The positive effects of estrogen therapy in patients with M / W-transsexualism include:
- Reduction of hair distribution for the male type. Pubic, armpit, facial hair
become thinner and less pigmented. However, the most resistant to hormone therapy, even in combination with anti-androgens, is facial hair growth, and patients almost always have to resort to additional methods of facial hair removal (epilation, electrolysis). - Breast development. The development and increase in breast size begins in M / F transsexuals almost immediately after the start of estrogen therapy and is most effective at maximal suppression of the level of androgens, which is achieved by a combination of estrogens with antiandrogens. However, breast development after 2 years of continuous estrogen therapy in sufficient doses, as a rule, stops. As a result, breast development is satisfactory in 40-50% of patients, while the remaining 50-60% require additional surgical correction.
- The effect of androgen delivery causes a decrease in the activity of the sebaceous glands of the skin, which becomes smoother, less prone to the formation of acne and acne. Sometimes, however, the skin may become excessively dry.
- There is an increase in the amount of adipose tissue, a decrease in the total muscle mass and redistribution of adipose tissue in the female type.
- 6. 7.
We evaluated the effect of cyproterone acetate therapy on hair growth rate. Permanent efficacy of treatment, expressed in the cessation of hair growth on the face, torso and limbs, was achieved only by 6-7 months. treatment with a dose of cyproterone acetate of at least 50 mg / day and only in 80% of patients. In 20% of patients we did not manage to completely stop hair growth, although we observed its slowing down. These patients had to apply electrolysis. At lower doses, less than 50 mg / day, hair growth can resume.
In patients before the surgical correction of the genitals that do not receive Cyproterone Acetate, we were not able to achieve good results in stopping the growth of hair, especially on the face.
We also noted the dependence of the effect of therapy on the age of patients: the older the age, the more difficult it is to achieve a good feminizing effect, even using fairly high doses of estrogen. So, if estrogen therapy is started at the age of 19-20, after 3 months already. you can observe the growth of the mammary glands, after 4 months. the structure of the hair on the arms, legs, torso, face significantly changes and their growth decreases (they become quite soft, thin), and if the treatment is started after 35 years, then it is almost impossible to cope with the growth of hair on the face, all patients have to use electro-epilation. Rarely enough, patients of this group can achieve significant growth of the mammary glands, so they often use endoprosthetics.
Decreased testicular size. The disappearance of erections.
Psychological effect – under the influence of estrogen therapy, the mind becomes calmer, the aggressiveness decreases.
Side effects of estrogen therapy
1. Hyperprolactinemia.
It is known that estrogens (both exogenous and endogenous) increase the synthesis and release of prolactin, cause proliferation of pituitary lactotrophs, and also reduce the inhibitory effect of dopamine on lactotrophs. We evaluated the effect of the dose of estrogen administered (all patients included in this group received ethinyl estradiol) in patients before and after the surgical correction of the genitals to the level of serum prolactin.
There is a dose-dependent effect of the effect of estrogen levels in plasma on the level of prolactin, which requires the appointment of estrogens in the lowest possible doses.
Excessive doses of estrogen not only cause hyperprolactinemia, but can also lead to the development of drug lactorrhea and pituitary adenoma.
Here is the observation of the development of drug lactorrhea with a jet separation of milk in quantities sufficient to feed the adopted child.
Patient P. was born normal, full-term boy. He remembers well from 6 years. Early development without features, did not differ from peers, but loved to play more with girls. He played with dolls, cars. With 10 years, there was a desire to wear women’s clothes. From the age of 12 I swam with girls in a T-shirt and shorts, because I was embarrassed by the lack of mammary glands. From the age of 14 he changed clothes in his mother’s dress and only in such clothes “felt like a man”. From the same age in a women’s dress went to get acquainted with the young men, got pleasure from it. At the age of 15, he came to the firm conviction that he was a girl, he began to urinate like a girl, squatting, painted his lips, powdered. He suffered greatly from the presence of “deformity” – the male genital organs. At the age of 17, while working as a nurse at a hospital, he began to do this independentlyinjections of folliculin and progesterone, which caused the development of the mammary glands. He enjoyed doing women’s housework, loved to mess with children. Having received a passport, he redid it on the female, thus finding a female civilian gender. Twice he tried to commit suicide (he took sleeping pills), since he could not endure the duality of his existence. Twice he was treated in psychiatric hospitals for transsexualism, unsuccessfully. When examined at the ESC of the Russian Academy of Medical Sciences at the age of 20 years, no abnormalities in somatic status were identified: complex as a man, male genitals, shave from 17 years of age. Erotic dreams are frequent, in them the patient plays the role of a woman, denies watering and masturbation. In the study of ejaculate determined oligoastenozoospermia. Sex chromatin is negative. At the age of 22, a course of treatment with cyproterone acetate was given to the patient at the Institute of Psychiatry of the Ministry of Health of the RSFSR. It was noted muscle weakness, reduction of sexual hairiness, the appearance of colostrum.
When examined at 23 years old, the mammary glands correspond to the age of 15-16 years (on their own initiative, they constantly take estrogens), colostrum is secreted from the nipples (abundant drops when pressed – lactorrhea ++). He insists on castration and amputation of the penis, since being a “woman”, he is ashamed of the inappropriate sex – “deformity”. On the roentgenogram of the skull, the shape and dimensions of the Turkish saddle are not changed, signs of increased intracranial pressure are revealed. On the EEG against the background of general phenomena of irritation, the focus of pathology is recorded in the left parietal lead. In the study by the radioimmunoassay method using standard serotype kits from the firm Opp, an increase in the level of prolactin to 24 ng / ml was detected (the norm for men is 4-15 ng / ml). Due to repeated suicidal attempts, the failure of psychiatric treatment, and also considering that the patient has a female civilian sex and the patient is adapted to the female social role, in 27 years the patient was subjected to castration and feminizing plastics of the external genitalia. Some time after the operation, the patient developed an interest in life. After the surgical and hormonal correction, the maternity instinct developed irresistibly. Unmarried, the patient achieved permission to adopt a child, simulated pregnancy, was discharged from a maternity hospital with her son. From the very first days after the “birth” lactation sharply increased, a jet branch of milk appeared, lactorrhea. The baby was breastfed up to 6 months of age.
This observation demonstrates the independence of the lactation development mechanism from the genetic sex and the need for careful monitoring of prescribed estrogen therapy.
We also found a correlation between the increase in prolactin level and the age of initiation of sex hormone treatment. In patients who began treatment before the age of 25, the level of prolactin is significantly lower. As can be seen from the graph, the older the start of estrogen treatment is, the higher the risk of an increase in serum prolactin levels. This dependence is probably associated with the depletion of the functional reserves of the body, aimed at maintaining the homeostasis of the body in general and hormonal homeostasis in particular. Studies have also shown an increase in the age-related excitability of the hypothalamus, which notes that homeostatic adaptive mechanisms can be disturbed both in diseases of the central nervous system and the endocrine system, and inevitable with aging of the body.
In our patients, we observed hyperprolactinemia in 54.2% of cases, all of these patients started estrogen therapy after 25 years. In 1 patient, the development of drug lactorrhea was observed in patients receiving 300 μg microfollin per day. The development of a pituitary adenoma (confirmed by computed tomography (CT) scan of the brain) was observed in another patient on the background of a long independent uncontrolled intake of excessive doses of estrogen drugs (more than 300 micrograms of ethinyl estradiol per day).
- Venous thrombosis and thromboembolism.
Cases of venous thrombosis in 2-6% M / W-transsexuals receiving ethinyl estradiol have been reported in the literature, and in vitro studies have shown that this thrombogenic effect is typical for oral ethinyl estradiol preparations and is not related to oral 17-B- preparations. estradiol valerate or transdermal forms of estrogen.
In the literature there are single descriptions of the occurrence of pulmonary thromboembolism, cerebral thrombosis.
In 2 patients on the background of uncontrolled intake of drugs (up to 5 tablets of biseurin per day, which corresponds to 250 μg of ethinyl estradiol), we observed the development of lower extremity thrombophlebitis (both patients smoked more than 10 cigarettes per day, and smoking is a risk factor for cardiovascular diseases when taking estrogen - drugs), which required a break in the reception of estrogenic drugs and the appointment of additional treatment, including antibiotic therapy, antiplatelet therapy.
The effect of estrogen on the prostate gland.
As you know, the volume of the prostate gland is reduced by the action of estrogen. In some cases, atrophy of the prostate during estrogen therapy can lead to urine leakage and painful urination.
In the literature, isolated cases of prostate cancer have been reported in M / F-transsexuals, and in all cases the age of patients upon detection of cancer was more than 50 years, in addition, estrogen therapy was also started after 50 years. Epidemiological studies have shown that castration before the age of 40 years is a factor preventing the development of prostate cancer, and the above-mentioned cases do not contradict this statement.
The effect of estrogen on liver function.
The literature reports a transient increase in liver enzyme activity under the action of estrogen.
The hepatotoxic effect of estrogens is also mentioned, although there is still not enough data to draw conclusions about their effects on the liver. Estrogens are supposed to be non-toxic to liver parenchymal cells, but they change their permeability with delayed bound bilirubin and bromsulfoftaleina.
We evaluated the effect of long-term estrogen therapy on liver function and did not find significant deviations of the estimated parameters (ALT, AST, alkaline phosphatase, total bilirubin) in patients receiving and not receiving estrogen therapy.
We summarized the possible side effects of estrogen replacement therapy (literature data and our own observations) negative effects can be observed not only with an excess of estrogens, but also with their lack, which is especially important in the postoperative period.
In addition, we noted that the possible side effects are directly dependent on the dose of the received estrogenic drug. We analyzed their frequency of occurrence. The analysis group included 50 patients, among whom 30 patients received 60 μg of ethinyl estradiol per day or more, 15 patients — 30 μg, and 5 patients — less than 30 μg. The data obtained are given in table. 14.
We did not observe such side effects that can occur with excessive estrogen consumption, such as thromboembolic complications and myocardial infarction, although this does not exclude their possibility. When they occurred, patients could be observed in specialized hospitals, which we may not know.
Treatment of cyproterone acetate.
There are ambiguous judgments in the literature regarding the effect of cyproterone acetate on the adrenal cortex. In laboratory animals, it causes atrophy of the adrenal cortex and, in high doses, inhibits the secretion of adrenocorticotropic hormone and cortisol in children with premature sexual development. Some authors note the same suppression in adults, others did not reveal such a decline.
To assess the effect of cyproterone acetate on the adrenal cortex in patients with M / G-transsexualism, we compared the levels of cortisol and 17-OHP in people receiving estrogen alone (group 1) and in patients receiving combined estrogen therapy with cyproterone acetate (group 2 ), and also not receiving hormonal therapy. We found no significant differences in the levels of cortisol and 17-OHP, reflecting the functional state of the adrenal glands, in patients with M / F-transsexualism, receiving combined estrogen therapy with cyproterone acetate, receiving only estrogen and not receiving hormonal therapy. The average values of cortisol and 17-OHP in all groups were within the normal range.
There are controversies in the literature regarding the side effects of cyproterone acetate. However, in our studies, side effects were noted in single cases or not at all.