Quote from: Mandy M on November 23, 2017, 03:09:23 AM
One of the more deleterious features of this site, and others like it, is that a small number of non-medics with their own subjective experiences promote guidance.
Not necessarily only subjective but based on actual science (i.e. peer-reviewed studies). We don't promote guidance, we provide information that may be useful to the reader and that they may, if they wish to, bring up with their doctors.
QuoteIf something appears to work for them, which is to be welcomed, it is promoted as if this is a universal truth.
Your assertion that E isn't effective for suppressing T enough in transwomen is absolutism and leaves no room for considering that it may be. You condemn promoting a universal truth and yet, that's exactly what you are doing.
In the past, E alone was used to suppress T in transwomen but this was dropped in favor of anti-androgens not because it was more effective but because it was safer due to the fact that E was not bio-identical and increased significantly the risk of clots.
QuoteSometimes, perhaps even often, this flies in the face of current established and scientifically backed protocols.
Based on my review, it would appear that established protocols for transwomen are actually often not scientifically backed (guesswork, arbitrary) or sometimes backed by poor evidence, outdated or even irrelevant. I encourage readers to go through those guidelines and actually read the references. You will see for yourself. It is especially unfortunate to note the many references missing from their papers that could help establish better, more up-to-date protocols like those studies in ciswomen and in men showing high levels of estradiol being safe, even at an advanced age or studies showing the significant differences between progesterone and other progestogens. IMO, there isn't much effort put into establishing those guidelines because if there was, there would be a more substantial list of references from which to draw better and more rational conclusions.
To promote blind adherence to guidelines and stifle critical/free thinking is, in my opinion, not in the best interest of the reader and unhealthy practice.
QuoteIt is also important that we monitor latest scientific research.
QuoteIn this regard, it is perhaps regrettable that KayXo has referred to research conducted as long ago as 1991 and 2003. Many more recent studies have moved along the scientific understanding of transgender treatment.
These studies even if old, remain important and relevant as findings in men in 1991 and 2003 should not be any different now. Men remain men, humans remain humans. However, you can find below a more recent paper with similar findings.
Interestingly, the established guidelines for transgender women discourage use of only estrogen based on much older studies in transwomen employing high doses of non bio-identical estrogens. Those findings clearly no longer remain relevant as these days, only or almost exclusively bio-identical estrogen is prescribed and hundreds of studies have shown that bio-identical E differs in significant ways as far as health risks go, especially if taken non-orally. You criticize me for providing old studies and yet you omit to mention that those protocols you like to abide by are based on even older studies that are no longer pertinent.
Lancet Oncol. 2013 Apr;14(4):306-16. (In men with advanced prostate cancer)
"Initially, patients in the oestrogen-patch group received (...) patches (...) to be self-administered and changed twice weekly for 4 weeks. The number of patches was reduced (...) if castrate testosterone concentrations in serum of 1ยท7 nmol/L or lower were achieved (regimen one)."
"The regimen was changed, therefore, to (...) patches to be changed twice weekly for 4 weeks, followed by use of (...) patches twice weekly when the target castrate testosterone concentration in serum was reached (regimen two).19 Patients with testosterone concentrations higher than castrate levels at 4 weeks remained on the induction regimen and had testosterone checked every 2 weeks."
QuoteCurrent WPATH and scientific papers do, indeed, suggest that Estrogen, through a feedback loop, does suppress testosterone. However:
"Estrogen alone is often not enough to achieve desirable androgen suppression, and adjunctive anti-androgenic therapy is also usually necessary. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5182227/
This backed by a scientific study and presented to the Endocrine Society in their Chicago conference 2014.
"Simply giving estrogen to male-to-female transgender patients won't completely suppress testosterone levels, researchers reported here." This study by Dr Leiniung is, however, a single study and presents conflicting advice, so we need to be wary until further research has been conducted."
https://www.medpagetoday.com/meetingcoverage/endo/46497
These conclusions are based on one study alone employing ORAL ESTRADIOL at certain doses. Had they prescribed higher doses which, according to studies in ciswomen with breast cancer, seem to still be quite safe or estradiol in the form of patches, gels, pellets or IM injection, testosterone levels could well have been suppressed. Also, estradiol when taken orally, tends to increase SHBG significantly such that free or bio-available T, if measured (they weren't for some odd reason), could have been well into the female range or even below, who knows? Total T doesn't tell the whole story and I find it surprising that they didn't consider this. Perhaps, desirable T suppression was achieved and they just didn't know it because free and bio-available T wasn't measured.
For all the reasons noted above, it is premature to arrive at such a conclusion based on this single somewhat incomplete study, ESPECIALLY considering there are SEVERAL other studies in men with prostate cancer where estrogen is given in the form of patches or even IM injections and where this effectively suppresses T, down to castrate levels. For some reason, these studies are not mentioned.
QuoteWPATH and the Endocrine Society guidelines are quite clear about the protocols regarding anti androgens. Most importantly of all, anti androgens permit lower doses of estrogen, which is beneficial for health reasons:
"Suppression of testosterone production and blocking of its effects contributes to the suppression / minimization of male secondary sexual characteristics. Unfortunately many of these characteristics are permanent upon completion of natal puberty and are irreversible. Androgen blockers allow the use of lower estradiol dosing, in contrast to the supraphysiologic estrogen levels (and associated risks) previously used to affect pituitary gonadotropin suppression."
Those assertions that there are risks with supraphysiologic estrogen levels are based on OLD studies (before 1990) that you like to dismiss and criticize, where non bio-identical estrogens were used in high doses. Check the references and you will see for yourself. In contrast:
Br J Obstet Gynaecol. 1990 Oct;97(10):917-21."There is some anxiety about the possible harmful sequelae of supraphysiological estradiol levels but no data are currently available to show any deleterious effects of these levels on coagulation factors, blood pressure, glucose tolerance or the occurrences of endometrial or breast cancer (Hammond et al. 1974; Thom et id. 1978; Studd B Thom 1981; Armstrong 1988)."
"Supraphysiological oestradiol levels are an uncommon consequence of oestradiol implants occurring most frequently in women with a history of depression or surgical castration.
These high serum oestradiol levels were not associated with any deleterious effects and may be necessary for the control of symptoms in specific women"
Hum Reprod. 2002 Mar;17(3):825-9."We examined metabolic parameters in cohorts of women with and without subcutaneous estrogen therapy with concomitant supra-normal concentrations of estradiol (SE)."
"Women with SE have similar triglyceride and HDL cholesterol levels but lower LDL cholesterol concentrations compared with post-menopausal women not taking ERT. The observations that the SE group showed reduced fasting insulin and WHR suggest that
supra-normal circulating concentrations of estradiol, delivered subcutaneously, may beneficially influence insulin metabolism."
Horm Metab Res. 1994 Sep;26(9):428-31."Thirteen osteopenic women received (...) estradiol valerate (...) by intramuscular injections once a week for 6 months (so called "pseudopregnancy")."
"Six patients were peri- or postmenopausal (49.5 +/- 4.8 years of age, group A)"
"The duration of the therapy was 6, and in 4 patients 9 months"
"Estradiol increased from 34.8 +/- 7.5 pg/ml to 3226 +/- 393 pg/ml after 3 months and to 2552 +/- 254 pg/ml after 6 months, respectively, in group A."
"The treatment was well tolerated. No adverse effects were seen, the patients expressed a feeling of particular well being, 3 of them wanted to have the injections repeated and none of them wanted to stop treatment because of troubles or side effects."
"Investigations of lipids, liver enzymes and haemostasiology to be published later will show the absence of unwanted metabolic effects of this regimen."
"The increase of bone density in our patients with gonadal dysgenesis was associated with an impressive secondary sexual development, especially of the breasts."
"In conclusion, our data show, that the treatment (...) by means of high parenteral estrogen-progestogen depot injections is effective. Virtually no side effects occurred. The therapy is well accepted by the patients."
"In addition, pseudopregnancy may be useful and effective in osteopenia and lacking secondary sexual development due to gonadal dysgenesis like in Ullrich-Turner syndrome (after completion of growth), where substitution doses of ovarian hormones may be not sufficient enough to guarantee satisfactory response.
There are several other similar studies in men too and even in transwomen taking *bio-identical estradiol* that show identical findings with high (supraphysiologic) levels/doses.
