Gender Affirming Hormone Therapy

WHAT IS GAHT?

Gender affirming hormone therapy (GAHT) consists of either estrogen or testosterone hormones. There are some trans and nonbinary people who take hormone therapy as part of a gender transition to help their bodies and appearance align with their gender identity. Your gender journey is yours to decide!

Why are you using GAHT instead of HRT?

HRT stands for Hormone Replacement Therapy.

Even though the term HRT is a general term used to describe any type of hormone intervention, it has specifically been adopted by the trans community to describe the process of gender affirming hormone therapy (GAHT).

The transition from hormone replacement therapy (HRT) to gender affirming hormone therapy (GAHT) is a recent effort to get specific about the healthcare needs of the transgender, non-binary, and gender non-conforming community.

Although we are referring to this treatment specifically from a gender-affirming perspective, you can decide what to call your medical transitional journey; HRT, GAHT or simply just transitioning.

Resource: What’s the Difference Between HRT and GAHT?

GAHT/HRT for trans and nonbinary people in Ontario is no longer a speciality area. This means, in most cases, HRT can be provided by primary care providers, including family doctors and nurse practitioners.

If they are inexperienced, Rainbow Health Ontario has created resources they can access to learn, such as Guidelines for Gender-Affirming Primary Care with Trans and Non-Binary Patients and Primary Health Care for Trans Patients. Rainbow Health Ontario also offer ongoing mentorship and training for healthcare providers to build their knowledge and clinical skills.

If you don’t have a primary care provider or if you do not feel comfortable bringing up hormone replacement therapy with your provider, you can use Rainbow Health Ontario’s Service Provider Directory to find a provider in your area.

There are various reasons why trans, nonbinary and other gender expansive folks choose to take testosterone as a gender-affirming hormone therapy. It can be used to support the development of facial/body hair, increased muscle mass/strength, stop menstruation, deepen voice and more. Some folks take testosterone because it makes them connect their body to their gender – the choice is for you to make!

Injectable (Needle)

Most common due to its lower cost.
Two injection sites:
- Intramuscular (IM) injection is most common.
- Subcutaneous (SC)
  - Less discomfort, lower rate of injection-site complications.
  - Easier for self-injection

Helpful images below to indicate areas for Intramuscular and Subcutaneous injection sites, from FOLX:

Transdermal (Patch/Gel)

Less common due to higher cost. Please see chart below for a detailed overview of medication offered, as per Rainbow Health Ontario’s recommendations.

Formulations	Starting/Low Dose	Maximum Dose	Cost per unit	*Approx Cost^(4 weeks)**
Testosterone enanthate^a (IM/SC)	20 – 50 mg q weekly or 40 – 100 mg q 2 weeks	100 mg q weekly or 200 mg q 2 weeks	$73.50 per 5 mL vial (each vial contains 200 mg/mL x 5mL = 1000 mg)	$14 – $29 Generally covered by ODB with EAP request
Testosterone Cypionate (IM/SC)^a			$64 per 10 mL vial (each vial contains 100mg/mL x 10mL =1000 mg)	$13 – $26 Generally covered by ODB with EAP request
Testosterone (transdermal) Patch^b	2.5 – 5 mg daily	5 – 10 mg daily	$164/60 x 2.5 mg patches $169/30 x 5 mg patches	$76.50 – $315
Testosterone Gel 1% (transdermal)	2.5 – 5 g daily (2-4 pumps, equivalent to 25 – 50 mg testosterone)	5 – 10 g daily (4-8 pumps, equivalent to 50 – 100 mg testosterone)	$67/30 x 2.5 g sachets $110 / 30 x 5 g sachets $175 / 2 pump bottles	Sachets: $62 – $205 Bottles: $81 – $32
References and Notes * Price quotes are provided by www.pharmacy.ca Note: Testosterone (in all forms) is considered a controlled substance in Canada; prescriptions should be written in accordance with provincial requirements for controlled substances. a) Testosterone enanthate is compounded in sesame oil, and testosterone cypionate is compounded in cottonseed oil; patients with allergy to either of these compounds should use the alternative agent b) Androderm brand, per drug monograph the 12.2 mg patch delivers 2.5 mg/day while the 24.3 mg patch delivers 5 mg per day c) Each pump bottle provides 60 pumps, 1 pump = 1.25 g of gel, equivalent to 12.5 mg of testosterone

More resources on Testosterone [Gender-Affirming Hormone Therapy];

Folx:

Informed Consent Considerations for Testosterone HRT

What Physical Changes to Expect on Testosterone Hormone Replacement Therapy

Testosterone Gel for Gender-affirming Hormone Therapy: What, Where, and How

Microdosing (Low Dose) Testosterone Hormone Replacement Therapy (HRT),

9 Myths You Might Have Believed About Testosterone HRT

The reasons why trans, nonbinary, and other gender expansive people take estrogen hormone therapy varies from person to person. It can be used to reduce coarse body hair and/or facial hair and to develop breasts and hips. Some people choose to take estrogen because it makes them feel right in their body! It’s up to you to decide what works best for you, with the help of an appropriately informed health care professional.

Estrogen therapy also, unlike testosterone, sometimes requires a suppression of androgens (testosterone) in the body with the addition of estrogen hormone treatments.

Anti-androgens

Anti-androgens work to block the effects of androgens such as testosterone.

These are taken in pill form.

Progestins

Less people choose to take progesterone with their estrogen and anti-androgens. Most of these folks will decide to wait a year after taking estrogen to take progesterone. Unfortunately, there is not a lot known about progesterone and how they affect overall changes in people who access estrogen-related HRT because it has not been well studied.

These are taken in pill form.

Learn more about the risks of taking progestins:

properties Rainbow Health Ontario, under PROGESTINS

Anti-androgen & Progesterone Routes (offered by FOLX)

Medication (Pills)

Most common/available

Injectable (Needle)

Most common due to its lower cost
One type of injection site: Intramuscular (IM) injection

Transdermal (Patch/Gel)

Less common

Please see chart below for a detailed overview of estrogen and anti-androgen, as per Rainbow Health’s recommendations.

Formulations	Starting Dose	Usual Dose	Maximum Dose	Cost^*(4 weeks)	Formulations
ANTIANDROGENS	Spironolactone (oral)	50mg daily – BID	100 mg BID	150 mg bid	$15 – $41
ANTIANDROGENS	Cyproterone (oral)	12.5 mg (1/4 50 mg tab) q2d – daily	12.5 mg (1/4 50 mg tab) – 25 mg (1/2 50 mg tab) daily	50 mg daily	$16 – $56
ESTROGENS	Estradiol (oral)^*	1-2mg daily	4 mg daily or 2 mg bid	6 mg daily or 3 mg BID	$18 – $54 Covered by ODB
	*Estradiol (transdermal, patch)^b**	50 mcg daily/apply patches 2x/week	Variable	200 mcg daily/apply patch 2x/week	$39 – $76^d
	Estradiol (transdermal, gel)^e**	2.5 g daily (2 pumps, contains 150 mcg estradiol)	Variable	6.25 g daily (5 pumps, contains 275 mcg estradiol), may be limited by surface area requirements for gel application	$58 – $154
	Estradiol Valerate^**Injectable (IM)^f	3-4 mg q weekly or 6-8 mg q 2 weeks	Variable	10mg q weekly	$36 – $46
* Price quotes are provided by www.pharmacy.ca The above-mentioned prices are accurate as of May 2018 and represent the price for a 4- weeks supply of a generic brand of medication (ranging from low dose to maximum dose). Prices include a usual and customary dispensing fee of $9.99, which may vary from pharmacy to pharmacy. Note: For patients on ODB, spironolactone, cyproterone, and oral estradiol are covered and do not require the submission of an EAP form.  **estradiol valerate IM must be prepared by a compounding pharmacy, price quote provided by Pace Pharmacy (including $10.99 dispensing fee) a) Rarely required or used. Maximal effect does not necessarily require maximal dosing. Use clinical judgement in selecting optimal individual dosing.   b) Estradot® brand c) Usual doses vary significantly between individuals. Use starting doses and titrate up based on patient response. Maximum doses are not often needed. Use clinical judgement in selecting optimal individual dosing. d) 200 mcg daily given as 2×100 mcg patches applied twice weekly (4 patches/week)   e) Estragel® brand f) Given as 1mL of 10 mg/mL estradiol valerate. Per updated Ontario guidelines, opened multi-use vials must be discarded after 28 days.

more information on Estrogen [Gender-affirming hormone therapy];

Rainbow Health:

Feminizing Hormone Therapy

Folx

Informed Consent Considerations for Estrogen HRT

What Physical Changes to Expect on Estrogen Hormone Replacement Therapy

Estrogen Patches for Hormone Replacement Therapy: What, Where, and How

Microdosing (Low Dose) Estrogen Hormone Replacement Therapy (HRT),

9 Myths You Might Have Believed About Estrogen HRT

Commonly, health care providers such as doctors and nurses can provide hormone injections. If you don’t have access to someone to administer your hormones, here are some locations that will do it for you:

Maple Leaf Medical Clinic

Another option is to self-administer your hormones!

One of the main reasons for self-administration of hormones is the lack of access to gender-affirming care due to discrimination and long waiting lists. This option provides a sense of empowerment, allowing for full autonomy and privacy if they choose to.

There are many resources on self-injecting, if this is a method you are interested in exploring, there are some resources below along with some detailed instructions on how to self-administer your GAHT/HRT. We often recommend having a peer or buddy to be with you or support you in injecting if you are unsure. If you need access to new and free needles and syringes, please contact us here for supplies; supplies@actoronto.org

Gender Affirming Hormone Therapy (GAHT) and HIV medications can be taken together and do not have any known effects on the influence or outcome of either medication. It is the societal and healthcare access barriers that are often what create health complications, not the drug interactions themselves. Rainbow Health’s Transgender Men’s 2010 Sexual Health and HIV Risk Rapid Response Report indicates, individual, interpersonal, and structural/ societal factors that may be harmful to the health outcomes of transgender folks. “Barriers to employment, social services, housing, legal assistance and health and mental health care” was among the two most common structural societal factors.

The most common method of treatment for HIV is antiretroviral therapy (ART), this is a combination of different drugs that help to suppress the virus by significantly reducing the amount of HIV in the blood. The National Institute of Health recommends that all transgender people living with HIV take ART. Although “some antiretroviral drugs may have interactions with gender-affirming hormone therapy”, there are many successful ART regiments. So, it is important to monitor your hormone and T cell levels regularly with your healthcare provider.

Contrary to previous studies and popular belief, a 2020 published article by the Clinical Infectious Disease journal found no difference in effectiveness of ART in transwomen taking GAHT than they did in cis women and men living with HIV on and ART regiment. However, one 2019 study found that “rates of viral suppression were significantly greater among TGWWH (transgender women with HIV) receiving GAHT when compared with those who were not.” Concluding that trans women living with HIV who maintain successful ART and GAHT regiments experienced higher rates of HIV suppression.

The CDC states that “there are no known drug interactions between (most) HIV medications and hormone therapy. This appears true of HIV treatments as well as HIV preventative medication.” Although PrEP is recommended for all trans folks on GAHT, not living with HIV, the Pre-Exposure Prophylaxis (PrEP) drug Descovy is not approved for trans masculine folks who are receiving frontal penetration, as the known effects have not been adequately evaluated. It is recommended transmen and cis women receiving front hole penetration take Truvada.

GAHT may reduce natural lubrication as well as thin the inner tissue of the front hole, which can increase the chances of fissures and routes of STBBI contraction. However, there is very little published research on transmen, sexual health, and HIV transmission, as opposed to the already scarce research currently done with trans women. Understanding the sex that you want, will help choose the best methods of STBBI prevention and/or a treatment regimen that works for you.

Resource

https://www.plannedparenthood.org/planned-parenthood-mar-monte/patient-resources/gender-affirming-care/hormone-therapy-self-injections

https://www.folxhealth.com/library/overcoming-fear-of-self-injection/

https://www.folxhealth.com/library/hrt-subcutaneous-intramuscular-injections/

https://www.folxhealth.com/library/how-to-self-inject-hrt-subcutaneous/

https://www.folxhealth.com/library/how-to-self-inject-hrt-intramuscular/

https://www.folxhealth.com/library/hormone-self-injection-guide/

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5977079/

https://www.medicalnewstoday.com/articles/hiv-and-gender-affirming-hormone-therapy#hormone-therapy-with-hiv

https://clinicalinfo.hiv.gov/en/guidelines/hiv-clinical-guidelines-adult-and-adolescent-arv/transgender-people-hiv

https://academic.oup.com/cid/article/70/6/1131/5477380

https://academic.oup.com/ofid/article/8/9/ofab404/6331030