Hormone Replacement Therapy for Transgenders Dos and Don'ts

1
Hormone Replacement Therapy for
Transgenders Dos and Don'ts

• Steven M. Brown, MD
• University of Wisconsin School of Medicine

stevethediseaseslayer_at_yahoo.com
2
A Case Report
3

• What is Hormone Replacement Therapy?

4
What is a Hormone?

• Organic compound, secreted by a gland, in minute
  quantities, into the bloodstream, that has a
  regulatory effect on the metabolism of tissue or
  organs at a site different than the site of
  secretion
• Alter the metabolism of cells or the synthesis
  and secretion of other substances (tropic
  hormones)
• Bind to receptors (specific proteins) to turn
  on functions in target tissues

5
Endocrinology
101Glands Groups of cells which
specialize in the secretion of hormones

• Some important glands
• Pituitary
• Anterior pituitary
• Growth hormone
• Thyroid stimulating hormone
• Adrenocorticotropic hormone (ACTH)
• FSH
• LH
• Prolactin

6
Additional glands

• Thyroid
• Pancreas
• Insulin
• Hypothalamus
• Parathyroid glands
• Adrenal glands
• Cortisol
• Testosterone
• Estrogen
• Aldosterone

7
The sex glands

• Ovaries
• Progesterone
• Estrogen
• Regulate reproduction, bone metabolism,
  regulation of blood cholesterol, breasts, skin
• Testes
• Testosterone
• Regulates reproduction, musculature, bone
  metabolism, cholesterol levels, red blood cell
  production

8
Chemical origins of sex hormones

• Derived from cholesterol
• Chemical structures of estrogen, progesterone,
  testosterone vary slightly
• Testosterone is a metabolite of progesterone
• Estrogen is a metabolite of testosterone
• Production is governed by negative feedback loops
• Present in males and females in differing
  concentrations

9
Chemical origins of sex hormones
10
Changes which occur in puberty

• Pre-wired biological clock, probably in the
  hypothalamus, coincides with practical
  reproductive considerations
• Hypothalamus releases Leutinising
  Hormone-Releasing Hormone (LHRH).
• LHRH passes down nerve endings, stimulates
  pituitary gland
• In girls, around age 10 to 13, FSH and LH are
  producedstarts the cyclic activity of the
  ovaries in the production of estrogen
• In boys, ages of 10 and 14 years, FSH and LH
  switch on testicular function in males (FSH
  triggers sperm production), LH triggers
  testosterone production

11
Why Use Hormone Replacement?

• Change physical appearance to maximize
  consistency between physical identity and
  internal gender identity
• Assist in passing
• Create better skin and hair patterns for
  subsequent cosmetic surgery such as facial
  feminization
• Assist FTM transgenders with beard growth
• For emotional well-being

12
What are some of the obstacles to HRT?

• Patient issues
• Ambivalence, coming out issues, fears of
  violence, fears of rejection, discrimination,
  social stigmatization
• Not transsexual or not intensely transsexual
• Financial considerations social and economic
  marginalization
• Access to health care
• Mistrust of medical establishment
• Ability to have sustained follow-up and
  monitoring
• Medical/behavioral contraindications
• Underlying disease states
• Unfavorable family history
• Unfavorable lifestyle (tobacco, alcohol)

13
What are some of the obstacles to HRT?

• Health care provider issues
• Lack of education
• Lack of clinical experience
• Relative paucity of studies
• Unanswered questions
• Personal discomfort
• Serious complications
• Fear of litigation
• Off-label administration of medications

14
Who Prescribes Hormone Replacement?

• Primary care physician
• Internist
• Family Practitioner
• Gender dysphoria clinic
• Endocrinologist
• Gynecologist
• Urologist
• SRS Surgeon
• Psychiatrists

15
Who SHOULDNT Prescribe Hormones

• Yourself
• Family
• Friends
• Internet buddies
• Urgent care physicians
• On-line doctors
• On-line pharmacies

16
Where Transgenders Get Hormones

• Black Market
• Friends
• Mexico
• Internet
• Local pharmacy

17
SOME IMPORTANT WARNINGS

• NEVER use hormonal medication prescribed for
  another person
• DONT self-medicate
• Use caution in purchasing hormones from Black
  market sources, the Internet, foreign countries,
  mail order houses and vendors who can get it or
  you
• Medication may be impure
• May be contaminated
• Temptation to bypass appropriate monitoring

18
SOME MORE WARNINGS

• Dont double dose
• Dont alter regimen without supervision

19
An HRT Do

• A clinician should collaborate with a mental
  health specialist who has extensive experience
  with the diagnosis of such patients to avoid
  mistreatment with hormones or sex-reversing
  surgical procedures

20
Harry Benjamin International Gender Dysphoria
Association
Standards of Care

• Requirements for HRT in adults
• Age 18 or older
• Demonstrable knowledge of what hormones can and
  cannot do
• Knowledge of social benefits and risks
• Documented real-life test for at least 3 months
  before HRT
• or
• Period of psychotherapy of duration specified by
  a mental health professional (usually 3 months)
• A letter from the mental health professional to
  the prescribing physician
• www.hbigda.org.

21
Some important principles

• There is a lot of misinformation, especially on
  the Internet
• Hormone therapy remains somewhat hit and miss
• Individual results will vary, especially for
  MTF
• Extremely important to let any treating physician
  and pharmacist know of all your medications to
  avoid drug-drug interactions and to reduce
  potential complications
• Need to keep spouse/significant others informed

22
Reproductive options

• To give opportunity to obtain children who are
  genetically their own
• Sperm banking prior to HRT for MTF
• FTMs banking of ovarian tissue or oocytes
• Embryo banking

Gender reassignment and assisted reproduction,
Human Reproduction 16 612-614 (2001)
23
Real-Life Test Pros and Cons

• Pros
• HRT can cause permanent changes including
  sterility and gynecomastia. RLT may confirm that
  transitioning is the right choice
• Cons
• HRT makes it easier to pass and easier to attempt
  RLT
• Most people who would consider hormones are
  pretty sure of what they want by that time
• HRT is diagnostic itselftrue transsexuals will
  feel calmer and relieved upon starting HRT if
  not truly transsexual, changes will cause
  worsening anxiety

24
Purposes of Feminizing Hormones

• Induce the development of female secondary sexual
  characteristics
• Anti-androgen treatment to reduce the effect of
  endogenous male sex hormones

25
An important principlehave realistic
expectations
26
Feminizing Hormones DO NOT

• Cause the voice to increase in pitch.
• Dramatically reduce facial hair growth in most
  people. There are some exceptions with people who
  have the proper genetic predisposition and/or are
  less than a decade past puberty.
• Change the shape or size of bone structure.
  However, they may decrease the bone density
  slightly.

27
Some important DOs

• DO review risks and benefits before starting any
  hormones
• DO be sure that this is what you really, really
  wantpermanent changes can occur within weeks
• DO be patient
• DO eat healthy and exercise
• DO reduce alcohol intake (reduce stress on liver)

28
Some important DOs

• DO have regular medical checkups (every 2-3
  months)
• DO watch your blood pressure
• DO take a good multi-vitamin/mineral supplement
  to help be sure the body has everything it needs
  for new development
• DO give the body time to adjust
• Use the lowest hormone dosage that affords the
  desired changes.
• DO make sure you are not allergic to Provera
  tablets before you use Depo-Provera sustained
  release intramuscular injection
• DO drink fluids, watch potassium intake if taking
  spironolactone

29
Some important DOs of Doctoring

• DO see a reputable doctor for your care
• DO get regular check-ups
• DO be honest and up front with your doctor about
  all medications
• DO make a list of questions prior to each
  visitdont be afraid to ask questions
• EDUCATE your doctor, especially if you disagree
• DO keep records of all changesphysical and
  emotional, and SHARE them with your doctors
• SEE your doctor for any discharge from breasts

30
Some important DONTS

• DONT go out on your own for meds
• DONT alter your medication regimen
• DONT BUY hormones on the Internet or through
  Mexico
• DONT BELIEVE everything you read on the
  Internet, including web pages, bulletin boards,
  and chat rooms
• DONT let your weight get out of control
• DONT smoke
• DONT taking the maximum planned dosage of all
  hormones at once
• DONT take pre-operative dosages of hormones for
  more than about 3 years

31
Effects of Feminizing Hormones on Males

• Effects vary from patient to patientfamilial,
  genetic tendencies
• Younger patients generally obtain and more rapid
  results
• Noticeable changes within 2-3 months
• Irreversible effects within 6 months
• Feminization continues at a decreasing rate for
  two years or more, often with a spurt of breast
  growth and other changes after orchidectomy

32
Effects of Feminizing Hormones on Males

• Breast development
• can take years, begins after 2-3 months
• final size about 1 to 2 cup sizes less than close
  female relatives
• less satisfactory results in older patients
• Only one-third more than a B-cup
• 45 dont advance beyond an A
• growth not always symmetric
• Larger male thorax dilutes effect
• enhanced by progesterone
• nipples expand
• areolae darken

clevelandplasticsurgery.com
33
Effects of Feminizing Hormones on Males

• Loss of ability to ejaculate/maintain erection
  (variable)
• Fertility and male sex drive drop rapidlythis
  may become permanent after a few months
• Increased female-type sex drive/attraction to men

34
Effects of Feminizing Hormones on Males

• Decreased testicular size (mostly flaccid)
• The prostate shrinks but does not disappear and
  prostate cancer is still possible (although risk
  is reduced)
• DO HAVE REGULAR PROSTATE EXAMINATIONS
• Decreased penis size, scrotal size (25 within
  first year), sometimes requiring the patient to
  stretch by hand to maintain adequate donor
  material for SRS
• Spontaneous erections suppressed within 3 months
  (but not totally eliminated)

35
Effects of Feminizing Hormones on Males

• Decreased facial/body hair
• Body hair lightens in texture and color,
  frequently disappears
• Cessation of male pattern baldness
• Limited regrowth of scalp hair which has been
  lost
• Improvement in thickness and texture of scalp
  hair
• Enhanced action of 2 or 5 minoxidil (Rogaine)
• Not much effect on distribution of facial hair
• Enhanced effect of electrolysis
• Decreased rate of growth

36
Cutaneous Effects of Feminizing Hormones on Males

• Redistribution of body and facial fat
• Face looks more femininereduced angularity,
  fuller cheeks
• Redistribution of fat from waist to hips and
  buttocks
• Skin softer/smoother/thinner, more translucent,
  less greasy
• Skin sometimes becomes excessively dry
• Improvement in spots and acne
• Redistribution of fat to hips and buttocks
• Brittle fingernails
• Increased susceptibility to scratching and
  bruising
• Tactile sensation becomes more intense
• Oil and sweat glands become less active,
  resulting in dryer skin, scalp, and hair

37
Effects of Feminizing Hormones on Males

• Sensory changes
• Heightened sense of touch
• Increased sense of smell
• Emotional changes
• More labile

38
Effects of HRT on Metabolism in MTFs

• Metabolism decreases
• Given a caloric intake and exercise regimen
  consistent with pre-hormonal treatment
• Weight gain
• Decreased energy,
• Increased need for sleep
• Cold intolerance

39
Other effects of hormones

• Reduced risk of Alzheimers
• Improved memory

40
Effects of Feminizing Hormones on Males

• Loss of muscle mass
• Loss of strength
• Estrogen prevents bone loss after testosterone
  deprivation

Long-term follow-up of bone mineral density and
bone metabolism in transsexuals treated with
cross-sex hormones, Clinical Endocrinology, 48
347-354
41
Changes in Sexual Orientation

• Of 20 transsexuals of various types that were
  interviewed, 6 heterosexual male-to-female
  transsexual respondents reported that their
  sexual orientation had changed since
  transitioning from male to femalethree of the
  respondents claimed that the use of female
  hormones played a role in changing their sexual
  orientation.
• Daskalos CT. Changes in the sexual orientation of
  six heterosexual male-to-female transsexuals.
  Arch Sex Behav. 199827605-614

42
Risks of Feminizing Hormones Some General
Principles

• Complete risks in transsexuals is not known
• Most studies are performed in biological women
• Limited research regarding risks
• Safety data and Food and Drug Administration
  approval do not acknowledge the use of hormones
  in transsexuals
• All administration is thus off-label
• Mortality not necessarily increased

43
Risks of Feminizing Hormones

• Blood clots
• 12 over age 40
• Usually start in the veins of the legs
• Can break off and block blood supply to the
  lungsa FATAL complication (pulmonary embolism)
• 20-fold increased risk in MTFs
• Risk increased with oral vs. transdermal
  estrogens
• Central retinal vein occlusion has been reported

Mortality and morbidity in transsexual subjects
treated with cross-sex hormones, Clinical
Endocrinology, 47 37-342 (1997)
44
Risk factors for Venous Thromboembolism

• Surgery
• Trauma (major or lower extremity)
• Immobility, paresis
• Malignancy
• Cancer therapy (hormonal, chemotherapy, or
  radiotherapy)
• Previous venous thromboembolism
• Increasing age
• Pregnancy and postpartum period
• Estrogen therapies
• Selective estrogen receptor modulators

• Acute medical illness
• Heart or respiratory failure
• Inflammatory bowel disease
• Nephrotic syndrome
• Myeloproliferative disorders
• Paroxysmal nocturnal hemoglobinuria
• Obesity
• Central venous catheterization
• Inherited or acquired thrombophilia
• Varicose veins
• Smoking

Risk Factors are Cumulative
Geerts et al. CHEST 2004338S-400S.
45
Reducing the Risk of Blood Clots

• Smoking cessation
• Pharmacologic support
• Relaxation therapy
• Behavioral therapy
• Discontinue HRT for 3-6 weeks prior to any major
  surgery, including SRS
• Review HRT with surgeon and anesthesiologist
  prior to minor surgery
• Discontinue HRT in injuries which result in
  immobilization

46
Risks of Feminizing Hormones

• Fluid retention
• Prolactin
• 14, in one study developed elevations
• Pituitary enlargement can sometimes require
  surgery
• Hypertension
• May vary with hormone regimen

Mortality and morbidity in transsexual subjects
treated with cross-sex hormones, Clinical
Endocrinology, 47 37-342 (1997)
47
The Cardiac Risks of Feminizing Hormones

• Most studies have and are being done in biologic
  women
• Much evidence suggests that estrogen lowers
  cholesterol levels, and raises HDL (good
  cholesterol)
• Increases triglycerides, blood pressure,
  subcutaneous and visceral fat
• Decreased LDL particle size (bad)
• Decreased insulin sensitivity (bad)

48
Estrogens and the Heart

• Current studies
• Womens Health Initiative
• 27,500 enrollees without CAD to test estrogen or
  estrogen plus progestin post-hysterectomy
• Womens Angiographic Vitamin and Estrogen
• Womens Estrogen/Progestin and Lipid Lowering
  Hormone Atherosclerosis Regression Trial
  (WELL-HART)

49
Hormones and the Heart

• JAMA July 17, 2002
• Risks and Benefits of Estrogen Plus Progestin in
  Healthy Postmenopausal Women
• 16,608, ages 50-79 studied
• Received placebo or Premarin plus Provera
• Study stopped after 5.2 years because of
  significantly increased risk of cancer in
  treatment group
• Reduced risk of colorectal cancer and hip
  fractures
• Increased risk of coronary artery disease,
  pulmonary embolism, stroke

50
Hormones and the Heart

• What is the risk-benefit ratio in post-menopausal
  women?
• Decreased hot flashes
• How does the risk-benefit ratio differ in
  transgenders?
• Physical feminization
• Reduced emotional stress

51
Reducing the Odds of Cardiac Complications

• If theres a history or strong family history of
  heart attack, coronary artery disease, or stroke
• Close supervision by a cardiologist, stress test
• Blood pressure, lipid control, blood thinners
• Estradiol (Estrace 1 or 2 mg), a naturally
  occurring estrogen, is preferred to Premarin
• Usual dose is 4 mg daily pre-op, 2 mg daily
  post-op
• Natural progesterone (Prometrium) does not have
  the adverse effects of medroxyprogesterone
  (Provera) on blood cholesterol or blood pressure
  levels
• Consider daily administration of aspirin 81 mg
  daily
• Reduce risk factors
• No smoking
• Watch weight
• Watch blood sugar

52
Risks of Feminizing Hormones

• Gallstone disease
• Liver disease (low risk)
• Weight gain
• Mood swings

53
Risks of Feminizing Hormones

• Cancer risk
• Fibroadenomathe most common breast tumor
• Influenced by estrogen
• Estrogen receptors present in 28-100 of patients
  with fibroadenoma
• Breast cancer
• Prostate cancer
• Has been reported

54
Contraindications to HRTin FTM Patients

• Absolute
• History of thromboembolism or thrombotic tendency
• History of macroprolactinoma
• History of breast cancer
• Active substance abuse
• Relative
• Coronary artery disease
• Cerebrovascular disease
• Hepatic dysfunction or tumor
• Strong family history of breast cancer
• Cholelithiasis
• Poorly controlled hypertriglyceridemia
• Poorly controlled diabetes mellitus
• Refractory migraine headaches
• Heavy tobacco use
• Uncontrolled hypertension

Endocrine Therapy of Transsexualism and Potential
Complications of Long-Term Treatment, Archives of
Sexual Behavior, 27 209-226 (1998)
55
DO Get Appropriate Monitoring

• Follow-up exams every 2 3 month
• Breast exam
• Measurements
• Looking for galactorrhea
• Weight
• Blood pressure
• Testicular size
• Examination of extremities for phlebitis, edema
• Visual fields

56
Appropriate laboratory monitoring

• Liver function tests
• Lipid profile
• Renal (kidney) function
• Blood pressure
• Fasting glucose
• Thyroid function
• Blood clotting times (every 6 12 months)
• Testosterone levels (lt50 ng/dl) in MTFs
• Prolactin (rule out prolactinoma)
• Breast self-examination
• Prostate examination
• Pregnancy testing (FTMs)

57
Monitoring changes

• Estrogen levels
• Testosterone levels (especially in pre-ops) or if
  considering antiandrogens in a post-opcan
  usually be followed o clinical grounds

58
MTF MonitoringJohns Hopkins
59
Other Tests Which Can Be Followed

• Calcium and phosphorus (skeletal health)
• Bone densitometry every two or three years

60
Testosterone levels

• 300-1000 ng/dl genetic males
• 5-85 ng/dl genetic females

61
Estrogen levels

• Levels may be misleading secondary to
  insensitivity of assays
• Dosing is more commonly made on clinical grounds

62
Administration of Hormones

• Orally (estrogens, progesterones, androgens)
• Advantage convenience
• Disadvantage increased stress on the liver

63
Administration of Hormones

• Sublingual
• Dissolve under the tongue
• Better absorption
• Avoid passing through the liver which may
  stimulate clotting problems
• Injections (estrogens, progesterones, androgens)
• Advantages
• Preferred in setting of liver disease
• Preferred mode of delivering androgens
• Disadvantages
• unsteady hormone levels (except for
  sustained-release preparations in oil or
  microscopic beads)
• pain
• infection risk from hypodermic needle usage

64
Administration of hormones

• Skin patches
• Advantage
• Convenience
• Disadvantage
• skin irritation, allergy to adhesive
• Cream (estrogens)
• Advantage
• moister and healthier skin.
• Disadvantage
• low transfer rate into the body,
• requires frequent spread on very large skin
  surfaces.

65
Dosing of HRT in Male to Females

• No generalized agreement
• General principles
• DONT mix drugs within categories
• Need drugs from these two categories
• Anti-androgens (discontinued post-operatively)
• Estrogens

66
Taking Just One Class of Medications

• Anti-androgens alone
• Serious bone density loss
• Estrogens alone
• Does not lower testosterone levels

67
Common anti-androgens

• Cyproterone acetate (Androcur, Cyprostat)
  (antigonadotropic)
• Not available in United States
• Androgen receptor antagonist
• 50-150 mg/daily
• Oral or injectable
• Risk of liver damage, thromboembolic disease
• Altered carbohydrate metabolism
• Medroxyprogesterone
• Nilutamide (androgen receptor blocker)
• Finesteride Propecia (testosterone
  antagonistdecreases DHT)
• 5 mg daily
• Reduces male pattern baldness

68
Androgen receptor antagonists

• Flutamide (Eulexin)
• Androgen receptor antagonist
• Hepatotoxic
• Reduced blood counts, including platelets
• Hypertension
• Fluid retention
• Depression, anxiety, nervousness, lassitude,
  insomnia, GI disturbances
• 250 mg one to three times daily

69
Antiandrogens

• Spironolactone
• Weak androgen receptor antagonist
• Diuretic
• Can cause elevated potassium levels
• Antihypertensive
• 100 to 400 mg daily

70
GnRH Agonists

• Act on pituitary
• Overstimulating pituitary
• Then desensitizing it to GnRH from hypothalamus
• Used in adolescents to delay puberty or when
  hormones are withdrawn prior to surgery to reduce
  reversion to male
• Limited experience
• Drugs
• Nafarelin acetate nasal spray
• Goserelin acetate injection
• Lupron
• Leunrorelin acetate

71
A word about herbals

• Not benignpotential for liver injury
• Still a medication and self-medicating
• Unregulated by FDA

72
Common estrogens

• Estradiol valerate (Estrace)
• Equivalent to natural 17 b-estradiol
• May be safer than ethinylestradiol
• Reduced risk of breast cancer and thrombosis
  although how much risk reduction in high doses of
  transsexuals is not known
• 4-6 mg pre-op in divided doses
• 1-2 mg daily post-op
• Best combined with an antiandrogen
• If hot flushes, night sweats appear, switch to
  ethinylestradiol may be helpful

73
Common estrogens

• Ethinylestradiol (Estinyl)
• Slowly metabolized by the liver, resulting in
  greater potency and longer half life
• Regarded by many as pre-op drug of choice
• More intense feminizing effects
• 50 mg twice daily, gradually reduced to 50 mg

74
Common estrogens

• Conjugated natural estrogens (Premarin)
• From urine of pregnant mares
• Ethical issues
• More expensive
• 5 7.5 mg daily pre-op (divided doses)
• 1 2.5 mg daily post-op

75
Common estrogens

• Estraderm patches

76
Common progestogens

• Anti-androgenic
• Not feminizing alone
• Enhances feminization from estrogen
• May help maintain libido
• May reduce cancer risk associated with estrogens

77
Medroxyprogesterone acetate Provera

• Good safety record
• May be slightly virilizingmay be metabolized
  into testosterone
• If virilization occurs, switch to dydrogesterone
• Typical dose 5 mg twice daily pre-op for 10 days
  of the month
• May enhance breast development
• 2.5 5 mg daily post-op

78
Natural Progesterone

• Micronized progesterone
• Progesterone USP
• Prometrium
• Molecular structure closer to the progesterone
  produced in a natal female's body
• Provera has been linked to depression in trans
  women
• Less androgenic
• More costly

79
Common HRT in the United States

• Estrogen preparations
• Conjugated estrogens (Premarin) 2.5-5.0 mg/day
• Estradiol (Estrace) 2-6 mg/day
• Ethinyl estradiol 0.100-0.300 mg/day
• Estradiol transdermal patches 0.1-0.4 mg twice
  weekly
• Estradiol valerate 20-40 mg every 2 wk
• Antiandrogens
• Spironolactone 200-400 mg/day

80
Failure to Respond

• In no changes are seen (including tender
  nipples) within 2-3 months
• or
• Feminization is very limited over a longer period
  of time

• Serum testosterone, DHEAS levels to rule out
  overproduction of androgens
• Referral to an endocrinologist

81
FTM Hormone Replacement

• Females respond quite well to hormone replacement
  as adolescents and as adults
• Experience all the changes that genetic males
  experience during puberty
• Most of these changes are irreversible

82
Why is FTM easier than MTF?

• In FTM, addition of androgens excites androgen
  receptors which are there but dormant
• Puberty occurs again, but differentiating as a
  male this time
• In MTF, bodies are already differentiated by the
  natural presence of androgen
• Males are thus immune to further pubertal
  changes

83
Effects of Masculinizing Hormones on Females

• Acne
• Male pattern baldness
• Increased muscle mass and development
• Growth of facial and body hair
• Thickening of vocal cords and deepening of voice
  (not always reversible), not always down to
  typical male pitch

84
Effects of Masculinizing Hormones on Females

• Enlarged clitoris (3-8 cm) with increased
  libidocan become overly, painfully sensitive,
  peaks after 2-3 years
• Atrophy of uterus and ovaries
• Growth spurt, closure of growth plates before
  puberty
• Increased bone density
• Reduced risk of blood clots

Testosterone increases bone mineral density in
female-to-male transsexuals a case series of 15
subjects, Clinical Endocrinology, 61
560-566 Venous Thrombosis and Changes of
Hemostatic Variables during Cross-Sex Hormone
Treatment in Transsexual People, J. Clin.
Endocrin. Metab. 88 5723-5729 (2003)
85

86
Effects of Masculinizing Hormones on Females

• Fertility decreases--menstrual cycle becomes
  irregular then stops, usually within 5 months
• Outer skin layer becomes rougher in feeling and
  appearance
• Prominence of veins
• Fat is redistributed. The face becomes more
  typically male in shape. Fat tends to move away
  from the hips and toward the waist
• Body odors (skin and urine) change. They become
  less "sweet" or "musky" and become more "tangy"
  or "metallic."
• Emotions change. Aggressive and dominant feelings
  may increase

87
Male hormones DO NOT

• Significantly decrease the size of the breasts.
• However, they may soften somewhat
• Change the shape or size of bone structure
• Grow a penis
• Prevent pregnancy
• Work overnight

88
Risks of Masculinizing Hormones

• Ovarian cancerlong-term exposure to endogenous
  and exogenous androgens are associated with
  ovarian epithelial cancer
• Steroids increase epidermal growth factors and
  transforming growth factor (TGF-a) which promote
  cancer growth
• Polycystic ovaries
• Endometrial hyperplasiarisk of endometrial
  cancer
• Breast cancerbreast cells may remain even after
  mastectomy

Ovarian Cancer in Female-to-Male Transsexuals
Report of Two Cases, Gynecologic Oncology 76
413-415 (2000)
89
Risks of Masculinizing Hormones

• Reduced HDL cholesterol (bad)
• Reduced LDL particle size (bad)
• Increases triglycerides
• Polycythemia (elevated red blood cell levels)
• Increased sweating
• Increased metabolism
• Hot flashes

90
Risks of Masculinizing Hormones

• Water and sodium retention
• Decreased carbohydrate tolerance
• Obesity and insulin-resistance
• Sleep apnea
• Increased aggressive behavior, hypersexuality
  (rare)
• Excessive testosterone can convert to estrogen,
  increase risk of breast cancer

91
Testosterone and the Liver

• Testosterone-induced hepatotoxicity
• Increased liver enzyme levels are a frequent
  occurrence
• occurs in about 15
• Hepatic adenomas
• Hepatocellular carcinomas
• Peliosis hepatitisblood-filled cavities in the
  liver

92
Contraindications of HRT in FTMs

• Absolute
• Pregnancy
• Active substance abuse
• Relative
• History of breast or uterine cancer
• Polycythemia
• Hepatic dysfunction or tumor
• Coronary artery disease
• Hyperlipidemia
• History of violent behavior
• Severe obstructive sleep apnea
• Androgen sensitive epilepsy
• Migraines
• Bleeding disorders (for injected testosterone)

Hormone replacement therapy (trans) http//en.wikp
edia.org/wiki/Hormone_re-placement_therapy_(trans)
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Common Androgen Replacement

• Injectable testosterone
• Testosterone enanthate 100-400 mg IM every 2-3 wk
• Testosterone cypionate 100-200 mg IM every 2-3 wk
• Can be self-administered
• Transdermal testosterone
• Testosterone transdermal patches 2.5-7.5 mg/day
• Testosterone gel 1 (AndroGel) 2.5-10 g/day
• Risk of inadvertent exposure to others who come
  into contact with skin

EXCESSIVE TESTOSTERONE MAY LEAD TO STROKE AND
HEART ATTACK
Endocrine Therapy of Transsexualism and Potential
Complications of Long-Term Treatment, Archives of
Sexual Behavior, 27 209-226 (1998)
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Other androgen replacement

• Testosterone pellets (Testopel)
• 6 -12 pellets under the skin every three months
• Local anesthetic
• More constant blood levels
• Oral
• Andriolnot available in the US
• Has to pass through liver
• Sublingual/buccal lozenge
• Striantabsorbed through oral mucosa, avoiding
  liver
• Gum irritation
• Taste changes
• Headaches

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Drug Interactions of Testosterone

• Drugs which decrease levels of testosterone
  levels
• Phenobarbital and Dilantin (seizure medicines)
• Rifampin
• Alcohol!
• Drugs which increase levels of testosterone
• Serzone, Prozac, Paxil (antidepressants)
• Sporanox, Diflucan (antifungals)
• Tagamet
• Biaxin, Zithromax (antibiotics)
• Protease Inhibitors (HIV treatment)
• Testosterone can also alter the effects of other
  drugs
• Increase the blood thinning effect of Coumadin
• Decreases the effectiveness of Inderal
  (propranolol) a blood-pressure medicine
• Increases the effect of some oral medicines for
  diabetes and can cause dangerously low blood
  sugar levels

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Progesterone Treatment in FTMs

• Short-course progesterone therapy to
• Induce menstrual period in first 2 years to shed
  build-up of endometrial lining (if a hysterectomy
  has not been performed)
• Reduces spot bleeding
• Decreases risk of uterine cancer

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FTM MonitoringJohns Hopkins
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Some FTM Dos

• Prior to hormone therapy, consider hysterectomy
  and bilateral salpingo-oophorectmy
• Eliminates risk of ovarian cancer
• Saves awkward situation of doing a hysterectomy
  on a masculinized patient
• Stress management
• Giving blood
• Be patient
• PAP smears, pelvic examination if you still have
  a uterus
• Check bone densitometry
• Endometrial ultrasounds every two years
• Take a calcium supplement

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Some FTM Donts

• Dont buy too many shoesyour feet will grow
• More is not better