As part of our Patients & Provider series, we’re inviting providers to answers trans health questions directly from our readers.
Top 5 Questions About Hormones
When considering hormones, there can be high variability in terms of individual goals, bodies, needs, risks, and reactions. I get a lot of questions from readers that I can’t always answer, so I reached out to Dr Kevin Hatfield for insight.
I met Dr Hatfield at the Gender Odyssey conference and found his answers refreshingly honest. Above all, they are easy to understand for someone who has no medical background but wants more information to be empowered to advocate for their choices. His approach – aligned with my philosophy of inclusive transition for all – is always to meet the individual where they are.
Feel free to ask your questions in the comments!
Low Dose HRT
Cream, gel, or injection? Subcutaneous (belly fat) or Intramuscular injections? Both Estradiol & Testosterone can be done in both locations.
What dose is a low dose? The definition of low dose varies by individual.
How low can you go? Hormone doses can be very small especially when custom compounded creams and gels are used. Some cis-women use very low-dose testosterone cream to increase testosterone blood level for a variety of reasons.
Starting & Stopping
How do you safely stop HRT, and then start again after a period of having stopped? Obviously consistency and regularity are key, but the reality is people do stop hormones, so knowing what is best in this case would be useful.
When using cross hormones they naturally reduce birth hormones. If birth hormones are suppressed to less than 20% of what they would be naturally, abrupt discontinuation of cross hormones can lead to hot flashes, fatigue and mood changes. The length of time that these symptoms last usually is related to the level of reduction and length of time the birth hormones have been reduced. The hormone producing birth gonads become lazy after longer-term suppression (cross hormone use) and will take more time to wake up and produce what they had previously. During this transition, side effects will continue.
Discontinuing cross hormones is best done slowly over the course of a couple months but side effects of discontinuation can vary by individual. Some people stop abruptly and might feel fine but this is not recommended.
Hair Loss Prevention
Recently I’ve had lots of folks asking how to avoid balding. I’ve heard of people using Finasteride with T, but they’re wondering whether a) it works at all to prevent hair loss, b) it has effects / counter-effects with T.
Finasteride and Dutasteride (more potent and recently generic) both work to prevent hair loss.
Each of these medicines though effective, reduce enlargement of the clitoris. Some patients use these medicines to prevent hair loss and then apply topical dihydrotestosterone cream to the area around the clitoris. (The cream is available in Europe but not in the US. It can be ordered online.)
When prescribing finasteride and dutasteride, I typically do a blood level of dihydrotestosterone to see where we are starting at so we can measure the efficacy of the dose that is being used. I usually try to reduce blood levels close to the upper limit for cis-women.
Hormonal Birth Control
There are several scenarios: a) person is not on T and wants to stop periods, b) the person is on T but is on low dose but not enough to stop periods.
Depending on longer-term fertility desires, some surgical interventions leave internal plumbing but permanently reduce or eliminate monthly bleeding and fertility. In an operating room under anesthesia, destruction of the uterine lining eliminates menses and fertility. [Hysterectomy with or without oophorectomy (ovaries) is another option.]
Nonsurgical menstrual suppression can usually be achieved with an easily/painlessly implantable device placed in the upper arm called NEXPLANON that lasts for 3 years. This device does not contain estrogen (progesterone only). In conjunction with low-dose testosterone – that might otherwise not be adequate to prevent menses – the use of nexplanon and low-dose testosterone virtually always eliminates the monthly cycle and also prevents pregnancy.
Non-estrogen containing IUDs (intrauterine device) that contain progesterone derivatives in coordination with low-dose testosterone are very similar to nexplanon. But IUDs can be much more painful to insert. This type of IUD/testosterone combination will stop monthly cycles and also eliminate fertility concerns.
Transfeminine spectrum (AMAB) Nonbinary Hormone Options
People often ask me whether they should go for estrogen only, anti-androgens only, or a combination.
I offer options to everyone based on their desires. There is no cookie-cutter approach. A thoughtful conversation about goals is always needed.
Some use just dutasteride or other things to reduce testosterone’s influence within the body without creating more visible changes. Some begin slowly and look for a comfortable middle ground as doses are changed and medicines are added.
I’ve also heard of other alternatives instead of the usual spironolactone to block androgens. The goals are usually to avoid some of the feminizing effects (breast growth) while preventing further masculinization.
SERMs are selective estrogen receptor modulators that were first developed to protect bone density without stimulating breast development or increasing the risk of breast cancer. The use of SERMs is relatively common in cis-women but is still considered unfamiliar territory for most prescribers who see patient for transgender care. Lack of familiarity and worry about long-term safety of these medicines sometimes requires thoughtful discussion with prescribers and monitoring of risks versus benefits.
Using a GnRH analog (aka puberty blocker) to suppress ALL gonad produced hormones can be, done but is extremely expensive. It is a concern that bone density will decline sharply without the presence of any sex hormones. If someone is only on a GnRH analog without adequate cross hormone levels, then osteoporosis (thin and brittle bones) will rapidly become an issue. Medical providers consider long-term use of GnRH analogs without any cross hormones to be medically unsafe.
Some use nonsteroidal anti-androgens (NSAAs) like bicalutamide which do not reduce testosterone production but strongly prevent testosterone from acting within the body, blocking all testosterone receptors outside the brain. These medicines can cause liver problems, therefore blood monitoring and careful discussion are necessary when these are prescribed.
About Dr Kevin Hatfield
Kevin Hatfield, MD, is a family doctor at The Polyclinic’s downtown Seattle satellite. He joined The Polyclinic in 2002 and has taken care of Trans* patients since 1999. He sees a large number of gender-diverse children and adolescents. Dr. Hatfield is an advocate for individualized patient care and helping patients make informed decisions regarding their health and well-being.
I bet you do. This only covers the top 5-ish questions that readers email me about.
What do you want to know?
Ask your questions about hormones in the comments!