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Hormones Male to Female 
While the individual's response to feminizing therapy will vary, we have observed several key changes that appear for the majority of transgendered.
Breasts
For the transgendered woman, breast development will vary greatly, as it does with the genetic female population. However, breast development will typically be less than what is experienced in the genetic female population.
With the transgendered woman, breast tissue growth is basically promoted by estrogens and anti-androgens, testosterone blockers. Under most circumstances, breast development exceeding a B cup is rare. Development will take at least 2 years to reach maximum size.
Changes in the nipple will likely be somewhat less than in the genetic female. The areola (the small ring of color around the nipple in the center portion of the breast) will change in appearance and size in relationship to the breast.
Soon after beginning hormone therapy (about 2 to 3 months), there will be a nodule-like formation behind the nipple and a feeling of tenderness or sensitivity in the area. This early stage of development is caused by an increase in the ductal system behind the nipple is part of the transition process and will usually normalize in a matter of months.
Body Hair
Body hair will generally lessen noticeably to almost entirely over a period of several years. Individuals will generally notice a diminishment of bodily hair occurring on the extremities, and most of the torso. As example, arm and leg hair as well as hair on the abdomen, chest, and shoulders will greatly lessen and in some instances disappear completely. Hair growth in specific regions including that around the areola, armpits and pubic area will not lessen to the same extent.
Skin
The general appearance of the skin, overall, will change greatly by becoming softer and less coarse. With proper skin care, which includes protection against the damaging effects of the sun, the skin's general appearance will be noticeably enhanced by the influence of estrogen and anti-androgens.
Fat Distribution
Over a period of time (1 to 2 years time), a change in the subcutaneous fat (located just beneath the skin) will occur. The hips, thighs and buttocks will collect the majority of this distribution, and the tendency to collect fat in the stomach will diminish somewhat. The resulting redistribution will result in a smaller waistline and larger hips.
Muscle Mass
A good deal of the size that is normally attributed to large or broad shoulders, arms and chest is actually contained in upper body muscle mass—not bones. Through the process of feminization much of the upper body bulk will disappear. Muscle mass will generally take longer to diminish (about 3 years) than the accompanying shift in fat distribution previously mentioned. As upper body mass is lost, a certain degree of looseness may be seen in the skin of the upper arms and shoulders. As is the case with normal weight loss in these areas, a period of one to two years may be necessary for the skin to adjust to the smaller frame.
Genitals
With regard to appearance, hormone therapy will produce its most marked change in lessening the size of the testes. Due to the influence of estrogen, the testes' production of testosterone and sperm will be greatly reduced.
Penile size will likely diminish somewhat. While penile skin is used for lining the neo-vagina, the amount of donor skin available is more a matter of inherent size than that of the diminishing effects of testosterone. Sexual function will decrease, but the degree of which is unpredictable. Erections may still continue, but will probably be much less frequent and long lasting, or may not be possible. Ejaculate will lessen, probably to the point of only producing a very small, clear discharge as a result of the prostate and the associated structures responsible for semen production being impeded.
Prostate Gland
The prostate will diminish in size due to the effects of estrogen and a testosterone blocker.
Cardiovascular
Coronary heart disease is the leading cause of death in the United States. Due to various lifestyle and hereditary factors, cardiovascular conditions may pose additional risks to those undertaking elective medical therapies, such as the variety of drug treatments engaged in the feminization process.
Infertility/Impotence
Long term use of estrogens and testosterone blockers may likely result in infertility, with permanent infertility being a distinct possibility. Sexual responsiveness will likely diminish over the course of hormonal therapy, potentially resulting in the inability to achieve or maintain an erection. These effects are the basis for feminizing hormone therapy being termed chemical castration.
If the transgendered individual has any concern or desire to "father" children in the future, it is imperative that the male-to-female transgendered individual choose the option of sperm banking – having samples of their sperm frozen and stored for later use – prior to beginning hormone therapy.
Beard Hair
Whatever active hair is present in the beard area upon onset of hormone therapy will remain. Given years of hormone therapy and removal of the testicles, the beard will remain albeit somewhat slower growing and not quite as thick. Naturally, this status is far from acceptable. A method of permanent hair removal, or combination of methods thereof, must be used to rid oneself of facial hair.
Permanent hair removal will show its greatest results by concentrating efforts on those areas least affected by hormone therapy, i.e., the beard area, and leaving treatment of chest hair and the like until last, if treatment is even required at all.
Raised Voice
The depth in pitch and resonance of the voice are unaffected by hormone therapy. However, inflection and manner of speech are very well suited to change. Additionally, pitch can be raised through persistent vocal practice. Given the importance of a gender congruent voice, surgical options have been explored in an attempt to alter pitch, but this most delicate of instruments is not likely to be properly retuned through surgery.
Medications
Estrogen
ESTROGENS - ORAL USE
Estradiol (Estrace)
17-Beta Estradiol provides the most potent estrogen available, and is most commonly taken by mouth. It may also be administered by way of a skin patch or injected into muscle, whereby the drug travels expeditiously through the bloodstream to the areas it affects or targets.
Oral estradiol provides a very effective means of feminization. Its dosing and subsequent adjustments, like other medications to follow, is dependant on measured testosterone levels, the degree of feminization achieved, side effects and other impediments to a healthy condition.
Oral estradiol is usually supplied in 0.5 mg (milligram), 1.0 mg, and 2.0 mg tablets.
Conjugated Estrogens-Naturally Occurring (e.g., Premarin)
The most common mixture of natural estrogens is called Premarin. Derived from the urine of pregnant mares, Premarin contains a number of different (conjugated) estrogens and is obtained through the extraction process. Compounds derived from such a process not only subject animals to unduly harsh conditions, but may contain additional substances that create a potential for unknown or adverse effects. In our observation, there is a greater likelihood of mood swings and depression seen in patients using naturally derived estrogens as compared to synthesized preparations such as estradiol.
Conjugated Estrogens-Synthesized (Cenestin)
Conjugated estrogens may be synthesized also. One such medication, Cenestin, is a slow-release conjugated estrogens product derived from plant sources. Cenestin contains the same three primary and six minor estrogens found in Premarin.
Other Estrogens
Other plant-derived estrogens, called esterified estrogens, are usually made from modified soy (Estratab, Menest).
Estropipate (Ogen, Ortho-Est) is a version of estrone, a weaker form of estrogen.
ESTROGENS - FOR INJECTION
Estradiol Valerate
Estradiol Valerate is formulated as a longer-acting product that is usually contained in an oil preparation. Like oral medications, injectable preparations are manufactured in differing strengths. In the case of Estradiol Valerate, the drug is typically formulated in a concentration between 10mg to 40mg of active ingredient per milliliter (mL).
While some may be fearful of injection, the amount administered will usually be contained in one mL. To give an idea about that amount of liquid, a small spoon holds about 5 milliliters. Estradiol Valerate may be typically injected weekly to monthly, with the frequency/concentration based on the measured testosterone levels for the patient.
The more direct route of administration provided by injection may speed the physical change by creating a higher and more constant source of estrogen. Ideally, injection should require less processing by the liver, but all to often improper administration (poor or no monitoring, self-medicating, etc.) instead creates undue health risks.
ESTROGENS - TOPICAL USE (Through the skin)
Interestingly, some of the most ineffective as well as some of the most beneficial preparations are available in topical form.
Creams
Estrogen creams (e.g., Premarin cream) are sometimes applied to areas of the skin, such as the breasts. The benefits from such an approach usually range from very minimal to unfelt.
Skin patches
Medication skin patches, also called transdermal or percutaneous patches, provide a very effective means of medicating. In this approach, the estrogen (estradiol is used) is transferred into the body directly through the skin. The transdermal approach offers ample delivery of medication for full feminization. And its consistent and prolonged release make for a safe and sensible approach.
But the transdermal approach is pricey, being probably the most expensive means of administration. Some individuals suffer skin irritation related to the adhesive. For others, the presence of a patch is awkward or tends to come loose from the skin, especially during sustained activity, such as sports or outdoor activities. The adherence problem can be addressed with the use of a skin preparation that helps the patch stay in place even in the presence of moist conditions or heavy perspiration. Transdermal patches uniformly contain estradiol as the active medication, produced in 0.05mg (50 micrograms, 50 mcg) and 0.1 mg (100 mcg) concentrations, and are branded under a variety of names such as Climara and Alora. The reader will notice that the dose amount contained in the patch is about one-tenth to one-twentieth as the same drug that is taken orally. These concentrations are considered potent since transdermal entry of the drug is many factors more efficient than oral administration.
Anti-Androgens
The use of an anti-androgen has been used for many years by endocrinologists as a biochemical means of controlling unwanted hair growth in the genetic female. In recent years, this treatment approach had been introduced in treatment of transgendered women and is now being widely practiced.
It has been our experience that anti-androgens have a role second only to estrogen in the feminizing process. Further, without the use of anti-androgens, adequate and desirable demasculinization will likely be greatly curtailed. And following genital surgery or castration, continued use of anti-androgens is strongly recommended if continued feminization is expected.
Spironolactone (Aldactone)
The drug most commonly used for the task of diminishing one's response to androgens is Spironolactone (branded as Aldactone). Like many other drugs in the category of anti-androgen, Spironolactone is used other than for its primary or generally intended purpose. In the case of Spironolactone, it is a diuretic and anti-hypertensive medication.
Spironolactone is a good choice for an anti-androgen. It is generally well tolerated, even when administered over a period of years. And when by happenstance, a mildly hypertensive patient enters into transgender treatment, often Spironolactone can be provided as a substitute; by doing so, the medication now serves a dual purpose. While Spironolactone is a potassium saving diuretic, the normal monitoring of blood chemistry during transgender treatment assures its safe administration.
Patients often report increased unpleasant side effects (such as a need for frequent urination) when doses over 300mg per day are taken. Typically doses of 200mg daily or less are well tolerated.
Finasteride (Proscar, Propecia)
Another good choice for an anti-androgen is Finasteride (Proscar, Propecia), and is able to be used in concert with Spironolactone. The primary use of Proscar (Finasteride 5 mg) was in the treatment of benign prostatic enlargement, but with its reintroduction as Propecia (Finasteride 1 mg), the drug is being largely marketed to promote scalp hair growth. For transgendered women, Finasteride when given in the larger dose promotes not only scalp hair growth but acts as an potent anti-androgen as it is highly effective in inhibiting the conversion of testosterone to DHT (dehydrotestosterone) responsible for male sexual characteristics. Finasteride is usually physically well tolerated over long durations, but is expensive.
Seek Endocrinologist’s advice for what medications and method will work the best for you.
Copyright © 2006 Seattle Transgender Help Network
Last modified: March 21, 2007 |
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