Hormones

Some Preparatory Thoughts

Please note that I am not - by any measure - competent to offer any specific advice regarding FHT! Nevertheless, I think that "common sense" dictates that anyone (any gender) considering hormonal intervention should first and foremost seek competent professional medical guidance, preferably involving:

• A licensed, transgender-knowledgeable Psychotherapist, *and*

• Your Family Physician, *and*

• A licensed, transgender-knowledgeable Endocrinologist!

Additionally, I think that authoritive guides written by professional, licensed, transgender-knowledgeable medical professionals (physicians, clinicians; clinical research scientists) should be of primary reference, followed by authoritative articles published in peer-reviewed medical journals. As a general rule-of-thumb, I believe that if a scientific / medical article appears in a journal listed in PubMed, it is likely - but not guaranteed - to be suitably peer-reviewed. Although not perfect, the peer-review system ensures that work that ultimately appears in print in these journals has been independently reviewed and critiqued, anonymously, by experts in the field, for clarity, relevance, integrity, and value regarding scientific advancement, prior to acceptance for publication by the scientific / medical journal's Editor or Editorial Staff. Accordingly, I would place "more weight" (trust) in older, peer-reviewed medical literature than in unsubstantiated information available elsewhere, including that provided on most web sites (including this one)!

Selected References & Guides

• *** Feminizing Hormonal Therapy For The Transgendered. A concise, authoritative guide by Dr. Sheila Kirk, M.D.

• Also, anyone considering hormonal therapy should definitely study the WPATH Standards of Care (Sixth Edition), published by WPATH: The World Professional Association For Transgender Health, Inc. WPATH was formerly known as "The Harry Benjamin International Gender Dysphoria Association, Inc. (HBIGDA). The Transsexual Road Map has provided a commentary on these Standards of Care.

• Dr. Anne Lawrence (M.D., Ph.D.) is well-known and is probably a generally reliable source of information. &rarr refer to her Medical & Other Resources for Transsexual Women, as well as her Frequently Asked Questions.
  • Credentials: "About the Author. I'm Anne Lawrence, M.D., Ph.D., author and designer of this site. I am a member of the Harry Benjamin International Gender Dysphoria Association (HBIGDA) and an associate member of the International Academy of Sex Research (IASR). I also serve on the Task Force on Gender Identity, Gender Variance, and Intersex Conditions of the American Psychological Association. I have a private medical practice in Seattle, Washington. A list of my past and forthcoming publications and presentations is available at this site."

  • However, in light of some of my other readings (above, below), I was somewhat puzzled (concerned) by one aspect of her her document Some Typical Hormone Regimens (Nov. 03, 2004). Specifically, even this exceedingly trans-aware does not, in my opinion, adequately differentiate between the various risks associated with different forms of estrogens, including the often-prescribed, but potentially harmul, oral Premarin. Additionally, she states that "Injectable (intramuscular) estrogen (NOT RECOMMENDED)" - regarded by many as be among the safest routes of administration - providing this explanation:
    "Injectable estrogen may cause less clotting tendency than oral estrogen and it is less expensive than transdermal estrogen. However, it requires the use of needles and syringes, and the ability to perform injections; it has a greater tendency to increase serum prolactin levels; and it is often associated with inadvertent or deliberate overdosage. Contrary to the belief of many consumers, there is no credible evidence that injectable estradiol produces superior feminization. I do not recommend the use of injectable estrogen and I no longer prescribe it in my practice."

  • Additionally, this document discusses progesterones and progestins without adequately differentiating bewteen them, in my opinion &rarr please refer here.

• *** Endocrine Therapy for Transgender Adults in British Columbia: Suggested Guidelines
  • This is really an excellent document, I believe - reasonably comprehensive & well-referenced. However, please note this comment!

  • While trans people considering hormonal intervention should study the *entire* document, I will mention two sections:
    • Appendix B: Summary of Harry Benjamin International Gender Dysphoria Association's Standards of Care

    • Appendix C: Informed Consent Form for Feminizing Medications.
      • Appendix C clearly itemizes the risks and limitations associated with hormonal intervention therapy, thus serving as a succinct "reality check!"

• The TransGenderCare.com - Medical Feminizing Program provides the following information, including some useful background (biochemical) information:

  
   About: About the TransGenderCare Medical Feminizing Program.
   Introduction: Introduction to our Medical Feminizing Program.
   Regimens: TransGenderCare's specific regimens and dosing tables.
   Section 1: The Biochemistry of Gender.
   Section 2: The Hormonal System. 
   Section 3: The Biochemistry of Sex Hormones.
   Section 4: The Feminization Regimen.
   Section 5: A Look at Medications.
   Section 6: Typical Results of Male-to-Female Hormonal Therapy.
   Section 7: Measuring Your Transition - Recording Body Size Measurements During Transition.
   Section 8: Male Genital Anatomy - A Summary Review of External and Internal Anatomy.
  

• Internet Discussion ("email") Groups. For some time time now I have been subscribed to several web-based trans-related discussion groups, including:
  • TS-Breasts: " ... for transsexual and trangendered women who are interested in breast growth through hormones, herbs, and surgery. ..."

  • TsDoItYourselfHormones: "This site is strictly for MTF-FTM transsexuals who are already on hormones without a prescription or may be considering starting hormones on their own and are not sure how to go about it. This group can also be used as a guide for obtaining hormones from a doctor. This group is for informational purposes only and is not intended to be a substitute for a doctor's care or advice and is only a source of opinionated information. HORMONES ARE DANGEROUS! Do not substitute what is said here over what a doctor might tell you. Neither I nor anyone in this group will be held responsible for any problems related to information obtained here. ..."

  • TSWoman: " ... This is a support group for all Transsexuals, Pre, Post, & Non Op, and IS NOT for TV/CD's or MALE ADMIRERS. ... This is a spam free site. Feel free to discuss anything that is relative to being a TS Woman EXCEPT: RELIGION , POLITICS or S.E.X. ..."

  • Each of these groups are accessible only to subscribers (free) and are moderated, meaning that annoying posts from spammers, flamers, advertisers, political and all other non-relebant posts are disallowed, which greatly facilitates the overall success and usefulness of these groups. You can participate in the discussions either at the web sites, or via email (for example, I receive emailed copies of all of the posts, that I can read, save or discard, and/or reply to, as I wish).

  • Although having fewer Members, the TSWoman group is more active with regard to the numbers of posts ("discussion threads"), and I personally find that the subject matter postd here is much more relevant, to me personally.

• "Leslea" (leslie_kate) seems particularly knowledgeable, and has provided three excellent guides (MS Word documents) that I think are quite thoughtful and well-written, that can be found in the Files section of TS-Breasts or TSWoman, or at alternative sites on the web (e.g., here). For convenience, I have copies of these files, below - permitted by Leslie permits via the terms of the GNU Free Documentation License at the end of each of these documents:
  1. Estrogen
  • There are many forms of estrogens and routes of administration (regarding the latter, please note this file, and the three guides by Leslea, listed here)! Accordingly, you are advised to carefully study the guide on estrogens by Leslea (above). For example, many protocols, even from "reputable sources," advocate starting with oral Premarin, which is not seem to be the best or safest option - bio-identical forms such as 17β-estradiol provide much lower risk than more complicated forms including Premarin!!

  2. Anti-Androgens

  3. Progestogens: Discusses the differences between progesterones vs. progestins.

  • These differences (progesterone vs. the progestin medroxyprogesterone - a progestin, not a progesterone) are also discussed in this post by Leslea to the TSWoman discussion group.

  • The Endocrine Therapy for Transgender Adults in British Columbia: Suggested Guidelines overall provides excellent information, but - based on the information provided by Leslea - the section of this guide describing Progestins and their usage (pp. A-4 and A-5) is confusing and potentially harmful!

• While not really making specific recommendtions regarding choice of drugs, the document Hormone Treatment in Transsexuals by Drs. H. Asscheman (M.D.) and J.J.G. Gooren (M.D.) nicely summarizes this topic.

• Jennifer O.'s web site, Hormones, appears to have a lot of useful information and sound advice.
  "Jennifer" (or "Savina"?) used to have a file at her old web site, that is no longer available. I had a printed copy, that included this URL: http://www.jennifer-o.com, and found the same information duplicated elsewhere on the web. I used this information to recreate this document:
  • How Are Hormones Delivered? - "In descending order of efficiency and safety, in the opinion of the author: ..."

• FAQ: Hormone Therapy   &rarr   "Mirrored" here: sexuality.org - Hormone Therapy FAQ.

• Tom Waddell Health Center - Protocols for Hormonal Reassignment of Gender (7/24/01)

Desired Outcomes

Excerpted from: Tom Waddell Health Center - Protocols for Hormonal Reassignment of Gender (7/24/01)

I. Treatment Principles

A. Patients' desired outcomes. Each patient has his or her own specific idea or definition of what it is to be transgender or what a transgender person needs. It is essential to explore these ideas and definitions, as patients often have specific goals and expectations in mind when they are in the process of transitioning from one gender to another.

Some common desires include:

1. For MTF:
• Decreased facial/body hair
• Increased breast size/breast growth
• Change in body fat distribution to gynoid "pear"
• Weight loss/weight gain
• Softening of facial skin and other features
• Decreased or elimination of erection/ejaculation
• Maintain a strong transgender identity
• Maintain a strong feminine identity
• Change in voice tone or quality
• Decreased or reverse male pattern baldness
• Vaginoplasty

Drug Interactions

Levels of Estradiol, Ethinyl Estradiol:
Increased by:

Astemizole  /  Cimetidine  /  Clarithromycin  /  Diltiazem  /  Erythromycin  /  Fluconazole
Fluoxetine  /  Fluvoxamine  /  Grapefruit  /  Isoniazid  /  Itrakonazole  /  Ketoconazole
Miconazole  /  Nefazadone  /  Paroxetine  /  Sertraline  /  Triacetyloleandomycin  /  Verapamil

Decreased by:

Benzoflavone  /  Carbamazepine  /  Dexamethasone  /  Napthoflavone  /  Phenobarbital
Phenylbutazone  /  Phenytoin  /  Progesterone  /  Rifampin  /  Sulfamidine  /  Sulfinpyrazone

Levels of Estrogen
Increased by:

Efavirenz  /  Indinavir  /  Vitamin C

Decreased by:
Nelfinavir  /  Nevirapine  /  Ritonavir  /  Smoking  /  Testosterone

"The Drug and Poison Information Centre of BC's Drug Information Reference lists three clinically significant interactions between estrogen and other medications: anticonvulsants (decreased estrogen effect), rifampin (decreased estrogen effect), and corticosteroids (increased corticosteroid effect). A more detailed list of interactions is available from the Transgender Health Program (Appendix A)."