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------------Estrogen Therapy for MTF Transsexuals-------------

This issue I thought I'd digress from my usual "do it yourself" topics to something you should not "do yourself" - the use of estrogens by transsexuals. Most of this admittedly technical information I obtained from research at the Santa Clara Valley Medical Center library, though literature is scarce on the subject even there.

Estrogens are powerful steroid hormones, chemicals which affect the form and function of the body and its organs.

There are three basic human estrogens: estradiol, estrone, and estrial. Estradiol is the most active form and estrial is the least active. In women, large amounts of estrogen are produced by the ovaries, and in men a small amount is present due to chemical conversion of testosterone.

Once you are grown and genetic male traits are fully developed, the only way your body organs have of knowing what sex you are is by the levels of male and female hormones which are present. Changing the hormone balance from male to female with drugs causes tissues which are supported by male hormones to diminish and stop functioning and those which are supported by female hormones to develop and begin functioning.

If your doctor has prescribed estrogens for you, it is probably in the form of Estinyl (ethinyl estradiol), Premarin (conjugated estrogens, a mixture of the three estrogens plus estrogen breakdown products) or injections (such as estradiol valerate). Though it would seem to be desirable, no suppository form of estrogen is available except as in the form of D.E.S, a drug which is not in favor today.
The most powerful single oral dose is the 0.5 milligram Estinyl tablet, but faster results can be obtained by using two or even all three of the Estinyl, Premarin, and injections. Any of the three will produce in time a certain amount of bodily feminization. (Note: Premarin alone has been shown to be unable to reduce blood testosterone levels to a female normal, though Premarin alone does produce feminizing effects, albeit slowly.

Also: generic Premarin has become suspect as to its quality, potency, and purity - many pharmacists discourage use of the generic, or suggest that dosages of the generic be increased relative to the dosage of the brand name Premarin product.) The effects include breast development (usually slight to average development; occasionally nearly none or quite a lot, depending on genetics and body type), reduction in size and firmness of the testicles and prostate gland, some reduction and repatterning of body hair, softening of the skin, recontouring of the body due to accumulating layers of feminine body fat, a considerable reduction or elimination of (masculine) sex drive, and improved effectiveness of facial hair removal by electrolysis.
Testosterone levels in the blood drop to very low levels due to effects of estrogen on the brain and directly upon the testicles. Since testosterone tends to fuel the male emotional characteristics of aggression and competition, many patients report feeling more mild or tranquil. Reduction of male hormone levels may also clear up acne and excessively oily skin. Little or no changes in voice quality can be expected, though sometimes a slight increase in range is noted.

The cost of oral hormone supplements is not excessive. Typical prices are: Provera 10 mg. 100 units, $40 (generic medroxyprogesterone HCL is much less.); Premarin 2.5 mg 100 units, $45 (generic less but not recommended); and Estinyl 0.5 mg 100 units, $55 (no generic available). Injections may run $15-40 plus office visit charges. Black market prices for the above begin at about three times the pharmacy cost.

Choice of an endocrinologist is best made by personal referral, either by a friend or therapist. The regimen and requirements of doctors varies widely, as does their level of experience in this very specialized field. Many doctors require concurrent counseling by a psychiatrist or psychologist.

If you experience any dissatisfaction with your therapist or doctor, a consultation with another may produce different results. There is little concrete knowledge of transhormonal therapy in the medical profession, and research on the subject is scarce - your doctor's expertise is probably mostly due to his or her experience. At the very least, your doctor should have good general experience in the administration, effects, and side effects of female hormones, and be aware of the Standards of Care (the Harry Benjamin International Gender Dysphoria Association criteria for surgical and hormonal treatment of transsexuals.)

Your doctor may be cautious in prescribing large amounts of estrogens to you if you have any of the following history or symptoms: high blood pressure, any heart disease or defects, clotting disorders such as phlebitis, stroke or cerebrovascular disease, liver function abnormalities, a history of heavy alcohol intake, kidney disease, migraine headaches or seizures, diabetes, family history of breast cancer, obesity, or heavy smoking.

Periodic checkups with your doctor are required to spot early signs of certain dangerous conditions. Among these are: benign or malignant tumors of the liver, breast, pituitary gland (in the brain), and kidney, along with phlebitis and elevation of blood pressure. Heart attack (myocardial infarction) and stroke have been reported in relatively young transsexuals receiving estrogens, especially those with clotting disorders. Changes in a part of the prostate gland known as the verumontanum can cause blockage of the urinary tract after long term use - this must be corrected surgically. Lactation or discharge from the breasts can be a sign of a potentially dangerous pituitary gland condition.

Your doctor will administer periodic blood tests and may check the following: testosterone (should be less than 85 nanograms per 100 milliliters), prolactin (should be less than 45 ng/ml), liver function scans, and clotting time. He may also feel your breasts for lumps and listen to blood flow in your major veins and arteries.

Once you have been using estrogens for a year or more, some effects may become irreversible even if estrogen intake is ceased. Certain chemical processes in the brain remain in a female pattern permanently, and changes in brain wave patterns have been reported. These effects may or may not be associated with emotional and personality changes. Breasts and female fat distribution may not subside after administration of estrogens, and sex drive may remain relatively low. For these reasons, it is important to be certain of your committment to feminization of your body.

Sudden changes in dosage of estrogens, either increasing or decreasing, have been known to produce severe mood changes. The effects may be likened to going through menopause, puberty, and pregnancy at the same time. Lethargy, depression, anxiety, difficulty in concentration, headaches, abdominal cramping, nausea, and other symptoms have been noted for periods of days or weeks. It may be wise to change dosages as gradually as possible. (Despite what your doctor may tell you!)

Changes in metabolism are common, with weight gain, water retention, and increased appetite as the major effects. Estrogen reduces the ability of the body to eliminate certain drugs such as Valium so that smaller dosages of these medications become as effective as larger dosages were before. This is also true for alcohol so be sure to reassess your limits - this explains why the tolerance for alcohol of women is typically less than that of men. Any physician you deal with should know of any medications you are taking - with surgery this can be critical due to the effects of estrogen on the blood clotting rate.

After genital surgery, estrogen doses may be greatly reduced if the desired degree of feminization has been achieved. Since the testicles are now absent, it is no longer necessary to suppress testosterone production. Risk factors are believed to be in proportion to dosage, so the minimum effective dose is preferred for long term use. This means reducing dosage by a factor of one fifth to 1/20th of previous levels.

Risks of estrogen use can be minimized by having injections alone. Injections of Delestrogen, Estradurin, etc. cause the estrogen to enter the bloodstream directly, without the first pass through the liver. This means the liver works much less hard in metabolizing the estrogen, and can return to doing the normal work that the liver does in digesting food and eliminating toxins. Injections are given deep into the muscle tissue of the buttocks, once a week to once a month. The effects are similar to the higher doses of oral hormones, and sometimes it appears that feminization progresses further with injections than with orals. If the injections are done at a doctor's office, the costs may be about equal to the cost of oral pills - but individual doctors' rates and charges vary a lot in this area.

Generally, an endocrinologist who prescribes injections can be persuaded to teach you to administer the injections yourself, with a short training session. By doing the injections yourself, and buying generic versions of the injectables, you can save up to 90% of the costs of oral hormones, making this by far the least expensive alternative. If you are going to be using hormones the rest of your life, and wish the safest, most effective, and cheapest method, then make self-injection your goal.

It is thought that estrogens should be taken along with a progestin (a chemical with effects similar to progesterone) such as Provera (medroxyprogesterone). A progestin will tend to maximize breast development due to enlargement of the milk sacs themselves (as opposed to breast fatty tissue) and will approximate more closely the natural female hormone balance. A more natural hormone balance may provide some shielding against some of the hazards mentioned previously. Also progestins greatly reduce male sex drive. I could find no agreement in the literature as to the recommended dosage but higher dosages seem to pose no known risk.

REAL progesterone in the form of capsules is now available, but rather expensive ($1.25 to $5.00 per daily dose). Real progesterone is available as an injection also, at a very low price - the disadvantage is that the effects last only 3-4 days, so an injection twice a week might be called for. Real progesterone has ALL the benefits of progesterone, instead of only some of them as with progestins. Most doctors who give injections use Delalutin (hydroxyprogesterone caproate) instead of real progesterone, but the TS giving herself her own injections might consider using real progesterone instead, because of the reduced costs.

Proper medical management of estrogen administration can reduce the hazards and maximize the benefits of transhormonal therapy. It makes good sense to know the facts and follow medical advice when using these powerful drugs.

This article was originally written for the ETVC Newsletter and later appeared in the newsletter of the Rainbow Gender Association, San Jose. Individuals are invited to copy or distribute this article, provided that the full text is included and proper credit is given.

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