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


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


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


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


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


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


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