Hormone Therapies
The general process of supplementing a woman's natural hormones is often called hormone replacement therapy or HRT. The oldest form of supplemental hormones is estrogen. When estrogen is taken alone (that is, not mixed with a progestin), it is called unopposed estrogen (also, estrogen replacement therapy or ERT). When estrogen is taken in combination with progestins, the process is called combined hormone therapy. For transgender women, the standard HRT regimen is inadequate. The latest and most effective therapies include more potent estrogens and anti-androgens.
This combination of medications not only offers greater feminization, but also provides a greater reduction of the masculinizing effects from past virilization. Each regimen and form of administration not only has its own specific benefits, but also carries with it a variety of differing risks. Over the years, we have used many different feminizing and de-masculinizing drugs with our patients in order to maximize the positive benefits while reducing any negative side effects. The feedback from these ongoing treatment methods coupled with consultations with other professionals, and discussions with patients who have experienced other regimens have allowed us to compile a sizeable amount of data concerning the administration of hormonal therapies. The following is a brief synopsis of medications that are used in feminizing hormone programs.
Estrogen
Oral use
Injection
Topical
Progesterone
Oral use
Injection
Anti-Androgens
The use of an anti-androgen has been used for many years by endocrinologists as a biochemical means of controlling unwanted hair growth in the genetic female. In recent years, this treatment approach had been introduced in treatment of transgendered women and is now being widely practiced. It has been our experience that anti-androgens have a role second only to estrogen in the feminizing process. Further, without the use of anti-androgens, adequate and desirable demasculinization will likely be greatly curtailed. And following genital surgery or castration, continued use of anti-androgens is strongly recommended if continued feminization is expected.
Spironolactone (Aldactone)
Finasteride (Proscar, Propecia)
Anti-Androgens whose potential risk may outweigh their benefit
Keep in mind that unlike estrogens, the drugs that are used as anti-androgens, when initially released, were typically intended for a variety of medical conditions, including some very serious conditions. In effect, through clinical use, these drugs have been re-purposed for a feminization regimen. Typically, drugs that address more serious medical conditions (e.g., cancer) have effects that may be not only potent, but harmful and unexpected, as their potential hazards may far outweigh their benefits. Simply put, these drugs may be more harm than good.
Such drugs include:
Leuprolide acetate (Lupron)
Flutamide (Eulexin)
Ketoconazole (Nizoral)
Cyproterone acetate (Androcur)
When one considers the advancements and availability of sound medical management in the area of transgender treatment, most often the feminization regimen required for the transgendered individual can be handled with little complication. Today, there are well trained providers available worldwide. Sadly, too few individuals have addressed their own internal conflicts and fears concerning their transgenderism. As a result, addressing one's transgender concerns may unsettle the individual wishing to pursue proper and sound medical treatment. The individual who may readily appreciate the risks associated with self-medication and less than acceptable therapies under other circumstances, may opt for such solutions in the transgender milieu. And accordingly, the likelihood of serious health risks and poor outcomes is unacceptably high as a result. Sensibility and proper medical management are the cornerstones for a successful outcome.
Herbal
Phytoestrogens, sometimes referred as natural or herbal hormones, are naturally occurring substances extracted from plants. Their molecules look a lot like estrogens that normally are produced in a woman's body. But they also resemble some anti-estrogens, like the breast-cancer drug tamoxifen.
With an interest developed through advertising and word of mouth, many transgender individuals have experimented with a variety of extracts from black cohosh, caraway, dates, dill, motherwort, red clover, and soya among others as a means of physically feminizing.
Not really natural supplements Even if products are pure, herbal experts are troubled by the use of "natural" remedies in "unnatural" ways. Soy in its natural state may protect against cancer and heart disease, but what happens when you take genistein, the largest group of phytoestrogens in soybeans, concentrate it into 100-milligram tablets, and sell it as a 'natural' alternative to hormone replacement? Scientists are not sure whether these pills will cause adverse reactions or tumors.
In fact, new research on concentrated genistein shows the compound increases both the size and number of malignant tumors in mice. University of Missouri nutritional scientist Ruth MacDonald, who conducted some of the genistein studies, says, "Lifelong consumption of soy foods may decrease breast cancer risk," as it appears to do among Asian women. But the phytoestrogen supplements "are not really 'natural.' You are taking far in excess of what you get if you were eating soy-it could be 1,000- or even 10,000-fold." At that dose, she believes, cancer risk may increase.
Soybean and red clover isoflavones are two varieties of these weak estrogen-like substances that are popular items in health food stores and through Internet sales. Advertised claims for isoflavones have also created great interest in genetic women who wish an alternative to estrogen or progesterone preparations in the treatment of hot flashes - the episodes of flushing, sweating and sensation of heat sometimes suffered by menopausal women.
While transgendered and genetic women may want natural hormones for differing reasons, they share the same desire for a suitable estrogenic effect. Genetic females have only recently used natural estrogen alternatives in large enough numbers to prompt formal study. Transgendered women using phytoestrogens, on the other hand, while comparatively small in number, have been frequently examined at TGIP and by other transgender providers relative to their self-administration of these natural hormone-like substances.
The effects of phytoestrogens seen at TGIP have been derived from numerous patients seen in clinical practice. While many individuals have reported large dosing of a variety of herbals for durations of months or years, we have not seen any significant feminization.
While whatever estrogenic properties exist only in a very weak form, very large and potentially toxic quantities are often consumed. Toxic results have shown in some individuals in the form of illness, and possibly, permanent organ damage.
Prompted by numerous advertisements that included claims about the benefits of soy for ending or lessening hot flashes, the North Central Cancer Treatment Group Clinic based at Mayo Clinic studied 177 breast cancer survivors. The results of this study were released February 28, 2000.
The flashes, which also affect women undergoing chemotherapy or tamoxifen treatment for breast cancer, can be accompanied by palpitations and feelings of anxiety, and can be very disruptive to life, the study said. "Despite optimistic hopes that this soy phytoestrogen product would alleviate hot flashes, the scientific data from this study demonstrated that it did not help," said Charles Loprinizi, one of the authors of the study.
The conclusion of the study based at Mayo Clinic found that the 177 breast cancer survivors who took soy pills did not experience any noticeable changes: the estrogen-like substance found in soybeans is not effective in stopping or decreasing hot flashes - disputing advertised claims for such products.
But whether natural or pharmaceutical, hormone therapy is not without risks. Those who maintain a self-administered herbal (or pharmaceutical) program should be regularly monitored by a physician.
Additionally, herbal hormone regimens when used in concert with traditional pharmaceutical programs will likely obstruct, instead of heighten feminization. These weak estrogen-like molecules do not augment, but compete with the pharmaceutical regimen.
And then there's the issue of dose. One has no idea what has been extracted from the plant, or its purity. And, like most everything in life, a little bit of herbal estrogen may be good for you, but a lot can hurt you. Ultimately, the transgendered woman who takes herbal hormones instead of medical hormone therapy is basically conducting an experiment of one. She may be slightly feminizing or not. She may or may not be endangering her health. But she is doing it "naturally."