Role and Risks of Estrogen Therapy
Many transgender men and women seek hormone therapy during the transition period to meet their gender expectations. In women, exogenous estrogen is a hormonal therapy used to feminize patients alongside anti-androgens to suppress masculine features (Unger, 2016). Estrogens are the mainstay therapy for transgender female patients and they work by suppressing gonadotropin secretion from the pituitary gland leading to a reduction in androgen production. Upon initiation of estrogen therapy, changes like breast growth, increased body fat, slowed the growth of facial hair, and erectile dysfunction can be observed (Tomlins, 2019). In some studies, hormonal therapies have been observed to have a positive effect on physiologic stress. The effect of estrogen therapy on individuals involves a decreased sex drive and loss of erectile function (Unger, 2016). Individuals will have decreased number of erections and may lose the ability to penetrate. Estrogen therapy may predispose individuals to weight gain, high blood pressure, and breast or prostate cancer. Some approaches to treatment like the use of ethinylestradiol and conjugated equine estrogens have increased the risk of venous thromboembolism.
Alternatives to estrogen Therapy
The most common alternative and sometimes used as combination therapy for trans women are anti-androgens. Anti-androgens are used to block the male sex hormone testosterone. In combination with estrogen therapy, anti-androgens reduce the dose of estrogen required to achieve the desired effect (Tomlins, 2019). One of the commonly used anti-androgens is cyproterone. This drug is initiated at a dosage of 25 to 50 mg daily and increased gradually to 100 mg daily (Tomlins, 2019). Another drug is spironolactone, a potassium-sparing diuretic that in higher doses blocks androgen receptors. Starting dose for this drug is 100 mg which is increased gradually to a maximum dosage of 400 mg daily (Tomlins, 2019). When using anti-androgens blood pressure, potassium levels, and liver function tests must be routinely monitored. Apart from anti-androgen therapies, progesterone is used by some clinicians to improve breast development (Tomlins, 2019). The lack of well-designed studies for this treatment approach makes it less commonly used.
Role of Hormones in Sexual Drive
Several steps in transitioning stage may negatively affect the sexual drive of transgender women. Hypoactive sexual desire is a common condition that is observed upon initiation of estrogen therapy (Defreyne et al., 2020). Soon after initiation of hormonal therapy, individuals will experience a decrease in the number of erections. However, they will still be able to have erotic sensations and orgasms (Unger, 2016). Decreased sexual drive may also be accompanied by ejaculation of a small amount. However, these changes are only short-term because after some time the body readjusts (Defreyne et al., 2020). Changes in a sexual desire upon initiation of hormonal therapy are only temporary with a net increase in dyadic sexual desire observed in the long term.
Julie is psychologically disturbed because she has to take estrogen pills every day and the presence of male features like facial hair makes it difficult to cope. She s utterly concerned about the decreased sexual drive that she feels will affect her relationship with her partner. Julie may be experiencing this stress because she is afraid of rejection and stigmatization that is common among transgender individuals in society.
Evaluation and Management
The plan is to address Julie’s psychological concerns and discuss alternative therapies that can be used. I will discuss considering the addition of anti-androgens in her medication to ensure masculine features like facial hair growth are suppressed (Tomlins, 2019). Cyproterone 25 mg for the start will be my choice of treatment for Julie at this point. Secondly, I will explain to Julie that alternative therapies like implants are available but preferred for women over 40 years due to the risk of thromboembolism (Tomlins, 2019). I will continue to monitor Julie every three months and titrate the dose of medication to achieve the desired physiological concentrations.
Defreyne, J., Elaut, E., Kreukels, B., Fisher, A. D., Castellini, G., Staphorsius, A., Den Heijer, M., Heylens, G., & T’Sjoen, G. (2020). Sexual desire changes in transgender individuals upon initiation of hormone treatment: Results from the longitudinal european network for the investigation of gender incongruence. The Journal of Sexual Medicine, 17(4), 812–825. https://doi.org/10.1016/j.jsxm.2019.12.020
Tomlins L. (2019). Prescribing for transgender patients. Australian Prescriber, 42(1), 10–13. https://doi.org/10.18773/austprescr.2019.003
Unger C. A. (2016). Hormone therapy for transgender patients. Translational Andrology and Urology, 5(6), 877–884. https://doi.org/10.21037/tau.2016.09.04
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