Hormone Therapy

[Guest]

Ziggy

In every long term dating relationship I have been in with a LB, I have insisted that - if they are inclined to take hormones - they "do it right' by seeking professional medical assistance and regular follow-up testing

Based on these experiences, it is my estimation that your knowledge in this matter not only meets or exceeds that of every endocrinologist I have personally met, but is very likely equal to that 2% of physicians in the world who have practical experience in transgender HRT

Rather than seeking further knowledge on this board, I would recommend you correspond directly with one of those "2%'ers" (typically surgeons who specialize in SRS or endocrinologists who specialize in transgender HRT) to get your answers

I suspect these MDs would be delighted to discuss these issues with anyone - even with a layperson  - whose knowledge puts them on a par with their own

As you reside in a location where clinical and anecdotal misconceptions abound - with consequential ill effects (both short and long term) for transgendered HRT patients - I suspect they would likely respond favorably to any opportunity to spread correct knowledge, or otherwise help out in any way
Thanks for your questions and your work in this important matter, and good luck in your future efforts

[Guest]

Ok, interesting news, I did just that. I met with the top specialist at Bumrungrad Hospital. While there I also challenged him on something, at which point he phoned up his friend whom he said was the top pre-op hormone specialist in Thailand.

The end result is that they noted that the Western regimen is completely different from the Thai regimen, and they accepted that fact, and basically said they were right. Looking at Thai LBs, I'm tending to agree. Note that the Thai regimen completely disagrees with everything on the internet by foreigners.

Their regimen is:

-Estrogen
-Progesterone
-NO anti-androgens

Reasons are:

-Progesterone keeps the libido up, meaning, their sex drive. With no progesterone, no sex drive.
-Anti-androgens have far too much negative side effects on young people, and he said never, ever
take them

On types of estrogen administration he said:

-Oral
-Patch is totally useless because the dosages are so small you'd have to stick
a minimum of 3 patches on your skin which is both expensive and not so great

While he said several different types are ok, Diane-35, a combined estrogen/progesterone is not a bad choice.

For dosages, he said 'try one 2mg / day, if it works, ok, if not, take 2". That is so typically Thai and probably right!

I forgot to ask about regular blood checks to monitor hormone levels, however, by virtue of the fact he didn't ask us to come back, I presume he thought they were somewhat useless (totally contrary to US view).

He also mentioned that some results from US studies have never been re-confirmed in Thai studies, for example, that estrogen/progesterone cause cardiovascular issues. He said the reasons for different results may be that all Thais are about 14-24 or so, whereas westerners are typically 30-50.

Also, for buying? I asked for prescription. He said no. Go buy it over the counter, it's cheaper.

[Guest]

Way to go, Ziggy!!

Question: Is this true for both pre and post op?

Great work.

Ronin

[rxpharm]

(ziggystardust @ Aug. 17 2006,08:39) Ok, interesting news, I did just that. I met with the top specialist at Bumrungrad Hospital. While there I also challenged him on something, at which point he phoned up his friend whom he said was the top pre-op hormone specialist in Thailand.

The end result is that they noted that the Western regimen is completely different from the Thai regimen, and they accepted that fact, and basically said they were right. Looking at Thai LBs, I'm tending to agree. Note that the Thai regimen completely disagrees with everything on the internet by foreigners.

Their regimen is:

-Estrogen
-Progesterone
-NO anti-androgens

Reasons are:

-Progesterone keeps the libido up, meaning, their sex drive. With no progesterone, no sex drive.
-Anti-androgens have far too much negative side effects on young people, and he said never, ever
take them

On types of estrogen administration he said:

-Oral
-Patch is totally useless because the dosages are so small you'd have to stick
a minimum of 3 patches on your skin which is both expensive and not so great

While he said several different types are ok, Diane-35, a combined estrogen/progesterone is not a bad choice.

For dosages, he said 'try one 2mg / day, if it works, ok, if not, take 2". That is so typically Thai and probably right!

I forgot to ask about regular blood checks to monitor hormone levels, however, by virtue of the fact he didn't ask us to come back, I presume he thought they were somewhat useless (totally contrary to US view).

He also mentioned that some results from US studies have never been re-confirmed in Thai studies, for example, that estrogen/progesterone cause cardiovascular issues. He said the reasons for different results may be that all Thais are about 14-24 or so, whereas westerners are typically 30-50.

Also, for buying? I asked for prescription. He said no. Go buy it over the counter, it's cheaper.

Hi Ziggy, I find the replies from the Bumrumgrad endocrinologist quite interesting! I am a pharmacist and have done quite a bit of reading about hormone use in transgender therapy. I do not claim to be an endocrinologist but I find a few statements he made surprising.

1) Diane-35 is a combination of 0.035 mg of ethinyl estradiol + 2 mg of cyproterone acetate.

Ethinyl estradiol is of course an estrogen.

Cyproterone is a steriodal antiandrogen with weak progestational activity. This results in a partial suppression of pituitary gonadotropin and a decrease in serum testosterone.

The main activity of cyproterone is anti-androgen action - and not progestational. This is the active drug in Androcur an anti-androgen agent used to treat testicular/prostate cancer.

Then he comments take 1x 2mg tablet a day if it works okay, if not take 2 x 2mg tablets a day. Combination tablets like Diane are usually not referred to as a mg strength as it can be confusing. He is probably referring to the cyproterone component.

His comments that anti-androgens have negative side effects on young people surprising as well, since he recommends Diane-35 for treatment. There are cases of successful treatment of young transsexuals in western countries with anti-androgens without negative side effects.

The normal dose for a woman who is using Diane - 35 is 1 tablet a day. For a preop ts, 1 tablet a day is likely not enough to cause much in the way of feminization. When we look at the western protocols ethinyl estradiol is recommended at 100 mcg a day (0.1mg). This would be equivalent to 3 tablets of Diane-35 daily. This would have a significant feminizing effect.

His comments about the patch are also quite surprising. The patch is formulated so that one patch will deliver about the same effect as 0.625 mg of Premarin, 0.035 mg of ethinyl estradiol daily, etc. In addition some patches are formulated in different strengths (25, 50, 100 mcg/day) formulations so it seems he is not familiar in prescribing it. This is not surprising since the patch is not popular in warm climate countries like Thailand.

I also find that he makes no mention of injectable hormone therapy quite surprising as a number of Thai ts I have spoken with use it.

It has been shown that injectable or transdermal female hormone therapy given in bio-equivalent doses to oral have less side effects.

It seems to me that he may not have much experience in treating Thai ts with hormone therapy. This is understandable as most lbs will self treat without spending the time to visit a doctor.

For postop lbs, the dosage of hormones can be reduced to the same amount used to treat post menopausal women, or those who have had hysterectomies.

Preop lbs need to take an amount of hormones that cause feminization while minimizing the risk of overdose side effects such as liver damage, blood clots, etc.

The notion that more female hormones are better prevails among Thai lbs and can cause unfortunate effects.

[Guest]

Ok, I should clarify what he says, vs what I interpreted.

His specialty is post-op. When I introduced May and said she was pre-op, he immediately said, Ok, I have to call my friend to be 100% sure on pre-op.

For the tablets, he did say, try this if not, take more. The 2mg was my ad lib from knowing many estrogens come in those doses.

The Diane-35 having progesterone, mmmm, I frankly forget if he said progesterone or slight anti-angrogen.

For the patch, I also thought he didn't know for sure. He said several times "you'd need to have at least 3 patches" to get the right dosage.

He didn't mention intr-muscular, and this is just something I forgot to ask. Unbelievably, the Anne Lawrence web-site strongly recommends against intra-muscular, which I found amazing.

So, basically, I am confident he was sure on the Thai regimen not agreeing with the Western regimen, and the basic principles of anti-androgens being bad for young ladyboys and progesterone being mandatory for libido (which contradicts all western transgender advice).

On the Climara, I too thought he was unsure of himself despite saying clearly "It's not strong enough".

So, my next stop is his friend, the theoretical "No.1 in Thailand" for pre-ops.

For post-ops he was very, very clear and said no anti-androgens, but you must take estrogens.

[rxpharm]

Ziggy, thanks for clarifying. It makes a bit more sense, but still surprising regarding his comments about anti-androgens causing negative side effects in young people as Diane-35 has an antiandrogen as part of its components.

I do agree with his statement that postop lbs do not have to take anti-androgens, just estrogens. Also looking closely at the Transgender Care website it does not say a postop has to take anti-androgens, it suggests if more feminization is desired taking anti-androgens with the estrogens would be recommended for some postop tgs. While I do not fully understand their reasoning, it may be that suppressing the remaining small androgen production from the adrenal glands assist with greater feminization from the recommended estrogen dose.

I do know a few Thai tgs who use Androcur, but since it is so expensive it is not very common. It seems Diane-35 is one of the most common preparations used, along with Premarin, Progynon (injectable estradiol), and sometimes Proluton (injectable hydroxyprogesterone).

Check your pm for costing of the Climera patch from the Far East Pharmacy on Sukhumvit Road (between Thermae and Robinsons).

[Guest]

Yes, I'm finding that Proluton, Progynon is the most common combination in Thailand.

It is interesting how the Thai LBs talk about the drugs. They have no clue what they are. They just say, as I asked 3 girls tonite, "Take Androcur make face nice, skin nice, still stay horny", "Take proluton, progynon, look like lady", "Take Diane, same-same Proluton/Progynon".

Anne Lawrence and Transgender Zone and Inhouse Drugs all recommend anti-androgens.

I think the anti-androgen in Diane is very small.

I'm a bit lost on why Anne Lawrence is stronly against injectables and Thailand is strongly against patches.

[rxpharm]

Looking closely at the Transsexual Women Resources website (Dr. Anne Lawrence) she writes the reason that IM is not recommended as below:

"Injectable estrogen may cause less clotting tendency than oral estrogen and it is less expensive than transdermal estrogen. However, it requires the use of needles and syringes, and the ability to perform injections; it has a greater tendency to increase serum prolactin levels; and it is often associated with inadvertent or deliberate overdosage. Contrary to the belief of many consumers, there is no credible evidence that injectable estradiol produces superior feminization. I do not recommend the use of injectable estrogen and I no longer prescribe it in my practice"

So her concerns are that a patient requires to use needles, syringes and must find a way to inject it, increased prolactin levels (more risk of lactation for a tg), plus more tendency to overdose.

The concerns about injection may be because of IM injection as opposed to subcutaneous that many insulin dependent diabetics use. Having spoken with a few Thai lbs many of them go to a clinic to have their injection. Very few self inject. This is related to a cost factor - I think it only cost 30 Baht for them to get the injection. In western countries paying a health care professional to inject would cost quite a bit more.

Overdosage of estrogens can happen with oral or the patch as well, so that concern really does not seem valid.

I think the use of higher doses of antiandrogens for the Thai lbs may not be common as I mentioned due to cost. Androcur 50 mg cost 60 Baht a tablet. This is a lot more expensive than Diane-35 which is about 6 Baht a tablet, or Premarin 0.625 mg is 3.75 Baht a tablet. The Climara patch is about 420 Baht for a box of 4 patches. I did not notice the strength on the box, but probably these are the 0.0375 mg/day strength (comes as 0.025, 0.0375, 0.05, 0.06, 0.075 and 0.1 mg per day strengths). I am not sure all these strengths are available in Thailand.

Having spoken with a couple of lbs who have tried Estraderm (another transdermal patch), they said they did not like it since it caused a bit of irritation and sometimes fell off. This is not a surprise since people sweat more in a tropical country like Thailand, plus shower/bathe more. In more temperate countries this is not the case. Of course the patch is more expensive than Progynon/Proluton and the oral estrogens.

I feel the popularity of hormones in Thailand is related to the cost and effectiveness factor. As mentioned before, the problem is most lbs get little or no advice about proper dosing. Many overdose themselves - I have spoken to some lbs who inject Progynon/Proluton 3 times a week - far more than they should. When I advise them it can be done just twice a month, some are incredulous while some give it a try. It is good when they do accept the advice, but difficult when they do not.

Dr. Lawrence's opinion on progesterones is as follows:

"Progestins are most often given in an attempt to increase breast development. Based on limited anecdotal evidence, I think that improved breast development sometimes can occur, but that the effects are usually not very significant. Progestins can also inhibit testosterone production, and are sometimes used for this purpose. I consider progesterone and other progestins to be unnecessary for most patients, and I prescribe them only rarely. "

Progesterone use in Thai lbs does occur if they use Proluton injection. It does not seem common for them to use an oral progesterone. I would be interested to know if the tgs who use Proluton show a more mature breast development than those who use estrogens alone, but I doubt any formal study would be done on this. For example some lbs have much better developed areola and nipples than others, perhaps this might be due to progesterone use.

Hope this may prove useful information.

[Guest]

Dr. Suvit, who is associate professor at John Hopkin's, the guy I talked to, said the progesterone was to maintain (or increase) lipido, no mention of breast development!

However, all that being said, if I look at Thai and Western LBs, its clear the Thai LBs are doing something right, scientifically understood or not. It just might be that, forget theory, the Thais simply have so many LBs who have likely tried everything, that they are now in a rhythm of what works, whereas the Americans are still trying to rationalize results through science.

[Guest]

Basically your body will always try to balance your endocrine system.

You may manipulate your hormone levels up to a certain degree and still benefit (femininity) from it, but after a certain point your body will try to compensate.

How much you can manipulate? Well, that is different for every individual. By some LBs Progesterone and Estrogens make wonders, by others not (since the body will down-regulate Prolactine levels and increase androgenic receptor's sensitivity).

There are no 100% Right Formulas, just guidelines. Most of the actions/interactions of those hormones are still not completely understood by the medical field.
Individual therapy should be INDIVIDUAL, so it should be checked and adjusted accordingly and over the years (what works for a newly TG, might not be the best choice 10 years later).

[Guest]

(ziggystardust @ Aug. 20 2006,01:31) ...However, all that being said, if I look at Thai and Western LBs, its clear the Thai LBs are doing something right, scientifically understood or not. It just might be that, forget theory, the Thais simply have so many LBs who have likely tried everything, that they are now in a rhythm of what works, whereas the Americans are still trying to rationalize results through science.

Genetics!

Generalizing, you may say that Asian males have a different morphology and different genetic characteristics than Western males.
In my opinion, Asians (Thais) have a few advantages that help them become feminine LBs:

- Lower androgenic sensitivity of the body's and facial-hair follicles.

- Different fat and fat-cell metabolism (especially under Estrogen/Progesterone therapy).

- More "female-like" morphology (body shape and proportions)

[Guest]

(ziggystardust @ Aug. 17 2006,09:39) The end result is that they noted that the Western regimen is completely different from the Thai regimen, and they accepted that fact, and basically said they were right. Looking at Thai LBs, I'm tending to agree. Note that the Thai regimen completely disagrees with everything on the internet by foreigners.

Their regimen is:

-Estrogen
-Progesterone
-NO anti-androgens

Reasons are:

-Progesterone keeps the libido up, meaning, their sex drive. With no progesterone, no sex drive.
-Anti-androgens have far too much negative side effects on young people, and he said never, ever
take them

There are several drugs used as Anti-Androgens, they differ in their activity as well as their benefits/side-effects. Extremely simplified:

Cyproterone (Androcur, Diane-35*, Preme*...): is the most commonly used. Normally it€™s well tolerated, side effects are dose-related.

Finasteride (Propecia, Finecia, Proscar,...): used in Western Europe and America for TS/TG therapy. Generally well tolerated and less toxic than Cyproterone on very long term therapies. Relation between dosage and side-effects is less evident than with Cyproterone.

Spironolactone (Aldactone, Jenaspiron,...): is a potassium-sparing diuretic drug that has also anti-androgenic properties. Side effects can be severe and not endocrine-related (as with all potassium-sparing diuretics).


Pre-Operative LB:
Most I know use Cyproterone (2 mg to 12.5 mg a day) combined with Estrogens and Progesterones.
A few friends (Asians) even got great results only using Cyproterone 12.5 mg + Finasteride 2 mg a day, without using any Estrogens.

Post-Operative LB:
In my opinion, anti-androgens should be taken only if REALLY needed = if androgenic effects are a problem or have increased after surgery.


*) Diane-35 and Preme contain also other active ingredients

[Guest]

I've been checking this more. Basically, by far, the dominant drugs used by LBs in Thailand are progynon, poluton. Everything else is a minority and typically used because of an alergic reaction to progynon. In that case they use Diane 35.

No patches are used, and that's what I'm most interested here, i.e., whether those would produce a result or not (the dosage is low). The reason for not using the patch (Climara), is cost, however, I'll try it with May this month.

It is disgusting no studies, nor drugs, have been done on nor created, for TGs.

[Guest]

(ziggystardust @ Jan. 10 2007,00:49) I've been checking this more. Basically, by far, the dominant drugs used by LBs in Thailand are progynon, poluton. Everything else is a minority and typically used because of an alergic reaction to progynon. In that case they use Diane 35.

No patches are used, and that's what I'm most interested here, i.e., whether those would produce a result or not (the dosage is low). The reason for not using the patch (Climara), is cost, however, I'll try it with May this month.

It is disgusting no studies, nor drugs, have been done on nor created, for TGs.

It's not the dosage written on the package that matters, but how good is the bioavailbility (how much of the taken drug actually lands to the desired receptors).

If you ingest a tablet of 2 mg, how much will finally land into your blood and be bioactive?
Same question for a patch, transdermal-gel or injection.

Unfortunately I don't know the pharmacokinetic data of Estradiol (how a drug gets absorbed, used/converted and expelled by the body).

Will try to search it...



Question:
sorry, maybe I missed it in your posts, but why don€™t you simply inject a long-acting Estradiol Ester (example Estradiol Valerate or Estradiol Decanoate)? At the end, the active molecule is EXACTLY the same. This way you can more easily monitor the dosage landing in your body and have more stable blood-levels than with the patches, it€™s cheap, more easy to use (better an injection weekly than the daily patch hassle) and also has less side effects (dermal).

[rxpharm]

The oral bioavailability of estradiol valerate is estimated to be about 10% - as you mentioned due to the extensive first pass effect due to hepatic (liver) metabolism.

Oral bioavailability of 17B estradiol

I found a good article discussing the pharmacokinetics of Estradiol Valerate 2 mg+ Dienogest 2 mg.
Pharmacokinetics of Estradiol Valerate 2mg + Dienogest 2mg

As noted in prior discussions, giving a medication by injection or transdermally changes the bioavailability to almost 100%. This allows for greater effectiveness with the use of lower doses (hence the lower strength of transdermal patches and injections compared to oral preparations).

One of the biggest drawbacks with the transdermal patches, especially in hot countries, is the failure of the patch to adhere for the prescribed length of time. There is a way to counter this by the use of benzoin, as explained in the following article.

Transgender Care - Benzoin

Candyman - you are quite knowledgeable about this - are you a medical professional?