Hormone replacement therapy (trans)

Hormone replacement therapy (HRT) for transgender and transsexual people replaces the hormones naturally occurring in their bodies with those of the other sex. Its purpose is to cause the development of the secondary sexual characteristics of the desired gender. It can not undo the changes produced by the first natural occurring puberty of transgender people, this is done by sexual reassignment surgery and for transwomen by epilation. Some intersex people also receive HRT, either starting in childhood to confirm the gender they were assigned, or later, if this assigment has proven to be incorrect.

HRT male-to-female

For transwomen, taking estrogens causes among other changes:

Related Topics:
Transwomen - Estrogens

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• the growth of breasts, with concomitant enlargement of the nipples, and
• redistribution of body fat.
• thinning of skin.

For male-to-female transgendered people, HRT often includes antiandrogens in addition to the estrogens and progestagens mentioned above.

Related Topics:
Transgendered - Antiandrogens - Estrogens - Progestagens

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HRT does not usually cause facial hair growth to be impeded; or the voice to changehttp://heartcorps.com/journeys/voice.htm.

Related Topics:
Facial hair - Voice

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Changes

Irreversible changes:

• breast development,
• enlarged nipples,

Reversible changes:

• decreased libido and changes in sexual behavior,
• redistribution of body fat,
• reduced muscle development,
• various skin changes,
• significantly reduced body hair,
• change in body odor and sweat production
• less prominence of veins

The psychological changes are harder to define, since HRT is usually the first physical action that takes place when transitioning. This fact alone has a significant psychological impact, which is hard to distinguish from hormonally induced changes. Many also report feeling more confident.

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Contraindications

• Absolute: history of estrogen sensitive cancer (for example breast cancer), history of thromboembolic disease (unless provided with concurrent anti-coagulation therapy), or history of macroprolactinoma.
• Relative: Liver, kidney, or heart disease and stroke (or any of the risk factors for heart disease: high cholesterol, diabetes, obesity, smoking); Strong family history of breast cancer or thromboembolic disease; Gallbladder disease

Types of Therapy:

Estrogens:

• Doses are often higher than replacement doses for cisgender women
• Injected, oral, and transdermal formulations are available.
• As dosage increases, risks increase as well. Therefore, women with relative contraindications should start at lower doses and increase dosage more gradually.
• Transdermal estrogen may be preferable in older transwomen and smokers as it may have less of an increase in risk for thromboembolism. However, the number of patches needed and cost may make this less practical. Furthermore, transdermal estrogen carries the risk of localised skin irritation.

Antiandrogens:

• Spironolactone is the most frequently used anti-androgen because it is relatively safe and inexpensive
• Spironolactone is a 'potassium sparing diuretic' that is also used to treat hypertension, edema, and low potassium levels caused by other diuretics. It can cause elevated potassium and is therefor contra-indicated in people with renal failure or who otherwise have elevated potassium levels.
• GnRH agonists such as goserelin acetate, though not strictly anti-androgens, may also be used successfully in the suppression of gonadal hormones.

Hormone Effects:

Cardiovascular:

• The most significant cardiovascular risk for transgender women is the pro-thrombotic effect of estrogens. (Increased blood clotting.) This manifests most significantly as an increased risk for thromboembolic disease: deep venous thrombosis (DVT) and pulmonary embolism (PE) which occurs when DVTs break off and migrate through the venous system to the lungs. It is important for any person on female hormones to immediately seek medical care if she develops pain or swelling of one leg (especially calf) as this is the predominant symptom of a DVT, or if she develops symptoms of PE: chest pain, shortness of breath, fainting, or palpitations (even without leg pain or swelling).
• In practice this becomes very important to transgender women undergoing surgery. Hormones should be withheld for a week before until two weeks after surgery.
• DVTs occur more frequently in the first year of treatment with estrogens. However this may represent a 'screening by treatment' of patients who may have genetic predispositions to thromboembolic disease, with those who are more likely to develop DVTs doing so early on in therapy. However, if patients have a family history of thromboembolic disease, screening for known disease may be appropriate.
• DVT risk is greater with oral rather than transdermal estrogens.
• DVT risk also increases with age and with smoking, so many clinicians advise using the safer transdermal formulations in patients who smoke or are older than age 40.
• If screening is undertaken for known pro-thrombotic mutations such as Factor V-Leiden, antithrombin III, and protein C or S deficiency, it should be done so to increase the safety of hormonal therapy and not as a screen for who may undertake hormonal therapy. Given that the risk of warfarin treatment in a relatively young, well-informed, and otherwise healthy population is quite low and that the risk of adverse physical and psychological outcome for untreated transgender patients is high, a prothrombotic mutation is not an absolute contraindication for hormonal therapy. (See: Levy, et al ?Endocrine Intervantion for Transsexuals? Clin Endo 2003. 59:409-418.)

Hair:

• Current facial hair is only slightly affected (some reduction in density, coverage, and slower growth) by anti-androgens. Those who are less than a decade past puberty and/or whose ethnicity generally lacks a significant amount of facial hair will have better results with anti-androgens. Those taking anti-androgens will have better results with electrolysis/laser hair removal than those who are not. If one is still in their teens or early twenties, there will be prevention of new facial hairs from developing if testosterone levels are within the female range.
• Body hair (chest, periareolar, shoulders, back, abdomen, rear, thighs, tops of hands, tops of feet, and even nose and ear) will, over time, turn from terminal ("normal") hairs to vellus hairs (very tiny, blonde "baby" hairs). Hair on the arms, perianal, and perineal will reduce but may not turn to vellus hair on the latter two regions. Lower leg hair becomes less dense in concentration. All depending upon genetics.

Urogynecological Effects:

• Transgender women report a sometimes significant reduction in libido, all depending upon the dosage of anti-androgens. A small number of post-operative transsexual women may take small amounts of testosterone to boost the libido. Many pre-operative transsexual women simply wait until after sex-reassignment surgery to begin an active sex life (due to how they feel towards their genitals and/or an aversion to anal sex) and for post-operative transsexual women how satisfied they are with the results. Progestogens can both raise one's libido and encourage female libidinal feelings.
• Spontaneous and morning erections decrease in frequency significantly, however some who have had an orchiectomy still experience morning erections. Voluntary erections can be maintaned since the brain is the most important sex organ, a developed repertoire of fantasies and good visualization is a must. It also depends on how one views their own genitals (disgust, strong aversion to, tolerable, etc.).

Childbearing:

• Childbearing, as experienced by cisgender women, is impossible.
• However, genetic offspring are possible. For transwomen wishing future genetic offspring, pre-operative sperm banking is available. This may be especially attractive to transgender lesbians as it would be possible for such a woman to have a genetic child even after SRS, with artificial insemination of her partner by previously banked sperm.

Bone:

• Both estrogens and androgens are necessary in both biological males and females for healthy bone. (Young healthy women produce about 10 mg of testosterone monthly. Higher bone mineral density in males is associated with higher serum estrogen.)
• Bone is not static. It is constantly being reabsorbed and created. Osteoporosis results when bone formation occurs at a rate less than bone reabsorption.
• Estrogen is the predominant sex hormone that slows bone loss (even in men.)
• Both estrogen and testosterone help stimulate bone formation (T, especially at puberty.)

Drug Interactions:

• Any drug can cause adverse reactions with other medications so it is wise to check with a doctor or pharmacist when starting any new medication
• Of the estrogen formulations commonly used, ethinyl estradiol (commonly found in birth control pills) has the greatest number of adverse reactions

Skin:

• The skin becomes thinner and therefore more translucent and pinkish (spider veins may appear or be more noticeable), more suscepitable to tearing and irritation from scratching or shaving, increased tactile sensation, and slightly lighter in color due to a slight decrease in melanin (pigment).
• Skin becomes softer
• Sebaceous gland activity (which is triggered by androgens) lessens which lowers the amount of sebum (oil) production on the skin and scalp, consequently the skin becomes less prone to the formation of acne due to the less quantity of oil that is produced
• The skin's pores become smaller due to the low quantities of sebum produce
• More subcutaneous (under skin) adipose (fat) tissue accumulates. This gives a more puffy/softer appearence. Consequently dimpling, or cellulite, will be more apparent on the thighs and buttocks due to this along with the thinness of the skin.
• Susceptibility to sunburn increases possibly due to the thinner skin and/or less skin pigment.

Gastrointestinal:

• Estrogens may predispose to gallbladder disease - especially in older and obese people
• Estrogens (especailly oral forms) may cause elevations in transaminases (liver function tests) indicating liver toxicity. LFTs should therefor be periodically monitored in transgender women

Neurological/Psychiatric:

• Mood changes can occur - including the development of depression
• Migraines can be made worse or unmasked by estrogen therapy
• Estrogens can induce the develpoment of prolactinomas, which is why prolactin levels should periodically be monitored in transgender women. Milk discharge from the nipples can be a sign of elevated prolactin levels. If a prolactinoma becomes large enough, it can cause visual changes (especially decreased peripheral vision), headaches, mood changes, depression, dizziness, nausea, vomiting, and symptoms of pituitary failure like hypothyroidism.

Metabolic:

• Estrogen therapy causes decreased insulin sensitivity which places transgender women at increased risk of developing type II diabetes.
• As muscle mass decreases with androgen deprivation, basal metabolic rate will fall and weight gain may occur even without changes in diet or activity.