Masculinizing hormone therapy: Difference between revisions
Clarified some things about what is and isn't understood about neurological changes, and about potential contraindications. Starting to work with another source, Gorton's book, which looks like it was the main source for the original Wikipedia article.
imported>Sekhet (Created page with "{{content warning|private body parts and periods}} {{disclaimer|The Nonbinary Wiki is written by volunteers who are not necessarily experts on medical topics. This wiki and it...") |
imported>Sekhet (Clarified some things about what is and isn't understood about neurological changes, and about potential contraindications. Starting to work with another source, Gorton's book, which looks like it was the main source for the original Wikipedia article.) |
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====Vaginal atrophy==== | ====Vaginal atrophy==== | ||
Masculinizing HRT can sometimes cause vaginal atrophy and dryness. Vaginal atrophy means that the inside of the vagina becomes more weak, delicate, fragile, and dry, and less elastic. On masculinizing HRT, the vagina and vulva are not as wet, but can still become wet when aroused. Vaginal atrophy is also common for cisgender women to have when they go through menopause. A trans-masculine person may start having vaginal atrophy 3 to 6 months after starting HRT, with maximum effect at 1 to 2 years after starting HRT.<ref name="soc 37" /> | Masculinizing HRT can sometimes cause [[vaginal atrophy]] and dryness. Vaginal atrophy means that the inside of the vagina becomes more weak, delicate, fragile, and dry, and less elastic. On masculinizing HRT, the vagina and vulva are not as wet, but can still become wet when aroused. Vaginal atrophy is also common for cisgender women to have when they go through menopause. A trans-masculine person may start having vaginal atrophy 3 to 6 months after starting HRT, with maximum effect at 1 to 2 years after starting HRT.<ref name="soc 37" /> | ||
If a trans-masculine person receives vaginal penetration, this may be more painful (dyspareunia), which can cause tiny rips (microtears) in the skin inside the vagina. Microtears increase the risk of communicating sexually transmitted infections (STIs). It is important for trans-masculine people to use lubrication to help make sure that sex is comfortable, and to use condoms specifically to protect against STIs, even when using other forms of birth control.{{Citation needed}} | If a trans-masculine person receives vaginal penetration, this may be more painful (dyspareunia), which can cause tiny rips (microtears) in the skin inside the vagina. Microtears increase the risk of communicating sexually transmitted infections (STIs). It is important for trans-masculine people to use lubrication to help make sure that sex is comfortable, and to use condoms specifically to protect against STIs, even when using other forms of birth control.{{Citation needed}} | ||
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===Neurological changes=== | ===Neurological changes=== | ||
A 2006 study found that HRT in trans men correlates with in an increase in brain volume up to male proportions.<ref name="eje-utrecht">{{cite journal|author=Hulshoff, Cohen-Kettenis|date=July 2006|title=Changing your sex changes your brain: influences of testosterone and estrogen on adult human brain structure|url=http://www.eje-online.org/cgi/content/abstract/155/suppl_1/S107|journal=European Journal of Endocrinology|issue=suppl_1|pages=107–114|doi=10.1530/eje.1.02248|issn=0804-4643|volume=155|display-authors=1|last2=Cohen-Kettenis|first2=P. T|last3=Van Haren|first3=N. E M|last4=Peper|first4=J. S|last5=Brans|first5=R. G H|last6=Cahn|first6=W.|last7=Schnack|first7=H. G|last8=Gooren|first8=L. J G|last9=Kahn|first9=R. S|access-date=2007-12-12|archive-url=https://web.archive.org/web/20110411003628/http://www.eje-online.org/cgi/content/abstract/155/suppl_1/S107|archive-date=2011-04-11|url-status=dead|doi-access=free}}</ref> | A 2006 study found that HRT in trans men correlates with in an increase in brain volume up to male proportions.<ref name="eje-utrecht">{{cite journal|author=Hulshoff, Cohen-Kettenis|date=July 2006|title=Changing your sex changes your brain: influences of testosterone and estrogen on adult human brain structure|url=http://www.eje-online.org/cgi/content/abstract/155/suppl_1/S107|journal=European Journal of Endocrinology|issue=suppl_1|pages=107–114|doi=10.1530/eje.1.02248|issn=0804-4643|volume=155|display-authors=1|last2=Cohen-Kettenis|first2=P. T|last3=Van Haren|first3=N. E M|last4=Peper|first4=J. S|last5=Brans|first5=R. G H|last6=Cahn|first6=W.|last7=Schnack|first7=H. G|last8=Gooren|first8=L. J G|last9=Kahn|first9=R. S|access-date=2007-12-12|archive-url=https://web.archive.org/web/20110411003628/http://www.eje-online.org/cgi/content/abstract/155/suppl_1/S107|archive-date=2011-04-11|url-status=dead|doi-access=free}}</ref> | ||
On the other hand, the reality of distinct differences between the brains of men and women is disputed by various neurologists. British neuroscientist Gina Rippon, author of the 2019 book ''Gendered Brain: The New Neuroscience that Shatters the Myth of the Female Brain'', argues that there is not a "single item type as a male brain or a female brain", instead that "everybody is actually made up of a whole pattern of things, which is maybe due to their biology and maybe due to their different experiences in life."<ref name=":2">{{Cite news|title='Every brain is different from every other brain’: Author Gina Rippon challenges gender stereotypes|url=https://www.theglobeandmail.com/life/health-and-fitness/article-every-brain-is-different-from-every-other-brain-author-gina-rippon/|access-date=2020-08-06}}</ref> She puts forward the idea that "every brain is different from every other brain".<ref name=":2" /> Rippon is opposed to the "continued emphasis on '[[gender essentialism|essentialist]]', brain-based explanations in both public communication of, and research into, many forms of gender imbalance."<ref>{{cite journal | last = Rippon | first = Gina | title = The trouble with girls? | journal = [[The Psychologist (magazine)|The Psychologist]] | volume = 29 | issue = 12 | pages = 918–922 | publisher = British Psychological Society | date = December 2016 | url = https://thepsychologist.bps.org.uk/volume-29/december-2016/trouble-girls | ref = harv }}</ref> | |||
====Effects on migraines==== | ====Effects on migraines==== | ||
Migraines are a poorly-understood type of headache with a neurological origin | Migraines are a poorly-understood type of headache with a neurological origin. The symptoms of a migraine can include hallucinations, light sensitivity, nausea, and vomiting. The cause of migraines is not well understood, but seems to correlate with a person's hormone balance. Many cisgender men and women who have had migraines find that their migraines change in frequency and severity after puberty or menopause. Usually, cisgender boys have worse migraines before puberty, whereas cisgender women have worse migraines between puberty and menopause. Many cisgender women have migraines just before a menstrual period, as part of premenstrual syndrome (PMS).<ref name=Stovner2007>{{cite journal | vauthors = Stovner LJ, Zwart JA, Hagen K, Terwindt GM, Pascual J | title = Epidemiology of headache in Europe | journal = European Journal of Neurology | volume = 13 | issue = 4 | pages = 333–45 | date = April 2006 | pmid = 16643310 | doi = 10.1111/j.1468-1331.2006.01184.x }}</ref><ref name=Broner2009>{{cite journal | vauthors = Lay CL, Broner SW | title = Migraine in women | journal = Neurologic Clinics | volume = 27 | issue = 2 | pages = 503–11 | date = May 2009 | pmid = 19289228 | doi = 10.1016/j.ncl.2009.01.002 }}</ref> | ||
Transgender people can see a change in the frequency or severity of migraines when they go on HRT, and during the time they are adapting to a new HRT regimen. | |||
====Effects on epilepsy==== | ====Effects on epilepsy==== | ||
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===Psychological and emotional changes=== | ===Psychological and emotional changes=== | ||
The psychological changes are | The psychological changes are hard to define, for a variety of reasons. These types of changes are more subjective and difficult to quantify. During any gender transition, there are usually other factors in a person's life that have effects on their emotions, stress levels, and mental health. An extremely high level of testosterone is often associated with an increase in aggression, but this is not a noticeable effect in most trans-masculine people. HRT doses of testosterone are much lower than the typical doses taken by steroid-using athletes, and create testosterone levels comparable to those of most [[cisgender men]] (men who are not transgender). These levels of testosterone have not been proven to cause more aggression than comparable levels of estrogen. | ||
Some trans-masculine people report mood swings, increased anger, and increased aggressiveness just after starting androgen therapy. Studies are limited and small scale, however, based on self reporting over a short period of time (7 months). In a study by Motta et al, trans men also reported better anger control.<ref>Does Testosterone Treatment Increase Anger Expression in a Population of Transgender Men? | Some trans-masculine people report mood swings, increased anger, and increased aggressiveness just after starting androgen therapy. Studies are limited and small scale, however, based on self reporting over a short period of time (7 months). In a study by Motta et al, trans men also reported better anger control.<ref>Does Testosterone Treatment Increase Anger Expression in a Population of Transgender Men? | ||
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The WPATH says that masculinizing HRT carries a possible increased risk of elevated liver enzymes.<ref name="soc 40" /> | The WPATH says that masculinizing HRT carries a possible increased risk of elevated liver enzymes.<ref name="soc 40" /> | ||
The risk of causing liver damage or liver cancer from masculinizing HRT is minimal. Only oral pills for testosterone have a high risk for these, which is why oral testosterone pills stopped being common or used in most countries decades ago. Excessively high levels of testosterone could also raise these risks. However, as with any drug that carries even a small risk of liver damage, | The risk of causing liver damage or liver cancer from masculinizing HRT is minimal. Only oral pills for testosterone have a high risk for these, which is why oral testosterone pills stopped being common or used in most countries decades ago. Excessively high levels of testosterone could also raise these risks. However, as with any drug that carries even a small risk of liver damage, liver function tests (or at least ALT) should be periodically monitored. | ||
===Metabolic changes=== | ===Metabolic changes=== | ||
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The WPATH says that masculinizing HRT likely increases the risk of polycythemia. | The WPATH says that masculinizing HRT likely increases the risk of polycythemia. | ||
Increased red blood cell mass usually from overproduction by the bone marrow. Testosterone (frequently in large doses) was previously used to treat anemia from bone marrow failure. A transgender man's hematocrit (the percentage of whole blood made up of red blood cells) should be judged against normal age adjusted values for men. Therapy is via phlebotomy (periodic therapeutic blood draws similar to blood donation). Tendency to become polycythemic worsens with age. Worse with injected testosterone (especially with longer intervals between doses) than with oral, transdermal, or Testopel. (Increase in RBCs occurs with the very high peaks from injection. So decreasing dose and interval to 7–10 days instead of 14 may help.) Severe polycythemia predisposes to both venous and arterial thrombosis (blood clots) such as: | Increased red blood cell mass usually from overproduction by the bone marrow. Testosterone (frequently in large doses) was previously used to treat anemia from bone marrow failure. A transgender man's hematocrit (the percentage of whole blood made up of red blood cells) should be judged against normal age adjusted values for men. Therapy is via phlebotomy (periodic therapeutic blood draws similar to blood donation). Tendency to become polycythemic worsens with age. Worse with injected testosterone (especially with longer intervals between doses) than with oral, transdermal, or Testopel. (Increase in RBCs occurs with the very high peaks from injection. So decreasing dose and interval to 7–10 days instead of 14 may help.) Severe polycythemia predisposes to both venous and arterial thrombosis (blood clots) such as: deep venous thrombosis, pulmonary embolism, heart attack, and stroke. Aspirin may decrease the risk.{{Citation needed}} | ||
===Question of risk of breast cancer=== | ===Question of risk of breast cancer=== | ||
The WPATH says that there is no increased risk or that it is inconclusive whether masculinizing HRT might increase the risk of breast cancer.<ref name="soc 40" /> The WPATH says, "Because the aromatization of testosterone to estrogen may increase risk in patients with a history of breast or other estrogen dependent cancers (Moore et al., 2003), consultation with an oncologist may be indicated prior to [masculinizing] hormone use."<ref name="soc 45" /> | The WPATH says that there is no increased risk or that it is inconclusive whether masculinizing HRT might increase the risk of breast cancer.<ref name="soc 40" /> The WPATH says, "Because the aromatization of testosterone to estrogen may increase risk in patients with a history of breast or other estrogen dependent cancers (Moore et al., 2003), consultation with an oncologist may be indicated prior to [masculinizing] hormone use."<ref name="soc 45" /> | ||
==Types of masculinizing hormone therapy== | ==Types of masculinizing hormone therapy== | ||
The safest, most effective, most affordable, and most common method of taking masculinizing hormone therapy is injection. People who are unable to do this because of a fear of needles | The safest, most effective, most affordable, and most common method of taking masculinizing hormone therapy is injection. People who are unable to do this because of a fear of needles can choose methods in which they absorb the HRT through their skin, in the form of patches and gels. Masculinizing hormone therapy is no longer commonly available in the form of an oral pill, because taking it by this route added some health risks. | ||
====Injected==== | ====Injected==== | ||
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====Growth hormone==== | ====Growth hormone==== | ||
Young people stop growing after their bones go through a change called epiphyseal closure. Complete fusion happens on average between ages 12–18 for cisgender girls (with the most common being 15-16 years) and 14–19 for cisgender boys (with the most common being 18-19 years).<ref>{{cite journal |pmid=16225203 |title=Age ranges of epiphyseal fusion in the distal tibia and fibula of contemporary males and females |journal=Journal of Forensic Sciences |volume=50 |issue=5 |pages=1001–7 |date=September 2005 |quote=complete fusion in females occurs as early as 12 years in the distal tibia and fibula. All females demonstrated complete fusion by 18 years with no significant differences between ancestral groups. Complete fusion in males occurs as early as 14 years in both epiphyses. All males demonstrated complete fusion by 19 years|last1=Crowder |first1=C |last2=Austin |first2=D |doi=10.1520/JFS2004542 }}</ref><ref>{{cite web |last1=Barrell |first1=Amanda |title=At what age do girls stop growing? |url=https://www.medicalnewstoday.com/articles/320668 |website=MedicalNewsToday |accessdate=9 June 2020}}</ref><ref>{{cite web |last1=Jarret |first1=Robert R. |title=Puberty: Tanner Stages – Boys |url=http://pediatric-house-calls.djmed.net/puberty-tanner-stages-boys/ |website=Pediatric HOUSECALLS |accessdate=9 June 2020}}</ref><ref>{{cite web |last1=Jarret |first1=Robert R. |title=Puberty: Tanner Stages – Girls |url=http://pediatric-house-calls.djmed.net/puberty-tanner-stages-girls/ |website=Pediatric HOUSECALLS |accessdate=9 June 2020}}</ref><ref>{{cite web |title="When do most males' growth plates close?" |url=https://answers.zocdoc.com/details/21489/when-do-most-males-growth-plates-close |website=Zoodoc |accessdate=9 June 2020}}</ref> Once that happens, a person's bones cannot grow anymore, so they can't get any taller. For young people who have not yet started or completed epiphyseal closure, they can take [[growth hormone]], potentially together with an aromatase inhibitor or a GnRH analogue, to increase final height. | |||
== Getting HRT == | == Getting HRT == | ||
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2. Capacity to make a fully informed decision and to consent for treatment;<ref name="soc 34" /> | 2. Capacity to make a fully informed decision and to consent for treatment;<ref name="soc 34" /> | ||
3. Age of majority in a given country<ref name="soc 34" /> (if younger, [[puberty blockers]] are the preferred option); | 3. Age of majority in a given country<ref name="soc 34" /> (if younger, [[puberty blockers]] are the preferred option, until they are of age); | ||
4. If significant medical or mental health concerns are present, they must be reasonably well-controlled. The WPATH says that if someone has mental health concerns, this does not mean that person is not allowed to get HRT. Rather, these concerns need to be managed before, or at the same time as, getting HRT.<ref name="soc 34" /> | 4. If significant medical or mental health concerns are present, they must be reasonably well-controlled. The WPATH says that if someone has mental health concerns, this does not mean that person is not allowed to get HRT. Rather, these concerns need to be managed before, or at the same time as, getting HRT.<ref name="soc 34" /> | ||
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====Ineligibility and contraindications==== | ====Ineligibility and contraindications==== | ||
Masculinizing HRT largely switches a person's health risks to be the same as if they had been [[sexes#assigned male at birth|assigned male at birth]]. This means that very few conditions would make it impossible or less safe for a person to take masculinizing HRT. The WPATH says HRT is only contraindicated in rare cases, due to serious health conditions.<ref name="soc 35">World Professional Association for Transgender Health. ''The Standards of Care,'' version 7. 2012. Page 34. https://wpath.org/publications/soc</ref> There are a few conditions that have been seen as contraindications to masculinizing HRT.<ref>{{cite web|last=Hembree, W.C.|url=http://www.endocrine.org/~/media/endosociety/Files/Publications/Clinical%20Practice%20Guidelines/Endocrine-Treatment-of-Transsexual-Persons.pdf|archive-url=https://web.archive.org/web/20140313131201/http://www.endocrine.org/~/media/endosociety/Files/Publications/Clinical%20Practice%20Guidelines/Endocrine-Treatment-of-Transsexual-Persons.pdf|url-status=dead|archive-date=2014-03-13|title=Endocrine Treatment of Transsexual Persons: An Endocrine Society Clinical Practice Guideline|date=September 2009|publisher=Journal of Clinical Endocrinology & Metabolism|page=18|accessdate=March 13, 2014|display-authors=etal}}</ref> Even in situations where going on masculinizing HRT could have an effect on someone's risk factors for certain conditions, usually this is not a reason to not go on HRT, and all that is needed is a conversation with a doctor to make sure the patient is aware of those risks, and knows how to mitigate the risks, such as through other healthy lifestyle choices. | Masculinizing HRT largely switches a person's health risks to be the same as if they had been [[sexes#assigned male at birth|assigned male at birth]]. This means that very few conditions would make it impossible or less safe for a person to take masculinizing HRT. The WPATH says HRT is only contraindicated in rare cases, due to serious health conditions.<ref name="soc 35">World Professional Association for Transgender Health. ''The Standards of Care,'' version 7. 2012. Page 34. https://wpath.org/publications/soc</ref> There are a few conditions that have been seen as contraindications to masculinizing HRT.<ref>{{cite web|last=Hembree, W.C.|url=http://www.endocrine.org/~/media/endosociety/Files/Publications/Clinical%20Practice%20Guidelines/Endocrine-Treatment-of-Transsexual-Persons.pdf|archive-url=https://web.archive.org/web/20140313131201/http://www.endocrine.org/~/media/endosociety/Files/Publications/Clinical%20Practice%20Guidelines/Endocrine-Treatment-of-Transsexual-Persons.pdf|url-status=dead|archive-date=2014-03-13|title=Endocrine Treatment of Transsexual Persons: An Endocrine Society Clinical Practice Guideline|date=September 2009|publisher=Journal of Clinical Endocrinology & Metabolism|page=18|accessdate=March 13, 2014|display-authors=etal}}</ref>The only absolute medical contraindications currently recognized by the WPATH are pregnancy, and unstable coronary artery disease and untreated polycythemia with a hematocrit of 55% or higher, as further described below. Even in situations where going on masculinizing HRT could have an effect on someone's risk factors for certain conditions, usually this is not a reason to not go on HRT, and all that is needed is a conversation with a doctor to make sure the patient is aware of those risks, and knows how to mitigate the risks, such as through other healthy lifestyle choices. | ||
The WPATH considers pregnancy an absolute medical contraindication, based on a 2004 study.<ref name="soc 45">World Professional Association for Transgender Health. ''The Standards of Care,'' version 7. 2012. Page 45. https://wpath.org/publications/soc</ref><ref name="carnegie 2004">Carnegie, C. (2004). "Diagnosis of hypogonadism: Clinical asessments and laboratory tests." ''Reviews in urology'', 6 (Suppl 6), S3-8.</ref> Masculinizing HRT can affect the developing fetus.<ref name="soc 45" /> It is still possible for someone to get pregnant while on HRT, and after having been on HRT, because HRT does not prevent pregnancy. People on masculinizing HRT need highly effective birth control to prevent getting pregnant while on HRT.<ref name="soc 45" /> People should temporarily stop | The WPATH considers pregnancy an absolute medical contraindication, based on a 2004 study.<ref name="soc 45">World Professional Association for Transgender Health. ''The Standards of Care,'' version 7. 2012. Page 45. https://wpath.org/publications/soc</ref><ref name="carnegie 2004">Carnegie, C. (2004). "Diagnosis of hypogonadism: Clinical asessments and laboratory tests." ''Reviews in urology'', 6 (Suppl 6), S3-8.</ref> Masculinizing HRT can affect the developing fetus.<ref name="soc 45" /> It is still possible for someone to get pregnant while on HRT, and after having been on HRT, because HRT does not prevent pregnancy. People on masculinizing HRT need highly effective birth control to prevent getting pregnant while on HRT.<ref name="soc 45" /> People on masculinizing HRT should temporarily stop taking that HRT while pregnant or trying to get pregnant. | ||
The WPATH considers unstable coronary artery disease and untreated polycythemia with a hematocrit of 55% or higher to be absolute medical contraindications, based on a 2004 study.<ref name="soc 45" /><ref name="carnegie 2004" /> | The WPATH considers unstable coronary artery disease and untreated polycythemia with a hematocrit of 55% or higher to be absolute medical contraindications, based on a 2004 study.<ref name="soc 45" /><ref name="carnegie 2004" /> | ||
It is important for patients to know that certain conditions are not contraindications, in order to prevent doctors from unethically withholding access to HRT. The WPATH says "it is unethical to deny availability or eligibility for hormone therapy solely on the basis of blood seropositivity for blood-borne infections such as HIV or hepatitis B or C."<ref name="soc 35" /> | It is important for patients to know that certain conditions are not contraindications, in order to prevent doctors from unethically withholding access to HRT. The WPATH says "it is unethical to deny availability or eligibility for hormone therapy solely on the basis of blood seropositivity for blood-borne infections such as HIV or hepatitis B or C."<ref name="soc 35" /> | ||
Clinicians differ in any additional conditions that they consider to be contraindications.<ref name="gorton 16">R. Nick Gorton, Jamie Buth, and Dean Spade. ''Medical Therapy and Health Maintenance for Transgender Men: A Guide for Health Care Providers.'' San Francisco, CA: Lyon-Martin Women's Health Services, 2005. Page 16-17. https://www.nickgorton.org</ref> Additional conditions that some clinicians may consider to be contraindications may include breast feeding, active known androgen sensitive breast cancer, or active endometrial cancer.<ref name="gorton 16" /> Conditions that some clinicians may consider to be relative contraindications may include androgen sensitive epilepsy, severe obstructive sleep apnea, severe hypertension due to the salt retaining effects of testosterone, active substance abuse, personal or significant family history of androgen sensitive breast cancer, history of uterine cancer, or bleeding disorders (for injected testosterone only).<ref name="gorton 16" /> Many of these conditions are believed to worsen in response to a normal male level of testosterone, which is sometimes only conjecture based on limited evidence. | |||
=== Finding a doctor === | === Finding a doctor === | ||