What is the recommended hormone therapy regimen for a transgender female to male transition?

Recommended Hormone Therapy Regimen for Transgender Female to Male Transition

The recommended hormone therapy regimen for transgender female to male (FTM) transition is testosterone therapy with a target serum level of 500-600 ng/dL in the mid-normal cisgender male reference range (300-1000 ng/dL). 1

Testosterone Administration Options

Primary Options:

• Testosterone cypionate or enanthate
  • Most commonly administered subcutaneously for patient comfort
  • Typically dosed every 1-2 weeks
  • Testosterone levels should be measured midway between injections 1

Alternative Options:

• Testosterone gels or patches

  • Particularly beneficial for patients with cardiovascular risk factors
  • Recommended for patients with risk of erythrocytosis
  • Levels can be measured at any time but most consistently in the morning 1

• Testosterone undecanoate

  • Provides extended release
  • Caution advised due to risk of pulmonary oil microembolism and anaphylaxis 1

Monitoring Protocol

Initial Phase:

• First follow-up: 1-2 months after starting therapy to assess efficacy
• Regular monitoring: Every 3 months during the first year 1

Laboratory Monitoring:

• Testosterone levels: Target mid-normal range (500-600 ng/dL)
• Complete blood count: Monitor for polycythemia
• Lipid profile: Watch for decreased HDL, increased LDL and triglycerides
• Blood pressure: May increase with testosterone therapy 1

Long-term Monitoring:

• Every 6-12 months after the first year if stable 1

Expected Effects and Timeline

Most effects begin to develop within several months of starting therapy:

• Voice deepening (irreversible)
• Increased facial and body hair
• Increased muscle mass and strength
• Decreased fat mass
• Cessation of menstruation (typically within 1-6 months)
• Clitoral enlargement
• Reduction in gender dysphoria, perceived stress, anxiety, and depression 2

Note that facial hair and male-pattern baldness continue to develop beyond 1 year of therapy 2

Managing Side Effects

Hematologic:

• If hematocrit rises above reference range:
  • Temporarily withhold therapy
  • Reduce dosage
  • Consider phlebotomy for severe elevations 1

Menstrual Management:

• For persistent menstruation despite testosterone:
  1. Add a progestin to hormone regimen (first-line)
  2. Consider GnRH analogs if progestins are contraindicated
  3. Hysterectomy with bilateral salpingo-oophorectomy as a definitive option 1

Other Side Effects:

• Acne: Topical or systemic treatments as needed
• Androgenic alopecia: Consider topical minoxidil
• Pelvic pain and genital dryness: May require management 1, 2

Cardiovascular Considerations

• Advise smoking cessation and weight management
• Monitor lipid profiles regularly
• Be aware of potential increases in blood pressure, triglycerides, and LDL cholesterol 1

Fertility Considerations

• Counsel patients about potential impact on fertility before starting therapy
• Consider fertility preservation options before initiating testosterone
• Do not prescribe testosterone to patients interested in preserving fertility without appropriate counseling 1

Important Caveats

1. Regular gynecological care remains important despite testosterone therapy 1
2. Some effects are irreversible (voice deepening, hair changes) and will persist even if testosterone is discontinued 1
3. Testosterone therapy has been shown to reduce risk of breast cancer (with or without mastectomy) 2
4. Polycythemia is a common side effect requiring regular monitoring 1
5. Avoid testosterone levels above physiologic range as this increases risk of side effects 1

Hormone therapy has been shown to have positive physical and psychological effects on transitioning individuals and is considered a mainstay treatment for many patients 3. While there are potential risks, testosterone treatment for FTM transition has generally not raised major safety concerns and is typically well-tolerated 4.