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If you are transitioning from male to female or from female to male, your hormone treatment will require you to have testing as you progress. Some of these tests will be to check the progress of your hormone and bodily changes, others will be done to monitor your general health.  Hormone therapy affects your body in many ways.

The process of transitioning varies from person to person and can take anywhere between several months and several years. Everyone is different and the rate at which your body changes will depend on many factors.  These include your genes, the age you are when your hormone treatment begins, and your general state of health.  

Tests and hormone treatment
Transitioning will require you to have coordinated care from a multi-disciplinary health team. Testing will be used to assess you before you start therapy and to monitor your health as you progress. 

The type of treatment you have depends on your age.

Children and adolescents
Children and adolescents who identify as transgender start with treatment that suppresses puberty. Drugs are used to block the actions of Gonadotrophin Releasing Hormone (GnRH). 

In normal puberty, GnRH stimulates the release of Luteinising Hormone (LH) and Follicle Stimulating Hormones (FSH) from the pituitary gland.  LH and FSH act on the female ovaries to produce oestrogen and progesterone and on the male testes to produce testosterone (Fig.1).   These hormones cause the physical developments seen in puberty such as breast and genital development, pubic hair growth, and changes in where fat deposits.

Female_Male-HPG-Axis-for-Transgender-article_2-(1).jpg

Fig. 1: Male and female hormones acting on the testes and ovaries.

The blocking drugs are called gonadotropin-releasing hormone agonists or GnRHa.  They turn off the secretion of LH and FSH. As a consequence, periods and breast development are supressed in transboys; muscle development, voice changes and beard development are stopped in transgirls. 
The laboratory tests to manage transgender progression may vary between different healthcare providers but those recommended in recently produced Australian standards are shown in Table 1.

Table 1: List of recommended medical examination and investigations for puberty suppression using gonadotrophin releasing hormone analogues (GnRHa).
Stage of Treatment Physical Examination Laboratory Tests
Initial examination and investigations prior to commencement of puberty suppression Height
Weight
Body Mass Index (BMI)
Blood pressure
Stage of puberty (Tanner)
Full blood count
Urea, electrolytes & creatinine
Liver Function Tests
Oestradiol 
&/or Testosterone
LH and FSH
Bone mineral density (may be considered)
Bone age/maturation
Lipid profile
Blood glucose
Monitoring during puberty suppression every 3 months Height
Weight
BMI
Blood pressure
Documentation of
physical changes or side effects
 
Monitoring during puberty suppression at 6 months
(just prior to the third dose of GnRHa)
  LH and FSH
Oestradiol or
Testosterone
Monitoring during puberty suppression every 12 months until completion of puberty suppression treatment Tanner stage of puberty Full blood count
Urea, electrolytes & creatinine
Liver Function Tests
Lipid profile
Blood glucose
Bone mineral density (as required)
LH and FSH
Oestradiol or Testosterone


Adults
In adults, hormone therapy means taking the hormones of your preferred gender.

Someone who transitions from female to male will take testosterone hormone therapy, and someone who transitions from male to female will take oestrogen.  These hormones start the process of changing your body into the gender you feel most comfortable with. For most people, this means taking them indefinitely. 

In transwomen, treatment causes breasts to form within a few months while other changes such as body hair becoming finer may take several years. For transmen, treatment causes changes in the skin, muscle mass, fat redistribution and the cessation of periods. The rate of change is variable and differs from person to person.

Hormone therapy carries some risks and so you will need to have regular tests to monitor your general health.  
If you are on oestrogen, your doctor will check your liver function and lipid/cholesterol levels.  This is because there is a small risk of liver damage and of blood clotting and stroke.  You may be asked to have a Full Blood Count, Liver Function Tests, lipid tests, kidney function tests and glucose tests for diabetes.

If you are taking testosterone, an increase in haemoglobin – the red cells/part of your blood – can make your blood thicker and this brings a higher risk of stroke and heart disease. There is also an increased risk of insulin resistance and type 2 diabetes. These effects are poorly understood and may be due to the hormone therapy itself or to the hormone changes that are happening in the body. To monitor these changes you may have to have a Full Blood Count, lipid tests, kidney function tests and glucose tests for diabetes.

As a result of your testosterone treatment, your overall health risk profile will change to that of a man. This means your risk of certain diseases may go up. 

As well as checking for the safety of hormone therapy you will have oestradiol or testosterone tests to monitor the gender related changes.

The recommended tests that are used to monitor oestrogen and testosterone therapy are shown in the Table below.
Stage of Treatment Physical Examination Laboratory Tests
Initial examination and investigations prior to commencement of gender affirming hormones Height
Weight
BMI
Blood pressure
Tanner stage of puberty
Full blood count
Urea, electrolytes & creatinine
Liver Function Tests
Oestradiol 
or Testosterone
LH and FSH
Lipid profile
Blood glucose
Monitoring during gender affirming hormone treatment every 3 months Height
Weight
BMI
Blood pressure
Documentation of physical changes: e.g. breast growth, voice changes, facial and body hair
Documentation of unwanted effects
 
Monitoring during gender affirming hormone treatment every 6 months
(Note: testosterone levels should be performed just prior to the testosterone undecanoate dose or half way in between doses of testosterone enanthate)
  Full blood count
Urea, electrolytes & creatinine
Liver Function Tests
LH and FSH
Oestradiol or
Testosterone
Monitoring during gender affirming hormone treatment every 12 months Tanner stage of puberty Bone mineral density (to document recovery after being on puberty suppression as required)
Blood glucose 
Lipid profile
 
Laboratory related issues 
The way that a laboratory manages test requests and test results has traditionally been based on male and female genders. With the acceptance of a wider gender spectrum laboratories are adapting their practices and removing barriers to the effective and respectful management of transgender people. 

The computing or information systems used in laboratories to process patient information and results were designed to allow for input of only two genders – male and female. These systems are being adapted to allow for appropriate classification of transgender people.

Some laboratory tests are sex specific and, for example, computing systems are used to ensure that pregnancy tests can only be performed on females and prostate-specific antigen (PSA) tests can only be performed on males. However, these tests may be appropriate in a transgender person. Laboratories are developing processes to ensure that these gender-driven requesting practices can be over-ridden in the relevant circumstances.

Reference intervals are a way by which test results can be compared to the general population that is deemed ‘healthy’.  In the past, laboratories have used healthy males and females to compile their reference intervals. However, for transgender people the ranges compiled for males and females are often not appropriate. This issue is receiving a lot of attention by the laboratory profession and it is likely that more transgender-appropriate reference intervals will become available. 

Other treatments
Support for transgender patients requires coordinated care from many different medical specialities including paediatrics, adolescent medicine, paediatric endocrinology, clinical psychology, fertility services, general practice, and nursing. There are other treatments for transgender people apart from hormone therapy and these include surgery but details of these should be sought elsewhere.

Information sources
Telfer, M.M., Tollit, M.A., Pace, C.C., & Pang, K.C. Australian Standards of Care and Treatment Guidelines for Trans and Gender Diverse Children and Adolescents Version 1.1. Melbourne: The Royal Children’s Hospital; 2018

Adriaansen MJ, Perry WNC, Perry HE, Steel RC. Binary male-female laboratory reference ranges do not reflect reality for transgender individuals on sex-hormone therapy. N Z J Med Lab Sci 2017; 71:101-5.

Goldstein Z, Corneil TA, Greene DN. When Gender Identity Doesn't Equal Sex Recorded at Birth: The Role of the Laboratory in Providing Effective Healthcare to the Transgender Community. Clin Chem. 2017 Aug;63(8):1342-1352.