What do feminisation hormones achieve?
Feminising hormones help to develop female secondary sex characteristics and suppress the male ones. Breast development, fat redistribution, reduced muscle mass, less body hair, changes in sweat and body odour, reduction in male pattern baldness. Erectile function decreases, libiod may reuce and ejaculation reduces while testicles shrink. There are also emotional changes and alterations in social functioning.
What effect will treatment have on my fertility?
Having your testicles removed, or suppressing your androgens while increasing your oestrogen, will have clear impacts on your fertility. Although we assume that fertility will be impaired, sperm can still be produced and can therefore achieve fertilisation. Some people have stopped treatment and fertility has returned, while some remain infertile.
The best way to preserve fertility is to cry-store sperm and to have this done before treatment starts. This can v=be done by your local cancer clinic or local fertility centre. Sometimes this is available through NHS funding, depending on where you live. Private options are more expensive but can be quicker.
What medication is used?
The general approach is to give oestrogen with an androgen / testosterone blocker, and in some cases to give progestogens as well.
Which oestrogen is best?
The safest preparation is 17-beta estradiol as this is considered to be bioidentical – identical to that produced by the human ovary. The ethinyl-estradiol found in many contraceptives is not used as it has higher risks of blood clots. Horse oestrogen found in Premarin and Prempak-C should also not be used.
What is the safest way to give oestrogen?
Estradiol is usually given as a patch, gel or a tablet. Injections are no longer recommended. The safest way is considered to be the transdermal route – ie the patch or gel form.
What are the antiandrogens for?
In pubertal children, the antiandrogens prevent the development of the irreversible secondary sex characteristics, a very welcome part of treatment for transgender youth. In older adolescents and adults, the anti-androgens minimise these characteristics and also allow for lower doses of estradiol to be used to achieve feminisation.
Which antiandrogen should we use?
There are broadly five antiandrogen regimes in use. Gonadotrophin Receptor Agonists (GnRH agonists) (puberty blockers), 5-alpha reductase inhibitors (finasteride, dutasteride), spironolactone, cyproterone acetate and biclutamide.
Gonadotrophin Receptor Agonists / GnRH agonists / puberty blockers
These are usually given by injection (or as a nasal spray) and block the signals from the brain to the ovary / testes and hence stop the natal hormone production. They are very effective, safe and reversible – with a low side effect profile. However they are expensive and have to be given by a doctor or nurse or with appropriate training. Commonly used are Decapeptyl (every twelve weeks) or Gonapeptyl (every four weeks).
5-alpha reductase inhibitors / finasteride / dutasteride
These block conversion of testosterone to dihydrotestosterone and can also lead to lower levels of testosterone when used with estradiol. As these are medications commonly used by GPs, there is less of a fear element when prescribing them and for this reason, along with their safety profile and low side effects, we use them as our first choice. They are also useful for those who want a partial feminisation, or in people who continue to experience male pattern hair loss even after androgens are suppressed by other medication or surgery.
Spironolactone is a potassium sparing diuretic, which in higher doses also has direct anti-androgen receptor activity as well as a suppressive effect on testosterone synthesis. High blood levels of potassium is a serious risk so care must be taken when using this medication. Users often report thirst and frequently needing to urinate. There is also concern that spironolactone may contribute to early breast bid fusion and hamper breast development.
Cyproterone Acetate / Bicalutamide
Cyproterone is a less commonly used progestagen which also has anti-androgen activity. It has been associated with severe liver disease and should therefore be avoided if possible. Biclutamide is a direct anti-androgen and has also been associated with liver abnormalities.
Orchidectomy - removal of the testicles
This is an ideal option for many transwomen as it should be a brief, inexpensive, out-patient procedure with a swift healing time and does not impair any future procedure for genital surgery and vaginoplasty.
What about progesterone?
There have been no well-designed studies of the role of progestagens in feminising hormone regimens. Many transgender women and healthcare professionals alike report an anecdotal improved breast and/or areolar development, mood, or libido with the use of progestagens. There is no evidence to suggest that using progestagens in the setting of transgender care are harmful.
What oestrogen levels should we aim for?
Again, there is little evidence to guide us, but the general feeling is to achieve the same levels as menstruating non-transgender women. Doses should be increased in line with physical effects, patient goals, blood levels and risk profiles. There is no evidence that very high levels of estradiol results in better feminisation.
International guidance aims for:
- Testosterone under 3.5 nmol/L
- Oestrogen levels between 300 – 800 pmol/L
Should I stop smoking?
Tobacco use in combination with estrogen therapy is associated with an increased risk of venous thromboembolism. It is much safer to stop smoking (and you will smell better too!)
What if I want to keep my erections?
Feminising treatment and anti-androgens can result in erectile dysfunction, and while this is good for some – for many it is unwanted. Sildenafil / Viagra / Tadalafil / Cialis etc can all be used with good effect.
Am I too old to achieve good feminisation?
It’s not all about the breast development, many older transgender women experience happy and acceptable feminisation effects on their bodies, and combined with the positive psychological effects mean that nobody is ever too old.
At what age should I stop taking hormones?
The short answer is, we don’t know as there is no evidence for either continuing them or stopping them. Everyone should weigh up the risks and benefits and make informed choices. Individualised care and shared decision making is the core of our approach.
What about measuring prolactin?
Although increased prolactin levels and, rarely, prolactin producing tumours have been associated with oestrogen treatment, at the levels we use for feminisation in transgender women, the risk of tumours is very low. For this reason, we should only measure prolactin levels in those with symptoms, rather than routinely. If anyone has symptoms of headaches, visual disturbances or excessive milky breast discharge then investigation should start.
Is there an increased risk of blood clots?
Non transgender women taking HRT do not have an increased risk of blood clots in the veins when they use estradiol patches. There is just not enough research or evidence to know whether the same is true for transgender women. In those women who have either a personal or family history of blood clots, each case should be assessed individually. The risks and benefits of both carrying on with treatment, or stopping treatment or not having treatment should be assessed. Good hydration, long haul flight advice, exercise, not smoking, healthy diet and weight can all contribute to a lower risk.
What if I suffer with migraines?
People with migraines can find that they are worse with hormone treatment and it is wise to start with low doses and work up slowly. Severe migraines or those that have an ‘aura’ are associated with an increased risk of stroke, and we do know that women on hormonal contraceptives are at an increased risk. We don’t know, however, whether this is true for the bioidentical oestrogens used in feminising treatment for transgender women.
Will I get depression or mental health issues?
Hormone treatments can contribute to mood disorders, but often the relief of starting treatment and the benefits of treatment actually improve mental well-being in transgender women.
What if I have cancer?
Oestrogen-sensitive cancers such as breast and pituitary are contraindications to having oestrogen therapy and careful discussion with your cancer care doctor are needed. If you have prostate cancer then we don’t yet know if oestrogen treatment is helpful or harmful. Certainly, antiandrogens are used in the treatment of prostate cancer. PSA blood tests can be unreliable when using transgender treatments.
Do I have to stop HRT if I’m going to have an operation?
For healthy transgender women who have no extra risk factors for blood clots (like smoking, personal or family history of clots in the veins, very high doses or oestrogen, or the use of the synthetic oestrogens) there is no evidence that says they should stop the HRT before surgery. The usual precautions during and after surgery should apply, and a good discussion of the pros and cons of stopping or continuing HRT should be had.
What are the treatment options for nonbinary people?
This should be an individualised approach depending on what the person would most like to achieve in their gender-affirming treatment. It may be that binding or tucking is sufficient, or maybe surgical procedures. Hormone treatment may just involve taking lower doses of the hormone that suits them best.