| Introduction
to Hormones All animals have hormones. Hormones are chemical messengers that travel through the blood and turn body functions on or off. For example, some hormones tell your heart to beat faster when you get scared while others control fat deposition. Hundreds of hormones are in our body's, carrying many different messages.
Before taking female hormones it is also necessary to carefully consider several other important points:
Firstly, why do you really want to start taking them? Bear in mind that some of the results of serious and prolonged use of hormones are obvious and permanent. For a non-transsexual man, with no intention of ever transitioning, to take hormones simply because he wants to "grow breasts" is at the very least foolish. The resulting breast development will soon become a source of embarrassment as a man, will not shrink by any significant degree when the hormones are stopped, and may well eventually require surgical removal (gynecomastia). Personally, I certainly had many cringing moments about my breast development prior to my transition, and became very very conscious of it. Secondly, there are medical risks associated with long term hormone use, although admittedly recent studies seem to show that these risks are much less than previously thought, for example post-operative MTF women seem to be no more at risk of getting breast cancer than genetic women on HRT. Thirdly, there are considerable costs associated with hormone treatment, particularly if "natural" hormones are preferred over much cheaper "synthetic" hormones which are thought to have higher risks of side effects and complications. $100 a month is a perfectly reasonable amount to budget for hormones and antiandrogens, given that this must be maintained year in year out the total expenditure for many young women can be more than, for example, their pension contributions! Finally it is necessary to be realistic about what feminising hormones can do, they are not some magic potion. Also the effects take a long time to realise, at least two to three years before maximum effects are achieved.
Types of
Hormone Oestrogens are steroid "female hormones" produced in large quantities by the ovaries of women, however they are also produced in small quantities by the testes of men. During a girls puberty it's the oestrogens that are responsible for the development of female secondary sexual characteristics such as breast enlargement, broadening of the pelvis and fat deposition around the hips. In a sexually mature woman with female reproductive organs oestrogens participate in the monthly menstrual cycle that prepares the body for a possible pregnancy, and they also participate in the pregnancy if it occurs. Oestrogens also have several non-reproductive effects: they are mental tonics and have anti-depressive effects; they antagonize the effects of the parathyroid hormone, minimizing the loss of calcium from bones and thus helping to keep bones strong; and they promote blood clotting and may lower the risk of heart disease (although a recent study has questioned this) .
In terms of the specific biochemicals contained in oestrogen-based hormone preparations, there are three main categories of interest to transsexual women:
For hormone therapy both synthetic and natural oestrogens are commercially available. Synthetic oestrogens are generally cheaper but more prone to side effects than are natural oestrogens. Products based on phyto-oestrogens are available in health food shops but are not subject to licensing or standardisation of their active constituents, and are usually of very low, and possibly ineffective dose - the sweeping claims made by manufacturers of such products should treated with great scepticism.
Progesterone
There are some prescription HRTs available that are based on synthetic progestogens (chemicals that have progesterone-like actions), e.g. Provera and Duphaston. True, non-synthetic, progesterone (as opposed to a progestin) is very rarely reported to have any adverse effect, and seems to provide a healthier balance for an aggressive oestrogen dosage in pre-op TS women, as well as improving libido and overall energy level. Androgens One of the well-known effects of testosterone is that it stimulates muscle growth. For this reason, some athletes and body builders (both male and female) take testosterone or similar drugs, called "anabolic steroids," to help them build bigger, bulkier muscles. However, these drugs have other dangerous side effects, and their use is illegal. Conversely in pre-SRS transsexual women it is highly desirable to block the masculinising effects of androgens (including those from the adrenal gland, not just the testes), these can be more safely and effectively fought with an "anti-androgen" drug than by mega-dosing with oestrogen. Spironolactone and finasteride are commonly recommended. Post-op women rarely find any antiandrogen useful except for finasteride. Transsexual women older than 25 or so seem to find the anti-androgen much more important than those who are younger.
In a transsexual woman the surgical removal of the testes either during sex re-assignment surgery or by a bilateral orchidectomy (castration) is highly desirable because of the virilizing effects of the testosterone they produce. Without the testes present, not only can smaller doses of female hormones can be administered but unopposed by testosterone this will often have a greater feminising effect on the body than before. Puberty Puberty can be defined as the biological developments which change boys and girls from physical immaturity to biological maturity, and many of the differentiation's in outward appearance and body shape between men and women occur or develop further during puberty. Unfortunately for a male-to-female transsexual, an inappropriate male puberty sets a physical mountain that can never be full conquered. A lot more information about puberty and its effects is given in the separate article which can be found here.
Effects
of Hormone Treatment In general, the increased oestrogen and progesterone blood levels resulting from the female hormone treatment will stimulate and promote the growth of female secondary sexual characteristics (breasts, fat distribution, pubic hair pattern, ...). Body shape is controlled by oestrogen so its use stimulates a female body shape to develop, and the woman's body shape and "figure" will become far closer to female norms in proportions.
Maximum feminisation occurs if hormonal treatment begins before a male puberty. If the testes have been removed in infancy or childhood, this therapy is usually started at the age of about 10 or 11, in order to initiate a female puberty. Unfortunately of course this ideal situation is very rare. If a male puberty has already occurred then the associated reduction in the levels of androgens such as testosterone will have little or no effect on most of the already developed of male secondary sexual characteristics (e.g. deepening of voice, facial hair, narrow pelvis, ...). The effects of female hormone treatment will vary considerably by individual, and can take 2 to 5 years to fully achieve. In order to maximise the physical effects and benefits, hormone treatment should be begun as young as possible, before the body has completely matured and can no longer develop in response to stimuli. The longer after male puberty (which typically ends by age 18) that female hormone therapy is started the less effective it will be - but not on a linear scale, the effects tail-off rapidly as time since puberty increases. For example, a woman starting hormones at age 20 may experience good breast development and a near cessation of facial hair growth, the same woman starting treatment at 30 will get considerably less breast development and only a slight reduction of facial hair growth, while if she started at 40 the effects will be less again, but not so significantly. The following table shows the affects of female hormone treatment begun after male puberty has completed (i.e. after about age 17).
As well as hormones, a doctor may be able to recommend other drugs to aid fat redistribution and weight control. One such drug is Metformin (one brand being Glucophage). Although normally associated with diabetes, it's now also considered useful for aiding and enhancing the bodyfat redistribution (including limbs and face) of transsexual women taking oestrogen. Despite a loss of several kilogrammes of muscle mass, adult male-to-female transsexuals actually have a tendency to gain weight after starting hormones as they put on so called "reproductive fat". An overall gain of 4-5kg (10-12 lbs) seems typical - with little improvement in the waist-hip ratio (WHR), a key physical "female indicator" that's subconsciously observed by other people. Liposuction body contouring is a common quick-fix option used by many transwomen these days, however, it is not a substitute for weight reduction in an obese individual. Unfortunately the tendency to gain weight can only be properly countered by appropriate exercising and dieting which will greatly assist and magnify the effects of drugs in developing a female type figure and body shape - a moderately active metabolism means that typically "male fat" on areas such as the stomach will be burnt up while female-type fat on areas such as the buttocks will still be deposited. Exercising should emphasise burning calories and general toning rather than aim to maintain or even increase physical strength, so daily sessions of aerobics, swimming or cycling are appropriate, but not power lifting, weights or even circuit training.
Happily, once lost, excessive "male" type muscle in areas such as the biceps is almost impossible for transsexual women to regain if post-SRS or taking hormones and anti-androgens. After perhaps an initial period of rigorous restriction (Atkin's et al), dieting really means a permanent change of eating habits, the aim is simply to adopt a healthy balanced diet that's relatively low in fat (this is rather easier to type than do, as I know!). A good rule of thumb is to eat about fifteen times your ideal body weight (e.g. 120 lbs x 15 = 1800 calories) or if less 2000 calories per day, unless you are exceptionally big framed and/or active when a few hundred extra calories may be appropriate. Avoid excessive long term dieting which becomes an eating disorder with malnutrition and osteoporosis. This triad may result in irreversible bone loss, psychological abnormalities and death. Eating disorders include moderate restriction of food intake, occasional bingeing and purging (bulimea) to severe food restriction (anorexia nervosa) and regular binging and purging (bulimea nervosa). Signs that you are excessively dieting include: constant fatigue; inability to concentrate; anaemia; the occurrence of stress fractures; depression; constipation; dry skin; and cold intolerance.
While female-type peripheral fat deposits on the bottom, legs and arms are not closely associated in women with increased health risks (heart disease, diabetes, ... ), excess fat around the waist is - strongly. Thus shifting fat from the waist to elsewhere in the body is win-win situation for the transsexual woman. Basically a good figure is a healthy figure, which is why women with good figures are more attractive to men! The final objective should be a weight loss to a female rather than male norm for your height and build (it is necessary to accept that most transwomen are physically more heavily built and thus heavier than genetic women of the same height), and a WHR of about 0.8. Unfortunately the underlying constraints of a male type skeleton make hourglass figures - i.e. a WHR of 0.7 or less - very rare in transwomen. Some transwomen do attempt to compensate for this by augmenting the size of their hips and buttocks with butt implants or even dangerous silicone injections. Attractiveness
with high oestrogen levels and the right with low. No
Miracles Hormones can greatly assist the transition of a short and lightly built young man in to a completely passable woman, but hormones (nor anything else) cannot turn a tall, rugged, heavily built, balding, and elderly man in to a pretty and petite girl. Such a man is always going to have difficulty passing successfully as a woman, indeed even after all available hormonal and surgical treatment, the brutal reality is that he may still appear to strangers as a man in drag with "boobs stuck on".
The doses provided by skin patches are lower than those of tablets because skin absorption does not involve the hormone passing through the liver (where a significant amount of an orally administered hormone will be metabolised and lost). So you cannot directly compare the dosage figures on the packets of the two types of preparation. Vaginal oestrogen is used to treat local symptoms, i.e. vaginal dryness, and not as a main source of whole-body hormone replacement. Vaginal oestrogen can also be used to help with dilation in post-SRS women.
There are a lot of hormone products on the market and finding the right one can be difficult. The questionnaire for The Million Women Study lists the following common UK preparations:
What suits one person will not suit another. There are really no
guidelines other than just to keep trying different preparations until you
find one that suits you. Hormone
Regime's for Transsexual Women
Hormone
Replacement Therapy after SRS Finding the right dose is a matter of balancing symptomatic relief (hot flushes, mood problems etc.) and osteoporoisis and cardiovsacular protection, against the risks such as breast cancer that are often associated with higher dosages.
Potential
Risks Side
Effects
When
considering the use of female hormones, absolute and relative
contraindications (undesirable conditions) must be considered.
Absolute contraindications which should prevent the
commencement of female hormone treatment include:
Relative contraindications which increase the risk of complications developing include:
Once on female hormone treatment, development of any of the following conditions should cause the transsexual woman to immediately seek the advice of a physician. These contraindications include:
As with any medication if you notice unexplained changes in your health notify your physician. The woman should report to her physician immediately the occurrence of nausea, vomiting, breast lumps, abnormal bleeding, leg cramps, water retention, headache, dizziness and light-headedness. Cigarette smoking is known to increase the risk of side effects with synthetic estrogens, and this may also occur with natural oestrogen. The risks of complications developing can be significantly reduced by leading a healthy lifestyle, for example:
T he news seems to be improving but is often contradictory, for example one large scale study found no evidence that transsexual women taking hormones are likely to die any younger than the general population, but another found that their mortality rate increased.
In addition to the primary feminisation effects, it now seems that long-term oestrogen therapy may actually have some benefits for the body of the male-to-female transsexual woman. The very limited research available seems to show that post-SRS transsexual women are no more at risk of breast cancer then genetic XY women on HRT. But the evidence is unfortunately slightly contradictory - some research on transsexual women indicates that long term oestrogen-based hormone replacement therapy (HRT) protects the women against heart disease but slightly increases the risk of breast cancer, while other research suggests that provided they are conservatively treated with oestrogens then they may actually may run a smaller risk of breast malignancy than genetic females because the mammagenesis (breast development) is initiated later in life. Two reports published in the Journal of the American Medical Association on 3 July 2002 unfortunately contained some bad news. A study of 16,600 genetic post-menopause women taking a combination of conjugated oestrogen (e.g. Premarin) and medroxyprogesterone acetate (a progestin, e.g. Provera) had found that the HRT did lower the risk of hip fracture, a measure of osteoporosis, but it raised the number of strokes by 41%, heart attacks by 29%, and breast cancer cases by 26%. It should be pointed out that the overall risk of these events is still low absolutely, the figures represent for every 10,000 women taking HRT, 7 extra heart "events", 8 more breast cancer cases, and 8 more strokes per year. The oestrogen-progestin combination was developed because taking oestrogen alone was shown to increase the risk of ovarian cancer, however one report effectively recommended that genetic women who have had a hysterectomy (i.e. their uterus removed) should consider taking oestrogen alone - this of course also applies to all post-op transsexual women.
Obtaining
Drugs without Prescription
On the web, the once popular and recommended New Zealand website Pharmacy Care New Zealand (http://www.pharmacycare.co.nz/ ) sadly closed its doors in 2001 to international customers, which left many girls with a major problem. It seemed to re-open (at http://www.pharmacycare.com) for a while in 2002, but from warning emails (thanks!) I know that it provided customers with a very poor service level and often a very long wait for their ordered goods, indeed it was allegedly even a credit card scam. Thankfully by early 2003 the site had closed again, hopefully for good. However, over the years the following other on-line pharmacies have been suggested to me as being prepared to ship hormones internationally without prescription:
And for optimists seeking a non-prescription herbal solution:
Important Notes:
If you have had experiences ordering hormones from the Internet, and can perhaps recommend another company, or have had a bad experience with one listed above, please let me know so I can update this section. Check out the Transsexual Women's Resources at http://www.annelawrence.com/hormoneindex.html for the latest information on obtaining mail order hormones.
My
Experience If
you have any questions, please feel free to email
me. More
Information
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For
male-to-female transsexual women, taking hormones becomes part of their
daily routine. Although the amounts taken can be reduced after sex
re-assignment surgery, it will still be necessary for them to take
hormones every day for the rest of their lives in order to remain
healthy. It must be emphasised that some of the effects of long
term hormone use are irreversible, at least without surgery, hormones
are not something that can be experimented with. The widely
followed 
Most of the preparations
that are licensed for use as female hormone therapy (these may be
conjugated oestrogens, but are usually based on oestradiol valerates)
are only available by doctor’s prescription. Oestradiol valerate is
the only form of hormone therapy that can be measured in blood, so blood
oestrogen measurements are meaningless in someone taking, say, Premarin.
In the
transsexual woman progesterone administered with oestrogen appears to
help promote breast growth: oestrogen stimulates cell mitosis and growth
of the ductal system, while lobular development and differentiation
seems to be dependent on progesterone (breast fat accretion seems to
require both). Progesterone consistently administered with
oestrogen also seems to reduce the risk of fibrosis, cysts, and cancer
from administration of oestrogen alone.
Gonads
Weight, Muscle Loss and Fat Re-Distribution
Medical opinion
has long been that the very high levels of hormone
therapy required in a pre-SRS woman who has not had an orchidectomy will
inevitably be associated with health risks in the long term - more than
two years - and that these risks increase with the age of the patient
(particularly if over 40). SRS or an orchidectomy
allows a radical reduction in hormone intake, indeed
the
endocrinology and hormone regimen of post-SRS
women is very similar to post-menopause
women on HRT, however
transsexual women who had SRS at an early age have the complication of
needing to take HRT for a very much longer period of their lives than most
women, so unknown side effects may yet emerge.
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