Estrogen: The first medication that most TS people ask for is Estrogen. It is extremely important to clarify some facts about estrogen. First off, simple forms of Estrogen such as 17b estradiol, which is a bioidentical estrogen, meaning it’s the same as that found naturally in the human body, don’t influence the clotting factor significantly. Many doctors will resist prescribing any form of estrogen with the excuse of “estrogen causes clotting”. I suspect this has more to do with traditional forms of estrogen, such as Premarin, taken orally, which does increase clotting and liver stress risks. It is almost as though the doctors refuse to admit there are very significant differences in the forms of estrogen available (from simple/bioidentical molecules to complex forms of estrogen) and the methods of delivery (how the estrogen gets into your body). The more complex the molecule, the more processing it undergoes in the liver, therefore more stress and more risks. Complex estrogen molecules tend to trigger estrogen receptors in the liver more strongly, thus affecting more strongly synthesis of factors and proteins related to clotting. An example of how silly the idea that estrogen always causes deadly clotting is that pregnant females have estrogen levels far in excess of what transsexual women ever achieve, yet they do not suffer unduly from life threatening clots, without other more serious health issues such as obesity, smoking, alcoholism or other medications as the more likely suspects. The reality is that doctors seem to seldom realize that with some research, they could easily learn that estrogen is not as dangerous as they assume, and that the methods of introduction and the complexity of the estrogen are what influence clotting risks. It is important to stress from the start what is meant by bioidentical, natural and synthetic when relating to HRT drugs. A bioidentical estrogen is the molecular form of the estrogen compound that is found naturally in all humans regardless of gender (only the quantities differ between men & women). Natural, refers to estrogen extracted in nature, from living plants or animals. Synthetic refers to compounds such as estrogen, produced from laboratory manipulation of more basic chemicals. Bioidentical estrogens can be made from natural and synthetic sources. Non-bioidentical forms of estrogen are the ones that are molecularly complex and difficult for the body to convert into 17b estradiol or for the liver to process, and may be produced from natural or synthetic sources as well. A bioidentical estrogen is 17B estradiol while non-bioidentical estrogens include ethinyl estrogen (EE) and the equine estrogens found in Premarin. A few of the main estrogen drugs available for HRT are ethinyl estradiol, Premarin, estradiol cypionate, estradiol valerate, 17b estradiol and herbal forms of estrogen also known as phytoestrogens or plant based estrogens. There are other estrogen drugs available that range the spectrum of molecular complexity that I don’t list, as this is a guide, not a compendium. Ethinyl Estradiol (EE) is a very molecularly complex form of estrogen that is very difficult for the liver to process. A simple rule of thumb is that the higher the liver stress, the higher the risk of clotting, the lower the liver stress, the lower the risk of clotting. EE is between 500 and 1500 times more damaging to a person’s liver than Premarin. Premarin is produced by extracting estrogen from the urine of pregnant mares. The horses are often poorly treated and the Premarin production industry has been under fire for this poor treatment of the horses for decades. Some of the estrogens within the drug are not bioidentical for the human body (the molecular forms are not the same as what are found in humans, as they are horse estrogens) and they can be very hard on the liver at roughly 3 to 6 times more damaging to the liver than oral estradiol or estradiol valerate tablets. Premarin is available as a pill, or as a water-based intramuscular daily injection (meaning at least once daily injections are necessary, making it inefficient for feminizing HRT purposes). Estradiol cypionate is a mildly complicated form of estrogen taken via intramuscular injection (IM or IM shot), and doesn’t usually cause much, if any liver stress. EC may cause some liver stress, due to it being slightly more molecularly complex than Estradiol Valerate. Estradiol valerate (EV) is a form of estrogen that the body can convert into estradiol (the same as the estrogen found in humans) fairly easily. It is significantly safer orally than Premarin, as it doesn’t contain substances foreign to the human body and doesn’t stay in the body as long, thus there is less liver exposure that can lead to liver stress. It is even safer taken sublingually and very safe when it is taken by IM shot, provided that basic safe injection practices are followed. 17b estradiol is taken in a tablet form, or transdermally via a gel, cream or patch. The estradiol is already in the 17b form most easily used by the human body, and as such, it is very easy on the liver. Herbal forms of estrogen such as soy and black cohosh are extremely dangerous for HRT purposes. The estrogens in herbal forms, also known as phytoestrogens (plant-based) bind very weakly with estrogen receptor sites at the cellular level, about 1/1000th as strongly as 17B estradiol, reducing the effectiveness of the estrogens. A result is that in order to achieve feminizing effects from herbals, very large quantities are required. The largest problem is not primarily the estrogen in the herbals, as it is from the fillers in the pills. The fillers are molecularly complex and are recognized by the liver as poisons, so the liver stress is increased from the start. The toxic effects of the fillers can be extremely severe, leading to liver stress, failure & in rare cases even death, when taking large feminizing doses of herbal estrogens. Another problem with herbal HRT is that the doses are not regulated, so the daily hormone intake is not the same each day. Some days are high-dose, others low-dose, which can cause moderate to severe mood fluctuations and yet more liver stress. Finally, herbal HRT drugs are very expensive (high cost and large intake) compared to pharmaceutical estrogens, making the cost very high, both for your pocket book and on your body. I personally do not endorse herbal HRT drugs for their negative side effects. The ways that estrogen is introduced to a person’s body, from most stressful to the liver, to the easiest on the liver are as such: Orally: A pill is swallowed. This is hard on the liver, as the first pass effect triggers the liver to try & filter out the estrogen. In lay-terms, the liver sees the estrogen as a poison and tries to remove it while it goes through the digestive tract. Liver metabolizes estrogen as it passes thru the digestive tract. Some of the estrogen in the liver recirculates in the digestive tract where it is further metabolized. This reduces the amount of estrogen, in the form of estradiol, that gets to the cells of the body and increases the stress on the liver. More stress equals more clotting risk and risks of liver toxicity and damage. Sublingually: A pill is dissolved between the cheek & gum or under the tongue, which is the slightly more effective of the 2 choices. Most of the estrogen gets absorbed into the bloodstream, so less is swallowed to put stress on the liver. Certain pills such as Premarin have a reputation of tasting rather bad, depending on the individual taking the drug (some people like the taste). Transdermally: Estrogen is absorbed through the skin, directly into the blood stream through a medium of a patch that is worn for a few days to a week at a time, or a gel or cream that is rubbed onto thin skin (inner thighs, breasts, lower back and tummy) up to several times a day. Patches can cause rashes (from the adhesive used) and gels can be messy and bothersome. Subcutaneously: A trocar (large needle) is used to inject a crystal of estrogen under the skin and the estrogen is released slowly over the course of 3 to 6 months This method provides an estrogen level that is useful for post-menopausal women, but is not useful for feminizing HRT, as the levels remain too steady to promote feminization in transsexual people who become desensitized to the estrogen. Intramuscularly (IM): Estrogen, usually EV or EC is injected into thick muscle tissue, usually in the upper gluteus maximus (the butt) or thigh. The IM estrogens used are suspended in an oil medium, usually sesame or castor oil (BEWARE OF ALLERGY RISKS!) so the estrogen is absorbed over the course of a week to 10 days (EV) or 10 to 14 days (EC). It is important to note that the transdermal, subcutaneous and intramuscular methods of introduction do not significantly influence the liver. The form of estrogen introduced via these methods can damage the liver if it is molecularly complex, such as EE. Another myth about estrogen is that it is a “magic pill”. It is not. Estrogen can feminize a masculinized body (one that has been made masculine from testosterone, usually the way male to female TS people start off) only to a certain extent. It will not change a person’s height, skeletal structure beyond minimal changes, nor will it feminize the voice. Estrogen will not eliminate facial hair, though it will slow its growth. Taking estrogen is not a guarantee that anything will happen either. Sometimes the effects of testosterone are just too pronounced for estrogen therapy to have appreciable physical effects. It won’t turn a 250-pound linebacker into a Cindy Crawford look-alike. Estrogen often does produce feminizing effects though. These may include softer skin, rounding of the hips, breast development (though for full breast development, a progestogen is essential! This will be covered in the chapter on progestogens), scalp hair thickens and the growth rate and volume increases. Estrogen can cause some facial changes as well, making a person appear more feminine. Body hair often decreases in thickness. Only electrolysis or laser treatments can get rid of hair, even semipermanently. Laser treatments may work for those people who happen to have dark hairs & hair follicles, and light or pale complexions, as the laser treatments heat the hair to kill it, and the colours of the hair & skin are key to it’s effectiveness. Estrogen often causes mental changes, such as a TS woman becoming more in touch with her emotions or being able to relate to people and situations in ways that were alien before estrogen therapy. Suffice to say, romantic movies take on a whole new meaning after being on estrogen for a month or 3. Overall the primary goal of feminizing estrogen therapy should be to feminize as fully as possible, while minimizing the risks of side effects such as clotting or DVTs (Deep Vein Thrombosis, a potentially life threatening clot that can severely damage most commonly the lungs, less commonly heart or brain and other organs). The problem for TS women is often reluctance on the part of the physician to prescribe enough estrogen to accomplish the feminizing goals of the patient, or to provide a safer HRT regimen. A post-menopausal woman born female does not need feminizing doses of estrogen, but only enough to ease or eliminate menopausal symptoms and prevent osteoporosis. A TS patient needs higher doses of estrogen, as her goals are completely different than the post-menopausal woman. The TS woman needs estrogen levels that can stimulate feminization. While natal women feminize when they are teenaged girls, teenagers have growth hormones which enhance the effects of estrogen upon their bodies. Since Human Growth Hormone (HGH) is EXTREMELY dangerous and can lead to conditions such as acromegaly (gigantism) and various cancers, it is MUCH safer to increase HRT doses to compensate for the difference to achieve feminization goals. To treat a TS woman with post-menopausal HRT doses is ineffective, and does significant harm to the TS woman, as her full potential cannot be accomplished on the inadequate doses. More simply, menopausal HRT is supplemental HRT. Feminizing HRT is full hormonal replacement and “half-assing it” will not suffice. TS female EV shots (weekly) range an average between 40 to 100 mg/month, and occasionally as high as 160mg/month without clotting problems (note that the injections don’t significantly increase clotting risks) or other significant health risks. It is very rare to find a doctor that is open to prescribing any shots though, as they still work under the impression that it is the estrogen itself that causes clotting risks, and IM shots shoot the bodily estrogen levels very high for a short period after the shot. Some doctors use other excuses to not prescribe shots, including that once in, you cannot get it out (it takes a week or more to metabolize rather than a day), or that it is metabolized too quickly. Since the goal of feminizing HRT requires estrogen, having it in your body isn’t a drawback and weekly shots counter how quickly EV metabolizes. For every excuse why a doctor doesn’t like to prescribe shots, there are several counter arguments that are based on science and common sense on why shots are not the dangerous choice that so many doctors seem to believe they are. Dosing varies from person to person. Numbers are ultimately not reliable in regards to estrogen levels, as some people react well to low doses; others require higher doses in order to attain similar results, regardless of blood estradiol levels. Instead, a more reliable method to determine dosing is by trial & error, starting low, and increasing every few weeks to few months, and then maintaining the dose until development plateaus. Once that occurs, a small increase often can trigger development to continue. This process needs to continue for SEVEN to TEN years for full feminization to occur. While most feminization does normally occur in the first 2 to 3 years, many TS women have significant development right up to the 10-year mark of being on feminizing HRT. Whenever on oral estrogens, liver function tests need to be done at 3, 6 and 12 months unless there seems to be some problem with the test results, or there is a deep chronic pain along the lower edge of the right lower rib. A switch to a more liver-friendly estrogen regimen may ease this discomfort or liver concern significantly. This information is NOT intended as medical advice. It is merely information gathered over several years, regarding the safest and most effective regimens of feminizing hormone replacement therapy, provided so that each individual may approach her own feminizing hormone regimen as educated as possible. Simply put, the author takes no responsibility for the actions or regimens of other people on hormone therapy, as each person must be responsible for her own health. (AKA do what you want with this info, but remember that you are responsible for yourself & should make efforts to confirm any information contained above). Copyright (c) 2005 Leslea Herber. Permission is granted to copy, distribute and/or modify this document under the terms of the GNU Free Documentation License, Version 1.2 or any later version published by the Free Software Foundation; with no Invariant Sections, no Front-Cover Texts, and no Back-Cover Texts. A copy of the license is included in the section entitled "GNU Free Documentation License".