Knotty questions from trans women

Once you start hormones do you need to take them forever or do you get to a point when changes are permanent post FGS?

If you have no oestradiol there is a bone risk and some replacement hormones are needed lifelong. You will be potentially at risk of osteoporosis, reduced muscle mass and cognitive issues.

Target doses for oestradiol vary with health parameters, and lifestyle factors such as smoking and age.
Alcohol, smoking, age and obesity, cardiovascular issues, and alcohol/liver impairment such as hepatitis and cirrhosis are all risk factors.

Higher target doses/levels in younger patients and lower levels in smokers and older patients and other risk factors.

When do you recommend Dexa Scan?

In trans health – for patients who have had BSO or Orchidectomy and have stopped taking either testosterone ( trans man) or oestrogen ( trans woman).

Height loss over 4cm

A low trauma fracture would warrant consideration of Dexa Scan.

You reach peak bone mass aged 25. It is useful in hormone deficient adults. It is a useful measure but cannot predict bone fracture risk accurately (50% of information only). Bone density alone is not enough and a Frax score is also undertaken.

We advise Vitamin D life long to improve bone health and many people are Vitamin D deficient

If I decide to stop hormones ( oestrogen and T blockers) what are the risks and what is best way to stop?

It is safe to stop hormones. It is not necessary to taper down. However, there might be hot flushes, mood disturbance and trigger dysphoria. Depending on how long you have been on hormones it is possible the testosterone or oestrogen may not return to baseline levels. The gonadal axis may not recover.

How long before the T goes back to baseline male after stopping T blocker?

It would depend on how long you have been on a blocker. In some young trans women, the recovery will be quicker but after ten years of blockers, it is unlikely the testosterone will recover.

Are the risk for BAME ( south Asian and African carribean) Trans person on HRT different and if so in what respect, given higher rates of obesity, diabetes, hypertension and use of anti psychotics?

The hormone treatment itself is not a risk factor people of BAME ethnicity are at increased risk of cardiovascular diseases, diabetes, hyperlipidaemia and raised cholesterol. With this in mind, it is likely the endocrinologist will tailor the target hormone levels with the above in mind. South Asians have raised diabetes risk and African and caribbean have raised diabetes and hypertension risks and both have higher cardiovascular risks. Lifestyle factors like exercise, diet and stress are relevant.

Trans men have higher baseline BMI than trans women. Testosterone is associated with increased BMI ( more muscle). Oestrogen does not raise BMI to the same extent.

BMI over 23 is same risk factor caucasian BMI risk factor 30.

Can I still get erection on Decapeptyl?

Unlikely but possible. Some patients can still can get an erection and some people can still ejaculate and some can still orgasm. Some patients take Viagra for libido.

Why does all trans women get the same protocol regardless of age?

This is not the case as individual titration and prescribing are undertaken. Over aged 45 we recommend transdermal (gel or patch for oestrogen)

What is the latest research on progesterone and breast growth in trans women? Are there any downsides?

We do prescribe progesterone on a patient-by-patient basis after good levels of oestrogen. We commence 1mg of oestrogen and increase to 2mg after 4 weeks to prevent pendulous breast growth. After 18 months a 6-month trial of progesterone 200mg nocte for breast growth. If it is beneficial it can be continued but kept under review.

Why can’t we have oestrogen implants on the NHS?

Implants are not licenced in the UK and there are worrisome peaks and troughs in oestrogen levels due to erratic bioavailability. Increased risk of blood clots as well.

What are alternatives to Decapeptyl?

Leuoproelin – prostrap can be used.

Do you prescribe Synarel spray ?

Yes, it is effective to suppress testosterone but it can be expensive.

Do you think Trans patients should reduce HRT dosage with age after 50?

Yes. It should be reviewed.

What precautions are needed for HIV patients.

HIV medications cause cvs risk and dyslipidaemia and raised triglycerides and hence need transdermal hormones and reduced target levels of oestrogen.

Can there be loss of height after starting hormones?

It is possible due to reduced testosterone levels even in adulthood and age. In a trans woman, the bone mineral density is reduced. If the loss is 4cm or more we would do an x-ray and a DEXA scan.

Can libido (sex drive) increase after HRT?

Yes, it can do for psychosexual reasons. Some people feel more confident and more congruent and able to explore sexuality. It cannot change sexual orientation.

What happens to prostate after hormone treatment and does this impact on prostate screening?

Blocking testosterone reduces the risks of prostrate cancer but does not eliminate them so screening is still needed. PSA scores might be reduced after T blockage. If there is haematuria, increased frequency and nocturia it will need investigation.