Gender Reassignment and the Role of the Laboratory in Monitoring Gender-Affirming Hormone Therapy
Abstract
:1. Introduction
2. Method
3. Gender Development
Genesis of Gender Incongruence
4. Guidelines for GAHT
4.1. Adolescent GI
4.2. Adult GI
5. Laboratory Tests in Transgender AFAB/AMAB Individuals
5.1. Red Blood Cell Indices
5.2. Renal Function
5.3. Liver Enzymes
5.4. Lipids
5.5. Cardiac Biomarkers
5.6. Reproductive Hormones
5.7. Ferritin
5.8. Prostate Specific Antigen
Laboratory Tests | Comments | Reference | ||
---|---|---|---|---|
Estradiol treatment | Testosterone treatment | Estradiol GAHT shifts haemoglobin, haematocrit to lower values in line with cisgender women’s reference intervals. Testosterone GAHTshifts reference intervals to higher levels in line with cisgender men’s reference intervals | [32] | |
RBC | Decrease | Increase | ||
Hemoglobin | Decrease | Increase | ||
Hematocrit | Decrease | Increase | ||
Creatinine | Decrease | Increase | The most reno protective calculated GFR either male/female is suggested; 24h creatinine clearance if indicated | [38] |
High sensitivity troponin I | Report a reference range that would allow critical results to be appropriately followed; an approach of least harm to the patient is suggested | [45] | ||
Ferritin | Laboratories use dual reference ranges for cisgender individuals. Interpretation is based on clinical presentation (e.g., pregnancy) in combination with full blood count, liver function test, and markers of inflammation, e.g., CRP. Iron overload: If secondary causes excluded, investigation for primary haemochromatosis gene may be indicated | [49] | ||
Reproductive hormones | Testosterone, Estradiol | Following stabilisation of treatment with gender-affirming hormones, guidelines suggest treatment goals are physiological levels of the affirmed gender identity cisgender adults. The time of measurement of the hormone is dependent on the method of administration as well as formulation of the GAHT | [2] | |
Reproductive hormones | LH, FSH, AMH, and DHEAS are variable in a transgender population and are interpreted with clinical information | [47,48] | ||
PSA | Data for reference ranges in transgender AMAB people and from screening for prostatic cancer is not available | [52] | ||
Renal function/liver function/lipid profile | Guidelines suggest monitoring of liver function/renal function and lipids during GAHT treatment. Sex-specific reference ranges are not ordinarily stated for the measurements | [44] |
5.9. Laboratory Test Reference Intervals for Transgender Population
6. Electronic Medical Record Systems (EMR)
7. GAHT and Other Laboratory Markers
7.1. Risk of Venous Thromboembolism in AMAB People
7.2. Hyperprolactinemia
7.3. Other Sex Hormone Dependent Tumours
7.4. Bone Mineral Density
8. GAHT, Vascular Health and Cardiovascular Disease, and Impact of Aging in Transgender Adults
9. Conclusions
10. Future Directions
Funding
Conflicts of Interest
References
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Tanner Stage | Pubic Hair (Male and Female) | Breast Development (Females) | Testicular Volume (Males) |
---|---|---|---|
1 | No hair | No glandular breast tissue palpable | Testicular volume < 4 mL or long axis < 2.5 cm |
2 | Downy hair | Breast bud palpable under the areola (1st pubertal sign in females) | 4–8 mL (or 2.5 to 3.3 cm long), 1st pubertal sign in males |
3 | Scant terminal hair | Breast tissue palpable outside areola; no areolar development | 9–12 mL (or 3.4 to 4.0 cm long) |
4 | Terminal hair that fills the entire triangle overlying the pubic region | Areola elevated above the contour of the breast, forming a “double scoop” appearance | 15–20 mL (or 4.1 to 4.5 cm long) |
5 | Terminal hair that extends beyond the inguinal crease onto the thigh | Areolar mound recedes into single breast contour with areolar hyperpigmentation, papillae development, and nipple protrusion | >20 mL (or >4.5 cm long) |
Guidelines | Society of Endocrinology | The World Professional Association for Transgender Health (WPATH) | Australian Professional Association for Trans Health (AusPATH) |
---|---|---|---|
Evaluation of prospective patients | Clinicians can add gender-affirming hormones after multidisciplinary team (MDT) team has confirmed the persistence of GI and sufficient mental capacity to give informed consent to treatment. The clinicians and mental health practitioners must be trained to diagnose GI. | Health care professionals have competencies in the assessment of transgender and gender diverse people wishing gender-related medical treatment and consider the role of social transition together with the individual. Liaise with professionals from different disciplines within the field of transgender health prior to gender-affirming treatment | |
Treatment |
|
| Unless there is agreement among the parents, the adolescent, and medical practitioner regarding competence, diagnosis, and treatment, a Family Court order is required for access to gender-affirming puberty blockers, hormone treatment, and surgery for adolescents under 18 years old. |
Puberty Induction Regimen | Transgender AMAB people: Increasing doses of oral or transdermal 17β-estradiol, until adult dosage is reached. In postpubertal transgender AMAB people, the dose is increased more rapidly. Transgender AFAB people: Increasing doses of testosterone until adult values are reached. In postpubertal males, the dose is increased more rapidly. Adult maintenance dose is to mimic physiological adult levels. | In eligible youth who have reached the early stages of puberty, the aim is to delay further pubertal progression with GnRHas until an appropriate time when GAHT can be introduced. In these cases, pubertal suppression is considered medically necessary. | |
Treatment of transgender AFAB/AMAB people | Transgender AFAB people: treatment with both parenteral and transdermal testosterone Transgender AMAB people: Oral, transdermal or parenteral oestrogen. Antiandrogens: spironolactone, cyproterone acetate, GnRH agonist. Estradiol and testosterone are maintained at premenopausal female levels. Gender-affirming hormones are maintained at normal adult ranges | Transgender AFAB people: Masculinising treatment, usually with testosterone. Transgender AMAB people: treatment is usually with oestrogen and androgen-lowering medication. | Transgender AFAB people: masculinising treatment is with different formulations of testosterone Transgender AMAB people: Feminising treatment includes oestrogen and androgen blockers. It is usual to start with low doses and titrate upwards. |
Monitoring | Periodic monitoring of hormone levels, metabolic parameters, and assessment of prostate gland, gonads, and uterus as well as bone density | Hormone levels are measured during gender-affirming treatment to ensure endogenous sex steroids are lowered and administered sex steroids are maintained at levels appropriate for the treatment goals of transgender people according to the Tanner stage. | For masculinising treatment, total testosterone levels are maintained at the lower male reference range, and for feminising treatment, estradiol is aimed to be within the female reference range. |
Reference | [2] | [3] | [4,5] |
Clinical Chemistry Tests | Other Tests | |
---|---|---|
LH, FSH, E2/T, 25(OH)D | Anthropometry: height, weight, blood pressure, Tanner stages | |
Suggested Interval | 6–12 months | 3–6 months |
Bone density using DXA | ||
Suggested Interval | 1–2 years | |
Reference | [2] |
Laboratory Tests | Other Tests | |
---|---|---|
Transgender AFAB people | T | Monitor for virilization |
Suggested Interval | 3 monthly until levels within adult range | Every 3 months the first year and then one or two times per year |
Haematocrit or haemoglobin | Screening for osteoporosis, cervical screening (if cervical tissue present), breast cancer screening as recommended | |
Suggested Interval | 3 monthly for first year then one/two times per year | |
Lipids at regular intervals | ||
Transgender AFAM people | Serum T and estradiol | Feminisation |
Suggested Interval | Every 3 months | Every 3 months the first year and then one or two times per year |
If treated with spironolactone, electrolytes | Routine cancer screening and bone density | |
Every 3 months the first year and then annually | ||
Reference | [2] |
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© 2024 by the author. Licensee MDPI, Basel, Switzerland. This article is an open access article distributed under the terms and conditions of the Creative Commons Attribution (CC BY) license (https://creativecommons.org/licenses/by/4.0/).
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Ramasamy, I. Gender Reassignment and the Role of the Laboratory in Monitoring Gender-Affirming Hormone Therapy. J. Clin. Med. 2024, 13, 5134. https://doi.org/10.3390/jcm13175134
Ramasamy I. Gender Reassignment and the Role of the Laboratory in Monitoring Gender-Affirming Hormone Therapy. Journal of Clinical Medicine. 2024; 13(17):5134. https://doi.org/10.3390/jcm13175134
Chicago/Turabian StyleRamasamy, Indra. 2024. "Gender Reassignment and the Role of the Laboratory in Monitoring Gender-Affirming Hormone Therapy" Journal of Clinical Medicine 13, no. 17: 5134. https://doi.org/10.3390/jcm13175134