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The Endocrine Society’s September 2017 guideline recommended fertility-preservation counseling for everyone seeking gender-affirming medical treatment. For adolescents, counseling was to occur before puberty suppression or affirmed-gender hormone therapy; for adults, before affirmed-gender hormone therapy. For adults, the guideline also recommended confirming diagnostic criteria for gender dysphoria or gender incongruence and eligibility for the endocrine phase of transition before treatment. Clinicians were advised to evaluate and address medical conditions that hormone depletion or affirmed-gender sex hormones could exacerbate.
On an Endocrine Society resource page dated October 25, 2024, the organization presented its September 2017 guideline, which recommended against puberty blocking and gender-affirming hormone treatment in prepubertal children with gender dysphoria or gender incongruence. For adolescents who met diagnostic and treatment criteria and requested treatment, the guideline suggested initial pubertal suppression after physical pubertal changes first appeared. Where suppression was indicated, it recommended gonadotropin-releasing hormone, or GnRH, analogues.
For adolescents requesting sex-hormone treatment, the September 2017 guideline recommended gradually increasing doses only after a multidisciplinary team of medical and mental-health professionals confirmed persistent gender dysphoria or gender incongruence and sufficient mental capacity for informed consent. The guideline said most adolescents had that capacity by age 16. It also recognized that compelling reasons could justify treatment before 16, while noting minimal published evidence for treatment below approximately 13.5 to 14 years.
A UCSF Transgender Care overview published June 17, 2016, described feminizing hormone therapy as generally combining an estrogen with an androgen blocker and, in some cases, a progestogen. It described spironolactone as having direct antiandrogen-receptor activity and suppressing testosterone synthesis. Hyperkalemia was identified as its most serious risk, but the overview characterized that risk as very uncommon when spironolactone was avoided in renal insufficiency and used cautiously with frequent monitoring in people taking ACE inhibitors or angiotensin-receptor blockers.
The same 2016 overview stated that finasteride and dutasteride inhibit the 5-alpha-reductase-mediated conversion of testosterone to dihydrotestosterone. Because they block neither testosterone production nor testosterone action, their antiandrogen effect was described as weaker than full androgen blockade. The overview also associated ethinyl estradiol with increased thrombotic risk and stated that its use and inherent risks were not warranted in gender-affirming care because regulation of cycles or bleeding wasn’t needed.
For masculinizing therapy, another UCSF Transgender Care overview published June 17, 2016, described the general approach as using one of several forms of parenteral testosterone. Listed effects included virilizing voice changes, facial- and body-hair growth, increased muscle mass, cessation of menses, clitoral growth, and vaginal dryness.
That overview stated that upward testosterone-dose titration should be guided by the patient’s goals alongside clinical response, hormone levels, and safety monitoring, including hemoglobin and hematocrit. It also reported no evidence that doses or levels above the normal male physiologic range produced a greater degree of virilization once testosterone had entered that range.
The 2016 overview reported that testosterone undecanoate had become available in the United States only through the restricted AVEED Risk Evaluation and Mitigation Strategy program because of rare pulmonary oil microembolism and anaphylaxis. Under the arrangement described at that time, every injection had to be given by a trained, registered healthcare provider in an office or hospital, followed by 30 minutes of monitoring for adverse reactions.
During hormone treatment, the Endocrine Society’s September 2017 guideline suggested measuring hormone levels to verify suppression of endogenous sex steroids and maintenance of administered sex steroids within the normal physiologic range for the affirmed gender. During sex-steroid treatment, it also advised clinicians to monitor prolactin, metabolic disorders, bone loss, and cancer risks—including cancer risks in people who had not undergone surgical treatment.