Table 1.
Comparison of national, international, and patient specific prescribing and monitoring guidelines for trans men (observed females at birth) with gender dysphoria.
Hormone Dosing and Routine Long Term Monitoring (once stable/after 12–36 Months)
|
Maximum Transdermal Testosterone Dose (mg) | Minimum Nebido Injection Frequency (Weeks) | Minimum Sustanon Frequency (Weeks) | ANNUAL MONITORING | Pelvic USS monitoring | Breast Screening (unless Mastectomy) | Cervical Screening (unless Total Hysterectomy) | Bone (DEXA) | AAA Screening | |||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Testosterone Level | Target Testosterone Levels (nmol/L) TD = Transdermal N = Nebido S = Sustanon Tr = Trough (Day of Injecton) Pk = Peak (7 Days after Injection) |
Full Blood Count | Haematocrit Levels Specific Advice (L/L) | Liver Function Tests | Lipids | Estradiol | Glucose | HBA1c | Prolactin | FSH&LH | SHBG | Urea and Electrolytes | TSH | Blood Pressure | Weight | |||||||||
Guideline or Clinic
| ||||||||||||||||||||||||
| International | ||||||||||||||||||||||||
| WPATH [10] | No specific dosing instructions given. WPATH recommends consulting Feldman and Safer [38] and Hembree et al. [39] for hormone regimes and lab monitoring protocols. Testosterone levels should be maintained “within the normal male range while avoiding supraphysiological levels”. WPATH also advises “Follow-up should include careful assessment for signs and symptoms of excessive weight gain, acne, uterine break-through bleeding, and cardiovascular impairment, as well as psychiatric symptoms in at- risk patients. Physical examinations should include measurement of blood pressure, weight, and pulse; and heart, lung, and skin exams” | Y | Y | |||||||||||||||||||||
| Endocrine Society [11] A | 100 | 12 | Y | 11.1–34.7 B | Y | YD | YD | YD | N | Y E | Y | N C | ||||||||||||
| National/Local | ||||||||||||||||||||||||
| Australia [40] | 100 | 8 | 3 | Y F | Y F | Y F | Y | YF | Y | Y F | Y F | Y G | Y G | Y M | ||||||||||
| San Francisco [13] | 103.25 | 10 | Y | Physiological male range | Y | If above male reference range- check testosterone level, adjust testosterone dose, short term blood donation may be the solution | N | Y | Y | Y H | ||||||||||||||
| NHS Wales [28] | 80 | 11 | 2 | Y | TD, N: 15–20 S: 8–12 Tr, 25–30 Pk |
Y | >0.52 seek GIC advice >0.6 stop treatment & seek urgent haematology advice |
Y | Y | Y | Y | Y | BiennialP | Y | Y | Y J | ||||||||
| NHS Scotland [27] | 100 | 10 | 2 | Y | S,N; Tr “lower 3rd of normal range” TD: “within normal male range” |
Y | “CV risk assess” | Y | Y | N C | ||||||||||||||
| GP CPD Red Whale [30] | 50 | 12 | 2 | Y | Y | Y | Y | Y | Y | Y | Y | Y | Y | YQ | Y | N C | Y J | |||||||
| GIC guidance | ||||||||||||||||||||||||
| London Transgender clinic (private) | 10 | 2 | Y | TD: 15–25 N: 15–30 S: 8–12 Tr, 25–30 Pk |
Y | <0.52 acceptable 0.52–0.55 increase hydration and repeat bloods before next injection or in 8 weeks 0.55–0.6 refer urgently to haematology |
Y | Y | Y | Y | Y | N | YK | YK | YK | |||||||||
| Laurels NHS | 80 | Y | 14–28 | Y | >0.56 seek prompt advice from haematologist and The Laurels | Y | Y | Y | YF | YF | N | Y | N | |||||||||||
| Gender GP (private) | 100 | 10 | 2 | Y | 9–38 Steady State 8–12 Tr |
Y | >0.52 suspend testosterone and refer endocrinology | Y | Y | Y | Y | Biannual | N | N C | ||||||||||
| Sheffield NHS | 100 | 10 | 2 | Y | S, N: 8–12 Tr, 25–30 Pk TD: 15–20 |
Y | > 0.52 suspend treatment and refer haematology | Y | Y | Y | Y | Y | Y | Y | N L | N | Y | Y | N | Y | ||||
| Tavistock NHS | 100 | 6 | 2 | Y | S: 10–12 Tr, 25–30 Pk N, TD: 15–20 |
Y | >0.52 hydration, repeat test in 8 weeks or on day of next injection >0.55 seek GIC advice immediately >0.6 pause treatment, seek urgent GIC and haematology advice |
Y | Y | Y | Biannual | Y | Y | YK | ||||||||||
| Nottingham NHS | 100 | 10 | 2 | YR | TD: “upper 1/2 of local ref range” S, N: “lower 1/3 of local reference range” Tr/ steady state |
Y | ≥0.52 routine referral to haematology ≥0.54 urgent referral to haematology |
Y | Y | Biannual | YK | YK | ||||||||||||
| Gendercare (private) | 100 | 10 | 2 | Y | S, N: 8–12 Tr, 25–30 Pk TD: 15–20 |
Y | Y | Y | Y | Biannual | Y | Y | YK | |||||||||||
| Leeds NHS | 80 | 8 | 2 | Y | S: “lower 3rd reference range” trough level N, TD: “middle third reference range” |
Y | If ≥54% withhold treatment & discuss with specialist | Y | Y | Y | Y | Y | Y | Y | ||||||||||
Key: Empty cell: no specific advice given; HBA1c, Glycated Haemoglobin; FSH&LH, Follicle Stimulating Hormone and Luteinizing hormone; SHBG, Sex hormone binding globulin; TSH, Thyroid Stimulating Hormone; CV, cardiovascular; A,”strong recommendations”; B, “the normal male range, dependent on the assay but is typically 320–1000 ng/dL”; C, Unless prolonged periods without sex hormones or additional risk factors; D, “at regular intervals”; E, plus conduct sub and periareolar breast examinations if mastectomy performed; F, Every 6 months; G, Every 3 months; H, from age 65 years on (earlier if risk factors); J, if patient wishes; K, screening as per https://www.gov.uk/government/publications/nhs-population-screening-information-for-transgender-people/nhs-population-screening-information-for-trans-people (accessed on 1 Jan 2022); L, unless considering surgery; M, Annually to document recovery after being on puberty suppression as required; Q, Offer screening also if any breast tissue post mastectomy; R, two to three times per year long term; S, and discuss technical limitations of breast screening post mastectomy, with unknown risks of breast cancer; T, also offer breast screening post mastectomy.