1. Transmen

2. Testosterone Effects in Transmen
ONSET (months)
MAXIMUM (years)
Skin oiliness/acne
Facial/body hair growth
Scalp hair loss
Increased muscle mass/strength
Fat redistribution
Cessation of menses
Clitoral enlargement
Vaginal atrophy
Deepening of voice
1 – 6
6 – 12
2 – 6
3 – 6
1 – 2
4 – 5
2 – 5
Hembree JCEM 2009, 94(9):3132–3154

3. Effect of Testosterone in Transmen (FtM)
Increased facial and body hair
Male pattern baldness
Voice change
Increased libido
Increased social drive and arousability
Cliteromegally
Increased muscular strength
Redistribution and decrease of body fat
Breast atrophy

4. Charing Cross Regimen Standard male HRT doses and regimens are used
INTRAMUSCULAR
Sustanon (250mg im 2-4 weekly)
Nebido (1000mg 12 weekly)
TRANSDERMAL
Gel (50-100mg)
SUBCUTANEOUS IMPLANTS mg

5. Contraindications Breast cancer Pregnancy Breast feeding
Primary liver tumour
Hypercalcaemia
Ischaemic Heart disease

6. Morbidity in 293 Transmen No. Observed SIR (95% CI)
Myocardial Infarction (6 fatal)
Angina Pectoris
Hypertension (>160/95mmHg)
Elevation of Liver Enzymes
Transient (<6 months)
Persistent (>6 months)
Alcohol related
Others
Acne
Venous thrombosis
Postoperative
Oedema 1 12 45 13 20 3 9 80 5
[ ] NA
2[ ]
[ ]
Van Kesteren Clin Endo

7. Morbidity: Female to male
No excess mortality
No excess morbidity
ACNE
MI rate one third expected

8. Haematological Effects of Androgen Therapy
Testosterone increases erythropoietin
Hematocrit increases with androgen therapy
12 -25%.
3-5% require phlebotomy or stop therapy
Immune function not effected

9. Effects of Testosterone on Lipid Parameters in Transmen
Elamin Clinical Endocrinology (2010) 72, 1–10

10. Effects of Testosterone on Lipid Parameters in Transmen
Total Cholesterol mmol/l
Triglyceride mmo/l
LDL Cholesterol mmol/l
HDL Cholesterol mmol/l
Elamin Clinical Endocrinology (2010) 72, 1–10

11. Total Cholestrol

12. Triglyceride

13. HDL

14. LDL

15. Cardiovascular Risk and testosterone treatment
Normal range
Cardiovascular Risk
Plasma Testosterone

16. Testosterone and Endometrial Hyperplasia
Endometrial hyperplasia occurs in 15%
Recommend hysterectomy and salpingoopherectomy after 2 years of treatment
If uterus is retained USS scan every 2 years
Futterweit 1998 Arch Sex Behav

17. BMD in Transmen
Turner 2004 Clin Endocrinol 61 (5), 

18. FtM
MtF
Van Kesteren 1998 Clinical Endocrinology 48 (3), 

19. Monitoring Preparation Dose Frequency Monitoring Method
Testosterone Values
Maximum Dose
Testosterone Injections (monthly)
 Sustanon or Testosterone Enantate
 250mgs
Injection
 (Dose can be from mgs)
4, 3 or 2 weekly
Trough on day of injection prior to injection and Peak – 7 days later
Trough level – 8 – 12nmol/ls
Peak level
25 – 30nmol/ls   
250mg every 10days
 Longer Acting Testosterone Injection
 Nebido 
(has a loading phase)
1,000mg
10 to 15 weekly
Trough on day of injection prior to injection prior to injection
15 – 20nmol/Ls
1000mg every 9 weeks
 Topical Testosterone gel
 Testogel
Testim
50mg/5gm
Daily
 Ensure no gel on arms and 4 – 6 hours after application of gel.
2 packets (100mg) daily

20. Monitoring Sustanon/Testosterone Enantate Initial frequency
Day 4th injection plus testosterone 7 days after injection
Nebido:
annual monitoring on the day of injection
Testim/Testogel
4-6 after the gel is applied
take the blood from the arm that the gel was NOT applied to
Initial frequency
depends on preparation
When dose stabilised
6 Monthly monitoring for 2 year then annual monitoring
Testosterone,
FBC,
LFTs
Lipids

21. Monitoring Cervical Smears Endometrial USS every 2 years
As per national guidelines
Endometrial USS every 2 years
Brest cancer risk is same a male breast caner risk after male chest reconstruction

23. Pubic Phalloplasty

26. Non Binary

27. Non Binary Clinical Approach
Advice should only be given where the clinician can give a clear indication to the person what physical changes will occur on hormone therapy and whether the desired mix of male and female features they desire is feasible with hormone therapy
It is also important to advise the individual that none of the hormone regimens used in this field have been examined by randomised controlled clinical trials.
The approach to hormone therapy also needs to be individualised
In those that desire gender neutrality GnRH analogues alone may be appropriate
The other approach is to allow natal hormone production to continue and attempt to suppress this sufficiently with anti-androgen therapy in a male-bodied person, or progestin or combined oestrogen/progestin treatment in a female-bodied person

28. Non Binary Clinical Approach
This is Specialist Gender Medicine
Decisions are made in the context of a multidisciplinary approach.
degree of fluidity
a clear formulation of the mix of male, female, and neutral physical features is made
significant psychological co-morbidities are excluded or managed.
In all people it is important to discuss the fact that hormone therapy will impact on reproductive potential
It is also good practice for the individual to be reviewed regularly by the members of the multidisciplinary team.
It is important to have psychological input to the care of the individual, as the impact of the physical changes in the person on the psychological function

29. Long term outcome in gender dysphoria

30. Figure 1. Death from any cause as a function of time after sex reassignment among 324 transsexual persons in Sweden (male-to-female: N = 191, female-to-male: N = 133), and population controls matched on birth year.
Dhejne C, Lichtenstein P, Boman M, Johansson ALV, et al. (2011) Long-Term Follow-Up of Transsexual Persons Undergoing Sex Reassignment Surgery: Cohort Study in Sweden. PLoS ONE 6(2): e doi: /journal.pone

31. Risk of various outcomes among sex-reassigned subjects in Sweden (N = 324) compared to population controls matched for birth year and birth sex.
Cases are 324 controls 3240 matched for bith and aquired gender 10.4 year follow up
Suicide 3 fold increase in suidcide deaths
Dhejne C, Lichtenstein P, Boman M, Johansson ALV, et al. (2011) Long-Term Follow-Up of Transsexual Persons Undergoing Sex Reassignment Surgery: Cohort Study in Sweden. PLoS ONE 6(2): e doi: /journal.pone 31 31

32. SMR adjusted for age and period of follow-up on hormone treatment by biological sex in 1331 transsexual subjects
Mean follow up is 18.8 for ftm and 19.4 for mtf
Asscheman Eu J Endo (2011) –642 32

33. Hazard ratios (95% CIs) of mortality according to the use of ethinyl estradiol in 964 Transwomen (median follow up of 18.6 years)
Asscheman Eu J Endo (2011) –642

34. Long Term Outcome in Gender Dysphoria
There is no difference in SMR for transmen
There may be an increase in SMR for transwomen
Suicide (x5.7)
AIDS (x30)
Cardiovascular Death (1.64)
(EE users only)
However Studies are confounded by changes in therapy over the last 10 years
Van kesteren (1996)
M t F 816
F t M 293 34

35. In Summary
Gender dysphoria requires hormonal therapy to achieve the secondary sexual characteristics of the desired gender
Hormonal therapy
carries physical risks
provides psychological benefit
Careful monitoring is required to prevent complications occurring
Hormonal therapy in gender dysphoria is
Effective
Safe

36. Contact Us Gender Identity Clinic Hammersmith W6 8QZ
Fulham Palace Road
Hammersmith
W6 8QZ
Tel:
Fax:
Web page:

37. GMC Guidance

38. GMC Guidance

39. Advice to those consider self meicating
We strongly recommend that you do not self medicate with hormone from the internet the hormones there can be of poor quality and many of the doses recommended but websites result in very high hormone levels. Starting hormones in an unsupervised way also means that the screening tests done at the gender service to see if there are any problems with your hormone system cant be done.
Prescribed hormones to allow appropriate monitoring and hormone titration under the guidance of a specialist Endocrinologist or your GP, this can be facilitated at the GIC
We can perform the following safety tests as indicated by the hormones you may be taking, but are not able to measure specific hormone levels:
Trans men: FBC, liver function tests, lipid profile
Trans women: prolactin, liver function tests