From the October & November 2000 Issues
TRANS WORLD MED
By Cerise Richards, M.D.
Promises and
Pitfalls of Trans HRT
Hormone
Replacement Therapy (HRT) is a term which originally referred to the need
for menopausal 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, Trans-HRT (THRT) refers to the desire to change the
body's balance of Estrogen and Testosterone 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. 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 underpins 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 ovarian 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 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 genitals. 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 facial 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.
MtF Hormone Therapy 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 side effects except for possible wound
infection or post-op 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 may be 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
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 have also 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 above drugs,
should be used in combination with estrogens for MtFs. Proscar (Finasteride)
may become a viable alternative because it suppresses the conversion of testosterone
to dihydrotestosterone, 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 Provera, medroxyprogesterone
acetate (MPA) and weekly injectable DepoProvera, which appears to decrease
pituitary gonadotropins, allowing adequate testosterone suppression in MtFs.
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 pregnant women and a large Veteran's 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 MtFs
has been drastically reduced and continues 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.
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 MtFs. Therefore mammograms become necessary. But can you
imagine the satisfaction. Actually approximately 50% of TSs go on to have
breast implants because for some people natural is just not enough. 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.
Female to Male Hormone Therapy
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 or 200-300 Mg of one 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, but the daily transdermal patch may
achieve the same results provided it is used in conjunction with 5-10 Mg 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. As treatment continues the ovaries
will resemble polycystic ovaries which have been associated with ovarian cancer
in two TSs. 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.
Testosterone has been associated with the development of Prostatic cancer
in 3 MTFs and therefore everyone needs to check their PSA annually. (Please
refer to the Trans World Med article regarding PSA in the March 2000 issue
of TGC News.) The cardiovascular complications seen with Estrogens are not
seen with Testosterone.
Well, what about all those phyto-estrogens
(PE) that you read so much about. PE are plant substances that can chemically
mimic estrogens by weakly binding to estrogen receptors. Their relative strength
appears to be in the range of 1:1000 to 1:100,000 when compared to estradiol.
PE are found in many food products such as soy, rye, flax, alfalfa, hops,
beer, tea, wine, coffee, spinach, broccoli, carrots, dried beans and herbal
medicines as saw palmetto, black cohash, wild yam and PC-SPES. The main classes
are the isoflavones, coumestans, lignans, phytosterols, and flavonoids. As
extrapolations of experiments on the cellular level in animals and population-based
studies in humans, PE have been imbued with beneficial properties that can
improve lipid profiles and cardiovascular disease, prevent breast and prostate
cancer, prevent osteoporosis and improve hot flashes in menopause. In most
of these areas there are contradictory papers and claims, except in the area
of soy products where isoflavones are quantified and their effects measured
in humans by looking at the levels of LH, FSH, estradiol, progesterone, estrone
and DHEA. In controlled diets, it does not appear that they can change these
hormonal levels in menopausal women.
Recently it has been discovered
that PE exhibit estrogenic and anti-estrogenic properties. It is naive to
assume that because they are naturally occurring compounds that they are safe
or effective as homeopathic medicines. Soy products have been shown to cause
hypothyroidism and goiter in babies and premenopausal women when they consume
2 oz. of soy protein or 40 milligrams of isoflavone per day. If the active
PE of herbals could be measured and a dose to effect relationship established,
then at least you would know what you are getting in the bottle and whether
it would be beneficial or toxic. In Germany such a movement is under way,
but in the U.S. there is no regulation of herbal remedies. My conclusion is
that you are completely in the dark and on your own with these preparations.
"Caveat Emptor."