Throughout this book the word "you" is used only for convenience. Under no circumstances does it imply coercion. All information in this book is given in good faith and is believed to be applicable throughout the UK at the time of publication. The publishers accept no responsibility for the accuracy of the information or for any outcome resulting from its implementation. All trademarks are acknowledged.

IMPORTANT: SOME OF THE INFORMATION ABOUT MEDICATIONS CONTAINED IN THIS BOOKLET HAS BEEN SUPERCEDED SINCE IT WAS WRITTEN IN THE 1990s. PLEASE BE GUIDED BY YOUR MEDICAL SPECIALIST.
HORMONES (TS>F)

INTRODUCTION
Like everything else to do with the condition, HRT dosages in transsexualism have received much discussion but very little tangible research, other than by patients themselves. The information given in this book includes all available, relevant data from the pharmaceutical industry plus data collected from people who take the medications. Where the two do not quite agree, the authors have deferred to the industry where more technical explanations are concerned; where actual effects of the medications are involved, they have deferred to the patients, including themselves.

Care has been taken to exclude old wives tales and information which is really only someone’s private opinion. Where debatable opinion has been included, it has been noted as such.

WHAT ARE HORMONES?
Strictly speaking, a hormone is a compound, not a drug. A drug is a substance which does not occur naturally in the body. No matter what sex one is, the body produces (female) oestrogenic and (male) androgenic hormones, but in each of the sexes the balance between them is different. By administering sex hormones one is not introducing new substances but changing the balance of what already exists.

There are many kinds of hormones other than the sex hormones. Hormones themselves do not have direct effects on the body; they are catalysts (message carriers) which tell the body what to do with itself. They are very important, not least because without them we would not grow, we would not be able to react to emotions including fear and danger, we would not be able to tolerate diseases or varying environments and diets. The list goes on. Insulin and cortisone are well known hormones.

The names of hormones often end with the letters -one (e.g., progesterone, cortisone, testosterone, etc.). Like enzymes, hormones are such a large group of chemicals that they are subdivided into classes, each class being further subdivided into precise types. Technically, no individual substance can be called oestrogen, progestogen or progesterone (etc.) just as there is no individual thing called metal. Strictly, one can speak of oestrogens, but not oestrogen.

It is very important to discuss one’s medical history honestly with the prescribing (preferably consultant) doctor. Each compound has its own peculiarities and so can have different effects on different people.

One myth certainly worthy of demolition is that "people with high blood pressure can not take hormones". In truth, people with uncontrollably high blood pressure would be courting danger to take such medication, but controlled hypertension does not automatically exclude one from taking them. Anyone on hormone replacement therapy (HRT) should have their blood pressure checked by their GP at six monthly intervals.

When the patient displays an element of doubt, rather than solid conviction, about their sexual identity, some doctors initially prescribe a low dose, building up to an optimum dose over a short period if the doubts fade. Starting treatment brings home the reality of what one is doing, and so people with such doubts are sometimes helped by a low dose of oestrogens to make a more definite decision, either way, about their identity.

DEFINITIONS
There are contraindications, special precautions, interactions and adverse reactions listed for most medications. Where HRT is concerned, particularly high dose HRT, these must be noted, understood, and discussed with one’s consultant doctor. The following conventional definitions are used in this discussion.

In each of these definitions, only situations relevant to people born ts>f will be discussed. For example, cervical cancer is not mentioned.

BADGE ENGINEERING
Development of medications is undertaken by pharmaceutical companies who patent them, giving each one a brand name. Research costing £50 - £100 million per medication is not unusual. As this has to be recouped, medications sold under brand names tend to be expensive. When the patent runs out, other companies are allowed to make the same medication under a generic name. Companies may change the recipe of someone else's medication in some minuscule (token) way to enable them to obtain a me-too patent, and a slice of the market.

The brand name is typically a catchy, often meaningless, word invented for the purpose. Generic names are based on the chemical contents of the medication. In the style of Latin plant names, they are self describing (to a chemist) and are precise. Thus, Paramol and co-dydromol are the same thing, Paramol being the brand name and co-dydromol the generic name. Brand names have capital first letters, generic names do not.

Unnecessary concern can arise if a doctor prescribes one thing and the pharmacist seems to dispense something else. The explanation is usually simple. Companies making the identical, generic version of a medication do not have to research it to such an expensive degree as the inventor and so are in a position to sell it more cheaply. On NHS prescriptions, when exact equivalents are available, the cheapest (generic) version might be dispensed, saving the Service vast millions of pounds annually. However, phamacists are not permitted to substitute ‘roughly equivalent’ medication on prescription; the medically active ingredients must be identical to the version on the prescription. In the rare event that a doctor prescribes a medication which is no longer available, the pharmacist contacts the doctor to ask what to substitute.

Generic and branded medications do not always look identical. They may be different colours, different shapes, and come in different packaging; the active ingredients will be the same. This book uses the most commonly used name, regardless of generic or brand. At the first mention of each medication the names of exact equivalents, where available, are given in square brackets.

Important note: Throughout this discussion, where medications are separated by "> OR <", it must NOT be assumed they are equivalent to each other, NOR that they can be casually interchanged without medical guidance. And they should NOT be taken concurrently, unless so prescribed, which is unlikely.

OESTROGENS
In treatment of transsexualism, PREMARIN [conjugated equine oestrogens] and ETHINYL OESTRADIOL are the most commonly prescribed oestrogenic compounds. They are not exact equivalents. Both should not be taken at the same time.

Premarin contains natural oestrogens extracted from PREgnant MARes’ urINe. To prevent stomach irritation it is sugar-coated and should be swallowed whole. It is chemically very close indeed to human oestrogens.

Ethinyl oestradiol is a synthetic oestrogenic substance. Although cheaper than Premarin, it has been alleged to increase the likelihood of liver enzyme abnormalities (W.J. Meyer, et al, University of Texas, and others).

For both Premarin and Ethinyl oestradiol the following apply:

Typical daily dosages:

The synthetic product, Stilboestrol (D.E.S.), used in the past for hormonal sex reassignment, was found to have potentially very dangerous side effects and should NOT now be used for reassignment purposes.

A common side effect of hormone therapy is headaches which paracetomol may not help to lessen, possibly because the pain is chemically induced. The best advice if this occurs severely and too regularly is to try a different oestrogenic compound. Alternatively, taking the medication just before going to sleep can sometimes help, shifting the timing of the headaches. With patience the effect may diminish, then stop.

It is extremely important not to exceed the optimum doses as doing so brings definite risks of life threatening situations. The body can only absorb so much oestrogen in a given period, leaving any surplus free to wander around the circulation causing mischief, possibly leading to deep vein thromboses (DVTs, blood clots), typically in the legs. Pieces of clot can then break off, travelling around the circulatory system until they become trapped in, and block, the finer blood vessels of the lungs, shortening the oxygen supply (causing pulmonary embolism), or the brain (causing CVA -- a stroke). Any severe pains in the calves or chest must be urgently reported to, and investigated by, a doctor. DVT in the leg is such a severe pain that walking becomes difficult, if not impossible. It is a much stronger pain than cramp.
IMAGE: How clots jam the oxygen supply in the blood

Parasuicidees are strongly advised not to overdose any of these medications. The result may not be lethal, nor rapid, but may be extremely painful.

DESIRED EFFECTS OF OESTROGEN THERAPY
There should be some development of breasts, usually over the same period as in a pubescent girl, i.e., roughly three to seven years. The nipples and areola may also increase slightly in size. Bust development depends on compatibility between the person and the compounds they are taking. The bust will seldom grow as it would had one been born fully anatomically female, particularly in older patients just beginning treatment.

In the ts>f child, blocking of masculine puberty by way of drugs helps considerably, but is seldom available.

There is likely to be some rounding of hips and considerable softening of skin tissues. Among the messages carried by oestrogens are instructions to redistribute body fat, and to move and increase minute deposits of water that lie beneath the skin surface (not sloshing lakes) which soften the skin. There are numerous small fatty deposits around the body, some of which are moved to the hips and thighs by oestrogen therapy. Assuming compatibility between patient and pills a feminized body shape results but takes several years to complete, the changes sometimes continuing for some years even after surgery. It is unlikely to replicate what might have been, had the person not been born transsexual, but is better than nothing. Hip shape is large determined by the pelvic bones which no amount of HRT can alter in shape.

Often there is a reduction and softening of body hair. In areas where body hair prevails in both sexes (under arm, eyebrow and pubic areas) it is unlikely to decrease, but may increase. Scalp hair may grow rather more quickly than before, and will become finer and more brittle over a period of several months. Oestrogens are not magical hair restorers. Unfortunately, they cannot bring back a head of hair which has long gone, but they can and often do reactivate those hair follicles which have merely been dormant. They cannot bring dead follicles back to life, but can considerably reduce or stop further scalp hair loss. Oestrogens do not significantly alter facial hair growth.

Wasting of genital tissue is an equivocal subject but to sum up a paragraph in the companion book, SURGERY, "the more (genital tissue) there is for the surgeon to work with, the better the results". This pertains to outer skin only. Preoperatively, reassignment HRT has been said to cause shrinkage of genital tissue. Patients are divided about whether this is true.

To address another dubious matter, it is frequently said that HRT in ts reduces the libido or sex drive. Caution should be exercised because patients have a habit of telling doctors what they think the doctor wants to hear. This is further complicated by ideas expressed in the mass media in the past, when women were not ‘supposed’ to have any sex drive. Like many other women, those born transsexual may only think they’re not supposed to have much of a libido. To add to the confusion one must question whether physical or mental libido is implied. Anecdotal evidence obtained by ts support groups over the years suggests no real change in libido that can definitely be put down to HRT. So much else alters in one’s life. As one researcher eloquently put it, randy cats remain randy cats. In the preoperative patient who has been on HRT for some time, penile erection may become painful, but less frequent, the latter being welcomed by most ts>f patients.

Infertility is another difficult subject. Although general opinion is that irreversible infertility may occur after about a year of oestrogen treatment, this is only general opinion and each patient is different. Such was the case of the unfortunate individual who, having been told HRT ‘definitely’ caused sterility, decided to have one last fling and, despite several years of oestrogen therapy, proved otherwise. Sperm count will be greatly reduced whilst oestrogens are taken but it may not be eliminated. These comments should be noted by those who are not completely certain of their sexual identity who must consider a plethora of what-ifs.

No amount of medication can unbreak the voice, reduce skeletal size nor work overnight miracles. Once formed, the body is not easily be changed. Ironically this has advantages for the younger patient because taking female hormones before puberty will prevent the voice from breaking and will prevent masculinization of the skeleton. Anti-androgens (e.g., Androcur, see later) will also put puberty on hold, but if used alone will not usually cause much physical feminization unless the patient also happens to have a naturally high oestrogen count. In preoperative prepubescent cases, stopping the HRT may well trigger masculine puberty.

The voice breaks at puberty because male hormones (androgens), suddenly being produced then, tell the larynx (voice box) to grow. If the action of these androgens is blocked before puberty, this organ (and the resonant chest cavities) will remain smaller. No known medication can shrink the voice box once it has grown. Surgery to the larynx is possible but difficult, unpredictable, and may make the voice more gruff and less feminine. Regarding the skeleton, during puberty the same male hormones instruct the bones to masculinize after which the bones cannot be un-grown.

A marked decrease in muscle bulk and strength is frequently observed during ts>f HRT, the person soon having approximately the same muscular strength and physical endurance as any other woman of the same age, stature and health. (Causing a vast decline in the amount of androgens in the body, reassignment surgery tends to enhance this feminization still further.) Many ts>f people are born with a female muscle structure and have female strength and endurance naturally, in which case the effects of oestrogens on the muscles may be less noticeable.

There are positive, incidental side effects of taking oestrogens, among the more notable being a possible decreased risk of heart attacks.

OTHER NOTES ABOUT OESTROGEN THERAPY
As the famous saying goes: the impossible we can do overnight, miracles take a little longer. If you were to take your first tablet, peering intensively into a mirror a few hours later, you would not be the first to do so. After about a month of being on a reasonably strong dose, the initial signs of medication should become just perceptible, at least to the person taking them.

It helps to be forewarned that the bust can become very sensitive indeed at this stage. Ts>females already have a marked tendency to considerable nipple sensitivity before any treatment and, initially, oestrogens can make them painful to touch, even by clothing. This intense sensitivity reduces as the body adapts to the situation but if soreness is too great, nipple creams marketed for nursing mothers provide some comfort. These can be bought over the counter at chemists’ and from retailers selling baby feeding bottles.

One result of oestrogen therapy has been described as being like stepping out of a suit of armour. Physical senses are heightened and the sixth sense is reported to become more acute. It can also become easier to cry: a good way of relieving pent-up emotions. Very regularly reported is a sense of well-being, also experienced by menopausal women who are on lower dose HRT. In sex reassignment, HRT has the psychological benefit of being a boost to seeing light at the end of the tunnel with the relief of knowing there is now actually something tangible to hang on in there for. Whether the sense of well being is due to this or biochemical effects on the brain has yet proved impossible to distinguish in both ts and in menopause.

Although more subtle and ill researched, other effects are much reported. Indecisiveness is common during the first two years of treatment; memorising of lists etc. can become difficult, even impossible, offering an explanation of the ‘dizzy blonde’ syndrome. Increased compassion and tenderness have been noted. Observers usually notice the person becoming nicer to live with than before, despite transsexualism being traumatic in the extreme. Probably this is due to better compatibility between the body and the correct hormones, as well as relief of beginning to see some cohesion between body and mind - at last.

Oestrogen therapy can increase the desire for sugar and sweet foods and, even without that, can cause weight gain due to metabolic alterations. Dietary discipline is therefore advised for medical, as well as aesthetic, reasons.

The nails are likely to become more brittle and may yellow slightly. No product has been proven to reduce this brittleness. Nail varnishes containing nylon fibres can reduce nail breakage simply by adding a reinforcing layer to the nails, but have to be applied regularly and may irritate cuticles. Welcome to the world of women.

OESTROGENS ARE NOT THE ONLY FRUIT
There are a number of other compounds and some drugs that can be used to assist the work of oestrogens’ when prescribed in conjunction with them.

Androcur [cyproterone acetate] is an androgen (male hormone) suppressant more commonly used in the treatment of prostatic cancer and to reduce the capacity for penile erection in sex offenders. In all people, male-versus-female hormones is a tug of war. Decreasing the androgens made by the body reduces their opposition to oestrogens and so, in effect, strengthens the latter’s messages to the body. Androcur is known to be very individualistic; it does not suit everyone. If adverse reactions occur, it is generally sensible to suspect it as the cause. Notably, depression, a common side effect, is best tackled by stopping the drug, rather than by prescribing antidepressants. (Other considerations aside, long term antidepressants can themselves have serious side effects which can continue for years after coming off them.)

Since the late 1980s progestogens have been used in conjunction with oestrogens to considerable effect once the person has been on the latter for 18 to 24 months. For the majority of, but by no means all, people, oestrogens would have had their maximum preoperative effect after about two years when a plateau is reached. However, whilst preoperative it is necessary to maintain the dosage to prevent the changes reversing.

At this stage it is often beneficial to introduce progestogens. Caution must be exercised regarding which type is taken as some are derivatives of testosterone and may provoke a completely wrong effect, i.e., physical masculinization. The same comment applies to some combination pills (oestrogens plus progestogens in one tablet) in which the progestogen content is often derived from testosterone. The most suitable progestogens are of the class called progesterones.

Progesterones offer particular benefits. Breast development resulting from oestrogen therapy is predominantly fatty. Progesterones consolidate this adipose tissue, converting it to lactative tissue, also increasing bust size. Thus the bust becomes more natural in shape, weight and bounce, which in turn helps to boost self confidence considerably. All the other positive effects of oestrogens may be boosted by progesterones, which turn the body’s oestrogen receptor sites harder on, making them more sensitive and receptive, overcoming the plateau obstacle. By this method nature is closely followed. Again patience is necessary; none of these changes occur overnight.

Whilst this area of HRT has been poorly researched - other than by ts-born people themselves - it throws important light on the role played by progesterones in all human beings. Text books usually claim this is a role entirely bound up in menstruation and pregnancy; that can only be part of the story when ts>f people, who neither menstruate nor can be pregnant, can be so much physically - and visibly - helped by progesterones.

The following compounds have been used with much success in hormonal reassignment when combined with oestrogens:

Their CONTRAINDICATIONS, SPECIAL PRECAUTIONS, INTERACTIONS, and ADVERSE REACTIONS are broadly the same as those listed for oestrogens (see above).

DIFFERENT METHODS OF ADMINISTRATION
Although the most common means of administration, tablets are not the only method available. Skin patches (Estradiol or Estraderm) have been used with varying success and are thought to have less side effects than tablets. Similar to adhesive plasters in appearance, they deliver the compound into the body whilst largely bypassing the liver, avoiding the risk of damage to that organ. Each patch is applied to a fresh area of (hairless) skin. The claim that patches avoid involving the blood stream is wrong; the blood stream is the main channel around the body. All hormones must travel by it, or go nowhere. An adverse local reaction and/or allergy to the materials from which the patch itself (or its adhesive) is made may occur. This can happen with ordinary adhesive plasters.

Injections and implants have also been employed. HRT implants are capsules inserted under the skin, releasing their dosage slowly. Both these methods are usually avoided in treatment of ts>f as it is difficult to adjust the dose if an adverse reaction occurs. In the case of injections it is impossible.

Despite claims by certain retail outlets, "bust development" creams supposedly based on oestrogens are of no use other than to the profit maker. oestrogens of suitable strength are only available on prescription. Further, development of the bust has to be sanctioned by the pituitary gland which is located not on the surface of the bosom but near the brain, and is accessible only via the blood stream. The theory behind such creams is as sensible as pouring petrol onto the wheels of a vehicle in the hope they will then turn.

Considerable research has been done into the extraction of oestrogen-like substances from herbs (usually certain roots, tubers or rhizomes); the first contraceptive pill owed its origins to the Mexican yam. However, such substances are only like oestrogens, more so under the microscope than in effect on the human body. To sufficiently extract and isolate them from their respective plants requires laboratory equipment and the quantity yielded by each plant is small. To achieve any real feminizing effect from ingesting herbs one would have to swallow so many one would seriously risk poisoning.

COMPATIBILITY
Debate over which compounds were most suitable for use in ts>f hormonal reassignment was once common. The global conclusion was that each person varies considerably from the next in how their body will respond to any chemical (not just sex hormones), and that only trial and error can really find the most suitable medication for anyone. Retrospectively it seems obvious that this should be so; our body’s own hormones largely shape each human both physically and emotionally, and each human is different.

To look at the case of Ms X. Preoperatively, X had been administered Premarin with great success. Fifteen months into treatment she developed a rash. Premarin was replaced by Ethinyl oestradiol at an equivalent dose. Breast tissue then abruptly decreased, loss of scalp hair became evident, as did an increase in body hair not only in greater quantity than, but also in places where it had never been, before. Fatty deposits shifted from her hips and thighs, reappearing on her waist. In short, all the changes reversed, causing great distress.

Some months later, after concluding that the situation was not going to improve, Ethinyl oestradiol was stopped and Premarin was reinstated but this time Provera was also prescribed. Normality returned and the rash stabilised. Provera was enhancing the oestrogens’ performance; by turning the body’s oestrogen receptor sites on harder, it ensured that Premarin was kept busy doing what it was supposed to do, leaving less of it spare to cause rashes.

Whilst still preoperative and remaining on Premarin, Ms X volunteered to swap Provera for Androcur. The previous catastrophe re-established itself, but this time she also became very aggressive where she had never been so before. Androcur usually reduces aggression. It was replaced with Provera and normality was again restored. Interestingly, postoperatively the last vestiges of the rash vanished even before the dosages of the compounds were reduced in the standard postoperative way. Someone else might experience the opposite of these situations. A third person may find little difference between various combinations of hormones.

AGE, METABOLISM, AND WEIGHT
As we age, the way our body functions alters. One of these changes concerns metabolism - the way our body’s processing factories work. Our metabolism gradually slows down, such that as we age, whatever we put into our body takes longer and longer to be used up in some way, or to be expelled as waste.

Unless a person’s metabolism is unusual, this generally applies to all medications, indeed anything ingested, including food. In practice those over about 60 years old may require a smaller dose of a medication in order to achieve a given result than a younger person. Administering the larger dose to an older person may even backfire, particularly with HRT where too much can start to have negative effects (because the body’s reaction to surplus HRT is, ‘what’s all this?’ and it tries to dispose of the substance altogether and can dispose of more than just the surplus).

Too much HRT is dangerous in anyone. How much is ‘too much’ can depend on the patient’s age age. Consider food intake. Regardless of physical activity an older person is more likely to feel full after a smaller meal than a younger person. Conversely, the younger person will need a greater amount of food to provide a given amount of energy. Whose metabolism is therefore more efficient is debatable.

Some medications (anaesthetics being a well known example) can be prescribed according to a person’s weight. Amongst ts support groups there has been some informal discussion about whether this might apply to HRT. Based on a common sense review of who’s taking what, the evidence suggests that in adults there seems to be no correlation between weight and dosage of HRT.

In passing, it is worth noting that long after ts support groups looked into these issues, more and more branches of medicine are now beginning to draw similar conclusions that (as yet inexplicable) individualism applies to all kinds of medication. For example, in chronic rheumatic conditions, basic analgesics have been found to be just as finicky despite the differences between one pill and the next being so slight that no-one yet understands why changing from one to the other can turn debilitation into a reasonably active life. Twenty years ago, any patient saying there was a big difference between supposedly similar medications would have been told it was all in the mind.

HORMONES AND SURGERY
For a simple and very good reason, a surgeon will probably require the patient to be totally clear of all prescribed hormones for six to eight weeks before any surgery takes place. Surgery carries a risk of thrombosis, the risk increasing with the degree of surgery. In plain language, the more major the surgery, the greater the risk. Ts>f sex reassignment surgery is major pelvic surgery.

Although the hospital should take precautions against this risk, it still exists and mixing oestrogens with major surgery definitely invites trouble. If a surgeon tells one to temporarily stop treatment there is no choice other than to comply. A blood test shortly before surgery tells the surgeon what one’s hormone levels are. If the oestrogen count is too high s/he will be perfectly within his/her rights to refuse to operate. This has happened; it is for one’s own, and the surgeon’s, protection.

After being on hormones for some time, to suddenly come straight off them can (but might not) cause problems such as hot flushes, uncharacteristic aggression and/or short temper, and reawakened genitalia, any of which may be evident. This equates to unusually severe premenstrual tension. Although not all patients experience it, it is often more noticeable to observers. Sometimes, a temporary low dose anti-anxiety drug may help, but must not be relied upon. Valerian taken with honey has been found beneficial and is healthier than mind-bending drugs.

Given a choice, it is not a good idea to take high dose HRT and suddenly stop it when reduction of the dose can be taken in steps. Thus someone on three tablets a day could reduce their intake to two a day for a week, then one a day for a week, and finally to one tablet every other day, before stopping them altogether.

NOTE: If a surgeon advises being clear of hormone therapy for eight weeks prior to surgery, this means that any schedule for coming off the treatment must be completed by the beginning of the eighth week before surgery (it generally taking that long for the effects of oestrogens to completely leave the blood stream).

POSTOPERATIVE HORMONE THERAPY
Two or three weeks after mobility is restored following surgery, HRT can be resumed. Postoperatively hormones are just as important as preoperatively, except that Androcur will be of no use since there will be rapidly decreasing amounts of androgens in the system. The HRT dose(s) may safely be reduced over the next two years to a maintenance level.

A rare quirk to be aware of is that, realising androgens are suddenly absent, the pituitary gland (near the brain) may try to instruct the adrenal cortex (of the kidneys) to increase production of androgens. It can succeed for a little while, before taking the hint and allowing oestrogens the majority rule. This quasi rebound effect is not common but may result in an increase of body hair for a short period postoperatively in which case the only concrete advice is to grin and bear it until the body settles down again.

Typical doses for the first post operative year are:

There is no point in continuing Androcur or other androgen suppressants beyond this time, unless specifically prescribed, e.g., for another condition.

After the first post operative year HRT is commonly continued at:

At some time before (approximately) the fifth postoperative year treatment can be further reduced (by taking it on alternate days if lower dose pills are not available). From this time onwards:

should be about right.

Usually one remains on a maintenance dose for life. There are various pros and cons to this. For example, if breast augmentation has been undertaken, little breast reduction may be noticed on cessation of HRT, which is certainly not true for people who have not had breast implants. Stopping HRT usually has menopause-like effects. However, remaining on the preoperative high dose for years is certainly a bad idea because the risks of cardiovascular diseases are linked to time and dosages.

When oestrogens have been taken for a long period, stopping them completely can increase the risk of osteoporosis ("brittle bone disease").

Poorly documented is that continuing hormones postoperatively has been shown to help promote further physical (e.g., bust) development, often very considerably, even years after surgery. However, postoperatively, it is more important than ever to find the lowest dose that will work and, for yet inexplicable reasons, it seems further physical developments are less likely to occur if the preoperative high dose is continued.

Postoperative progestogens are now receiving more study. They continue to have beneficial effects in those who responded to them preoperatively and are usually taken at half or two-thirds of the preoperative dose for the first year or two, and then reduced by as much again a year or two later. By about the fifth to sixth year post op there would appear to be little point in continuing progestogens. Beyond this time, common sense, one’s body, and one’s consultant are the best guides, the ultimate aim being to find the lowest dose(s) necessary to maintain the secondary sexual characteristics.

¡CAUTION!
Adverse effects can occur at any time although most people do not experience major problems, just the common, niggling ones. One side effect which must be watched for is severe pain in the calves which may signal a DVT (deep vein thrombosis, blood clot) which must receive urgent medical attention. Severe pain means what it says, not a twinge, not like a sprain or cramp, and not like muscular rheumatism (see above).

Severe chest pain, alone or with leg pain, may indicate pulmonary embolism - a blood clot in the lung - possibly originating from thrombosis in the leg (see above). Blood clots can also cause a stroke. Severe chest pains must be treated as an emergency and medical assistance must be sought immediately. Again we stress: severe means what it says.

The higher the dose of hormones, the higher the risk of DVT. Its occurrence does not automatically bar HRT in the future, except in certain cases. In the event of a DVT, one would probably be told to stop taking hormones immediately, which is correct. But one might also be told that hormones can never be taken again, which may be incorrect. A regimen would have to be negotiated between the hormone-prescribing consultant doctor, the cardiovascular consultant, and the patient, once the clot has been rectified, assuming it is (blood clots can kill). Whilst it is present, the advice of the physician dealing with it must be followed.

The likelihood of developing thrombosis is linked to obesity, increasing age and physical inactivity. Another factor strongly influencing DVT occurrence is smoking, the risks increasing in proportion to the number of cigarettes smoked. It is wise to make an honest attempt to cut down, if not stop completely.

In the past, peer-group rumour had it that one "should not" tell the consultant about past serious illnesses for fear that not having a life history of a ‘perfect’ bill of health would preclude treatment for transsexualism. This may have been true many years ago but is certainly not true now. The key to any medical treatment is to be honest with the consultant doctor about one’s medical history. Being partly responsible for your well being, the consultant is more likely to question one's suitability for any treatment if one rations the truth about one's medical history.

Provided common sense and care are used, there should be no great risk of dropping dead as a result of hormone therapy, contrary to scare mongering myths. With sensible dosages and no prior cardiovascular disease, the above risks exist, but are not enormous.

Breast cancer can be suffered by full-blooded males who have never even sniffed oestrogens but taking oestrogens is thought by some authorities to slightly increase the risk. Debate on the matter rages around the world since it also pertains to the contraceptive pill taken by millions of women. Any such risk for the person born ts>f is countered by the likely reduction of the risk of prostate cancer (the prostate gland is usually left in situ during SRS).

The risk of breast cancer in sex reassigned women (who were ts>f) compared to other women is hard to comment on as there are thankfully not enough cases in reassigned women to make statistics meaningful. Lumps in the breasts require examination by a GP, may not be painful, and may not be cancer. Most lumps are not cancerous but some are and breast cancer can kill. This HRT risk is small, but exists and monthly self examination for lumps is strongly recommended. It is best to ask one’s GP or his/her nurse to show how and where to check for lumps.

The above warnings ought not be seen as a ticket to hypochondria. Thousands of women around the world, transsexual or not, have been taking these compounds for years with no evidence of the above diseases. Any medication carries risks and it is simply necessary to be forewarned of what to watch out for. It is not necessary to work oneself up into a frazzle if none of the preceding lumps and/or pains are in evidence. Worry can itself cause cardiovascular disease, and stress can increase the risk of cancer developing in anyone.

Risks and problems allied to hormone therapy are directly related to the strength of hormones taken, and the duration of high dose intake. Very high doses taken for life can pose considerable risks. This is one reason why long term high dose HRT without surgery is dangerous, posing potential risks to people who are subjected to unnecessary or experimental delays in being granted reassignment surgery.

All these things must be balanced against alarmingly high suicide statistics which occur in untreated transsexualism. As with any medication, the final word is that it is safer to take too little than too much.

We gratefully acknowledge the kind assistance of Dr Russell Reid, Consultant Psychiatrist, London, in the checking of, and amendments to, the manuscripts for this book.


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