What hormone levels should be monitored in a trans patient taking testosterone?

Hormone Level Monitoring for Transgender Patients on Testosterone Therapy

For transgender patients on testosterone therapy, regular monitoring should include total testosterone levels (target 300-1,000 ng/dL), complete blood count with hematocrit (maintain <54%), and lipid profile due to risk of cardiovascular effects. 1, 2

Essential Hormone Levels to Monitor

Primary Hormone Monitoring

• Total testosterone levels:
  • Target range: 300-1,000 ng/dL (physiological male range)
  • Timing: Morning measurements preferred (when levels are highest)
  • Frequency: At baseline, 3-6 months after initiation, then annually 1, 2

Critical Safety Parameters

• Complete blood count with focus on:

  • Hematocrit (maintain <54%)
  • Hemoglobin
  • Rationale: Testosterone therapy commonly causes erythrocytosis/polycythemia, occurring in up to 43.8% of patients, particularly with injectable formulations 1, 2

• Lipid profile:

  • Monitor for unfavorable changes in lipid profiles
  • One year of gender-affirming hormone therapy (GAHT) has shown undesirable effects on lipid profiles in transgender men 1

Additional Recommended Monitoring

• Liver function tests:

  • Testosterone can affect liver enzymes
  • Baseline and periodic monitoring recommended 2

• Blood pressure:

  • Studies show increased risk of hypertension in some patients
  • Regular monitoring essential as hypertension has been reported as a reason for discontinuation of therapy 3

• Bone mineral density:

  • Particularly important if testosterone dosing is inadequate
  • Inadequate dosing may negatively impact bone density 1

Monitoring Frequency

1. Baseline: Complete panel before initiating therapy
2. Follow-up: 3-6 months after starting therapy
3. Maintenance: Every 6-12 months once stable

Clinical Considerations and Pitfalls

• Testosterone formulation impacts monitoring needs:

  • Injectable testosterone carries highest risk of erythrocytosis (43.8%)
  • Gel preparations have intermediate risk (11.3-17.9%)
  • Transdermal patches have lowest risk (2.8-5.5%) 4

• Cardiovascular risk assessment:

  • Testosterone therapy may increase cardiovascular risk factors
  • Studies show a three-fold increase in death due to unfavorable cardiovascular outcomes in transgender women, suggesting careful monitoring is needed for all patients on hormone therapy 1

• Common pitfalls to avoid:

  • Failing to monitor hematocrit, which can lead to undetected erythrocytosis
  • Not adjusting testosterone dosage when levels are outside target range
  • Overlooking blood pressure changes that may indicate developing hypertension 3
  • Ignoring lipid profile changes that may increase cardiovascular risk 1, 5

• Steady-state considerations:

  • It takes approximately 9 months to reach steady-state testosterone levels
  • Significant heterogeneity exists in levels achieved among patients 6

By monitoring these key hormone levels and clinical parameters, providers can help ensure safe and effective testosterone therapy for transgender patients while minimizing potential adverse effects.