Why Is Men’s Only Treatment Helpful Long Term

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The goal of masculinizing hormone therapy is the development of male secondary sex characteristics, and suppression/minimization of female secondary sex characteristics. General effects include the development of facial hair, virilizing changes in voice, a redistribution of facial and body subcutaneous fat, increased muscle mass, increased body hair, change in sweat and odor patterns, frontal and temporal hairline recession, and possibly male pattern baldness. Sexual and gonadal effects include an increase in libido, clitoral growth, vaginal dryness, and cessation of menses. An ovulatory state is common, though not absolute and long-term fertility may be affected, though some transgender men are able to discontinue testosterone and achieve successful pregnancy.[1] Masculinizing hormone therapy may bring about changes in emotional and social functioning, though these can vary from person to person and stereotypes should be avoided. The general approach involves the use of one of several forms of parenteral testosterone.

All testosterone preparations currently used in the U.S. are "bioidentical", meaning they are chemically equivalent to the testosterone secreted from the human testicle. Prior use of oral methyltestosterone and other synthetics commonly encountered in bodybuilding communities has resulted in unsubstantiated concerns about negative hepatic effects of testosterone use in transgender men. Testosterone is available in a number of injected and topical preparations, which have been designed for use in non-transgender men with low androgen levels (see table). Since the label dosing (not included in table) for these medications are based on the treatment of men with low, but not no, testosterone, higher dosing may be needed in transgender men (see table) than are commonly used in non-transgender men.

Route of injection (intramuscular vs. subcutaneous): While testosterone for injection is labeled for the intramuscular route, many providers have administered testosterone using the subcutaneous route with good efficacy and patient satisfaction, and without complications. Benefits of subcutaneous administration include a smaller and less painful needle, and may avoid scarring or fibrosis from long term (possibly > 50 years) intramuscular therapy (Grading: T O M).[4,5]

While some providers choose to omit hormone level monitoring, and only monitor for clinical progress or changes, this approach runs the risk of a suboptimal degree of virilization if testosterone levels have not reached the target range. A prospective study of 31 transgender men newly started on either subcutaneous 50-60mg/week testosterone cypionate, 5g/day 1% testosterone gel, or 4mg/day testosterone patch found that after 6 months only 21 (68%) achieved male range testosterone levels and 5 (16%) had persistent menses, with only 9 (29%) achieving physiologic male-range estradiol levels.[5] Some genderqueer and gender-nonconforming/nonbinary patients may prefer to maintain testosterone levels in an intermediate range. Regardless of initial dosing scheme chosen, titrate upwards based on testosterone levels measured at 3 and 6 months. Once hormone levels have reached the target range for a specific patient, it is reasonable to monitor levels yearly. As with testosterone replacement in non-transgender men, annual visits and lab monitoring are sufficient for transgender men on a stable hormone regimen. Endocrine Society guidelines recommend monitoring of hormone levels every 3 months.[6] In practice this is not realistic and not likely to add value once a stable dosing has been achieved.[7] Other reasons for measuring hormone levels in the maintenance phase include significant metabolic shifts such as the onset of diabetes or a thyroid disorder, substantial weight changes, subjective or objective evidence of regression of virilization, or new symptoms potentially precipitated or exacerbated by hormone imbalances such as hot flashes, pelvic cramping or bleeding, or migraines. Such patients may also require more frequent office visits to manage coexisting conditions. Increased frequency of office visits may also be useful for patients with complex psychosocial situations to allow for the provision of ancillary or wraparound services.

Informed consent is a process which occurs between a patient and a provider. The process should include an individualized discussion of the risks, benefits, unknowns, alternatives, and risk of no treatment. We are no longer recommending the use of consent forms for hormone therapy. Many other common interventions such as contraception or HIV pre-exposure prophylaxis do not involve the use of consent forms, and rely on a discussion and shared decision making between patient and provider. If the informed consent process is properly documented in the chart, consent forms do not likely provide any additional legal protections to the provider. Elimination of consent forms helps to demystify and destigmatize hormone therapy. Providers can use the information provided in these guidelines to frame their individualized discussions with patients.

Objective: To determine age-specific, all-cause mortality, disease-specific mortality, and life expectancy for men aged 65 to 75 years who are treated only with immediate or delayed hormonal therapy for newly diagnosed, clinically localized prostate cancer.

BPH produces symptoms by obstructing the flow of urine through the urethra. Symptoms related to BPH are present in about one in four men by age 55, and in half of 75-year-old men. However, treatment is only necessary if symptoms become bothersome. By age 80, some 20% to 30% of men experience BPH symptoms severe enough to require treatment. Surgery was the only option until the recent approval of minimally invasive procedures that open the prostatic urethra, and drugs that can relieve symptoms either by shrinking the prostate or by relaxing the prostate muscle tissue that constricts the urethra.

The American Urological Association (AUA) Symptom Index provides an objective assessment of BPH symptoms that helps determine treatment. However, this index cannot be used for diagnosis, since other diseases can cause symptoms similar to those of BPH.

A urinalysis, which is performed for all patients with symptoms of BPH, may be the only laboratory test if symptoms are mild and no other abnormalities are suspected from the medical history and physical examination. A urine culture is added if a urinary infection is suspected. With more severe, chronic BPH symptoms, blood creatinine of blood urea nitrogen (BUN) and hemoglobin are measured to rule out kidney damage and anemia. Measuring prostate specific antigen (PSA) levels in the blood to screen for prostate cancer is recommended, as well as performing the DRE. PSA testing alone cannot determine if symptoms are due to BPH or prostate cancer, because both conditions can elevate PSA levels.

Treatment decisions are more difficult for men with moderate symptoms. They must weigh the potential complications of treatment against the extent of their symptoms. Each individual must determine whether the symptoms interfere with his life enough to merit treatment. When selecting a treatment, both patient and doctor must balance the effectiveness of different forms of therapy against their side effects and costs.

Finasteride use comes with some side effects. Impotence occurs in 3% to 4% of men taking the drug, and patients experience a 15% reduction in their sexual function scores regardless of their age and prostate size. Finasteride may also decrease the volume of ejaculate. Another adverse effect is gynecomastia (breast enlargement). A study from England found gynecomastia in 0.4% of patients taking the drug. About 80% of those who stop taking it have a partial or full remission of their breast enlargement. Because it is not clear that the drug causes gynecomastia or that it increases the risk of breast cancer, men taking finasteride are being carefully monitored until these issues are resolved. Men exposed to finasteride or dutasteride are also at risk of developing post-finasteride syndrome, which is characterized by a constellation of symptoms, including some that are sexual (reduced libido, ejaculatory dysfunction, erectile dysfunction), physical (gynecomastia, muscle weakness) and psychological (depression, anxiety, suicidal thoughts). These symptoms can persist long term despite discontinuation of finasteride.

Surgical treatment of the prostate involves displacement or removal of the obstructing adenoma of the prostate. Surgical therapies have historically been reserved for men who failed medical therapy and those who developed urinary retention secondary to BPH, recurrent urinary tract infections, bladder stones or bleeding from the prostate. However, a large number of men are poorly compliant with medical therapy due to side effects. Surgical therapy can be considered for these men to prevent long-term deterioration of bladder function. 2b1af7f3a8