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Estradiol Concentrations for Adequate Gender-Affirming Feminizing Therapy: A Systematic Review
Journal article   Open access   Peer reviewed

Estradiol Concentrations for Adequate Gender-Affirming Feminizing Therapy: A Systematic Review

Gabrielle N Winston-McPherson, Tiffany A Thomas, Matthew D Krasowski, Sofia B Ahmed, Lauren R Cirrincione, Brooke M Katzman, Christina C Pierre, Chantal L Rytz, Keila Turino Miranda, Zil Goldstein, …
LGBT health, Vol.12(7), pp.477-489
10/2025
DOI: 10.1089/lgbt.2024.0407
PMID: 40552461
url
https://doi.org/10.1089/lgbt.2024.0407View
Published (Version of record) Open Access

Abstract

Guidelines recommend serum estradiol concentrations of 100-200 pg/mL for transgender women prescribed oral, subcutaneous, or transdermal estradiol with or without adjunct antiandrogen as gender-affirming feminizing hormone therapy (HT). The purpose of this systematic review was to evaluate if the guideline range of 100-200 pg/mL for estradiol concentration is associated with indicators of adequate gender-affirming feminizing HT, specifically feminizing sufficiency, insufficiency, testosterone suppression, or toxicity in transgender women. The Populations/Intervention/Comparator/Outcome model was applied to the study question, whereby the target population included transgender, gender-diverse, and nonbinary adults using gender-affirming feminizing HT by any route of administration, with or without adjunct antiandrogen use. The comparator was defined as estradiol concentrations within (100-200 pg/mL or 367-734 pM) versus outside (</>100-200 pg/mL) the guideline range; evaluated outcomes were listed by the same clinical guidelines that recommend using the 100-200 pg/mL range. Embase, MEDLINE, and Web of Science were queried over a 24-year time frame (January 1, 1999-April 20, 2023); the search was restricted to English. The extracted outcomes were categorized as indicators of therapeutic insufficiency, sufficiency, toxicity, or hormone concentration. There were 49 studies that met the inclusion criteria, of which 9, 42, 25, and 5 studies included indicators of therapeutic insufficiency, sufficiency, toxicity, or hormone concentration, respectively. The search did not identify articles demonstrating that the 100-200 pg/mL guideline range provides optimal feminizing outcomes or reduces adverse events. : Evidence does not support using the guideline range of 100-200 pg/mL to indicate sufficient feminization in transgender women using gender-affirming feminizing HT.
 transfeminine feminizing therapy therapeutic range reference interval transgender women estradiol

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