------------Estrogen Therapy for MTF Transsexuals------------- 

This issue I thought I'd digress from my usual "do it
yourself" topics to something you should not "do yourself" - the
use of estrogens by transsexuals. Most of this admittedly
technical information I obtained from research at the Santa Clara
Valley Medical Center library, though literature is scarce on the
subject even there.

Estrogens are powerful steroid hormones, chemicals which
affect the form and function of the body and its organs.

There are three basic human estrogens: estradiol, estrone, and
estrial. Estradiol is the most active form and estrial is the
least active. In women, large amounts of estrogen are produced
by the ovaries, and in men a small amount is present due to
chemical conversion of testosterone.

Once you are grown and genetic male traits are fully
developed, the only way your body organs have of knowing what sex
you are is by the levels of male and female hormones which are
present. Changing the hormone balance from male to female with
drugs causes tissues which are supported by male hormones to
diminish and stop functioning and those which are supported by
female hormones to develop and begin functioning.

If your doctor has prescribed estrogens for you, it is
probably in the form of Estinyl (ethinyl estradiol), Premarin
(conjugated estrogens, a mixture of the three estrogens plus
estrogen breakdown products) or injections (such as estradiol
valerate). Though it would seem to be desirable, no suppository
form of estrogen is available except as in the form of D.E.S, a
drug which is not in favor today.

The most powerful single oral dose is the 0.5 milligram Estinyl
tablet, but faster results can be obtained by using two or even
all three of the Estinyl, Premarin, and injections. Any of the
three will produce in time a certain amount of bodily
feminization. (Note: Premarin alone has been shown to be unable
to reduce blood testosterone levels to a female normal, though
Premarin alone does produce feminizing effects, albeit slowly. 

Also: generic Premarin has become suspect as to its quality,
potency, and purity - many pharmacists discourage use of the
generic, or suggest that dosages of the generic be increased
relative to the dosage of the brand name Premarin product.)

The effects include breast development (usually slight to
average development; occasionally nearly none or quite a lot,
depending on genetics and body type), reduction in size and
firmness of the testicles and prostate gland, some reduction and
repatterning of body hair, softening of the skin, recontouring of
the body due to accumulating layers of feminine body fat, a
considerable reduction or elimination of (masculine) sex drive,
and improved effectiveness of facial hair removal by
electrolysis.

Testosterone levels in the blood drop to very low levels due to
effects of estrogen on the brain and directly upon the testicles. 
Since testosterone tends to fuel the male emotional
characteristics of aggression and competition, many patients
report feeling more mild or tranquil. Reduction of male hormone
levels may also clear up acne and excessively oily skin. Little
or no changes in voice quality can be expected, though sometimes
a slight increase in range is noted.

The cost of oral hormone supplements is not excessive.
Typical prices are: Provera 10 mg. 100 units, $40 (generic
medroxyprogesterone HCL is much less.); Premarin 2.5 mg 100
units, $45 (generic less but not recommended); and Estinyl 0.5 mg
100 units, $55 (no generic available). Injections may run $15-40
plus office visit charges. Black market prices for the above
begin at about three times the pharmacy cost.

Choice of an endocrinologist is best made by personal
referral, either by a friend or therapist. The regimen and
requirements of doctors varies widely, as does their level of
experience in this very specialized field. Many doctors require
concurrent counseling by a psychiatrist or psychologist.

If you experience any dissatisfaction with your therapist or
doctor, a consultation with another may produce different
results. There is little concrete knowledge of transhormonal
therapy in the medical profession, and research on the subject is
scarce - your doctor's expertise is probably mostly due to his or
her experience. At the very least, your doctor should have good
general experience in the administration, effects, and side
effects of female hormones, and be aware of the Standards of Care
(the Harry Benjamin International Gender Dysphoria Association
criteria for surgical and hormonal treatment of transsexuals.)

Your doctor may be cautious in prescribing large amounts of
estrogens to you if you have any of the following history or
symptoms: high blood pressure, any heart disease or defects,
clotting disorders such as phlebitis, stroke or cerebrovascular
disease, liver function abnormalities, a history of heavy alcohol
intake, kidney disease, migraine headaches or seizures, diabetes,
family history of breast cancer, obesity, or heavy smoking.

Periodic checkups with your doctor are required to spot early
signs of certain dangerous conditions. Among these are: benign
or malignant tumors of the liver, breast, pituitary gland (in the
brain), and kidney, along with phlebitis and elevation of blood
pressure. Heart attack (myocardial infarction) and stroke have
been reported in relatively young transsexuals receiving
estrogens, especially those with clotting disorders. Changes in a
part of the prostate gland known as the verumontanum can cause
blockage of the urinary tract after long term use - this must be
corrected surgically. Lactation or discharge from the breasts
can be a sign of a potentially dangerous pituitary gland
condition.

Your doctor will administer periodic blood tests and may
check the following: testosterone (should be less than 85
nanograms per 100 milliliters), prolactin (should be less than 45
ng/ml), liver function scans, and clotting time. He may also
feel your breasts for lumps and listen to blood flow in your
major veins and arteries.

Once you have been using estrogens for a year or more, some
effects may become irreversible even if estrogen intake is
ceased. Certain chemical processes in the brain remain in a
female pattern permanently, and changes in brain wave patterns
have been reported. These effects may or may not be associated
with emotional and personality changes. Breasts and female fat
distribution may not subside after administration of estrogens,
and sex drive may remain relatively low. For these reasons, it
is important to be certain of your commitment to feminization of
your body.

Sudden changes in dosage of estrogens, either increasing or
decreasing, have been known to produce severe mood changes. The
effects may be likened to going through menopause, puberty, and
pregnancy at the same time. Lethargy, depression, anxiety,
difficulty in concentration, headaches, abdominal cramping,
nausea, and other symptoms have been noted for periods of days or
weeks. It may be wise to change dosages as gradually as
possible. (Despite what your doctor may tell you!)

Changes in metabolism are common, with weight gain, water
retention, and increased appetite as the major effects. Estrogen
reduces the ability of the body to eliminate certain drugs such
as Valium so that smaller dosages of these medications become as
effective as larger dosages were before. This is also true for
alcohol so be sure to reassess your limits - this explains why
the tolerance for alcohol of women is typically less than that of
men. Any physician you deal with should know of any medications
you are taking - with surgery this can be critical due to the
effects of estrogen on the blood clotting rate.

After genital surgery, estrogen doses may be greatly
reduced if the desired degree of feminization has been achieved. 
Since the testicles are now absent, it is no longer necessary to
suppress testosterone production. Risk factors are believed to be
in proportion to dosage, so the minimum effective dose is
preferred for long term use. This means reducing dosage by a
factor of one fifth to 1/20th of previous levels.

Risks of estrogen use can be minimized by having injections
alone. Injections of Delestrogen, Estradurin, etc. cause the
estrogen to enter the bloodstream directly, without the first
pass through the liver. This means the liver works much less hard
in metabolizing the estrogen, and can return to doing the normal
work that the liver does in digesting food and eliminating
toxins. Injections are given deep into the muscle tissue of the
buttocks, once a week to once a month. The effects are similar to
the higher doses of oral hormones, and sometimes it appears that
feminization progresses further with injections than with orals.
If the injections are done at a doctor's office, the costs may be
about equal to the cost of oral pills - but individual doctors'
rates and charges vary a lot in this area.

Generally, an endocrinologist who prescribes injections can
be persuaded to teach you to administer the injections yourself,
with a short training session. By doing the injections yourself,
and buying generic versions of the injectables, you can save up
to 90% of the costs of oral hormones, making this by far the
least expensive alternative. If you are going to be using
hormones the rest of your life, and wish the safest, most
effective, and cheapest method, then make self-injection your
goal.

It is thought that estrogens should be taken along with a
progestin (a chemical with effects similar to progesterone) such
as Provera (medroxyprogesterone). A progestin will tend to
maximize breast development due to enlargement of the milk sacs
themselves (as opposed to breast fatty tissue) and will
approximate more closely the natural female hormone balance. A
more natural hormone balance may provide some shielding against
some of the hazards mentioned previously. Also progestins
greatly reduce male sex drive. I could find no agreement in the
literature as to the recommended dosage but higher dosages seem
to pose no known risk.

REAL progesterone in the form of capsules is now available,
but rather expensive ($1.25 to $5.00 per daily dose). Real
progesterone is available as an injection also, at a very low
price - the disadvantage is that the effects last only 3-4 days,
so an injection twice a week might be called for. Real
progesterone has ALL the benefits of progesterone, instead of
only some of them as with progestins. Most doctors who give
injections use Delalutin (hydroxyprogesterone caproate) instead
of real progesterone, but the TS giving herself her own
injections might consider using real progesterone instead,
because of the reduced costs.

Proper medical management of estrogen administration can
reduce the hazards and maximize the benefits of transhormonal
therapy. It makes good sense to know the facts and follow
medical advice when using these powerful drugs.

This article was originally written for the ETVC Newsletter and
later appeared in the newsletter of the Rainbow Gender
Association, San Jose. Individuals are invited to copy or
distribute this article, provided that the full text is included
and proper credit is given. 

SOURCE: FEMINET