Hormone replacement therapy (male-to-female) – Wikipedia …

Hormone replacement therapy of the male-to-female type (MTF HRT) is a type of hormone replacement therapy for transgender and transsexual people. It changes the balance of sex hormones in the body. Some intersex people also receive HRT, either starting in childhood to confirm the assigned sex, or later, if this assignment has proven to be incorrect.

Its purpose is to cause the development of the secondary sex characteristics of the desired sex. It cannot undo many of the changes produced by the first natural occurring puberty, which may necessitate surgery and/or epilation (see below).

The requirements for hormone replacement therapy vary immensely, often psychological counseling is required.

Under WPATH guidelines the Mental Health Provider requires individuals to satisfy two sets of criteria eligibility and readiness to undertake any stage of transition including hormone replacement therapy. Eligibility involves the patient meeting requirements from a major diagnostic tool, such as the ICD-10, DSM-IV-R or the DSM-V. ICD-10 requirements are for either Transsexualism or Gender identity disorder of childhood.[1]

The ICD-10 criteria for Transsexualism include the individual having a transsexual identity of over 2 years, a strong and persistent desire to live as a member of the opposite sex, usually accompanied by the desire to make their body as congruent as possible with the preferred sex through surgery and hormone treatments. These individuals cannot be diagnosed with Transsexualism if it is believed to be a result of another mental disorder, or a genetic, intersex or chromosomal abnormality.

The ICD-10 criteria for Gender identity disorder of childhood in males include the individual being pre-pubescent and having intense and persistent distress about being a boy. The distress must be present for at least six months. The child must either:

The DSM-IV-R criteria for Gender Identity Disorder includes four main criteria. The DSM-IV-R also requests that the individual's sexuality is noted.

In children this may be demonstrated by them meeting four or more of the following criteria:

Adolescents and Adults must display a persistent desire to be the other sex, frequent passing as the other sex, desire to live or be treated as the other sex, or the conviction that they have the typical feelings and reactions of the other sex.

In boys this may manifest as an assertion that their penis or testes are disgusting or will disappear, or asserting that it is better not to have a penis.

In adults and adolescents this manifests as a preoccupation with removing primary or secondary sex characteristics, such as a demand for surgery or hormone replacement therapy.

The DSM-V moves from Gender Identity Disorder to Gender Dysphoria to avoid the implication that gender nonconformity is in itself a mental disorder, but a similar entry remains in the DSM-V so that individuals may still seek treatment.[2] The DSM-V, unlike the DSM-IV and ICD-10, separates Gender Dysphoria from sexual paraphilias, and diagnoses on the basis of a strong desire that one has feelings and convictions typical of the other sex, or that one strongly desires to be treated as the other sex or be rid of one's sex characteristics.

The readability of patients to transition is also relevant to undertake hormone replacement therapy, which includes the patient's likelihood to take hormones in a responsible manner, have made progress in mastering other identified problems that leads to improving or continuing stable mental health, and have had further consolidation of gender identity during psychotherapy or Real Life Experience of their desired gender role.[3]

Some organizations still require a period of time living as the desired gender role, based on standards such as the Standards of Care for the Health of Transsexual, Transgender, and Gender Nonconforming People (WPATH). This period is sometimes called the Real Life Experience (RLE). The Endocrine Society in 2009 specified that individuals should either have a documented 3 months Real Life Experience or a period of psychotherapy of length specified by the mental health provider, usually a minimum of 3 months.[3]

Some people, especially individuals from the transgender community, say that RLE is psychologically harmful and is a form of "gatekeeping" effectively barring people from transitioning for as long as possible, if not permanently.[who?]

Some individuals choose to self-administer their medication ("do-it-yourself"), often because available doctors have too little experience in this matter, or no doctor is available in the first place. Sometimes, trans persons choose to self-administer because their doctor will not prescribe hormones without a letter from the patient's therapist stating that the patient meets the diagnostic criteria for GID and is making an informed decision to transition. Many therapists require at least three months of continuous psychotherapy and/or a real life test in order to write such a letter as is suggested in the HBIGDA Standards of Care. As many individuals must pay for evaluation and care out-of-pocket, expense can also be prohibitive to pursuing such therapy.

However, self-administration of certain medications (namely ethinyl estradiol) and antiandrogens (namely spironolactone, cyproterone acetate, flutamide, and nilutamide) is potentially dangerous and can cause an elevation in liver enzymes or other potentially dangerous adverse effects.[4]

For trans women, taking estrogens causes, among other changes:

For male-to-female transgender people, HRT often includes antiandrogens in addition to the estrogens and progestogens mentioned above.

HRT does not usually cause facial hair growth to be impeded or the voice to change.

The psychological changes are harder to define, because HRT is usually the first physical action that takes place when transitioning and the act itself of beginning HRT has a significant psychological effect, which is difficult to distinguish from hormonally induced changes.

However, a problem may arise with the structure of hip bones, since cisgender women generally have larger hip bones to accommodate pregnancy.

During HRT, especially in the early stages of treatment, blood work should be consistently done to assess hormone levels and liver function. It is suggested by Endocrine Society that individuals have blood tests every 3 months in the first year of hormone replacement therapy for estradiol and testosterone and monitor spironolactone, if used, every 23 months in the first year.[3]

The optimal ranges listed for estrogen only apply to individuals taking bioidentical hormones (i.e., estradiol, including esters) and do not apply to those taking synthetic or other non-bioidentical preparations (e.g., ethinyl estradiol or conjugated equine estrogens (Premarin)). While the ranges given are optimal, the Endocrine Society further state that estrogen levels of 200pg/ml ought not to be exceeded.[80]

There should also be medical monitoring, including complete blood counts, renal and liver function, lipid and glucose metabolism, as well as monitoring prolactin levels, body weight and blood pressure.[81]

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