What Are the Popular Treatment Philosophies?

The following estrogen dosage philosophies are popular for treatment of male-to-female transsexuals:

 

Table 1: Estrogen dosage philosophies

		Dosage	Reasoning
1	A	Adjust estrogen to achieve a serum estrogen level in the normal range of a female; more or less ignore the serum androgen level	The body cannot make good use of more estrogen than a female would naturally generate	Androgens do not directly compete with estrogens for estrogen receptor sites	A higher level of exogenous estrogen might cause adverse effects
	B	Administer consistently low dosage of estrogens
2		Adjust estrogen for gross empirical results while paying extra attention to health	See discussion below
3	A	Adjust estrogen to achieve a serum androgen level in the normal range of a female; more or less ignore the serum estrogen level	The body might be able to make good use of more estrogen than a female would naturally generate	Androgens might compete with estrogen for estrogen receptor sites	High levels of exogenous estrogen over a limited period, i.e., less than 3 years, do not usually cause adverse effects in a person with a very healthy liver.
	B	Administer consistently high dosage of estrogens

Clearly, philosophy 1 and 3 reasonings flatly contradict each other. There are good endocrinologists in each camp, which demonstrates that we still really do not know exactly how hormones work. However, there is more compelling evidence for the reasoning of philosophy 1. In some people philosophy 1 might have a not have quite as steep of a ramp of results as philosophy 3--but, with patience, the results are often just as good. The A philosophies adjust to the body's assimilation of the estrogens, whereas the B philosophies assume "one size fits all."

Philosophy 2 occupies an awkward but extremely important space in between, where we acknowledge that in some cases neither endogenous nor exogenous hormone levels are great indicators, because the levels in "typical" post-pubescent non-transsexual bodies do not always relate well to the plethora of absorption and response factors in a given post-pubescent transsexual body, especially when anti-hormones are added to the mix. If there is unusually little development after, say, 6 months of hormone therapy, then consider using gross empirical results, e.g., breast growth and fat redistribution, as the primary rather than secondary indicator, provided ones health (especially blood clotting and liver function) is not compromised. Finally, note that the endogenous level of estrogen in females (F2M) seems to be a less important factor for development than the endogenous level of androgens in males (M2F) anyway.

The following estrogen coadministration philosophies are popular for treatment of male-to-female transsexuals:

 

Table 2: Coadministration philosophies

1	Add anti-androgen	The remaining endogenous androgens (including those from the adrenal gland) can be more safely and effectively fought with an anti-androgen than by mega-dosing with estrogen. Spironolactone and finasteride are recommended. Post-ops rarely find any antiandrogen useful except for finasteride. Of transsexuals taking estrogen, those who are older than 25 or so seem to find the anti-androgen much more important than those who are younger.
2	Add progesterone or progestin	Progesterone administered with estrogen helps promote breast growth: estrogen 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 estrogen seems to reduce the risk of fibrosis, cysts, and cancer from administration of estrogen alone. On the other hand, synthetic progesterone (progestins) can partly reverse the lipid (cardiovascular) benefits of estrogen. Moreover, progestins have a slightly androgenic effect in some people, and apparently can even antagonize estrogen absorption. 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 estrogen dosage, as well as improving libido and overall energy level.
3	Add another estrogen	This may cause faster results for some people, but generally not better results in the long run.

Cycling

It is possible to vary the hormone dosages on a monthly basis so as to roughly mimic a female menstrual cycle.

Cycling hormones before removal of the testes is not recommended. The gonadotropin axis (feedback mechanism) is already precarious in a pre-op under hormone therapy; small fluctuations in the hormone regimen can translate into large variations in the endogenous androgen level, causing significant physical and emotional discomfort.

Cycling in post-ops is a more interesting topic. Unfortunately, therapy results are even more difficult to evaluate than the usual non-cycling hormone therapy, due to the increase in variables and decrease in objective data.

There is mounting anecdotal evidence, and the theory put forth by at least one reputable endocrinologist, that estrogen receptors can become saturated, temporarily reducing the sensitivity and/or quantity of available receptors. If that is the case, then giving the receptors a rest would improve hormone therapy results. For example, many people have reported a significant surge in breast development when estrogen dosage is sharply increased after months or even years of a very conservative dosage. In some cases, the surge in development continues for quite a few months if the estrogen is cycled. Development often trails off again after 3-6 months, after which, it seems that another, or longer, rest is called for.

Cycling is worth trying for those post-ops who have not achieved significant breast development (sub-A cup). If the estrogen boosts are administered via intramuscular injection or transdermal film, and the patient has no history of adverse reactions to hormones (e.g., blood clotting or prolactin problems), it is generally considered to be a safe experiment.

If one is going to cycle, given the current lack of data to suggest otherwise, one may as well more or less mimic a 28 day female cycle, rather than picking another cycle out of the air. This can be roughly achieved by intramuscular injection of estrogen in oil on day 1, then taking another shot of 1/2 dosage on day 13. Some people will experience menopausal symptoms (hot flashes, night sweats, severe mood swings, etc.) in the days proceeding each shot; if the discomfort is unacceptable, a small, constant dosage of oral or transdermal estrogen can be used to provide a "floor" serum estrogen level. If progesterone is part of the regimen, it can be cycled by intramuscular injection in oil on day 8, or by ramping it orally from days 1-14 with the peak on day 8. Some say that cycling the progesterone is more important than cycling the estrogen; other say that the progesterone must be constant to best avoid breast cancer. Of course, many variations are possible. There is no formula better for a transsexual than "do what works." If enough people report that a different cycle is more appropriate, that will be reflected here in the future.

Estradiol cypionate probably has a longer half-life than estradiol valerate. If ev is not available but ec is, consider eliminating the oral/transdermal floor, as it might not be necessary.

Cycling in this manner usually results in at least some noticable development for 1-3 months, then the rate of improvement generally trails off in an asymptotic curve. In any case, one should revert to a very conservative regimen for 3-6 months (whether it be either low-dosage non-cycling or low-dosage cycling) before trying again. If one does not achieve any result whatsoever from cycling within a few months of starting, it will likely not help to continue the cycling.

Aggressive cycling is meant to facilitate bursts in development, and is not appropriate for pre-ops or lifetime maintenance. However, lifetime post-op cycling can be done safely with more conservative dosages.

For reference--endogenous androgens in genetic women generally peak just before ovulation and again just before menstruation--that is, on roughly days 13 and 27 of the cycle as defined in this document.

Next: How are hormones delivered?