Hormonal sex re-assignment of phenotypic males requires long-term treatment with antiandrogen therapy in order to effectively change their body habitus to approximate a phenotypical female. Breast development must undergo the Tanner stages ( as described for adolescents ) and, once developed, should be considered as female breasts from a medical risk point of view. Inadequate breast development may be augmented by implant surgery. Soft skin, fat deposition in phenotypical female proportion, decrease of body and facial hair and an arrest and reverse of head hair recession are physical signs of appropriate therapy. Testicular atrophy and erection and ejaculation dysfunction are also a result of suppression of testosterone. Esthetically, voice pitch can be maximized with voice therapy. Psychologically, patients often describe a feeling of inner calm and tranquillity, a better ability to recognize and control anger and impatience, and often describe a decrease in libido once on antiandrogen therapy.
All patients are initially assessed by Dr. J. Prior, Endocrinologist, and extensive medical, surgical, and social history is taken. In biological males, prolactin, testosterone, FSH cholesterol, HDL cholesterol, and hemoglobin AIC are measured. In biological females, progesterone in the week before the period, FSH, testosterone, HDL cholesterol, and hemoglobin AIC are measured.
Male to Female Transsexual Patients At our clinic, we have a three part approach for the pre- operative patient to effect these changes: estrogen, progesterone, antiandrogen. Post-operatively, with the main androgen source removed, antiandrogen treatment subsides.
Our hormone regime consists of considerably less estrogen than previous conventional therapy. Premarin(R) is given in physiologic doses, 0.625 mg p.o. three out of four weeks, and rarely increased beyond 2.5 mg depending on the patients risk factors. Breast development may take up to two years. In conjunction with premarin, Provera(R) seems to be needed for breast maturation and nipple ( Tanner stage III to IV ) development. Estrogen has the highest known side effects of the three drugs used in our clinic, and an extensive medical and family history is taken prior to prescribing estrogen. Smoking is an absolute contraindication to the use of Premarin, ( any patient who smokes that presents on estrogen is asked to go on low dose Premarin ( 0.625 mg OD 3 out of 4 weeks until they stop smoking ) as is obesity or family history diabetes, ischemic heart disease or hyperlipidemias.
Biochemical signs of excessive estrogen intake include a pathological rise in serum prolactin level, abnormal glucose tolerance, an increase in triglycerides, and in sex hormone- binding globulin. Pulmonary embolism, breast cancer, prolactinoma, and stroke in otherwise healthy individuals are well known side effects of high dose estrogen therapy. With our conservative approach in over three hundred patients over the last eight years, we have had only two complications ( DVT, pulmonary embolism ) while on low dose estrogen therapy, and they were in compliant patients. The risk from estrogen treatment must not be underestimated.
Provera acts to block the conversion of testosterone to dihydrotestosterone and to suppress LH at the hypothalamic level, further suppressing testosterone. It also appears to act directly on bone to prevent bone loss.1 Provera effectively decreases estrogen receptors and increases estrogen degradation, thereby potentially decreasing estrogen risks and serum lipids. It also appears necessary, in conjunction with estrogens, for final breast and nipple development. Pre-surgical doses range anywhere from 10-50 mg daily to 10-20 mg post-surgically. If beard growth remains a problem, Provera helps the antiandrogen Spironolactone work more effectively. This is why the Provera dose, being safest to raise, may often be higher if beard growth remains a concern.
Spironolactone ( Combined with physiological doses of cyclic oral estrogen and progesterone treatment ) can lower testosterone levels to the female range in previously untreated and estrogen- treated men.2 Spironolactone is a true anti-androgen because it clearly blocks the action of dihydrotestosterone at the cell nuclear level. It decreases testosterone levels, increasing estrogen levels, and resulting in an increase of 2 ( secondary ) LH ( therefore, allowing for less Provera to be used ). Spironolactone appears to be the most vital factor in beard growth reduction. The combined use of these three antiandrogen drugs diminish beard growth to an acceptable level and possibly eliminate the need for electrolysis which can result in considerable scarring.
Female to Male Transsexuals
I.M. testosterone 200mg every two to three weeks is what is initially administered and adjusted by pre-injection testosterone blood levels done at least once a year. Lowering of voice, head hair loss, beard growth, increase in body hair, pubic hair to male pattern, and increased muscle bulk and strength are noted within months. These patients become amenorrheic and the clitoris undergoes hypertrophy. Acne, weight gain, an increase in blood pressure and the potential to lower
HDL cholesterol levels are the adverse effects of this therapy. These side effects can usually be managed by topical or antibiotic therapy for acne, diet instruction and exercise programs.
The gender patients are followed up at six month to one year interval depending on their clinical status. Follow-up tests for the male-to-female transsexuals include testosterone, DHEAS, prolactin cholesterol, HDL cholesterol and hemoglobin AIC, and for the female-to-male transsexuals, a pre-injection testosterone level, cholesterol HDL, hemoglobin AIC, and alkaline phosphatase.
In summary, the Gender Dysphoria Clinic uses conservative hormonal sex re-assignment and careful follow-up. We believe this type of regimen meets our goals:
1) To feminize or masculinize body shape. 2) To eliminate male hair pattern or emulate male hair pattern. 3) To decrease male sex responses or alternatively to masculinize responses. 4) To do no harm.
1. Prior, J. Accepted for publication. NEJM Nov. 1, 1990.
2. Prior, J.C. Vigna, Y.M., Watson, D. Spironolactone with physiological female steroids for pre-surgical therapy of male- to-female transsexualism. Archives of Sex Behav. Vol 18, No. 1, pg 49-57, 1989.
This information I received from the Gender Identity Clinic at the Vancouver General Hospital, Vancouver, British Columbia, CANADA.
Michelle S. ( 71162, 1552 )