Better hormonal methods

Natalie was deeply frustrated by her lack of feminization after 3 years of hormone therapy.  She certainly experienced the side-effects but didn't get the feminization she urgently craved.

When she first started hormone therapy, her family doctor, who had only treated two other transgender patients, prescribed Natalie 8 mg of oral estradiol per day, which is eight times greater than the dose that most menopausal women are given, a dose that was never intended for this drug. He also prescribed 400mg of oral spironolactone per day, for its testosterone-blocking properties, as described in the medical cook to which he referred.  After two years on this amateurish regime she had little to show for it.  Her cup size was stuck on an A minus, in fact very, very minus.  There was no appreciable facial feminization.  What had in fact changed were the side-effects she was now experiencing, including fatigue, dizziness & diminished sexual desire & function, probably relating to the use of the androgen blocker in pretty high dosage, a dosage that simply isn't needed when hormone therapy is sufficiently effective.

The balance between side-effects & benefits

Trying to improve the risks to benefits ratio, as we call it, for feminizing hormone therapy is not as simple as it might seem.  Believe it or not,oral hormones, those cheap pills that you only have to swallow, without painful shots or procedures, are on the one hand by far the weakest, least effective source of feminizing hormones, yet paradoxically by far the most dangerous & side-effect prone, in terms of clotting risk (clots can kill you), gall stones, depression and high triglyceride levels.  Finally realizing the futility of oral hormone therapy, in her third year of hormone therapy Natalie switched to the South American injectable known as Perlutal, while continuing the spironolactone at its high dosage level.  And her feminization rate sped up noticeably, but at what a steep price!  Her cup size grew to a B minus and her nipples became noticeably more sensitive.  What she didn't anticipate however, were the dramatic side-effects which rapidly surfaced using these injectables not legally available in the United States. 


Natalie developed a voracious appetite, particularly for carbs & sugars, and the weight rapidly piled on. She began to experience dramatic moos swings & her friends told her she was acting crazy.  The patterns I have observed with Perlutal & several other related South American drugs are not universal but clearly frequent.  Behavior becomes erratic, moods swinging widely between a manic optimism & a suddenly, weepy depression.  Paranoia is not uncommon and the thoughts become irrational, deluded & resemble the disjointed thoughts of patients with psychosis or schizophrenia. 

Going first class

So Natalie finally came to our office on the quest for a form of hormonal feminization that would be as effective as the injectables or better, while avoiding these severe mental side-effects.  She wanted to avoid those heavy mental side-effects which had been playing havoc with her life, while at the same time obtaining a decent amount of rapidly accumulating hormonal feminization.  And she wanted to us to restore both her sexual drive & her sexual function since she was, or she wanted to be sexually versatile. 

We switched Natalie to a steady-state estradiol delivery system at a more than middle of the road dosage & complemented it with non-oral progestins.  We discontinued the spironolactone all together since it was destroying her sex-life & draining her of all her energy.   .  After all, her new, steady state, unremitting source of feminizing hormones would adequately block whatever androgen she was still capable of producing.  The rate of Natalie's feminization, because her feminizing treatments were non-intermittent, accelerated even more rapidly, yet her sexual function became rapidly restored. 

The moral of the story

The vast majority of trans-women still obtain their hormones from oral products, an approach which is ineffective & risky.  Only professional &/or consumer ignorance can explain this ridiculous situation.  Furthermore there is absolutely no reason for the trans-woman to have to tolerate sexual dysfunction if she still wishes it to remain.  All it takes is a true expert. As for Natalie, she is doing very well, well feminized yet living her life, both sexually & generally, on her own personal terms.