Trans-World MedTrans-World Med
Transgender HRT
Published by Transgender Community News
and TGForum
By Cerise Richards, MD
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 ?, TGForum 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