Beware of HRT possible mind warping effects

[tsukiyoarts]

I do not actually know where to start talking about this. I may have already mentioned which HRT warped my normal mind way of working to a degree at the first months, some of you saw it; but looking back, I see it actually changed me considerably. Now I am more stable, but I still feel some of it. I am not sure if it is because of Androcur, which was banned in USA because it could do that, but espironolactona did me no good. Yet in fact, estrogen would physically affect your mind anyway the further you use them. It does for many of us at different degrees.

I got more easily angered, with some irrational thinking among other things, and sometimes I did not even noticed, at others I made a conscious effort to control them. It was embarassing. On the other side, I became more daring, and that opened more doors to me. Sometimes I felt quite peaceful as too mentioned before. What also surprised me, was which I lost some ability at some things, such as arts; but improved at other areas. Other point is which I started to write in a "cuter", more emotional way to an extent. My gestures became more feminine too, but they already were so to a lesser extent as a child.

That was quite beyond what I anticipated, but I accept it all because I would not refuse my transition for nothing in this world. Know this if you will start a transition or is at its very beginning, to know if you really want to pass through such experiences, or to prepare for them.

Dearly,
Tsukiyoarts

[Cindy]

Differences in mental issues are common on HRT and are a side effect that the prescribing physician should warn about.

Androcur has a well documented side effect of inducing or triggering depressive episodes in some people and they can be quite sudden. Spiro can also do this but the effect is less common.

The brain has a high level of androgen receptors and is one reason that TG people feel dysphoric when they are on the wrong androgen.

[tsukiyoarts]

Good night Cindy,

I think it was worse just at the first months, I am more stable now, but not fully. Yet I have not faced any really difficult situation to know how I would deal with it now I am on HRT. Surely I will have to warn my endocrinologist if things get too uncomfortable for me (and for others). I did get some positive traits too, or perhaps I was just putting to good use new negative traits.

Tsukiyoarts

[kat69]

It's pretty common to have any number of reactions to changing someone as biologically cored as hormones.  The levels you were at before hormones plus your body's ability to process them all make it a unique experience for each one of us.  The important thing, and you're already doing it, is acknowledging the changes and ensuring it's normal.

Good for you, and keep the faith!

[Allison S]

Im about 6 weeks in on low doses of spiro and estradiol and I feel way off. It's so much more effort for me to focus and do simplest tasks. I may be going through a lot of stress in my life in general but I think the meds have some impact. They must be

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[tsukiyoarts]

Hello dist123,

Actually, I know what you mean. That was one of the reasons for me to jump boat to Androcur in Brazil. Here we only have those two choices as far as I know. It is more expensive though. There usually is this disruption of your body and mind in the beginning at any choice, sometimes it goes away with time, sometimes not. I was already in the danger zone of spironolactona, my nails were getting quite purple sometimes, I was losing too much weight, and going too much to bathroom.

Tsukiyoarts

[RobynD]

I think your brain re-wires sort of and then you learn to adapt to the new configuration. It definitely changes things though there is no doubt out. For myself along with the massive reduction in depression and anxiety, the positive sex drive changes etc came challenges like attention span differences, sleep differences etc.

[Ellement_of_Freedom]

I was already in the danger zone of spironolactona, my nails were getting quite purple sometimes, I was losing too much weight, and going too much to bathroom.

Tsukiyoarts

I had a similar experience! And when my endo took over my HRT she noticed my blood pressure was dangerously low due to the spiro. I had to get right off it and that's when I started androcur. The lesser of two evils for me. I'm just too slim, the drop in blood pressure is too severe. Otherwise I'd stay on spiro because I really liked the body hair reduction I experienced on it.

[kelly_aus]

I am not sure if it is because of Androcur, which was banned in USA because it could do that, but espironolactona did me no good.

Just a quick correction here, Androcur wasn't banned in the US, the FDA simply never approved it due to apparent liver toxicity - which is not an issue with proper monitoring.

As for the changes you describe, I can't say I really experienced any of them to any serious degree, if at all, which is probably related to the fact that individuals do seem to react to HRT in similar, but individual, ways.

[Mandy M]

I think Androcur (Cyproterone Acetate) is a dangerous drug. It certainly made me feel very off, mentally as well as physically.

It does take time for the brain to settle to new hormones. They are powerful things.

I think professional help is always advisable. A good, gender specialist, endocrinologist is a must. If you feel that you cannot live in your natal genital state, and you also find anti-androgens to be debilitating, then you may wish to discuss surgery with them. Removal of testicles removes any need for these medications, after all. You can simply take a low(ish) dose of estrogen.

[kelly_aus]

I think Androcur (Cyproterone Acetate) is a dangerous drug. It certainly made me feel very off, mentally as well as physically.

Mental health issues are a known side effect - beyond the commonly known depression. This is in all the product literature. It's also something your therapist and endo/gyno should have discussed with you. At transition doses, it's likely as safe as spiro, if you have proper monitoring.

It does take time for the brain to settle to new hormones. They are powerful things.

For some people this is quite true, others seem to have little issue.

I think professional help is always advisable. A good, gender specialist, endocrinologist is a must. If you feel that you cannot live in your natal genital state, and you also find anti-androgens to be debilitating, then you may wish to discuss surgery with them. Removal of testicles removes any need for these medications, after all. You can simply take a low(ish) dose of estrogen.

Yep, good medical professionals are very handy, but this is no excuse to not also educate yourself on the matter. And there's a far simpler alternative to surgery if your E levels are reasonably stable and sufficient, don't take an antiandrogen at all. This doesn't require terribly high levels or doses for most.

[Mandy M]

And there's a far simpler alternative to surgery if your E levels are reasonably stable and sufficient, don't take an antiandrogen at all. This doesn't require terribly high levels or doses for most.

It depends whether you want to be empirical or simply go by what you feel: which is fine for some people. Empirically, if you have testicles then estrogen alone will simply not suppress testosterone levels sufficient for most MtF's. That's an empirical fact. Alas.

p.s. hormones are powerful for everyone on the planet. They deserve some respect and professional direction.

[kelly_aus]

It depends whether you want to be empirical or simply go by what you feel: which is fine for some people. Empirically, if you have testicles then estrogen alone will simply not suppress testosterone levels sufficient for most MtF's. That's an empirical fact. Alas.

p.s. hormones are powerful for everyone on the planet. They deserve some respect and professional direction.

Really? I haven't taken an AA in 8 months and still have testicles. My T level is low/mid female range and has stayed at that level, excepting an initial minor blip upwards when I discontinued using cypro. Neither my dose or E level is high. This is not uncommon and certainly not unknown, as the research I did quelled my initial skepticism. I'd recommend some further research - I'd suggest looking at some of the Oncology journals in addition to Endo and Gyno journals. (Androgen Deprivation Therapy is a place to start.)

A growing number of trans women are transitioning on a E only regimen like mine or a combo of E and P. My medical team has no issues with such a regimen, and I've found it nothing but a positive.

[Mandy M]

I have done plenty of research and none of it gives any scientific backing for your assertion that E is sufficient for pre-operative transgender patients to lower their T levels to natal female levels.

Whilst, one case alone is an insufficient data sample can we at least have from you some hard science please: levels before and after switching to E only, ensuring like for like tests. Clearly, if you have been on anti-androgens prior to this E-only regime then your T level will have been lowered. It doesn't automatically switch back on again afterwards so it may be possible to have an AA + E regime for a time and then switch to E only.

Estrogen on its own is not a WPATH recommended regime for transgender patients transitioning from male to female.

[KayXo]

Estrogen on its own is not a WPATH recommended regime for transgender patients transitioning from male to female.

Because it is believed that higher doses of estrogen are needed to effectively suppress testosterone production from testicles and that those higher doses are more likely to cause problems such as DVT, stroke, etc. BUT...

this fear comes from a time when non bio-identical estrogens were prescribed to transsexual women and did have an exaggerated impact on the liver and its production of several proteins and factors leading to increased health risks. If one takes the time to read the studies that have been published in the last 20-30 years, one will eventually realize those risks are significantly minimized/diminished on bio-identical estrogen, ESPECIALLY if taken non-orally and that the high doses/levels *sometimes* needed to suppress T to castrate/female levels are generally quite safe so that anti-androgens aren't needed and when the risks of anti-androgens are weighed against the risks of higher levels of bio-identical estradiol, one may realize it may be worthwhile to go with E alone (at the doctor's discretion of course).

Estrogen in men does suppress T effectively.

J Clin Endocrinol Metab. 1991 Sep;73(3):621-8.

"These results provide direct evidence that E2 inhibits gonadotropin secretion at the pituitary level in men"

Gonadotropins signal testes to produce T and direct spermatogenesis.

J Urol. 2003 May;169(5):1735-7.

"transdermal estradiol (...) patches were applied weekly for 8 weeks and then the number of patches was reduced to maintain castrate levels of testosterone."

"Median follow-up is 15 months (range 12 to 20). The patches were well tolerated by all patients. Estradiol levels greater than 1,000 pmol/l. were maintained using (...) patches and higher levels were achieved by increasing the number of patches."

"One patient had fluid retention and was withdrawn from study at 10 months but no other cardiovascular toxicity occurred. None of the coagulation activators, inhibitors or fibrinolytic factors was induced by transdermal estradiol therapy, and increased levels of prothrombin, fibrinogen and D-dimer at baseline were decreased (p  0.001, p  0.001, p 0.049, respectively). Arterial inflow was increased (p 0.004), while venous outflow was unaffected and arterial compliance improved (p 0.17)."

"In our study the physiological ratios of estrone-to-estradiol, sex hormone binding globulin, low density lipoprotein-to-high density lipoprotein, and factor VII and factor XII were maintained, (data not shown), and increased levels of prothrombin, fibrinogen and D-dimer were decreased. As a result, transdermal estradiol therapy reversed the hypercoagulable state"

"Moreover, transdermal estradiol therapy improved the vascular flow and increased arterial compliance, changes suggestive of a cardiovascular benefit.10"

So, not only did non-oral estradiol reduce T to castrate levels but it reduced coagulation and improved cardiovascular markers in old men with advanced prostate cancer.

Other similar studies have been undertaken with similar results. If studies show parenteral (non-oral) bio-identical estradiol to be safe (even beneficial) and effective at suppressing T in this population at greater risk of health problems, then why not in transwomen? Doctors treating us should look into this, I think.

[kelly_aus]

I have done plenty of research and none of it gives any scientific backing for your assertion that E is sufficient for pre-operative transgender patients to lower their T levels to natal female levels.

Well, sadly, I suspect you've been looking in the wrong places or are being way too specific. The info is out there and it's not new. Unlike Kay, I don't drop links as I find it preferable that people find the info themselves - I did give you some hints though.

Whilst, one case alone is an insufficient data sample can we at least have from you some hard science please: levels before and after switching to E only, ensuring like for like tests. Clearly, if you have been on anti-androgens prior to this E-only regime then your T level will have been lowered. It doesn't automatically switch back on again afterwards so it may be possible to have an AA + E regime for a time and then switch to E only.

So the data is wrong? Multiple studies by endocrinologists, oncologists and other researchers are wrong? Somehow, having read the studies, I doubt it. You also make assumptions about my regimen that are incorrect - I stopped E entirely prior to discontinuing my AA.. I then recommenced taking E without an AA - my E levels dropped and my T rose until my E level was reestablished at a sufficient level.

Estrogen on its own is not a WPATH recommended regime for transgender patients transitioning from male to female.

Synthetic estrogens, such as ethinyl estradiol used to be on WPATH's recommended regimen for tans patients, which shows they can and do change when needed. This is an area where I can see change happening.

I don't post this E only idea in an effort to get people to change their own regimen, I post this info so that people can be informed and educated about their care and make informed decisions on their ongoing care in consultation with their doctors. My doctor(s) have no issue with an E only regimen using modern, bio identical estrogens via a non-oral delivery method, as their own research suggested better E1:E2 ratios when the oral route was avoided.

[Becca Kay]

I am about 6 weeks into HRT and I feel mentally better than i ever have in my life.  No 'weird' behavior or side effects.  I keep worrying that this will end or go away and that it's temporary.  I've not felt so good in so long

[Mandy M]

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. If something appears to work for them, which is to be welcomed, it is promoted as if this is a universal truth. Sometimes, perhaps even often, this flies in the face of current established and scientifically backed protocols. Of course, personal opinions and experiences are a valuable resource, and may feed into scientific understanding, but they do not substitute for empirical peer-reviewed research. It is also important that we monitor latest scientific research. In 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.

Both the World Professional Association for Transgender Health (WPATH) and the Endocrine Society have created transgender-specific guidelines to help serve as a framework for providers caring for gender minority patients. These guidelines are mostly based on clinical experience from experts in the field. Guidelines for hormone therapy in transgender men are mostly extrapolations from recommendations that currently exist for the treatment of hypogonadal natal men and estrogen therapy for transgender women is loosely based on treatments used for postmenopausal women. It is important to note that, in many cases, MtF patients are reliant on non-specific treatment studies.

Therefore, let's be clear about this. Current WPATH and scientific papers do, indeed, suggest that Estrogen, through a feedback loop, does suppress testosterone. However:

"Hormone therapy for transgender women is intended to feminize patients by changing fat distribution, inducing breast formation, and reducing male pattern hair growth Estrogens are the mainstay therapy for trans female patients. Through a negative feedback loop, exogenous therapy suppresses gonadotropin secretion from the pituitary gland, leading to a reduction in androgen production. 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

WPATH 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."

http://transhealth.ucsf.edu/trans?page=guidelines-feminizing-therapy

The bottom line here to everyone who sees this is please go and seek professional medical help. Do not self-prescribe. Have your blood levels regularly checked and be very wary about something diverging from current WPATH guidelines. At the least, ensure you discuss this thoroughly with a properly trained medical professional.


See also:

Giltay EJ, Gooren LJ. Effects of sex steroid deprivation/administration on hair growth and skin sebum production in transsexual males and females. J Clin Endocrinol Metab 2000;85:2913-21. 10.1210/jcem.85.8.6710

Dittrich R, Binder H, Cupisti S, et al. Endocrine treatment of male-to-female transsexuals using gonadotropin-releasing hormone agonist. Exp Clin Endocrinol Diabetes 2005;113:586-92. 10.1055/s-2005-865900

[kelly_aus]

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. If something appears to work for them, which is to be welcomed, it is promoted as if this is a universal truth. Sometimes, perhaps even often, this flies in the face of current established and scientifically backed protocols. Of course, personal opinions and experiences are a valuable resource, and may feed into scientific understanding, but they do not substitute for empirical peer-reviewed research. It is also important that we monitor latest scientific research. In 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.

This isn't personal opinion - it is the opinion of my medical team, which is supported by the science. More recent studies?

Both the World Professional Association for Transgender Health (WPATH) and the Endocrine Society have created transgender-specific guidelines to help serve as a framework for providers caring for gender minority patients. These guidelines are mostly based on clinical experience from experts in the field. Guidelines for hormone therapy in transgender men are mostly extrapolations from recommendations that currently exist for the treatment of hypogonadal natal men and estrogen therapy for transgender women is loosely based on treatments used for postmenopausal women. It is important to note that, in many cases, MtF patients are reliant on non-specific treatment studies.

WPATH and the Endocrine Society both in the past recommended drugs like Premarin and ethinyl estradiol and yet no longer do, mostly due to research and advancements that were not trans specific - or are the work of medics working directly with trans people, which often goes unpublished.

Therefore, let's be clear about this. Current WPATH and scientific papers do, indeed, suggest that Estrogen, through a feedback loop, does suppress testosterone. However:

"Hormone therapy for transgender women is intended to feminize patients by changing fat distribution, inducing breast formation, and reducing male pattern hair growth Estrogens are the mainstay therapy for trans female patients. Through a negative feedback loop, exogenous therapy suppresses gonadotropin secretion from the pituitary gland, leading to a reduction in androgen production. 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

WPATH 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."

http://transhealth.ucsf.edu/trans?page=guidelines-feminizing-therapy

The bottom line here to everyone who sees this is please go and seek professional medical help. Do not self-prescribe. Have your blood levels regularly checked and be very wary about something diverging from current WPATH guidelines. At the least, ensure you discuss this thoroughly with a properly trained medical professional.

At no point did I suggest self-prescribing. I've presented it as an option for discussion with your medical professionals. And that 2nd link doesn't state what you've quoted quite as emphatically as you've put it. The study is also limited in the delivery methods used.

Will it work for everyone? Probably not. Should it work for many? Yes. Anti-androgens are not, for the most part, friendly drugs, they all have side effects we can do without. Why take a drug that's not needed?

[Mandy M]

Anti-androgens are not, for the most part, friendly drugs, they all have side effects we can do without. Why take a drug that's not needed?

If you wish to suppress testosterone effectively then, yes, WPATH guidelines are clear that estrogen alone is unlikely to be sufficient or, more seriously, you may need dangerously high levels of estrogen.

However, I do completely agree with you about anti-androgens. If someone has followed WPATH protocols, including the correct amount of time, and has the support of two medical letters, then surgery is a preferable option. It is, of course, more or less irreversible and not without its own complications.