General FAQs

Here you will find some answers to the most common questions from primary care clinicians and healthcare professionals, including answers to questions about hormones and prescribing.

If your question is not answered here and you would like some clinical advice from one of our GPs, you can email us at indigo.advice@nhs.net

Here are a few suggestions:

  • Normalise introducing yourself with your name and pronouns
  • If you’re not sure how to address someone – ask what pronouns they use
  • Don’t assume a patient's gender or sexual orientation
  • Avoid gendered language eg. sir, ladies and gentlemen
  • Use the patient’s correct name and gender at all times, regardless of whether or not they are in the room
  • Correct others when they use the wrong name/gender – this gets easier with time
  • Recognise that gender and sexual orientation are on a spectrum and can be fluid
  • Don’t ask invasive questions - trans people spend a lot of time answering questions from other people and it gets exhausting
  • For further reading check out the GMC guidance on trans healthcare https://www.gmc-uk.org/ethical-guidance/ethical-hub/trans-healthcare

We are a new pilot NHS adult gender service in Gender Manchester, which has been commissioned to provide care that is local, timely and easier to access.

Indigo is a partnership between gtd healthcare and LGBT Foundation, delivering a service which has been designed by and for trans communities in Greater Manchester. Our service is an innovative model of trans healthcare which is based in primary care. This means our clinical services are delivered by experienced GPs in practices across Greater Manchester, with additional services being delivered in community settings.

You can find out more about Indigo at https://indigogenderservice.uk/about-us

For more information about our services, please visit https://indigogenderservice.uk/our-services/services-we-offer

Indigo Gender Service is a new pilot service. In order to access our services, patients will need to meet the following criteria before 1 December 2020: 

  • aged 17 or over;  
  • registered with a GP in Greater Manchester and eligible for NHS treatment; 
  • on a waiting list for a gender clinic and have not yet had their first appointment. 

For more information, please visit https://indigogenderservice.uk/our-services/accessing-service

You can change a patient’s name and gender marker without any ‘proof’.

The patient does not have to have undergone any medical intervention for you to
change their record.

Detailed instructions are available here:
https://pcse.england.nhs.uk/help/registrations/adoption-and-gender-re-assignment-
processes/#:~:text=When%20a%20patient%20changes%20gender%2C%20they%20are%20given%20a%20new,a%20newly%20created%20medical%20record

GMC guidance is available here:
https://www.gmc-uk.org/ethical-guidance/ethical-hub/trans-healthcare#confidentiality-
and-equality

Indigo Gneder Service will:

  • provide patients with assessment, diagnosis and discussion about hormone therapy
  • screen for contraindications to hormone therapy and discuss side effects
  • undertake pre-hormone blood tests and examination
  • discuss fertility including gamete storage and contraception
  • communicate recommended treatment and regimes to GPs using formally agreed shared care protocols supported by GMMMG
  • act as a knowledge base for questions and concerns from GP colleagues - please email indigo.advice@nhs.net and we will aim to get back to you within 2 working days
  • discuss and refer for surgical interventions in line with the service specification

GPs are expected to:

As the waiting lists for GICs can be as long as 3-4 years for the first appointment, patients may either be self-medicating with hormones bought from the internet, or ask you to provide a bridging prescription.

If a patient is already taking hormones, for harm reduction purposes we recommend doing monitoring bloods and talking to them about the risks.

Consider providing a bridging prescription as an alternative to the patient purchasing hormones from the internet.

Check out the GMC guidance on bridging prescriptions https://www.gmc-uk.org/ethical-guidance/ethical-hub/trans-healthcare#mental-health-and-bridging-prescriptions

Full details of this can be found here: http://gmmmg.nhs.uk/html/gmmmg_app_scgs.php

Our GPs will write an individualised care plan to support you with prescribing.

If you have specific concerns, please email us at indigo.advice@nhs.net and one of our doctors with expertise in this area will be happy to discuss these with you.

Nottingham Centre for Transgender Health is keeping a holding list for Indigo, in the event that we see the 700 patients already on our historic list within the two years of the pilot. Details of how to refer to this list are here: https://indigogenderservice.uk/our-services/information-gps

 

 

 


Hormone specific FAQs for Primary Care Clinicians

Hormone therapy is often used in patients with gender incongruence to alleviate gender dysphoria and produce either masculinising or feminizing effects.

Indigo Gender Service is commissioned by NHSE to assess, diagnose and recommend treatment plans including hormone therapy.

Shared care protocols via GMMMG have been produced to support primary care clinicians across Greater Manchester with initiation, monitoring and titration of hormone therapy following an individualised and personalised care plan. These can be found here: http://gmmmg.nhs.uk/html/gmmmg_app_scgs.php

These FAQs and the embedded links to further information will hopefully answer many of the questions around the commonly used hormones in trans and non-binary healthcare. For further clinical advice please contact indigo.advice@nhs.net


Testosterone

Testosterone is the most commonly used hormone to achieve masculinising effects. It is given as either a topical gel or intramuscular injection.

Gels can take longer than injections to achieve masculinizing effects but they are easily stopped if there are any significant side effects or if it is not tolerated by the patient. Lower doses can be given and dose adjustments can also be made easily. In some patients it may be better to start with a gel before considering transfer over to injectable testosterone. Gels may be preferable for some patients who have needle phobias or do not want injections. Gels can be difficult to apply especially if multiple pumps are needed.

The most commonly testosterone preparations are:
Gels

  • Testogel® pump (1 pump = 20.25mg) 2 – 5 pumps daily usually applied in the morning.
  • Bloods taken 4 – 6 hours after application aiming for upper ½ of local male reference range.
  • Tostran® pump (1 pump = 10mg) 5 – 10 pumps daily usually applied in the morning.
  • Bloods taken 4 -6 hours after application aiming for upper ½ of local male reference range.

Injections

  • Sustanon® 250mg/1ml given IM every 2 – 4 weeks aiming for a trough level in the lower 1/3 of the local male reference range.
  • Nebido® 1g/4ml given by deep IM injection every 10 – 14 weeks (after loading dose) aiming for a trough level in lower 1/3 of the local male reference range.
  • Trough levels should be taken just before the next injection is given and doses adjusted according to results.

Many people self-inject Sustanon® usually into the anterolateral thigh. Preference should be discussed with each patient and they should be shown how to safely self-inject by a primary care clinician and given appropriate equipment including needles, syringes and sharps boxes. Indigo has a nurse who can show patients how to self inject, but we ask that they come with their own equipment.

Nebido® is not suitable for self-injection due to the volume and requirement of a deep IM injection, this should be administered by a primary care clinician, usually a practice nurse.

For the majority of people on testosterone cessation of menses will occur. However, testosterone can cause virilisation of a foetus so contraception should be discussed if there is penis in vagina intercourse. Suitable options include the progesterone only pill, implant or coil. Oestrogen based contraception is often not wanted by trans men.

If testosterone alone does not stop periods and this is causing distress or dysphoria then other additional options include the progesterone only pill, cyclical medroxyprogesterone or GnRH analogues if there is no underlying gynaecological pathology.

It is important to monitor for polycythaemia. This is more common with injectable forms of testosterone especially Nebido®. Haemoglobin of >18.5 g/dl and / or haematocrit > 0.52 L/L require either dose or route modification. Some patients require venesection to lower their haemoglobin or haematocrit to prevent thrombosis.
Cardiovascular risk factors should also be monitored annually including BMI, blood pressure, lipid profile and QRisk where appropriate. Primary prevention advice and treatment should be given as per standard NICE guidance https://www.nice.org.uk/guidance/cg181

Testosterone will reduce fertility and gamete storage should be discussed prior to treatment. Referral for gamete storage is done via the patient’s own primary care clinician with no need for an IFR if the patient is under 42. Further information can be found at - https://gmeurnhs.co.uk/Docs/CCG%20Manchester/Manchester%20Assisted%20Conception%20Policy.pdf

Fertility can return on stopping testosterone but this is variable and more research is needed. Trans men have become pregnant after stopping testosterone therapy.

Further information on gamete storage for trans and non-binary people can be found at - https://www.hfea.gov.uk/treatments/fertility-preservation/information-for-trans-and-non-binary-people-seeking-fertility-treatment/

No, it is usually recommended that a patient is on testosterone for 6 - 12 months prior to chest reconstruction or ‘top’ surgery as it is commonly known. Testosterone does not have to be stopped prior to any other types of surgery.

Facial and body hair growth, scalp hair loss, voice deepening and clitoral enlargement are irreversible effects of testosterone therapy.

Some effects of testosterone such as increased muscle mass, body fat redistribution, acne and vaginal atrophy are reversible on stopping treatment.

Yes, if a patient decides they want to continue lifelong then they should be able to. Monitoring is important and dose or interval adjustments may be needed on an individualised basis. Cardiovascular health should be monitored and treated accordingly.

There are some potential drug interactions with testosterone including:

  • Warfarin – anticoagulant effect may be increased
  • Insulin and antidiabetic drugs – testosterone may improve glucose tolerance and reduce the need for diabetes medications.
  • Corticosteroids or ACTH – testosterone may enhance oedema formation and caution is needed in cardiac and hepatic disease.

This list is not exhaustive and the BNF should be checked for comprehensive information.

Potential contraindications include:

  • Known hypersensitivity to testosterone or any of its excipients
  • History of breast or endometrial cancer
  • Liver tumours
  • Unstable coronary heart disease

Testosterone should also not be given in pregnancy or breastfeeding.

Once stable on a dose and formulation, the patient should have bloods twice a year. Every 6 months for testosterone and annually for FBC, LFTs, lipid profile. Monitoring may need to be more frequent if a patient has underlying comorbidities. Indigo will be able to give advice and support regarding monitoring.

Further information on doses and monitoring can be found on the Indigo prescribing policy.


Oestrogen

Oestrogen is the mostly commonly used hormone to achieve feminising effects. It is given as a gel, tablet or patches. It is not given in combination with progesterone as this does not have any additional feminizing effects and may increase side effects.

Oestradiol not ethinyloestradiol is used to lower the risk of VTE.

Patients may have a preference for a particular formulation or there may be a medical reason to use a certain mode of administration. Patches are often used if there is a higher risk of VTE as the risk of clot formation is lower than with tablets. Side effects such as nausea may make tablets difficult for some patients.

The most commonly used preparations are –

  • Progynova® or Elleste Solo® tablets 2 – 8mg daily (dose can be divided) aiming for levels of 400-600 pmol/l. Blood samples to be taken before morning dose.
  • Sandrena® or Oestragel® starting at 0.5 – 6mg daily aiming for levels of 400 – 600pmol/l. Blood samples taken 4 – 6 hours after gel application.
  • Everol® or Progynova® patches 50 – 400mcg / 24 hours aiming for levels of 400 -600 pmol/l. Blood samples taken before dose titrations or the next patch is due.

Thromboembolic and cardiovascular disease are potential risks especially if there are additional risk factors. The VTE risk is four times higher than women not taking oestrogen and most occur within the first 2 years of treatment.

Cardiovascular risk factors should also be monitored annually including BMI, blood pressure, lipid profile and QRisk where appropriate. Primary prevention advice and treatment should be given as per standard NICE guidance https://www.nice.org.uk/guidance/cg181

Changes in lipid profiles and liver function tests can also occur and monitoring is important. There is a higher incidence of gallstones.

Oestrogen will reduce fertility and gamete storage should be discussed prior to treatment. Referral for gamete storage is done via the patient’s own primary care clinician with no need for an IFR if the patient is under 42. Further information can be found at - https://gmeurnhs.co.uk/Docs/CCG%20Manchester/Manchester%20Assisted%20Conception%20Policy.pdf

Further information on gamete storage for trans and non-binary people can be found at - https://www.hfea.gov.uk/treatments/fertility-preservation/information-for-trans-and-non-binary-people-seeking-fertility-treatment/

Due to the increased risk of VTE oestrogen is often stopped prior to surgery and for a short time afterwards. This reduces the risk of VTE. Practice varies internationally and there is no universally agreed guidance regarding this. Risks and benefits must be discussed with the patient. More research is needed in this area to develop best practice guidelines.

Breast growth is irreversible. Reduced testicular volume, sperm production, erectile dysfunction and spontaneous erections have variable amounts of reversibility.

Some effects such as softening of the skin, body fat redistribution, reduced muscle mass and slowed growth of facial and body hair are reversible on stopping oestrogen.

Yes, if a patient decides they want to continue lifelong then they should be able to. Monitoring is important and dose or interval adjustments may be needed on an individualised basis.

Cardiovascular health should be monitored and treated accordingly.

There are some potential drug interactions with testosterone including:

  • Enzyme inducing medications - the metabolism of oestrogens may be increased by concomitant use of substances known to induce drug-metabolising enzymes, specifically cytochrome P450 enzymes, such as anticonvulsants (e.g. barbiturates, phenytoin, primidone, carbamazepine) and anti-infectives (e.g. rifampicin, rifabutin, nevirapine, efavirenz) and possibly also felbamate, griseofulvin, oxcarbazepine, topiramate and products containing the herbal remedy St. John's Wort (Hypericum perforatum).
  • HIV medications - when co-administered with sex hormones, many combinations of HIV protease inhibitors and non-nucleoside reverse transcriptase inhibitors , including combinations with HCV inhibitors, can increase or decrease plasma concentrations of oestrogen. The net effect of these changes may be clinically relevant in some cases. Therefore, the prescribing information of concomitant HIV/HCV medications should be consulted to identify potential interactions and any related recommendations.
  • Strong and moderate CYP3A4 inhibitors - such as azole antifungals (e.g. fluconazole, itraconazole, ketoconazole, voriconazole), verapamil, macrolides (e.g. clarithromycin, erythromycin), diltiazem and grapefruit juice can increase plasma concentrations of oestrogen.

This list is not exhaustive and the BNF should be checked for comprehensive information.

Potential contraindications include:

  • Active or recent arterial thromboembolic disease including angina or myocardial infarction
  • History of breast cancer
  • History of venous thromboembolism
  • Active or recent arterial thromboembolic disease
  • Oestrogen dependent cancer
  • Thrombophilic disorders
  • Acute or active liver disease

Once stable on a dose and formulation patients should have bloods annually for FBC, LFTs, lipid profile. Monitoring may need to be more frequent if a patient has underlying comorbidities. Indigo will be able to give advice and support regarding monitoring.

 


GnRH Analogues (Hormone Blockers)

In adults GnRH analogues are mainly given to trans women or non-binary people where oestrogen alone does not suppress testosterone levels in to the female reference range usually < 3. They can also be used in trans men if testosterone alone does not stop menstrual bleeding or cyclical cramping.

They are given by injection and initially usually given monthly for 2 months and if well tolerated 3 monthly long term or until genital reconstructive surgery where the testes are removed.

The most commonly used in trans health due to its side effect profile and cost effectiveness is Decapeptyl® but all of the GnRH analogues are effective.

  • Triptorelin (Decapeptyl® SR) - intramuscular injection
  • Goserelin (Zoladex®) - intramuscular injection
  • Leuprorelin (Prostap®) - subcutaneous or intramuscular injection

These are best administered by a trained healthcare professional such as a practice nurse.

They are normally very well tolerated and the effects are reversible on stopping treatment. A significant testosterone flare does not usually occur as the patient will already be taking oestrogen and have a partially suppressed testosterone level. Changes in mood and worsening of depression can happen. Rarely GnRH analogues may unmask a previously unknown pituitary adenoma presenting with headaches, vomiting and visual change.

Reversible infertility will occur with GnRH analogues alone but as these are given alongside hormone therapy which can lead to irreversible changes to fertility gamete storage should be discussed as above prior to starting treatment.

No, for genital reconstruction or ‘bottom’ surgery as it is commonly known it is important to keep testosterone suppressed. Oestrogen is often stopped to reduce the risk of VTE but GnRH analogues can be continued. Once the testes have been removed there is no need to continue GnRH analogues.

There are some potential drug interactions to be aware of:

  • Drugs which raise prolactin levels should not be prescribed concomitantly as they reduce the level of GnRH receptors in the pituitary
  • Co-administration with drugs affecting pituitary secretion of gonadotropins, caution should be exercised and it is recommended that the patient's hormonal status be supervised.

This list is not exhaustive and the BNF should be checked for comprehensive information.

Hypersensitivity to GnRH (gonadotropin releasing hormone), its analogues or to any of the excipients is the only contraindication.

Caution should be given in:

  • History of depression
  • Metabolic bone disease
  • Diabetes (particularly leuprorelin and goserelin)
  • Risk of osteoporosis (leuprorelin)
  • Hypertension (Goserelin)

No additional blood monitoring is needed over the investigations that are being undertaken for either oestrogen or testosterone. Blood pressure and BMI should be checked every 6 months.

Other medications used in trans and non-binary healthcare

Antiandrogens that are sometimes used are finasteride, spironolactone and cyproterone. These will not be routinely prescribed by Indigo.