Issues around Hormone Therapy due to the coronavirus situation

The coronavirus situation in the UK is evolving and changing each day and is impacting everyday life and NHS services. We recognise that issues related to hormone therapy may arise and have put together the following to help address common issues.

Testosterone injections

Sustanon/Enanthate: If a GP practice cannot accommodate testosterone injections for a patient then it is possible and advisable to switch the patient to a testosterone gel (to be self-administered by patient). Our advice on this is as per the conversion leaflet: https://gic.nhs.uk/wp-content/uploads/2019/09/HRT-starting-doses-and-conversions.pdf

Nebido: Patients already established on Nebido injections can be reassured that Nebido is a long-acting testosterone formulation. Therefore, it is unlikely that testosterone levels will drop out of target range if an injection is delayed by a week or two. However, we do not recommend that the injections are given early. If there are problems accommodating these injections then it is possible to switch the patient to a testosterone gel (see link to conversion leaflet as above).

Decapeptyl/GnRH injections and anti-androgens

Patients due to receive gonadotropin releasing hormone analogue injections (GnRHa; triptorelin; leuprorelin; goserelin) who display symptoms suggestive of Covid-19, or who are self-isolating, should inform their GP in advance of their appointment, NOT attend for their injection, and remain in self-isolation for the period currently recommended by government and the NHS. Their injection should be given as soon as possible after they complete the recommended period of self-isolation. A GnRHa injection may be safely delayed for a several weeks, with a very low risk of a resumption of testosterone or estradiol release.

GnRHa medication usually continues to suppress hormone release for many weeks after the next injection is due. This continuance of effect is longer in patients who have received a GnRHa for a long time; for someone who has received it for a year of more, it might take two years for its effects to cease. Some patients worry about not having their injection at the usual time and may report symptoms suggesting a resumption of hormone release; however, because GnRHa medication is highly effective and reliable in suppressing this, the most likely cause for such symptoms is anxiety. However, reducing the risk of Covid-19 transmission must be prioritised.

If symptoms of hyperandrogenism return then a GP may wish to prescribe Finasteride 5mg per day as an interim anti-androgen until the patient can resume Decapeptyl/GnRH injections (assuming liver function acceptable and no other contraindication to Finasteride).

If Finasteride is not adequate, as a third line option Cyproterone Acetate 50mg a day could be considered if the patient reports objective evidence of testosterone levels rising, such as return of spontaneous erections, body and facial hair regrowth, and if benefits outweigh the risks. There is an association with low mood so this should be considered carefully in patients with a history of depression. Long term cyproterone acetate has also been associated with development of meningiomas so this should be borne in mind. As soon as it is feasibly possible the patient should be switched back to decapeptyl injections.

Monitoring hormone therapy

Blood tests: We realise there may be issues arranging non-urgent blood tests, but if there are safety issues relating to hormone therapy then we would expect blood tests to be considered urgent. For routine monitoring blood tests, we expect there may be delays but suggest that they should be arranged as soon as is reasonably possible.

Managing complications of testosterone therapy

Polycythaemia: actions for haematocrit levels

  • Haematocrit less than 0.52 is acceptable.
  • Haematocrit 0.52 – 0.55: Advise patient to drink 2L water, ensure they are not smoking. Repeat bloods just before next Sustanon or Nebido injection, or 8 weeks later if using gel. If still raised on repeat, GP to seek advice from GIC.
  • Haematocrit 0.55 – 0.60: GP to inform GIC urgently. Check FBC history to see if a pattern. Advise patient to drink 2L water, ensure they are not smoking. If it is an isolated episode, repeat bloods just before next Sustanon or Nebido injection, or 8 weeks later if using gel. If pattern of polycythaemia on injections, then we advise switching to testosterone gel (as above) and also assess for other potential causes such as Obstructive Sleep Apnoea..
  • Haematocrit 0.6 or above: GP to pause testosterone therapy and refer urgently to haematology for venesection, also inform GIC urgently. After haematology clearance then return to testosterone as topical therapy, with haematology plan for venesection.

Dyslipidaemia

Normal cardiovascular risk assessment and management applies. Seek advice if significant changes in lipids. Calculate the Q-risk score of the patient using the male gender to make intervention decisions.

Abnormal Liver Function Tests

If values less than 3x the upper limit of normal: check medicines and alcohol history, retest in 4-6 weeks. If LFTs are abnormal on repeat, then perform further investigations to determine the cause: Hepatitis B and C serology, HIV serology, Ferritin, Caeruloplasmin, liver auto-immune screen, ultrasound of the liver.

Values of greater than 3x the upper limit of normal: GP to suspend hormone therapy and refer to local hepatology.

Managing complications of oestrogen therapy

Thromboembolism

Stop oestrogen therapy until patient is anti-coagulated. When haematology advises that it is safe to do so, oestrogen therapy with topical formulations (gel or patch) can be resumed. Anti-coagulation should be lifelong to continue oestrogen therapy. Inform the GIC team.

Hyperprolactinaemia

Small rises in prolactin are often seen with oestrogen therapy.

  • If prolactin is higher than normal but less than 1000 then repeat the prolactin. If repeat prolactin level remains elevated then discuss with GIC endocrine team. Review medications for those that can cause hyperprolactinaemia.
  • If prolactin is higher than 1000 then refer to local endocrine service for assessment and MRI of pituitary.

Abnormal Liver Function Tests

If values less than 3x the upper limit of normal: check medicines and alcohol history, retest in 4-6 weeks. If LFTs are abnormal on repeat, then perform further investigations to determine the cause: Hepatitis B and C serology, HIV serology, Ferritin, Caeruloplasmin, liver auto-immune screen, ultrasound of the liver.

Values of greater than 3x the upper limit of normal: GP to suspend hormone therapy and refer to local hepatology.

General medicines safety

We urge all patients to follow instructions and take medicine as prescribed. If applying topical gels or patches, they should follow the manufacturer’s instructions.

General health advice

We urge patients not to smoke. If the patient is smoking then we may need to stop or reduce hormone therapy until they have ceased smoking completely for 3 months. This is due to clotting and cardiovascular risks being increased with smoking in combination with hormone treatment. . Vaping and e-cigarettes are acceptable in the context of hormone treatment.

We encourage patients to follow a healthy diet, stay well-hydrated and to stay physically active.

Medication shortages and alternative formulations

Please see the following link for our advice: https://gic.nhs.uk/gp-support/updates-on-physical-interventions/

Contact with the GIC endocrine team

Our GP hormone advice line is not currently being monitored as our staff are working remotely due to the current coronavirus situation.

Rest assured, we can reply to queries sent in by secure email. Please email your query to gic.endocrine@nhs.net. There are likely to be delays in response times. Please note we are not an emergency service.

If the supply of hormone products fails is it dangerous?

Please note that physical harm is unlikely to occur if hormone therapy is temporarily reduced or stopped. There may be a slight return of characteristics of birth assigned sex but these should revert when hormone therapy resumes.

For patients who have had genital reconstructive surgery, physical health complications are unlikely unless they are off hormone therapy for more than two years.

If requiring further support, we suggest that patients are directed to local third sector organisations and online community support groups during this time.https://gic.nhs.uk/info-support/support-groups-and-resources/