Not all transgender patients undergo gender reassignment surgery (GRS) but for those who do so there are many challenges facing them.  GRS is a major crossroads in the trans journey involving two abrupt alterations, one structural, the other both structural & functional.

Life after surgery

The first change involves the external genitalia, shifting from penis to vagina which people focus upon almost exclusively, while ignoring the deeper changes.  This procedure doesn’t influence the rest of the body in terms of its functions, its state of general health or its metabolism.  It is purely local & structural.  In contrast the second procedure involves removal of the primary sex organs or gonads; a process which people frequently forget or choose to ignore, despite its life-changing influences.  
The gonads are the sources of our sexual hormones and include the ovaries in women & the testes in men.  The sexual hormones they elaborate in turn influence the fetal development, before we are even born, of our sexual characteristics, including either the penis or the vagina, thus determining what shows up at birth.  Now when it comes to the consequences of GRS the focus is far too often placed on these external genitalia because they are the outward, visible declarations of our sexuality and sexual identities, but removal of the gonads is far more important, being as it is both irreversible & potentially cataclysmic in terms of our physical & mental health.

What exactly is being lost here, functionally? 

In the male to female transsexual, removal of the testes translates hormonally into the loss of adult male levels of testosterone.  Male levels of testosterone are both defeminizing and masculinizing, keeping in mind that defeminization and masculinization are two separate issues even though they may operate synergistically, like the two engines of a twin-engine airoplane. Slow down one engine and/or speed up the other & the plane will turn in a certain direction.  
To clarify, let’s look at this scenario in terms of the breast, an obvious, sexually-defining hormonal target.  Because well-developed breasts are a hallmark characteristic of the female condition, people tend to think of them as targets solely for the feminizing hormones, in other words for estradiol and progesterone, but the fact is that androgens such as testosterone also have a significant impact on the breast, although in a defeminizing way that opposes the feminizing influences of estrogen and progesterone. Breast size and development depend on the net balance between feminizing & androgenizing hormones, the hormonal balance-sheet.  Why does this matter?  
Consider the case of a 40-year-old woman who has had both of her ovaries surgically removed for valid health reasons. Does this surgery cause her to become dramatically masculine, overnight?  The answer is that despite a dramatic loss of feminizing hormonal influences, there is no reason for her breasts to become masculinized, because she simply does not possess a male-typic level of testosterone capable of masculinizing her. Now in contrast consider a trans-woman who’s been taking effective doses of feminizing hormones for three full years, at a dosage sufficient enough to chemically castrate her. What will happen when she suddenly discontinues feminizing hormone therapy? The answer is that while it may take some months, depending on her dose of feminizing hormones and how long-acting they happen to be, sooner or later her testes will come back online. Sometime after that her breasts will begin to shrink back in the male direction, as a result of the masculinizing effects of her reemerging androgens, in contrast to the genetic female where there isn’t sufficient androgen present to effectively masculinize her.

Orchiectomy

So orchiectomy, the process of having one’s testicles removed surgically, is the most important of the processes involved with GRS as well as being permanant.  Some patients however will have an orchiectomy without GRS, in an effort to accelerate feminization while reducing the need for higher hormonal doses.  Either way, the patient in question is being castrated.  The hormonal consequences will be just the same, involving severe, abrupt deprivation from testosterone. 

Castration

Removal of the testes in the genetic male and of the ovaries in the genetic female leads to a sudden, severe hormonal drop off with testosterone depletion in both cases. Testosterone levels nosedive down to levels below those even characteristic of the genetic female norm.  Female castration occurs following an operation known as a TAH-BSO, which is applied in young women for a variety of health reasons including endometriosis and cancer. The bodies of these young women have been accustomed, up until the moment when their ovaries were removed, to the presence of generous levels of the sexual hormones even including testosterone, lying within the normal female range.  Hormonal withdrawal in these women, not only from estradiol & progesterone but also from testosterone is abrupt & drastic & the consequences can be seismic, both physically & mentally.  And the same set of problems that genetic women experience when surgically castrated tend also to crop up in trans-women following orchiectomy, unless some form of adequate hormone therapy is maintained so as to prevent hormonal deprivation.  Unfortunately, replacement hormone therapy is rarely either administered or sought after in the post-operative trans-woman. 

Hormone deprivation

The two kinds of patients for whom precision hormone therapy is most critically needed include the genetic woman who has undergone a premature menopause consequent to surgical removal of the ovaries and the post-operative trans-woman.  Their problems are just about identical as are their symptoms & the forces that drive them.  Treatment in both groups requires considerable professional expertise as well as an awareness on the part of both types of patient that even when hot flashes fade away, the body still suffers from the consequences of hormonal depletion.  So the optimal post-surgical life for both the trans-woman & the young genetic woman who has lost her ovaries, mentally, emotionally, intellectually, sexually & in a broadly physical sense involves optimal, expertly administered precision HRT. 

Lack of HRT

For many but not all trans-women, gender reassignment is the ultimate goal, the moment when one crosses the gender river.  But this moment, far from being an end, a culmination, is actually only the beginning.  Once the testes have been removed, the only significant source of sex hormones is hormonal therapy arriving from the outside.  Despite this, many if not most post-operative trans-women, believing they have now reached their ultimate feminine goal, back off from receiving feminizing hormone therapy or quit it completely, believing as they do that having a vagina is all they need.  This is a terrible mistake. 

Problems assailing the post-op trans-woman

Far too many post-operative trans-women receive little or no ongoing hormone therapy, focused medical follow-up or problem-oriented health monitoring.  This might have been a vaguely acceptable approach in the past, when we believed that sex hormones were only sexual in their influences, but now we know better.  Now finally appreciating the true scope of sex hormone influence, not only slow but rapid & not only sexual but broadly physical & critically mental, it behooves us to show more insight & more medical responsibility.  We need to become more aware of the importance of the body’s hormonal milieu. 

The symptoms

It shouldn’t be so surprising therefore to discover that many post-operative trans-women, having achieved their life’s desire, are surprisingly tired, haggard & disappointed, lacking physical energy & assailed by frequent episodes of anxiety, panic attacks, mood swings, depression & even suicidal urgings, not because of who they are as many judgmentally assume, looking with jaundiced eye at the trans-woman & her life choices, but because of hormonal deficiency & lack of adequate, precisely metered hormonal care.  And they lack both sexual interest & orgasmic function as well.   
Other more easily overlooked problems include changes in personality, either overt or subtle, cognitive dysfunction including glitches in memory & concentration, generalized aches & pains resembling so called fibromyalgia, frequent headaches, insomnia & irritable bowel symptoms.  And these are just the obvious, overt problems.  At the same time, unbeknownst to the patient, sex hormone depletion is inexorably fueling the silent development of early heart disease, osteoporosis, dementia, insulin resistance & weight gain, cholesterol problems & accelerated cosmetic aging. 

How can we be so negligent?

Considering these dire consequences of chronic hormone depletion, how can this standard of care, this deplorable deficiency continue?  Because modern medicine is still far too symptoms-oriented in its approach, depending on the use of addictive sedatives and analgesics such as opiates, as well as mind-numbing, sex-destroying anti-depressants & marijuana, drugs that, despite frequently being ineffective, may be not only dangerous but riddled with side-effects that further compound the complications of castration, such as brain-fog, worsening sexual dysfunction, weight gain, even diabetes.  Better treatments are available that happen to be user-friendly, even sex-friendly, methods that actually work based on a precision form of hormone therapy.  These methods won’t be found in rigid protocols, medical cookbooks, so called standards of care or the frozen bibles of managed care. 

Total care

Perhaps people don’t care what happens to a group of people whom they sometimes find embarrassing or discomforting such as the transgendered.  Whatever the reason, it is urgently needed that we change the current approach, not only for trans-women but for those genetic women who are crossing the threshold of menopause as well.  Ultimately only the trans-woman herself can force the issue of improved post-operative health care, & that is why we at O’Dea Medical have placed a particular emphasis on post-operative trans-care, not only vaginal care but care for the brain, the mind, the bones, the heart, the metabolism, the life!  
Crossing the gender river & achieving ones goal should make the trans-woman feel her verybest ever.  Unfortunately the lack of ambient feminizing hormones even in the absence of testicles or of male levels of testosterone may cause the gender dysphoria that for so long has bothered the trans-woman emotionally to continue unabated.  More than ever before trans-hormone therapy needs to be precise & accurate after GRS since it has now become the only significant source of sexual hormones in her body.  Dips & depletions in the presence of hormones at this point have a far greater negative impact than in the pre-operative transsexual, who may dislike her continued production of male hormones but who at least isn’t hormonally running on empty. 

What about oral hormone therapy in the post GRS trans-woman?

Of those few women who do continue on hormone therapy after GRS, the majority are taking oral estrogen from their family doctors, without accompanying progesterone or testosterone treatment.  This can be a problem.  First of all many trans-women at the time of gender reassignment simply haven’t received adequate feminizing therapy so far, and although they are now demasculinized, they have still been far from adequately feminized.  Some of these women, when now introduced to truly effective forms of feminizing HRT for the very first time, will continue to progressively feminize for another 5 or so more years as they play catch up.   Oral hormone therapy is thoroughly inadequate for these women since oral estradiol is mainly converted into estrone and is very short acting, leaving the body totally depleted for more than half the day.  And finally testosterone therapy in very subtle dosages may also be necessary. 

The bottom line

To sum up, many post-GRS or post-orchiectomy women feel that with their testes removed & a functional vagina surgically created, they are now fully transitioned & have all the femininity they will ever need, particularly if they have already obtained breast implants, silicone injections & other measures of faux femininity.  The problem with this kind of thinking is that while surgery may have removed their source of masculinizing hormones, it does nothing to create a source of feminizing hormones.   This is a dangerous road to travel since it carries with it a host of physical & mental problems, problems too easily blamed on the marginalized trans-woman herself instead of her lack of hormones.  The hard fact is that once the trans-woman recovers from surgery, she is on her own, often medically abandoned, isolated & thoroughly undertreated.     
The good news is that precision hormone therapy can restore this woman, emotionally, intellectually, sexually and physically to a state of good health while often dispensing with the need for symptomatic care, but that requires good judgment & hormonal expertise.