Friday, May 10, 2013

Ch 15: Ready to start Transition? General steps and procedures

    In discussions today now that we have talked about coming out, and what that entails I thought I would talk about the general steps involved in a transition.  Generally speaking someone looking to transition should likely be in counseling for three to six months before being recommended to a endocrinologist.  At which point the individual should discuss the transition process with their PCP and be referred to an endocrinologist if they intend to start hormone therapy.  Now the endocrinologist I went to then wanted me to see an actual psychologist for confirmation, this is not always the case, but in some cases to work with a local doctor they want to make sure you are certain and get a second opinion before you start taking 'drugs' that will alter your mind and body.

   Now it is possible to start or have started the living as a female or male one year requirement, though under insurances sometimes for surgery for FtM they require a twenty-four month period.  Not really sure why the difference in time just that that's what the insurance I have requires for reimbursement.  Personally I have been on hormones now five months, and will likely start being 'full-time' with wig and name change sometime at the beginning of July.  That gives me twelve months plus before my planned surgery in or about September 2014.  Surgery itself can involve facial augmentation, breast implants and the vaginoplasty.  Personally I'm hoping I only need the vaginoplasty.

   Recovery time for surgery is generally a minimum of two weeks before normal tasks can be undertaken and treatment is ongoing for cleanliness and to make sure no complications occur.  At that point the only thing left to do is either hope your hair on your head grows out or continue to wear a wig, and for those who are hairy they may need to have some form of hair removal done to be considered passable.  Name changes and gender change procedures for licenses and birth certificates are different by the laws of each state.

   So, Hormones, most common is some sort of estrogen, estrodial being the most common and some sort of androgen blocker like spironolactone.  The androgen blocker acts to inhibit the release of testosterone to reduce its affects on the body and let the estrogen become the primary hormone in the body.  Now the controversial hormone or one that isn't always used is Progesterone, while some argue that the added breast growth happens naturally and there are no proven additional side affects beyond what estrogen already causes, others believe the risks outweigh the advantages.

   "Background on Normal Natal Female Breast development.

     Soucasaux (2003) provides a useful but brief overview of natal female breast development but there are many more online articles. Natal female breast development starts in female puberty that precedes the start of menstruation (menarche). Natal means that the female designation was determined at birth. Breast development proceeds in 5 anatomical stages know as the Tanner Stages of breast development (Tanner 1981, 2010) based on nipple and breast structure.

     The two primary tissues in the breast that undergo development are the lobular (milk-producing lobes) and ductwork (milk delivery) tissues. Lobes are made up of clusters of acini (from the Latin for berry because of they form clusters like blackberries on a vine) which are the milk-producing structures. The acini are also called alveoli. During Tanner Stages 1-4 breast development and growth is mediated by estrogen and influences primarily the ductwork tissue. Tanner stage 5 extends into early adulthood and may not be completed until pregnancy.
From Soucasaux (2003)

     When menstruation starts (menarche) progesterone begins to surge on a monthly basis and influences development of lobular structures (Brisken 2002). Progesterone is released in the second half of the menstrual cycle from the body and the corpus luteum, the remnant of the follicle that contained the egg released from the ovary; this surge in progesterone prepares the uterine lining for implantation of the embryo and pregnancy. During pregnancy a bigger and longer surge of progesterone completes breast development and greatly increases breast size in preparation for infant nursing," (

   While the risks associated with progesterone can be various in nature and each case should be taken in a case by case basis.  It seems the largely accepted practice is to start on one medicine, monitor the reaction, increase dosage and allow the body to get used to the adjustments slowly.  This allows the doctor to make adjustments as needed and stop the intake of the hormones if something in the process goes wrong or a side affect shows up.

   But once MtF individuals reach a given stage of breast growth where the estrogen isn't going to naturally boost breast growth further the risks of progesterone should be measured against those of implant surgery.  Generally speaking without the science to back it up and with lack of studies on the area there is no proven increased risk beyond the side affects estrogen already causes.  That being said we don't know if it will compound some of the possible risk areas or increase the chances beyond what the estrogen already causes.  In either case there are risks with implant surgeries as well, and personally if I can naturally grow my breasts to a 'normal' size without implants I would rather have that option given to me than be forced to spend a lot of money on a surgery I probably wouldn't need.
     "So should MTF TS take Progesterone as part of HRT? The answer, like a lot of medical decisions, is that endocrinologists and patients should discuss the risks and benefits and make a decision and then to carefully monitor the results. To include progesterone in MTF TS HRT runs the risks of potential serious side effects. To not include progesterone runs the risk of having unsatisfactory breast development that leads to the breast augmentation surgical risks including loss of sensitivity, pain, absorption and encapsulation (Pitanguy, 2007; vanElk, et al. 2009 Kaasa, T. et al. 2010; Araco, A. 2011, Walters, 2012). The 50% risk of needing to have breast augmentation is clearly too high. There is not currently enough information to make these decisions with formal quantified risk assessments because of the dearth of published scientific evidenced-based research. We can, with some certainty, rule out advice to otherwise non-underweight patients to gain weight in order to have bigger breasts because of the well-established risks of being overweight. At the risk of repeating, given the dearth of research results and the resulting unquantified risks, we can conclude with great certainty that MTF TS HRT should not be undertaken without careful monitoring by an endocrinologist experienced in this area.

      Finally, we ought to be researching and considering new, innovative approaches to MTF TS transition such as:
• Should progesterone be given on a menstrual-cycle-like schedule during HRT to mimic natal female development? (I am told some do-it-yourselfers actually use this approach.)
• Should progesterone be given after several years of non-progesterone HRT when estrogen development stops, just as natal female breast development occurs with menstrual and pregnancy progesterone? This would require objective measurement of breast size and growth that is not consistently done at present. Cup size is just too inaccurate. Breast “sizers” (Pitanguy, 2007) or laser metrology may do the trick.
• Should HRT be the initial part of transition? Why not just start with breast augmentation without hormones, followed by Sexual Reconstructive Surgery and then HRT? This would reduce the potential risks from testosterone blockers. (I am told this is compatible with WPATH guidelines and has already been use with some patients.)
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to be continued...
(P.S. sorry for any typos, I'm not proofing these or editing them a lot before posting them for reading, I hope any misstatements or typos are minimal enough that the intended message is still being received.)
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