Impact On Fertility And Pregnancy
Please note that gender-affirming hormone therapy is not a form of pregnancy prevention and, with masculinizing hormone therapy, exposure to testosterone will cause birth defects. If you receive GAHT you should speak to your health care provider on approaches to take if you wish to prevent pregnancy.
The long-term impact of gender-affirming therapy on fertility is not fully known. We do understand that families are formed in many ways. A member of the Cooper health care team can talk to you about sperm or egg preservation if you are considering becoming a biological parent in the future. Any preservation of sperm or eggs ideally should be done prior to starting hormone therapy.
Formulations & Recommended Doses Of Anti
* Price quotes are provided by www.pharmacy.ca. The above prices are accurate as of May 2018 and represent the price for a 4-weeks supply of a generic brand of medication unless indicated otherwise . Prices include a usual and customary dispensing fee of $9.99, which may vary from pharmacy to pharmacy. Note: For patients on ODB, spironolactone, cyproterone, and oral estradiol are covered without the submission of an EAP form.
** Estradiol valerate IM must be prepared by a compounding pharmacy, price quote provided by Pace Pharmacy
a) rarely required or used. Maximal effect does not necessarily require maximal dosing. Use clinical judgement in selecting optimal individual dosing b) Estradot® brand c) Usual doses vary significantly between individuals. Use starting doses and titrate up based on patient response. Maximum doses are not often needed. Use clinical judgement in selecting optimal individual dosing d) 200 mcg daily given as 2×100 mcg patches applied twice weekly e) Estragel
® brand f) Estradiol valerate IM must be prepared by a compounding pharmacy, commonly at the minimum concentration of 10mg/mL. Per updated Ontario guidelines, opened multi-use vials must be discarded after 28 days.
Why Choose The Transgender Center For Hormone Therapy
Leaders in the field: At the Washington University at St. Louis Childrens Hospital, we offer the only multidisciplinary care available to transgender, nonbinary or genderqueer children and adolescents in the St. Louis region.
A supportive environment: We dont encourage anyone to express a particular identity. Instead, we offer a relaxed, open space where youth are free to talk about their goals with hormone therapy.
Answers to all your questions: Theres limited research on the long-term effects of hormone therapy for transgender kids and young adults, but well be happy to go over the data that does exist. Well talk about what you can expect from hormone therapy and set realistic expectations about what hormones can and cant do.
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About Starting Gender Confirming Estrogen Hormone Therapy
Beginning feminizing hormone therapy is an exciting and important step in a transgender womans transition, as she becomes her authentic self. But starting estrogen hormone therapy also comes with some risks, challenges and unknowns as a woman literally changes her body chemistry to align with her identity.
Hormones do affect every person differently. But, as the saying goes, in most cases the best surprise is no surprise. So, in this article, the hormone replacement experts at Sotto Pelle explain some of the issue you may experience as you begin to undergo your feminizing estrogen hormone therapy. Having this information and knowing generally what to expect from feminization hormone therapy can help you communicate more effectively with your medical provider as you work together to map out the steps in your transition.
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Starting Doses And Costs
There are many different estrogen options available. Your Primary Care Provider will discuss these options with you to determine which is the best fit for you. As with all medications, it is important to follow the prescribed dosing and administration schedule. It is also important to note that the starting doses of hormones will vary from one individual to the next based on health history, bloodwork results and desire for physical changes. The options are outlined in this section.
Anti-Androgen & Progestin Therapy
It is common to see a type of medication called an anti-androgen combined with feminizing hormones when starting or maintaining a feminizing medication regimen. Anti-androgens act to block the effects of naturally-occurring testosterone , which helps promote feminizing changes. There are a couple different anti-androgen options available in Canada that your primary care provider can discuss with you.
Spironolactone is a very commonly used anti-androgen in Canada and around the world. The cost of this medication varies depending on the dose that works for you. Pricing in Alberta can range from $20 $50 / month without any kind of drug coverage/insurance.
Estrogen Preparations and Starting Doses
There are many different estrogen options available. Your Primary Care Provider will discuss these options with you to determine which is the best fit for you. As with all medications, it is important to take your medication as prescribed.
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How Do We Monitor For Safety
Labs are collected prior to starting hormones and every 3 months for the first year of treatment. In the second year, labs are checked every 6 months. Tests that are monitored include cholesterol, liver tests and hormone levels, including prolactin. These labs can be drawn at Lurie Childrens or at a local facility.
The Truth About Feminizing Estrogen Therapy
Beginning feminizing hormone therapy is an exciting step in a transgender womans transition. But starting feminizing hormone therapy can also make a person a little nervous about the risks and side effects of venturing into new, uncharted territory.
Unfortunately, despite the fact that gender-affirming hormone therapy has been around for nearly 100 years, there are still many misconceptions about the effects of estrogen therapy for transgender women. The Internet is full of misinformation and movies and TV also rarely portray medical information accurately.
In previous articles, the hormone therapy experts at SottoPelle have discussed the types of feminizing hormones as well as what to expect when starting estrogen HRT. In this article we dispel many of the just-plain-wrong myths about transgender hormone therapy so that you can confidently embark on your journey to living your authentic life!
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Myth #: Feminizing Estrogen Therapy Kills Your Sex Drive
Libido is highly individualized and personal. So the connection between libido and hormone therapy are as unique as you are. When trans women experience changes in their sexual drive it is likely due to decreased testosterone levels due to blockers not estrogen.
Talk to your physician if you have concerns about changes to your sex drive. Blood work can be conducted to assess your testosterone levels. And together you can figure out what is best for your sex life.
Effects On Primary And Secondary Sex Characteristics
Hey! While talking about bodies in this section, we use medical terms like penis and testes to describe our bits. This is just so you know what we’re talking about, as our communities often use similar words for quite different body parts – particularly our genitals.
When talking about yourself, or being referred to by others, we encourage you to use and request the language you feel most comfortable with instead! For more information about affirming language for our bodies and bits, .
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Feminizing Hormone Replacement Therapy Medication And Timing
While your healthcare provider will help you develop an individualized treatment plan, feminizing hormone therapy often begins by taking 100 to 200 milligrams daily of a diuretic called spironolactone to begin blocking male hormone receptors and suppress testosterone production. Some individuals begin taking estrogen immediately, in tandem with spironolactone, to further reduce testosterone production and develop more feminine characteristics. In other cases, estrogen is introduced after several weeks of spironolactone use. Your doctor will recommend the best plan for your needs.
There are various methods for administering estrogen, including orally, by injection, or as a cream, gel, spray, or patch. Commonly used forms of estrogen during a male-to-female transition include:
- Patches: 17B-Estradiol patch
Myth #: Feminizing Estrogen Therapy Will Change Your Voice
Estrogen feminizes many aspects of your body, but unfortunately vocal cords arent one of them if your voice has already changed.
However, if you were assigned male at birth and take hormone blockers as a teenager, then testosterone will not get a chance to thicken your vocal cords, and your voice will not deepen as much.
In other words, if testosterone during puberty already thickened your vocal cords and deepened your voice, estrogen wont reverse that. However, if altering your voice is important to you, voice therapy or surgery can help!
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Comparison To Previous Studies
To our knowledge, there is no published data specifically evaluating feminizing hormone regimens and estradiol concentrations in older trans individuals. Previous studies that have enrolled older trans women have noted increased mortality from ischaemic heart disease in those aged 40-64 years , however they have not reported on estradiol dose, formulation, route and concentration with aging. Furthermore, current recommendations for aging trans women are predominantly expert opinion pieces , with many recommendations being extrapolated from the menopausal hormone therapy literature. Our study provides an insight into the prescribing patterns of experienced Australian transgender healthcare providers, in the context of cardiovascular risk factors that emerge with aging.
Risks Of Hormone Therapy
There is some uncertainty about the risks of long-term cross-sex hormone treatment. The clinic will discuss these with you and the importance of regular monitoring blood tests with your GP.
The most common risks or side effects include:
- hair loss or balding
There are other risks if youâre taking hormones bought over the internet or from unregulated sources. Itâs strongly recommended you avoid these.
Long-term cross-sex hormone treatment may also lead, eventually, to infertility, even if treatment is stopped.
The GP can help you with advice about gamete storage. This is the harvesting and storing of eggs or sperm for your future use.
Gamete storage is sometimes available on the NHS. It cannot be provided by the gender dysphoria clinic.
Read more about fertility preservation on the HFEA website.
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Mood And Mental Health
Many people find that their mood on feminising hormones is calmer, and that their mental health becomes a lot easier to manage. For some people this is due to the euphoria experienced from starting hormones, for others its just a general sense of calm and better mental health.
This doesnt mean that trans and gender diverse people on hormonal therapy dont still experience mental health issues and require support for them, and theres nothing wrong with needing help. For more information, check out our mental health page.
Indications For Bmd Screening
- All patients over 65 years old.
- Patients 50-64 years old at higher risk for osteoporosis .
- Consider before 50 years in:
- Certain high-risk conditions such as hyperparathyroidism or malabsorption syndrome.
- Patients who have undergone orchiectomy and have been on low-dose or no hormones for any significant length of time .
- Patients who have been on anti-androgens or a GnRH analogue for a significant length of time without co-administration of exogenous estrogen.
Keep in mind:
- There are no studies to guide the interpretation of BMD results and fracture risk in trans people, and whether to use sex assigned at birth or affirmed gender. One option is be to interpret results in comparison to both cis men and cis women.
- Frequency of BMD screening will depend on the results of the initial scan.
- 1 Feldman J, Safer J. Hormone Therapy in Adults: Suggested Revisions to the Sixth Version of the Standards of Care. International Journal of Transgenderism 2009 11:146.
Keep in mind:
In Ontario, transfeminine patients who have changed their OHIP sex marker to Ã¢â¬ÅfemaleÃ¢â¬ï¿½ can be screened as part of the organized Ontario Breast Screening Program.
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Risk Evaluation: Absolute Contraindication To Feminizing Hormone Replacement Therapy
As seen previously, the HRT for MtF transgender carries risks. In some cases, comorbidities can preclude HRT due to its absolute contraindication. This is because the risks for the patient are too high. Among these cases there are:
- previous venous thrombotic events related to an underlying hypercoagulable condition
- history of estrogen-sensitive neoplasm
- Transgender Medicine: A Multidisciplinary Approach.Leonid Poretsky, Wylie C. Hembree. Springer, 2019
- Principles of Transgender Medicine and Surgery, second edition.Randi Ettner, Stan Monstrey, Eli Coleman. Routledge, 2016.
- Management of Gender DysphoriaCarlo Trombetta, Giovanni Liguori, Michele Bertolotto. Springer, 2015
Current Guidelines For Feminizing Hormone Therapy In Aging Transgender Individuals
There is no evidence to guide continuation or cessation of feminizing hormone therapy in aging trans individuals . Recommendations are mainly speculative and reflect experience with hormone replacement in postmenopausal women. ENIGI guidelines recommend changing to transdermal preparations beyond the age of 45 years due to the first pass effect of the liver and associated thrombotic risk of oral estrogens. Other expert groups suggest the lowest effective dose, with preference for transdermal formulation in those beyond 50-55 years, due to potential cardiovascular side effects becoming more apparent . Whilst ranges of estradiol are provided by some guidelines, these are based upon expert opinion and their applicability to older individuals is unclear .
Complete discontinuation of hormones in aging trans individuals, especially in those who have undergone orchidectomy, may lead to profound bone loss . Additionally, in people who have not undergone orchidectomy, withdrawal of feminizing hormone therapy may result in virilization . As such, continuation of estradiol in an age-appropriate dose beyond the age of 50 years is recommended .
Overall, the risks and benefits of continuing versus withdrawing feminizing hormone therapy is an individualised discussion, and shared decision making is recommended . Unless there are clear contraindications, feminizing therapy should not be withheld or withdrawn from trans individuals based purely on age .
Undergo Hrt In Atlanta With An Experienced Transgender Care Provider
Over the past few years alone, there have been a number of compelling studies that support the safety and efficacy of hormone replacement therapy. In turn, it has become a common form of treatment in the provision of transgender care.
For transgender patients who seek hormone replacement therapy, initiating and monitoring treatment requires a mindful approach in developing a successful program. This why working with an experienced and proficient primary care provider can work to a patients benefit. From the knowledge and experience that goes into a hormone therapy program to providing an autonomous environment that encourages open communication and understanding, transgender patients should feel as though they can fully trust their healthcare provider.
Erin Everett, NP-C, AAHIVS, is committed to the LGBTQ community, providing a relaxed, supportive, non-judgmental environment where patients can address their health. If you would like to learn more about transgender hormone replacement therapy in Atlanta, such as the cost of HRT or information regarding any of the other primary care services available, visit the contact page.
How To Get Access To Estrogen Hormone Therapy
If a person decides to transition, it is essential to receive estrogen hormone therapy from healthcare professionals.
Buying and taking hormones from other sources carries many risks, such as poor quality of drugs, improper doses, and possible harm.
In order to start the process, a person must discuss their options with a healthcare professional.
Transcaresite has a directory of trans-friendly medical professionals. If an individuals healthcare insurance covers the cost of transitioning, it is important to check that the healthcare professional a person chooses is in their insurance network.
The World Professional Association for Transgender Health recommends healthcare professionals and individuals undergo several steps before starting estrogen hormone therapy.
The GLMA is the national LGBTQI+ medical association that also has provider listings for trans-affirming care.
- psychiatric, including any mental health conditions
- social, such as social support and legal history
- family, such as a history of psychiatric illnesses, suicides, and substance use
- developmental, such as education level and any history of trauma
- any instances of substance use
What Should I Know Before Starting Feminizing Or Masculinizing Hrt
Before starting hormone therapy, itÃ¢s important to learn about the short-term and long-term effects of gender-affirming hormone replacement therapy, as well as the risks associated with this kind of treatment.
Someone may choose to start HRT to ease gender dysphoria or emotional distress associated with societal transphobia. They may also select HRT to improve their social functioning or sexual satisfaction in relation to their gender identity. There are many reasons why people may choose to be on HRTs.
There are several benefits of HRT, including improved psychological and social functioning, sexual satisfaction and overall quality of life. However, there are risks and changes that you should consider before starting HRT. Be sure to think through impacts on fertility, sexual functioning and other health problems with your doctor.
Thus, HRT allows for these hormonal and physical changes to occur and, as a result, decrease gender dysphoria and psychological distress that stems from a transphobic society.
Feminizing HRT can impede the effects of testosterone via hormone blockers and the replacement of testosterone with estrogen. Feminizing treatment can also impact your fertility and sexual functioning.
Masculinizing HRT impedes the effects of estrogen on your system by replacing estrogen with testosterone and encouraging the development of masculine features. This replacement process can also impact your fertility.
Comparison To Group Aged < 45 Years
Clinical and laboratory parameters of the < 45 years group are outlined in Table 3. There was no difference in serum estradiol concentration achieved between the 45 and < 45 years age groups . However, there was a significant difference in the proportion of individuals treated with transdermal estradiol between the two age groups .
Table 3 Clinical Characteristics .
Figure 2 Serum estradiol concentration by age group .
The median oral estradiol dose was 4 mg in the 45 years group, which was lower than the median dose of 6 mg in the < 45 years group . Individuals in the < 45 years group were more commonly prescribed a progestogen .
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