Hormone Therapy FAQ


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FAQ: HORMONE THERAPY FOR TRANSSEXUALS

This document contains a list of frequently asked questions and their answers regarding hormone therapy (secondary sexual reassignment) for transsexuals. More generally, this document contains information about gonadal hormones and anti-hormones, so it can be a helpful reference for the treatment of androgen and estrogen-sensitive conditions--for example, certain cancers of the reproductive organs and breasts.

Version 95/03/08

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Please send additions, corrections, and suggestions to valerie@shell.portal.com.

Questions Answered in this Document

Fine Print (Read It!)

Contents copyright 1994 by Valerie Lambert, valerie@shell.portal.com. All rights reserved. Permission is granted to freely redistribute, provided that the entire document (including this copyright notice and all disclaimers) is reproduced intact and without charge (beyond a nominal charge for accessing e-mail, public news, and www in general). Hardcopy or cybernetic redistribution for profit requires negotiation with the author.

The answers in this document are collected from a variety of sources: personal experience, second-hand anecdotes, medical literature, pharmaceutical company advertizement, and verbal advice of medical doctors. Despite the authoritative tone of this document, it is presented for educational interest only, not direct advice. It contains opinions, sweeping generalizations, and at least one mistake. The author is not a medical doctor, and makes no claim or warranty as to the suitability of the information in this document for application to any group or individual. YOU, the reader, take sole responsibility for interpretation and application of this information. Form your own opinions by doing your own research. May your favorite deity permanently curse you if you seriously consider sueing the author for misinforming you.

The endocrine feedback system is intricate, delicate, and poorly understood. Even the experts do not entirely agree on how to best meddle with it. Hormone therapy is fraught with risk as well as promise. Be sure you have fully considered the implications before you start. Work with a medical doctor who is qualified to interpret your signs, symptoms, blood tests, and development in the context of your personal medical history. Do not take hormones that you did not obtain directly from a licensed pharmaceutical distributor; the quality of drugs obtained through other channels is not only suspect, but possibly dangerous--especially those in injectable form.

Notes

Questions with Answers

  1. What are hormones, and how do they work?

Hormones are long-range chemical messengers of the body, manufactured and controlled by the endocrine system. Hence the title of endocrinologist for hormone doctors.

The hypothalamus produces gonadotropin-releasing hormone (GnRH). This signals the anterior pituitary gland to synthesize and release luteinizing hormone (LH). To a lesser degree, GnRH also triggers the synthesis and release of follicle stimulating hormone (FSH). Subsequently, LH and FSH signal the gonads (ovaries in females, testes in males) to synthesize and release hormones that cause differentiation of the body tissue into female or male form: estrogens, progesterones, and testosterones. A small quantity of testosterones are also produced by the adrenal gland. Proportionally, females have more estrogens and progesterones than males. Males have more testosterones.

Estradiols are synthetic estrogen analogues. Estrogens and estradiols excite estrogenic receptors, causing the body to differentiate into female form and function. Natural and synthetic estrogens are hereafter referred to simply as estrogens.

Progestogens (or progestins) are synthetic progesterone analogues. Progesterones and progestogens excite progesteronic receptors, which in cooperation with estrogenic activity, cause the body to further differentiate into female form and function. Natural and synthetic progesterones are hereafter referred to simply as progesterones.

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 hereafter referred to simply as androgens.

Anti-hormones can be useful in transsexual hormone therapy because they block hormone action or production. There are several mechanisms:

Aggressive hormone therapy indirectly reduces natural gonadal hormone production by fooling the pituitary into thinking that there are plenty of hormones already in the body; consequently, the pituitary reduces the LH and FSH signals that stimulate the gonads.

Postnatally administered hormones do not cause development of primary sex organs (uterus, ovaries, vagina, testes, or penis) that are opposite those born with. However, postnatal contrasexual hormone therapy does cause development of secondary sex characteristics as described below.

2. What effect does female hormone therapy have on a male, and how soon?

The longer after puberty hormone therapy is started, the less effective it is--but not a linear scale, e.g., results are considerably more dramatic in an 18 year old than a 28 year old, but results are not on the average dramatically different between a 38 year old and a 48 year old.

The following effects have been observed in varying degrees--anywhere from little to moderate--with extended treatment. With effective and continuous dosages, most of the changes that a particular body is genetically prone to start within 1 to 4 months, start becoming irreversible within 6 to 9 months, start leveling off somewhat within 18 months, and be mostly done within 3 years. The leveling may take longer if the testes are not removed. High levels of estrogen will cause faster development up to a point, but not better results in the long term than moderate levels of estrogen.

Many people also report the following effects, but they are not verified in any medical literature that the author has read:

Female hormones do not:

The longer after puberty hormone therapy is started, the less effective it is--but not a linear scale, e.g., results are considerably more dramatic in an 18 year old than a 28 year old, but results are not on the average dramatically different between a 38 year old and a 48 year old.

The following effects have been observed in varying degrees--anywhere from little to moderate--with extended treatment. With effective and continuous dosages, most of the changes that a particular body is genetically prone to will start with the very first administration of androgens, start becoming irreversible (only the vocal cord thickening) almost immediately, start leveling off somewhat within 2 years, and be mostly done within 3 years. The leveling may take longer if the ovaries are not removed.

Male hormones do not:

ADMINISTRATION OF FEMALE HORMONES

The popular treatment combinations are:

Some endocrinologists mimic a female cycle by decreasing or eliminating estrogen for one week of the month and/or adding or increasing progesterone for the same week. The author is not aware of solid evidence that this is either beneficial or harmful, although a recent study in females seemed to show that cycling progesterones may decrease the beneficial effect of estrogen on cardiovascular health. The primary effect of cycling is the invocation of extreme mood swings similar to PMS in females.

ADMINISTRATION OF MALE HORMONES

The popular treatment combinations are:

HORMONES ARE DELIVERED BY THE FOLLOWING METHODS:

RESULTS

A hormone therapy regimen that works well for one person may not for another. If development is not well under way in, say, 4 months, some experimentation may be in order; try different hormone types and/or combinations.

Hormone dosage can usually be reduced to a nominal maintenance level after the testes or ovaries are surgically removed.

5. How can the intended effects of hormone therapy be maximized and the dangers minimized?

IN GENERAL:

          + Minimum: liver, thyroid, kidney and lipid (cholesterol)
            profiles; serum prolactin and sugar levels; blood clotting
            time. 
          + Interesting: calcium and phosphorus (skeletal health); serum
            androgen levels. The androgen test is rather expensive, and
            not necessary if one is using clinical results (visible body
            changes and, for male-to-female transsexuals, cessation of
            spontaneous erections) for feedback of therapy
            effectiveness. Particularly in female-to-male transsexuals,
            androgen therapy creates such dramatic clinical results that
            there is usually little reason to pay for the test except to
            satisfy curiousity, or if the clinical results are
            unsatisfactory. 
   
     * Be constantly aware of the body so that adjustments can be made
       if any new problems develop during therapy. 
     * Have regular medical checkups (every 2-3 months); pay close
       attention to vital signs. 
     * Eat well, and take a good multi-vitamin/mineral supplement to
       help be sure the body has everything it needs for new
       development. 
     * Do not start taking the maximum planned dosage of all hormones at
       once. Start with a low dose of one, and carefully watch for
       negative vital signs and symptoms. If there are no problems after
       one month, increase the dosage to the planned level. Wait another
       month before adding the next hormone or anti-hormone. Do not
       change the regimen radically or more often than once per month.
       Give the body time to adjust. 
     * Use the lowest hormone dosage that affords the desired changes.
       Not everyone needs the same dosage, because of differences in
       body weight and genetically-disposed sensitivity to the hormones.
       Hormone dosage can usually be reduced to a nominal maintenance
       level after the testes or ovaries are surgically removed. It is
       not recommended to take pre-operative dosages of hormones for
       more than about 3 years. 
     * Have bone density checked once every few years. 
     * Try the daily dosage of a hormone before moving to a
       sustained-release version, e.g., make sure you are not allergic
       to Provera tablets before you use Depo-Provera (the sustained
       release intramuscular injection). 

MALE TO FEMALE

FEMALE TO MALE

In the U.S., most reputable therapists and medical doctors who regularly work with transsexuals follow the Harry Benjamin Standards of Care, a plan that specifies that one must undergo a minimum of 3 months of psychotherapy to obtain a letter of recommendation to an endocrinologist. One can choose to work with doctors who do not follow the Benjamin Standards, but, in any case, it is a very good idea to meditate and cogitate on the implications for at least 3 months before starting hormone therapy. Some transsexuals find the Benjamin Standards too constrictive--even insulting; others find it worth the trouble to go through the hoop in order to be referred to an endocrinologist who is particularly knowledgeable in the treatment of transsexuals. Choose carefully.

Male-to-female transsexuals: if a sympathetic endocrinologist is not available, try local gynecologists; they are sometimes more understanding, and are used to prescribing estrogens and progesterones.

One should only take hormones that were obtained directly from a licensed pharmaceutical distributor; the quality of drugs obtained through other channels is not only suspect, but likely dangerous-- especially those in injectable form.

Some people are able to get their health insurance company to cover hormones just like any other prescription drug, especially if the doctor prescribes them for a "hormone imbalance" rather than "transsexual hormone therapy." When a health insurance company subcontracts out prescription drug coverage to another company, benefits for hormones are not generally questioned since there is little communication between the two companies.

7. Are birth-control pills a good source of estrogen?

No. Although early birth-control pills contained significant quantities of estrogen, modern ones do not. A typical birth-control pill now contains a tiny dose of progesterone, with or without a tiny dose of estrogen--less than one-tenth the strength required for an effective course of treatment for a male-to-female transsexual. If one is absolutely determined to use a particular birth-control pill, then one should carefully study the PDR to understand the doses of the component hormones of the pill in question, compared to the typical dosages of the same hormones in this FAQ.

8. How can lactation be induced?

This section is provided for curiosity only; the author has no medical references--only anecdotes from other transsexuals and mothers, popular media, and some experience with bovines--to substantiate the answer.

In summary, one has to be committed to the notion of actively and consistently nursing and/or expressing; it is quite a project.

If the milk is to be used for feeding a baby, one should consult the PDR for warnings about usage of hormones and other drugs while nursing.

For more information, try contacting your local chapter of the La Leche Society. They specialize in issues of breast-feeding.

9. How can a male be neutered without causing feminization?

One can cause the gonads to dramatically reduce androgen production by shutting down the output of LH and FSH from the pituitary gland. This can be done one of two ways:

Note that neither of these methods can be used for reliable birth control; some small amount of sperm may still be produced, even if the androgen levels are forced to be very low.

Stopping the administration of progesterone or GnRH agonist will result in the gonads resuming androgen (and sperm) production within a few months. The degree to which production is restored depends on how long the progesterone or GnRH agonist was used; the author's guess is that treatment of more than a few months will result in some degree of atrophy of the gonads; more than six months may result in permanent sterility. There has been little research on the reversibility of this treatment.

10. Exactly what hormones are available? What are the details on popularity, dosage, availability, price, contraindications, adverse effects, etc.?

ESTROGENS

The following estrogens are popular for treatment of male-to-female transsexuals, and are presented in descending order of preference in the humble opinion of the author:

The following estrogens have been suggested for treatment of male-to-female transsexuals, but the author does not have information about how effective they are. Since their primary indication is for replacement therapy in females, they are probably suitable and relatively safe. They are presented in alphabetical order:

The following estrogens have been suggested for treatment of treatment of male-to-female transsexuals, but the author does not have information about how suitable, effective, or safe they are. They are presented in alphabetical order:

The following estrogens have been suggested for the treatment of transsexuals, but, in opinion of the author, the adverse effects strongly outweigh the potential benefits. They are included here for the sake of warning, and are presented in alphabetical order:

The following natural sources of phytoestrogens (estrogen-like compounds) have been identified, but the author is not aware of an effective course of treatment using them. They work by weakly binding to estrogen receptors. In males, this may result in a mild feminizing effect (in females, it may give the opposite result, that is, a mild androgenic effect, since the phytoestrogens are competing with endogenous true estrogens for the estrogen receptors). Since phytoestrogens are not nearly as efficacious as true estrogens, huge and potentially toxic amounts of these items would have to be consumed. They are presented in alphabetical order:

Preparations advertized to contain "raw ovaries" from any animal have not been proven to be effective.

PROGESTERONES

The following progesterones are popular for treatment of male-to-female transsexuals. They are presented in alphabetical in order.

The following progesterones have been suggested for treatment of treatment of male-to-female transsexuals, but the author does not have information about how suitable, effective, or safe they are. They are presented in alphabetical order:

The following natural sources of phytoprogesterones (progesterone-like compounds) have been identified, but the author is not aware of an effective course of treatment using them. Since phytoprogesterones are not nearly as efficacious as true progesterones, huge and potentially toxic amounts of these items would have to be consumed. They are presented in alphabetical order:

ANDROGENS

The following androgens are popular for treatment of female-to-male transsexuals, and are presented in descending order of preference in the humble opinion of the author:

The following androgens have been suggested for treatment of treatment of female-to-male transsexuals, but the author does not have information about how suitable, effective, or safe they are. They are presented in alphabetical order:

The following natural sources of phytoandrogens (androgen-like compounds) have been identified, but the author is not aware of an effective course of treatment using them. Since phytoandrogens are not nearly as efficacious as true androgens, huge and potentially toxic amounts of these items would have to be consumed. They are presented in alphabetical order:

ANTI-ANDROGENS

The following anti-androgens are popular for treatment of pre-operative male-to-female transsexuals. They are presented in descending order of preference in the humble opinion of the author:

The following anti-androgens have been suggested for treatment of treatment of pre-operative male-to-female transsexuals, but the author does not have information about how suitable, effective, or safe they are. They are presented in alphabetical order:

The following natural sources of phytoantiandrogens (anti-androgen-like compounds) have been identified, but the author is not aware of an effective course of treatment using them. Since phytoantiandrogens are not nearly as efficacious as true antiandrogens, huge and potentially toxic amounts of these items would have to be consumed. They are presented in alphabetical order:

ANTI-ESTROGENS

The following anti-estrogens have been suggested for treatment of treatment of pre-operative female-to-male transsexuals, but the author does not have information about how suitable, effective, or safe they are. They are presented in alphabetical order:

OTHER ANTI-HORMONES (GNRH AGONISTS)

These pharmaceuticals can be used to dramatically reduce gonadal hormone production in both males and females. This type of chemical castration might be worth investigating for those cases when the pre-operative TS cannot take the hormones of choice because of other health problems (e.g., hormone dependent tumors or blood clotting disorders), and cannot yet have the surgery performed. They are presented in alphabetical order. Lupron seems to cause more adverse reactions than the others.


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