What is the typical hormone regimen for starting male to female gender affirming care?

Male to Female Gender Affirming Hormone Therapy Protocol

The standard hormone regimen for starting male to female gender affirming care consists of estradiol as the cornerstone medication, typically combined with an anti-androgen such as spironolactone to suppress testosterone production. 1, 2, 3

Core Components of Feminizing Hormone Therapy

• Estradiol is the primary medication for feminizing hormone therapy and is available in multiple formulations:

  • Oral tablets
  • Transdermal patches
  • Injectable formulations (estradiol valerate or cypionate) 1, 2

• Anti-androgens are typically added to enable lower doses of estrogen while achieving adequate testosterone suppression, with common options including: 1, 3

  • Spironolactone (most commonly used in many countries)
  • Cyproterone acetate (not available in the US)
  • GnRH agonists (puberty blockers)
  • Bicalutamide
  • Finasteride 1, 2

Target Hormone Levels and Monitoring

• Target hormone levels should be: 1, 2, 3

  • Testosterone <50 ng/dL
  • Estradiol in the cisgender female reference range

• Monitoring schedule: 2, 3

  • Baseline assessment before starting therapy (complete blood count, liver function, lipid profile, glucose, baseline hormone levels)
  • Check hormone levels at 3 months after initiating therapy
  • Monitor every 3-6 months during the first year
  • Annual monitoring once stable 2, 3

Expected Physical Changes

• Feminizing hormone therapy induces several physical changes: 1, 2, 3
  • Breast development (variable results)
  • Decreased muscle mass (3.0-5.5% reduction in lean body mass)
  • Softening of skin
  • Decreased body and facial hair growth
  • Decreased libido
  • Reduced erectile function
  • Decreased hemoglobin levels to female reference range 1, 2

Potential Side Effects and Risks

• Feminizing hormone therapy carries several risks that require monitoring: 1, 3
  • Increased risk of venous thromboembolism
  • Increased risk of ischemic stroke and myocardial infarction
  • Weight gain
  • Potential compromised bone structure 1, 2, 3

Special Considerations

• Fertility preservation counseling must be provided before starting hormone therapy, as treatments may affect fertility 2, 3

• Some transgender women may use chest binding or genital tucking to minimize gender dysphoria. These practices have mental health benefits but can cause physical complications: 4

  • Chest binding can cause restrictive lung defects
  • Genital tucking may have risks but can improve mental health 4

• For transgender individuals with pre-existing cardiovascular conditions, more frequent monitoring may be necessary 3

• Laboratory values should generally be interpreted based on affirmed gender for individuals on hormone therapy for more than 1 year 2, 3

Practical Algorithm for Initiating Therapy

1. Complete baseline assessment (labs, medical history, mental health evaluation) 2, 3
2. Provide fertility preservation counseling 2, 3
3. Start with:
   • Estradiol (typically 2-6 mg daily oral, 0.1-0.4 mg/day transdermal, or 5-20 mg IM every 1-2 weeks) 1, 5
   • Anti-androgen (typically spironolactone 100-300 mg daily) 1, 5
4. Check hormone levels at 3 months and adjust dosing as needed 2, 3
5. Monitor for side effects and continue regular follow-up 1, 2, 3

Common Pitfalls to Avoid

• Failing to provide comprehensive baseline assessment before initiating therapy 2, 3
• Not monitoring hormone levels regularly, especially during the first year 2, 3
• Overlooking cardiovascular risk factors that may be exacerbated by hormone therapy 1, 3
• Neglecting mental health support during transition 3, 6
• Using ethinyl estradiol, which carries higher thrombotic risk than other estrogen formulations 1, 5

Despite the established protocols, access to gender-affirming care remains challenging for many transgender individuals due to financial barriers, insurance issues, lack of service availability, and provider knowledge gaps 6.