Wilhelm GAHT

What is GAHT?

Gender-affirming hormone therapy (GAHT) is a medical treatment that uses hormones or hormone blockers to help a person's physical traits match their gender identity.

Masculinizing: testosterone

Feminizing: estrogen plus anti-androgens

What is gender dysphoria?

What is gender incongruence?

Distress caused by incongruence between gender identity and assigned sex. It is a DSM-5 (mental disorders) diagnosis.

Gender incongruence is a mismatch between a person's expressed gender and their assigned sex. It is related to sexual health rather than a mental disorder.

What screenings should be assessed before starting hormone therapy?

What baseline labs?

CV risk, mental health, fertility goals, smoking, and VTE risk, age, puberty stage, BP, BMI, and baseline labs.

CBC, LFTs, testosterone or estradiol, and potassium/renal function if spironolactone is used.

What psychosocial factors are assessed in adolescents?

physical factors?

Persistent dysphoria, mental health, and family/social support.

Tanner (puberty) stage, height, weight, BMI, and growth velocity.

When is puberty suppression considered?

What drugs are used?

During early puberty with persistent gender dysphoria.

GnRH agonists such as leuprolide, triptorelin, and histrelin. They reversibly halt puberty progression.

Continuous GnRH → pituitary receptors become desensitized → ↓ LH + FSH → ↓ sex hormone production

What routes are for testosterone use in transmasculine youth?

How is dosing approached?

Injectables, transdermal gels, buccal products, and pellets.

Start low and titrate gradually toward adult dosing.

What is the adult target serum testosterone range?

300-1000 ng/dL.

What estradiol routes can be used in transfeminine youth?

What anti-androgen may be used?

Oral, transdermal patch, or injectable.

Spironolactone, finasteride, and GnRH agonists.

What is the target estradiol range for feminizing therapy?

100-200 pg/mL.

What fertility counseling is important with GAHT?

What fertility preservation options may be discussed?

Testosterone and estrogen can impair fertility, so discuss preservation before therapy.

Sperm banking and oocyte cryopreservation.

Which masculinizing changes are permanent?

reversible?

Voice deepening and facial/body hair growth.

Fat redistribution and menstrual cessation.

When does testosterone erythrocytosis require action?

Hct >54%.

Testosterone can cause erythrocytosis by stimulating the bone marrow to produce more red blood cells.

What is the testosterone target during feminizing therapy?

Less than 50 ng/dL.

What are permanent feminizing effects?

reversible?

Breast development.

Decreased libido, body fat redistribution, and softer skin.

What medications should be avoided with spironolactone?

ACE inhibitors, ARBs, and other medications that increase potassium.

What hormonal contraception is suggested with GAHT?

Progesterone-only hormonal contraception.

What treatment access barriers can affect GAHT?

Cost, insurance, and prior authorization requirements.

What does Michigan law say about pharmacists' refusal of dispensing GAHT?

A pharmacist may refuse based on religious or moral objections.

If a pharmacist refuses to dispense GAHT, they must either arrange for another pharmacist at the store to fill the prescription or transfer the prescription to another convenient pharmacy.