Feminising hormone treatment for trans women and non-binary people

The following information has been produced by the Nottingham Centre for Transgender Health (NCTH) and is designed to inform healthcare professionals of the recommended hormonal treatment for trans and non-binary people.

We recommend clinicians and GPs download the full guide to prescribing which can be found here: NCTH Network Guide to prescribing of Hormone Treatment (Printable) (opens in new window)

In this section:

 

Introduction

Hand holding across a field of wheat The NCTH is a national service which carries out assessments to determine eligibility and readiness for hormone treatments amongst other functions. Once hormone treatment has been recommended the patient is guided through an information sheet to enable them to give informed consent. NCTH is not commissioned by NHS England to do blood monitoring, prescribe or administer hormone treatment. NCTH aims to work collaboratively with primary care teams in England to offer support and advice to GP's and their patients.

 

Primary care responsibilities-GMC guidance

The General Medical Council 2018 have online ethical guidance for General Practitioners for treating adult patients who are trans and non-binary. This guidance states:

 

GPs must co-operate with GICs (Gender Identity Clinics) and gender specialists in the same way as they would other specialists, collaborating with them to provide effective and timely treatment for trans and non-binary people. This includes:

  • Prescribing medicines recommended by a gender specialist for the treatment of gender dysphoria.
  • Following recommendations for safety and treatment monitoring.
  • Making referrals to NHS services that have been recommended by a specialist. With regard to the prescribing of off licence medication.

Most of the medications used for the treatment of gender dysphoria are not licensed for this specific indication, although GPs will be familiar with their use in primary care for other purposes.


Further information can be found at: Trans healthcare - ethical topic - GMC (gmc-uk.org)

 

Initiating Feminising Hormone Treatment

It is the NCTH's responsibility to carry out the following:

  • Assess for a diagnosis of gender dysphoria.
  • Discuss hormonal treatments including likely effects, risks and impact on fertility.
  • Assess for readiness for hormonal treatments.
  • Provide guidance to GP's in relation to baseline blood and blood pressure, height and weight monitoring before commencing hormonal treatment.
  • Review baseline blood monitoring.
  • Arrange an endocrinology review within the clinic for those patients with significant physical health issues or significant abnormalities in baseline blood results.
  • Send an information sheet about feminising hormone treatment which has been signed by the patient and a clinician in the clinic with advice to the GP to start hormones including advice on the preparation and dose.
  • Review of the patient as clinically needed.
  • Advise the GP on preparation changes and dose adjustments, and ongoing monitoring required.
  • Provide endocrinological advice to the GP regarding adverse effects if they come to the attention of the GP.

The usual baseline blood tests are as follows:

FBC, U&E's, LFT's, Lipid profile, Prolactin, Oestradiol, Testosterone, SHBG, LH, FSH and Glucose or HBA1C. These baseline bloods should be sent to the NCTH to be reviewed.


GP responsibilities

NCTH works collaboratively with GP's and will request GP's to do the following:

  • Baseline blood monitoring. It is also recommended to record blood pressure, height and weight and to send copies of all the results to the NCTH.
  • Refer to local fertility services and request funding for gamete storage from the local CCG for those patients who wish to preserve their fertility prior to hormone treatment. Gamete storage is not funded through gender services which are themselves funded nationally via NHS England.
  • Prescribe hormone treatments as advised by NCTH.
  • Arrange blood monitoring as advised by NCTH and send copies of the results to NCTH.

 

Patient responsibilities

Without safe monitoring of hormone therapy we may no longer support the prescribing of hormone therapy. We will require patients on hormone treatments to do the following:

  • To attend review appointments every 3 to 4 months.
  • To attend for blood monitoring.
  • To be alert for and report any adverse effects e.g. DVT Hormone regimens used.

The hormone regimens that we commonly use in the initiation phase are summarised in Table 1.

Most patients will start with oestrogens which also have the effect of supressing the testosterone. For most patients the testosterone suppression will not be enough to put the testosterone level into the female range. The addition of a testosterone blocker aids feminisation, reduces the risk of capitol hair loss and reduces facial and body hair vigour and thickness. Some patients who do not want surgery may opt not to have a testosterone blocker.

For patients wanting genital surgery including removal of the testes, they will need to show a fully supressed testosterone treatment prior to surgery. However, not all patients wish to have surgery or to have a fully supressed testosterone level.

Patients undergoing surgery will need to come off oestrogens approximately 6 weeks prior to a planned operation to reduce the risk of thromboembolic complications. After surgery, patients will go back onto oestrogens, typically 2 to 4 weeks after their operation but will no longer require a testosterone blocker if their testes have been removed.

 

Ongoing Feminising Hormone Treatment

Once satisfactory oestrogen levels have been achieved the blood monitoring required is set out in Table 2. Once treatment is established and other treatments such as surgeries, speech and language therapy, psychotherapy and facial hair removal treatment are complete, patients are discharged from NCTH.

The GMC advocates:

Once the patient has been discharged by a GIC or gender specialist, the prescribing and monitoring of hormone therapy can be carried out in primary care without specialist input. From the patient's perspective, management in primary care is far easier, and there is no specific expertise necessary to prescribe for and monitor patients on hormone therapy.

Once patients are discharged, a re-referral to a specialist team can be made if it is felt that the patient is experiencing distress or difficulties in adjustment in relation to their gender or treatment, regret, or adverse effects of hormone treatment.

 

Treatment Protocols

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