Masculinizing hormone therapy

Overview

Masculinizing hormone therapy is used to make physical changes in the body that are caused by hormones during puberty. Those changes are called secondary sex characteristics. For people with gender incongruence, this hormone therapy can help better align the body with gender identity. Masculinizing hormone therapy is part of gender-affirming hormone therapy.

Masculinizing hormone therapy involves taking the hormone testosterone. It lowers the ovaries' ability to make estrogen. Masculinizing hormone therapy can be done alone or along with masculinizing surgery.

Talk with your healthcare professional about the benefits and risks of masculinizing hormone therapy.

Why it's done

Masculinizing hormone therapy is used to change the body's hormone levels. Those hormone changes lead to physical changes that help better align the body with a person's gender identity.

Some people who want masculinizing hormone therapy have discomfort or distress because their gender identity differs from their sex assigned at birth or from their sex-related physical characteristics. This is called gender dysphoria.

Masculinizing hormone therapy can:

• Improve psychological and social well-being.
• Ease psychological and emotional distress related to gender incongruence.
• Improve quality of life.

Your healthcare professional might advise against masculinizing hormone therapy if you:

• Are pregnant.
• Have a hormone-sensitive cancer, such as breast cancer.
• Have problems with blood clots, such as when a blood clot forms in a deep vein, a condition called deep vein thrombosis, or when there's a blockage in one of the pulmonary arteries of the lungs, called a pulmonary embolism.
• Have significant medical conditions that haven't been addressed.
• Have behavioral health conditions that haven't been addressed.
• Have a condition that limits your ability to give your informed consent.

Risks

Research has found that masculinizing hormone therapy can be safe and effective when given by a healthcare professional with expertise in transgender care. Talk with a member of your care team if you have questions or concerns about the changes that are likely to happen in your body due to masculinizing hormone therapy.

Masculinizing hormone therapy may lead to health issues called complications. Complications of masculinizing hormone therapy can include:

• Weight gain.
• Acne.
• Male-pattern baldness.
• Sleep apnea.
• Changes in cholesterol levels. This might raise the risk of heart health concerns.
• High blood pressure.
• Making too many red blood cells. This condition is called polycythemia.
• Reduced fertility.
• Drying and thinning of the lining of the vagina.
• Pelvic pain.
• Discomfort in the clitoris.
• Blood clots in a deep vein or in the lungs.

Evidence suggests that people who have masculinizing hormone therapy don't have a higher risk of breast cancer, ovarian cancer, endometrial cancer or heart disease when compared with cisgender women. Cisgender women are those whose gender identity aligns with their sex assigned at birth.

To lower the risk of complications, the goal for people taking masculinizing hormone therapy is to keep hormone levels in the range that's typical for cisgender men. Cisgender men are those whose gender identity aligns with their sex assigned at birth.

Fertility

Masculinizing hormone therapy may limit fertility by disrupting ovulation. The risk of permanent infertility may rise with long-term use of hormones. Even after stopping hormone therapy, infertility treatment might be needed to get pregnant.

If you want to have biological children, talk with your healthcare professional about your choices. They may include:

• Egg freezing. This also is called mature oocyte cryopreservation. Egg freezing has multiple steps that involve triggering ovulation, getting the eggs and then freezing them.
• Embryo freezing. This also is called embryo cryopreservation. If you want to freeze embryos, you need to have the eggs fertilized before they are frozen.
• Ovarian tissue cryopreservation. This involves removing and freezing ovarian tissue. The tissue later is thawed and put back in the body.

Although testosterone might limit fertility, pregnancy still can happen if you have your uterus and ovaries and you have sex with a person who makes sperm. If you don't want to get pregnant, always use birth control. Talk with your healthcare professional about your birth control choices.

How you prepare

Before you start masculinizing hormone therapy, your healthcare professional checks your overall health. This helps address any medical conditions that could affect your treatment. The evaluation may include:

• A review of personal and family medical history.
• A physical exam.
• Lab tests.
• A review of vaccinations.
• Screening tests for some conditions and diseases.
• Screening tests and treatment, if needed, for tobacco use, drug use, alcohol use disorder, and HIV or other sexually transmitted infections.
• Questions about birth control, fertility and sex.

You also might have a behavioral health evaluation by a healthcare professional with expertise in transgender health. The evaluation may assess:

• Gender dysphoria.
• Mental health concerns.
• Sexual health concerns.
• The impact of gender incongruence at work, at school, at home and in social settings.
• Substance or supplement use.
• Support from family, friends and caregivers.
• Your goals and expectations of treatment.
• Care planning and follow-up care.

What you can expect

Start masculinizing hormone therapy only after you've talked about the benefits and risks, as well as all treatment options available to you, with a healthcare professional who has expertise in transgender care. Be sure you know what is likely to happen during treatment. Get answers to any questions you may have before you begin hormone therapy.

Masculinizing hormone therapy typically starts by taking a low dose of testosterone. Then the dose is slowly raised over time. Testosterone often is given through a shot, also called an injection, or through a gel put on the skin. Other forms of testosterone include testosterone pellets placed under the skin, a long-acting shot and capsules you take by mouth twice a day.

The testosterone that's used for masculinizing hormone therapy is identical to the hormone that the body naturally makes. Don't use synthetic androgens, such as oral methyl testosterone or anabolic steroids. They can hurt your liver, and they cannot be accurately monitored.

While taking masculinizing hormone therapy, you meet regularly with your healthcare professional to:

• Keep track of your physical changes.
• Watch hormone levels. Over time, the dose of testosterone may need to change to ensure you are taking the lowest dose necessary to get and keep the physical effects that you want.
• Have lab tests to check for changes in cholesterol, blood sugar, blood count and liver enzymes that could be caused by hormone therapy.
• Support behavioral health.

You also need routine preventive care. Depending on your situation, this may include:

• Breast cancer screening. Follow breast cancer screening recommendations for cisgender women your age.
• Cervical cancer screening. Follow cervical cancer screening recommendations for cisgender women your age. Masculinizing hormone therapy can cause cervical tissues to thin. That can make the cells on a Pap test harder to interpret. If you have questions or concerns about this, talk with your healthcare professional.
• Bone health assessment. Follow the bone density assessment recommendations for cisgender men your age. You may need to take calcium and vitamin D supplements for bone health.

Results

After you start masculinizing hormone therapy, you'll likely see changes in your body over time:

• Menstruation stops. This happens within 2 to 6 months of starting treatment.
• Voice deepens. This begins 3 to 12 months after the start of treatment. The full effect happens within 1 to 2 years.
• Facial and body hair grows. This begins 3 to 6 months after treatment starts. The full effect happens within 3 to 5 years.
• Body fat is redistributed. This begins within 3 to 6 months. The full effect happens within 2 to 5 years.
• Clitoris gets bigger, and the vaginal lining thins and becomes drier. This begins 3 to 12 months after treatment starts. The full effect happens in about 1 to 2 years.
• Muscle mass and strength go up. This begins within 6 to 12 months. The full effect happens within 2 to 5 years.

If menstrual bleeding doesn't stop after taking testosterone for several months, your healthcare professional might suggest that you take medicine to stop it.

Some of the physical changes caused by masculinizing hormone therapy can be reversed if you stop taking testosterone. Others, such as a deeper voice, a larger clitoris, and more body and facial hair, cannot be reversed.

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