Despite the futile attempts of individuals such as Harry Benjamin to standardize the medical treatment of trans-women, the overall patterns of care in these patients have been & still are pretty much a case of “anything goes”.  This is particularly true when it comes to the field of hormone therapy. 

Hormone therapy for the trans-woman; the scientific principles

Many transsexuals who seek the feminine life elect to bypass hormone therapy altogether, depending instead on surgical procedures such as breast implants, facial feminization and the injection of silicone and other fillers into the buttocks, in order to impart a superficial veneer of femininity. While the end result may pass from a distance, no degree of genuine feminization ensues.  From close up these patients remain quite masculine, both superficially and in terms of personality and affect.  However, if that’s what these patients want, more power to them, at least when they remain preoperative.

Fake Femininity

In contrast those patients who undergo gender reassignment surgery without ever receiving feminizing HRT have put themselves at great risk, since their sole source of sexual hormones at this point involves a trickle emanating from their adrenal glands & the sexual hormones, far from being redundant exert many physical benefits having nothing to do with sexuality.  As a consequence, these patients, like all other eunuchs, because that is what they now are, face a growing, incremental increase in a variety of health problems, both mentally and physically. They are highly prone to depression, anxiety, suicidal ideations and premature physical aging as well as a host of other unexpected complications such as premature heart disease. (See our article on treatment of the post-operative trans-patient).

Online hormones

Of those trans-women who have been wise enough to embrace feminizing hormone therapy, a large majority do so without medical supervision via the Internet or by obtaining illegal injectables provided by others in the trans-community seeking to exploit them financially.  As will become soon apparent however, the sexual hormones have an enormous impact not only on one’s sexual organs & physical appearance but also upon a person’s general health.  Consequently they carry with them a large spectrum of risks and side effects. Unsupervised, one-size-fits-all approaches in these patients are extremely dangerous both mentally and physically and should be avoided.  That having been said however, current modes of medical supervision may not always be a great deal better, and here’s why. 

Amateur endocrinology

When hormone therapy were first considered and designed for the trans-woman half a century ago, our understanding of sex hormone action differed greatly from what we now know today. Indeed, even today, many if not most clinicians appear to be largely ignorant of the exciting new discoveries medical science has provided regarding the sexual hormones. In other words, the fundamental sets of principles on which most forms of HRT are still based, both for trans-women and for menopausal women, are now thoroughly obsolete and incorrect. Nevertheless these are the models that most practitioners at the clinical level still depend upon when treating trans-women.

Traditional hormone therapy

Tradition-based trans-HRT has been around for decades and it began when doctors simply adopted the contemporary methods then in vogue for menopausal treatment & multiplied their dosages times 3 or 4.  No attempt was made to conjure up a treatment protocol tailor-made for the trans-woman & they didn’t take into account that these oral hormones were never intended to be given in such high doses.  Now it follows that if the methods used for menopause at the time made sense, then so perhaps might have the methods for trans-care, despite the higher dosage.  The problem is that they didn’t make any sense at all. 

Oral Hormones

For many years the standard approach to menopausal hormone therapy involved an orally administered pill of conjugated estrogens derived from the urine of pregnant mares, also known as conjugated equine estrogens (CEEs), familiar through the brand name Premarin.   And in women who still retained a uterus, they were accompanied by a synthetic progestin known as medroxy-progesterone acetate (MPA), with the brand name Provera, which was added to prevent a build-up in the lining of the womb.  Many doctors still prescribe these two pills when they elect to treat the menopausal hormonally, although I personally stopped prescribing any in the 1980s, when non-oral alternatives became available in the US.  And in women who had already undergone a hysterectomy & consequently didn’t need any progesterone, I had been using natural estradiol pellet implants since the late 1970s. 

The bad study that changed everything

In the year 2001, a cataclysmic shift took place in the way doctors treated menopause when a study was reported that roundly condemned menopausal therapy of any sort, on the basis of problems observed solely with the use of Premarin & Provera.  In my opinion this single study on which large decisions were made by the government, by professional bodies and by the majority of medical doctors was deeply flawed, poorly interpreted and scared the daylights out of millions of women worldwide.  You will find further discussions of this study on another website of ours dedicated to menopausal therapy know as precisionHRT.com.

Problems unique to oral hormones

What we can learn from the WHIM study is that oral hormones, even at the lower doses used to treat menopause, notably CEEs with MPA (Premarin & Provera), significantly increase the risk of clot related strokes, such that the government insists that no woman over 60 should risk taking hormone therapy, although they foolishly fail to differentiate between oral hormones and non-orals, which do not carry the same unfortunate risk. 

Why should oral hormones be urgently avoided?  

Oral estrogens can be considered in three fundamental groups, oral equine estrogens (Premarin), the synthetic estrogen of birth control pills known as ethinyl estradiol and finally oral human estrogens. Some practitioners, while condemning the use of equine estrogens, prefer the human estrogens because they seem more “natural”.  After all, they feel that estradiol, the principal estrogen of young women would be the optimal hormone to administer to trans-women.  Unfortunately this reasoning is incorrect.  Oral estradiol is a semi-synthetic hormone derived from plant-based chemicals. When administered orally it passes through the liver where about two thirds of it is converted into another estrogen known as estrone, so the prescription for estradiol does not translate into estradiol delivery.  Furthermore the hormones thus delivered are present for only a limited amount of time such that most of the 24 hour day is spent without estrogen delivery and the delivery pattern of estrogen is erratic.

Birth control pills

As for the synthetic estrogen of birth control pills, ethinyl estradiol is associated with a clotting risk that is significantly greater than that of the natural estrogens. Some physicians in Asia prescribe a birth control pill called Diane whose progestin, cyproterone acetate has anti-androgen effects. This progestin, in conjunction with ethinyl estradiol can synergize in terms of the production of clots but when given at the higher doses used by trans-women, it is particularly risky.

Passing through the liver

Oral estrogens must pass through the liver before entering the systemic circulation. As a result the liver is selectively overdosed with estrogen but since it is not an indifferent conduit it becomes a dangerous estrogen target. The liver is richly endowed with the alpha sub-type of the estrogen receptor making an estrogen overdose both dangerous and side effect laden. Oral estrogens selectively increase sex hormone binding proteins, thus limiting the availability of estrogen to its target tissues & limiting feminization.  At the same time oral estrogens increase the risks for clotting, gallbladder disease, elevated triglycerides, pancreatitis, edema & hypertension.  They also promote fatigue & depression because of their paradoxical tendency to diminished brain estrogen levels. The clotting problem alone can lead to stroke, heart attack, lung clots and sudden death.

Never take oral estrogens!

The oral route for hormones maximizes risks and side effects while being the least effective for feminizing. Nevertheless, the vast majority of transgendered patients in this country obtain their estrogen in its oral form.  I believe that oral estrogens have no place in the treatment of menopause, but in trans-women, where the doses are significantly higher, this is urgently true. Although many doctors still prescribe oral hormones, I would assume that this is out of sheer ignorance. Why expose trans-women to an increased risk for clots, strokes, heart attacks and sudden death, when non-oral treatments are widely available and do not have this kind of side effect and risk profile?  At the same time non-oral estrogens can be far more effective in the treatment of the trans-woman.

The good news

The good news is that non-oral feminizing hormones are generally available, some of which have a far more favorable benefits to risks ratio.  Having said that, in addition to obtaining non-oral hormones it is a generally good idea to have them prescribed, supervised & monitored by a true professional with training and experience. Hormones are not candy. Their safe administration requires considerable expertise, particularly in the field of both pre-& post gender reassignment trans-care. Hormonal experts are called endocrinologists and should not be confused with practitioners who lack endocrine training yet who choose to casually prescribe and administer these powerful drugs.

What is an endocrinologist anyway?

Endocrinology is a sub-specialty of internal medicine dealing with the science of hormones. It is a highly precise, quantitative discipline, as it should be considering that hormones and their actions can be measured with exquisite precision. These tiny agents, despite being present in infinitesimal amounts, exert massive actions on the body at large and not just its sexual targets.  To those who insist that anyone should be able to administer them, let’s illustrate by looking at something basic; the very definition of hormones themselves. Most people think of hormones as ‘chemical messengers’ but this simply isn’t true. Hormones do not carry messages, but are instead chemical switches that activate or deactivate receptors. And they do this in a manner that is not chemical but physical, when they dock physically with their matching receptor structures. Over the last 20 years, our endocrine understanding of hormones has become revolutionized, but the new information has not trickled down as yet to medical practice in the doctor’s office, in many cases. When it does so, trans-care will become revolutionized as it really ought to be.