The decision to start puberty blockers is different for everyone. This page is meant to provide information that can help you and your family make an informed decision about care. Some questions you or your family may have include:
- What is puberty?
- What do puberty blockers do?
- What are the different kinds of puberty blockers?
- What are the benefits, risks, and costs involved?
- Are puberty blockers right for me?
Puberty Blockers FAQ: Contents
- What is puberty?
- What do puberty blockers do?
- Will puberty blockers stop all changes in my body?
- What will happen if I start puberty blockers later in puberty?
- Are puberty blockers permanent?
- When can I start taking puberty blockers?
- How do we know when puberty has started?
- How long will it take puberty blockers to start working?
- How long can I stay on puberty blockers?
- What are the different kinds of puberty-blocking medications?
- Leuprolide acetate
- Triptorelin
- Histrelin
- Nafarelin
- Are these medicines safety-approved?
- Will the injections hurt?
- Will the Histrelin implant hurt?
- What if I’m scared of injections
- What is the difference between longer-term options like injections or implants compared to daily options like the nasal spray?
- What are the benefits of puberty blockers?
- What are the risks of puberty blockers?
- Bone health
- Fertility
- Access and Cost
- Are puberty blockers right for me?
- Putting It All Together
- Articles and References
What Is Puberty?
Puberty is the process the body goes through to become capable of making a baby (reproductive development). Puberty starts with messages within the brain to the pituitary gland to start releasing two hormones: Luteinizing Hormone (LH) and Follicle-Stimulating Hormone (FSH.) These two hormones travel to the testicles or ovaries, and encourage them to start producing what are called sex steroid hormones: testosterone and estrogen. The system in the body that controls the production and release of LH and FSH is called the hypothalamus-pituitary-gonad axis (HPG axis). During and after puberty, the HPG axis regulates how, when, and the amount of sex steroid hormones (testosterone and estrogen, primarily) that are produced by the gonads (the ovaries or testicles) in most bodies.
Puberty starts at different ages in different bodies, and usually lasts several years. Puberty is one of the major hormonal transitions that most people experience in their lifetimes.
Fun Fact: Acne and armpit hair are caused mostly by hormones produced by the adrenal glands, less so those produced by ovaries and testicles. Puberty blockers don’t affect the adrenal glands, so acne and armpit hair aren’t generally as affected by puberty blockers!
Expected body changes in people with testicles during puberty (without puberty blockers):
- Testicle growth
- Penis growth
- Facial and body hair
- Change in facial bones
- Rapid growth (growth spurt) typically with broader shoulders and narrower hips
- Increase in muscle mass
- Voice changes (deepens)
Expected body changes in people with ovaries during puberty (without puberty blockers):
- Breast growth
- Changes in body shape, including fuller hips
- Menstrual periods start (usually more than two years after breast changes begin)
- Rapid growth (growth spurt)
- Voice changes (deepens, but less so)
What Do Puberty Blockers Do?
Puberty blockers are in the drug class called “GnRH analogues”. “GnRH” stands for “Gonadotropin-Releasing Hormone”, GnRH is the hormone that tells the pituitary gland in the brain to release LH and FSH, which then prompt the ovaries and testicles to make sex steroid hormones. So GnRH analogs work by changing LH and FSH release from the pituitary gland. This means that, over time, the gonads make less testosterone or estradiol.
While each available GnRH analogue works a little differently, the action in the body is to delay the changes associated with puberty.
Will Puberty Blockers Stop All Changes In My Body?
No, puberty blockers may not stop armpit hair from growing and may not improve acne.
Puberty blockers primarily impact the puberty changes that we call “secondary sex characteristics”. These are changes that happen to reproductive organs such as the breasts, the ovaries, the uterus, the vagina, testicles, and the penis. Puberty blockers temporarily slow down or stop these organs from developing towards reproductive maturity.
If blockers are started early in puberty, some pubertal changes that have already happened may reverse. For example, in bodies with ovaries, breast size may get smaller if they have already started to develop. In bodies with testicles, testicle size may decrease, and penis growth will likely be slowed or halted.
Are Puberty Blockers Permanent?
Puberty blockers are mostly reversible. If you decide to stop puberty blockers without starting hormone therapy, your body will most likely start going through your original puberty again. The length of time that someone takes puberty blockers is an individual decision, and they can be stopped at any time. We work closely with our patients who decide to stop taking blockers to help manage that transition.
When Can I Start Taking Puberty Blockers?
Puberty blockers can be started after your body shows the first signs of puberty. It is generally not recommended to start puberty blockers before puberty.
How Do We Know When Puberty Has Started?
The clinical guidelines for puberty are called Tanner Stages: they go from Tanner Stage 1, which is a body before puberty starts to Tanner Stage 5, which is reproductively mature body after puberty ends. Puberty is considered to have started at Tanner Stage 2.
Doctors can ask you about your body and/or look for the signs that puberty has started during a physical exam. In bodies with testicles, these changes include increased testicle and penis size. In bodies with ovaries, the development of breast buds under the areola are among the first signs of puberty. In both types of bodies, the development of downy pubic hair is a sign that puberty is starting. Doctors can also do blood tests to check puberty hormone levels. You can learn more about determining your stage in puberty here.
How Long Will It Take Puberty Blockers To Start Working?
Injectable puberty blockers typically cause an increase in puberty hormones in the first two to three weeks. After about four weeks the puberty blockers are typically effective at decreasing testosterone or estradiol levels back to prepuberty levels.
How Long Can I Stay On Puberty Blockers?
Puberty blockers are used until you decide you want to either resume your original puberty process or until you are ready to start hormone therapy, and may be continued while starting hormone therapy. The usual recommendation is to start hormones in addition to or instead of blockers after about two years of blocker use in order to help protect bone health; however, the timeline should be individualized for each person with the input of their family and their healthcare team.
What Are The Different Kinds Of Puberty-Blocking Medicines?
GnRH analogues are available as:
- injections
- implants
- nasal sprays
Leuprolide acetate (often called by the brand names Lupron Depot or Eligard)
Form: injection
This medicine is given as an injection (shot). It comes in a once a month, every three months, or every 6 month preparations.
Triptorelin (brand name Triptodur)
Form: injection
Triptorelin is also given as an injection, once every six months.
Histrelin (brand name Supprelin) and Goserelin (brand name Zoladex)
Form: implant
Procedure visit required.
This medicine is a little plastic rod placed under the upper arm’s skin (implant). The implants are recommended to be replaced every 12 months by the manufactuers. Some studies have indicated they frequently continue to effectively work for 18 to 36 months. When it stops releasing its treatment, it needs to be removed and may be replaced at that time. This can be done in a medical clinic like your primary care provider’s office, or in an operating room. The longer the rods are in the body, the more brittle they may become, which may make earlier removal preferable when possible.
Nafarelin (brand name Synarel)
Nafarelin is a nasal spray, that is used up to three times a day.
Are These Medicines Safety-approved?
The Endocrine Society and the World Professional Association for Transgender Health support puberty blockers. Puberty blockers are not approved by the Food and Drug Administration (FDA) for the treatment of gender dysphoria. They are FDA approved for treating early onset puberty in adolescents.
Will The Injections Hurt?
Injections and the implant procedure may be painful.
The injection is given in your arm, leg, or bottom. The area where you get it may be sore for a few days after the injection. Sometimes a cold spray or numbing cream (topical lidocaine) reduces pain from injections by numbing the skin before the needle stick. You can take Tylenol (acetaminophen) or Advil (ibuprofen) to help lessen any pain. Ask your provider if you are interested in using numbing cream before your injection. You can learn techniques to help reduce pain with injections. Contact your provider if the pain from the injection or implant gets worse on the next day or you have a rash.
Will The Histrelin Implant Hurt?
If you get the implant inserted in a clinic, they will give you an injection to numb your upper arm before the procedure. The numbing injection can feel a little stingy or uncomfortable. If you have it done in an operating room, you will receive medicine to make you sleep (anesthesia) during the procedure. After the process, your arm may be sore for a few days where it was inserted. You can take Tylenol (acetaminophen) or Advil (ibuprofen) to help lessen any pain.
What If I’m Scared Of Injections?
When injections feel scary, we recommend several ways to help manage our scary feelings.
What Is The Difference Between Longer-Term Options Like Injections Or Implants Compared To Daily Options Like The Nasal Spray?
One major difference is how often you take the medicine.
Injections and implants may be a good choice for people who won’t be able to easily take meds daily or take them multiple times a day.
The spray may be a good choice for people who can’t tolerate injections or the implantation procedure. They may also be a good choice for someone who does not want a longer-lasting option.
All options can be very expensive. If insurance coverage is available, your plan may only cover one form of blocker. Other factors may mean one type is more accessible than the others, too.
What Are The Benefits Of Puberty Blockers?
It can be distressing for transgender and gender diverse people to go through puberty. Puberty blockers can help with this distress by slowing down puberty, which reduces puberty changes that do not match with your gender identity. Multiple steadies have indicated that puberty blockers help decrease distress and improve mental health.
Starting puberty blockers can give you time to consider what you and want and need for your future.
For some people puberty blockers may reduce the need for or complexity for future surgeries or other treatments. For example, blockers may prevent hair growth in people with testicles and decrease the need for hair removal procedures in the future. Blockers may also prevent breast growth in people with ovaries and decrease the need for breast removal surgeries for people who do not want to have breasts.
Puberty blockers may also improve safety for people for whom visible pubertal changes may be dangerous.
What Are The Risks Of Puberty Blockers?
The long-term safety of puberty-blocking medicines is not entirely understood. There may be long-term risks that we do not know about yet. However, we have many years of data in patients treated with these medications for central precocious puberty (puberty that starts too early,) showing good safety. The first puberty blockers were approved for use in central precocious puberty in the 1980s. The first trans youth to take puberty blockers are now in their 30s or early 40s.
Bone Health
Blocking puberty can lower bone density over time. Studies in trans youth and youth with central precocious puberty indicate that bone density is likely to increase again after puberty blockers are stopped and when cross-hormone therapy is started. While on puberty blockers, we recommend taking calcium and vitamin D and doing bone strength-building exercises like walking, jumping, and weight lifting. We may check your bone health every two years while on blockers.
Fertility
Puberty blockers alone do not typically affect your ability to have a baby in the future (fertility.)
However, permanent changes to fertility can happen to people who stay on puberty blockers and then take cross-sex hormones potentially resulting in permanent infertility. Talking more about this with your healthcare providers can help you understand the potential impact on your fertility before starting any medicines.
Access And Cost
Puberty Blockers can be very difficult to access, especially without insurance coverage.
If insurance does cover puberty blockers for transgender youth, a prior authorization is usually required. This process may take up to several months.
Without insurance, the cash pay price for blockers can be many thousands of dollars per treatment cycle; however, there may be some more cost effective options. Your provider can help you navigate this.
This cost can change every year. Some insurance companies do cover puberty blockers for use in transgender children. How much your insurance covers depends on your insurance plan. Sometimes insurance companies will only help pay for one type of blocker and not others.
Cost for implants may be increased if you get medicine to sleep during the implantation procedure (anesthesia).
Talking To Insurance About Coverage
If you have questions about coverage, you can call your insurance company. Here are some tips for talking to insurance about coverage.
Questions you may want to ask include:
- Are these medicines covered by my insurance plan?
- If a specific option is not covered, will insurance cover an alternative?
- What are my deductible, copay, and/or coinsurance fees? What is my out-of-pocket cost for these medications?
- Have I met my deductible this year?
For help navigating the insurance process, we also offer Care Navigation appointments. The makers of these medicines may also have support programs that can help you with insurance questions. TransFamily Support Services offers care navigation and support in navigating care denials, as well.
There are some non-GnRH analogue medications that can be used to manage pubertal changes if puberty blockers are inaccessible. They work differently and may not be as effective as blockers for the desired changes. We discuss raloxifene for use in bodies with ovaries and bicalutamide for use in bodies with testicles in other blogs.
Are Puberty Blockers Right For Me?
If you are interested in puberty blockers, we recommend talking with your provider about how the risks and benefits of puberty blockers may apply in to you specifically so that you have a good understanding of what to expect if you decide to start or not start puberty blockers.
What About Mental Health Therapy?
In most cases, it is helpful for you and your family to connect with a mental health provider experienced in gender identity before and during treatment. A mental health provider can help you through decisions and changes that happen as you get older and help your family learn how to support you through those changes. While mental health care and support is highly encouraged, it should not be a barrier to medical care. If you have questions about accessing medical care but are unable to access mental health care, please talk to your provider.
Pulling It All Together
Puberty blockers may:
- give youth more time before any pubertal changes become less reversible.
- may cause a surge in puberty symptoms before causing them to decrease.
- delay existing pubertal changes from continuing to develop.
- decrease the complexity or need for some future gender affirming procedures.
- be stopped at any time although they can take a few months to wear off depending on which form was used.
- are mostly reversible. Stopping puberty blockers typically allows the original pubertal process to continue.
- be used alongside hormone therapy.
- be difficult and expensive to access.
Puberty blockers generally should not:
- be started before puberty starts.
- used without a doctor’s supervision.
Puberty blockers
- are FDA-approved to treat central precocious puberty (puberty that starts too early).
- have been used to treat central precocious puberty since the 1980s.
- are used off-label in transgender youth. (Off-label means puberty blockers are not FDA-approved for gender dysphoria.)
