When to start hrt treatment
Gender Health: Gender Affirming Hormone Therapy | UCLA Health
hi I'm Stan Korn Minh I'm an
endocrinologist and I practice at this
at Ronald Reagan Medical Center and I'm
Shira grok and I'm also an
endocrinologist and I practice in the
UCLA Santa Monica Center so we are going
to be talking about gender health today
and specifically talking about gender
affirming hormone therapy I'm going to
start by just going through some
definitions so that hopefully we can all
be on the same page and then dr. Corman
is gonna go on to talk about feminizing
hormone therapy and then I'll be back to
talk about masculinizing hormone therapy
all right so um again so going through
some of these definitions when we're
talking about gender identity or
experience gender that's one's internal
self an internal sense of their their
gender identity or as gender expression
is going to be the external
manifestations of your gender so the
pronouns that you prefer to be used how
you know the name that you choose the
the clothing that you're wearing gender
dysphoria is a term to describe the
distress that one experiences when their
gender identity and their designated
gender at birth don't match up and this
replaced what used to be called gender
identity identity disorder now we refer
to that as gender dysphoria and usually
that's diagnosed after about six months
of feeling that again your gender
identity and your gender that was
assigned at Birth don't don't match up
so we're talking about transgender
patients these are people whose gender
identity differs from need sex
designated at birth whereas cisgender is
gonna refer to those that are that are
not transgender a transgender male are
individuals that were assigned female at
birth but identify as men whereas
transgender females or those that are
assigned male at birth and identify as
females
and lastly gender non-binary are
individuals that don't fit into this
binary gender narrative and other terms
for that could be genderqueer or gender
non-conforming alright so now doctor
corenman is going to talk about
feminizing hormone therapy
so feminizing normal 30 is used to
attain a desired level of femininity and
at the same time minimize matte
masculinity and our goal is to achieve
and maintain hormone levels that are
adequate to reach those goals for the
for the administration of estrogens
we're trying to achieve a serum
estradiol generally in the range of 100
to 300 pica grams per ml and because so
many of the trans females are large it
sometimes takes a lot of estrogen to get
to the right place so these are the
goals these are the effects of hormone
administration of estrogen
administration you definitely see a
redistribution of body fat on a decrease
of muscle mass and strength and the
patient's really want that softening of
the skin decreased oiliness a decreased
sexual desire not necessarily
elimination of cetra sexual desire and
in some cases there's an increase of
sexual desire decrease in spontaneous
erections is very common and sexual
dysfunction that is an inability to
achieve a normal erection is also very
common you get a significant amount of
breast growth but not a great amount of
the breast growth and most of the
patients will find that in order to
achieve the level of breast size that
they want they have to get
supplemented with implants there's a
decrease of testicular volume and that's
variable from person to person and you
get a decrease of sperm production
the sperm production decrease according
to the Europeans at least is reversible
if you want to produce enough sperm of
to father a child in which case you have
to stop the hormonal management and then
terminal hair growth is decreased and
scalp hair is not really preserved and
certainly not improved but doesn't
continue to be lost and the changes in
voice do not occur so that achieving a
female voice requires a different
process so what hormones do we use we
use oral estradiol I tend to use mainly
oral estradiol because it's you can
adjust it to suit the individual
patients need very simply and we use up
to six milligrams a day that's been
demonstrated to be safe in the European
studies and I like to use the estrogens
twice a day because estradiol is a
short-acting hormone and it works better
if you give it twice a day you can also
give an estradiol patch in which case
the estradiol is leaking into the
systemic circulation more or less
continuously you can give intramuscular
estradiol valor' rate or sipping a
sybian aid was in short supply recently
I don't know if it's fully replaced and
you give it every one to two weeks I
usually give these hormones weekly
because I don't want there to be very
high levels followed by low levels I
would much rather there be slummin
elevate
followed by somewhat lower levels now we
do not use the sublingual estrogens we
also try to have anti-angiogenic therapy
the idea is to interfere with the
effects of testosterone so
spironolactone is given almost
universally in doses of one to two
hundred milligrams a day I prefer not to
go to 200 but to go to 100 because
spironolactone in addition to being a
weak anti testosterone is also an
antihypertensive and for certain
patients the blood pressure will go down
and they will have lightheadedness and
not feel so great and also the serum
potassium rises and that can be
troublesome although not very often in
young people so I try to keep the
spironolactone bound to 100 milligrams a
day it's really only very effective when
the testosterone level itself has been
brought down because it's a week and
it's a week inhibitor we use we do not
use Sai proto and acetate in the United
States but we do sometimes use flew to
mind we do not use GnRH antagonists or
agonist because they're expensive even
compared to the other drugs we use
Madrasi progesterone acetate is a
progestin that is anti androgenic I
don't use that because it tends to
increase body weight with increased fat
I tend to use micronized progesterone
and I use it specifically to inhibit
androgen production by the testes
because it has a direct particular
effect finally we use finasteride or
duty
which are 5-alpha reductase inhibitors
their function is to reduce the effects
of testosterone on sexual tissues and
they operate directly at the level of
the sexual videos and they are effective
in reducing for example hair loss and to
reduce the stick Euler size and peanut
size now what are we worried about
well estrogens are caused thromboembolic
disorders that is venous clots mainly
and they caused it in high doses but the
experience with transsexuals has been
that it does not do that at levels of 6
milligrams per day or below there
sometimes an estrogen induced elevated
prolactin probably too much worried
about a very minor effect their
occasional people are very sensitive to
estrogens and get a high serum
triglycerides which are not great for
your heart but the the frequency of
significant hypertriglyceridemia is very
low however we like to measure the serum
lipids the cholesterol and triglycerides
and all our patients the increase of
insulin resistance may be associated
with the obesity that sometimes happens
in these patients they tend to gain
weight and I try to encourage them not
to get obese but some do question about
whether an increase the rate of
gallbladder disease is not really
settled an increase in breast cancer
we blame estrogens to increase breast
cancer in postmenopausal women that
question arises in these cases but the
evidence seems to be that breast cancer
in transgender men is no higher than
breast cancer in cysts males and finally
cardiovascular disease the way I think
of that is cardiovascular disease is the
leading cause of morbidity and mortality
in population in the population as a
whole and we should worry about
cardiovascular disease in everyone and
you don't get away for free if you're a
transgender on therapy you still have
the same risk as everyone else for every
other disease and so how do we monitor
patients I usually see them every three
months until we get them settled and
then see them every 6 to 12 months we
measure estradiol and testosterone to
make sure the estradiol gets into the
normal rate because many of these
patients are large it takes really
significant dose to get there and we
will monitor the electrolytes to check
the potassium particularly if they're on
spironolactone we do cancer screening
both estrogens and androgens improve
bone density so we don't really think
there's a likelihood of diminished bone
density in fact generally improvement
over what they would order otherwise be
but we like to man manage to look at
bone density in the appropriate time and
finally we'll get a prolactin
occasionally to make sure it's not going
up and now Cheryl will tell us about
male masculinizing hormones
alright so similar to the feminizing
hormones you know some of our goals are
going to be to attain the desired level
of masculinity and then to minimize any
in
feminine characteristics that the
patient desires to minimize and also to
eliminate menstrual cycles in most cases
in order to do this we want to make sure
we're retaining adequate hormone levels
so we are gonna be also monitoring those
hormone levels and make sure you know
we're checking on things like the bones
generally to achieve these changes we
want a serum testosterone level in the
normal male range different labs are a
little bit different but generally in
the you know 400 to 700 range with
appropriate so what are the changes that
people can expect to experience with
masculinizing hormone therapy so
definitely there can be an increase in
skin oiliness and acne that generally
starts to occur relatively relatively
quickly about maybe in the first few a
few months of therapy facial and body
hair growth that takes a little bit
longer usually starts around six months
of therapy and is maximal at four to
five years scalp hair loss can occur
with the testosterone and that also
starts to occur maybe around six months
for you know for each patient it's gonna
be a little bit different the exact
effects that they have in a time that
these effects occur increased muscle
mass and strength can occur and it does
take a few months for that to start to
change importantly just the testosterone
alone is often not enough and really
encourage our transgender men to also be
you know exercising and lifting weights
if they want to attain a certain body
habitus frat weed distribution does
occur in and the cessation of menses and
about you know generally occurs by
hopefully by six months for some people
that's quicker and for some people that
can take a little bit longer clitoral
clitoral enlargement can start in the
first few months and is generally
maximal at one to two years sometimes
that can become an issue for people if
they're I'm having it sensitivity in
that area and sometimes that has to be
it has to be addressed vaginal atrophy
would be another change as well as
deepening of the voice
so for transgender men we are gonna see
some voice change as opposed to as we
mentioned with the transgender women
and these the red arrows are to signify
the changes that will are more permanent
and that won't go away even if you do
stop the therapy though those are
changes that should be permanent so how
do we do that's what types of
testosterone do we use and so most
commonly we're either using
intramuscular testosterone and that's
given every one to two weeks and
similarly to dr. quorum and I usually
would recommend once a week so you're
not getting as many high testosterone
levels and then low testosterone levels
and the dose is gonna vary depending on
the person so the dose for all of us is
gonna vary depending on one's body
weight and so we try to take that into
account when starting hormone therapy
the transdermal patches are sorry
transdermal gels there's multiple
different formulations of this but
that's also commonly used and those are
used on a daily basis and you know may
result in some you know a little bit
more steady levels but you know
depending on the person people sometimes
do better either with the injections or
the tram the transdermal gels
there's also patches and the elation
with these is that a lot of patients
could not irritate skin irritation from
the patches so I'd say those are a
little less commonly used but definitely
still an option in terms of the
longer-lasting testosterone so there is
an injectable testosterone that lasts a
few months as well as testosterone
pellets that are inserted under the skin
we don't use these as commonly and one
of the main reason would be that it's
it's harder to adjust because once
you've given that dose it's not easy to
to then adjust the dose and they do
require some special monitoring to do
the injections and special services to
do the implants so what are the things
that we're monitoring and transgender
men one of the main things that we're
monitoring is the red blood cell counts
and so the test on is a normal effect of
testosterone to stimulate the production
of red blood cells and so we generally
do see an increase in red blood cells
one of the things that we want to watch
for is that we you know don't want the
levels to go too high
and well I'll show you a slide on this
but in general a few you know when
starting a soft drone that we expect the
levels to go into the normal male range
but we do want to moderate and make sure
they're not going over the normal male
range which could potentially put people
at risk for for blood clots the liver
dysfunction you know a lot there's a lot
of recommendations out there to monitor
liver function but to be honest these
are really the liver dysfunction really
only occurred in older derivatives of
testosterone not the testosterone that
we're using today so this is really not
an active concern of ours
um cardiovascular disease and Sieber
that cerebral vascular disease strokes
and heart attacks we don't have any
evidence to suggest that this is
increased and transgender males after
starting hormone therapy you know in
general as dr. Corvin mentioned this is
a very you know common cause of death
and in particularly actually more and
you know more so in males and females
but across across both sexes and so you
know I think the theoretical concern
would we be putting people in a
different risk category based on the
testosterone therapy we don't have any
long-term studies to suggest that that
is the case there was some data that
came out recently suggesting that there
are some minor changes and the
cholesterol numbers and so an increase
in LDL which is in triglycerides which
are kind of the worst bad cholesterol
and a decrease in some of the good
cholesterol but we don't you know that
may that might just be putting people
into the normal male physiologic range
for high blood pressure again so we're
the the therapy can lead to a small
increase in blood pressure generally not
a clinical concern and breast and
uterine cancer there's there used to be
concerns about this and the more recent
data really suggests that we don't
really know that there's any increased
risk and it's there the risk is probably
quite minimal or non-existent so this is
I'm talking about the the hemoglobin or
the red blood cell counts push again
sorry about that okay so here the the
HDB that's the hemoglobin or red blood
cell count you can see before therapy
this is in the normal
you know sis female range and then as
you go through therapy the numbers will
go up but even if you know 15 that's the
normal assess male range and so that's
an expected change that that's not
concerning as long as we're you know
monitoring alright so one one issue that
definitely comes up is persistent menses
and this can be you know very bothersome
to patients and frustrating generally we
expect the menses or the periods to stop
within about six months of starting
testosterone therapy and what we would
consider persistent leading is someone
who has testosterone levels in the male
range consistently and is still bleeding
at six to twelve months out so the first
thing that we want to consider is just
the general things that can cause
bleeding so just like in cysts females
they can have fibroids and you know
these are benign tumors and the uterus
that can cause bleeding we always want
to think about these general conditions
that can lead to to bleeding the other
thing to start to think about is the
dosing of testosterone and so if the
testosterone is dosed every two weeks
maybe you know and it's an injection
sometimes moving out to every one week
to get more stable levels could be
helpful and again just making sure that
our the testosterone levels are in the
desired ranges
aromatisse inhibitors are a medication
that can decrease estrogen and this
these have been shown to be helpful and
and and you know stopping periods one of
the issues that comes up is that we mean
these are also used in conditions like
breast cancer and with long term use we
do worry a little bit about the bones
and so generally they try to use that
for you know six months to a year until
things are optimized so that we could
then stop that medication progesterone
is another option to sometimes help with
decreased bleeding some people feel that
weight loss can be helpful so
testosterone is converted to estrogen
and fat tissues and so the idea would be
that if someone does have excess weight
sometimes the losing some weight can can
help decrease the estrogen levels and
then lastly if these if these methods
aren't working than either endometrial
ablation or hysterectomy would really be
more definitive
therapy if the other medications are not
working and sometimes a hysterectomy is
is part of a patient's plan regardless
of this as well so monitoring is in
terms of frequency of monitoring it's
going to be very similar in our
transgender male population so we want
to see patients every few months the
first usually the first year therapy or
until things are stable and then once or
twice a year after that and at those
visits we'll be you know checking on the
desired changes looking at hormone
levels making sure everything is steady
and that we don't you know see any
adverse reactions for particularly for
transgender males we want to be
measuring their hemoglobin again every
three months in the beginning and then
once or twice a year and after you know
if we change a dose we definitely you
know want to then follow up and see how
their hemoglobin levels are doing we're
also monitoring blood pressure weight
cholesterol just general markers of
health and then a standard kind of
cancer screening first for whatever
tissues are present and so if you do
have a uterus president then we would
want to be you know doing pap smears as
generally recommended same with
mammograms and it just it just depends
on what tissues we need to look at and
in the bone density you know as
appropriate based based on the patient
this is you know always something that's
kind of in the back of our minds since
the sex hormones can affect the bone all
right so we've you know talked a little
bit about some of the risks with hormone
therapy and we have you know we also
just want to make sure we talk on talked
about all the benefits and so you know
beyond the desired physical changes and
obviously that's a large part of what
patients are seeking when we start
hormone therapy there is you know from
our experience at dramatic improvement
and just general well-being you know
unfortunately there's not tons of data
that we can quote for this but people
are starting to look at this more and
you know some studies have shown you
know significant sorry a significant
decrease and anxieties about a third one
study showed about a 30 percent decrease
in anxiety scores improvement and
depression and just improvement in
general well-being and I think this is
really important in our transgender
population because in general there is a
higher rate of
and anxiety and so this is a really
important outcome that we need to
remember that people do do better on
hormone therapy and a lot of my patients
have stopped taking a lot of their any
depressive meds
because they don't feel they don't need
them anymore and they're doing well yeah
and kind of along with that I mean
oftentimes you know we do we do
encourage patients to you know
especially when they're starting therapy
to be actively seeing us at their
psychiatrist just to be able to talk
through all the changes that they're
going through so in conclusion the
physical changes that you should expect
with hormone therapy they are variable
person-to-person and the changes will
take different amounts of time to
develop so that some of the changes
changes could start in a month but some
can take up to a year to become evident
the emotional changes with starting
hormone therapy are extremely favorable
and while we don't have great long-term
data on the risks of hormone therapy and
transgender patients probably a lot of
the risks that have been identified are
a bit overplayed and so you know this is
where we're over the next you know
decade we're gonna be getting more and
more information on exactly what the
risks are
hormone therapy should be monitored
every three months when we're first
starting for about the first year or so
or until things are stable and then
should be monitored once or twice a year
after that and any concerns such as
persistent menses these things should
really you know be addressed with
someone who has experience and taking
care of patients and taking care of
gender health alright so do we have any
questions from the internet okay okay
so the first question is maybe doctor
corenman can answer this question so
what's what is the role of progesterone
for a mood sexual desire and our breasts
of element well that's a good question
the progestins generally have been shown
to depress mood
progesterone itself the one
I tend to use is not very strong at the
pressing mood so I think it's favorable
as I mentioned progesterone directly
affects testicular testosterone
secretion to inhibit it so that if
someone has a persistent high
testosterone level after starting on
estrogen therapy I always put them on
progesterone furthermore the evidence is
weak to non-existent that progesterone
really improves breast development there
are a few people who feel that once they
went on the progesterone their breast
development proceeded further but we
usually put put them on it within the
first six months and they're still
having breast development from the
estrogens at that time so it's hard to
determine whether the progesterone
really stimulates breast development the
next question here is what should I do
if I'm a transgender female around the
age of menopause and I think I presume
this is getting at you know what should
we give in that says females have a
decrease in estrogen at the time of
menopause you know what should we what
should we be doing with with with
estrogen replacement and you know this
ultimately is gonna really depend on the
patient and so if if you are someone
that has had your testes removed it's
gonna be very different because your
testosterone levels will be very low if
we stop the estrogen and in those cases
it's there's no right or wrong answer
but it would be reasonable to consider
at least decreasing the the estrogen
amount since that would mimic
essentially a natural menopause now for
patients that still retain their their
testes it's a little bit more difficult
because when we if we stop the estrogen
altogether
their testosterone levels will go up but
it still could be reasonable to adjust
the doses and maybe use a slightly lower
dose at that point in life I don't know
if you have any other recommendations
doctor corenman
well
one of the questions is will you get
symptomatic a woman who goes through the
menopause becomes very symptomatic has
hot flashes etc and that's not the usual
finding with the transgenders and in
addition so if they don't have symptoms
the motivation to use the hormones is
less and my inclination is to stop them
and see what happens by that time the
testes are usually gone pretty much in
terms of being secretory organs because
they've been suppressed for twenty
thirty forty years alright so the next
question here is what percent of
transgender men have persistent periods
so there there is some data I think out
of there was a Dutch study that showed
at about six months about 85% have
stopped having periods so that still
leaves about 15% that are that are
having persistent periods and then we
need to start to address some of the
issues the issues that we talked about
okay let's see so what are the effects
of what are the effects of hormone
therapy on bone strength and you know
transgender males or transgender females
so yeah we actually hoping maybe this
question would come up and we do have
some information on this and you know as
I think as we both alluded to we don't
have great long-term data but this is
something that we are you know trying to
look at so this was a study that was
published last year one of endocrine
journals where they you know we're
looking at patients over a period of two
years and both at transgender men and
transgender women and what they found
and transgender men after starting this
is two years after starting hormone
therapy there was no change in bone
density so that's measured on a DEXA or
bone density machine and transgender
females actually one of the studies
showed maybe there was a benefit but
ultimately when they compared that back
to sis men there really wasn't a
change so I mean what we have so far is
it's very short-term data so you know
two years is not a lot of time to get
bone changes but at least at that point
there doesn't seem to be negative
effects that being said this is this is
bone density this is not these are not
looking at fractures or breaking bones
they did try to look at that but there
was only one fracture over the period of
a year that they were looking and so we
it's not fracture data but it is bone
density is thought to be a surrogate for
for fractures and what goes on is the
transgender females are getting high
doses of estrogens estrogens are good
for bone they inhibit bone resorption so
they should be in better shape and their
bone density should not go down with the
years as it does in assists women in the
males that transgender males they have
testosterone tends to increase bone
density and it and they're getting
testosterone levels that are actually
higher than the comparable levels
insists males as they get older so in
both cases bone should be protective and
I don't worry too much about it because
physiologically speaking they're in good
bone shape yeah okay so what can you do
for gender non-binary patients so for
example if I want some masculine
characteristics but not others is that
possible looking what can we do in those
scenarios so I have a couple of patients
like that and I don't mind giving them
low doses of testosterone and it really
makes a huge difference in their lives I
don't try to achieve any particular
numerical goal I try to achieve a
psychosocial goal I feel good when I'm
treated I behave comfortably my life is
improved I think that you have to
understand that achieving a particular
berkel value in a blood test is not a
proper medical goal it's helping the
patient feel well I think the one other
aspect isn't you know unfortunately
different different people do have
different responses and so it's hard to
kind of pick and choose which
characteristics you would like to
develop so that part is a little bit
difficult but you know we can adjust
adjust our dosing and adjust our
regimens to try to achieve different
results okay and then can you please
discuss persistent pelvic pain and
transgender men so this is another big
topic that can be that can be difficult
and actually this another thing that we
are hoping may be able to discuss but
we're we weren't sure if we have time
okay so similar to the perk to the
persistent menses you know we always
want to make sure that we're looking at
other other reasons for pelvic pain so
such things as endometriosis there are
lots of reasons for pelvic pain that we
need to make sure we're just addressing
the the typical region the typical
symptoms that can happen and insist
females as well but there are particular
things that that can make transgender
men more susceptible to pelvic pain and
so the use of testosterone is going to
lead to some vaginal atrophy and that
what that can result in is vaginitis or
like inflammation of the cervix and that
that can cause pain vaginal atrophy
itself can cause discomfort and so you
know actually sometimes in those cases
or even you can use actually local
vaginal estrogen to help with those
symptoms and its of just a local effect
so it doesn't get absorbed systemically
to affect your estrogen levels there's
other people also postulate that some of
the change and weight distribution and
change in muscle mass might lead to kind
of slight slight changes that could that
could predispose to to pelvic pain
anyone who's under you know has had
surgeries like sex reassignment
surgeries that is that is definitely you
know you always want to think about you
know could there be any complications
associated with that I could be leading
to pelvic pain and the emotional aspects
are definitely very real can be
really you know tough to get the pelvic
exams that are that are recommended if
you still have those organs and it can
be painful as well and so all of that
leads to too emotional you know
emotional aspects to the pain and you
know it some people do report cyclical
symptoms and maybe you know things are
different at different times and there
and injectable testosterone regimen so
for some of those people you could
consider transdermal estrogen or
something oh sorry transdermal
testosterone or something that will lead
to a little bit more stable levels you
know sometimes these are things we have
to try and see if they're helpful and if
that doesn't work try something or
something else these are patients who
have not had surgery however these are
not common problems they are relatively
uncommon we have any other other
questions that have come in alright well
thank you so much for joining us today
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