Jared Rocco and Ryan Kelly-Romero are final-year PharmD candidates at The University of New Mexico College of Pharmacy.
Transgender and nonbinary (TGNB) people have a gender identity that is different from the sex they were assigned at birth. The transgender population represents an estimated 0.5% of the U.S. population; however, this is likely an underestimate as gender identity has not been traditionally collected in census data.1
There is no “one-size-fits-all” approach to gender-affirming care, which may include hormone therapy, surgery, facial hair removal, speech therapy, behavioral changes, and changing personal pronouns. Clinical knowledge of hormone therapy is essential in the care of TGNB people, as some effects are irreversible, and research suggests there are improvements in mental health after gender-affirming care.2–5 Historically, a referral from a mental health professional was a requirement, but now medical providers who feel comfortable making an assessment and diagnosis of gender dysphoria are able to diagnose gender dysphoria without a referral, thus increasing access to care for this population.6
As student pharmacists, it is essential to understand the medication treatment options for TGNB. Feminizing hormone therapy includes estradiol plus or minus an antiandrogen, whereas masculinizing therapy is testosterone monotherapy.
Feminizing hormone therapy
The goal of feminizing hormone therapy is the development of female secondary sex characteristics and minimization of male secondary sex characteristics. Outcomes include, but are not limited to, breast development (the only irreversible effect), a redistribution of body fat, muscle mass reduction, reduction of body hair, and change in sweat and odor patterns.7 The primary formulation of estrogen used for feminizing therapy is 17-beta estradiol. Antiandrogens such as spironolactone are also used in feminizing therapy, as they suppress the effects of testosterone. Estrogen is available orally, as a transdermal patch, and as an injection.
Current gender-affirming guidelines such as the World Professional Association for Transgender Health (WPATH), UCSF Transgender Care, and Endocrine Society suggest initial dosing of oral estradiol of 1–2 mg/day and a maximum of 8 mg/day. The spironolactone initial dose is 25–50 mg/day, with a maximum dose of 200 mg twice a day.7
Masculinizing hormone therapy
Masculinizing hormone therapy leads to the development of male secondary sex characteristics and the decrease of female secondary sex characteristics. General effects include the irreversible outcomes of body and facial hair changes, voice deepening, possible hair loss (i.e., male pattern baldness), and clitoral enlargement. Reversible effects include a redistribution of body fat, increased muscle, change in sweat and odor patterns, and cessation of menses.7
The medication for masculinizing therapy is testosterone monotherapy. Testosterone is available as an injection, topical gel, patches, and some pharmacies will compound other formulations. Testosterone cypionate dosing starts between 30–50 mg/week injected subcutaneously or intramuscularly with a typical max dose of 100 mg/week.7
Follow the patient’s lead
Titration of these medications is based on a patient’s goals, response to therapy, and laboratory monitoring. Informed consent is the cornerstone of therapy and focuses on the health care provider and patient’s ability to understand risks, benefits, alternatives, and unknowns. Together, the patient and health care provider, including pharmacists, make decisions to ensure the patient’s goals are met while keeping their safety as a priority.
Every TGNB patient has individual goals, so when in doubt, follow their lead on their health care!
References
- Conron KJ, Scott G, Stowell GS, et al. Transgender health in Massachusetts: Results from a household probability sample of adults. Am J Public Health. 2012;102(1):118–22.
- Gómez-Gil E, Zubiaurre-Elorza L, Esteva I, et al. Hormone-treated transsexuals report less social distress, anxiety and depression. Psychoneuroendocrinology. 2012;37(5):662–70.
- St. Amand C, Fitzgerald KM, Pardo ST, et al. The effects of hormonal gender affirmation treatment on mental health in female-to-male transsexuals. J Gay Lesbian Ment Health. 2011;15(3):281–99.
- Newfield E, Hart S, Dibble S, et al. Female-to-male transgender quality of life. Qual Life Res. 2006;15(9):1447–57.
- White Hughto JM, Reisner SL. A systematic review of the effects of hormone therapy on psychological functioning and quality of life in transgender individuals. Transgend Health. 2016;1(1):21–31.
- Deutsch MB, Feldman JL. Updated recommendations from the world professional association for transgender health standards of care. Am Fam Physician. 2013;87(2):89–93.
- Deutsch MS. Guidelines for the primary and gender-affirming care of transgender and gender nonbinary people. San Francisco: UCSF Transgender Care. Available at: https://transcare.ucsf.edu/guidelines. Accessed February 17, 2023.