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Hormone Replacement Therapy for Transgenders Dos and Don'ts

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Title: 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)
93
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)
94
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

95
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

96
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

97
FTM MonitoringJohns Hopkins
98
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

99
Some FTM Donts
  • Dont buy too many shoesyour feet will grow
  • More is not better
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