Gender-Affirming

Hormone Therapy
Informed Consent Model
 Informed
Consent Model
of Transgender Hormone
Management
 Prior to Initiation
• Review Informed Consent Information

• Discuss HRT related issues specific to the patient

• Discuss Fertility Options

• Initiation Labs: CBC, CMP, Lipids, HS-CRP

• Questions/Concerns

• Some insurance companies and providers require

letters of recommendation from QMHP’s prior to
initiation
 Goals of Feminizing
Therapy
• Slow Body Hair Growth, Slow Male-Pattern Balding

• Body Fat Redistribution

• Breast Growth

• Soften Skin

• Genital Size Reduction

• Reduction of Spontaneous Erections

• Mental and Emotional Affirmation of the Patient’s Gender

 Risks of Androgen
Blockers

• Spironolactone: Frequent urination, hypotension,

dizziness and orthostatic hypotension,
hyperkalemia, heart palpitations.

• -lutamides may cause liver irritations

 Feminizing Therapy
• Estrogens
• Estradiol tablets SL:

• begin 1mg BID, then 2mg BID, up to 3mg BID

• Estradiol valerate IM or SubQ

• Begin 5mg IM once a week, then 10mg

• Estrogen cream

• Estrogen patches: best for higher health-risk patients

• 0.1mg patch q 4 days, then 2 0.1mg patches, rotating sites

 Feminizing Therapy
• Androgen Blockers
• Spironolactone - Potassium-sparing diuretic, stops Testosterone production

• start at 50mg BID, after 1 month, increase to 100mg BID

• Bicalutamide, Flutamide- Block androgen receptors

• 50mg QD standard dose

• better for hypotensive patients or pt’s who can’t tolerate spiro due to potassium
effects

• Testosterone and Estrogen levels will increase- not useful to monitor T

• Finasteride- Blocks conversion of Testosterone to DHT

• up to 5mg QD

• Not useful if testosterone already suppressed

 Feminizing Therapy
• Progesterone?

• Unclear if there is any therapeutic benefit; very little

research has been done

• Many patients report improved breast fullness and better

sleep if taken at night, may have unknown feminizing
effects

• Some women like the feeling of cycling 2 weeks on 2

weeks off to mimic a menstrual cycle

• May turn into testosterone, may increase clotting risk.

 Feminizing Therapy
• Quantitative Treatment Goals
• Serum Estradiol between 50 and 200 ng/dL in AM before taking
E2 or on trough day if injection

• Serum Testosterone Below 25 ng/dL

• Maintain Prolactin levels below around 25-30ng/mL

• CBC values will drop to female ranges

• Maintain Adequate vitamin D above 50 nmol/L

• Monitor Blood Glucose and Hgb A1c

 Goals of Masculinizing
Therapy
• Stop Menstruation

• Increase male pattern body hair and hairline

• Enlargement of Genitals

• Body Fat Redistribution

• Deepening of Voice

• Gender affirmation- Reduce Dysphoria

• (sometimes it gets worse before it gets better)

 Masculinizing Therapy
• Testosterone therapy
• Testosterone cypionate, enanthionate IM or SubQ

• Begin at 50mg a week, then 100mg a week (can be divided into 2 doses)

• Testosterone undecanoate IM

• One injection of 750mg every 10 weeks after 2 loading doses

• Axiron, Testim, Androgel or other topical (messy messy messy)

• Daily application of 50-100mg. Apply to areas that will not contact loved ones.

• Testopel implants

• 8-12 implant rods inserted under the skin of the belly every 3 months

• Androderm or Testoderm Patches

• 4-6mg a day

• Testosterone Troches (bitter bitter bitter!)

• not recommended due to propensity to cause liver irritation

 Masculinization Therapy
• Quantitative Treatment Goals
• Serum Testosterone between 350ng/dL and
800ng/dL drawn on the trough day

• Serum Estradiol below 50ng/dL is preferred

• CBC and other labs will resemble male reference

ranges

• Maintain healthy Lipid profile and Comprehensive

metabolic
 Patient Monitoring
• Year 1:
• Labs every 3 months

• CBC,CMP, Lipids,

• prolactin, HS-CRP, HgbA1c every 6

• Monitor blood pressure, heart, lungs, check for DVT

• Mental health check ins- help the pt find a good counselor

• Help the patient find support and community

• Help the patient change legal documents

 Patient Monitoring

• Year 2:
• Labs every 6 months with general check up

• Help the patient obtain medically necessary

surgeries

• Continued mental health support

 Patient Monitoring
• Year 3 and up:
• Annual exam and labs

• Sexual health exams:

• Offer support and or medication for anxiety and dysphoria during sensitive exam

• Safer sex discussion- help the patient understand their worth and protect themselves

• if there is a cervix, it needs a pap. Testosterone causes atrophy of the tissue- 10 times
more likely to get an inadequate sample in people on testosterone- check HPV
automatically

• If there is a prostate it needs to be checked, PSA when appropriate

• Receptive anal sex = anal pap. Much higher risk for anal carcinoma in people with
HIV/AIDS

• Breast and chest exams

• STI testing
 HRT Side Effects
• Many studies are inconclusive, outdated, or non-
existent

• Many beg the question:

• Are the negative health effects from hormone

therapy, lifestyle, genetics?

• Regardless of origin, these negative effects

should be controlled to maintain long-term health.
 HRT Side Effects
• Transgender care is a work in progress

• Expected side effects are somewhat based on

outdated studies.

• Many studies did not look at health markers that

are now considered essential to monitor

• Ethinyl Estradiol is no longer used due to

Cardiovascular risks
Common HRT Side-Effects
• Hypertension

• Hyperlipidemia

• Increased Blood Clotting Risk

• Liver Irritation

• Polycythemia (FtM)

• Osteoporosis (MtF)

• Hyperprolactinemia (MtF)

• Diabetes (MtF)
 Naturopathic Philosophy

• Healing Power of Nature

• Identify and Treat the Cause

• Heal the Whole Person

• Prevention
 Hypertension
• Elevated Blood Pressure

• Increased risk for:

• Cardiovascular Disease

• Stroke

• Heart Attack

• End Organ Damage

 Hypertension

• What your patients can do: Lifestyle

• DON’T SMOKE!

• Avoid Caffeine

• Minimize dietary Sodium, increase Potassium

• Regular Cardiovascular exercise

 Hypertension
• What you can do: Nutrition

• CoQ10- Especially important with Statin therapy

• Potassium 4,700mg a day- use caution with

patients on Spironolactone

• Argenine 3,000-9,000mg a day

• Magnesium 1-2,000mg a day

• Vitamin D 5000IU a day

 Hypertension
• What you can do: Supplements

• Crataegus (Hawthorne)

• Melatonin- Controlled Release

• Rawolfia Serpentina (Reserpine)

• Viscum (Mistletoe)

• Tribulis terrestris for trans masculine

• Beets

• Parsley

• Pomegranate
 Hypertension
• Antihypertensives
• Propranolol and Prazosin may be useful as both
a blood pressure medications and anti-anxiety
medications to help with dysphoria

• Use caution when prescribing other diuretics that

affect electrolytes-potassium, magnesium,
calcium-to trans feminine people on
Spironolactone.
 Hyperlipidemia
• Elevated cholesterol or triglycerides

• Increased risk for:

• Coronary artery disease

• Heart attack

• Stroke

• Non-Alcoholic Steatohepatitis
 Hyperlipidemia
• What you can do to help: Lifestyle

• Maintain a low sugar, no trans fats diet high in

lean proteins, vegetables, and balanced fatty
acids

• Cardiovascular exercise

• NO FAT SHAMING

• Inflammation Model of Disease

 Hyperlipidemia
• What you can do to help: Supplements

• Niacin 500mg 3x a day

• Fish oil, or Omega 3 fatty acids 2-3 g a day

• Probiotics 25 billion CFU’s a day

• Alpha-Lipoic Acid

• Centella asiatica (Gotu Kola)

 Thromboembolism
• Estrogen increases the blood’s propensity to clot:

• increased plasma fibrinogen and coagulation factor activity

• Decreased antithrombin III

• Increased platelet activity and aggregation

• For trans feminine the effect is directly from taking estrogen, for trans masculine testosterone aromatizes to
estrogen

• Recent studies raised red flags at the FDA, but most of the study participants were cis-men over 60 and had pre-
existing heart disease

• Risk is: 1 per 10,000 annually before age 40, and approaching 5–6 per 1000 annually by age 80 in cis-patients.

• MtF and FtM trans people have a risk of 8.0% vs. 5.6%, respectively

• Increased risk for:

• Deep Venous Thrombosis

• Stroke

• Pulmonary Embolism

• Heart Attack
 Thromboembolism
• What you can do to help: supplements

• Willow Bark Tea

• Uncaria tomentosa (cat’s caw)

• Fish oil or Omega 3 Fatty acids

• Vitamin E

• Garlic and Onion

• Angelica sinensis

• Ginkgo biloba
 Liver Inflammation
• The liver processes and eliminates hormones via
glucuronidation and most are excreted as conjugated
metabolites in the urine.

• Elevated liver enzymes indicate inflammation and

irritation of the liver

• Increased risk for:

• Cirrhosis

• Liver Cancer
 Liver Inflammation
• What you can do to help: Supplements

• Circuma longa (Turmeric)

• Schizandra chinensis berries

• Silybum marianum (Milk Thistle)

• Castor oil packs

• Brassicas (Diindole Methane)

 Polycythemia
• Polycythemia Vera = increased number of red blood cells
beyond the normal range: Hemoglobin greater than 18.5,
Hematocrit above 52%

• Testosterone stimulates erythropoietin, increasing RBC

production

• Increased risk for:

• Thromboembolism

• Stroke

• DVT
 Polycythemia Vera
• What you can do to help:

• Therapeutic Phlebotomy

• Reduce Testosterone dose

• Avoid smoking and alcohol

• Cordyceps Mushroom

• Hydroxyurea
 Osteoporosis
• Seen more frequently in studies in Trans Feminine
people, but possible for Trans Masculine as well.

• Estrogen may decrease bone density

• Having no Hormones as in patients with

gonadectomy decreases bone density. Hormone
Therapy must be lifelong.

• Increased risk for:

• Fractures
 Osteoporosis
• What you can do to help:
• Increase weight bearing exercise

• Vibration therapy

• Phytoestrogens- Genisten, Icariin, Pueraria

• Avoid smoking and alcohol

• Vitamin D 2-4,000IU/day (5000 in Oregon)

• Calcium 500-2000mg/Magnesium 1000mg/Boron 3mg

• Folate/B12/B6
 Hyperprolactinemia
• Elevated levels of Estrogen can increase Prolactin

• Mild to moderate elevations seen in a few Trans Feminine

people

• Small risk of Prolactinoma

• may stimulate nipple discharge/breast milk production

• Sexual dysfunction, loss of libido are possible

• Possibly increased risk for breast cancer

• Hankinson SE, Willett WC, Michaud DS, et al. FE. Plasma prolactin levels and
subsequent risk of breast cancer in postmenopausal women. J Natl cancer Inst 1999;
91:629-34
 Hyperprolactinemia
• Unclear what long term health risks elevated Prolactin may have in
trans feminine patients

• <50 reduce estrogen, monitor for sx

• >50 MRI to R/O Prolactinoma

• What you can do to help: Supplements

• Vitex agnus-castus (Chaste Berry)

• Vitamin B6 (Pyradoxine) 10-100mg/day

• Bromocryptine
 Diabetes

• Increased risk in trans feminine population on

HRT

• based on case studies

• Estrogen stimulates NOS activity

 Diabetes

• What you can do to help:

• Gymnema sylvestre

• Trigonella (Fenugreek)

• Momordica (Bitter Melon)

• Optimize vitamin D
 Common Physical Issues
• Trans Masculine:

• Rapid muscle growth and body building can lead to upper body nerve and muscle
compression and entrapment- thoracic outlet syndrome, carpal tunnel syndrome

• Lower abdominal/pelvic cramping and pain with orgasm

• Vaginitis due to Atrophy, BV, Candida

• male pattern baldness

• Trans Feminine

• Breast growth is itchy and painful

• Emotions may become more intense

• with very low testosterone, erections may not be possible for penetration

• Male pattern baldness

 Reference Studies
• Coleman, E., Bockting, W., Botzer, M., Cohen-Kettenis, P., DeCuypere, G., Feldman, J., Fraser, L., Green, J., Knudson, G.,
Meyer, W. J., Monstrey, S., Adler, R. K., Brown, G. R., Devor, A. H., Ehrbar, R., Ettner, R., Eyler, E., Garofalo, R., Karasic, D.
H., Lev, A. I., Mayer, G., Meyer-Bahlburg, H., Hall, B. P., Pfaefflin, F., Rachlin, K., Robinson, B., Schechter, L. S., Tangpricha,
V., van Trotsenburg, M., Vitale, A., Winter, S., Whittle, S., Wylie, K. R., & Zucker, K.Standards of Care for the Health of
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• Jamie Feldman, M.D., Ph.D. New Onset of Type 2 Diabetes Mellitus with Feminizing Hormone Therapy: Case Series
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 Reference Studies
• Hypertension

• CoQ10

• Rosenfeldt, F L; Haas, S J; Krum, H; Hadj, A; Ng, K; Leong, J-Y; Watts, G F (2007). "Coenzyme Q10 in the treatment of hypertension: a meta-analysis
of the clinical trials".Journal of Human Hypertension 21 (4): 297–306

• Vitamin D

• Min B Effects of Vitamin D on Blood Pressure and Endothelial Function. Korean J Physiol Pharmacol. 2013 Oct;17(5):385-392. Epub 2013 Oct 17.

• Argenine

• Gokce N. L-arginine and hypertension. J Nutr. 2004 Oct;134(10 Suppl):2807S-2811S; discussion 2818S-2819S.

• Steppan J1, Nyhan D, Berkowitz DE. Development of Novel Arginase Inhibitors for Therapy of Endothelial Dysfunction. Front Immunol. 2013 Sep
17;4:278. eCollection 2013.

• Cicero AF1, Borghi C. Evidence of clinically relevant efficacy for dietary supplements and nutraceuticals. Curr Hypertens Rep. 2013 Jun;15(3):260-7

• Melatonin

• Grossman E1, Laudon M, Zisapel N. Effect of melatonin on nocturnal blood pressure: meta-analysis of randomized controlled trials.Vasc Health Risk
Manag. 2011;7:577-84. doi: 10.2147/VHRM.S24603. Epub 2011 Sep 15.

• Rauwolfia

• Shamon SD, Perez MI. Blood pressure lowering efficacy of reserpine for primary hypertension.Cochrane Database Syst Rev. 2009 Oct 7;(4):CD007655.
doi: 10.1002/14651858.CD007655.pub2.
 Reference Studies
• Hawthorne

• Ann F Walker, Georgios Marakis, Eleanor Simpson, Jessica L Hope, Paul A Robinson, Mohamed Hassanein, Hugh CR Simpson Hypotensive effects of hawthorn for
patients with diabetes taking prescription drugs: a randomised controlled trial Br J Gen Pract. 2006 June 1; 56(527): 437–443

• Rauwolfia

• Shamon SD1, Perez MI. Blood pressure lowering efficacy of reserpine for primary hypertension. Cochrane Database Syst Rev. 2009 Oct 7;(4):CD007655. doi:
10.1002/14651858.CD007655.pub2.

• Beet Roots

• Siervo M1, Lara J, Ogbonmwan I, Mathers JC. Inorganic nitrate and beetroot juice supplementation reduces blood pressure in adults: a systematic review and meta-
analysis. J Nutr. 2013 Jun;143(6):818-26. doi: 10.3945/jn.112.170233. Epub 2013 Apr 17.

• Parsley

• Wright CI, Van-Buren L, Kroner CI, Koning MM. Herbal medicines as diuretics: a review of the scientific evidence. J Ethnopharmacol. 2007 Oct 8;114(1):1-31. Epub
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• Hyperlipidemia

• Niacin

• Julius U1, Fischer S. Nicotinic acid as a lipid-modifying drug--a review. Atheroscler Suppl. 2013 Jan;14(1):7-13. doi: 10.1016/j.atherosclerosissup.2012.10.036.

• Omega 3 fatty acids

• Kastelein JJ1, Maki KC2, Susekov A3, Ezhov M3, Nordestgaard BG4, Machielse BN5, Kling D5, Davidson MH5 Omega-3 free fatty acids for the treatment of severe
hypertriglyceridemia: The EpanoVa fOr Lowering Very high triglyceridEs (EVOLVE) trial. J Clin Lipidol. 2014 Jan-Feb;8(1):94-106. doi: 10.1016/j.jacl.2013.10.003.
Epub 2013 Oct 14.

• Popescu LA1, Vîrgolici B, Lixandru D, Miricescu D, Condruţ E, Timnea O, Ranetti AE, Militaru M, Mohora M, Zăgrean L. Effect of diet and omega-3 fatty Acids
Probiotics

Jones ML1, Tomaro-Duchesneau C, Martoni CJ, Prakash S. Cholesterol lowering with bile salt hydrolase-active probiotic bacteria, mechanism of action, clinical evidence,

Reference Studies
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a-Lipoic Acid
Harding SV1, Rideout TC, Jones PJ. Evidence for using alpha-lipoic acid in reducing lipoprotein and inflammatory related atherosclerotic risk. J Diet Suppl. 2012
Jun;9(2):116-27. doi: 10.3109/19390211.2012.683136.

Fish oil

Marangoni F1, Poli A. Clinical pharmacology of n-3 polyunsaturated fatty acids: non-lipidic metabolic and hemodynamic effects in human patients. Atheroscler Suppl. 2013

Aug;14(2):230-6. doi: 10.1016/S1567-5688(13)70003-5.

Gao LG1, Cao J, Mao QX, Lu XC, Zhou XL, Fan L.

Influence of omega-3 polyunsaturated fatty acid-supplementation on platelet aggregation in humans: a meta-analysis of randomized controlled trials. Atherosclerosis. 2013

Feb;226(2):328-34. doi: 10.1016/j.atherosclerosis.2012.10.056. Epub 2012 Nov 2.

Garlic, Angelica, vitamin E

Mousa SA. Antithrombotic effects of naturally derived products on coagulation and platelet function.Methods Mol Biol. 2010;663:229-40. doi: 10.1007/978-1-60761-803-4_9.

Garlic

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LIVER

Turmeric
Liver

Schizandra, Silybum, Turmeric

Chien CF1, Wu YT, Tsai TH. Biological analysis of herbal medicines used for the treatment of liver diseases. Biomed Chromatogr. 2011 Jan;25(1-2):21-38. doi:

10.1002/bmc.1568.

Reference Studies
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10.3748/wjg.v17.i18.2288.

Cordyceps

Li XG, Xiao JH. Current studies and prospect of anti-thrombotic effect of Cordyceps fungi. Zhongguo Zhong Yao Za Zhi. 2013 Oct;38(19):3246-50.

Osteoporosis

Phytoestrogens

Ming LG1, Chen KM, Xian CJ. Functions and action mechanisms of flavonoids genistein and icariin in regulating bone remodeling. J Cell Physiol. 2013

Mar;228(3):513-21. doi: 10.1002/jcp.24158.

Castelo-Branco C1, Soveral I. Phytoestrogens and bone health at different reproductive stages. Gynecol Endocrinol. 2013 Aug;29(8):735-43. doi:

10.3109/09513590.2013.801441. Epub 2013 Jun 6.

Prolactinemia

Vitex

van Die MD1, Burger HG, Teede HJ, Bone KM. Vitex agnus-castus extracts for female reproductive disorders: a systematic review of clinical trials.Planta Med. 2013

May;79(7):562-75. doi: 10.1055/s-0032-1327831. Epub 2012 Nov 7.

 Reference Studies

Diabetes
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2010 Nov;75(11):788-93. doi: 10.1016/j.steroids.2009.12.007. Epub 2010 Jan 7.

Gymnema

Tiwari P1, Mishra BN2, Sangwan NS1. Phytochemical and pharmacological properties of Gymnema sylvestre: an important medicinal plant. Biomed Res Int.

2014;2014:830285. doi: 10.1155/2014/830285. Epub 2014 Jan 6.

Rizvi SI1, Mishra N. Traditional Indian medicines used for the management of diabetes mellitus. J Diabetes Res. 2013;2013:712092. doi: 10.1155/2013/712092. Epub
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