Hormonal Treatment of Transsexual Adults: State of the Art

Female-to-Male (FTM) Hormone Treatment

“FTM hormone treatment is very straightforward. You just need to give testosterone as you would to a hypogonadal male. You can give testosterone transdermally or by injection. Gels are less efficient,” explained Dr. Safer.

Testosterone is given until the normal range for male testosterone is reached. Supraphysiolgic levels only increase side effects. FTM testosterone treatment can be expected to increase muscle mass, decrease fat mass, increase facial hair and increase libido. Menses usually cease and the voice deepens.1

“The main safety concern is hematopoiesis, which may increase the risk of heart disease. We try to keep the hematocrit below 55%. Other risks to watch out for are sleep apnea and a negative shift in cholesterol levels,” noted Dr. Safer. FTM patients may also be monitored for liver dysfunction, hypertension, weight gain, cystic acne and psychological changes.1

Male-to-Female (MTF) Hormone Treatment

“MTF hormone therapy is more complicated. You usually need to knock down testosterone as well as add estrogen. This may require a cocktail of an androgen antagonist, estrogen and a gonadotropin-releasing hormone analogue. The most commonly used androgen antagonist is spironolactone. It is safe, inexpensive, and we have lots of experience with it,” said Dr. Safer.

Physical changes in the first 3 months of treatment may include decreased libido, breast enlargement, and loss of facial and body hair. Breast development peaks at 2 years. Prostate and testicular atrophy occur over a longer period of time.1

Venous thromboembolism is the main complication of MTF hormone therapy. It is important to avoid supraphysiologic blood levels of estrogen.1 “This risk has been reduced by switching away from the synthetic ethinyl estradiol to estradiol, which became available about 10 years ago. It is also important to urge all patients not to smoke,” said Dr. Leinung.

MTF hormone treatment may result in favorable lipid parameters but may increase weight, blood pressure and insulin resistance. MTF patients should have routine screenings for both breast and prostate cancer.1

Sex Reassignment Surgery

Surgical techniques for sex reassignment surgery have improved greatly. Removal of gonads and cosmetic genital surgery with preservation of sensation are standard of care, with a high rate of patient satisfaction.1 “After MTF surgery, it is no longer necessary to suppress testosterone, so treatment becomes a lot easier,” said Dr. Safer.

“Surgery is a very individual decision. It has been, and continues to be, limited by lack of insurance coverage. Most surgery is MTF, but only about 30% of patients elect to have the procedure,” said Dr. Leinung.