%expand% %gdefine(pickone,'%arg(%rand(%num-args%))) %expires:(never) Cerise Richards - January 2001

%expand(%include(D:\\http/ads/ads0.html))

Transgender HRT

Hormone Replacement Therapy (HRT) is a term which originally referred to the need for perimenopausal women to replace the body’s female hormones, estrogen and progesterone, which decrease markedly after the age of fifty. This is usually undertaken to lessen hot flashes, flushing and sweating, and to combat osteoporosis.

In the TG population, Transgender HRT (THRT) refers to the desire to change the body’s balance of Estrogen (E) and Testosterone (T) to produce the secondary sex characteristics of the opposite sex. Of interest to us is that both males and females produce the same precursors of Estrogen and Testosterone and it is the ovaries or testes, which determine the dominant hormone and subsequent secondary sex characteristics. We also know that men naturally produce small amounts of E and women produce varying amounts of T. So the object of THRT is simple in theory. Suppress the original sex organs and stimulate or supply the opposite sex hormone.

To better understand this process, we should understand a little of the science which under pins this treatment. In women it appears that Estradiol is the predominant estrogen produced by the ovary in the amount of 50 to 500 micrograms per day. This occurs in varying amounts under the pulsatile influence of follicle stimulating hormone (FSH) and luteinizing hormone (LH) produced by the Pituitary gland at the base of the brain. At a higher level in the brain, gonadotropin releasing hormone (GnRH) is released from the hypothalamus to regulate the pituitary through a negative feedback mechanism which senses the gonadotropins circulating in the blood. When the ovaries stop producing estradiol, the FSH level climbs in a futile attempt to produce more hormone, effectively shutting down the system. These changes define chemical menopause.

In men, a similar production of FSH, LH and GnRH begins at birth and increases at puberty with increased testosterone (T) production. A similar climacteric cycle occurs around age seventy with testicular atrophy and decreased testosterone production. But this chain of events in men can be initiated by the introduction of exogenous estrogens at any time we desire. Since the body’s hormonal receptors in skin, fat and hair are similar in both sexes and equally receptive to either Estrogen or Testosterone, we may redefine our appearance with the introduction of the desired hormone.

We are all familiar with the secondary sex characteristics, which define our outward appearance. The size of our hands and feet, the depth of our voice, the amount of facial and body hair present, the deposition of body fat, the amount of breast development and the appearance of our external genitalia. This is what we want to change and as we grow older beyond puberty the task becomes more difficult. The fixed aspects of the skeleton can be changed only with plastic surgery and SRS appears to be the best solution to date for external genital reconstruction. The good news is that modern medicine has come to our rescue in regard to THRT. The bad news is that with the rewards come the risk in varying degrees.

First in the MTF TS, we shall discuss the methods of androgen suppression. The simplest and most effective way is castration, which will remove 98% of the testosterone production at the source. There are no physical side effects except for possible wound infection or bleeding which is extremely rare. Since this is irreversible it is not recommended for initiates who wish to live as a woman in a trial situation. The other 2% of the body’s testosterone is produced by the adrenal gland and maybe suppressed by spironolactone, a diuretic, which acts directly on the adrenal by suppressing aldactone. This can lead to serious electrolyte imbalance with rare cardiac and renal problems without proper medical follow up. Other antiandrogens such as Flutamide (Eulexin) and Nilutamide directly interfere with Testosterone uptake at the androgen receptor. While these drugs have been used to suppress facial hair growth in hirsute women, they do not produce enough testosterone suppression for men. They also have been shown to increase total testosterone levels while working only at the periphery. Severe liver damage and rare deaths have been reported with the last two drugs. It is my opinion, that none of the above drugs, should be used in combination with estrogens for MTF’s. Proscar (Finasteride) may become a viable alternative because it suppresses the conversion of testosterone (T) to dihydrotestosterone (DHT), the active metabolite, with very few side effects.

In Europe cyproterone acetate, a progesterone-like drug, is the mainstay of androgen suppression. In this country we have oral Provera, medroxyprogesterone acetate (MPA) or weekly injectable DepoProvera, which appears to decrease pituitary gonadotropins, allowing adequate testosterone suppression in MTF’s. These work very well as an adjunct to estrogens producing true and improved breast development. Since we are not concerned about their effects on the uterus, they do not have to be cycled. All female hormones carry a warning about increased blood clotting leading to stroke, heart attack or pulmonary embolism. They cannot be taken by anybody with chronic Liver disease, uncontrolled Diabetes or a history of leg vein thrombosis. But on the other hand they have been used safely for thirty years with very little morbidity. The warnings come from problems associated with pregnancy and a large study of men who took large doses of conjugated estrogens, DES, for prostate cancer and developed all of the above complications. Since then, the doses of estrogen given to MTF’s have been drastically reduced and continue to be reduced as testosterone inhibition is achieved.

Another group of injectable GnRH agonists, Lupron and Zoladex, produce almost complete testosterone suppression without the above complications. These are given every 3 months and their effects cannot be reversed. Testicular atrophy with diminished libido and infertility will be irreversible after 2 years, but erections can still be achieved with Viagra if desired. (See: Viagra, For Me?, TG Forum Dec. 6, 2000)

Don’t be discouraged, now comes the good news. Through the magic of chemistry, we have created a very potent copy of Estradiol, ethinyl estradiol or Estinyl, which will produce all the desired secondary changes in very small doses of 50-100 micrograms per day. Breast development will begin almost immediately. You will go through periods of breast growth and standstill achieving maximum effect at two years of treatment. There will be some intermittent tenderness and possible nipple discharge and a new responsibility to check for lumps and bumps because breast cancer has been reported in MTF’s. Therefore mammograms become necessary. But can you imagine the satisfaction. Actually approximately 50% of TS’s go on to have breast implants because for some people natural is just not enough. That's another topic for another day. Body hair and sexual hair will decrease significantly, although facial hair may require electrolysis when heavy beard growth is present. Balding will be arrested and head hair texture will improve with no more oily hair. For some, personality changes will be evident, a softer you, and for some depression will become a problem. Oh, those PMS hormones! Fat deposition will change in the stomach and hips, but overall there maybe a gain in body weight secondary to increased fluid retention. For males over 40 a twice weekly transdermal estradiol patch, Esclim, is suggested for lower daily dosing and less chance of cardiovascular complications.

For the FTM TS, the goals are the same and the hormones more effective. Menses can be completely suppressed with Medroxyprogesterone acetate (MPA) and Testosterone. Biweekly injections of the Testosterone Esters will usually produce all of the desired secondary sex characteristics within two to three months. The important thing to remember is that these are irreversible. The oral preparation is generally worthless because stomach acid inactivates the drug, but the daily transdermal patch may achieve the same results provided it is used in conjunction with a small daily of oral MPA. Facial hair, sexual hair and acne will increase as if going through male puberty. A deepening of the voice occurs uniformly within 2 months. Redistribution of fat to the abdominal area will occur with a general increase in muscularity and weight gain. Libido will increase and in some cases clitoral size will increase to permit vaginal penetration. Phalloplasty can be achieved with abdominal plastic surgery, but is problematic at best. As treatment continues the ovaries will resemble polycystic ovaries which have been associated with ovarian cancer in two TS’s. Eventual ovariectomy and mastectomy with SRS is therefore recommended. Side effects of Testosterone are directed to the Liver where jaundice or an increase in liver enzymes may interrupt treatment. This is usually reversible. The cardiovascular complications seen with Estrogens are not seen with Testosterone.

All of the above requires continued care and dose adjustment by a physician with training and experience treating TS's. Well, what about all those phyto-estrogens that you read so much about and do not require a doctor's prescription? Tune in next month when we will discuss, "Hormonal Homeopathy".

Best Wishes for your New Future.

Cerise Richards, MD

Email Sign Ups | Retrieve Your TGF Email
Member Profiles