Category:Feminization

Feminizing Effects in Transgender Females^[1][2][3]

Effect	Onset	Max
Change in body fat distribution	3–6 mo	2–3 y
Decrease in muscle mass and strength	3–6 mo	1–2 y
Softening of skin / decreased oiliness	3–6 mo	Unknown
Decreased sexual desire	1–3 mo	3–6 mo
Decreased spontaneous erections	1–3 mo	3–6 mo
Male sexual dysfunction	Variable	Variable
Breast growth	3–6 mo	2–3 y
Decreased testicular volume	3–6 mo	2–3 y
Decreased sperm production	Unknown	>3 y
Decreased terminal hair growth	6–12 mo	>3 y a
Scalp hair	Variable	— b
Voice changes	None	— c

^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

Abbreviations: Unk, Unknown.

Feminizing Effects in Transgender Females^[1][2][3]

Effect	Onset	Max
Change in body fat distribution	3–6 mo	2–3 y
Decrease in muscle mass and strength	3–6 mo	1–2 y
Softening of skin / decreased oiliness	3–6 mo	Unknown
Decreased sexual desire	1–3 mo	3–6 mo
Decreased spontaneous erections	1–3 mo	3–6 mo
Male sexual dysfunction	Variable	Variable
Breast growth	3–6 mo	2–3 y
Decreased testicular volume	3–6 mo	2–3 y
Decreased sperm production	Unknown	>3 y
Decreased terminal hair growth	6–12 mo	>3 y a
Scalp hair	Variable	— b
Voice changes	None	— c

^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

Abbreviations: Unk, Unknown.

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 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

Baseline and Follow-up Protocol During Induction of Puberty^[4]

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)

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

Protocol Induction of Puberty^[4]

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 "Hormone Regimens in Transgender Persons"
• Adjust maintenance dose to mimic physiological estradiol levels (see "Monitoring of Transgender Persons on Gender-Affirming Hormone Therapy: Transgender Female").

Protocol Induction of Puberty^[4]

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 "Hormone Regimens in Transgender Persons"
• Adjust maintenance dose to mimic physiological estradiol levels (see "Monitoring of Transgender Persons on Gender-Affirming Hormone Therapy: Transgender Female").

Hormone Regimens in Transgender Persons

Transgender females a
Estrogen
Oral
Estradiol	2.0 – 6.0 mg/d
Transdermal
Estradiol transdermal patch	0.025 – 0.2 mg/d
(New patch placed every 3 – 5 d)
Parenteral
Estradiol valerate or cypionate	5 – 30 mg IM every 2 wk
	2 – 10 mg IM every week

Anti-androgens
Spironolactone	100 – 300 mg/d
Cyproterone acetate b	25 – 50 mg/d
GnRH agonist	3.75 mg SQ (SC) monthly
	11.25 mg SQ (SC) 3-monthly

Abbreviations: IM, intramuscularly; SQ, sequentially; SC, subcutaneously.

^aEstrogens used with or without antiandrogens or GnRH agonist.
^bNot available in the United States

Hormone Regimens in Transgender Persons

Transgender females ^a

Estrogen

Oral

Estradiol

2.0 – 6.0 mg/d

Transdermal

Estradiol transdermal patch (New patch placed every 3 – 5 d)

0.025 – 0.2 mg/d

Parenteral

Estradiol valerate or cypionate	5 – 30 mg IM every 2 wk
	2 – 10 mg IM every week

Anti-androgens

Spironolactone	100 – 300 mg/d
Cyproterone acetate b	25 – 50 mg/d

GnRH agonist

monthly	3.75 mg SQ (SC)
3-monthly	11.25 mg SQ (SC)

Abbreviations: IM, intramuscularly; SQ, sequentially; SC, subcutaneously.

^aEstrogens used with or without antiandrogens or GnRH agonist.

^bNot available in the United States

Monitoring of Transgender Persons on Gender-Affirming Hormone Therapy:

Transgender Female

1. . 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.
1. Serum testosterone levels should be ,50 ng/dL.
2. Serum estradiol should not exceed the peak physiologic range: 100–200 pg/mL.
2. For individuals on spironolactone, serum electrolytes, particularly potassium, should be monitored every 3 mo in the first year and annually thereafter.
3. Routine cancer screening is recommended, as in nontransgender individuals (all tissues present).
4. . 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.