It may be helpful to know that it is well-established that a patient has a clear right to change their title, name and gender marker on their records, on request. Declining such a request could be interpreted as unjustified discrimination. An individual does not need to have undergone any treatment, or have a Gender Recognition Certificate etc. In fact, no formal deed of change of name is required (this is required for other official documents), though we do encourage this deed poll name change as an important part of the social transition process.
Clinical information and guidance for hormone therapy
Reference material
This information is provided as reference material. The documents do not apply to individual patients/people.
We are happy to provide ongoing advice on monitoring and managing hormone therapy for patients currently under our care or who were previously under our care.
We cannot endorse hormone therapy, nor take responsibility for monitoring or managing hormone therapy, nor give individualised advice for patients/people we have not seen or assessed ourselves as this can be unsafe. When we receive queries such as these, we may direct GPs/healthcare professionals to the information here in the first instance. Where needed, we may be able to provide further general advice in the interest of safety and harm reduction.
Shared care prescribing guidance
Shared care prescribing guidance
The information contained in these documents have been compiled in order to support GPs and other medical practitioners in safe prescribing and monitoring arrangements.
The documents outline the roles and responsibilities of the Gender Specialists, General Practitioners and Clients and contains both a shared care agreement and a client letter of consent for the initiation of hormones. It is imperative that clients who take the preparations, as listed, do so under medical supervision, and are monitored as recommended.
Latest updates
Please ensure that the latest updates on the medications and interactions, as listed, are obtained from the BNF.
Ongoing hormone monitoring and management leaflets
These documents provide ongoing hormone monitoring and management guidance. They are meant to be used as supplementary documents to our shared care protocols, serving as a quick glance dose titration and monitoring guide.
On discharge from our service, this is the information we send to GPs to guide immediate and longer-term monitoring and management of hormone therapy in primary care. The guidance is consistent with the ongoing hormone monitoring & management leaflet (above).
These information booklets are typically given to patients at their initial appointment with our service, outlining what to expect from hormonal treatment and the risks (i.e., the benefits and risks), and also explains the monitoring requirements. These are currently being reviewed/updated.
Supporting your patients waiting to be seen at the GIC
Waiting times to be seen at any gender identity clinic in the UK at present are extremely long due to steadily increasing numbers of referrals. We understand this puts even more pressure on you as a GP, nurse or healthcare professional to find ways to support people seeking treatment for gender dysphoria and gender identity issues. The information below is aimed at improving your knowledge, and provides details of ways you can help support and signpost your patients while they wait to be seen.
General things to note
Gender dysphoria is not a psychological disorder
However, many people with gender dysphoria do suffer from mental health issues, and these can and should be treated concurrently through referral to local mental health teams. You don’t need to delay referral to the Gender Identity Clinic.
Non-binary genders
Not all people seeking help for gender identity issues will identify as the binary male/female. It is important to acknowledge and respect this, and check how the person would like to be addressed. For example, non-binary people may wish to use gender neutral pronouns such as ‘they/them’ or ‘ze/zem’ instead of ‘he/him’ or ‘she/her. If you get it wrong, just apologise and correct yourself.
Hormone therapy will usually be lifelong and hence ongoing monitoring is required, taking into account any age related conditions. AGE UK has a very good fact sheet (PDF)
Support needed before referral or in the early stages of referral
Social transitioning
This is an extremely important part of managing gender dysphoria. It’s really important to stress to your patient the importance of making a social gender role change into whatever role best suits them; and to encourage them as far as possible to let their family, friends and workplace know. We need to see evidence that the person is committed to their gender identity and able to cope with the challenges of transitioning. There are many resources and support groups to help social transitioning (see info and support section of website).
We encourage people to make their name change via deed poll. When they do so please update your patient’s name and gender marker on your practice records.
Smoking cessation
It is of paramount importance that you urge your patient to quit smoking. Anyone seeking hormone therapy (likewise for surgery) must have completely quit smoking for 3 months, due to increased cardiovascular and thromboembolic disease risks. We will not endorse hormones for anyone that is smoking and may have to stop or reduce therapy if they return to smoking.
Fertility
Please strongly urge patients to consider their fertility before commencing hormone therapy. Discuss options including gamete storage and support and refer to fertility clinics as needed. At present, NHS funding for this is dependent on the local area and you will have to apply to your CCG or Primary Care Organisation. We hope this will change in the future.
The NHS Interim Gender Dysphoria Protocol 2013 highlights that transgender patients receiving gamete storage should be treated using similar protocols as with those receiving radiotherapy, chemotherapy, and other gamete damaging procedures. If you need to seek further clarification, please contact the local CCG / Primary Care Organisation directly. Please see the Human Fertilisation and Embryology Authority website for more information regarding local fertility clinics: www.hfea.gov.uk
Self medication
We strongly advise against internet-sourced hormones. With regard to private gender specialists – we advise GPs to be discerning and check credentials. We are unable to endorse hormone therapy or take over management until we have assessed the patient ourselves. We can however discuss concerns with GPs upon request.
Support needed once referred or being seen at the GIC
Physical health
It’s important that anyone planning to commence treatment for gender dysphoria is as physically healthy as possible. As GP you can help in the following ways:
Long-term conditions: Ensure any significant or long term conditions are under good control – e.g. diabetes, COPD, heart conditions.
Venous Thromboembolism: If your patient has had a previous thromboembolic event they will need to be lifelong anti-coagulated before starting oestrogens so may need referral to an anti-coagulation clinic.
Diet, exercise and wellbeing: The process of addressing gender dysphoria and transitioning can be stressful and there can be many challenges – doing all you can to support your patients’ wellbeing is crucial. The physical health risks of hormone therapy are increased in people that are overweight or have health issues such as hypertension, hypercholesterolaemia and diabetes. Please advise your patient on healthy diets and exercise and refer to support services where needed.
Surgery: Genital reconstructive surgery will be delayed until BMI is lower than 31, with a waist measurement of less than 102cm. This is because surgical risks are increased if you are very overweight and surgical outcomes and healing are likely to be impaired.
Cholesterol: It is very important for people on hormone therapy to manage their cholesterol levels. Please help patients to follow a healthy lifestyle to manage their cholesterol and consider medication if necessary, guided by cardiovascular risk assessments as per your normal practice.
Bone health: Many of the patients we see have a low baseline vitamin D level, and making changes to hormone levels can further impact on bone health. We aim for a baseline vitamin D level greater than the lower end of the reference range for the local laboratory, and advise treatment of lower levels. If the patient is on low dose hormones, stops taking therapy for any reason, or there are any significant concerns about bone health, monitoring with DEXA scanning should be considered.
Health screening call ups: If your patient has made a name change and changed their gender identity on your system, it may be that they miss call ups for health screenings that they need, such as breast screening, cervical smears and AAA screens. Please flag up this issue on your notes system if you can, and encourage patients to be aware of making appointments for health screenings as they may not get automatically called up.
As well as the national screening programme list, transmasculine people that have been on testosterone for two years and retain their uterus will need two-yearly pelvic ultrasound scanning to monitor for endometrial hyperplasia. Where possible the transabdominal approach is preferred rather than transvaginal approach which may worsen dysphoric feelings.
Sexual health
Sexual health – please promote sexual health and use of contraception irrespective of whether patients are taking hormones.
With transgender patients, the same as with any patient, it is important not to assume sexuality.
For male bodied people who have sex with male bodied people it is of increased importance to advise use of condoms, HIV testing, hepatitis A and B vaccine and consideration of PrEP (Pre-Exposure Prophylaxis, for HIV).
Hormone therapy is NOT a contraceptive method. Pregnancy can still occur so precautions must be taken.
CliniQ in London is a sexual health service specifically for transgender and non-binary people https://cliniq.org.uk/. There may be other similar clinics nearer to the patient, under a more local sexual health service.
Surgery
Please urge patients not to seek surgery outside of the care of gender specialists. It is a non-reversible step to take and it is much better to wait until settled in social transition and established on hormones, with the expertise and support of the GIC.
Alternative hormone medication options in case of supply issues:
If there are local supply issues with particular formulations of hormonal medications, there are alternatives (as outlined below).
After any change in hormonal medications, please repeat the monitoring as indicated below and as per our clinical guidelines.
If further advice is needed, please don’t hesitate to contact us. The BNF and EMC website also have further information on the medications outlined in our clinical guidelines.
Oestrogens (estradiol)
Please note
We use estradiol (valerate or hemihydrate) formulations as our standard oestrogen therapy. As these modern estradiol formulations are safer, we do not typically recommend Premarin or Ethinylestradiol.
Estradiol tablets: Progynova, Elleste Solo, Zumenon : all equivalent at the same doses
Estradiol gels:
Sandrena gel, available as 0.5mg and 1mg sachets.
Oestrogel 0.06% gel, each pump actuation delivers 0.75 mg estradiol.
Estradiol patches: Progynova TS, Evorel, Estradot, Estraderm: all equivalent at the same doses
Approximate conversions between estradiol formulations:
Estradiol tablets 2mg OD: Estradiol patches 50 micrograms twice a week: Estradiol gel 1mg OD
Estradiol tablets 4mg OD: Estradiol patches 100 micrograms twice a week: Estradiol gel 2mg OD
Estradiol tablets 6mg OD: Estradiol patches 150 micrograms twice a week: Estradiol gel 3mg OD
Estradiol tablets 8mg OD: Estradiol patches 200 micrograms twice a week: Estradiol gel 4mg OD
Monitoring after a change to oestrogen (estradiol) therapy:
After any change to dose or formulation of estradiol, monitoring is due 8 weeks later as follows:
Bloods for: oestradiol, testosterone, prolactin, liver function
For accurate results, the timing of blood tests should be:
Estradiol tablets: 4-6 hours after tablets swallowed whole as a single dose
Estradiol gel: 4-6 hours after gel applied to skin of body or legs (not arms)
Estradiol patch: 48-72 hours after patches applied to skin
*the target ranges for oestradiol levels are outlined in the clinical guidelines.
Sustanon and Testosterone Enantate can be considered equivalent at the same doses and injection frequencies/intervals.
Nut allergies
Sustanon should not be used in people with peanut allergy, so if a person has nut/peanut allergy then use Testosterone Enantate (or other alternatives would be testosterone gel or long-acting Nebido injections, as outlined below).
When there are supply issues with either Sustanon or Testosterone Enantate, patients can generally be switched from one to the other as they are seen as equivalent at the same dose and frequency. However, patients with a peanut/nut allergy cannot be switched from Testosterone Enantate to Sustanon but they could be switched to a testosterone gel or long-acting Nebido injections.
Three options for the alternatives are outlined below:
If the patient is switched from Sustanon to Testosterone Enantate (or vice versa) repeat monitoring is due at the 4th injection after that change, as trough and peak monitoring as two separate blood tests, one week apart, as follows:
TROUGH blood test – (day of, before injection): testosterone (usual aim 8-12 nmol/l), full blood count, liver function tests, lipids (fasting 6 hrs prior to test)
PEAK blood test – (one week after injection): testosterone level (usual aim < 30 nmol/l)
Please also measure blood pressure and
If the patient prefers to switch to a testosterone gel, an appropriate starting dose is Testogel pump 16.2 mg/g gel at 2 actuations of the pump once per day (40.5 mg testosterone).
Care should be taken not to transfer any gel through skin to skin contact, in particular with either a female or a child, for 6 hours after gel is applied to skin. Once gel is dry, the skin covered with clothing, and hands are washed with soap and water, there is minimal risk of transfer.
If switched to Testogel, monitoring is due 8 weeks later as follows:
Blood should be drawn for:testosterone (usual aim 15-20 nmol/L), full blood count, fasting lipids, liver function.
The blood test should be taken 4-6 hours after the gel is applied to the skinmaking sure the gel is put on the body or legs, not the arms.
Please also measureblood pressure and
If the patient wishes to switch to long-acting Nebido injectionsthey should be aware that, as compared to Sustanon/Testosterone Enantate, Nebido injections are usually given every 12 weeks (after an initial loading phase), and are, therefore, often more convenient with simpler monitoring requirements (just trough blood tests rather than trough and peak). The medication is delivered via larger injections, given slowly over about two minutes into the gluteal muscle, and may be more painful. There is a rare risk of pulmonary oil microembolism, which is easily treatable by supplemental oxygen, hence, as per the manufacturer’s guidance and out advice, Nebido injections should be given by healthcare professionals in a health care setting with access to oxygen such as GP practices. The patient should not be smoking and their weight should be over 55kg to switch to Nebido as per the following guidance (if less than 55kg, the dose should be reduced to Nebido 750 mg).
If the patient prefers to switch to Nebido injections, please let us know and send us recent (within last 3 months) safety bloods (full blood count, liver function, lipids) if there are no significant abnormalities and no polycythaemia (haematocrit should be less than 0.52), then we can provide you with the Nebido loading protocol.
Whatever formulation the patient is switched to, pleasesend the next set of results togic.endo@nhs.net for review and advice on adjustments to therapy. Please confirm the dose and formulation of the hormonal medications when sending results.
Long-acting injections:
Nebido (must be administered by trained healthcare professional in health-care setting as per manufacturer’s instructions). There is no alternative long-acting testosterone preparation but it is possible to switch to short-acting testosterone injections or testosterone gels once the serum testosterone level falls below 15 nmol/L.
Monitoring after a change in testosterone therapy:
After any change to dose or formulation of testosterone, monitoring is due:
Testosterone gels: monitoring is due 8 weeks after any change to dose or brand of gel as follows:
Bloods for:testosterone, full blood count, liver function, fasting lipids
For accurate results, the timing of the blood test should be 4-6 hours after gel applied to skin of body or legs (not arms).
Sustanon/Testosterone Enantate: monitoring is due at the 4th injection after any change to dose or injection frequency/interval, or if switching between the two formulations. This requires trough and peakmonitoring as two separate blood tests, as follows:
TROUGHblood test – (day of, before injection): testosterone, full blood count, liver function tests, lipids (fasting 6 hrs prior to test)
PEAKblood test – (one week after injection): testosterone level
Nebido: monitoring is due at the 3rd injection after any change in injection frequency/interval (or dose, but this is less common), with blood tests taken as a trough sample on the day of a Nebido injection, prior to the injection, as follows:
Bloods for:testosterone, fasting lipid profile, full blood count, liver function.
To note, no peak testosterone is needed.
*the target ranges for testosterone levels vary by testosterone formulation, and are outlined in the clinical guidelines.
GnRH analogues
As per our shared care guidelines, there are several options of GnRH analogues, including injectable or subcutaneous implant formulations given on a monthly, 3-monthly or 6-monthly basis. Before switching to a longer-acting formulation, it is worth checking that a patient is otherwise tolerating GnRH analogue therapy well. There is also a nasal spray for those who cannot tolerate injections.
We usually recommend either of the following GnRH analogues:
Decapeptyl (triptorelin) SR 11.25 mg (IM) every 12 weeks
Zoladex (goserelin) 10.8 mg (sub cut) every 12 weeks
Other alternative GnRH analogues:
Leuprorelin (Prostap) 11.25 mg (IM) every 3 months
Leuprorelin (Prostap) 3.75 mg (IM) monthly
Goserelin 3.75 mg (sub cut) monthly
Decapeptyl SR 3 mg (IM) monthly
Decapeptyl SR 22.5 mg (IM) every 6 months
Nafarelin (Synarel) nasal spray, 200-400 micrograms twice a day (see BNF)
Monitoring after a change to GnRH analogue therapy:
After any change to dose or formulation of a GnRH analogue, standard oestrogen therapy or testosterone therapy monitoring is due 8 weeks later.
Finasteride
When there is a problem sourcing Finasteride, Dutasteride 0.5 milligrams is a suitable alternative.
Information sessions for GPs
We run twice-yearly Gender Identity Clinic Information Session for GPs, nurses and healthcare professionals.
In these sessions our team of experts will deliver a high calibre evening of learning for GPs, nurses and healthcare professionals working at all levels. Hear about the latest updates in the field of gender work and find out more about prescribing guidelines. Meet gender specialists who have decades of experience working across primary and acute care, and network with your colleagues and peers.
At the session you will hear information on gender services, prescribing, as well as helpful advice about how best to look after this growing population of patients. There will be an opportunity to have your questions answered, and to share your concerns, ideas and experiences.
What you’ll take away
How to refer patients with gender dysphoria directly to a multidisciplinary gender identity clinic
An understanding that people in a new gender role usually need a lifelong prescription of maintenance hormone therapy and the implications for you
That a patient’s prior change of gender role is rarely clinically relevant and does not need to be mentioned
The need to consider birth gender when offering routine screening for cervical and breast cancer and aortic aneurysm
Clarity around how a patient with a new role would like to be addressed and how to amend records accordingly to avoid subsequent upset and possible complaints
