Management of Gender Clients
Hormone therapy for “Female-to-Male” (FtM) clients:
A resource for General Practice
Hormone therapy (when client has ovaries)
The goal of hormone therapy is twofold: to reduce endogenous hormone levels and hence the secondary sexual characteristics of the individual’s assigned (birth) gender, and to induce characteristics of the new gender by direct stimulation of target receptors. Medical conditions that can be exacerbated by hormone depletion or cross-sex hormone treatment should be evaluated prior to initiation of treatment. The cross-sex hormone level should be maintained as close as possible to the physiological range of the desired gender.
Testosterone acts both to block the pituitary-gonadal axis, and to induce masculinisation by stimulating receptors in target organs.
Injections can be short acting or long acting. Testosterone can be initiated as Primoteston containing 250mg/ml IM every 2-3 weeks. There is a swing in hormone levels with a high level in the first week then a fall-off in the second. The full 250mg may give levels that are too high, i.e. above the physiological male range most of the time. It is not difficult to measure a lower dose, e.g. 200mg. It can be given into the upper outer quadrant of the buttock, or the anterior-lateral thigh.
The long-acting injection (Reandron-1000) provides a smooth physiological level. The regime is the same as for natal males. Reandron is becoming the injectable of choice because in 2013 it became easy to change the patient’s gender with Medicare with a GP letter. The Authority indication is “primary testicular disorder”.
Oral formulations do not work very well, and may cause abnormal LFTs.
Testosterone gel may be used, and gives a physiological level. Again, the patient needs to be male with Medicare. A double dose (2 sachets daily) may be required to prevent break-through bleeding. Gel can be absorbed by people who come in close contact with the applied area. There is an underarm roll-on formulation (Axiron) which makes this less likely, and has a shorter drying time.
Patches are convenient, but can irritate the skin.
Implants can be used but are expensive, multiple pellets are required each time, and extrusion is possible. Again, they are more use after ovaries are removed.
Testosterone cream is available by private prescription from Lawley in WA as Androforte, or can be compounded locally. Dose is measured by the length in cms of the application.
C. Contraindications and Precautions
There are no absolute contraindications, as no major adverse outcomes from Testosterone have been identified in population studies so far. However, data are insufficient to allow meaningful assessment of the risk of cardiovascular events. Clients should not smoke, and manage risk factors as per general cardiovascular risk guidelines.
Pre-treatment bloods should include serum Testosterone, FBE, fasting lipids and BSL, LFTs.
Abnormal LFTs need diagnosis prior to commencing Testosterone.
Acne is the most troublesome side effect and should be managed as usual with topical agents e.g. Epiduo, and oral antibiotics if required. Do not hesitate to refer to a Dermatologist as Roaccutane may be required.
Weight gain can occur, especially central obesity in clients with a predisposition. FtMs should “work out” to make their testosterone work for them.
Male-pattern baldness may occur, and can be treated as for biological men.
Aggression is reported anecdotally but trials show that most clients feel calmer.
Anecdotally some clients report myalgia, and occasionally migraine or cluster headaches.
Testosterone injections almost always abolish all menstrual bleeding, but if they don’t, then adding a small dose of continuous progesterone e.g. Norethisterone 5 mg daily for a few months will do this.
Some FtMs are already on Depo-Provera to abolish cycles when they come for assessment. This is ceased when they start testosterone.
Polycythaemia can occur on testosterone. Smoking and dehydration (e.g. from excessive alcohol intake) make this worse. Occasionally venesection may be required.
Monitoring hormone therapy in FtM
The rate and degree of change depend on the dosage, the age of the client, and the client’s intrinsic responsiveness. The latter is probably genetically determined.
Facial hair growth, fat redistribution and increased muscle mass may not plateau until 5 years.
Skin oiliness may start as early as one month should plateau by 2 years.
Deepening of the voice starts at 6-12 months and plateaus by 2 years.
Menses should cease by 6 months.
Male pattern baldness may continue to develop through the lifespan.
On Primoteston there will always be a supraphysiological testosterone level in the 3 days post-injection. The most useful timing for bloods is half-way between injections, when the result should be in the male range, and LH suppressed. If the testosterone is too high the dose can be reduced.
FtMs may experience symptoms of irritability as the level drops at around day 12, and may need injections every 11-12 days. Some have injections every 3 weeks with no problems. Some patients are motivated to learn self-injecting.
On Reandron the level should be checked at the trough, and the interval between doses increased or decreased as per product guidelines for biological males.
Check FBE, LFTs, fasting BSL and lipids 12 monthly or as clinically indicated.
FtMs require Pap smears if they have ever had any kind of penetrative sex. The cervix may need to be treated with topical oestrogen for 2 weeks prior to the Pap or it may return a low-grade abnormality.
The long-term effects of testosterone on cervix, uterus and ovaries are unknown; the number of genital tract cancers reported in this population is small. There may be a small increased risk of endometrial cancer.
If breasts are present, screen as per female guidelines. After male chest reconstruction, there are still a few breast cells present, and breast cancer is not impossible.
It is not known if fertility is completely suppressed by testosterone, or when this might become irreversible.
A sensitive sexual history should be taken. Some FtMs have male partners, some have vaginal sex, and some could not contemplate vaginal sex.
Follow-up appointments involve an awareness of the issues below, although not all will be addressed at once.
Significant dates such as when the client commenced hormone therapy and when the client changed their identity documents should be clearly noted in the file.
1. Hormone therapy -
a. positive clinical changes
b. side-effects or problems
c. dose and timing
2. Family situation
4. Work and training
5. Symptoms of mood disorder/suicidal risk
6. Management of cardiovascular risk factors
7. Transition issues such as
a. planning change of documents
b. planning mastectomy