Hormone replacement therapy ( HRT ) of the female-to-male ( FTM ) type is hormone replacement therapy and therapy sex change is used to change secondary sexual characteristics of transgender and transsexual from feminine (or sex) to masculine. Usually called "sex hormone therapy" (XHT) or "hormone therapy", it is one of two types of HRT for transgender and transsexual (the other is male-female), and is mostly used to treat transgender women.. Some intersex people also receive this form of HRT, either from childhood to confirm the sex assigned or later if the assignment is proven wrong.
The purpose of this HRT form is to lead to the development of secondary sex characteristics of desired sex, such as deepening sound and masculine patterns of hair, fat, and muscle distribution. Can not undo many of the changes produced by natural puberty, which may require surgery and other treatments (see below). The drugs used in HRT type FTM include, in particular, androgens (ie testosterone) and GnRH analogues.
While HRT can not undo the effects of one's first puberty, developing secondary sex characteristics associated with different genders can alleviate some or all of the distress and discomfort associated with sex dysphoria, and may help people to "pass" or be seen as a gender which they identify. Introducing exogenous hormones into the body affects every level and many patients report changes in energy levels, moods, appetite, etc. The goal of HRT, and indeed all somatic treatment, is to provide patients with a more satisfying body that is more congruent. with their gender identity.
Video Hormone replacement therapy (female-to-male)
Medical use
- To produce masculinization and/or defeminization in transgender men and gender individuals.
- To produce masculinization and/or defeminization on intersex people.
Maps Hormone replacement therapy (female-to-male)
Requirements and accessibility
Contraindications
Some contraindications to androgen therapy exist. Absolute medical contraindication is pregnancy.
Relative medical contraindications are:
- Androgen-sensitive epilepsy
- Migrants
- Sleep apnea
- Polycythemia (increased number of red blood cells)
- Heart failure, renal failure, or severe hypertension susceptible to sodium retention and fluid overload
- Significant liver disease
- Coronary artery disease or risk factor for this condition
- History of uterine cancer
- Bleeding disorders (for testosterone injected)
- Significant history of violent behavior
- History of breast cancer (testosterone has antiproliferative effects in most but not all breast cancers)
- Acne (mild to severe)
Security
Hormone therapy for transgender individuals has been shown in the medical literature to be safe in adults, when supervised by a qualified medical professional.
Interactions
Testosterone is metabolized by the cytochrome P450 enzyme system (especially the CYP3A isoform) in the liver. There are certain drugs that increase or decrease the activity of the P450 cytochrome enzyme and may cause an increase or decrease in testosterone levels:
- Enzyme inducer - May cause decreased levels of testosterone (and other sex steroids) levels: Phenobarbital and Dilantin (seizure medications), Rifampis (antibiotics), and Alcohol.
- Enzyme inhibitors - May cause elevated levels of testosterone: Serzon, Prozac, Paxil (antidepressants), Sporanox, Diflucan, and other 'azole' antifungals, Tagamet (anti-ulcer agents that can cause gynecomastia in men because of this effect). Biaxin and other erythromycin type antibiotics, Protease Inhibitors (HIV treatment).
Testosterone may also alter the effects of other drugs:
- Increases the blood-thinning effect of coumadin (warfarin)
- Reduces effectiveness of Inderal (propranolol), a non-selective beta blocker used in the management of cardiovascular conditions
- Increases the effects of some oral medications for diabetes and can cause very low blood sugar levels.
Because of this interaction, it is recommended that trans men make their health care providers aware of their hormone therapy, when this is relevant to their care for other medical problems.
Type of therapy
Testosterone
The half-life of the testosterone terminal in the blood is about 70 minutes, so it is important to have an ongoing supply of hormones for masculinization.
Injected
The drug formulation 'Depot' is made by mixing substances with drugs that slow down its release and prolong the action of the drug. The two main forms used in the United States are testosterone esters of testosterone cypionate (Depo-Testosterone) and testosterone enanthate (Delatestryl) which are almost interchangeable. Enanthate testosterone is recognized slightly better with respect to testosterone release, but this may be more of a concern for bodybuilders who use drugs at higher doses (250-1000 mg/week) than the replacement doses used by transgender men (50 -100 mg/week ). These testosterone esters are mixed with different oils, so some individuals can tolerate better than others. Testosterone enanthate is more expensive than testosterone cypionate and more typically prescribed for hypogonad men in the United States. Testosterone cypionate is more popular in the United States than elsewhere (especially among bodybuilders). Other formulations exist but are more difficult to obtain in the United States. Injectable testosterone formulations available in Europe and the United States, undecanoate testosterone (Nebido, Aveed) provide much better testosterone delivery with much less variation beyond the eugonadal range than other formulations with injections required only four times a year. However, each three-month dose requires a 4 mL injection of oil that may require multiple simultaneous injections. Testosterone undecanoate is also much more expensive because it is still under patent protection. Testosterone propionate is another widely available testosterone ester, including in the United States, Canada, and Europe, but is very short-acting compared to other testosterone esters and should be administered once every 2 or 3 days, and for this reason, is rarely used.
Adverse side effects of the injected testosterone ester are generally associated with high peak levels within the first few days after the injection. Some side effects can be corrected by using shorter dosing intervals (weekly or every ten days instead of twice monthly with testosterone enanthate or testosterone cypionate). 100mg per week provides a peak testosterone level much lower than 200mg every two weeks, while retaining the same amount of androgens. These benefits should be weighed against the discomfort and inconvenience of doubling the number of injections.
Testosterone ester injected should start with a low dose and be titrated upward by level via (blood level is taken just before the next shot). Level 500 ng/dl trough sought. (The normal range for cisgender men is 290 to 900 ng/dl).
Transdermal
Both testosterone patches, creams and gels are available. Both estimates of the normal physiological level of testosterone are better than the higher peaks associated with injection. Both can cause local skin irritation (more than that with patches).
Patches slowly spread testosterone through the skin and changed daily. The cost varies, like all drugs, from country to country, about $ 150/month in the US, and about 60 Euro in Germany.
Transdermal testosterone is available worldwide under the brand names Andromen Forte, Androgel, Testogel, and Testim. They are absorbed rapidly when applied and produce a temporary drug depot in the skin that diffuses into the circulation, peaking at 4 hours and decreasing slowly for the rest of the day. The cost varies, like all drugs, from one country to another, ranging from $ 50/month to $ 280/month (in US Dollars).
Transdermal testosterone poses the risk of accidental exposure to others who come into contact with the patient's skin. This is especially important for patients whose intimate partners are pregnant or those who are parents of small children as both groups are more susceptible to the effects of masculinizing androgens. Case reports of significant virilization in young children after exposure to topical androgen preparations (both prescription and supplement products) used by their caregivers show this very real risk.
Implant
Implants, as subcutaneous pellets, can be used to administer testosterone (Testopel brand name). 6 to 12 pellets are put under the skin every three months. This should be done at the doctor's office, but it is a relatively small procedure performed under local anesthesia. Pellets cost about $ 60 each, so a larger cost of testosterone is injected when the cost of doctor visits and procedures are included. The main advantage of Testopel is to provide a much more constant level of testosterone but requires attention only four times a year.
Oral
Oral testosterone is given exclusively as undecanoate testosterone. It is available in Europe and Canada, but not in the United States. After being absorbed from the gastrointestinal tract, testosterone is smoothed (at very high blood levels) to the liver where it can cause liver damage (though very rarely) and exacerbate some of the bad effects of testosterone, such as lower HDL (good) cholesterol. In addition, the first liver metabolism of the liver can also cause testosterone levels too low to provide satisfactory masculinisation and suppress menstruation. Because of the short-term terminal of testosterone, oral undecanoate testosterone should be administered two to four times per day, preferably with food (which increases its absorption).
Sublingual/buccal
In 2003, the FDA approved the form of testosterone (Striant) buccal. Sublingual testosterone can also be made by some compounding pharmacies. The cost for Striant is greater than other formulations ($ 180-210/month). Testosterone is absorbed through the oral mucosa and avoids 'first passing metabolism' in the liver which is the cause of many adverse effects with undecanoate oral testosterone. Throat lozenges can cause gum irritation, taste changes, and headaches but most side effects are reduced after two weeks. Candies are 'mucoadhesive' and should be applied twice daily.
Alternative androgen
Synthetic Androgens
Synthetic anabolic-androgenic steroids (AAS), such as nandrolone (as esters like nandrolone decanoate or nandrolone phenylpropionate), are androgen-receptor agonists (AR) similar to testosterone but are not usually used in HRT for transgender men or for androgen replacement therapy. (ART) in cisgender men. However, they can be used in place of testosterone with the same effect, and can have certain advantages such as lack or no local potential in so-called androgenic networks that express 5? such as skin and hair follicles (which result in reduced skin levels and hair-related side effects such as excessive body hair growth and hair loss on the scalp), although this can also be detrimental in certain aspects of masculinization such as facial hair growth and hair growth normal body). Although many AASs have no potential in androgenic tissue, they have effects similar to testosterone in other tissues such as bone, muscle, fat, and voice box. Also, many AASs, such as nandrolone esters, are aromatized to estrogen to a much lesser degree relative to testosterone or not at all, and for this reason, are associated with reduced or no estrogenic effects (eg, gynecomastia). AAS aged 17? such as methyltestosterone, oxandrolone, and stanozolol are actively orally but carry a high risk of liver damage, while the AAS is not 17? alkylates, such as nandrolone ester, should be administered by intramuscular injection (through which they act as long-lasting depots similar to testosterone esters) but do not have a greater risk of liver damage than testosterone.
For clarification, it should be noted that the term "anabolic-androgenic steroid" is essentially the same as "androgen" (or with "anabolic steroid"), and that natural androgens such as testosterone are also AAS. All of these drugs have the same mechanism of action as AR agonists and have similar effects, although their potential, pharmacokinetic, oral activity, anabolic and androgenic effect ratios (due to different capacities to be metabolized locally and amplified by 5 -reductase) aromatization (ie, conversion to estrogen), and the potential for liver damage are all different.
Dihydrotestosterone
Dihydrotestosterone (DHT) (referred to as androstanolone or stanolone when used medically) may also be used instead of testosterone as androgen. DHT availability is limited; it is not available in the United States or Canada, for example, but is available in certain European countries, including England, France, Spain, Belgium, Italy and Luxembourg. DHT is available in formulations including topical gels, buccal or sublingual tablets, and as esters in oils for intramuscular injection. With respect to testosterone, and similar to many synthetic AAS, DHT has a potential advantage because it is not potentially localized in so-called androgenic networks that express 5? -reductase (because DHT is already 5? -reduced) and not aromatized into estrogen (not a substrate for aromatase).
Analog GnRH
In all people, the hypothalamus releases GnRH (a hormone that releases gonadotropin) to stimulate the pituitary to produce LH (luteinizing hormone) and FSH (follicle stimulating hormone) which in turn causes the gonads to produce sex steroids. In adolescents of both sexes with relevant indicators, GnRH analogues, such as leuprorelin, may be used to delay the advancement of induced sex steroids, inappropriate pubertal changes for a period of time without causing changes in directions corresponding to sex. Analog GnRH works initially to stimulate the pituitary and then rapidly decreases the sensitivity to the GnRH effect. For several weeks, gonad androgen production is greatly reduced. There is much controversy about the earliest ages, and for how long clinically, morally and legally safe to do this. International Benjamin Care License Standard from Benjamin International Benjamin from Tanner Stage 2, but does not allow the addition of sex hormones up to 16, which could be five years or more. Sex steroids do have other important functions. The high cost of GnRH analog is often a significant factor.
Antiestrogen
Antiestrogens (or so-called "estrogen blockers") such as aromatase inhibitors (AI) (eg, anastrozole) or selective estrogen receptor modulators (SERMs) (eg, tamoxifen) may be used to reduce the effects of high levels of endogenous estrogen (eg, breast development, distribution of feminine fat) in transgender men. In addition, in those who have not completed or completed epiphyseal closure (which occurs during adolescence and is mediated by estrogen), antiestrogens can prevent pelvic widening and increase the final height (high estrogen limit by causing the epifisis to melt).
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5? -Reductase inhibitor
5? -Reductase inhibitors such as finasteride and dutasteride can be used to slow or prevent hair loss and excessive body hair growth in transgender men taking testosterone. However, they can also slow or reduce certain aspects of masculinization, such as facial hair growth and normal body hair growth of men. A potential solution is to start taking 5-uctuctase inhibitors after these desired aspects of masculinization are well established.
Progestogen
Depo-Provera (depot medroxyprogesterone acetate, or DMPA) can be injected every three months as used for contraception. Generally after the first cycle, menstruation is greatly reduced or eliminated. It may be useful for transgender men before starting testosterone therapy.
Growth hormone
In those who have not experienced or completed epiphyseal closure, growth hormone may be given, potentially coinciding with an aromatase inhibitor or GnRH analogue, to increase the final height.
Effects
The main effects of HRT type FTM are as follows:
- Reversible changes
- Increased libido
- Redistribution of body fat
- Termination of ovulation and menstruation
- Muscle enhancement
- Increased sweating and body odor changes
- Superior vein and rough skin
- Acne (especially in the first few years of therapy)
- Changes in blood lipids (cholesterol and triglycerides)
- Increase in the number of red blood cells
- Changes that can not be changed
- Sound depth
- Facial and body hair growth
- Male pattern baldness (on some individuals)
- Clitoral enlargement
- Accelerate growth and closure of growth plates if given before the end of puberty
- Breast atrophy - may shrink and/or soften the breasts
Many transgender men can not pass as cisgender men without hormones. The most commonly cited reason for this is that their voices can express it.
Physical changes
Skin Changes
- Increased activity of oil glands and sweat.
- Body odor changes - less sweet and musky, more metallic and sharper.
- If a severe odor is a problem, antibacterial soaps such as chlorhexidine can be used in the armpits while bathing. After 1-2 weeks of daily use, there is a noticeable reduction in odor.
- Acne: generally worse in the first few years of testosterone therapy (mimicking second puberty). Can be treated with standard acne therapy. Initial treatment is with increased clearance (at least twice daily) with anti acne or oil scrubs. If this does not work, additional therapy may be prescribed by the doctor.
- Some doctors see acne as contraindicated to increase the dose of testosterone.
Hair Changes
- The action of testosterone on hair follicles is mainly due to androgens, dihydrotestosterone, more potent DHT.
- With androgen therapy, genetics primarily determines how much hair will develop (and where) as well as whether male pattern baldness will develop.
- altered testosterone (in papilla dermis hair follicle cells) by 5? -reductase to DHT. There are two forms of this enzyme: types 1 and 2. However, type 2 is the most important form for the development of male hair loss patterns. Men with deficient 5-defectase type deficiency 2 (but type 1 functional) have never developed male hair loss patterns.
Facial changes
Facial changes develop gradually over time, and sexual dimorphism (physical differences between the sexes) tends to increase with age. In populations of the same size and ethnicity:
- Eyebrow: Men tend to develop bone eyebrows that are heavier than women.
- Cheek: Women's cheeks tend to be fuller and more rounded. Under the influence of estrogen, fat is stored under the skin and the overall contour of the face and body becomes softer. This is reversed by androgens.
- Nose: The tip of the nasal bone tends to grow more in males than females, creating larger noses (longer or wider).
- Jaws: Jaws in men tend to grow wider and deeper than in women.
- Larynx: At puberty, bone and cartilage of the voice box tend to enlarge less in women than men. In some men, the larynx becomes seen as a bone "Adam's apple."
- Lips: Women tend to have lips that are thicker and fatter than men of the same size because of estrogen.
Gynecological changes
- Mens should stop within 5 months of testosterone therapy (often faster). If the bleeding continues for 5 months, transgender men are strongly encouraged to see a gynecologist.
- Clitoromegaly occurs, and often peaks within 2-3 years of therapy. The size generally ranges from 3 to 8, cm by 4-5, cm to average. It is genetically determined, but some doctors recommend topical clitoral testosterone in addition to growth before methotcooplasty. However, this testosterone is absorbed and must be calculated into your total regimen.
- After long-term androgen therapy, the ovaries may develop polycystic ovarian morphology (PCOS). (In PCOS and transgender men there is a testosterone receptor setting in the ovaries.)
- Untreated PCOS is associated with a possible increased risk of endometrial cancer and decreased fertility.
- It is not known whether the risk of ovarian cancer is increased, decreased or unchanged in transgender men compared with women. This is unlikely to be determined in the near future because ovarian cancer is a relatively rare disease and transgender male populations are too small to conduct a suitable study. However, it has been recommended by some doctors that transgender men have oophorectomy within 2-5 years after starting androgen therapy because of the increased risk. (Note: The dose of testosterone can often decrease after oophorectomy.)
- The risk of endometrial cancer is also unknown. However, the high prevalence of endometrial hyperplasia has been noted in a small study of transgender men undergoing hysterectomy.
Often the first sign of endometrial cancer is bleeding in post-menopausal women. Transgender men who experience bleeding after menstrual cessation with androgen therapy should have an endometrial (and possibly ultrasound) biopsy done to exclude endometrial cancer.
- Some sources recommend an endometrial ultrasound every two years. Testosterone usually causes endometrial atrophy. Any transgendered man with endometrium that is not thinning on ultrasound should have a biopsy to evaluate for endometrial cancer and may use progesterone to cause endometrial decay. Vaginal bleeding from progesterone may be emotionally uncomfortable for a trans man, but it is medically better to develop endometrial cancer.
- Until now, every adult with a uterus/cervix is ​​advised to do a Pap smear every year. This interval can be increased to every 2-3 years for certain people at the suggestion of a gynecologist. However, recent research associates cervical cancer with sexually transmitted virus; trans men who have never had vaginal sex may not be at risk. However, because the long-term effects of testosterone on cervical tissue are not well understood, Pap smears can be considered as general precautions.
- Some transgender men report a decrease in breast size with androgen therapy. However, no morphological changes are found when this is studied and it is likely due to fat loss in the breast.
- Androgen therapy (and estrogen production suppression) can cause vaginal atrophy and drought, which can lead to dyspareunia (painful vaginal intercourse). This can be reduced by topical estrogen cream.
- Most transgender men report significant increases in libido. Some report that this is somewhat decreased after several years on testosterone. (Natural testosterone levels peak in women just before ovulation which can lead to increased libido in the mid-cycle of many women.)
Reproductive changes
- As the age at which transgender people begin therapy decreases, retention of reproductive potential becomes more important.
- If a transgender has not undergone hysterectomy and oophorectomy, he may regain fertility at the cessation of testosterone. With ovarian changes from long-term androgen therapy, however, it may take months of cessation of testosterone and possibly reproductive technology aids in becoming pregnant. Testosterone should be retained during pregnancy.
- If a transgender man plans to have a hysterectomy/oophorectomy, future reproduction may still be maintained by:
- Oocyte bankingÃ, - hormonal stimulation for "hyper-ovulation" with transvaginal oocyte crop for freezing. Prior to using the cryopreservation method "slow freezing" there was a very low survival rate of crushed oocytes. However, the advent of vitrification, the rapid freezing process, has made the cryopreservation of oocytes a viable option for the preservation of fertility. This allows the possibility of an egg to be fertilized and placed in a substitute, compared to a transgender who must carry the pregnancy itself.
- Embryo banking - oocyte harvesting as above with immediate fertilization and embryo banking. Sperm donors should be selected before oophorectomy. Allows the possibility of an embryo to then be placed in a substitute, as opposed to a transgender who must carry the pregnancy itself.
- Ovarian tissue banking, - Ovarian tissue freezes after oophorectomy. Even after long-term androgen therapy, the ovaries usually retain a usable follicle. The use of frozen ovaries will eventually require re-planting into transgender for stimulation and harvesting, but may eventually be performed in the laboratory because of techniques to improve tissue culture. This option usually does not allow placement into the replacement because it may require the use of immunosuppressants in the alternate parts.
Unaffected characteristics
A number of skeletal and cartilage changes occur after the onset of puberty at various levels and times. Sometimes at the end of the year the adolescent epiphyseal closure (in other words, the ends of the bones are closed together) occurs and the length of the bone has been fixed for life. As a result, the total height and length of arms, legs, arms, and legs are not affected by HRT. However, details of bone shape change throughout life, bones become heavier and deeper engraved under the influence of testosterone. Many of these differences are described in the book Desmond Morris Manwatching .
- Pelvis: The pelvis in women tends to be wider than the male and tilted forward; pelvis in men tend to be more circular and sloping upward.
- Hands: Men's hands and feet tend to be larger than the hands and feet of women of the same height.
- Upper Arm: The upper arm in women tends to be significantly longer (about 1 ") than in men of the same height.
- Head: Women tend to have smaller heads than men of the same height.
- Chest: Female rib cages tend to be narrower than males of the same height.
Neurological changes
- Headaches: A pre-existing migraine headache can be significantly aggravated by androgen therapy. Headaches can also be a problem in men without previous headache disorders.
- Epilepsy: some seizure disorders are androgen dependent. This may be aggravated or (very rarely) under the guise of androgen therapy.
- Sleep deprivation worsens almost all seizure disorders, so concurrent obstructive sleep apnea caused or exacerbated by androgen therapy may also be responsible.
- Recent research has found that cross-hormone therapy in trans men results in an increase in brain volume to male proportions.
Psychological changes
Psychological changes are more difficult to define, because HRT is usually the first physical action to occur when transitioning. This fact alone has a significant psychological impact, which is difficult to distinguish from hormonal changes. Most trans men report increased energy and increased sex drive. Many also reported feeling more confident.
While high testosterone levels are often associated with increased aggression, this is not a noticeable effect in most trans men. The dose of HRT testosterone is much lower than the common dose taken by athletes who use steroids, and creates testosterone levels that are comparable to most cisgender men. This testosterone level has not been proven to cause more aggression than comparable estrogen levels. It is estimated that the initial effects of physical treatments are greatly relieved, and lowered pre-existing aggression, resulting in overall aggression rates declining.
During HRT, especially in the early stages of treatment, blood work should be done consistently to assess hormone levels and liver function.
Israel et al. has suggested that for trans men pre-oophorectomy, therapeutic testosterone levels should be optimally within the normal male range, whereas estrogen levels should be optimally fall within the normal range of women. Before oophorectomy, it is difficult and often impractical to completely suppress estrogen levels into the normal male range, especially with exogenous testosterone scented into estrogen, hence why the range of women is referred instead. In trans post-oophorectomy men, Israel et al. recommends that both testosterone and estrogen levels fall right within the normal male range. See the table below for all exact values ​​they suggest.
The optimal range listed for testosterone is applicable only to individuals who use bioidentic hormones in testosterone form (including esters) and do not apply to those who consume synthetic AAS (eg, nandrolone) or dihydrotestosterone.
See also
- Hormone replacement therapy (male-female)
References
External links
- Tom Waddell Clinic Transgender Protocol - the clinical protocol of MTF and FTM intended for service providers
- Medical Therapy and Healthcare for Transgender Men: A Guide for Healthcare Providers: free online medical books.
- Testosterone cypionate vs. enanthate
Source of the article : Wikipedia
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