Chapter 7 202 2.3. Treatment protocol For the TM participants, gender-affirming hormone therapy consisted of testosterone and, for some, additional use of cycle-regulating medication (e.g. progestins or hormonal contraceptives). Testosterone was administered as either transdermal gel (50 mg once daily), intra-muscular injection of short-acting testosterone esters (250 mg once per 3 weeks) or as an intra-muscular injection of long-acting testosterone undecanoate (1000 mg once every 12 weeks). Participants could also use medication to regulate their menstrual cycle, either using progestogens (lynestrenol, norethisteron, levonorgestrel, medroxyprogesterone) or combined estrogen-progestin oral contraceptives (COCs). For the TF participants, gender-affirming hormone therapy consisted of estrogens and anti-androgens. Estradiol was either administered orally, using estradiol valerate (2 mg twice daily), or transdermally with an estradiol patch (100 µg patches every 3 days) or estradiol gel (1–1,5 mg once daily). Anti-androgens were used in the form of cyproterone acetate (10 mg daily) or injections of the GnRH analog triptorelin (3.75 mg once every 4 weeks or 11.25 mg every 12 weeks) or leuproreline (3.75 mg once every 4 weeks). Several TF participants started using only anti-androgens (n=1) or estrogens (n=2) at the start of GAHT: these participants were excluded from the current analyses. A flowchart of participant in- and exclusions is displayed in Figure 7.1. 2.4. Demographic and clinical characteristics Participants visited the clinic at the start and after 3 months of GAHT, and clinical characteristics (e.g. sex assigned at birth, age at baseline measurement, body mass index, medication use, form and dosage of hormone use, use of menstrual cycle regulation or contraceptives) were obtained from the medical files from these appointments. At the Amsterdam UMC and UMCG, serum testosterone measurements were conducted using liquid chromatography-tandem mass spectrometry (LC-MS/MS) with a lower limit of quantitation of 0.1 nmol/L, and an interassay coefficient of variation of 4% to 9%. Serum estradiol measurements were conducted using LC-MS/MS with a lower limit of quantitation of 20 pmol/L and an inter-assay coefficient of variation of <7%.
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