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Hormone Replacement Therapy for Transgenders Dos and Don'ts Steven M. Brown, MD University of Wisconsin School of Medicine

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Presentation on theme: "Hormone Replacement Therapy for Transgenders Dos and Don'ts Steven M. Brown, MD University of Wisconsin School of Medicine"— Presentation transcript:

1 Hormone Replacement Therapy for Transgenders Dos and Don'ts Steven M. Brown, MD University of Wisconsin School of Medicine

2 A Case Report

3 What is Hormone Replacement Therapy?

4 What is a Hormone? Organic compound, secreted by a gland, in minute quantities, into the bloodstream, that has a regulatory effect on the metabolism of tissue or organs at a site different than the site of secretion Alter the metabolism of cells or the synthesis and secretion of other substances (tropic hormones) Bind to receptors (specific proteins) to turn on functions in target tissues

5 Endocrinology 101 Glands: Groups of cells which specialize in the secretion of hormones Some important glands – Pituitary Anterior pituitary – Growth hormone – Thyroid stimulating hormone – Adrenocorticotropic hormone (ACTH) – FSH – LH – Prolactin

6 Additional glands Thyroid Pancreas – Insulin Hypothalamus Parathyroid glands Adrenal glands – Cortisol – Testosterone – Estrogen – Aldosterone

7 The sex glands Ovaries – Progesterone – Estrogen – Regulate reproduction, bone metabolism, regulation of blood cholesterol, breasts, skin Testes – Testosterone – Regulates reproduction, musculature, bone metabolism, cholesterol levels, red blood cell production

8 Chemical origins of sex hormones Derived from cholesterol Chemical structures of estrogen, progesterone, testosterone vary slightly Testosterone is a metabolite of progesterone Estrogen is a metabolite of testosterone Production is governed by negative feedback loops Present in males and females in differing concentrations

9 Chemical origins of sex hormones

10 Changes which occur in puberty Pre-wired biological clock, probably in the hypothalamus, coincides with practical reproductive considerations Hypothalamus releases Leutinising Hormone-Releasing Hormone (LHRH). LHRH passes down nerve endings, stimulates pituitary gland In girls, around age 10 to 13, FSH and LH are producedstarts the cyclic activity of the ovaries in the production of estrogen In boys, ages of 10 and 14 years, FSH and LH switch on testicular function in males (FSH triggers sperm production), LH triggers testosterone production

11 Why Use Hormone Replacement? Change physical appearance to maximize consistency between physical identity and internal gender identity Assist in passing Create better skin and hair patterns for subsequent cosmetic surgery such as facial feminization Assist FTM transgenders with beard growth For emotional well-being

12 What are some of the obstacles to HRT? Patient issues – Ambivalence, coming out issues, fears of violence, fears of rejection, discrimination, social stigmatization – Not transsexual or not intensely transsexual – Financial considerations social and economic marginalization – Access to health care – Mistrust of medical establishment – Ability to have sustained follow-up and monitoring – Medical/behavioral contraindications Underlying disease states Unfavorable family history Unfavorable lifestyle (tobacco, alcohol)

13 What are some of the obstacles to HRT? Health care provider issues – Lack of education – Lack of clinical experience – Relative paucity of studies – Unanswered questions – Personal discomfort – Serious complications – Fear of litigation – Off-label administration of medications

14 Who Prescribes Hormone Replacement? Primary care physician – Internist – Family Practitioner – Gender dysphoria clinic Endocrinologist Gynecologist Urologist SRS Surgeon Psychiatrists

15 Who SHOULDNT Prescribe Hormones Yourself Family Friends Internet buddies Urgent care physicians On-line doctors On-line pharmacies

16 Where Transgenders Get Hormones Black Market Friends Mexico Internet Local pharmacy

17 SOME IMPORTANT WARNINGS NEVER use hormonal medication prescribed for another person DONT self-medicate Use caution in purchasing hormones from Black market sources, the Internet, foreign countries, mail order houses and vendors who can get it or you – Medication may be impure – May be contaminated – Temptation to bypass appropriate monitoring

18 SOME MORE WARNINGS Dont double dose Dont alter regimen without supervision

19 An HRT Do A clinician should collaborate with a mental health specialist who has extensive experience with the diagnosis of such patients to avoid mistreatment with hormones or sex-reversing surgical procedures

20 Harry Benjamin International Gender Dysphoria Association: Requirements for HRT in adults – Age 18 or older – Demonstrable knowledge of what hormones can and cannot do – Knowledge of social benefits and risks – Documented real-life test for at least 3 months before HRT or – Period of psychotherapy of duration specified by a mental health professional (usually 3 months) – A letter from the mental health professional to the prescribing physician Standards of Care:

21 Some important principles There is a lot of misinformation, especially on the Internet Hormone therapy remains somewhat hit and miss Individual results will vary, especially for MTF Extremely important to let any treating physician and pharmacist know of all your medications to avoid drug-drug interactions and to reduce potential complications Need to keep spouse/significant others informed

22 Reproductive options To give opportunity to obtain children who are genetically their own Sperm banking prior to HRT for MTF FTMs banking of ovarian tissue or oocytes Embryo banking Gender reassignment and assisted reproduction, Human Reproduction 16: (2001)

23 Real-Life Test Pros and Cons Pros – HRT can cause permanent changes including sterility and gynecomastia. RLT may confirm that transitioning is the right choice Cons – HRT makes it easier to pass and easier to attempt RLT – Most people who would consider hormones are pretty sure of what they want by that time – HRT is diagnostic itselftrue transsexuals will feel calmer and relieved upon starting HRT; if not truly transsexual, changes will cause worsening anxiety

24 Purposes of Feminizing Hormones Induce the development of female secondary sexual characteristics Anti-androgen treatment to reduce the effect of endogenous male sex hormones

25 An important principle have realistic expectations

26 Feminizing Hormones DO NOT Cause the voice to increase in pitch. Dramatically reduce facial hair growth in most people. There are some exceptions with people who have the proper genetic predisposition and/or are less than a decade past puberty. Change the shape or size of bone structure. However, they may decrease the bone density slightly.

27 Some important DOs DO review risks and benefits before starting any hormones DO be sure that this is what you really, really want…permanent changes can occur within weeks DO be patient DO eat healthy and exercise DO reduce alcohol intake (reduce stress on liver)

28 Some important DOs DO have regular medical checkups (every 2-3 months) DO watch your blood pressure DO take a good multi-vitamin/mineral supplement to help be sure the body has everything it needs for new development DO give the body time to adjust Use the lowest hormone dosage that affords the desired changes. DO make sure you are not allergic to Provera tablets before you use Depo-Provera sustained release intramuscular injection DO drink fluids, watch potassium intake if taking spironolactone

29 Some important DOs of Doctoring DO see a reputable doctor for your care DO get regular check-ups DO be honest and up front with your doctor about all medications DO make a list of questions prior to each visitdont be afraid to ask questions EDUCATE your doctor, especially if you disagree DO keep records of all changesphysical and emotional, and SHARE them with your doctors SEE your doctor for any discharge from breasts

30 Some important DONTS DONT go out on your own for meds DONT alter your medication regimen DONT BUY hormones on the Internet or through Mexico DONT BELIEVE everything you read on the Internet, including web pages, bulletin boards, and chat rooms DONT let your weight get out of control DONT smoke DONT taking the maximum planned dosage of all hormones at once DONT take pre-operative dosages of hormones for more than about 3 years

31 Effects of Feminizing Hormones on Males Effects vary from patient to patientfamilial, genetic tendencies Younger patients generally obtain and more rapid results Noticeable changes within 2-3 months Irreversible effects within 6 months Feminization continues at a decreasing rate for two years or more, often with a spurt of breast growth and other changes after orchidectomy

32 Effects of Feminizing Hormones on Males Breast development – can take years, begins after 2-3 months – final size about 1 to 2 cup sizes less than close female relatives – less satisfactory results in older patients – Only one-third more than a B-cup – 45% dont advance beyond an A – growth not always symmetric – Larger male thorax dilutes effect – enhanced by progesterone – nipples expand – areolae darken

33 Effects of Feminizing Hormones on Males Loss of ability to ejaculate/maintain erection (variable) Fertility and male sex drive drop rapidly this may become permanent after a few months Increased female-type sex drive/attraction to men

34 Effects of Feminizing Hormones on Males Decreased testicular size (mostly flaccid) The prostate shrinks but does not disappear and prostate cancer is still possible (although risk is reduced) DO HAVE REGULAR PROSTATE EXAMINATIONS Decreased penis size, scrotal size (25% within first year), sometimes requiring the patient to stretch by hand to maintain adequate donor material for SRS Spontaneous erections suppressed within 3 months (but not totally eliminated)

35 Effects of Feminizing Hormones on Males Decreased facial/body hair – Body hair lightens in texture and color, frequently disappears – Cessation of male pattern baldness – Limited regrowth of scalp hair which has been lost – Improvement in thickness and texture of scalp hair – Enhanced action of 2% or 5% minoxidil (Rogaine ® ) – Not much effect on distribution of facial hair Enhanced effect of electrolysis Decreased rate of growth

36 Cutaneous Effects of Feminizing Hormones on Males Redistribution of body and facial fat – Face looks more femininereduced angularity, fuller cheeks – Redistribution of fat from waist to hips and buttocks Skin softer/smoother/thinner, more translucent, less greasy Skin sometimes becomes excessively dry Improvement in spots and acne Redistribution of fat to hips and buttocks Brittle fingernails Increased susceptibility to scratching and bruising Tactile sensation becomes more intense Oil and sweat glands become less active, resulting in dryer skin, scalp, and hair

37 Effects of Feminizing Hormones on Males Sensory changes – Heightened sense of touch – Increased sense of smell Emotional changes – More labile

38 Effects of HRT on Metabolism in MTFs Metabolism decreases – Given a caloric intake and exercise regimen consistent with pre-hormonal treatment Weight gain Decreased energy, Increased need for sleep Cold intolerance

39 Other effects of hormones Reduced risk of Alzheimers Improved memory

40 Effects of Feminizing Hormones on Males Loss of muscle mass Loss of strength Estrogen prevents bone loss after testosterone deprivation Long-term follow-up of bone mineral density and bone metabolism in transsexuals treated with cross-sex hormones, Clinical Endocrinology, 48:

41 Changes in Sexual Orientation Of 20 transsexuals of various types that were interviewed, 6 heterosexual male-to-female transsexual respondents reported that their sexual orientation had changed since transitioning from male to female…three of the respondents claimed that the use of female hormones played a role in changing their sexual orientation. Daskalos CT. Changes in the sexual orientation of six heterosexual male-to- female transsexuals. Arch Sex Behav. 1998;27:

42 Risks of Feminizing Hormones Some General Principles Complete risks in transsexuals is not known – Most studies are performed in biological women – Limited research regarding risks – Safety data and Food and Drug Administration approval do not acknowledge the use of hormones in transsexuals – All administration is thus off-label – Mortality not necessarily increased

43 Risks of Feminizing Hormones Blood clots – 12% over age 40 – Usually start in the veins of the legs – Can break off and block blood supply to the lungsa FATAL complication (pulmonary embolism) – 20-fold increased risk in MTFs – Risk increased with oral vs. transdermal estrogens – Central retinal vein occlusion has been reported Mortality and morbidity in transsexual subjects treated with cross- sex hormones, Clinical Endocrinology, 47: (1997)

44 Risk factors for Venous Thromboembolism Surgery Trauma (major or lower extremity) Immobility, paresis Malignancy Cancer therapy (hormonal, chemotherapy, or radiotherapy) Previous venous thromboembolism Increasing age Pregnancy and postpartum period Estrogen therapies Selective estrogen receptor modulators Acute medical illness Heart or respiratory failure Inflammatory bowel disease Nephrotic syndrome Myeloproliferative disorders Paroxysmal nocturnal hemoglobinuria Obesity Central venous catheterization Inherited or acquired thrombophilia Varicose veins Smoking Geerts et al. CHEST 2004:338S-400S. Risk Factors are Cumulative

45 Reducing the Risk of Blood Clots Smoking cessation – Pharmacologic support – Relaxation therapy – Behavioral therapy Discontinue HRT for 3-6 weeks prior to any major surgery, including SRS Review HRT with surgeon and anesthesiologist prior to minor surgery Discontinue HRT in injuries which result in immobilization

46 Risks of Feminizing Hormones Fluid retention Prolactin – 14%, in one study developed elevations – Pituitary enlargement can sometimes require surgery Hypertension – May vary with hormone regimen Mortality and morbidity in transsexual subjects treated with cross- sex hormones, Clinical Endocrinology, 47: (1997)

47 The Cardiac Risks of Feminizing Hormones Most studies have and are being done in biologic women Much evidence suggests that estrogen lowers cholesterol levels, and raises HDL (good cholesterol) Increases triglycerides, blood pressure, subcutaneous and visceral fat Decreased LDL particle size (bad) Decreased insulin sensitivity (bad)

48 Estrogens and the Heart Current studies – Womens Health Initiative 27,500 enrollees without CAD to test estrogen or estrogen plus progestin post-hysterectomy – Womens Angiographic Vitamin and Estrogen – Womens Estrogen/Progestin and Lipid Lowering Hormone Atherosclerosis Regression Trial (WELL-HART)

49 Hormones and the Heart JAMA: July 17, 2002 – Risks and Benefits of Estrogen Plus Progestin in Healthy Postmenopausal Women 16,608, ages studied Received placebo or Premarin ® plus Provera ® Study stopped after 5.2 years because of significantly increased risk of cancer in treatment group Reduced risk of colorectal cancer and hip fractures Increased risk of coronary artery disease, pulmonary embolism, stroke

50 Hormones and the Heart What is the risk-benefit ratio in post- menopausal women? – Decreased hot flashes How does the risk-benefit ratio differ in transgenders? – Physical feminization – Reduced emotional stress

51 Reducing the Odds of Cardiac Complications If theres a history or strong family history of heart attack, coronary artery disease, or stroke –C–Close supervision by a cardiologist, stress test –B–Blood pressure, lipid control, blood thinners Estradiol (Estrace ® 1 or 2 mg), a naturally occurring estrogen, is preferred to Premarin ® –U–Usual dose is 4 mg daily pre-op, 2 mg daily post-op Natural progesterone (Prometrium ® ) does not have the adverse effects of medroxyprogesterone (Provera ® ) on blood cholesterol or blood pressure levels Consider daily administration of aspirin 81 mg daily Reduce risk factors –N–No smoking –W–Watch weight –W–Watch blood sugar

52 Risks of Feminizing Hormones Gallstone disease Liver disease (low risk) Weight gain Mood swings

53 Risks of Feminizing Hormones Cancer risk – Fibroadenomathe most common breast tumor Influenced by estrogen Estrogen receptors present in % of patients with fibroadenoma – Breast cancer – Prostate cancer Has been reported

54 Contraindications to HRT in FTM Patients Absolute – History of thromboembolism or thrombotic tendency – History of macroprolactinoma – History of breast cancer – Active substance abuse Relative – Coronary artery disease – Cerebrovascular disease – Hepatic dysfunction or tumor – Strong family history of breast cancer – Cholelithiasis – Poorly controlled hypertriglyceridemia – Poorly controlled diabetes mellitus – Refractory migraine headaches – Heavy tobacco use – Uncontrolled hypertension Endocrine Therapy of Transsexualism and Potential Complications of Long-Term Treatment, Archives of Sexual Behavior, 27: (1998)

55 DO Get Appropriate Monitoring Follow-up exams every 2 – 3 month – Breast exam Measurements Looking for galactorrhea – Weight – Blood pressure – Testicular size – Examination of extremities for phlebitis, edema – Visual fields

56 Appropriate laboratory monitoring – Liver function tests – Lipid profile – Renal (kidney) function – Blood pressure – Fasting glucose – Thyroid function – Blood clotting times (every 6 – 12 months) – Testosterone levels (<50 ng/dl) in MTFs – Prolactin (rule out prolactinoma) – Breast self-examination – Prostate examination – Pregnancy testing (FTMs)

57 Monitoring changes – Estrogen levels – Testosterone levels (especially in pre-ops) or if considering antiandrogens in a post-opcan usually be followed o clinical grounds

58 MTF MonitoringJohns Hopkins

59 Other Tests Which Can Be Followed Calcium and phosphorus (skeletal health) Bone densitometry every two or three years

60 Testosterone levels ng/dl genetic males 5-85 ng/dlgenetic females

61 Estrogen levels Levels may be misleading secondary to insensitivity of assays Dosing is more commonly made on clinical grounds

62 Administration of Hormones Orally (estrogens, progesterones, androgens) – Advantage: convenience – Disadvantage: increased stress on the liver

63 Administration of Hormones Sublingual – Dissolve under the tongue Better absorption Avoid passing through the liver which may stimulate clotting problems Injections (estrogens, progesterones, androgens) – Advantages: Preferred in setting of liver disease Preferred mode of delivering androgens – Disadvantages: unsteady hormone levels (except for sustained-release preparations in oil or microscopic beads) pain infection risk from hypodermic needle usage

64 Administration of hormones Skin patches – Advantage: Convenience – Disadvantage: skin irritation, allergy to adhesive Cream (estrogens): – Advantage moister and healthier skin. – Disadvantage: low transfer rate into the body, requires frequent spread on very large skin surfaces.

65 Dosing of HRT in Male to Females No generalized agreement General principles – DONT mix drugs within categories – Need drugs from these two categories Anti-androgens (discontinued post-operatively) Estrogens

66 Taking Just One Class of Medications Anti-androgens alone – Serious bone density loss Estrogens alone – Does not lower testosterone levels

67 Common anti-androgens Cyproterone acetate (Androcur®, Cyprostat®) (antigonadotropic) – Not available in United States – Androgen receptor antagonist – mg/daily – Oral or injectable – Risk of liver damage, thromboembolic disease – Altered carbohydrate metabolism Medroxyprogesterone Nilutamide (androgen receptor blocker) Finesteride Propecia (testosterone antagonistdecreases DHT) – 5 mg daily – Reduces male pattern baldness

68 Androgen receptor antagonists Flutamide (Eulexin) – Androgen receptor antagonist – Hepatotoxic – Reduced blood counts, including platelets – Hypertension – Fluid retention – Depression, anxiety, nervousness, lassitude, insomnia, GI disturbances – 250 mg one to three times daily

69 Antiandrogens Spironolactone – Weak androgen receptor antagonist – Diuretic – Can cause elevated potassium levels – Antihypertensive – 100 to 400 mg daily

70 GnRH Agonists Act on pituitary – Overstimulating pituitary – Then desensitizing it to GnRH from hypothalamus – Used in adolescents to delay puberty or when hormones are withdrawn prior to surgery to reduce reversion to male – Limited experience – Drugs: Nafarelin acetate nasal spray Goserelin acetate injection Lupron Leunrorelin acetate

71 A word about herbals Not benignpotential for liver injury Still a medication and self-medicating Unregulated by FDA

72 Common estrogens Estradiol valerate (Estrace®) – Equivalent to natural 17 -estradiol – May be safer than ethinylestradiol – Reduced risk of breast cancer and thrombosis although how much risk reduction in high doses of transsexuals is not known – 4-6 mg pre-op in divided doses – 1-2 mg daily post-op – Best combined with an antiandrogen – If hot flushes, night sweats appear, switch to ethinylestradiol may be helpful

73 Common estrogens Ethinylestradiol (Estinyl®) – Slowly metabolized by the liver, resulting in greater potency and longer half life – Regarded by many as pre-op drug of choice – More intense feminizing effects – 50 g twice daily, gradually reduced to 50 g

74 Common estrogens Conjugated natural estrogens (Premarin®) – From urine of pregnant mares – Ethical issues – More expensive – 5 – 7.5 mg daily pre-op (divided doses) – 1 – 2.5 mg daily post-op

75 Common estrogens Estraderm® patches µg/day tramdermally

76 Common progestogens Anti-androgenic Not feminizing alone Enhances feminization from estrogen May help maintain libido May reduce cancer risk associated with estrogens

77 Medroxyprogesterone acetate Provera® Good safety record May be slightly virilizingmay be metabolized into testosterone If virilization occurs, switch to dydrogesterone Typical dose 5 mg twice daily pre-op for 10 days of the month May enhance breast development 2.5 – 5 mg daily post-op

78 Natural Progesterone Micronized progesterone Progesterone USP Prometrium – Molecular structure closer to the progesterone produced in a natal female's body – Provera has been linked to depression in trans women – Less androgenic – More costly

79 Common HRT in the United States Estrogen preparations – Conjugated estrogens (Premarin) mg/day – Estradiol (Estrace) 2-6 mg/day – Ethinyl estradiol mg/day – Estradiol transdermal patches mg twice weekly – Estradiol valerate mg every 2 wk Antiandrogens – Spironolactone mg/day

80 Failure to Respond In no changes are seen (including tender nipples) within 2-3 months or Feminization is very limited over a longer period of time Serum testosterone, DHEAS levels to rule out overproduction of androgens Referral to an endocrinologist

81 FTM Hormone Replacement Females respond quite well to hormone replacement as adolescents and as adults Experience all the changes that genetic males experience during puberty Most of these changes are irreversible

82 Why is FTM easier than MTF? In FTM, addition of androgens excites androgen receptors which are there but dormant Puberty occurs again, but differentiating as a male this time In MTF, bodies are already differentiated by the natural presence of androgen Males are thus immune to further pubertal changes

83 Effects of Masculinizing Hormones on Females Acne Male pattern baldness Increased muscle mass and development Growth of facial and body hair Thickening of vocal cords and deepening of voice (not always reversible), not always down to typical male pitch

84 Effects of Masculinizing Hormones on Females Enlarged clitoris (3-8 cm) with increased libido can become overly, painfully sensitive, peaks after 2-3 years Atrophy of uterus and ovaries Growth spurt, closure of growth plates before puberty Increased bone density Reduced risk of blood clots Testosterone increases bone mineral density in female-to-male transsexuals: a case series of 15 subjects, Clinical Endocrinology, 61: Venous Thrombosis and Changes of Hemostatic Variables during Cross-Sex Hormone Treatment in Transsexual People, J. Clin. Endocrin. Metab. 88: (2003)


86 Effects of Masculinizing Hormones on Females Fertility decreases--menstrual cycle becomes irregular then stops, usually within 5 months Outer skin layer becomes rougher in feeling and appearance Prominence of veins Fat is redistributed. The face becomes more typically male in shape. Fat tends to move away from the hips and toward the waist Body odors (skin and urine) change. They become less "sweet" or "musky" and become more "tangy" or "metallic." Emotions change. Aggressive and dominant feelings may increase

87 Male hormones DO NOT Significantly decrease the size of the breasts. – However, they may soften somewhat Change the shape or size of bone structure Grow a penis Prevent pregnancy Work overnight

88 Risks of Masculinizing Hormones Ovarian cancerlong-term exposure to endogenous and exogenous androgens are associated with ovarian epithelial cancer Steroids increase epidermal growth factors and transforming growth factor (TGF- ) which promote cancer growth Polycystic ovaries Endometrial hyperplasiarisk of endometrial cancer Breast cancerbreast cells may remain even after mastectomy Ovarian Cancer in Female-to-Male Transsexuals: Report of Two Cases, Gynecologic Oncology 76: (2000)

89 Risks of Masculinizing Hormones Reduced HDL cholesterol (bad) Reduced LDL particle size (bad) Increases triglycerides Polycythemia (elevated red blood cell levels) Increased sweating Increased metabolism Hot flashes

90 Risks of Masculinizing Hormones Water and sodium retention Decreased carbohydrate tolerance Obesity and insulin-resistance Sleep apnea Increased aggressive behavior, hypersexuality (rare) Excessive testosterone can convert to estrogen, increase risk of breast cancer

91 Testosterone and the Liver Testosterone-induced hepatotoxicity – Increased liver enzyme levels are a frequent occurrence occurs in about 15% Hepatic adenomas Hepatocellular carcinomas Peliosis hepatitisblood-filled cavities in the liver

92 Contraindications of HRT in FTMs Absolute – Pregnancy – Active substance abuse Relative – History of breast or uterine cancer – Polycythemia – Hepatic dysfunction or tumor – Coronary artery disease – Hyperlipidemia – History of violent behavior – Severe obstructive sleep apnea – Androgen sensitive epilepsy – Migraines – Bleeding disorders (for injected testosterone) Hormone replacement therapy (trans) placement_therapy_(trans)

93 Common Androgen Replacement Injectable testosterone – Testosterone enanthate mg IM every 2-3 wk – Testosterone cypionate mg IM every 2-3 wk – Can be self-administered Transdermal testosterone – Testosterone transdermal patches mg/day – Testosterone gel 1% (AndroGel) g/day Risk of inadvertent exposure to others who come into contact with skin EXCESSIVE TESTOSTERONE MAY LEAD TO STROKE AND HEART ATTACK Endocrine Therapy of Transsexualism and Potential Complications of Long-Term Treatment, Archives of Sexual Behavior, 27: (1998)

94 Other androgen replacement Testosterone pellets (Testopel) – pellets under the skin every three months – Local anesthetic – More constant blood levels Oral – Andriolnot available in the US – Has to pass through liver Sublingual/buccal lozenge – Striantabsorbed through oral mucosa, avoiding liver Gum irritation Taste changes Headaches

95 Drug Interactions of Testosterone Drugs which decrease levels of testosterone levels: – Phenobarbital and Dilantin (seizure medicines) – Rifampin – Alcohol! Drugs which increase levels of testosterone: – Serzone, Prozac, Paxil (antidepressants) – Sporanox, Diflucan (antifungals) – Tagamet – Biaxin, Zithromax (antibiotics) – Protease Inhibitors (HIV treatment) Testosterone can also alter the effects of other drugs: – Increase the blood thinning effect of Coumadin – Decreases the effectiveness of Inderal (propranolol) a blood-pressure medicine – Increases the effect of some oral medicines for diabetes and can cause dangerously low blood sugar levels

96 Progesterone Treatment in FTMs Short-course progesterone therapy to – Induce menstrual period in first 2 years to shed build-up of endometrial lining (if a hysterectomy has not been performed) Reduces spot bleeding Decreases risk of uterine cancer

97 FTM MonitoringJohns Hopkins

98 Some FTM Dos Prior to hormone therapy, consider hysterectomy and bilateral salpingo-oophorectmy – Eliminates risk of ovarian cancer – Saves awkward situation of doing a hysterectomy on a masculinized patient Stress management Giving blood Be patient PAP smears, pelvic examination if you still have a uterus Check bone densitometry Endometrial ultrasounds every two years Take a calcium supplement

99 Some FTM Donts Dont buy too many shoesyour feet will grow More is not better

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