every 3 months	Before initiation (ususally done by specialist) Perform a blood test to obtain baseline figures for oestradiol, testosterone, prolactin, FSH, LH, LFT, FBC, lipids and HbA1c Prolactin < 400 mU/l (if raised redo and refer tospecialist if still high) LH + FSH can be used to help determine whether to increase or decrease dosage Monitor menstruation (see below)
Zoladex	Goserelin into abdominal wall GnRH analogue	Additional treatment with GnRH analogues is rarely neccessary May be required if amenorrheoa not achived after three months of commencing testosterone therapy Prefered over cyproterone After gonadectomy, GnRH analogue is discontinued	3.6mg every 28 days 10.8 mgevery 3 months	Before initiation (ususally done by specialist) Perform a blood test to obtain baseline figures for oestradiol, testosterone, prolactin, FSH, LH, LFT, FBC, lipids and HbA1c Prolactin < 400 mU/l (if raised redo and refer tospecialist if still high) LH + FSH can be used to help determine whether to increase or decrease dosage Monitor menstruation (see below)
Prostap	Leuprorelin GnRH analogue	Additional treatment with GnRH analogues is rarely neccessary May be required if amenorrheoa not achived after three months of commencing testosterone therapy Prefered over cyproterone After gonadectomy, GnRH analogue is discontinued	3.75mg every 28 days	Before initiation (ususally done by specialist) Perform a blood test to obtain baseline figures for oestradiol, testosterone, prolactin, FSH, LH, LFT, FBC, lipids and HbA1c Prolactin < 400 mU/l (if raised redo and refer tospecialist if still high) LH + FSH can be used to help determine whether to increase or decrease dosage Monitor menstruation (see below)

Menstruaton

Usually ceases within 3 months
- If does not cease within 3 months of treatment initiation
  - check FSH, LH & oestradiol and refer to specialist
  - LH + FSH can be used to help determine whether to increase or decrease dosage
- Once ceased for 6 months
  - unexplained vaginal bleeding must be refered to specialist

Switching from testosterone to nebido

FBC to ensure hamatocrit is below 0.52
continue testosetrone gel
start nebido 1000mcg
stop testosterone 2 weeks after starting nebido
another injection at 6 weeks
then again at 12 weeks then loading dose is over
then book in for blood test to be taken immediately before 12 week dose is due for: testosterone, FBC, LFT and lipids.
adjust dose according to this BT usually every 12 weeks

Femonising treatments (Female to Male)

Oestrogen
GnRH analoguese
- Decapeptyl SR (Triptorelin)
- Goserelin (Zoladex) Implant
- Leuprorelin (Prostap) Less cost-effectiv

Medication	Formulation	Additional Notes	Dose	Monitoring
Oestradiol	Oestrogel Sandrena	First line	0.5-4mg daily Typical starting dose 2mg daily	Before starting treatment Perform a blood test to get baseline figures for oestradiol, testosterone, prolactin, FSH, LH, LFT, FBC, lipids and HbA1c At least 2 weeks after starting medication oestradiol, testosterone, prolactin, FSH, LH, LFT, FBC, lipids and HbA1c 4 weeks after each dosage change oestradiol, testosterone, LH and prolactin Ongoing, once oestradiol and testosterone within range oestradiol, testosterone, progesterone, prolactin, LFT, HbA1c, lipids, weight & BP every 6 months for two years then annually (if on GnRH analgue then no need to measure testosterone) Trans women on oestradiol need to have mammography screening Treatment goals Testosterone target range is < 3.0nmol/L Once this is acjieved oestrafiol taret range 200–600 pmol/l If oestradiol is within range but testosteone high add GnHR analogue to supress testosterne production Prolactin < 400 mU/l (if raised redo and refer tospecialist if still high) LH + FSH can be used to help determine whether to increase or decrease dosage
Transdermal patches	Evorel	First Line	50 – 200 mcg twice /week Typical starting dose 100mcg twice / week	Before starting treatment Perform a blood test to get baseline figures for oestradiol, testosterone, prolactin, FSH, LH, LFT, FBC, lipids and HbA1c At least 2 weeks after starting medication oestradiol, testosterone, prolactin, FSH, LH, LFT, FBC, lipids and HbA1c 4 weeks after each dosage change oestradiol, testosterone, LH and prolactin Ongoing, once oestradiol and testosterone within range oestradiol, testosterone, prolactin, LFT, HbA1c, lipids, weight & BP every 6 months for two years then annually (if on GnRH analgue then no need to measure testosterone) Trans women on oestradiol need to have mammography screening Treatment goals Testosterone target range is < 3.0nmol/L Once this is acjieved oestrafiol taret range 200–600 pmol/l If oestradiol is within range but testosteone high add GnHR analogue to supress testosterne production Prolactin < 400 mU/l (if raised redo and refer tospecialist if still high) LH + FSH can be used to help determine whether to increase or decrease dosage
Oral	Progynova Elleste Solo (Zumenon not recommended)	Second Line Avoid in patients over 40 years, smokers or those with liver disease due to lower risk of thrombosis and liver dysfunction	1-12mg daily Typical starting dose 4mg daily	Before starting treatment Perform a blood test to get baseline figures for oestradiol, testosterone, prolactin, FSH, LH, LFT, FBC, lipids and HbA1c At least 2 weeks after starting medication oestradiol, testosterone, prolactin, FSH, LH, LFT, FBC, lipids and HbA1c 4 weeks after each dosage change oestradiol, testosterone, LH and prolactin Ongoing, once oestradiol and testosterone within range oestradiol, testosterone, prolactin, LFT, HbA1c, lipids, weight & BP every 6 months for two years then annually (if on GnRH analgue then no need to measure testosterone) Trans women on oestradiol need to have mammography screening Treatment goals Testosterone target range is < 3.0nmol/L Once this is acjieved oestrafiol taret range 200–600 pmol/l If oestradiol is within range but testosteone high add GnHR analogue to supress testosterne production Prolactin < 400 mU/l (if raised redo and refer tospecialist if still high) LH + FSH can be used to help determine whether to increase or decrease dosage
GnRH analogue		3rd Line If oestrogen is within target range but testosterone is still above this will suppress the testosterone Produces an initial phase of stimulation Continued administration is followed by down-regulation of gonadotrophin-releasing hormone receptors, thereby reducing the release of gonadotrophins (follicle stimulating hormone and luteinising hormone) which in turn leads to inhibition of androgen and oestrogen production After gonadectomy, GnRH analogue is discontinued and oestradiol is usually continued lifelong	Decapeptyl SR (Triptorelin) 11.25mg I/M 3 monthly Goserelin (Zoladex) Implant Leuprorelin (Prostap) Less cost-effective	Before starting treatment Perform a blood test to get baseline figures for oestradiol, testosterone, prolactin, FSH, LH, LFT, FBC, lipids and HbA1c At least 2 weeks after starting medication oestradiol, testosterone, prolactin, FSH, LH, LFT, FBC, lipids and HbA1c 4 weeks after each dosage change oestradiol, testosterone, LH and prolactin Ongoing, once oestradiol and testosterone within range oestradiol, testosterone, prolactin, LFT, HbA1c, FSH/LH lipids, weight & BP every 6 months for two years then annually (if on GnRH analgue then no need to measure testosterone) Trans women on oestradiol need to have mammography screening Treatment goals Testosterone target range is < 3.0nmol/L Once this is acjieved oestrafiol taret range 200–600 pmol/l If oestradiol is within range but testosteone high add GnHR analogue to supress testosterne production Prolactin < 400 mU/l (if raised redo and refer tospecialist if still high) LH + FSH can be used to help determine whether to increase or decrease dosage
Cyproterone acetate		Associated with hepatotoxicity & increased risk of thrombosis so not prefered for long term use Blocks increased testosterone action consequent upon initial administration of GnRH analogue	50mg bd may be used for upto 2 weeks

Additional notes

Around 2/3 of patients will achieve target treatment goals with oestrogen alone, 1/3 will need a GnRH analogue to supress testosterone (leuprolide / goserelin)
Transdermal preparations are suitable for 80% of patients

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