Informational Resource for Transgender and Gender Diverse Adolescents and Their Families – Puberty Blockers

Information About Puberty Blockers

NOTE: This information is compiled from several sources readily available on the internet. To review the original sources, please see the footnotes. Nothing in this informational resource should be construed as medical advice.

This information guide is intended for adolescents and their families who have questions about gender affirming care. This guidance resource is intended to be used for informational purposes only, and is not a substitute for medical advice from a competent health care provider. While the intention of this guidance manual is to be helpful to you, please consult a knowledgable healthcare provider for medical advice, treatment, and additional informational based on your specific health care needs and medical history.

All About Puberty Blockers

Puberty is the process of development that makes bodies capable of contributing to reproduction (making babies). It starts at different ages for different people, and usually lasts several years. For people with ovaries puberty starts, on average, at around 10 years old. For people with testicles puberty starts, on average, at about 12 years old. This varies from person to person, but as there are can be trends in families, someone can often get an idea of when they will start puberty from their biological parents or older siblings.

A lot of different things happen during puberty, and one of them is that humans begin to produce luteinizing hormone (LH) and follicle-stimulating hormone (FSH). These hormones are what tell testicles to begin producing testosterone or ovaries to start producing estrogen. With testosterone and estrogen present, bodies will start to undergo changes — unless puberty is blocked.

If someone has testicles, these changes will probably include (among other things):

  • Overall growth

  • Testicle growth

  • Penis growth

  • Deepening voice

  • An increase in body and facial hair

If someone has ovaries, these changes will probably include (among other things):

  • Breast growth

  • Bone changes that lead to fuller hips

  • The start of a menstrual period (eventually)

Now, if someone is transgender or gender diverse (or thinks they might be) the idea of going through the puberty associated with their testicles or ovaries might sound pretty horrifying. If that’s the case, the process of puberty can be delayed using a medicine called a puberty blocker. If someone takes puberty blockers, the brain does not send the signal to start puberty to their ovaries or testicles, so they don’t develop in the ways described above. This gives people more time to think about what kind of puberty might be right for them. If someone who has been using a puberty blocker decides they want the puberty associated with the ovaries or testicles they have, great! Generally they can simply stop using the blocker and have the puberty they would otherwise have. If someone who is taking a blocker decides they want a different kind of puberty than they would otherwise have, great! When they’re ready, they can begin taking hormones that they don’t automatically produce very much of, and that will help them have a different kind of puberty. For some people, this can be a much more comfortable experience. For some people, this also means a body that is more congruent with their gender, and potentially fewer surgeries in adulthood. (For instance, people with ovaries who block puberty and then begin testosterone do not develop breasts.)

(Seattle Children’s Gender Clinic Puberty Blockers)

When Are Blockers Most Effective?

Current medical information indicates that blockers are most effective when someone is in Tanner Stage 2. This is a developmental stage that indicates someone's body has entered puberty but is still early in the process. For people with ovaries, this will probably happen between ages 8 and 13. This stage is marked by the development of breast buds, which feel like small lumps similar to a blueberry or chickpea behind the nipples. For people with testicles, this stage will probably happen between the ages of 9 and 14 and is marked by darkening of the scrotum, and an increase in testicular length and volume. When the testicles are greater than 2.5 centimeters on the long axis, the person is in Tanner Stage 2.

It's important to note that things like body hair and acne are not indicators of the hormones that blockers block and should not be used to determine when a blocker is appropriate.

Current medical information indicates that it’s ineffective to start a blocker before puberty has started; there’s nothing to block. On the other hand, starting blockers more than 2 years after the start of the menstrual period of someone with ovaries will also not be helpful because puberty is completed. Although blockers are very good at suppressing periods, other medications are often used first. Blockers virtually always have an effect on people with testicles, and some form of testosterone suppression will also be continued as a part of gender affirming hormone therapy (GAHT) for most people with testicles who ultimately opt for GAHT. It will take a couple of weeks to a couple of months for the blocker to start working effectively. In the first 2-3 weeks there will probably be a spike in hormone levels, so people using blockers may notice some progression in puberty at first, before the blocker levels balance out.

Although blockers can be effective for a long time, they generally shouldn’t be used for more than 2 years without the addition of estrogen or testosterone. This is because long-term use of blockers without the addition of hormones contributes to lower bone density which could lead to additional health problems. Bones need hormones!

(Seattle Children’s Gender Clinic Puberty Blockers)

Risks of Blockers

Speaking of bone density, weaker bones are one of the risks of blockers. If someone is using a blocker, it is super important to get bone-building exercise. Bone-building exercises include walking, jumping, and lifting weights, and people using blockers should aim to get about 30 minutes of these activities most days of the week. Vitamin D and calcium supplements are also important. If someone gets fractures frequently, or has been diagnosed with osteoporosis, osteopenia, osteogenesis imperfecta, or diseases that impact the absorption of nutrients (such as Crohn’s disease, other inflammatory bowel diseases, or anorexia), they should make sure to talk with their medical provider about these concerns prior to starting blockers.

Some people think that taking a blocker means that someone won’t be able to contribute genetic material to babies of their own when they grow up. This is not the case. Current medical information indicates that using blockers alone will not typically impact fertility.

That said, if someone uses blockers starting from Tanner Stage 2, and then goes directly on to GAHT without going through the puberty they would have had without GAHT, they will probably not be able to contribute genetically to babies of their own. This is something to talk about with health care providers and loved ones, and to think about carefully in making decisions about treatment.

Those are the known and established risks of puberty blockers. There may be other long-term risks that haven't been identified. However, these medicines have been used for over 40 years to block precocious (early) puberty, so there is a fair amount of information about their safety. The World Professional Association for Transgender Health and the Endocrine Society both recommend blockers for transgender kids, and blockers are FDA approved for precocious puberty.

(Seattle Children’s Gender Clinic Puberty Blockers, WPATHSOC8, S43 - S79, Endocrine Treatment of Gender-Dysphoric/Gender-Incongruent Persons: An Endocrine Society Clinical Practice Guideline)

How Does Someone Know If Blockers Are the Right Choice?

This is a really big question! The truth is, everyone’s answer is a little bit different. Blockers may be right for someone who needs to take a break from puberty to think about what kind of puberty is right for their body. In trying to figure that out, talking with a gender-care-informed health care provider about the risks and benefits of blockers is really important. Many people also find that talking with a supportive mental health professional can be really helpful.

(Seattle Children’s Gender Clinic Puberty Blockers, WPATHSOC8, S43 - S79, Endocrine Treatment of Gender-Dysphoric/Gender-Incongruent Persons: An Endocrine Society Clinical Practice Guideline)

What Are the Different Kinds of Puberty-Blocking Medicines?


This informational guidance has talked about what blockers do, what they don’t do, and the risks associated with them. Now it's going to talk about different kinds of medicines that block puberty, how those medicines are administered, and a bit about access and legality. This can be helpful information to have when talking with medical providers about blockers.

Most blockers are in a group of medicines called gonadotropin-releasing hormone agonists (GnRH agonists). Many are administered by injection, like a vaccine, and this can be uncomfortable for some people. Discomfort can be managed by talking with a medical provider about numbing cream (lidocaine) and/or Tylenol or Advil.

Formulations

NOTE: The information has been collected to create a comprehensive guide for individuals and health care professionals less familiar with these treatment regimens, but is NOT intended to be a substitute for medical advice from a doctor or other health care professional familiar with your particular case and medical history. Please take these medication as directed by your doctor.

Leuprolide Acetate

This medicine is most commonly given as an intramuscular injection (shot) (video demonstration here and here) in the upper, outer quadrant of the buttocks once every 3 months and sometimes monthly. Alternatively, subcutaneous injections, which use a shorter needle inserted under the skin, can be used for certain formulations; however, the subcutaneous liquids tend to be very viscous, or thick, and the injections can be somewhat challenging. The most common dose used for puberty blocking is the adult formulation of leuprolide acetate (brand name Lupron Depot) 22.5mg, every 3 months, as it is the dose that works best for most bodies. The ingredients in the pediatric and adult formulas are the same.

Leuprolide acetate formulation options:

  • Lupron Depot-Ped

    • Monthly weight-based pediatric formulation

      • Start at 7.5mg – 11.25mg dose, injected intramuscularly every month if weight ≤ 55lbs

      • Start at 11.25mg – 22.5mg dose, injected intramuscularly every month if weight > 55lbs

    • Every 3 months pediatric formulation

      • Available in 11.25mg or 30mg dose. 11.25mg is effective in 78.4% of adolescents, 30mg dose is effective in 95.2% of adolescents. Dosing is not weight-based. Start with 11.25mg dose and if ineffective, administer 30mg dose at follow-up injection.

  • Lupron Depot (adult) —intramuscular injections, not weight-based

    • Adult dose, 22.5mg every 3 months —PREFERRED dose in ADOLESCENTS

      • Alternative options:

        • 7.5 mg for 1 month

        • 30 mg for 4 months

        • 45 mg for 6 months

  • Eligard —subcutaneous injections, not weight-based

    • 7.5 mg subcutaneously every month

    • 22.5 mg subcutaneously every 3 months

    • 30 mg subcutaneously every 4 months

    • 45 mg subcutaneously every 6 months

  • Fensolvi — 45 mg administered by subcutaneous injection once every 6 months, not weight-based, fairly viscous and challenging to inject. Has pediatric approval.

*Leuprolide acetate purchased from a compounding pharmacy is often dosed DAILY, not monthly or longer.

Other options

These medicines are in the same family as leuprolide and work similarly. Think of them as leuprolide’s cousins.

Triptodur (triptorelin) — a single intramuscular injection of 22.5 mg once every 24 weeks. Very viscous and challenging to inject.

Synarel (nafarelin) —nasal spray GnRH agonist with 200mcg per actuation (spray or pump). Administer 2 actuations in each nostril twice daily, may increase to 3 actuations if inadequate response to 2 after 1 month. Less effective than injections overall, but more affordable.

Implants (Histrelin)

This medicine is a little plastic rod placed under the skin of the upper arm (implant). The implant releases medicine for 1.5 to 3 years or longer. When it stops releasing its treatment, it needs to be removed and a new one may be replaced at that time. Unfortunately, after 18 months the plastic becomes brittle and makes the implant harder to remove, so replacement is recommended at 12–18 months. This can be done in a medical clinic like a primary care provider’s office or in an operating room.

Dosing information compiled from Seattle Children’s Gender Clinic “Gender-Affirming Hormone Protocols” and Fenway Health’s “Medical Care of Gender Diverse Children and Adolescents.”

How Long Will It Take for Puberty Blockers to Work?

Puberty blockers actually increase the effects of puberty for the first 2-3 weeks, but then stop them. People usually know in about 3-4 weeks if their puberty blockers are working. They typically feel less dysphoria and more calm. (Seattle Children’s Gender Clinic Puberty Blockers, Endocrine Treatment of Gender-Dysphoric/Gender-Incongruent Persons: An Endocrine Society Clinical Practice Guideline)

Accessing Puberty Blockers

Ideally, puberty blockers are prescribed and managed by a medical care team. Not everyone has that option. (What states ban gender affirming care? Find out here.) If not, there may be other options available. Some clinics have continued to provide care; contact GLMA or STYEP to find local clinicians. A next best solution would be to travel to a state without bans. This might not be possible due to cost or other barriers we encourage people take a look at groups like Elevated Access and mutual aid groups in their area, like STYEP, which may be able to help with costs.

See our sourcing page to learn more about how to access medications.

References

  1. Seattle Children's. (2023, June). Puberty Blockers. Documents for Patients and Families. https://www.seattlechildrens.org/globalassets/documents/for-patients-and-families/pfe/pe2572.pdf

  2. E. Coleman, A. E. Radix, W. P. Bouman, G. R. Brown, A. L. C. de Vries, M. B. Deutsch, R. Ettner, L. Fraser, M. Goodman, J. Green, A. B. Hancock, T. W. Johnson, D. H. Karasic, G. A. Knudson, S. F. Leibowitz, H. F. L. Meyer-Bahlburg, S. J. Monstrey, J. Motmans, L. Nahata, T. O. Nieder, S. L. Reisner, C. Richards, L. S. Schechter, V. Tangpricha, A. C. Tishelman, M. A. A. Van Trotsenburg, S. Winter, K. Ducheny, N. J. Adams, T. M. Adrián, L. R. Allen, D. Azul, H. Bagga, K. Başar, D. S. Bathory, J. J. Belinky, D. R. Berg, J. U. Berli, R. O. Bluebond-Langner, M.-B. Bouman, M. L. Bowers, P. J. Brassard, J. Byrne, L. Capitán, C. J. Cargill, J. M. Carswell, S. C. Chang, G. Chelvakumar, T. Corneil, K. B. Dalke, G. De Cuypere, E. de Vries, M. Den Heijer, A. H. Devor, C. Dhejne, A. D’Marco, E. K. Edmiston, L. Edwards-Leeper, R. Ehrbar, D. Ehrensaft, J. Eisfeld, E. Elaut, L. Erickson-Schroth, J. L. Feldman, A. D. Fisher, M. M. Garcia, L. Gijs, S. E. Green, B. P. Hall, T. L. D. Hardy, M. S. Irwig, L. A. Jacobs, A. C. Janssen, K. Johnson, D. T. Klink, B. P. C. Kreukels, L. E. Kuper, E. J. Kvach, M. A. Malouf, R. Massey, T. Mazur, C. McLachlan, S. D. Morrison, S. W. Mosser, P. M. Neira, U. Nygren, J. M. Oates, J. Obedin-Maliver, G. Pagkalos, J. Patton, N. Phanuphak, K. Rachlin, T. Reed, G. N. Rider, J. Ristori, S. Robbins-Cherry, S. A. Roberts, K. A. Rodriguez-Wallberg, S. M. Rosenthal, K. Sabir, J. D. Safer, A. I. Scheim, L. J. Seal, T. J. Sehoole, K. Spencer, C. St. Amand, T. D. Steensma, J. F. Strang, G. B. Taylor, K. Tilleman, G. G. T’Sjoen, L. N. Vala, N. M. Van Mello, J. F. Veale, J. A. Vencill, B. Vincent, L. M. Wesp, M. A. West & J. Arcelus (2022) Standards of Care for the Health of Transgender and Gender Diverse People, Version 8, International Journal of Transgender Health, 23:sup1, S1-S259, DOI: 10.1080/26895269.2022.2100644. https://doi.org/10.1080/26895269.2022.2100644

  3. Wylie C Hembree, Peggy T Cohen-Kettenis, Louis Gooren, Sabine E Hannema, Walter J Meyer, M Hassan Murad, Stephen M Rosenthal, Joshua D Safer, Vin Tangpricha, Guy G T’Sjoen, Endocrine Treatment of Gender-Dysphoric/Gender-Incongruent Persons: An Endocrine Society Clinical Practice Guideline, The Journal of Clinical Endocrinology & Metabolism, Volume 102, Issue 11, 1 November 2017, Pages 3869–3903, https://doi.org/10.1210/jc.2017-01658

  4. Thompson, J, Cavanaugh, T, Hopwood, RA, & Vetters, R. Protocol for the Gender Affirming Care of Transgender, Non-binary, and Gender Diverse Children and Adolescents. April 2019. Fenway Health, Boston. https://fenwayhealth.org/wp-content/uploads/Medical-Care-of-Gender-Diverse-Children-Fenway-Health-Spring-2019-1.pdf

  5. Seattle Children's. (2023, June). Seattle Children’s Gender Clinic Gender-Affirming Hormone Protocols. https://www.seattlechildrens.org/globalassets/documents/clinics/gender/scgc-gah-protocols.pdf