The main aim of hormone treatment is to enable a safe gender transition with the associated desired positive changes, both physical changes and emotional ones. It is usually a careful step in a 3-stage process that includes the Real Life Experience (RLE), hormone therapy and gender reassignment surgery (in that order).

Hormone treatment needs careful monitoring

Monitoring and treatment go hand-in-hand and hormone treatment needs to be medically supervised from the outset. The following is a guide to help you get the right treatment at the right stage and to avoid many of the common pitfalls in what is potentially a dangerous medical treatment.

When to start hormone treatment

The Standards of Care underpin the 3-step process of treatment: the RLE, hormone therapy and surgery (in that order). Hormone treatment can be started following the recommendation of one mental health professional, usually a consultant psychiatrist with specialist experience in gender identity disorders, but the Standards of Care recommend the need of the RLE. The time for the RLE is open to interpretation, but it is usually a minimum of 3-6 months or with the addition of 3 months of psychotherapy before initiation.

Specialist services, however, feel that hormone treatment should be delayed until the individual has demonstrated a positive RLE in terms of psychological and social stability, and any issues addressed during the transition. Therefore the RLE varies from person to person, but it is generally accepted that a period of 2 years is appropriate.

When not to start hormone treatment

Although many people are eager to start hormone treatment as soon as possible, there are circumstances when hormones might not be the next appropriate step.

The following is a list of reasons for not taking hormone therapy:-

1. If you are aged under 18 years old.

2. If the hormones are not being prescribed and supervised by an appropriate medical professional. For example, do not take hormones obtained from internet websites, from the blackmarket or from private practioners who are not willing to offer regular follow-up.

3. Do not take hormones when they are not part of a carefully planned 3 stage process, including the RLE (before treatment), hormone therapy and gender reassignment surgery.

4. Hormone therapy should only be started following the recommendation of a mental health professional with a special interest in gender issues. A psychiatric assessment is needed before advancing to seeing the endocrinology (hormone specialist) team.

5. Hormone treatment is contraindicated in certain cases. You need to be in good physical health and a number of blood tests and investigations need to be carried out before starting. Certain medical conditions, such as severe liver disease, may preclude you from certain types of hormonal treatments.

Risks of starting treatment too early

Hormone therapy needs to be carefully planned and is the middle phase of the 3 stage process: RLE, hormone treatment and surgery. If hormones are started too early in the RLE, then it can become very difficult (and sometimes impossible) to reverse the effects if there is concerns, or in the worst cases, regret.

Also hormone treatment needs to be coordinated to fit in with the type of surgery aimed for.

For example, in MTF transsexuals, hormone therapy leads to shrinking of the male genitalia. Whilst this is a welcomed effect for many people, it is important to realise that a certain amount of skin needs to be preserved in order to create a vagina with surgery (called Vaginoplasty). Therefore if hormones are started prematurely, then there is often a significant reduction in the size of the scrotum and therefore very little skin available to carry out the operation successfully. This can lead to a very small vaginal opening post-surgery, which can be very unsatisfactory for some, particularly if there is an interest in sexual relationships in the future.

In FTM transsexuals, hormone treatment leads to an increase in the clitoral size. If a phalloplasty operation is chosen (to produce a penis structure), then this hormone treatment needs to be carefully timed to fit in with the plans for this complex surgery.

Side effects and Risks

There are significant risks associated with hormone therapy. There must be strategies in place to minimise side effects, manage any complications and modify the treatment regime to meet the needs of the individual.

Risks associated with MTF therapy

The main risks associated with Oestrogen therapy include the following:-

1. Increased risk of thromboembolic disease.

Simply put, there is a significant risk of blood clots (similar to women taking the oral contraceptive pill). The risk of blood clots in the leg, called Deep Vein Thrombosis, is 20 times more common than in the general population. There is also a significant increased risk of Myocardial Infarction (heart attacks). If there are other risk factors associated with blood clots, such as high blood pressure, obesity and smoking, then the risk may be even greater.

2. Increased risk of breast cancer.

There is an increase risk of breast cancer that is similar to that found in genetic women who are taking oestrogen drugs for hormone replacement therapy. This risk can be increased if there are other factors than can contribute, such as a family history of breast cancer (and therefore genetic predisposition).

3. Abormal liver function.

There is a small risk of liver problems with oestrogen therapy, and, in some cases, can lead to a medical condition called Jaundice. This is very rare, and is related to the dose of the therapy. Higher doses carry a greater risk, although regular blood monitoring largely prevents any serious problems. For those with existing liver problems, transdermal skin patches can be used to administer oestrogen as these are not associated with liver complications.

4. Fertility problems.

Although this may seem like stating the obvious, oestrogen therapy suppresses the function of the testes and sperm production and therefore fertility is reduced. Therefore, if having children is possibly an option for the future, then it may be necessary to consider the option of putting a sperm sample in storage, for later use. This needs to be done before hormone therapy is started.

Risks associated with FTM therapy

The main risks associated with testosterone treatment include the following:-

1. Increased risk of stroke and heart attacks.

Testosterone therapy can cause an increase in the production of red blood cells and can lead to a medical condition known as Polycythaemia. The extra red blood cells can increase the risk of blood clots and therefore there is dose-related increased risk of heart attacks and strokes.

2. Abnormal liver function.

There is a small risk of changes in liver function, with abnormal liver enzymes, and in some rare cases, a risk of liver cancer. These risks are very small and are related to the dose of treatment. Regular monitoring of liver enzymes by blood tests is sufficient to medically supervise the treatment.

3. Increased risk of endometrial cancer.

Testosterone treatment in the long-term is associated with an increased risk of endometrial (womb) cancer. Again this is rare bur regular monitoring by ultrasound scanning of the abdomen is needed. This scan is similar to the scans used to monitor pregnancy and is very sensitive at detecting abnormal changes to the uterus (womb). It is recommended that a scan is carried out every 2 years.

4. Possible risk of change in bone density.

There have been suggestions that long-term treatment with testosterone is associated with a medical condition known as Osteoporosis. This leads to a reduction in bone density and an increased risk of fractures and back problems. Oestrogen and osteoporosis are well known to be related to each other in previous research, but there has be no formal link found between testosterone and the condition.

The Blog is available. We would love to hear all your experiences with hormonal therapy, both good and bad. What treatments have you been given and how successful was it? Have you suffered some unpleasent side effects or medical conditions as a result of the treatment? Please share your story with us.