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lower cost, effectiveness and tolerability May not significantly lower T levels alone Starting dose: 50 mg po daily Usual maintenance dose: 200-300 mg daily Can be divided bid Cyproterone Second-line, see Estrogen Consent form for Risks. Eligible for Special Authority if spironolactone is contraindicated, not tolerated or ineffective. Starting dose: 12.5 mg po daily Usual maintenance dose: 12.5 –50 mg po daily (Use in lowest effective dose & try dose reductions where possible) Finasteride An anti-androgen with primarily peripheral action Eligible for Special Authority if needed to augment effect of primary anti-androgen 2.5 mg po every other day Alternative: not using a blocker A higher dose of estradiol may effectively suppress testosterone production Maintain estrogen levels in sufficiently high range Estrogen 17-beta estradiol (Estrace®) Lowest risk of all estrogens and first choice Starting dose 1-2 mg po daily Usual maintenance dose 4-8 mg daily Can be divided bid Estradiol patch (Estradot®/Estraderm®) Eligible for Special Authority for clients >40 years old with additional risk factors Starting dose 50 mcg patch twice per week. Usual maintenance dose: 100-400 mcg twice per week Estradiol valerate (injectable) Only available compounded Starting dose at 5 mg IM/SC weekly Usual maintenance dose 10-20 mg IM/SC weekly Weekly dosing is preferred to minimize peak/trough variation Biweekly injection (of 2x the weekly dose) may be tolerated in some individuals Progesterone Not routinely recommended but may be included based on patient preference No clear evidence of benefit and possible increased risk Potential role in breast/nipple development (unproven) Micronized progesterone (Prometrium®) First choice but more expensive Starting dose 100 mg po daily Usual maintenance dose 100 – 400 mg daily Medroxyprogesterone (Provera®) Starting dose 5 mg po bid Usual maintenance dose 10-15 mg bid 10 Overview of estrogen-based hormone therapy Trans Care BC Primary Care Toolkit It is important to review risks, benefits and potential side effects with patients prior to initiating treatment. Sample consent forms are included in this package- see Appendix C for Estrogen/Testosterone-blocker consent form and Appendix D for Progesterone consent form. There is variation in practice among clinicians regarding dosing for hormone initiation, hormone maintenance and ordering labwork, and much of the decision-making depends on the clinical situation. Care providers may use eCase or call the RACE Line at 604-696-2131 or toll free at 1-877-696-2131 and request the “Transgender Health” option to consult an experienced clinician. Risk considerations: Contraindications to estrogen therapy may include unstable cardiovascular disease, active hormone-sensitive cancer, end-stage liver disease and allergy. Many patients choose to begin or continue hormone therapy in spite of higher risks. In such cases, care providers should do a careful informed consent process that takes into consideration the capacity of the patient to make an informed decision and the significant harm that can come from withholding treatment. Care providers may use eCase or call the RACE Line at 604-696-2131 or toll free at 1-877-696-2131 and request the “Transgender Health” option to consult an experienced clinician. Dose Titration: Titrate dose of estrogen and androgen-blocker q 4-6 weeks until maintenance dose is achieved (e.g. 2 mg estrace + 50 mg spiro x 4-6 weeks, then 3 mg estrace + 100 mg spironolactone x 4-6 weeks, then 4 mg estrace + 150 mg spironolactone x 4-6 weeks, etc.) A slower titration rate may be preferred by some patients or may be chosen based on clinical indication. Goal of therapy: To maintain testosterone levels in the female range, estrogen levels in the 300-800 pmol/L range, minimize side effects and maintain expected rates of physical changes (degree of change influenced in part by patient preference). Lab monitoring Request the lab to report female reference ranges Baseline and annually thereafter ● Total testosterone, CBC, ALT, fasting glucose, lipids, prolactin and if on spironolactone: CR and electrolytes Following dose changes and 4-6 weeks after gonadectomy ● Total testosterone, estradiol, ALT, and if on spironolactone: CR and electrolytes Areas for review in follow up visits Subjective Objective ■ Effects of hormones: physical, emotional ■ Current dose/desire for dose change ■ Side effects/concerns ■ Mental health: mood, body image, libido ■ Social: significant others, support, acceptance, safety, housing, finances ■ Lifestyle: exercise, nutrition, smoking, substance use ■ Blood pressure ■ Weight (baseline and q 6 months prn) ■ Mental status (brief assessment) ■ Cardiovascular and abdominal exam (baseline and yearly) ■ Labs ■ Other investigations as indicated Trans Care BC Primary Care Toolkit Managing side effects of estrogen, screening & health promotion 11 Managing side effects of estrogen, screening & health promotion Managing side effects of Estrogen/Testosterone blockers and other common concerns Persistent dizziness/ postural hypotension Caused by spironolactone, usually temporary and mild If severe or persistent switch to cyproterone. See Medication table for Special Authority eligibility Low libido Consider maintaining testosterone at higher level Trial of progesterone Difficulty
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