After gender reassignment surgery

Wendy had gender reassignment surgery in her mid-20s.  Once post-op she was maintained on 2mg of micronized oral estradiol a day for many years.  Little did she know that 2 mg estradiol wasn't actually what she was getting. 

When estradiol is taken by mouth it must pass through the liver before reaching the circulation, but the liver converts about two thirds of it into a weak, user unfriendly estrogen known as estrone, & the hormones only stay around for about 4 or 5 hours out of a 24 hour day and never remain at a steady level.  And that's just one of the reasons why Wendy dragged herself to our office some 15 years later, feeling very sorry for herself, as well she might. 

Desiccated & depleted

Wendy's complaints were widespread but sadly typical for many post-op trans-women.  Wendy was in a stable marriage  with a supportive husband and two lovely children. Everything should have been wonderful but it wasn't. She complained of a lack of sex drive, premature cosmetic aging especially of the face and sun exposed areas, significant weight gain with the development of a dumpy figure, depression and chronic anxiety. Additionally she had noticed over the years the loss of about 50% of her vaginal depth & her vagina was dry & irritated, leading to painful intercourse.  To make matters worse at no time since surgery had she ever experienced an orgasm, not even one!

Better delivery route, better hormones

Wendy's problems were not surprising, given that her estradiol pills were being converted into a derivative hormone characteristic of old age and because they were oral she only received hormones for 4 or 5 hours out of the day, delivered in an up & down, unsteady fashion.  She would need her hormones to be administered non-orally so that the estradiol could be delivered unchanged, and the pattern of delivery should estrogenize her throughout the day instead of briefly, & in an unvarying, steady delivery pattern.  So I changed Wendy to a higher dose of estradiol being delivered non-orally & generating a generous, steady  dose of hormone throughout the day, with little conversion by the liver into weak estrogens.  And I added several other hormones that I frequently employ in my post-GRS women.

A happy outcome

Wendy did remarkably well although it took about a year before all of the improvements became finally noticeable. The emotional changes were rapid, her anxiety & depression clearing up within a week.  When administered correctly, estradiol is a powerful, natural anti-depressant.  Whereas before the new regime she had been sexually disinterested & forced to fake it, she rapidly became sexually eager, aware & easily aroused.  Thankfully her vagina was able to accommodate her renewed activity level having become self-lubricating. Orgasms went from never to within as little as 2 or 3 minutes.  Most amazing of all however, was what Wendy had to say about her vanishing surgical vagina.  Over a 12 month period of time on her new hormonal regime she had recovered about 80% of her lost vaginal depth. 

Post operative women are often neglected

Wendy's story isn't unique.  Problems like this crop up all the time in post-operative trans-women, sometimes as a result of bad healthcare & sometimes because the patient herself avoids hormone therapy, usually out of sheer ignorance.  The moral of the story is that it takes more than a vagina to make a woman.  Many post-op trans-women lack femininity at the time of their reassignment surgery either because they took the surgical route far to early, a case of the cart before the horse, or because their hormonal source was oral & highly ineffective. And then, to compound the problem, many quit hormone therapy altogether or they simply continue taking cheap, ineffective oral estrogens. 

The chemistry of castration

Many post-operative trans-women are seemingly unaware that following the removal of the testes, either during a simple orchiectomy or as part of gender reassignment surgery, they have effectively been castrated and that the only way for their bodies to obtain sexual hormones is from the outside.  But what if they aren't interested in sexual function? Over the last few decades medical science has revealed that sex hormones are in a sense poorly named, because they have a broad influence over the body at large, the brain & immune systems and the mind.  These effects spread far beyond the realms of sexuality or reproduction.

The moral of the story

It shouldn't be surprising therefore to discover that castration in both men & women frequently leads to an enormous increase in a wide variety of serious conditions.  In the trans-woman this includes weight gain with or without diabetes, loss of the characteristic feminine hourglass figure, back pain, chronic diffuse body pain  or fibromyalgia, headache, insomnia, fatigue, depression, anxiety, suicidal feelings & urges, memory loss & cognitive dysfunction, in addition to early heart disease, osteoporosis, dementia & premature cosmetic & physical aging.  So the post-operative trans-woman truly needs ongoing, enlightened hormonal care for the rest of her life because of the physical, mental & sexual benefits it can provide when expertly administered.