TG Medical:    Blood Curdling Hormones

Now that I have your attention, I would like to discuss the most frequent and most important side-effect of female hormones. It is a well established fact that estrogens and progestens cause an increase in the clotting mechanisms of blood and produce blood clots in the deep veins of the legs, which may become life threatening. The complications of stroke, heart attack and pulmonary embolus have been well documented in young women on oral contraceptives (OC) and menopausal women on HRT.  The risk of thrombosis or clotting increases sharply with age, from roughly one in 10,000 people per year before age 40 to one in 100 per year for those over age 75.  The net effect or absolute risk will be 3 additional cases in 10,000 OC users, but nearly 40 cases in 10,000 HRT users. The relative risk has been shown to be increased 2 - 4 fold in these groups with a 5-fold increase in heart attacks and a 3-fold increase in stroke in the 45 to 60 year old menopausal group. Over the past 40 years, the amount of estrogen in birth control pills has been steadily reduced from 100 micrograms of ethinyl estradiol, a synthetic preparation, to 50 or even 30 micrograms to decrease but not eliminate the frequency of these side effects. But the transsexual population is at even greater risk because of the large doses they are given to suppress testosterone production. These doses as noted in my last article are usually in the 100 microgram range for ethinyl estradiol and at most are reduced to 50 micrograms per day over years. The Amsterdam group reported the incidence of venous thrombo-embolic episodes (VTE) at 12 % for MTFs above the age of 40 and at 2.1% for those less than 40 years of age. These are the serious complications of when the clot dislodges from the leg and cuts off the circulation to the lungs, kidneys or liver.  The majority of small clots go undetected and are usually recurrent before the big one leaves the leg which on rare occasion results in sudden death.

Many factors besides hormones contribute to VTE especially if you have a family history from either parent or second degree relative, who may have contributed a gene for clotting called Factor V (5) Leiden. This mutation of a single amino acid on a single gene is responsible for a 50-fold increase in blood clotting if both parents have the gene and a 6-fold increase if only one parent contributes it. This is important before you have SRS surgery because the mere fact of lying in a hospital bed for a day or two will produce venous blood clotting. Which brings me to the second cause for VTE. When the body becomes immobile from a long car ride or plane trip without walking breaks, then venous stasis in the legs will bring on this clotting phenomenon. Other associated factors are smoking, high blood pressure and obesity. Precautionary measures can be taken by reducing your hormones one month prior to surgery, taking low dose anticoagulants during surgery and using pressure devices on your legs to keep the blood moving. The most impressive finding in the MTF group is that after 4 months of treatment with oral ethinyl estradiol and cyproterone acetate, the European progesten, the measurable clotting factors increased to the levels of the genetic carriers. It was felt in one study that this was the result of the chemical formulation and oral intake. Therefore the switch was made to the transdermal preparation of 17 Beta-estradiol (E2), which closely resembles the natural hormone. At a transdermal dose of 100 micrograms daily of E2 there appears to be a much smaller and limited effect on clotting and is therefore recommended for the over 40 age group and maybe for everyone. Now, how often have I said that. Not to be left out, the FTM group treated with testosterone has a very mild increase in clotting factors, which does not seem clinically significant. As you increase the Testosterone level you get a corresponding decrease in natural E2.

In the case of heart attack and stroke, which contributed to the closure of the US Premarin trial and the Norwegian Estrogen trial, it appeared that these major complications in older women appeared shortly after the start of therapy and within the first year. Therefore it would seem prudent to gradually increase your dosing beyond the first year. Oh, I know everybody wants to see the physical effects of hormones immediately, but we're talking about a lifetime, not one year.  This harkens back to my earlier proposal of one year of medical castration with injections of Lupron every 3 months followed by transdermal E2 started after one year. While this is not current therapy I do believe that we shall see it evolve in the near future. The best thing that you can do now is take a quarter aspirin each day (81mg) to prevent clotting if you are on hormones and call your doctor if you notice any redness or tenderness in your calves not associated with exercise.

Best of Luck in Your New Future,

Cerise Richards, M.D.