Hormone replacement therapy (female-to-male)Current Opinion in Endocrinology, Diabetes and Obesity 20 6: Endocr Pract ; Lesbian, gay, bisexual, and transgender-related content in undergraduate medical education. J Am Med Assoc ; Safer JD, Tangpricha V. Out of the shadows: Endocrine Pract ;
Transgender Health & Transitioning | Revel & Riot
Hormone replacement therapy HRT of the female-to-male FTM type is hormone replacement therapy and sex reassignment therapy used to change the secondary sexual characteristics of transgender and transsexual people from feminine or androgynous to masculine. Usually called "cross-sex hormone therapy" XHT or "hormone therapy", it is one of two types of HRT for transgender and transsexual people the other being male-to-female , and is predominantly used to treat transgender men.
Some intersex people also receive this form of HRT, either starting in childhood to confirm the assigned sex or later if the assignment proves to be incorrect. The purpose of this form of HRT is to cause the development of the secondary sex characteristics of the desired sex , such as voice deepening and a masculine pattern of hair, fat, and muscle distribution. It cannot undo many of the changes produced by naturally occurring puberty , which may necessitate surgery and other treatments see below.
While HRT cannot undo the effects of a person's first puberty , developing secondary sex characteristics associated with a different gender can relieve some or all of the distress and discomfort associated with gender dysphoria , and can help the person to "pass" or be seen as the gender they identify with.
Introducing exogenous hormones into the body impacts it at every level and many patients report changes in energy levels, mood, appetite, etc. The goal of HRT, and indeed all somatic treatments, is to provide patients with a more satisfying body that is more congruent with their gender identity.
Several contraindications to androgen therapy exist. Hormone therapy for transgender individuals has been shown in medical literature to be safe in adults, when supervised by a qualified medical professional. Testosterone is metabolized by the cytochrome P enzyme system specifically CYP3A isoforms in the liver. There are certain drugs that increase or decrease the activity of cytochrome P enzymes and may cause increased or decreased levels of testosterone:. Because of these interactions, it is advised that trans men make their healthcare providers aware of their hormone therapy, when this is relevant to their treatment for other medical issues.
The terminal half-life of testosterone in blood is about 70 minutes, so it is necessary to have a continuous supply of the hormone for masculinization.
The two primarily used forms in the United States are the testosterone esters testosterone cypionate Depo-Testosterone and testosterone enanthate Delatestryl which are almost interchangeable.
These testosterone esters are mixed with different oils , so some individuals may tolerate one better than the other.
Testosterone enanthate costs more than testosterone cypionate and is more typically the one prescribed for hypogonadal males in the United States. Testosterone cypionate is more popular in the United States than elsewhere especially amongst bodybuilders. Other formulations exist but are more difficult to come by in the United States. A formulation of injected testosterone available in Europe and the United States, testosterone undecanoate Nebido, Aveed   provides significantly improved testosterone delivery with far less variation outside the eugonadal range than other formulations with injections required only four times yearly.
Testosterone undecanoate is also much more expensive as it is still under patent protection. Testosterone propionate is another testosterone ester that is widely available, including in the United States, Canada, and Europe, but it is very short-acting compared to the other testosterone esters and must be administered once every 2 or 3 days, and for this reason, is rarely used.
The adverse side effects of injected testosterone esters are generally associated with high peak levels in the first few days after an injection. Some side effects may be ameliorated by using a shorter dosing interval weekly or every ten days instead of twice monthly with testosterone enanthate or testosterone cypionate. This benefit must be weighed against the discomfort and inconvenience of doubling the number of injections.
Injected testosterone esters should be started at a low dose and titrated upwards based on trough levels blood levels drawn just before your next shot. Both testosterone patches , creams and gels are available. Both approximate normal physiological levels of testosterone better than the higher peaks associated with injection. Both can cause local skin irritation more so with the patches. Patches slowly diffuse testosterone through the skin and are replaced daily.
Transdermal testosterone is available throughout the world under the brand names Andromen Forte, Androgel, Testogel and Testim. They are absorbed quickly when applied and produce a temporary drug depot in the skin which diffuses into the circulation, peaking at 4 hours and decreasing slowly over the rest of the day. Transdermal testosterone poses a risk of inadvertent exposure to others who come in contact with the patient's skin. This is most important for patients whose intimate partners are pregnant or those who are parents of young children as both of these groups are more vulnerable to the masculinizing effects of androgens.
Case reports of significant virilization of young children after exposure to topical androgen preparations both prescription and 'supplement' products used by their caregivers demonstrates this very real risk. Implants, as subcutaneous pellets, can be used to deliver testosterone brand name Testopel. This must be done in a physician's office, but is a relatively minor procedure done under local anesthetic.
The primary advantages of Testopel are that it gives a much more constant blood level of testosterone yet requires attention only four times yearly. Oral testosterone is provided exclusively as testosterone undecanoate. It is available in Europe and Canada, but not in the United States.
Once absorbed from the gastrointestinal tract , testosterone is shunted at very high blood levels to the liver where it can cause liver damage albeit very rarely and worsens some of the adverse effects of testosterone, like lower HDL good cholesterol. In addition, the first pass metabolism of the liver also may result in testosterone levels too low to provide satisfactory masculinization and suppress menses. Because of the short terminal half-life of testosterone, oral testosterone undecanoate must be administered two to four times per day, preferably with food which improves its absorption.
In the FDA approved a buccal form of testosterone Striant. Sublingual testosterone can also be made by some compounding pharmacies. Testosterone is absorbed through the oral mucosa and avoids the 'first pass metabolism' in the liver which is cause of many of the adverse effect with oral testosterone undecanoate. The lozenges can cause gum irritation, taste changes, and headache but most side effects diminish after two weeks.
The lozenge is 'mucoadhesive' and must be applied twice daily. Synthetic anabolic—androgenic steroids AAS , like nandrolone as an ester like nandrolone decanoate or nandrolone phenylpropionate , are agonists of the androgen receptor AR similarly to testosterone but are not usually used in HRT for transgender men or for androgen replacement therapy ART in cisgender men.
Although many AAS are not potentiated in androgenic tissues, they have similar effects to testosterone in other tissues like bone , muscle , fat , and the voice box. Also, many AAS, like nandrolone esters, are aromatized into estrogens to a greatly reduced extent relative to testosterone or not at all, and for this reason, are associated with reduced or no estrogenic effects e. For the sake of clarification, it should be noted that the term "anabolic—androgenic steroid" is essentially synonymous with "androgen" or with "anabolic steroid" , and that natural androgens like testosterone are also AAS.
Dihydrotestosterone DHT referred to as androstanolone or stanolone when used medically can also be used in place of testosterone as an androgen. In all people, the hypothalamus releases GnRH gonadotropin-releasing hormone to stimulate the pituitary to produce LH luteinizing hormone and FSH follicle-stimulating hormone which in turn cause the gonads to produce sex steroids.
In adolescents of either sex with relevant indicators, GnRH analogues , such as leuprorelin can be used to suspend the advance of sex steroid induced, inappropriate pubertal changes for a period without inducing any changes in the gender-appropriate direction. GnRH analogues work by initially over stimulating the pituitary then rapidly desensitizing it to the effects of GnRH. Over a period of weeks, gonadal androgen production is greatly reduced. There is considerable controversy over the earliest age, and for how long it is clinically, morally and legally safe to do this.
The Harry Benjamin International Gender Dysphoria Association Standards of Care permit from Tanner Stage 2, but do not allow the addition of gender-appropriate hormones until 16, which could be five or more years. The sex steroids do have important other functions. The high cost of GnRH analogues is often a significant factor. Antiestrogens or so-called "estrogen blockers" like aromatase inhibitors AIs e. In addition, in those who have not yet undergone or completed epiphyseal closure which occurs during adolescence and is mediated by estrogen , antiestrogens can prevent hip widening as well as increase final height estrogen limits height by causing the epiphyses to fuse.
Depo-Provera depot medroxyprogesterone acetate, or DMPA may be injected every three months just as it is used for contraception. Generally after the first cycle, menses are greatly reduced or eliminated. This may be useful for transgender men prior to initiation of testosterone therapy. In those who have not yet undergone or completed epiphyseal closure, growth hormone can be administered, potentially in conjunction with an aromatase inhibitor or a GnRH analogue, to increase final height.
Many transgender men are unable to pass as cisgender men without hormones. The most commonly cited reason for this is that their voice may reveal them. Facial changes develop gradually over time, and sexual dimorphism physical difference between the sexes tends to increase with age.
Within a population of similar body size and ethnicity:. Frequently the first sign of endometrial cancer is bleeding in post-menopausal women. Transgender men who have any bleeding after the cessation of menses with androgen therapy should have an endometrial biopsy and possibly an ultrasound done to rule-out endometrial cancer.
A number of skeletal and cartilaginous changes take place after the onset of puberty at various rates and times. Sometime in the late teen years epiphyseal closure in other words, the ends of bones are fused closed takes place and the length of bones is fixed for life.
Consequently, total height and the length of arms, legs, hands, and feet are not affected by HRT. However, details of bone shape change throughout life, bones becoming heavier and more deeply sculptured under the influence of testosterone. Many of these differences are described in the Desmond Morris book Manwatching.
The psychological changes are harder to define, since HRT is usually the first physical action that takes place when transitioning. This fact alone has a significant psychological impact, which is hard to distinguish from hormonally induced changes. Most trans men report an increase of energy and an increased sex drive. Many also report feeling more confident. While a high level of testosterone is often associated with an increase in aggression , this is not a noticeable effect in most trans men.
HRT doses of testosterone are much lower than the typical doses taken by steroid-using athletes, and create testosterone levels comparable to those of most cisgender men. These levels of testosterone have not been proven to cause more aggression than comparable levels of estrogen. It is assumed that the effect of the start of physical treatment is such a relief, and decreases pre-existing aggression so much, that the overall level of aggression actually decreases.
Some transgender men report mood swings, increased anger, and increased aggressiveness after starting androgen therapy. Many transgender men, however, report improved mood, decreased emotional lability, and a lessening of anger and aggression. During HRT, especially in the early stages of treatment, blood work should be consistently done to assess hormone levels and liver function. Before oophorectomy, it is difficult and frequently impractical to fully suppress estrogen levels into the normal male range, especially with exogenous testosterone aromatizing into estrogen, hence why the female ranges are referenced instead.
In post-oophorectomy trans men, Israel et al. See the table below for all of the precise values they suggest. The optimal ranges listed for testosterone only apply to individuals taking bioidentical hormones in the form of testosterone including esters and do not apply to those taking synthetic AAS e.
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