------------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.  





                           SOURCE: FEMINET