New Endocrine Society Transgender Guildlines

[Elli.P]

The Endocrine Society released an update to their Transgender Clinical Practice Guidelines on 13 Sept 2017. The biggest noted change are more specific recommended MTF hormone levels. The 2009 guide recommended: "Serum estradiol should be maintained at the mean daily level for premenopausal women (less than 200 pg/ml), and the serum testosterone level should be in the female range (less than 55 ng/dl)." I always thought the Serum estradiol recommendation was vague and left much up to the doctors discretion.

The new 2017 guide recommends more specific MTF hormone levels: "Clinicians should measure serum estradiol and serum testosterone and maintain them at the level for premenopausal females (100 to 200 pg/mL and less than 50 ng/dL, respectively)." They've now specified what the lower level for the Serum estradiol should be.

This is big news because if you're like me, I have to fight with my doctor over what the level should be.

Be sure to update your doctors!

Here is a link to the new guidelines:
Endocrine Treatment of Gender-Dysphoric/Gender-Incongruent Persons: An Endocrine Society Clinical Practice Guideline

[Jailyn]

Well that is very handy to have, thanks!!!

[AnonyMs]

Its a bit of a long read, but there's a few things I've noted

Some of the authors are from Netherlands and Belgium, and I've always had a particularity negative impression as to their expertise in this area.

It doesn't seem to support informed consent.

Supportive of non-binary and partial transition, for HRT:
"Not all individuals with GD/gender incongruence seek treatment as described (e.g., male-to-eunuchs and individuals
seeking partial transition)."

I hope I'm reading this out of context:
"If the social transition has not been satisfactory, if the person is not satisfied with or is ambivalent about the effects of sex hormone treatment, or if the person is ambivalent about surgery then the individual should not be referred for surgery."

I believe this is incorrect:
"Treatment with physiologic doses of estrogen alone is insufficient to suppress testosterone levels into the normal range for females."

There's still doctors that prescribe ethinyl estradiol, in Australia at least, so this is good:
"Among estrogen options, the increased risk of thromboembolic events associated with estrogens in general seems most concerning with ethinyl estradiol specifically (134, 140, 141), which is why we specifically suggest that it not be used in any transgender treatment plan."

No mention of implants for HRT. I believe implants are by far the best form of HRT.

My estrogen levels are above what they recommend, and I prefer it that way. I don't think they are correct.

[Elli.P]

AnonyMs,
I agree wih you, those are all valid points. But even with all the parts that need improvement, overall I think it's a step in the right direction compared to  the 2009 guidelines.

I mainly went looking for the guidelines because my doctor has been trying to tell me that my estrogen level of 48 pg/mL was good enough. My argument to her was that 48 pg/mL is only 20 pg/mL above my baseline before HRT which was 28 pg/mL. She contended that the guidelines said less then 200 pg/mL and that any level below 200 pg/mL was ok as long as you have feminization results. I have had results but in my opinion they have been minor at the 6 month mark taking HRT.

I have an appointment with her on Tues. to talk to her about the new guidelines, which I don't think she is aware of. We will see what happens. Depending on the outcome of the appointment it may be time to find a new doctor. But I think the new guidelines may help my argument.

-Elli


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[KayXo]

The Endocrine Society released an update to their Transgender Clinical Practice Guidelines on 13 Sept 2017. The biggest noted change are more specific recommended MTF hormone levels. The 2009 guide recommended: "Serum estradiol should be maintained at the mean daily level for premenopausal women (less than 200 pg/ml), and the serum testosterone level should be in the female range (less than 55 ng/dl)." The new 2017 guide recommends more specific MTF hormone levels: "Clinicians should measure serum estradiol and serum testosterone and maintain them at the level for premenopausal females (100 to 200 pg/mL and less than 50 ng/dL, respectively)." They've now specified what the lower level for the Serum estradiol should be.

The estradiol level ranges from 20 to up to 762 pg/ml during a woman's menstrual cycle, is quite low the first few years of puberty and ranges anywhere from 800-75,000 pg/ml during pregnancy. So that it makes no sense to set an average level for which to aim due to how wide the range is and how much levels fluctuate during a premenopausal woman's lifetime. Besides, if we were to actually set an average level of that very wide range, that level would obviously be much higher.

The other drawbacks I see with using ciswomen as a reference and measuring estradiol levels:

- The goal for transwomen, at least in the first few years, is to develop female secondary sexual characteristics while trying to minimize those of male-type. Ciswomen are entirely different in that first, they weren't exposed to high levels of testosterone for several years and second, the context in which they developed female secondary sexual characteristics is radically different (age, growth hormone levels, telomere length, etc.).
- estrogen levels fluctuate in time
- SHBG may be higher in some of us who take oral estrogen so that our estradiol levels may be 'in range' BUT bio-available estrogen may be significantly lower in comparison
- in oral E users, estrone is significantly higher vs. ciswomen such that the ratio estrone:estradiol is quite different and may have a significant effect on results obtained
- ciswomen may be more sensitive/responsive to E due to a different hormonal environment in-utero

In addition...

(Total) Testosterone levels are anywhere from under 10 ng/dl to up to 120 ng/dl in women. The problem with measuring T levels is that unlike ciswomen, some of us take anti-androgens that BLOCK the measured testosterone, SHBG may be higher in some of us so that really the bioavailable T is much lower and our biology/genetics may have altered our sensitivity to T such that it may differ markedly.

And finally, just recently, it was admitted in a journal:

Lancet Diabetes Endocrinol. 2017 Apr;5(4):291-300.

"The precise concentration of oestradiol that results in adequate feminisation with the lowest risk of complications is not known.28"

Unfortunately, it seems to me, not much "deep" thinking goes into establishing guidelines for us.