Clinical practice guidelines for transsexual, transgender and gender diverse minors | Anales de Pediatría
Pubertal suppression therapy may be considered when a child, at the onset of puberty or during its progression, experiences gender dysphoria that is triggered or worsened by the development of secondary sex characteristics. In these situations, timely intervention is important, as delaying treatment can result in irreversible physical changes that the child may not want.
Current practice does not always strictly follow the eligibility criteria set out by the World Professional Association for Transgender Health (WPATH), and in some cases pubertal suppression is initiated in individuals younger than the typical age used to define a “mature minor,” often around 12 years.
The standard treatment involves the use of gonadotropin-releasing hormone (GnRH) analogues, which are usually given either monthly or every three months. These are not freely available in all countries and alternatives can be used..
Category | Details |
a) GnRH analogues (first-line treatment in Spain) | Recommended treatment with triptorelin acetate or leuprolide. • 1-month depot: 3.75 mg (if weight <20 kg: 70–100 µg/kg), IM every 28 days • 84-day (12-week) depot: 11.25 mg If patient does not respond (progression of secondary sex characteristics, persistence of menses, or detectable LH levels): • Shorten interval to 21–25 days • Increase dose up to 160 µg/kg/28 days • Or reduce interval between trimestral doses |
b) Alternative drugs | • 6-month triptorelin: 22.5 mg IM every 6 months • 6-month leuprolide: 30–45 mg IM every 6 months → Less evidence; seldom used • Histrelin (LHRH analogue implant): releases 50–65 µg daily → Approved in USA from age 2 → Not currently available in Spain |
c) Alternative drugs (late stages) | Antiandrogens (postpubertal trans women only): |
Spironolactone | • 25–50 mg/day initially • Increase to 100–300 mg/day (single or divided doses) • Some guidelines: max 200 mg/day • Take with food • If >100 mg/day → divide into 2–4 doses |
Cyproterone acetate | • Risk of meningioma (increases with dose and duration) • Use only if other options unsuitable • Short-term use recommended • Max: 25 mg/day • More effective than GnRH analogues for erections, acne, hirsutism |
Progestogens | • Norethisterone acetate: 5–15 mg/day • Dienogest: 2 mg/day • Micronized progesterone: 100–300 mg/day → Used to induce amenorrhoea during testosterone treatment → Medroxyprogesterone more potent but more side effects |
Finasteride | • 2.5–5 mg/day • 5-alpha reductase inhibitor (does not reduce testosterone levels) • Possible adverse effects: depression, sexual dysfunction • Also used for hair loss at 1 mg/day |
Reference
Guía clínica de atención a menores transexuales, transgéneros y de género diverso
Amadora Moral-Martosa,, Julio Guerrero-Fernándezb, Marcelino Gómez-Balaguerc, Itxaso Rica Echevarríad, Ariadna Campos-Martorelle, María Jesús Chueca-Guindulainf, Emilio García Garcíag, Raúl Hoyos-Gurreah, Diego López de Larai, Juan Pedro López-Sigueroj, José María Martos Tellok, Cristina Mora Palmab, Isolina Riaño Galánl, Diego Yeste Fernándezm