How Can the Intended Effects of Hormone Therapy Be Maximized and the Dangers Minimized?

Exams

• Before starting hormone therapy, take a full physical exam, and have blood drawn to check liver function (enzymes) and clotting factors. If you can possibly afford it, also take tests for thyroid, kidney, electrolyte, lipid (cholesterol), prolactin, sugar, estrogen, and androgen levels. It is also interesting to monitor the skeletal health via the calcium and phosphorus levels, especially if you are more than 40 years old (better yet, with a bone densitometer).
• If you take oral estrogen or progestin (synthetic progesterone), repeat the liver and clotting tests a few months after each significant increase of dosage. At the very minimum, recheck them 6 months and 12 months after starting. Even after achieving a stable long-term (> 2yr) oral regimen, it is not a bad idea to recheck the liver and clotting again every couple of years. If you are only on injectible or transdermal hormones, a single recheck 9-12 months after starting should be sufficient, if you are otherwise healthy.
• If you take spironolactone, have an electrolyte test about a month after each significant increase of dosage, especially if you have any known problems with potassium levels.
• There may be a dramatic spike in the prolactin level, causing significant discharge from the nipples (lactation) for up to a week, if a high estrogen dosage is suddenly stopped; this is similar to the process in a female who has just bore her child. However, if nipple discharge is noted when there has not been a significant estrogen dosage change for several months, take a serum prolactin test: >100 ng/ml is cause for concern; pituitary gland monitoring and a reduction in estrogen dosage is probably indicated.
• Breast cancer risk seem to be low in comparison to females receiving estrogen replacement therapy. Certain studies in females seem to show that the cancer risk is lowered by consistently administering progesterone with the estrogen. Perform monthly breast self-exams, anyway; take mammograms every 2 years before age 40, every year thereafter. Prostate cancer risk is significantly reduced in comparison to males not receiving estrogen therapy. Have the prostate examined once a year if possible, anyway.
• Hypothyroidism will partially or completely block development, so if there is family history or any other signs of that disorder, take the appropriate tests. Correct this before attempting cross-sexual hormone therapy.
• Serum hormone levels can sometimes be used to get an idea of how how well they are being assimilated.

Dosage

• Do not start taking the maximum planned dosage of all hormones at once. Start with a low dosage of one, and carefully watch for negative vital signs and symptoms. If there are no problems after 1-2 months, increase the dosage to the planned level. Wait another 1-2 months before adding the next hormone or anti-hormone (2 months is better). Give the body time to adjust.
• Use the lowest hormone dosage that affords the desired changes. Not everyone needs the same dosage, because of differences in body weight and genetically-disposed sensitivity to the hormones. Hormone dosage can usually be reduced to a nominal maintenance level after the testes are surgically removed. It is not recommended to take pre-operative dosages of hormones for more than about 3 years. Reduce the dosage to a conservative level after surgery, especially after you are reasonably satisfied with breast and other secondary sex characteristic development (keep in mind that this development is almost always less pronounced than in females; you must adjust your expectations accordingly). The lower the level you can stand for lifetime maintenance (consistent with skeletal and mental health, of course), the better.
• Divide oral preparations into twice-daily takings, if practical.

General

• Be constantly aware of your body so that adjustments can be made if any new problems develop during therapy.
• Have regular medical checkups (minimally every year; more often if you have any significant health problem); pay close attention to vital signs.
• Eat well, and take a good multi-vitamin/mineral supplement to help be sure the body has everything it needs for new development. It might be worth paying special attention to the B vitamens: it has been reported by some that 1-2mg/day folic acid seems to help increase estrogen assimilation, and that, more generally, the entire B-complex (hello vegemite) has helped many feel better overall during pre-op level estrogen therapy (just do not go overboard with mega doses of supplements). Also, milk thistle has been promoted as a liver tonic, which seems reasonable because it contains silymarin. Silymarin has been shown to protect the liver from free radical damage by directly acting as an antioxidant, as well as by increasing the liver's content of glutathione and superoxide dismutase, which help the liver detoxify a wide range of hormones, drugs, and chemicals. Perhaps most interesting is silymarin's reputed ability to stimulate protein synthesis and the production of new liver cells, suggesting that it may be useful not only in preventing acute liver toxicity, but also in promoting recovery from chronic liver damage.
• Estrogens delivered orally burden the liver, and excite it to produce extra blood clotting factors, more than other delivery methods. However, orals are not generally considered highly dangerous unless a pre-op dosage is administered for more than 3 years, or the liver is already weakened by alcohol, drug use, or infection, or you or your immediate family have a history of blood clotting disorder. In any case, it is a good idea to reduce alcohol and other drug intake.
• Susceptibility to hardening of the arteries decreases somewhat, but susceptibility to blood clots, phlebitis (inflammation of lower extremity and pelvic veins), varicose veins, elevated high blood pressure increases somewhat (especially with oral estrogens). Stop smoking, reduce stress, and increase aerobic exercise. Investigate persistent calf pain or an increase of calf diameter by x-ray or ultrasound to determine if it is caused by a blood clot before massaging it. Leg and foot cramping not caused by a blood clot might be reduced with potassium and vitamin E supplements (but one should not take potassium concurrently with spironolactone). Stop oral estrogens and progestins at least one month before having major surgery that would keep you in bed for more than 1 full day without any walking (to reduce the risk of thrombosis). If you take a significant oral estrogen dosage, consider adding about 80mg/day aspirin to reduce the risk of blood clots; take it with food and liquid to reduce the risk of stomach ulcer--or, better yet, use the enteric safety-coated variety (note that aspirin seems to affect a separate and unrelated clotting mechanism, so the protection is incomplete).
• Since spironolactone is a diuretic, anyone taking it should drink plenty of water, especially before and after exercise, and may need to reduce dietary intake of potassium--especially if the kidneys are already stressed.

Results

A hormone therapy regimen that works well for one person may not for another. If development is not well under way in, say, 6 months, some experimentation may be in order; try different hormone types and/or combinations. However, if you change the regimen very often, it will be difficult to tell which one was working best. Be patient. The obvious exception is if you have a strong adverse effect that you or your physician deem dangerous; in that case you obviously must stop taking the hormone (or anti-hormone) in question.

It is unusual for the therapy to not work; the most common cause is the choice of oral preparations since the absorbtion varies among individuals. Since the endocrine system is a complex self-balancing mechanism, there are several disorders that can effect cross-sexual hormone therapy, including hypothyroidism. If there is family history or any other signs of such disorders, do not hesitate to check for them.

Next: How can one obtain hormones?