Hormone Therapy
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Hormone Therapy

Trans persons often want to access hormonal treatment. Treatment with hormones is possible from puberty onwards - taking puberty development stages, emotional maturation and the ability to give free and informed consent into account. Younger transgender adolescents may initiate puberty blockers to inhibit the development of secondary sexual characteristics from the start of Tanner stage 2, and only with parental consent and if they have the full capacity to give informed consent.

Hormone therapy can be accessed in one of two ways: privately, at one’s own cost with a prescription from a GP/endocrinologist, or on the National Health Service (Schedule V) through the Gender Wellbeing Clinic.

When starting hormonal treatment, the endocrinologist (hormone specialist) is involved in supervising the transition. An assessment with a child psychologist to determine capacity to give informed consent is also part of this process for children under 16 years of age. The endocrinologist checks the current hormone levels and guides the patient in taking a correct and safe decision for hormonal treatment.

For individuals continuing hormone treatment that have either started abroad or via informal markets, an initial visit at the Gender Wellbeing Clinic is required to receive coverage through the free healthcare entitlement (when available). This process is generally fast-tracked for those who are already undergoing hormone therapy. Some hormone preparations available abroad may not be available in Malta.

The plan for follow-up of hormonal treatment is developed on a case-by-case basis, and can include follow-up appointments with the Gender Wellbeing Clinic or a general practitioner. Follow up care includes a medical assessment such as bone densitometry, blood pressure and BMI measurement, and blood investigations, as well as an assessment of the psycho-social and sexual wellbeing of the client.

Gender affirming hormonal treatment is a safe and effective therapy. It has been linked with a decrease in psychopathology, depressive symptoms and body uneasiness (Fisher at al., 2016). However, before initiation of GnRHa, anti-androgens and/or estrogens treatment, or progestogen and/or testosterone treatment, the hormone-prescribing physician needs to screen for conditions that may worsen with the start of treatment (T’Sjoen et al., 2019).

Puberty blockers
Pubertal hormone suppression in trans adolescents is best initiated, after they show their first pubertal changes (Tanner stage G2), and have sufficient capacity to give informed consent (T’Sjoen et al., 2019). In adolescents desiring feminizing hormone treatment, it is advised to use puberty induction with 17beta-estradiol, often using a gradually increasing dose schedule; whereas in adolescents desiring masculinising hormone treatment, puberty induction with testosterone is advised, often using a gradually increasing dose schedule (T’Sjoen et al., 2019). The hormone-prescribing physician should discuss the effects and possible adverse health effects of GnRHa, anti-androgens, and/or estrogen treatment, and/or testosterone treatment, including fertility preservation options and consequences for genital surgery, based on the person’s goals, prior to any hormonal intervention (T’Sjoen et al., 2019).

Photo: The Gender Spectrum Collection

Trans men and other trans and non-binary people taking testosterone
The optimal testosterone administration, when administering a full dose, tries to mimic young cisgender men's hormonal levels. The aim is to develop a testosterone concentration in the blood that falls within the "normal" range for cisgender men. A testosterone treatment can consist of subdermal pellets, dermal patches, topical gel, and/or injections. Injectable testosterone esters have variable frequencies for injection, anywhere from 1 to 12 weeks between shots. In Malta, the most common method of testosterone administration is via intramuscular injections - Testosterone enanthate, one dose every 3 to 4 weeks, or Testosterone undecanoate one dose every 10 to 12 weeks. These injections can be either administered by the Primary HealthCare nurses in the Health Centres' treatment room, or by a GP or nurse of the person's choice within the private sector.

Trans people taking testosterone should be informed about the following effects: increased facial and body hair, increased lean mass and strength, decreased fat mass, deepening of the voice, increased sexual desire, cessation of menstruation, clitoral enlargement, and reductions in gender dysphoria, perceived stress, anxiety, and depression (Irwig, 2016).

Typically, menstrual bleeding stops after a few months of testosterone treatment. Though not a common occurrence, menstrual bleeding can persist during testosterone treatment. In this case, one of the options is for the client to take the mini pill on a continuous basis (i.e. without having a day off), to temporarily stop the cycle.

When administering testosterone, an irreversible deepening of the voice begins after 6 weeks to 3 months. The subcutaneous fat distribution changes (e.g. from the hips to the stomach). The skin becomes rougher and greasier and acne can occur. Menstruation usually stops completely. Sexual desire increases, and the clitoris grows larger (to a limited extent). The muscle mass and strength also increase. After a while, beard growth and body hair can occur (or body hair increases), depending on the person’s genetics. If the person's genetics have a tendency for this, they may also lose head hair. Some breast atrophy occurs, which makes the breasts look a bit weaker and smaller due to fat loss or redistribution.

Some trans men also experience negative psychological side effects such as increased irritability. The extent to which and the speed with which the body changes differs from person to person and is also genetically determined. Height is not affected in adult persons.

Under the influence of hormonal treatment with testosterone, ovulation typically no longer takes place, but testosterone cannot be considered as contraception, as it can still be possible to become pregnant. As soon as the testosterone treatment stops, the cycle starts (slowly) again, given that the ovaries and fallopian tubes are still present. In the event of pregnancy, testosterone treatment must be interrupted for at least 1 year in preparation for this pregnancy. In the case of unexpected pregnancy while taking testosterone, testosterone must be stopped immediately for the health of the fetus. It is only after the surgical removal of the uterus and ovaries that infertility is definitive.

Some trans people assigned female at birth opt for low doses of testosterone; for some a low dose is only to start and for others this is a long-term decision. Low dose testosterone will ultimately lead to the same irreversible physical outcomes, just on a longer timeline. Continued menstruation is more likely on a lower dose. Long-term effects, including on fertility, are not yet well-established.

Testosterone therapy is considered to be a safe life-long treatment for trans people which can start during puberty and is still possible even in menopause. There are only a few medical situations for not administering testosterone. Extra caution is required for existing liver function problems, as testosterone may exacerbate these and lead to further complications. Severe obesity, diabetes and hypercholesterolemia should be discussed and monitored before starting testosterone treatment, with adequate follow-up; more frequent follow-up appointments may be appropriate in these cases. However, delaying access to testosterone should be minimised as much as possible to ensure that the mental health of the trans person is not compromised. It is important to monitor the number of red blood cells because a dose of testosterone that is too high can cause an overproduction of red blood cells. This increases the risk of thrombosis. Extra attention is to be paid in the administration of testosterone if the person is diagnosed with sleep apnea.

Trans women and other trans and non-binary people taking oestrogen
Treatment in trans and non-binary people taking oestogren usually consists of both medication that inhibits the production of testosterone and oestrogens. Inhibiting testosterone production is only necessary for transgender persons before or who do not wish to undergo genital surgery, because after orchiectomy, the major source of testosterone production (the testes) is no longer present. After gonadectomy, lifelong oestrogens are necessary in the absence of contraindications. A specific age at which the dose must be reduced or where oestrogens should be interrupted is not known. The general health status will be decisive here.

Anti-androgens inhibit testosterone production and/or block the testosterone receptor. The desired effects can include reduction of sexual desire (fewer spontaneous erections), less body hair and cessation of the process of hair loss. Side effects reported are fatigue, listlessness, muscle weakness and infertility. However, hormonal treatment should not be considered as an adequate form of contraception.
Oestrogens also suppress testosterone production and lead to decreased body and facial hair, decreased muscle mass, breast growth, and redistribution of fat (Tangpricha & den Heijer, 2017). Height does not change in adults. The voice is not affected and speech therapy is often used to help with this. Often there is also only a limited effect on beard growth. Laser or electrical epilation may then be required. The body hair at other body zones usually responds better to the treatment. The most encountered side effect of oestrogens is the increased risk of thrombosis (blood clots). Advice from the endocrinologist is recommended. Blood clots occur primarily in people who smoke.

Some trans people assigned male at birth opt for low doses of oestrogen; for some a low dose is only to start and for others this is a long-term decision. Low dose oestrogen will ultimately lead to the same irreversible physical outcomes, just on a longer timeline. Continued ability to have an erection is more likely on a lower dose. Long-term effects, including on fertility, are not yet well-established.

Some people have an increased risk of complications due to oestrogens and therefore should not use such medications. Oestrogens are absolutely forbidden in case of severe hypertension (high blood pressure), a known risk of thrombosis, a history of cerebral haemorrhage and severe liver diseases. A solution in consultation with the coagulation specialist (haematologist) will then have to be found. When using oestrogens, there is always a very small increased risk of breast cancer, and especially if the trans person has a family history of this. Monthly self-examination is essential, and a mammography is recommended as in the case of cisgender women. As with trans people taking testosterone, based on current medical knowledge, hormonal treatment does not have an increased risk of mortality or cancer compared to a control population.

  • Fisher, A. D., Castellini, G., Fanni, E., Casale, H., Amato, A. L., Maseroli, E., . . . Maggi, M. (2016). Cross-sex hormone treatment and psychobiological changes in transsexual persons: 2-years follow-up data. Journal of Sexual Medicine, 13(5), S84-S85. doi:10.1016/j.jsxm.2016.03.014
  • Irwig, M. S. (2017). Testosterone therapy for transgender men. The Lancet Diabetes & Endocrinology, 5(4), 301-311. doi:10.1016/S2213-8587(16)00036-X
  • Tangpricha, V., & den Heijer, M. (2017). Oestrogen and anti-androgen therapy for transgender women. The lancet. Diabetes & endocrinology, 5(4), 291-300.