Talk:Test

DSM-5 Criteria for Gender Dysphoria in Adolescents and Adults
 A marked incongruence between one’s experienced/expressed gender and natal gender of at least 6 mo in duration, as manifested by at least two of the following:  A marked incongruence between one’s experienced/expressed gender and primary and/or secondary sex characteristics (or in young adolescents, the anticipated secondary sex characteristics) A strong desire to be rid of one’s primary and/or secondary sex characteristics because of a marked incongruence with one’s experienced/expressed gender (or in young adolescents, a desire to prevent the development of the anticipated secondary sex characteristics) A strong desire for the primary and/or secondary sex characteristics of the other gender A strong desire to be of the other gender (or some alternative gender different from one’s designated gender)  A strong desire to be treated as the other gender (or some alternative gender different from one’s designated gender) A strong conviction that one has the typical feelings and reactions of the other gender (or some alternative gender different from one’s designated gender) </ol> The condition is associated with clinically significant distress or impairment in social, occupational, or other important areas of functioning.</li> Specify if: <ol> The condition exists with a disorder of sex development.</li> The condition is posttransitional, in that the individual has transitioned to full-time living in the desired gender (with or without legalization of gender change) and has undergone (or is preparing to have) at least one sex-related medical procedure or treatment regimen—namely, regular sex hormone treatment or gender reassignment surgery confirming the desired gender (e.g., penectomy, vaginoplasty in natal males; mastectomy or phalloplasty in natal females).</li> </ol> </ol>

Criteria for Gender-Affirming Hormone Therapy for Adults
<ol> Persistent, well-documented gender dysphoria/gender incongruence</li> The capacity to make a fully informed decision and to consent for treatment</li> The age of majority in a given country (if younger, follow the criteria for adolescents)</li> Mental health concerns, if present, must be reasonably well controlled</li> </ol>

Criteria for Gender-Affirming Hormone Therapy for Adolescents
Adolescents are eligible for GnRH agonist treatment if: <ol> A qualified MHP has confirmed that:</li> <ul> the adolescent has demonstrated a long-lasting and intense pattern of gender nonconformity or gender dysphoria (whether suppressed or expressed),</li> gender dysphoria worsened with the onset of puberty,</li> any coexisting psychological, medical, or social problems that could interfere with treatment (e.g., that may compromise treatment adherence) have been addressed, such that the adolescent’s situation and functioning are stable enough to start treatment,</li> the adolescent has sufficient mental capacity to give informed consent to this (reversible) treatment,</li> </ul> And the adolescent:</li> <ul> has been informed of the effects and side effects of treatment (including potential loss of fertility if the individual subsequently continues with sex hormone treatment) and options to preserve fertility,</li> has given informed consent and (particularly when the adolescent has not reached the age of legal medical consent, depending onb applicable legislation) the parents or other caretakers or guardians have consented to the treatment and are involved in supporting the adolescent throughout the treatment process,</li> </ul> And a pediatric endocrinologist or other clinician experienced in pubertal assessment</li> <ul> <li>agrees with the indication for GnRH agonist treatment,</li> <li>has confirmed that puberty has started in the adolescent (Tanner stage G2/B2),</li> <li>has confirmed that there are no medical contraindications to GnRH agonist treatment.</li> </ul> </ol> Adolescents are eligible for subsequent sex hormone treatment if: <ol> <li>A qualified MHP has confirmed:</li> <ul> <li>the persistence of gender dysphoria,</li> <li>any coexisting psychological, medical, or social problems that could interfere with treatment (e.g., that may compromise treatment adherence) have been addressed, such that the adolescent’s situation and functioning are stable enough to start sex hormone treatment,</li> <li>the adolescent has sufficient mental capacity (which most adolescents have by age 16 years) to estimate the consequences of this (partly) irreversible treatment, weigh the benefits and risks, and give informed consent to this (partly) irreversible treatment,</li> </ul> <li>And the adolescent:</li> <ul> <li>has been informed of the (irreversible) effects and side effects of treatment (including potential loss of fertility and options to preserve fertility),</li> <li>has given informed consent and (particularly when the adolescent has not reached the age of legal medical consent, depending on applicable legislation) the parents or other caretakers or guardians have consented to the treatment and are involved in supporting the adolescent throughout the treatment process,</li> </ul> <li>And a pediatric endocrinologist or other clinician experienced in pubertal induction:</li> <ul> <li>agrees with the indication for sex hormone treatment,</li> <li>has confirmed that there are no medical contraindications to sex hormone treatment.</li> </ul> </ol>

Tanner Stages of Breast Development and Male External Genitalia
The description of Tanner stages for breast development: <ol> <li>Prepubertal</li> <li>Breast and papilla elevated as small mound; areolar diameter increased</li> <li>Breast and areola enlarged, no contour separation</li> <li>Areola and papilla form secondary mound</li> <li>Mature; nipple projects, areola part of general breast contour</li> </ol> For penis and testes: <ol> <li>Prepubertal, testicular volume, 4 mL</li> <li>Slight enlargement of penis; enlarged scrotum, pink, texture altered, testes 4–6 mL</li> <li>Penis longer, testes larger (8–12 mL)</li> <li>Penis and glans larger, including increase in breadth; testes larger (12–15 mL), scrotum dark</li> <li>Penis adult size; testicular volume. 15 ml</li> </ol>

Baseline and Follow-Up Protocol During Suppression of Puberty

 * Every 3–6 mo
 * Anthropometry: height, weight, sitting height, blood pressure, Tanner stages


 * Every 6–12 mo
 * Laboratory: LH, FSH, E2/T, 25OH vitamin D


 * Every 1–2 y
 * Bone density using DXA
 * Bone age on X-ray of the left hand (if clinically indicated)

Abbreviations: DXA, dual-energy X-ray absorptiometry; E2, estradiol; FSH, follicle stimulating hormone; LH, luteinizing hormone; T, testosterone;

Protocol Induction of Puberty

 * Induction of female puberty with oral 17b-estradiol, increasing the dose every 6 mo:
 * 5 μg/kg/d
 * 10 μg/kg/d
 * 15 μg/kg/d
 * 20 μg/kg/d
 * Adult dose = 2–6 mg/d
 * In postpubertal transgender female adolescents, the dose of 17b-estradiol can be increased more rapidly:
 * 1 mg/d for 6 mo
 * 2 mg/d


 * Induction of female puberty with transdermal 17b-estradiol, increasing the dose every 6 mo (new patch is placed every 3.5 d):
 * 6.25–12.5 μg/24 h (cut 25-μg patch into quarters, then halves)
 * 25 μg/24 h
 * 37.5 μg/24 h
 * Adult dose 5 50–200 μg/24 h
 *  For alternatives once at adult dose, see Table 11. 
 *  Adjust maintenance dose to mimic physiological estradiol levels (see Table 15). 


 * Induction of male puberty with testosterone esters increasing the dose every 6 mo (IM or SC):
 * 25 mg/m2/2 wk (or alternatively, half this dose weekly, or double the dose every 4 wk)
 * 50 mg/m2/2 wk
 * 75 mg/m2/2 wk
 * 100 mg/m2/2 wk
 * Adult dose = 100–200 mg every 2 wk
 * In postpubertal transgender male adolescents the dose of testosterone esters can be increased more rapidly:
 * 75 mg/2 wk for 6 mo
 * 125 mg/2 wk
 *  For alternatives once at adult dose, see Table 11. 
 *  Adjust maintenance dose to mimic physiological testosterone levels (see Table 14). 

Abbreviations: IM, intramuscularly; SC, subcutaneously.

Baseline and Follow-up Protocol During Induction of Puberty
''BMD should be monitored into adulthood (until the age of 25–30 y or until peak bone mass has been reached). For recommendations on monitoring once pubertal induction has been completed, see Tables 14 and 15.'' Abbreviation: DXA, dual-energy X-ray absorptiometry
 * Every 3–6 mo
 * Anthropometry: height, weight, sitting height, blood pressure, Tanner stages
 * Every 6–12 mo
 * In transgender males: hemoglobin/hematocrit, lipids, testosterone, 25OH vitamin D
 * In transgender females: prolactin, estradiol, 25OH vitamin D
 * Every 1–2 y
 * BMD using DXA
 * Bone age on X-ray of the left hand (if clinically indicated)

Medical Risks Associated With Sex Hormone Therapy
Transgender female: estrogen
 * Very high risk of adverse outcomes:
 * Thromboembolic disease
 * Moderate risk of adverse outcomes:
 * Macroprolactinoma
 * Breast cancer
 * Coronary artery disease
 * Cerebrovascular disease
 * Cholelithiasis
 * Hypertriglyceridemia

Transgender male: testosterone
 * Very high risk of adverse outcomes:
 * Erythrocytosis (hematocrit . 50%)
 * Severe liver dysfunction (transaminases . threefold upper limit of normal)
 * Coronary artery disease
 * Cerebrovascular disease
 * Hypertension
 * Breast or uterine cancer

Hormone Regimens in Transgender Persons
Abbreviations: IM, intramuscularly; SQ, sequentially; SC, subcutaneously. aEstrogens used with or without antiandrogens or GnRH agonist. bNot available in the United States cOne thousand milligrams initially followed by an injection at 6 wk then at 12-wk intervals. dAvoid cutaneous transfer to other individuals.

Masculinizing Effects in Transgender Males
aPrevention and treatment as recommended for biological men. bMenorrhagia requires diagnosis and treatment by a gynecologist.

Feminizing Effects in Transgender Females
a Complete removal of male sexual hair requires electrolysis or laser treatment or both. b Familial scalp hair loss may occur if estrogens are stopped. c Treatment by speech pathologists for voice training is most effective

Monitoring of Transgender Persons on Gender-Affirming Hormone Therapy: Transgender Male
<ol> <li>Evaluate patient every 3 mo in the first year and then one to two times per year to monitor for appropriate signs of virilization and for development of adverse reactions.</li> <li>Measure serum testosterone every 3 mo until levels are in the normal physiologic male range: </li> <ol style="list-style-type:lower-alpha"> <li>For testosterone enanthate/cypionate injections, the testosterone level should be measured midway between injections. The target level is 400–700 ng/dL to 400 ng/dL. Alternatively, measure peak and trough levels to ensure levels remain in the normal male range.</li> <li>For parenteral testosterone undecanoate, testosterone should be measured just before the following injection. If the level is, 400 ng/dL, adjust dosing interval.</li> <li>For transdermal testosterone, the testosterone level can be measured no sooner than after 1 wk of daily application (at least 2 h after application).</li> </ol> <li>Measure hematocrit or hemoglobin at baseline and every 3 mo for the first year and then one to two times a year. Monitor weight, blood pressure, and lipids at regular intervals.</li> <li>Screening for osteoporosis should be conducted in those who stop testosterone treatment, are not compliant with hormone therapy, or who develop risks for bone loss.</li> <li>If cervical tissue is present, monitoring as recommended by the American College of Obstetricians and Gynecologists.</li> <li>Ovariectomy can be considered after completion of hormone transition.</li> <li>Conduct sub- and periareolar annual breast examinations if mastectomy performed. If mastectomy is not performed, then consider mammograms as recommended by the American Cancer Society.</li> </ol>

Monitoring of Transgender Persons on Gender-Affirming Hormone Therapy: Transgender Female
<ol> <li>. Evaluate patient every 3 mo in the first year and then one to two times per year to monitor for appropriate signs of feminization and for development of adverse reactions.</li> <ol style="list-style-type:lower-alpha"> <li>Serum testosterone levels should be ,50 ng/dL.</li> <li>Serum estradiol should not exceed the peak physiologic range: 100–200 pg/mL.</li> </ol> <li>For individuals on spironolactone, serum electrolytes, particularly potassium, should be monitored every 3 mo in the first year and annually thereafter.</li> <li>Routine cancer screening is recommended, as in nontransgender individuals (all tissues present).</li> <li>. Consider BMD testing at baseline (160). In individuals at low risk, screening for osteoporosis should be conducted at age 60 years or in those who are not compliant with hormone therapy.</li> </ol>