MtF
Hormone FAQ
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NOTICE -
The material presented in this document is presented strictly for educational
purposes only! Because of the inherent risks associated with cross-gender
hormone therapy, it is in the best interests of those considering
such treatment to do so under medical supervision. This FAQ was prepared
solely as a general primer for those seeking information on the subject
and thus should not be treated as an authorative guide but rather as basis
from which to conduct a informed dialog with your treatment provider. |
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| How
does hormone therapy work? - |
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Essentually there are three types of naturally occurring hormones: Estrogens,
progesterones, and testosterones. Females and males each have them in different
ratios, but they are all present. Proportionally, females have more estrogens
and progesterones, where as males more testosterones.
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The primary hormonal agents which
cause the body to differentiate into female form and function are: Estrogens,
which include natural and synthetic estradiols, estrones, and estriols
that excite estrogenic receptors. And progesterones, which include synthetic
progesterone analogues such as progestins, progestagens, and gestagens
that excite progesteronic receptors.
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Various testosterones are collectively
known as androgens. They excite androgenic receptors, causing the body
to differentiate into male form and function. Natural and synthetic
testosterones are generally referred to simply as androgens.
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Anti-hormones (typically in the
form of anti-androgens) are useful in transsexual hormone therapy because
they block hormone action or production. The basic mechanisms are: |
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| Androgen
receptor antagonists which block the action of androgens at certain receptor
sites. |
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| Androgen
conversion inhibitors which block the conversion of one type of androgen
to another. |
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| Gonadal
androgen production inhibitors which suppress the pituitary signal that
stimulates gonadal production of androgens. |
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| Adrenal
androgen production inhibitors which directly suppress the adrenal production
of androgens. |
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Aggressive hormone therapy indirectly reduces gonadal hormone production
by fooling the pituitary into thinking that there are plenty of hormones
already in the body; consequently, the pituitary reduces the luteinizing
hormone signals that stimulate the gonads thus reducing additional hormone
production.
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Postnatally administered hormones
as typically used in transsexual hormone therapy do not cause development
of primary sex organs or genitalia (uterus, ovaries, vagina, testes,
or penis) opposite those of birth. However, postnatal contrasexual hormone
therapy does cause development of secondary sex characteristics in much
the same manner as for the opposite gender. |
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| What
effect does female hormone therapy have for the M-t-F transsexual? - |
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|
The following effects have been observed in varying degrees, anywhere from
slight to moderate, with extended treatment. High levels of estrogen will
cause faster development up to a certain point, but generally do not create
better results in the long term than more moderate treatment levels. |
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| Fertility
decreases and sperm counts drop rapidly. Sometimes it will return to almost
normal levels if hormonal treatments are discontinued within the first
couple of months, but permanent sterility can occur in as little as six
months. Estrogens, progesterone, progestins, and gonadal androgen production
inhibitors are the chemicals primarily responsible for lowering fertility,
although this should not be counted on for birth control since a slight
sperm count can remain until the testes are surgically removed. |
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| Male
sex drive decreases, spontaneous erections usually stop, and directly stimulated
erections can become infrequent as well as difficult to maintain. Penile
skin shrinks if erections are not regularly encouraged, testes and prostate
atrophy, and semen secretion decreases usually resulting in less intense
or unobtainable ejeculatory orgasms. |
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| Breast
size increases. Typical growth is one to two cup sizes below closely related
females (mother, sisters). The growth is not always symmetrical although
neither is it for natal females. Sometimes the areoles and nipples swell,
but generally not significantly, unless the body is less than a decade
past puberty. |
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| Body
fat is redistributed, tending to migrate away from the waist and toward
the hips and bottom. The face becomes more typically female in shape. |
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| Body
hair growth (not including head, face, or pubic area) usually slows, becomes
less dense, and may lighten in color. Hair on the scalp may become thicker,
and male pattern baldness generally stops advancing. |
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|
In addition to those listed above the followings following effects are
often reported although not supported by any specific medical literature
available to us at the time this article was written: |
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| The
metabolism decreases and if exercise is not increased, muscle tone is lost,
especially from areas that were not well developed before hormone therapy
began. Given a caloric intake and exercise regimen consistent with pre-hormonal
treatment, one tends to gain weight, lose energy, need more sleep, and
tend to become cold more easily. |
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| Outer
skin layer becomes thinner, lending a finer translucent appearance and
increased susceptibility to scratching and bruising. Tactile sensation
may become more intense. |
| Oil
and sweat glands become less active, resulting in dryer skin, scalp, and
hair. Body odors (skin and urine) change, becoming less "tangy" or "metallic"
and more "sweet" or "musky". Sometimes, tear glands also become less active,
resulting in dryer eyes. |
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| Internal
emotions are amplified, becoming more apparent, distinguishable, and influential.
Some people report reduced anxiety and increased sense of well-being although
this is likely a placebo effect. Changing the hormone therapy (adjusting
dosages up or down in the regimen) sometimes causes short periods of depression
or general moodiness. |
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|
Female hormone therapy does not: |
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| Reduce
facial hair growth significantly. |
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| Cause
the voice to increase in pitch. |
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| Change
the shape or size of bone structure. However, it may cause some slight
loss of bone density. |
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| How
soon do these effects begin? - |
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|
With effective and continuous dosages, most of the changes to which particular
body is genetically prone will start within 2 to 4 months of entering therapy,
becoming irreversible within 6 to 12 months, start beginning to level
somewhat within 2 years, and be mostly done within approximately 5 years.
The leveling generally takes longer if the testes are not removed. These
timelines are of course generalizations based on what many have typically
reported, but do not necessarily mean that everyone will find development,
or reversibility, to be within these limits. |
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| What
are the typical hormone treatment options? - |
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The popular treatment combinations related to M-t-F hormone therapy are: |
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| Adding
another type of estrogen. |
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|
This may cause faster results for some people, but generally not better
results in the long run. |
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***
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Adding an anti-androgen may enable one to reduce the estrogen dosage while
still obtaining acceptable development in a reasonable time frame,
along with very similar results in the long run as opposed to a strictly
high dose estrogen regimen. An anti-androgen fights the androgens remaining
in the body by either by blocking the actions of androgens, or suppressing
their production, rather than seeking to simply overwhelm them as is generally
the case with strictly high dose estrogen treatments. |
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There is some indication that progesterone administered with estrogen may
promote extra breast growth by increasing the volume of the lactation and
ducting tissues. Some studies relating to birth control pills usage by
natal females would seem to show that progesterones administered with estrogens
reduce the risk of cancer from administration of estrogens alone. Yet,
in some people, synthetic progesterones have a slightly androgenic effect
and can apparently even antagonize estrogen absorption, although many believe
that the use of non-synthetic progesterone may overcome this adverse effect
and provide a healthier balance for an aggressive estrogen dosage. |
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| Note:
Some
endochrinologists seek to mimic a female menstrual cycle by decreasing
or eliminating estrogen for one week of the month and/or adding or increasing
progesterone for the same week. Generally this type of treatment is only
preformed with patients who are also receiving anti-androgens so as to
mitigate the effect of causing large variations in the endogenous androgen
level. At this time we are not aware of any specific evidence that this
type of treatment is either beneficial or harmful, although there are some
indications that cycling progesterones may decrease the beneficial effect
of estrogen on cardiovascular health, and may also promote extreme mood
swings similar to PMS in natal females. |
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| How
are these hormones administered? - |
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|
Hormones are typically delivered by the following methods: |
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| Generally
considered the safest and most efficient method, it is usually the least
expensive option and causes less liver stress and clotting danger than
oral delivery. The main disadvantages are pain and a slight infection risk
from hypodermic needle usage. Sustained release intramuscular preparations
(hormones suspended in oil) are recommended. |
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| This
is perhaps the most popular delivery method due to the convenience. Fairly
steady hormone levels can be attained if divided into twice or thrice daily
dosages. Athough there is a significantly increased stress on the liver
since it has to process the hormones multiple times. Estrogen taken orally
may also increase blood clotting factors and enhance the risk of thrombosis.
Yet on the positive side, there are some indications that oral treatments
are more beneficial for blood cholesterol levels than other methods. |
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| Although
perhaps one of the least popular methods, the rectal suppository is a most
effective option if one can retain it long enough. Supplys a fairly steady
hormone level which is perhaps 3 to 4 times as effective as oral delivery
methods given the same weight (mg) of hormones. |
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| Transdermal
patch or film |
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| Less
liver stress and clotting danger than oral delivery. Steady hormone levels
can be maintained if multiple patches are applied on staggered dates, although
multiple simultaneous patches are typically required for pre-op dosages.
Main disadvantages are inconvenience, skin irritation, and expense. |
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| Absorption
is variable depending on the preparation, and the nature of the skin it
is applied to, yet also creates less liver stress and clotting danger than
oral delivery. The main disadvantage is the low transfer rate into the
body, too low to be effective unless it is very frequently rubbed on very
large skin surfaces. Application to just the breast area does not limit
the distribution to that area and the little estrogen absorbed is distributed
throughout the body in insufficient quantity to make the breasts grow significantly.
Generally the only obvious effect from this type of treatment is moister
and healthier skin. |
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| Note:
One
should beware of non-prescription creams and gels from so called "transformation"
outlets. If a preparation is not strong enough to require licensing, it
is usually not strong enough to cause significant development either. |
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| How
can the advantageous effects of hormone therapy be maximized and the dangers
minimized? - |
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Before starting hormone therapy, one should have a complete physical exam
including the following blood tests: |
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| At
a minimum you will want to check liver function (enzymes) and blood clotting
factors. |
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| Additionally
recommended are tests for kidney, electrolyte, lipid (cholesterol), prolactin,
sugar, estrogen, and androgen levels. |
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| Hypothyroidism
will partially or completely block development, so if there is family history
or any other signs of that disorder, take the appropriate tests and correct
this before attempting cross-sexual hormone therapy. |
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| It
may may also be interesting to check calcium and phosphorus levels (skeletal
health), especially for those over 40 years old. |
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Not everyone requires the same dosage, because of differences in body weight,
genetically-disposed sensitivity to the hormones, and other factors. Discuss
your treatment options with your physican to select the best choices for
your individual treatment, some general considerations in this area are: |
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| Selecting
the safest form of estrogen available, usually one that breaks down quicky.
If possible do not start taking the maximum planned dosage of all hormones
and anti-hormones at once. Start with a conservative dosage, then increase
it. Use the lowest hormone dosage that affords the desired changes,
and divide oral preparations into twice-daily takings, if practical. |
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| Choosing
a method of delivery, other than oral if possible, especially if you have
any history of blood clotting disorders. Estrogens delivered orally create
extra stress on the liver thus causing it to produce extra blood clotting
factors. However, oral treatment is not generally considered overly dangerous
unless a pre-op dosage is administered for more than 3 years, or the liver
is already weakened by alcohol, drug use, or infection. |
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|
Although one can generally use clinical results (visible body changes)
for feedback on the effectiveness of a given therapy, appropriate follow-up
care is still important. |
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| If
you take oral estrogen or progestin (synthetic progesterone), repeat the
liver and clotting tests a few months after each significant increase of
dosage. At the very minimum, recheck them 6 months and 12 months after
starting, and again every couple of years. If you are only on injectible
or transdermal hormones, a single recheck 9-12 months after starting should
be sufficient, if you are otherwise healthy. |
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| If
you take spironolactone (Aldactone) as an anti-androgen, have an electrolyte
test about a month after each significant increase of dosage, especially
if you have any known problems with potassium levels. |
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| Breast
cancer risk factors seem tend to be low in comparison to females receiving
estrogen replacement therapy. However you should still perform monthly
breast self-exams, and take mammograms every 2 years before age 40, then
every year thereafter. |
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| If
a high estrogen dosage is suddenly stopped there may be a dramatic spike
in the prolactin level, causing significant discharge from the nipples
(lactation) for up to a week. However if significant discharge is noted
when there has not been a significant estrogen dosage change it may be
a sign of a dangerously elevated prolactin level due to intolerance of
the estrogen dosage and you should immediately take a test to measure the
serum prolactin level; otherwise, taking the test every 6-12 months anyway
just to be safe is recommended. |
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| Note:
General
guidelines for good health should also be maintained. Stop smoking (Nicotine/cigarettes
increase the degradation of estrogens), reduce stress, and increase aerobic
exercise to reduce weight gains which may be caused by hormone therapy.
Eat well, and take a good multi-vitamin & mineral supplement to help
be sure the body has everything it needs for new development. Those taking
spironolactone should also bear in mind that it is a diuretic, and should
drink plenty of water, especially before and after exercise. |
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| How
is hormone therapy obtained? - |
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Most reputable therapists and medical doctors who regularly work with transsexuals
follow the Harry Benjamin Standards
of Care, which provide specific guidelines related to hormone referral
letters. One can choose to work with doctors who do not follow the Benjamin
Standards, but unless hormone therapy is the only goal and you have no
interest in receiving any further treatment such as gender reassignment
surgery, it is usually best to follow the accepted standards to avoid wasting
time by having to do so at a later date anyway to continue treatment.
***
Hormones are manufactured and
controlled by the endochrine system, thus an endochrinologist is the specialist
one usually sees for matters related to hormone therapy. Although, if a
sympathetic endocrinologist is not available, you might want to try local
gynecologists as they are sometimes more understanding, and are often used
to prescribing estrogens and progesterones.
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Some people in the USA have reportedly
taken advantage of the FDA Personal Use Import Policy to purchase hormones
directly from international sources. However it is important to note that
one should only take hormones that were obtained directly from a licensed
pharmaceutical distributor as the quality of drugs obtained through other
channels is not only suspect but possibly dangerous, especially those in
injectable form. |
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| What
are the most popular hormones and dosages used in such therapy? - |
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For specific information about contraindications, adverse effects, etc.
it is recommended that you consult the Physician's Desk Reference (PDR)
for more information. Brand names and preferences may vary in different
countries, however the following are some typical hormone regimens used
in the USA:
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Note:
Unless
otherwise specified the typical dosages illustrated are pre-operative amounts
for specific hormones used exclusive of any other hormone treatment, some
physicians may however combine different types of hormones using lower
dosages of each to achieve the same overall effectiveness. |
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| Estradiol
(Estrace®), 4 - 8mg daily |
| Conjugated
Estrogens (Premarin®), 1.25 - 7.5mg daily |
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| Ethinyl
Estradiol (Estinyl®), 0.1 - 0.25mg daily |
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| Estradiol
Valerate (Delestrogen®), 7 - 20mg each week IM or 15 - 40mg per 2 weeks
IM (intramuscular) |
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***
| Estradiol
(Climera®), 2 - 4 film patches (0.1mg) changed twice weekly |
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***
| Medroxyprogesterone
Acetate (Provera®), 2.5 - 10mg daily in conjunction with estrogens |
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| Injectable
Progesterone - |
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| Medroxyprogesterone
Acetate (Depo-Provera®), 50mg per 2 weeks injectible in conjunction
with estrogens |
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| Spironolactone
(Aldactone®), 100 - 300mg daily in conjunction with estrogens |
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| Note: Outside
the USA, Cyproterone Acetate (Androcur®), 10 - 100 mg daily in conjunction
with estrogens, is often used in place of spironolactone. However it has
never been approved by the US FDA. |
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After orchiectomy (castration), or SRS, post-operative maintenance dosages
are typically 1/4 - 1/2 of the pre-operative levels shown above for estrogens
and/or progesterones. Anti-androgens are generally discontinued altogether. |
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Contributions
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