Friday, November 16, 2012

6 Month HRT Report


6 months into male to female hormone therapy as of yesterday and I can feel the change inside now more than ever.  I am going to go over all the physical changes and effects but I am telling you the greatest change is on the inside and to me it is beautiful!  I do not feel like the same person anymore at all and I could not be happier about that.  I never felt happy with myself before, fluctuating between hating myself and not liking myself, but now for the first time in my memory I am comfortable in my own skin.  All the physical changes aside (and all of them take a long time to fully come to fruition), the mental change I have experienced is amazing, more than I ever expected and definitely worth the price of admission.

Like the picture above implies, I am going places, moving from point A to point B and definitely enjoying the ride.  After 6 months all the physical changes of HRT are reversible except breast growth (which becomes permanent after 6 months) but there is no reverse gear on this vehicle of life that I am on.  I assume that the mental changes would be reversible as well and I am not going to back to the place I was in, ever.  I have even filled in the dark hole and do not think I could find it if I tried.  I get emotional now from time to time and cry and so forth, sometimes for little reason.  But it really is a good feeling overall, its hard to describe it.  Its like letting go instead of letting things build up and the overall anxiety that had escalated in me over the years has vanished.  I was telling my therapist yesterday that I no longer have any panic attacks, my hives have cleared up and for the first time since age 16 and I no longer use any drugs.  I did see myself as using them ,especially marijuana, for so long as a form of self medication for mental stress, anxiety and depression.  Apparently the hormones have taken away the need for all that because I was never able to quit before without a horrible mood setting in.  The quasi suicidal cocaine use stopped a few years ago, not too long after I first started letting the real me inside come out by crossdressing and allowing myself to look in the mirror and see an image I did not detest.  The pot smoking I seemed to still need to maintain my mood until I started hormones, and now I don't miss it at all.  I was also able to stop using the medicine I was prescribed for anxiety after I started reducing testosterone with Spironolactone, so I now feel that T was a major source of my problems. 

Let's take a look at the physical changes I have noticed from HRT so far.  I feel like my face has changed and taken on a softer, more feminine look.  This is not dramatic but is noticeable with or without makeup and the pores on my face are smaller which allows me to use less makeup.  People tell me now my skin looks great and I always had bad skin before.  I still have problems with irritation from shaving so I will be so glad to finish hair removal by electrolysis.  I have always had very sensitive skin, still do and my therapist told me yesterday that because of that I can expect some skin damage, in the form of pock scarring, from electrolysis.  That is not something I wanted to hear and I already have some acne scars from my teenage years and some possible minor damage from electrolysis so far.  I have suspended my electrolysis until I can go somewhere that uses the newest equipment and deals with a lot of trans women.  I found a place in Charlotte, about 3.5 hours away, that I want to try very soon and get large blocks or full facial clearings done in one day.  I have had about 30 hours so far and the average is 100-200 hours to clear facial hair so I have a ways to go.  I feel mine will be closer to the 100 hours and I plan to get started back next month and will report how that goes.

To go over the other effects I am including a table from the Endocrine Society, which I think has the definitive document on hormone treatment and effects as well as all other aspects of MTF and FTM medical treatments.  Here is the  online link for the entire document in pdf form: 
  
 http://www.endo-society.org/guidelines/final/upload/endocrine-treatment-of-transsexual-persons.pdf

And the feminizing effects table:

Endocrine Treatment of Transsexual Persons:An Endocrine Society Clinical Practice Guideline

TABLE 14.
Feminizing effects in MTF transsexual persons
EffectOnset1Maximum1
Redistribution of body fat3–6 months2–3 yr
Decrease in muscle mass and strength3–6 months1–2 yr
Softening of skin/decreased oiliness3–6 monthsUnknown
Decreased libido1–3 months3–6 months
Decreased spontaneous erections1–3 months3–6 months
Male sexual dysfunctionVariableVariable
Breast growth3–6 months2–3 yr
Decreased testicular volume3–6 months2–3 yr
Decreased sperm productionUnknown>3 yr
Decreased terminal hair growth6–12 months>3 yr2
Scalp hairNo regrowth3
Voice changesNone4

The thing that stands out to me on this table is that All the known listed effects have started by the 6 month mark of HRT, so I will review my personal observations at this point in time.  They say YMMV (Your Mileage May Vary) and hormones affect everyone differently but I find this chart a good base to begin measuring my observed and expected physical changes.

Redistribution of body fat:  I started seeing this prior to the 3 month mark and definitely have a lot of fat redistribution going on now.  I also have some addition of body fat, as I picked up a little weight, but that is to be expected with hormones if one is not vigilant enough although I have not changed sizes at all.  Really the only negative thing I want to get rid of from the weight gain is a small degree of love handles but I am glad I have not gotten a beer type belly like I did before if I put on weight.  My butt and hips have put on weight as well as my upper thighs and I never put any fat on my arms or legs before.  My face used to get puffy when I would gain weight but that has not happened, although I notice my cheeks have filled out some from the redistribution.

Decrease in muscle mass and strength:  I noticed this starting before the 3 month mark also and it is continuing but does seem to be a slow process.  My arms and legs were quite muscular as well as certain parts of my upper body, primarily from a period of weight lifting as a teenager and heavy work as an adult.  I suppose no one really wants to lose strength but I have noticed a degree of loss there already.  The muscle mass itself I will be more than happy to be rid of.  I am hoping to make a lot more progress in this area by next summer so that I will feel more comfortable showing more of my body but it had already made a difference by late this summer as I was not as conscientious about wearing shorter sleeve tops.  I still don't feel comfortable in public going sleeveless but I hope to get there eventually.

Softening of skin, decreased oiliness:  I have probably noticed less of the softening of skin at first than most people report but I think that is mainly because my skin was quite soft before starting hormones.  My skin is naturally soft as well as sensitive and since its been a few years since I have done any significant physical work and I have a good moisturizing regimen, I have kept it pretty soft.  Here at the 6 month mark I am noticing it becoming even softer though and that is always a good thing.  The decreased oiliness I have noticed and that has helped me maintain better facial skin etc.

Decreased libido:  As far as having a decrease in the need to have sex or have an orgasm, that has decreased significantly.  I used to feel an organic need to have that happen often and I think that is normal in genetic males but that feeling is rare now if not non existent and certainly much easier to control.  As far as not being in the mood to be romantic or to please my partner that has not really decreased and personally I have always been about pleasing the other person when in a relationship.  The table lists the maximum effect achieved in 6 months so maybe no more changes are in order here.

Decreased spontaneous erections:  The table says this starts at 1 month and has maximum effect by 6 months and that is consistent with my experience.  I don't have those anymore on a spontaneous basis and that is very nice not to have something that you cannot control.

Male sexual dysfunction:  The table says variable and I think that is my experience so far so I will leave it at that.

Breast growth:  With the table listing a 3-6 month onset I have to feel pretty good to be where I am now although I feel I am only now achieving a full cup size.  Mine had actually started budding if not fully growing before I started HRT because of the phytoestrogens and Spironolactone I was using.  The therapist tells me that even though my estrogen level was not really enhanced prior to starting hormones (it was 11/pn/ml), the phtyoestrogens in the herbs help condition the estrogen receptors so that they will have a quicker and hopefully better effect throughout the 2-3 year period of growth listed here.  I will add that many report breast growth even after 3 years or even longer and my doctor has told me he doesn't feel they will achieve full size before some form of surgery.  I don't know that I will ever want any breast augmentation and probably won't if I can get decent growth from hormones because I do like the sensitivity, but I think its important to wait at least 2 years if that's to be done.  I know some do it but its not considered a good idea before the 2 year mark because any significant growth behind the breast implants can cause problems. 

Decreased testicular volume:  I started noticing this effect before the 3 month mark and at the 6 month mark its definitely more pronounced.  I will say it certainly makes tucking easier, which is very nice.

Decreased sperm production:  There doesn't seem to be a quantified time period here but I don't think I am producing any sperm at all now, or very little at most.  I have read that fertility is usually eliminated if not severely compromised by the 6 month HRT mark and I am sure that is the case with me. 

Decreased terminal hair growth:  I assume they are referring to body hair here and I noticed this effect starting prior to the 3 month mark but here at the 6 month mark when it is supposed to be starting I am really noticing it in certain areas.  For instance, I am not sure I have to shave my arms anymore.  Right now its been almost 3 weeks and I am testing it to see how this goes but women do have hair on their arms and most do not shave them, it's just usually light and fine and not noticeable.  That's what I am seeing there now, or not seeing, because I do have some hair coming back there now but I can't see it and can barely feel it.  In the past if I would go awhile without shaving my arms I would get visible stubble there that was dark and did not look good.  My legs have to be shaved less often also and when it comes back it is not really dark and visible like before.  The only area that I do not seem to have hair at all is my back.  I only had a few, maybe 18 hairs, and they only appeared a few years ago.  Now the hairs on my back do not seem to be coming back at all.  Central body areas seem to be affected last but here at the 6 month mark I am seeing slower growth there now as well.

Scalp hair: The table says no regrowth but I hear a lot of reports of people regrowing some lost hair to varying degrees, but if someone has significant hair loss it is not coming back.  I am lucky to have not had any real hair loss or thinning.  There are two small areas, on the right and left side around the temples where I had some hair starting to recede and I actually do see some hair regrowing in both of those areas.  My forehead is a little high and it is genetic and not from hair loss but it is something I would like to address surgically at some point.  I consider it a male characteristic but many if not most trans women have this as well as some females.  The surgery was designed for females but at least I have learned to live with it and do not allow that to affect my confidence now. 

Hormone levels and regimen

Now that we have reviewed my observed effects from HRT so far let's take a look at the hormones I am taking and where I am on my medical transition.  Below is another table (15) from the Endocrine Society on monitoring and recommended levels.  At the end of October, after 5.5 months of HRT,  I had a doctor's appointment to test my blood including my hormone levels.  The estrogen level was 128.5 pg/ml and testosterone was 14 ng/ml.  I told my doctor I wanted my estrogen level closer to 200 and he told me he thought it would come up but was at a therapeutic level now and within recommended female range, which he said was 19 to 356, depending on the part of the cycle she is in, and with an average of 150.  The following quote from ehow.com gives similar figures.  "The normal range of estrogen varies depending upon the patient's age. Typically a women aged 20 to 29 will have an average level of 149 pg/ml (pictograms per milliliter). A female aged 30 to 39 will average a level of 210 pg/ml. And those over 40 but not in menopause will have an average level of 152 pg/ml. These average levels can vary day to day depending on each female's menstrual cycle."

My therapist was telling me the endocrinologist in Raleigh liked her patients estrogen levels at 75-80 and testosterone below 30, but that doctor is considered conservative.  She said if I was seeing that doctor she would cut my dose so I am really glad I have the doctor I do.  I am aware of endocrinologists in other cited that prefer patients in the 150-160 range.  The chart below recommends estrogen levels in female range and below 200 and testosterone levels below 55.  I guess I am good shape now and hormonally female.  My E level has risen 50% since my 3 month test and we will keep testing it every 3 to 4 months so I feel it will rise more and I am good hands with the doctor I see. 


Endocrine Treatment of Transsexual Persons:An Endocrine Society Clinical Practice Guideline
TABLE 15.

Monitoring of MTF transsexual persons on cross-hormone therapy
1. Evaluate patient every 2–3 months in the first year and then 1–2 times per year afterward to monitor for appropriate signs of feminization and for development of adverse reactions.
2. Measure serum testosterone and estradiol every 3 months.
    a. Serum testosterone levels should be <55 ng/dl.
    b. Serum estradiol should not exceed the peak physiological range for young healthy females, with ideal levels <200 pg/ml.
    c. Doses of estrogen should be adjusted according to the serum levels of estradiol.
3. For individuals on spironolactone, serum electrolytes (particularly potassium) should be monitored every 2–3 months initially in the first year.
4. Routine cancer screening is recommended in nontranssexual individuals (breasts, colon, prostate).
5. Consider BMD testing at baseline if risk factors for osteoporotic fracture are present (e.g. previous fracture, family history, glucocorticoid use, prolonged hypogonadism). In individuals at low risk, screening for osteoporosis should be conducted at age 60 and in those who are not compliant with hormone therapy.

Below is another table from the Endocrine Society showing recommended MTF HRT regimens.  My estrogen dosage is transdermal estradiol patch 0.2 mg twice weekly and anti androgen Spironolactone 150mg/d.  The estrogen patch provides the female hormone and the antiandrogen suppresses the male hormone that is being produced in my body.  Item 2.c. in Table 15 above states that doses  of estrogen should be adjusted according to the serum levels of estradiol. 


Endocrine Treatment of Transsexual Persons:An Endocrine Society Clinical Practice Guideline



TABLE 12.

Hormone regimens in the transsexual persons
Dosage
MTF transsexual persons1
    Estrogen
        Oral: estradiol
2.0–6.0 mg/d
        Transdermal: estradiol patch
0.1–0.4 mg twice weekly
        Parenteral: estradiol valerate or cypionate
5–20 mg im every 2 wk
2–10 mg im every week
    Antiandrogens
        Spironolactone
100–200 mg/d
        Cyproterone acetate2
50–100 mg/d
    GnRH agonist
3.75 mg sc monthly

Basically what I am taking now is 2 0.1 estradiol patches (Vivelle Dot) x 2 per week and 150 mg of Spironolactone (Aldactone) daily. I have changed the administration of the patches since November 1 and I hope this will raise my level a little bit. I am putting on 2 patches at the time twice a week now whereas I was simply putting on a new patch every 2 days and leaving them on at least 4 days. That way the 16 patches I am prescribed monthly lasted me at least 31 days and the new way (which is the recommended way) they will only last 28 days. Even though my doctor says I am now on the highest dose he will give me, when I go back next time I am going to ask him to give me 18 patches/month so they will last the full 30 to 31 days. If not I will just get the refills a little early. As far as the Spiro, I was taking 200 mg daily but it is a diuretic and I was having a heck of a time with frequent urination and feelings of dehydration. I thought I was experiencing "dehydration paranoia" but my last blood test showed my sodium to be a little low and the doctor asked me if I was drinking enough water. I do drink a lot of water but I was feeling something was not right so a couple of weeks before the last blood test I cut myself down to 150 mg daily to see what it would do to the T level . My testosterone stayed about the same and is right where it needs to be so the doctor and I agreed to cut my Spiro dose to 150mg/d. The low sodium is the only problem I have experienced so far with my HRT regimen and I feel I am tolerating the current dose well.

This has all been a little technical but I want to give the most detailed and accurate picture of what is going on with my medical transition right now.  I do want to state that the best thing about HRT for me is that I am finally getting to experience, I think, what it feels like to be normal.  I will never be truly normal and I'm perfectly ok with that but at least I can feel normal inside and possibly more importantly, feel good about myself.  I want to leave y'all with some quotes from one of my favorite songs and one whose lyrics have a great deal of meaning to me right now, I Hope You Dance, sung by Lee Anne Womack.  I get emotional listening to this one sometimes and I am including a link below to a video of the song with lyrics.  Its definitely worth a listen.

"Whenever one door closes I hope one more opens."
"I hope you never fear those mountains in the distance."
"Never settle for the path of least resistance."
"When you get the choice to sit it out or dance, I hope you Dance."


https://www.youtube.com/watch?v=y2SfmcNg8js