Transitioning 101 - HRT

For the vast majority of those who have or who plan to transition, Hormone Replacement Therapy or HRT for short, is an important goal and as such I felt it a good subject to add to this little series of posts.  For those that aren't familiar with what HRT is, there are tons of sites on the Internet that can explain it far better than I ever could here; but in simple terms for someone like myself who is a MtF it basically comes down to taking medication to suppress the testosterone that my bodily naturally produced while also introducing Estrogen (and in some cases other things) into my system.  As I said that's a very simplistic view of HRT and only from a MtF perspective, but for my purposes here I believe it will suffice.  As I only have experience from the MtF perspective this post will focus on that, though those going through a FtM transition also can undertake HRT as well with the focus on introducing testosterone into their systems.

Basically there are three ways to obtain HRT for the purpose of transitioning:

• Via the WPATH Standards Of Care (SOC).  This entails following the process that is outlined in the WPATH SOC which normally means obtaining an authorization letter from an appropriate mental health professional as a first step.  Upon obtaining that letter, the next step would be a visit to a medical professional, who can prescribe the appropriate medications and monitor the patients blood work at regular intervals.  This is generally done by an Endocrinologist, though other types of Doctors can do it such as in my case where a GP handles mine.

• Via "Informed Consent (IC)".  This process does not require following the WPATH SOC, instead it relies upon the individual to acknowledge the potential risks/benefits of the treatment.  As such it does not require any authorization from a mental health professional.  Rather it only requires a medical professional who is willing to follow the IC model.  Beyond that the process is generally the same, they prescribe appropriate medications and monitor blood work in generally the same manner as above.

• Via Self-Medication (DIY).  This process generally does not rely on medical professionals at all; though some will have their blood work done either independently or via their GP or other medical professional.  It does rely on obtaining the desired medication without a prescription which generally means having to order it from somewhere outside of the United States.  As a side note, it's my *understanding* that this isn't really an option for FtM transitioners (at least in the United States) as Testosterone is a controlled substance.

Each of these methods has their supporters as well as their detractors.  When I first was thinking about transitioning I looked into HRT quite a bit as it was something I wasn't very familiar with.  I gave each of those options plenty of thought and consideration.  For me personally I settled on the first (WPATH SOC) option above for reasons I'll get to later; but for now I thought I'd share my initial thoughts on each.  Please keep in mind that the thoughts below are *my own personal thoughts* - as best as I can recall them from nearly three years ago.  I'm not saying my thoughts are right for everybody, or even anybody, but they are what I thought at the time.

• The WPATH SOC route.  My first thoughts on this were that I didn't like it.  I'd never really been a proponent of "therapy" - I was raised to "handle my own problems" - so that was an immediate turn off.  Further more I wasn't really keen on having to justify myself to someone to be able to start HRT.  However, since I knew I did want to pursue SRS at some point and there were no surgeons (at least none that I can find) that would perform that without following the WPATH SOC, I felt that going this route for HRT might be beneficial.

• The IC route.  This actually held the most appeal to me; however, finding a Doctor who would do HRT via IC in this area did not seem like an easy task.  I did search a fair amount and the closest I came up with was several hours away in another state.  Additionally based upon my desire for SRS that I mentioned above, it made this option less attractive to me than the WPATH route.

• The DIY route.  The truth is that I never seriously considered this.  I saw many people who swore by it, no therapists to deal with, often no Doctors to deal with, and so on.  However, I also saw plenty of people having trouble getting and/or refilling their medications; and the fact that I was on other medicines further concerned me.  I never really gave this option serious consideration.

I put a lot of thought into those options and talked them over quite a bit with J as well.  We finally decided that since I did want to pursue SRS that the WPATH SOC option was what I should pursue.

Looking back nearly three years from when I made that decision I don't have a problem with the one I chose as I do still want SRS, though the timetable for that has been pushed back a bit further than we initially thought for various reasons.  And despite my prior aversion to therapy, I've been quite happy with the therapist I've chosen and I believe that was beneficial to me for many reasons.  I do now also believe that I could have been successful on the IC route.  However, I still think my decision was right for *ME* as like I said I'm happy with my therapist and I'm incredibly happy with the Doctor supervising my HRT and had if I had gone the IC route I wouldn't be dealing with either of them - not to mention the distance I'd have to travel to have arranged that.  I also still stand by the fact that I feel DIY was not for me.  I'm not going to disparage it, as for some it's their best and/or only option; though I do recommend for those that go the DIY route that if at all possible they still get their blood work checked as while they appear to be rare, there are potential issues with HRT.  This is a fact that I'm painfully aware of as even though my blood work is regularly monitored I did spend time in an emergency room and subsequently the hospital with an issue that was related to my HRT (though there were other medications that also contributed to things).

With that out of the way I'm going to talk about the medications I'm personally familiar with:

• Spironolactone - Which was used to reduce my testosterone levels.

• Estradiol - Which was used to increase my estrogen levels.

• Progesterone - Which in theory *may* help with breast development

I was on Spironolactone for approximately 15 months, starting at 50mg and ending at 200mg.  I say ending as once I had my Orchiectomy I no longer needed to take the medication.  I am still currently taking Estradiol and because of the aforementioned procedure (not to mention when I finally have SRS) I will do so indefinitely.  For the Estradiol I've been on it 29 months now.  I was started on 2mg, and worked up to my current 6mg; though pending my next blood work and visit with my HRT Doctor we may adjust that down to 4mg as my levels were a little higher than she would like at my last visit.  The last medication I listed - Progesterone - is something that I've only been on for the last 3 months.  I had read about it but as my Doctor had never brought it up and I hadn't found any conclusive data one way or the other on it's effectiveness, I had not broached it myself.  However, at my last visit in February, she did offer to put me on it and I decided to give it a try to see what (if anything) it might do for my breasts.  My dosage is 5mg, though unlike the other medications I've mentioned, that's not daily.  I'm currently on a 10 day on, 20 day off, cycle with it.  Now the medicines I'm on, much less their dosages may well likely vary from whatever anyone reading this may be on.  HRT is not a cookie cutter process.  There are lots of things that factor into it and plenty of different ways to handle it.  So anyone/everyone else's mileage may definitely vary.  Additionally, my initial dosages may seem overly low, and for many they are.  My HRT Doctor elected to start me on HRT at my first visit, but we agreed that we'd start with those low dosages to see how my body reacted, especially considering my other medications.  At my next visit (3 months later) after confirming my blood work looked good, my dosages were upped (100mg Spironolactone / 3mg Estradiol) and then later on they were upped again (200mg/4mg) and finally to (200mg/6mg).

That being said I thought I'd share some observations on each medication I've used.  Again, these are simply *my* observations, nothing more.  Each person's experience may well differ.

• Spironolactone (Spiro going forward as I'm tired of typing the whole name) - The dosages I was on - at least once I hit the 3 month mark of HRT and my initial dosages were upped - well they did the trick.  The "issue" I had with it was simply the fact that Spiro is a diuretic and considering I was already on a diuretic for my blood pressure, I spent *a lot* of time in the bathroom.  As such I was careful as to when I took it as I didn't want to be out shopping and have to make constant restroom stops, especially since at the time I wasn't really comfortable in the ladies room yet.  And yes I did broach the fact that perhaps I didn't need the blood pressure diuretic since I was on the Spiro, but my HRT Doctor really didn't want to pull me off of something she didn't prescribe in the first place; and my regular GP felt that they were enough different that I should stay on both.  Eventually I actually did end up off of both as I no longer needed Spiro, and after my aforementioned ER/Hospital visit it was determined that my blood pressure was under enough control that I no longer needed to be on that medication either.

• Estradiol - I didn't see many visible changes at the 2mg dosage; though perhaps part of that was that my Spiro dosage was also low at the time.  However, as the dosages went up I did start seeing changes such as breast growth, skin softening, and my body hair thinned out.  I haven't really seen much fat redistribution - perhaps it's my age, perhaps it's the fact that I've been actively losing weight, I don't know, but it's not the end of the world.  I will note that originally I simply swallowed the pills, but at some point - probably around the 4mg dosage - I started dissolving the pills under my tongue (sublingual) in lieu of swallowing them.  I have no way of knowing if this had any impact on the changes I noticed or if it was simply the dosage change; but either way I was happy with the way things going so I continue to take the medicine in that manner.

• Progesterone - This is a tough one to quantify as I've only been on it for three cycles.  I will say that J calls them my "c*nt pills" as she says they make me incredibly moody.  I personally don't see it, so I'm not sure if it's coincidence, if she's exaggerating, or if it's true as I have read accounts that back the moodiness up.  As far as results go, I do believe it is helping, but what I'm seeing may well be "in my mind" or even if things have improved with regards to my breast development, perhaps it's simply the Estradiol, I have no real way of knowing as of now.  Pending my next visit (which is actually today), I would like to continue on this medication for at least another three month set of cycles to see what happens.  

So that's my "experience" with HRT and the particular medications I'm on or have been on.  With that being said I do want to reiterate something that I actually dedicated a topic (well "half a topic") to on last February.  Specifically, about HRT NOT being "Magic".  What's below is an excerpt from that post that I still believe to be relevant some 15 months later:

That brings me to HRT.  Am I glad I'm on it?  By all means.  Have I seen the progress that some have?  Not even close.  Yes I've seen some progress, I have some breast growth, my skin is softer, and so on; but it hasn't done for me what it does for some.  However, even if it had - it's not some magic thing that will suddenly make you feel better.  HRT can make all the changes in the world, but if you don't work on your appearance, your voice, your mannerisms, etc., you still won't pass any better than you did pre-HRT.  And from a mental perspective you may feel better in that you're actually pursuing transition which may make you feel better mentally and possibly emotionally I suppose.  But again if you are making statements to the effect that if I can't get on HRT NOW I might end my life - well then I question if you really belong on HRT in the first place.  If you're in that kind of mental state, I just don't know that bringing hormones to the party is the right thing to do.  It especially bothers me when very young people make those kinds of statements - yes I understand that the younger you start the more changes you MAY see.  But I've seen plenty of older people who have done just fine.  I like to think my transition is going well and I'm in my 40's.  

There was more to the post than what is above - the full post is HERE for those that care, but the point I wanted to make is that while I do believe that HRT is an important component to transition, it is simply a component.  There are many other things that contribute to how successful (or not) a transition is.  I see far too many people that seem to honestly believe that they are going to get on HRT and suddenly everything will be rainbows and unicorns for them.  To paraphrase a commercial - "that's not how this works, that's not how any of this works".  And while I believe there are exceptions to what I'm about to say, I feel for the most part it's accurate.  A lot of people that do believe that HRT is the end-all, be-all, to their transition point to "transition timelines" that have been posted to make their point.  What I feel they are missing is that the vast majority of those timelines are NOT an apples to apples comparison.  There are often differences (and these mostly apply for MtF transitioners) such as:

• Lighting and angle of the photo - usually it's better in the later photos.

• Makeup.  It may be non-existent in the original/early photo(s), and it may be present in the later photos.  And even if it is present early on, it's often more expertly applied in the later photos.

• Hair.  Often hair has been grown/cut and/or styled in a more feminine way, or in the case of people such as myself the before was a balding photo and the after is a wig.

• Eyebrows.  This can be a big one as often in early photos eyebrows are unkept, bushy, etc.  In later photos they often have been waxed or threaded and generally look nicer.  It's amazing how much impact something as seemingly minor as eyebrows can make on a photo.

• Clothing.  Often there is a significant difference in the outfits in the early versus later photos and again this can make a huge difference.

I don't think I've ever seen a set of before/after photos that showed "huge" changes that didn't include one or more of the above points.  I'm not saying they don't exist, I'm sure there are "exceptions" out there, likely those who started HRT *very early*, but for most of us I don't believe that to be the case.

Don't get me wrong, I'm a firm believer in HRT, but only as a *part* of a transition and not as the one single key thing - I don't believe there is one single key thing that makes or breaks a transition, but that's simply my opinion.

With that I think I'll wrap up, I've got to get ready to go see my HRT Doctor, the appointment is still a few hours away, but to quote Baymax from Big Hero 6 - "I am not fast".  Plus she's 90 minutes from here so I need to get going.  

- M