What is the recommended protocol for gradually tapering and discontinuing testosterone therapy in an adult transmasculine patient, including dose reductions, monitoring intervals, and adjustments for comorbidities such as cardiovascular disease, hypertension, polycythemia, or liver disease?

Testosterone Dose Reduction in Transmasculine Patients

The evidence provided does not contain transgender-specific guidelines for testosterone discontinuation or tapering protocols. The available literature focuses on testosterone replacement therapy (TRT) in cisgender men with hypogonadism, which involves fundamentally different physiologic goals and contexts than gender-affirming testosterone therapy. Applying these protocols directly to transmasculine patients would be inappropriate and potentially harmful.

Critical Evidence Gap

The provided studies address:

• Monitoring parameters for TRT in hypogonadal cisgender men 1
• Cardiovascular and metabolic effects of testosterone 1
• Perioperative continuation of testosterone in transgender patients 1
• Tapering strategies for other medications (antidepressants, antipsychotics, hormone therapy) 2, 3, 4, 5

None of these sources provide protocols for discontinuing gender-affirming testosterone therapy in transmasculine individuals.

What the Evidence Does Tell Us

Monitoring Parameters During Testosterone Therapy

If dose reduction is necessary due to complications, the following parameters require monitoring based on TRT literature:

Polycythemia Management:

• Hematocrit elevation is the most common adverse effect requiring dose adjustment 1
• Injectable testosterone causes erythrocytosis in 43.8% of patients versus 15.4% with transdermal preparations 1
• If hematocrit becomes elevated, therapy should be stopped until it decreases to acceptable levels 6
• Monitoring should occur at 3-6 months after any dose change, then annually 1, 6

Cardiovascular Considerations:

• Patients with congestive heart failure require middle-range testosterone goals (350-600 ng/dL) due to fluid retention risk 1
• Patients over 70 years or with chronic illness should use easily titratable formulations (gel, spray, patch) rather than long-acting injectables 1

Formulation-Specific Considerations:

• Transdermal preparations allow more gradual titration than injectable forms 1
• The perioperative guideline states testosterone therapy "will generally be continued" in transgender patients 1

Extrapolation from Other Medication Tapering Literature

While not directly applicable, tapering principles from other medications suggest:

• Abrupt discontinuation increases adverse outcomes compared to gradual tapering 2, 4, 5
• Tapering periods of months (not weeks) reduce withdrawal phenomena 2, 4
• Hyperbolic dose reductions (reducing by fixed percentages rather than fixed amounts) may minimize physiologic disruption 4, 5
• Final doses before complete cessation may need to be very small fractions of therapeutic doses 5

Clinical Reality

For transmasculine patients requiring testosterone dose reduction or discontinuation, consultation with experienced gender-affirming care providers is essential. The decision to reduce or stop testosterone has profound implications for gender dysphoria, mental health, and quality of life that are not addressed in the hypogonadism literature provided. The physiologic context differs fundamentally: transmasculine patients are not returning to a "baseline" endogenous testosterone state but rather to endogenous estrogen dominance, which may trigger dysphoria and psychological distress.

Common clinical scenarios requiring dose adjustment include:

• Polycythemia (hematocrit >52%) requiring dose reduction or temporary cessation 1, 6, 7
• Cardiovascular events necessitating risk reduction 1
• Liver function abnormalities 6
• Patient preference or fertility planning

The absence of evidence-based protocols represents a significant gap in transgender healthcare literature that urgently requires research attention.