Pediatric Annals

CME 

Cross-Gender Hormone Therapy in Adolescents

John Steever, MD

Abstract

Many transgender youth experience significant amounts of emotional distress regarding the incongruence between their internal gender identity and their physical body. Cross-gender hormonal medical treatments, as managed by a multidisciplinary medical/mental health team, assist patients in transitioning to their desired gender by aligning the physical body to match the gender identity. The World Professional Association for Transgender Health Standards of Care and the Endocrine Society’s Clinical Practice Guidelines provide a basic road map for practitioners. Expectations of the youth and the concerns of the family must be addressed and the youth psychologically supported during the transition period. Issues around future fertility should be explored as well. The goal of this article is to introduce the general pediatrician to cross-gender hormone treatments, their management, monitoring laboratory tests and clinical effects, and the issues surrounding their use in adolescents.

[Pediatr Ann. 2014; 43(6):e138–e144.]

Abstract

Many transgender youth experience significant amounts of emotional distress regarding the incongruence between their internal gender identity and their physical body. Cross-gender hormonal medical treatments, as managed by a multidisciplinary medical/mental health team, assist patients in transitioning to their desired gender by aligning the physical body to match the gender identity. The World Professional Association for Transgender Health Standards of Care and the Endocrine Society’s Clinical Practice Guidelines provide a basic road map for practitioners. Expectations of the youth and the concerns of the family must be addressed and the youth psychologically supported during the transition period. Issues around future fertility should be explored as well. The goal of this article is to introduce the general pediatrician to cross-gender hormone treatments, their management, monitoring laboratory tests and clinical effects, and the issues surrounding their use in adolescents.

[Pediatr Ann. 2014; 43(6):e138–e144.]

Many transgender youth experience significant amounts of emotional distress regarding the incongruence between their internal gender identity and their physical body. This psychological distress is the basis for the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) gender dysphoria diagnosis. Cross-gender hormonal medical treatments for transgender individuals help align the youths’ bodies to their gender identity (as opposed to the anatomic sex typically assigned at birth based upon anatomy), and thus alleviate the gender dysphoria. These hormonal regimens suppress the patient’s endogenous sex hormones and promote an “appropriate” puberty. Current guidelines regarding the administration and monitoring of cross-gender hormones include the World Professional Association for Transgender Health (WPATH) Standards of Care and the Endocrine Society’s Clinical Practice Guidelines. Both of these documents reflect the state of medical science while acknowledging that there are significant gaps in the evidence base that forms our understanding of transgender medicine.

A Multidisciplinary Team

Medical providers and mental health practitioners should work closely together in the evaluation of gender-variant adolescents. Ideally, a multidisciplinary team that includes mental and medical health evaluations is preferred. Mental health providers can assess the gender dysphoria (GD), provide patient- and family-supportive psychotherapy, assess for any coexisting mental health diagnosis that interferes with the GD diagnosis, and advocate on the youth’s behalf. Mental health professionals can also provide family counseling to help support the youth during their time of transition. A counselor knowledgeable in transgender care can also provide information so that the youth may make an informed decision about gender transition and hormonal therapy. Of course, gender hormone therapy should be individualized to the patient’s gender-transition goals.1 Practitioners should make no assumptions about the extent that youth wish to transition toward masculinization or feminization; some youth will want as many procedures/treatments as possible, and others prefer a partial transition. It is important for all members of the team to be aware that they should not impose a binary view of gender on the youth, but rather support the youth as they explore their own gender identity.

Practitioners who care for gender-variant youth must realize that these are normal children and that they are not mentally ill.1,2 Although many youth will have other concomitant mental health issues, the state of gender discordance is not a mental illness. The diagnosis of GD should be made by a qualified mental health professional at presentation and may need to be reevaluated prior to initiation of any type of medical hormonal therapy.1,3,4 Many prepubertal children who meet criteria for GD will “desist” as they mature into adolescents.2,5,6 Thus, a reevaluation prior to hormonal therapy will help to reconfirm the diagnosis; evaluate for potential transition issues; and to exclude other diagnoses such as schizophrenia, delusional disorder, or body dysmorphic syndromes.3,7 If a youth continues to express dysphoria around gender issues as a teenager, it is unlikely that it will change as they reach adulthood. The above-mentioned treatment guidelines have tended to be more patient-centered and have shied away from specifying a specific length of time that a young person needs to be engaged in care with a mental health professional before a letter of support can be provided in support of medical or hormonal interventions.

Managing Expectations

Prior to initiation of cross-gender hormones, expectations of the various potential therapies must be explored.8 Many patients and families will have unrealistic expectations about the results or timing of the results of hormonal and surgical treatments. The use of a support group with older (and treatment-experienced) transgender individuals may be important to help set the expectations of transgender youth.8 Although somewhat controversial, a “real life” test is advocated by both the Endocrine Society and WPATH. They consider it to be an important component of the transitioning process as it helps to evaluate the patient’s ability to function as the preferred gender. Youth should be encouraged to live for a period of time in the desired gender either prior to initiating hormones or at the onset of hormone use. The Endocrine Society guidelines suggest surgical intervention after a period of real-world experience that has resulted in a satisfactory social role change.7 Other authors have recommended at least a year of “real world” experience prior to irreversible surgical procedures.8 Not all providers agree with the need for a “real life” test and prefer to follow the transition path as defined by the youth themselves.

Fertility Concerns

Though rarely cited by adolescents as an issue, fertility counseling should be done with the patient and the family prior to the initiation of hormonal therapy.4 For transgender men, the option of egg banking or embryo freezing should be discussed. Once testosterone is started, the ovaries release fewer eggs. Testosterone has teratogenic effects on a developing fetus, so transgender men should not seek pregnancy while on cross-hormone therapy. There are data to suggest that ovarian function recovers if the testosterone therapy is interrupted, but this has not been well studied. For transgender women, sperm banking prior to estrogen therapy should be explored. Once estrogen has been started, sperm count decreases. There is evidence that sperm count will rise if estrogen is halted. The possibility of testicular biopsy with cryopreservation can also be explored. Many of these options are expensive and not readily available to most families. Finally, for those youth who began puberty blockers with gonadotropin-releasing hormone (GnRH) agonists at an early age (Tanner stage 2), there is no current technique to preserve fertility.4

Medical Care

Prior to initiation of cross-gender hormones, the medical clinician should evaluate the patient for any medical conditions that could be exacerbated by hormonal therapy. Medical conditions such as known thromboembolic disease, macroprolactinoma, severe liver disease, coronary artery disease, cerebrovascular disease, severe migraines, breast or uterine cancer, and erythrocytosis may need evaluation and stabilization by subspecialists prior to the initiation of cross-gender hormones. A strong family history of these conditions may also prompt a referral to a specialist for evaluation and medical clearance.

The medical evaluation should include a detailed medical history and a careful physical exam that includes a height, weight, and blood pressure. Genital and breast exams can be sensitive issues for many transgender individuals and may need to be deferred by the clinician until trust between the patient and the provider is firmly established. Direct visualization of the Tanner stage is important, but the use of a careful history and pictures may be useful as a proxy at the initial evaluation. Common initial laboratory evaluations prior to the cross-gender therapy include a complete blood count, estradiol/testosterone levels, renal and liver functions, lipids, glucose, electrolytes, and hemoglobin A1c. A baseline prolactin level is often recommended for male-to-female transgender youth on estrogen-containing regimens.9,10 During the induction of the desired puberty for the first year on hormones, the anthropometry and the endocrine labs should be measured every 3 to 6 months. Electrolytes should be checked every 3 months for those on the testosterone blocker, spironolactone. Annual monitoring labs include a complete blood count, liver and renal functions, and estrogen and testosterone levels for those on hormones (Table 1). Depending on the hormonal regimen and other medical conditions, additional annual monitoring labs may include electrolytes, lipids, fasting glucose, insulin, hemoglobin A1c, prolactin, liver enzymes, and kidney functions. Ideally, annual monitoring labs should be done in the context of an annual comprehensive physical.

Monitoring Recommendations for Hormone Therapy in Adolescents

Table 1.

Monitoring Recommendations for Hormone Therapy in Adolescents

Routine primary medical care should not be neglected. The annual physicals should not simply focus on transition issues, but also take a more holistic approach. Immunizations records should be reviewed and youth provided with missing vaccines. Routine dental and ophthalmologic care is important. Recommendations regarding routine gynecologic care apply to all youth and young adults with a cervix and uterus.

Of course, depending on the individual, there are potentially other behaviorally related medical health concerns.11 As a part of the initial/annual physical exam, social history questions may reveal behaviors that put a patient’s health at immediate or future risk. A HEADSS assessment (Home, Education, Activities, Drugs, Sex, and Suicide) should be a part of all youths’ medical history.12 From there, testing for sexually transmitted diseases (including HIV, gonorrhea, chlamydia, and syphilis) may be indicated. Lab work to evaluate for hepatitis A, B, and C may be indicated. Tobacco and other substance use should be explored. Mental health assessments around the issues of depression and suicide can also be done by the primary care provider, not just the mental health experts.

Cross-Gender Hormones

Cross-gender hormones (estrogen for male-to-female youth and testosterone for female-to-male youth) (Table 2) are recommended at the age of 16 years.3,7 However, every patient is different and for some youth, starting hormones earlier may be important or deemed medically appropriate. Earlier hormone use, although not officially advocated by the Endocrine Society or WPATH, may be considered if the medial provider, mental health specialist, family, and the patient are all in agreement on the GD diagnosis and need to initiate physical transition.1,4 The use of hormones has been shown to improve quality of life on social, emotional, and mental health dimensions.13 Delay of appropriate hormone use may lead to depression and unnecessary mental health difficulties.1 Ideally, GnRH agonists are started at Tanner stage 2 in a pubertal child to suppress the natal puberty, but many youth may have their first presentation well beyond the onset of puberty. The optimal regimen would continue this treatment to suppress puberty and to allow for a reduced dose of medications.4,7,9 For many families who cannot afford GnRH agonists due to high cost, “full dose” cross-gender hormones are recommended.1 Additionally, the use of GnRH agonists has been associated with bone mineral density loss, so its long-term use should be closely monitored.14

Hormone Regimens Available in the United States

Table 2.

Hormone Regimens Available in the United States

To date, there have been few published reports of clinical trials comparing safety and efficacy between the various estrogen and testosterone regimens,4,15,16 and none of the current medications have been approved by the U.S. Food and Drug Administration (FDA) for a gender transition indication. Current treatment protocols aim for hormonal levels in the normal physiologic range; the maintenance of sustained supra-physiologic levels of either estrogen or testosterone place the patient at increased risk for serious adverse reactions such as thrombosis.4 Generally speaking, a clinical response to the chosen regimen is the most important guide to dose adjustment. The use of luteinizing hormone levels in the normal range may serve as a marker of adequate hormone level.17

Feminizing Regimens

For male-to-female transgender transitioning youth, estrogens with or without an androgen receptor blocker are the mainstays of therapy.8,15 Ideally, these treatments would start early enough to prevent certain pubertal milestones such as vocal pitch dropping, bone fusion, and facial hair. Once those milestones have been reached, estrogen therapy will not reverse those features.1,4,7 Changes may be noted in as little as 1 month (decreased erections, decreased libido), but most changes aren’t readily apparent until 3 to 6 months, with maximum effects by 3 to 5 years (Tanner stage 5 breasts, redistribution of body fat).7 Many effects are reversible, but some are permanent. Common side effects include a decrease in libido, decrease in spontaneous erections, testicular volume reduction, and the increased risk of thromboembolic events.

Current recommended regimens include oral estradiol, transdermal estrogens in creams and patches, and the injectable estrogens of estradiol valerate or cypionate. Ethinyl estradiol is no longer recommended, as it induces a clinically relevant prothrombotic state and predisposes the patient to thromboembolism-type side effects compared with other forms of estrogen.18,19 There is no evidence that a particular estrogen regimen improves breast shape and development. There is also no evidence that any medically approved type or method of administration is more effective than any other in producing the desired physical changes.4 Theoretically, sublingual use of oral estradiol should boost estrogen levels, as this route avoids the first pass through the liver; however, data are lacking on the clinical efficacy and relevance to this method.

There are data that using high doses of estrogen can lead to premature breast bud fusion and poor breast development.18 Self-medication with excessive hormones obtained from other clinics or off the internet may be associated with a dissatisfaction with breast development and request for mammoplasty.18 Based on breast hemi-circumference measurement, trans-women achieve near-genetic female norms, but the breast may appear smaller with poor cleavage formation due to the larger chest diameter of the genetic male.18 Therefore, most regimens recommend starting at lower doses and gradually increasing the dose over 6 to 12 months.7 Depending on the degree of pubertal development from which the patient is starting, certain pubertal milestones cannot be reversed, and this must be a part of the discussion around transition expectations that should occur between the patient and the multidisciplinary team. It should be pointed out that estrogen- and testosterone-blocking regimens will not raise the vocal pitch, regrow scalp hair due to male-pattern balding, or cause facial hair to regress. Facial bone structure will not remodel to a more feminine shape.

Antiandrogens may potentiate the effects of the estrogen by blocking the binding of androgen to their receptors. Thus, masculine secondary sexual characteristics are diminished. Common antiandrogens include spironolactone, and 5-alpha reductase inhibitors (finasteride and dutasteride). The most commonly used testosterone blocker in adolescents is spironolactone. These adjuncts to estrogens are used as a part of the feminizing regimens.4,7,9 They are used to decrease the doses of the estrogen regimen and, therefore, decrease the risk of side effects from the estrogen.4 GnRH agonists (eg, leuprolide acetate) have also been used to decrease the production of testosterone, which allows for a lower dose of estrogen to be prescribed. Due to the high cost, GnRH agonists are not commonly used. An additional medication, cyproterone acetate, is commonly used elsewhere in the world but is not approved for use in the United States.4

Progesterone

The use of progesterones in transgender women is controversial. Some clinicians report areolar growth and a more “natural” appearance, but there are no clinical trials to support this assertion. Other studies have found no effect of progesterone on breast growth.20 Certainly, there is evidence that exogenous progestins can induce a pro-inflammatory profile in healthy men.21 Common side effects noted in women include depression, weight gain, edema, lipid changes, and a possible increase in breast cancer risk.4,20 From the Women’s Health Initiative Study, the overall risks of adding progesterone to estrogen in otherwise healthy genetic women was greater than the benefits.22 Future research will need to assess the role, if any, that progesterones may play in the medical management of transgender women.

Contraindications for Feminizing Hormones

The most common absolute contraindications for estrogens include prior venous thrombotic events (eg, clots, strokes, heart attack, and deep vein thrombosis), estrogen-sensitive neoplasms, and end-stage liver disease.4 Smoking may increase the risk of venous thromboembolism in adults but may not play as great a role in adolescents.23 Youth with strong family histories of increased thrombotic events should be considered for an evaluation by a hematologist prior to starting estrogen, and medication dosages may need to be adjusted to minimize the risk of a thrombotic event.

Masculinizing Regimens

The mainstay of treatment for individuals transitioning from female-to-male transgender youth is testosterone. In the ideal scenario, puberty has been blocked with a GnRH agonist at Tanner stage 2. Testosterone is then started at age 16 to induce the desired masculine puberty. The use of testosterone will cause the vocal pitch to drop, facial hair to growth, a body fat distribution to a more masculine body habitus, and a cessation of regular menstruation. Testosterone will also alter the hematologic and lipid profiles to match genetic males. Side effects include acne, increased body odor, irritability and mood changes, and male-pattern balding. As noted in Table 3, certain effects are reversible if the testosterone is interrupted, but other effects are permanent. There are very little data on the return of fertility in transgender men who have been on testosterone.

Effects of Cross-Gender Hormones

Table 3.

Effects of Cross-Gender Hormones

The most commonly used testosterones are transdermal or injectable and containing testosterone cypionate and testosterone enanthate. All injectable testosterone preparations are delivered intramuscularly, but subcutaneous routes provide acceptable testosterone levels. Shots are generally administered every 1 to 2 weeks. Topical preparations are available, but they are rarely recommended in adolescents. Both preparation types are effective, but transdermal preparations may take longer for clinical changes to occur. Changes may be noted in 1 month (acne, mood changes), but full effects may not be seen for 3 to 5 years. Concerns about aromatization of testosterone back to estrogen have been noted with high doses of testosterone. For this reason, testosterone levels should be kept in the male biologic normal range.7 Oral versions of testosterone are not available in the United States. Long-acting testosterone (testosterone undecanoate) is also not available in the United States.

Conditions that may be exacerbated by testosterone include breast or uterine cancer, erythrocytosis, and severe liver dysfunction as noted by transaminases greater than three times the upper limit of normal. Many transgender men have polycystic ovary syndrome, and there is some concern that adding testosterone may worsen the health risks (diabetes, cardiac disease, hypertension, and female reproductive cancers).4

Contraindications for Masculinizing Hormones

Contraindications for testosterone include pregnancy, uncontrolled coronary artery disease, and uncontrolled polycythemia with a hematocrit greater than 55%.4 A history of breast cancer, which is less likely in adolescents, is a relative contraindication due to conversion of testosterone into estrogen by aromatization. Consultation with an oncologist would be recommended prior to testosterone therapy in this rare situation.4 For those female-to-male transgender persons who are sexually active with biologic males, highly effective birth control is important due to the significant masculinizing effects of testosterone on a developing fetus.

References

  1. Olson J. Management of the transgender adolescent. Arch Pediatr Adolesc Med. 2011;165(2):171–176.
  2. Byne W, Bradley SJ, Coleman E, et al. Report of the American Psychiatric Association Task Force on Treatment of Gender Identity Disorder. Arch Sex Behav. 2012;41(4):759–796. doi:10.1007/s10508-012-9975-x [CrossRef]
  3. Hembree WC. Guidelines for pubertal suspension and gender reassignment for transgender adolescents. Child Adolesc Psychiatr Clin N Am. 2011;20(4):725–732. doi:10.1016/j.chc.2011.08.004 [CrossRef]
  4. Coleman E, Brockting W, Butzer M. Standards of care for the health of transsexual, transgender, and gender-nonconforming people. Int J Transgenderism. 2011;13:165–232. doi:10.1080/15532739.2011.700873 [CrossRef]
  5. Cohen-Kettenis PT. Treatment of adolescents with gender dysphoria in the Netherlands. Child Adolesc Psychiatr Clin N Am. 2011;20(4):689–700. doi:10.1016/j.chc.2011.08.001 [CrossRef]
  6. Drummond KD. A follow-up study of girls with gender identity disorder. Dev Psychol. 2008;44(1):34–45. doi:10.1037/0012-1649.44.1.34 [CrossRef]
  7. Hembree WC. Endocrine treatment of transsexual persons: an Endocrine Society clinical practice guideline. J Clin Endocrinol Metab. 2009;94(9):3132–3154. doi:10.1210/jc.2009-0345 [CrossRef]
  8. Gooren L. Hormone treatment of the adult transsexual patient. Horm Res. 2005;64(suppl 2):31–36. doi:10.1159/000087751 [CrossRef]
  9. Moore E. Endocrine treatment of transsexual people: a review of treatment regimens, outcomes, and adverse effects. J Clin Endocrinol Metab. 2003;88(8):3467–3473. doi:10.1210/jc.2002-021967 [CrossRef]
  10. Mueller A. Hormone-related tumors in transsexuals receiving treatment with cross-sex hormones. Eur J Endocrinol. 2008;159(3):197–202. doi:10.1530/EJE-08-0289 [CrossRef]
  11. Garofalo R. Overlooked, misunderstood and at-risk: exploring the lives and HIV risk of ethnic minority male-to-female transgender youth. J Adolesc Health. 2006;38(3):230–236. doi:10.1016/j.jadohealth.2005.03.023 [CrossRef]
  12. Cohen E. HEADSS, a psychosocial risk assessment instrument: implications for designing effective intervention programs for runaway youth. J Adolesc Health. 1991;12(7):539–544. doi:10.1016/0197-0070(91)90084-Y [CrossRef]
  13. Gorin-Lazard A. Is hormonal therapy associated with better quality of life in transsexuals? A cross-sectional study. J Sex Med. 2012;9(2):531–541. doi:10.1111/j.1743-6109.2011.02564.x [CrossRef]
  14. Plosker GL, Brogden RN. Leuprorelin. A review of its pharmacology and therapeutic use in prostatic cancer, endometriosis and other sex hormone-related disorders. Drugs. 1994;48(6):930–967. doi:10.2165/00003495-199448060-00008 [CrossRef]
  15. Wierckx K. Long-term evaluation of cross-sex hormone treatment in transsexual persons. J Sex Med. 2012;9(10):2641–2651. doi:10.1111/j.1743-6109.2012.02876.x [CrossRef]
  16. Biro FM, Huang B, Crawford PB, et al. Pubertal correlates in black and white girls. J Pediatr. 2006;148(2):234–240. doi:10.1016/j.jpeds.2005.10.020 [CrossRef]
  17. Gooren LJ. Long-term treatment of transsexuals with cross-sex hormones: extensive personal experience. J Clin Endocrinol Metab. 2008;93(1):19–25. doi:10.1210/jc.2007-1809 [CrossRef]
  18. Seal LJ. Predictive markers for mammoplasty and a comparison of side effect profiles in transwomen taking various hormonal regimens. J Clin Endocrinol Metab. 2012;97(12):4422–4428. doi:10.1210/jc.2012-2030 [CrossRef]
  19. Toorians AWFT. Venous thrombosis and changes of hemostatic variables during cross-sex hormone treatment in transsexual people. J Clin Endocrinol Metab. 2003;88(12):5723–5729. doi:10.1210/jc.2003-030520 [CrossRef]
  20. Meyer M. Physical and hormonal evaluation of transsexual patients: a longitudinal study. Arch Sex Behav. 1986;15(2):121–138. doi:10.1007/BF01542220 [CrossRef]
  21. Zitzmann M. Endogenous progesterone and the exogenous progestin norethisterone enanthate are associated with a proinflammatory profile in healthy men. J Clin Endocrinol Metab. 2005;90(12):6603–6608. doi:10.1210/jc.2005-0847 [CrossRef]
  22. Writing Group for the Women’s Health Initiative I. Risks and benefits of estrogen plus progestin in healthy postmenopausal women: principal results From the Women’s Health Initiative randomized controlled trial. JAMA. 2002;288(3):321–333. doi:10.1001/jama.288.3.321 [CrossRef]
  23. Carr BR. Estrogen and progestin components of oral contraceptives: relationship to vascular disease. Contraception (Stoneham). 1997;55(5):267–272. doi:10.1016/S0010-7824(97)00029-2 [CrossRef]

Monitoring Recommendations for Hormone Therapy in Adolescents

Clinic/Laboratory Test Description
Feminizing regimens
Clinical follow up Every 2 to 3 months in the first year, then every 6 to 12 months: Height, weight, BP, Tanner staging
Initial and annual basic laboratory tests CBC, liver and kidney functions, testosterone and estradiol levels, lipids, prolactin and electrolytes, fasting glucose and hemoglobin A1c (if positive family history), bone age and density
Testosterone and estradiol levels Every 3 months initially, then annually Goal serum testosterone: <55 ng/dL Goal serum estradiol: <200 pg/mL (Goal is not to exceed peak female physiologic levels)
Electrolytes (for spironolactone patients) 3 to 6 months in the first year, then annually
Masculinizing regimens
Clinical follow up Every 2 to 3 months in the first year, then every 6 to 12 months: Height, weight, BP, Tanner staging
Initial and annual basic laboratory tests CBC, liver and kidney functions, testosterone and estradiol levels, fasting glucose and hemoglobin A1c (if positive family history), bone age and density
Testosterone levels Every 3 months initially, then annually (midway between injections) Goal serum estradiol: <50 pg/dL Goal serum testosterone: 350 to 700 ng/dL (Goal is normal male physiologic levels)

Hormone Regimens Available in the United States

Regimen Dosage
Male-to-female individuals
Estrogens
  Estradiol (oral) 2 to 6 mg daily
  Estradiol (transdermal) 0.1 to 0.4 mg twice weekly
  Estradiol valerate or cypionate (parenteral) 5 to 20 mg every 2 weeks OR 2 to 10 mg intramuscular every week
Antiandrogens
  Spironolactone 100 to 200 mg daily
  GnRH agonist 3.75 mg subcutaneous monthly
  Finasteride 1 to 5 mg daily
  Dutasteride 0.5 mg daily
Female-to-male individuals
Testosterones
  Testosterone cypionate or enanthate (parenteral) 100 to 200 mg every 2 weeks OR 50 to 100 mg every week
  Gel 1% (transdermal) 2.5 to 10 mg daily
  Patch (transdermal) 2.5 to 7.5 mg daily

Effects of Cross-Gender Hormones

Effect Onset (Months) Maximum (Years) Reversible?
Masculinizing effects of testosterone
  Skin—acne 1 to 6 1 to 2 Yes
  Facial—body hair 6 to 12 4 to 5 No
  Scalp hair loss 6 to 12 No
  Increased muscle mass 6 to 12 2 to 5 Yes
  Fat redistribution 1 to 6 2 to 5 Yes
  Cessation of menses 2 to 6 Yes
  Clitoral enlargement 3 to 6 1 to 2 No
  Vaginal atrophy 3 to 6 1 to 2 Yes
  Deepening of voice 6 to 12 1 to 2 No
Feminizing effects of estrogen
  Redistribution of body fat 3 to 6 2 to 3 Yes
  Decreased muscle mass 3 to 6 1 to 2 Yes
  Softening of skin 3 to 6 Unknown Yes
  Decreased libido 1 to 3 3 to 6 Yes
  Decreased spontaneous erections 1 to 3 3 to 6 Yes
  Breast growth 3 to 6 2 to 3 No
  Decreased testicular volume 3 to 6 2 to 3 No
  Decreased sperm production Unknown >3 Yes
  Decreased terminal hair growth 6 to 12 >3 Yes
Authors

John Steever, MD, is Assistant Professor of Pediatrics, Mount Sinai Adolescent Health Center, Mount Sinai Medical Center.

Address correspondence to: John Steever, MD, Mount Sinai Adolescent Health Center, 312-320 E. 94th Street, New York, NY 10128; email: John.steever@mountsinai.org.

Disclosure: The author has no relevant financial relationships to disclose.

10.3928/00904481-20140522-09

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