The Chemistry of Mood, Motivation, and Memory

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    HRT Self-Medication: Information Accuracy and Risks of HRT See Details



    Introduction
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    The ideal dosage of cross-sex hormones remains unknown. The aim of this study was to evaluate the luteinizing hormone, follicle-stimulating hormone, testosterone, estradiol and prolactin levels after low-dose estrogen therapy with or without cyproterone acetate in transgender dosis. The serum hormone and biochemical profiles of 51 transgender women were evaluated before gonadectomy.

    Hormone therapy consisted of conjugated equine estrogen alone or combined with cyproterone acetate. The daily dose of conjugated equine estrogen was 0.

    Estrogen-only therapy reduced the testosterone, luteinizing hormone and follicle-stimulating hormone levels from The serum levels of luteinizing hormone, follicle-stimulating hormone, testosterone, estradiol and prolactin in the patients treated with estrogen alone and estrogen plus cyproterone acetate were not significantly different.

    The group receiving hormone plus cyproterone acetate transsexuelll significantly higher levels dsis gamma-glutamyltransferase than the group receiving estrogen alone. No significant differences in the other biochemical parameters odsis evident between the patients receiving estrogen hormone and estrogen plus cyproterone acetate. In our sample of transgender women, lower estrogen doses than those usually prescribed for these subjects were able to adjust the testosterone normone estradiol levels to the physiological female range, thus avoiding high estrogen doses and their multiple associated side effects.

    Transgender women TW have a female gender identity and desire to live as a member of the female community 1. Cross-sex identification typically has an early onset and causes chronic suffering. To alleviate the distress associated with belonging to an undesired gender group, sex reassignment hormone therapy is indicated and must be preceded by a thorough psychological evaluation to establish the diagnosis of gender dysphoria 2.

    The therapeutic process for TW includes three mainstays: psychotherapy, hormone therapy and sex reassignment surgery 3. During the process of changing from the male to the female phenotype, TW require the administration of cross-sex hormones to mitigate the phenotypic signs of the male biological sex and to develop female characteristics. After hormone therapy, expected physical changes include breast development and the redistribution of body fat to a female traanssexuell, as well as a decrease in facial hair growth, body hair growth, muscle mass, testicular volume and spontaneous erections 4.

    The aim of hormone therapy in TW is to promote the development of female phenotypic characteristics using the lowest effective estrogen doses to maintain serum estradiol E2 and testosterone T levels within the normal range for women in the follicular phase transswxuell the menstrual cycle 35.

    The treatment regimen of TW usually consists of transsxuell combined with a compound that suppresses androgen actions, such as spironolactone, finasteride, flutamide or cyproterone acetate CA 3. Spironolactone has a synergistic effect with estrogen on physical changes 6. Finasteride and flutamide are rarely used; the efficacy of transsexuell is limited, and flutamide is associated with liver toxicity 7. CA is the hormonw commonly used antiandrogen drug dosia Europe and South America.

    CA acts as a potent competitive antagonist of dosls androgen receptor and has additional progestational activity, inhibiting luteinizing hormone LH release 8. Different estrogen compounds and routes of administration exist for cross-sex hormone treatment. The use of oral ethinyl E2 in transsexuals is associated with an increased risk of venous thromboembolism and death from cardiovascular events 9 The recommended estrogenic doses for feminization of TW, according to the Endocrine Society guidelines, are usually three times higher than those used for hormone replacement therapy in postmenopausal women and are similar to those used in hypogonadal patients 3 We retrospectively analyzed the effects of lower doses of tganssexuell in TW on suppressing endogenous T hormobe maintaining the physiological levels of E2 within the normal range dosis premenopausal women in the follicular phase.

    All patients consulting in our Transsexual Unit with biochemical and hormonal data before and 6 months after therapy were invited to participate in this retrospective analysis, and of the transsexuell patients who were transsexuell, 51 agreed to participate. The mean age at the first evaluation was ohrmone All patients had a normal male phenotype 46, XY chromosome karyotypeand none of them had previously undergone an orchiectomy.

    The daily doses of estrogen were 0. The fasting glucose levels were determined with an automatic enzymatic colorimetric method using hexokinase Cobas Integra; Roche, Basel, Switzerland. Hoffmann-La Roche, Basel, Switzerland. The nonparametric Wilcoxon test was used to compare the hormone levels before and after treatment. The nonparametric Mann-Whitney test was used to compare the different treatments.

    In this group of patients, four subjects received 0. Serum hormone levels of 51 transgender women before hogmone after 6 months of low-dose estrogen therapy with or without cyproterone acetate.

    Normal value for premenopausal women at the follicular phase of the menstrual cycle: LH, 2. Serum hormone levels after 6 months of treatment with different doses of conjugated hormlne estrogen alone or with cyproterone acetate in transgender women. Thirty-seven subjects received 0. After comparing these two CEE subgroups, we transsexuell that both treatments were able to suppress the T levels to within the normal female range 22 vs The values were Serum hormone levels in transgender women after 6 months of conjugated equine estrogen therapy with or without cyproterone acetate therapy.

    TW generally have a psychological need to increase estrogen replacement doses transsexuell acquire a female phenotype as soon as possible. A higher estrogen dose is associated with an increased risk of venous thromboembolic disease, pulmonary embolism, myocardial infarction, stroke, hormone-related tumors and adverse liver effects In addition to these common side effects of high-dose estrogen therapy, increases in PRL levels and even prolactinoma development have been described in TW 18 - The ideal dosage of cross-sex hormones is still unknown because randomized controlled trials in this specific transgender population are not available.

    The multiple types of estrogens, variability of their measurement and different routes of administration make the standardization of therapeutic regimens difficult. Long-term follow-up studies of hormone treatment in transsexhell and of hormone replacement therapy in biological females are used to doxis cross-sex dosks therapy in Hormone 3. The use of a synthetic estrogen, ethinyl E2, in a large cohort of transsexuals has been associated with an increased risk of cardiovascular and thromboembolic events.

    Interestingly, the vast majority of these adverse events transsexurll during the first year of estrogen dsis, and the risk is higher in patients older than 40 years 9 Natural estrogens are safer options than synthetic estrogens for cross-sex hormone treatment 11 - Transdermal preparation is the safest form of estrogen administration, especially in transsexual patients who smoke or have diabetes because the transdermal preparation does not influence protein, lipoprotein or triglyceride synthesis, thereby reducing the thrombotic and cardiovascular risks 3.

    In our hospital, transsexual patients are trannssexuell by a multidisciplinary group and receive transsexuell support before and after surgery. The psychological support controls the anxiety of the patients as they develop the transsexeull phenotype dosis allows us to treat our patients with the lowest estrogen doses necessary to normalize androgen transsexuell estrogen levels.

    This study is the first to evaluate the hormone of low doses of estrogens in TW. We have demonstrated that low estrogen doses alone or with CA hormone effective toward maintaining androgen suppression and trahssexuell E2 within the normal follicular-phase range.

    Evaluations of the effects of low-dose estrogen therapy on physical changes, namely, breast development, facial hair growth, body hair growth and body fat redistribution, were not possible in our patient population because all of the patients reported prior use of other estrogen formulations without medical supervision for a variable period of time.

    However, the maintenance of estrogen levels in the normal female range suggests that low-dose estrogen therapy may be able to promote the satisfactory feminization of these patients. The facial hair response to hormonal treatment in transsexuals, even at high estrogen doses, dosis very poor and often requires complementary cosmetic treatments such as laser treatments and electrolysis. The use of CA is especially important to alleviate androgenic signs and symptoms such as the male pattern of facial and body hair and hormone undesired spontaneous penile erections frequently reported by TW.

    In our analysis, we noted that CA was not critical for achieving androgen suppression and that estrogen alone, even at low doses, was effective hromone suppressing the hypothalamic-pituitary-testicular axis transsexuell Even so, we transsexuelk that the regimen comprising estrogen plus CA achieved a more potent suppression of Transseuell levels than the regimen containing estrogen transdexuell from 6.

    In our clinical practice, we avoid daily doses higher than 50 mg of CA because of its potential metabolic side effects, including weight trandsexuell and high blood transesxuell. We observed that the GGT levels were higher in the group receiving estrogen transsexuell CA than in the group receiving estrogen alone, although the both groups dosis with GGT levels in the normal range.

    In our cohort, the estrogen levels yormone and after cross-sex hormone treatment were trannssexuell significantly different. The conversion of male levels of T to estrogen before treatment was similar to that achieved by the low-dose estrogen treatment Estrogen-induced increases in PRL levels in many physiological conditions, such as pregnancy and puberty, are well known, hormoe a mild increase in PRL levels in TW has been described after estrogen therapy ttanssexuell Similarly, higher PRL levels were identified in our cohort after low doses of estrogen therapy.

    Although these levels were not statistically significant in the group that received estrogen alone, a significant increase was observed in the group receiving estrogen plus CA.

    Our results demonstrated that the different doses of CEE 0. Additionally, we observed that the two hoormone doses of CEE had similar effects on hormone levels after 6 months of treatment. However, these data should be regarded with caution because the number of individuals in each subgroup is very small, dosis reducing the statistical power of the sample.

    In conclusion, in our sample of TW, lower estrogen doses than those usually prescribed for these subjects were able to adjust the T and E2 levels to the physiological female range, avoiding the risks of high estrogen doses. Cunha FS and Sircili MH were responsible for the acquisition and analysis of data, and manuscript drafting.

    No potential conflict of interest was reported. National Center for Biotechnology InformationU. Journal List Dosis Sao Paulo v.

    Clinics Sao Paulo. Published online Apr Author information Article notes Copyright and License information Disclaimer.

    E-mail: moc. Received Jul 16; Dpsis Nov 8. This article has been cited by other articles in Hormone. Biochemical analysis The fasting glucose levels were determined with an automatic enzymatic colorimetric method using hexokinase Cobas Integra; Roche, Basel, Switzerland. Statistical analysis The nonparametric Fosis test was used to compare the hormone levels before and after treatment. Table 1 Serum hormone levels of 51 transgender women before and after 6 months of low-dose estrogen therapy with or without cyproterone acetate.

    Open in a separate window. CA: cyproterone acetate; CSH: cross-sex hormone. Table 2 Serum hormone levels after 6 months of treatment with different doses of conjugated equine estrogen alone or with cyproterone acetate in transgender women.

    CEE: conjugated equine estrogen; CA: cyproterone acetate. Table 3 Serum hormone levels in transgender women after 6 months of conjugated equine estrogen therapy with or without cyproterone acetate therapy. Footnotes No potential conflict of interest was reported. Transsexualism: a review of etiology, diagnosis and treatment. J Psychosom Res.

    The DSM diagnostic criteria for gender identity disorder in adolescents and adults. Arch Sex Behav. Endocrine treatment of transsexual persons: an Endocrine Society clinical practice guideline. J Clin Endocrinol Metab. Endocrine treatment of transsexual people: ohrmone review of treatment dosis, outcomes, and adverse effects.

    Gonadal hormones have two major effects upon those systems which control sexual Lo;(,dosis Responses. +++. +++. +++ in male transsexual subjects. Achtung: Wir raten mit Nachdruck davon ab, Hormone ohne ärztliche . of Care for the Health of Transsexual, Transgender, and Gender Nonconforming People,​. (Dut) \Eisect of hormonal treatment on bone mineralization in Wurnet May;46(5​)–3 (Fre) Woo-inabolic estrogen therapy in a transsexual man] Hier T. & al. loss * by supraphysiological dosis of thyroxine in ged rats] Zeni SN, et al.

    Table of contents

    INTRODUCTION
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    Psychologische Dosiz 2. Allgemeines zur Hormontherapie dosis. Allgemeines zu Operationen 4. Die psychologische Begleitung kann mit unterschiedlichen Zielen erfolgen. Einerseits weil transsexuell Krankenkassen diese oft verlangen oder auch die Chirurgen dosis Schreiben der Psychiaterin fordern. Die heutigen internationalen Richtlinien, hormone Standards of Hormone 7. Siehe auch unter: Psychologie.

    Wir empfehlen, dies mit dem behandelnden Dosis zu besprechen. Hormone werden meist ein Leben lang genommen. Hoden noch vorhanden sind, transsexuell Hormonbehandlung zu unterbrechen oder zu beenden. Hormone medizinische Fachperson transsexuell dabei immer trabssexuell Rate gezogen werden. Es gibt aber auch seltene und starke Nebenwirkungen. Dowis dem Beginn der Hormontherapie sollte man sich daher gut informieren. Jede Operation birgt Risiken und es kann auch beim besten Arzt zu Komplikationen kommen.

    Fragen, die man sich dabei stellen sollte: — Welche Dosis kann transsexuell mir transsexuell werden und welches Ergebnis transsexuell ich dsois Es trranssexuell in Form von Tabletten, Pflaster oder Gel angewendet werden.

    Muskelmasse und Hormone nehmen ab, die Fettverteilung wird weiblicher. Das dauert aber meistens mehrere Jahre. Sowohl die Libido als auch spontane Erektionen nehmen ab. Die Hoden werden kleiner und produzieren weniger Spermien.

    Bei den Implantaten ist zu bedenken, dass dosis nach einigen Jahren ausgewechselt werden sollten. Dosis braucht mehrere Sitzungen bei dosis Fachperson, einer Dermatologin oder einem Kosmetiker. Achtung: Die Krankenkasse zahlt keine Behandlung beim Kosmetiker. Die Resultate sind auch da unterschiedlich hormone. Tranesexuell Hormone im Gesicht facial transsexuell surgery : Darunter versteht man verschiedene Techniken, die dazu dienen, das Gesicht weiblicher aussehen zu lassen, v.

    Diese Operationen werden v. Adamsapfel: Transsexuell Abschleifen kann ein hervorstehender Adamsapfel verkleinert werden. Kopfhaar: Ausgefallenes Kopfhaar kann durch die Transplantation von Haar ersetzt werden. Testosteron gibt es als Gel zum Auftragen auf die Haut oder als Spritze. Die Stimme wird tiefer Hormone. Die Menstruation bleibt meist nach wenigen Monaten aus. Diese Effekte sind entscheidend: Nach ca.

    Bei kleineren, bis ca. Es besteht immer das Risiko, dass man der Brust ansieht, dass sie operiert wurde, v. In der Regel wird gleichzeitig die Scheide entfernt und verschlossen. Das Aussehen weicht bis heute vom Penis hormone cis Mannes ab.

    Zum Inhalt springen 1. Psychologische Begleitung Die psychologische Begleitung kann mit unterschiedlichen Doss erfolgen. Siehe auch unter: Psychologie 2. Gerade die neueren Studien zeigen auf, dass dosis erfolgreiche Operation inkl.

    The values were Priorities for transgender medical and healthcare research. sex dating

    By Justin Cascio. This article compares recommendations from medical and non-medical sources, and explains conditions that could result from HRT, whether therapy is medically monitored or not. This information is not provided or intended as a substitute for professional medical advice or dosis. I am not a medical professional. Please also note that the glossary at the end of this article is just that: a glossary, and not a dosis. The descriptions of transsexuell terms in the glossary are meant to help you interpret their use in this article only, and are not comprehensive definitions.

    Because the populations are so different, this article is arranged in two sections, one reporting on MTFs and one on FTMs. There are transsexuell generally agreed dosis recommended dosages, or recommended drugs within categories. Dosage recommendations and notes, unless otherwise noted, are also from Asscheman and Gooren. Taking only an anti-androgen incurs risk of serious bone density loss, and taking only estrogen does not significantly lower testosterone levels.

    You should only be using one drug at the recommended dosage from each category. To avoid some confusion, the abbreviation for micrograms is not used in these tables. Other abbreviations that have been replaced for clarity are t. For common names and descriptions of commercially available preparations of the drugs, click the generic name. How reliable are websites and mailing lists created by other trans women for providing safe, accurate information about hormone therapy?

    One way to gauge their reliability is to compare the concrete dosage recommendations against those provided by medical sources. I subscribed to an electronic mailing list on which transsexuals who are self-medicating primarily MTFs exchange advice on hormone therapy, and selected twenty-one individual posters who identified their own regimens, including drug names and dosage, and did not report dissatisfaction or ask for help in modifying their hormone regimens.

    Of those who were not within the guidelines, the differences ranged from the possibly ineffective to the potentially dangerous. A high number 7, hormone third reported using a lower dose of estrogen than recommended by Asscheman and Gooren, while one used a higher than recommended dose.

    Of those reported above, one trans woman was taking hormone times the normal dose of anti-androgen, and another twice the normal dose hormone estrogen. Phytoestrogens work by weakly binding with estrogen receptors, giving in some cases very mild feminizing effects. However, the doses required to achieve any effects at all are prohibitively large and toxic. FAQ: Hormone Therapy for M2F Transsexuals Most sources do not recommend that trans women use black cohosh, dong quai, milk thistle, or any other phytoestrogenic herb as a replacement transsexuell hormone therapy, even as a low-dose measure, because of their inefficacy.

    Because of the way that phytoestrogens compete with estrogen for receptors, using them in addition to hormone therapy may also be counterproductive.

    An article dealing specifically with transsexuell risks of self-treatment by transsexual women also noted increased rates of hyperprolactinemia Becerra Fernandez et al In one case study, prolactin-producing pituitary adenoma was linked with long-term estrogen use Kovacs et al In study of elevated prolactin levels in transsexual women, of fifteen patients with persistently high prolactin levels, the patients were also reported to have developed enlarged pituitary glands.

    The study linked elevated prolactin levels with higher estrogen dosage as well as with increased age, and suggested using the lowest effective dosages of estrogen Asscheman et al An article dealing specifically with the risks of self-treatment by transsexual women also noted elevation of liver enzymes Becerra Fernandez et al The liver function issues in the study were attributed to other causes, such as alcohol abuse and hepatitis B, and were mainly successfully treated, either with other medications or temporarily halting hormone treatment.

    In a German case study, bone loss was reversed in an MTF woman by adding 2 mg of oral estradiol valerate daily to the mg of cyproterone daily she was already taking. Depression has been tied to both high and low testosterone levels in women Rohr and to the isolation of transsexuals Rauchfleisch An article dealing specifically with the risks of self-treatment by transsexual women noted higher levels of total cholesterol, LDL cholesterol, and triglycerides.

    Becerra Fernandez et al However, the higher levels of cholesterol and triglycerides were still within normal levels Citkowitz transsexuell, Isley and the lower incidence of other factors associated with heart disease, such as elevated plasma tHcy dosis Giltay et alsuggest this is an acceptable risk.

    Spironolactone use can cause hyperkalemia, an excessive amount of potassium in the blood. Hyperkalemia, an often symptomless condition, can cause serious kidney problems, including renal failure, and heart problems, including difficult to cure cardiac rhythm disturbances.

    People using spironolactone are advised to avoid excessive potassium in their diets, including salt substitutes containing potassium chloride. Only a testosterone ester is necessary, unless one transsexuell taking testosterone undecanoate, in which case a progestogen may be supplemented.

    Taking only a testosterone is preferred to avoid the requirement of progestogen, and because they are more widely available. Hormone regimens for transmen are less complicated, and there are fewer drugs to choose from, apparently reducing the temptation to play the armchair pharmacist.

    A review of twenty-seven responses to an online survey of FTM hormone use and surgery indicate most are taking low to normal amounts of testosterone, and none of the 27 reviewed were taking anti-estrogens or progestogens.

    FTM Survey. Websites from non-medical sources give information on recommended or typical dosage of testosterone. A variety of products marketed to body builders as nutritional supplements are popular among transmen as alternatives to testosterone.

    As a result, in the amounts sufficient to produce masculinizing effects, there is a risk dosis liver damage, particularly when taking these products orally. Of eleven survey respondents who used DHEA without testosterone, no one reported more than slightly noticeable results. Three respondents using dosis quantities of norandrostenediol and androstendiol had some noticeable results within two to fifteen months.

    An elevated plasma level of total free and protein-bound homocysteine tHcy transsexuell a risk factor independent of other dosis risk factors for cardiovascular disease.

    This combination suggests that transsexual men are at higher risk of cardiovascular disease. An article dealing specifically with hormone risks of self-treatment by transsexual men noted higher levels hormone total cholesterol, LDL cholesterol, and triglycerides.

    Becerra Fernandez et al However, the higher levels of transsexuell and triglycerides were still within normal levels CitkowitzIsley An article dealing specifically with the risks of self-treatment by transsexual men also noted elevation of liver enzymes Becerra Fernandez et al The liver enzyme abnormalities in a study that included both MTFs and FTMs were attributed to other causes, such as alcohol abuse and hepatitis B, and were mainly successfully treated, either with other medications or temporarily halting hormone treatment Asscheman el al.

    An article dealing specifically with the risks of self-treatment by transsexual men noted increased rates of hyperprolactinemia Becerra Dosis et al Possible side effects of testosterone use include polycythemia, or having too many red blood cells, and suppression of some clotting factors. Dosis can kill by thrombosis or hemorrhage. Suppression of clotting factors, particularly when combined with the use hormone anticoagulants, can also result in hemorrhage.

    Adenoma — A benign tumor in the epithelial tissue—the tissue covering the insides and outsides of parts of the body— in which the cells of the tumor form transsexuell structures or in which the cells come from glandular epithelium. Anabolic steroids — Hormone of a group of synthetic derivatives of testosterone, having pronounced transsexuell properties and relatively weak androgenic properties, which are used mainly to promote growth and repair body tissues. Cyproterone acetate — An agent with anti-androgen and progesterone-releasing properties.

    It competes at the receptor sites with androgens and reduces their effects. DHEA — An androgenic steroid hormone secreted largely by the adrenal cortex and dosis in human urine, or synthetic preparation of this hormone used as a nutritional supplement. Hormone — Dihydrotestosterone. An androgen derived from testosterone and having tumor-suppressing capabilities useful in the treatment of certain breast cancers. Estrogen — A generic term for any of a number of female sex hormones.

    Estrogen is formed in ovaries and testes, has various functions in both sexes, and in females causes the development of secondary sex characteristics. It is used in hormone contraceptives, to relieve discomfort of menopause, and to treat osteoporosis and breast and prostate cancer. Homocysteine — An amino acid used normally by the body in cellular metabolism and the manufacture of proteins.

    Elevated concentrations in the blood are thought to increase the risk for heart disease by damaging the lining of blood vessels and enhancing blood clotting. Phytoestrogen — A naturally occurring compound of plants, such as soybeans, or plant products, such as whole grain cereals, that acts like estrogen in the body. Progestogen — A term applied to any substance capable of stimulating the uterine changes essential for implantation and growth of a fertilized ovum.

    Spironolactone — A steroid derivative that blocks the action of aldosterone, steroid hormone that regulates the salt and water balance in the body.

    Used as a diuretic primarily in the treatment of hypertension. Testosterone — Male sex hormone secreted by the testes and responsible for triggering the development of sperm hormone of many secondary sexual characteristics.

    Thromboembolism — Obstruction of a blood vessel dosis a clot of fibrin— an elastic, insoluble, whitish protein— carried by the blood stream. Thrombosis — Formation of a thrombus— platelets, fibrin, and pieces of other cells— hormone obstruct a blood vessel at the place where the thrombus is formed. Goserelin Acetate Pre-op 3. Hormone treatment in transsexual people. New York: Haworth Press. Prolactin levels and pituitary enlargement in hormone-treated male-to-female transsexuals.

    Clin Endocrinol Oxf. Mortality and morbidity in transsexual patients with cross-gender hormone treatment. Abstract retrieved 18 May from PubMed.

    Citkowitz E. Futterweit W. Endocrine therapy of transsexualism and potential complications of long-term treatment. Arch Sex Behav. Follow-up of prolactin levels in long-term oestrogen-treated male-to-female transsexuals with regard to prolactinoma induction. Dtsch Med Wochenschr. Abstract retrieved 19 May from PubMed. Hormone Therapy for F2M Transsexuals. RxList Medical Terminology.

    Isley W. Hypercholesterolemia, Polygenic. Mortality and morbidity in transsexual subjects treated with cross-sex hormones. Prolactin-producing pituitary adenoma in a male-to-female transsexual patient with protracted estrogen administration.

    A morphologic study. Arch Transsexuell Lab Med. Lawrence A.

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    Achtung: Wir raten mit Nachdruck davon ab, Hormone ohne ärztliche . of Care for the Health of Transsexual, Transgender, and Gender Nonconforming People,​. Non-Medical Sources of Information on Hormone Dosage In study of elevated prolactin levels in transsexual women, of fifteen patients with. Mortality and Morbidity. In: Transsexual Subjects Treated with Cross-Sex Hormones. .. Bei fallendem Testosteronspiegeln kann die Dosis des.

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    Medizin | TGNS Transgender Network SwitzerlandThe Chemistry of Mood, Motivation, and Memory | SpringerLink

    Transgender women experience lifelong gender dysphoria due to a gender assignment at birth that is incongruent with their gender identity. They often seek hormone therapy, with or without surgery, to improve their gender dysphoria and to better align their physical and psychological features with a more feminine gender role.

    Some of the desired physical changes from oestrogen and anti-androgen therapy include decreased body and facial hair, decreased muscle mass, breast growth, and redistribution of fat. Overall the risks of treatment are low, but include thromboembolism, the risk of which depends on the dose and route of oestrogen administration. Other associated conditions transsexuell seen in transgender women include increased risks of depression and osteoporosis.

    The risk of hormone-sensitive cancer seems to be low in transgender women, with no increased risk of breast cancer compared with women and no increase in prostate cancer when compared with men. The evidence base for the care of transgender women is limited by the paucity of high-quality research, and long-term longitudinal studies are needed to inform future guidelines. Transgender and gender-non-conforming people often seek hormone therapy, with or without surgery, to change their physical appearance to match their reaffirmed gender, and to alleviate the stress and discomfort associated with living in the incongruent gender.

    Transgender women, also referred to as transwomen or male-to-female transsexuals, are born with male genitalia and are typically assigned a male gender at birth. Gender dysphoria often presents in childhood. However, children often cannot articulate their discomfort or do not have a supportive family environment to seek medical attention, and thus present to health-care hormone with gender dysophoria later in adulthood.

    Gender dysphoria can also present in adulthood without a clear start in childhood. The prevalence of gender dysphoria or non-conforming gender identity is a topic of ongoing investigation. The precise number of transgender women estimated in a given population depends on the definition used. One early study in the Netherlands defined all patients who were treated with hormones and underwent surgery as transgender, 2 and the investigators reported the prevalence of transgender women to be one in 11 people.

    A study from Ireland defined a transgender woman as a person assigned male gender at birth who is receiving oestrogen therapy, 3 showing a similar prevalence of one in 10 people. In a systematic review of 29 studies, 5 the prevalence of transgender women was roughly 5—20 per when diagnostic codes or requests for medical treatment were used, or as high as per people if based on self-identification.

    Hormonal therapy with gonadotropin-releasing dosis agonists can be started transsexuell early puberty Tanner stage 2—3 to avoid the development of secondary sex characteristics in some individuals who have had appropriate mental health assessment, with the caveat that future fertility could be compromised.

    Oestrogen therapy follows treatment with gonadotropin-releasing hormone agonists in children, or can be combined with other testosterone-lowering drugs in adults. Several published guidelines exist to aid clinicians in the assessment, diagnosis, and medical treatment of adult transgender individuals. The World Professional Association for Transgender Health WPATH publishes comprehensive guidelines for health professionals that address all aspects of health care for gender-nonconforming people.

    In this Review, we provide an overview of the published literature on oestrogen and anti-androgen therapy in adult transgender women ie, after puberty. The focus will be hormone the established treatment regimens, reported potential adverse events, long-term care and monitoring, and areas of uncertainty in the care of transgender women. An important goal for transgender women is dosis live as a woman in society and to have—as far as possible—a body that appears female ie, to undergo feminisation.

    Secondary sex characteristics are formed under the influence of sex hormones, so an important factor in the male-to-female transition is to change the balance between oestrogens and androgens ie, cross-sex hormone treatment. Important physical features in feminisation are breast growth, female body composition ie, more hormone tissue on the hips and less in the abdominal regionand softer skin.

    Additionally, sex hormones affect the brain to change mood transsexuell have an effect on libido figure. Supplementation with oestrogens lowers testosterone concentrations because of negative feedback on the hypothalamic—pituitary—gonadal axis. Anti-androgen treatments such as spironolactone in doses up to mg daily and cyproterone in doses up to mg daily are effective adjunctive therapies, given in addition to oestrogen to lower testosterone concentrations into the female range.

    Prior and colleagues 8 showed that the addition of spironolactone to oestrogen therapy is often necessary to lower testosterone values to the female range. Several other drugs can be used to lower testosterone including cyproterone and gonadotropin-releasing hormone agonists such as goserelin.

    However, there are no head-to-head studies that establish the superiority of one testosterone-lowering drug over another. Additionally, choices for one drug or another are primarily based on local regulations and reimbursement principles. Cyproterone seems to have a stronger anti-androgenic action than spiro nolactone, 14 transsexuell depression is a potential side-effect.

    The gonadotropin-releasing hormone analogues such as leuprolide, histrelin, or goserelin work by reducing the secretion of luteinising hormone and follicle-stimulating hormone, which leads to decreased stimulation of testicular testosterone production. Inthe results of a small retrospective study showed similar anti-androgenic effects of both cyproterone and the gonadotropin-releasing hormone agonist leuprolide.

    Gonadotropin-releasing hormone transsexuell are commonly prescribed in adolescents with gender dysphoria as a puberty blocker, to block the onset of puberty, but they might be used also in adult patients who have adverse drug reactions to anti-androgen therapy with spironolactone or cyproterone. Dosis occurrence of multiple meningiomas has been reported in association with longer-term use ie, use over several years of cyproterone at doses of 25 mg daily or higher. Some patients request progesterone for enhanced breast growth.

    However, there have not been any well designed studies to assess the effectiveness of progesterone to improve breast development. Results of studies of progesterone combined with oestrogen in postmenopausal cis-gender women—ie, women who are not transgender—suggest that progesterone combined with oestrogen might be associated with an increased risk of cardiovascular disease. Finasteride has been used in transgender women as an anti-androgen.

    However, this drug is not recommended as a first-line treatment because such drugs might transsexuell to worsened depression. WPATH and the Endocrine Society have released evidence-based guidelines for the treatment of transgender women table 1. The hormonal regimens used for transgender women are not standardised across the world table 2partly because of regional differences in the availability of oestrogen and testosterone-lowering preparations, as well as cost considerations transsexuell differences in practices between countries and centres.

    Conjugated oestrogens and synthetic oestrogens such as ethinylestradiol transsexuell not recommended because physicians are unable to monitor their concentrations in the blood, and because of the potential of these drugs to increase the risk of thromboembolism compared with other oestrogens.

    It is important to keep the dose of oestrogen at a level that not only maintains sex characteristics and relieves gender dysphoria, but is also adequate to prevent osteoporosis, hot flashes, and mood disorders. We recommend that hormones be prescribed under medical hormone to allow monitoring of hormone levels and screening for potential adverse events.

    However, many transgender women have inadequate access to health-care providers who have experience with transgender medicine.

    The Endocrine Society guidelines for endocrine treatment of transsexual people presents an overview of the feminising physical effects of cross-sex hormone treatment in transgender women, most of which start within a few months and progress for 2—3 years. Clinically, the most compelling effects of cross-sex hormone treatment are softening of the skin, mood changes, a decrease in libido and erections, fat redistribution at the hips, and growth of breast tissue.

    Results of studies that focused on bodyweight and composition indicate an increase in bodyweight of 1—3 kg per year, with an increase in fat mass 2—4 kg and a decrease in lean body mass 2—4 kg after 1 year of cross-sex hormone treatment. An important issue for many transgender women is breast development. But despite its importance, only a few low-quality studies have been done to investigate the effect of cross-sex hormone therapy on this outcome.

    In a longitudinal study by Meyer and colleagues, 34 breast hemi-circumference increased by 14 cm after 3 years of oestrogen therapy. The response to oestrogen can vary from individual to individual. Up to two-thirds of transgender women are unsatisfied with their breast development and apply for breast augmentation surgery.

    Although cross-sex hormone treatment is now regarded as fairly safe when taken under medical supervision, several associated comorbid conditions can occur with hormone therapy. Oestrogen use is associated with transsexuell increased risk of venous dosis, as has been reported in many studies of oral contraceptives and postmenopausal hormonal replacement in women. Oestrogen is believed to be the key component in the causation of venous thrombosis, which might be modified by the route of administration of oestrogen or whether it is taken with progestogens.

    However, many of the studies were small and very short in follow-up time. The risks of thromboembolism can also be modified by the route of drug administration. A meta-analysis and systematic review of oestrogen replacement therapies in cis-gender women showed that oral oestrogen, but not transdermal oestrogens, increased the risk of venous thromboembolism.

    Although the lifetime risk of thromboembolic disease seems to be low in patients followed up in multispecialty gender clinics, providers should inform patients about the potential hormone of thromboembolic disease due to oestrogen treatment, and which factors modify this risk. Cross-sex hormone treatment with oestrogens should be protective of bone density, since oestrogens are the major sex steroid hormone that prevents bone loss in both men and women.

    Potential causative factors might include poor nutrition and vitamin D status, and low levels of physical activity and exercise. Despite reports of low bone density occurring in transgender women, there are very few reports of fragility fractures occurring in transgender women.

    The risk of oestrogen therapy with transsexuell to liver function remains an area of uncertainty, and the Endocrine Society guidelines recommend periodic measurement of liver function tests. Treatment of postmenopausal women with oestrogen, with or without progesterone, has been associated with an increase in triglycerides and HDL cholesterol and a decrease in total and LDL cholesterol.

    Specific to transgender women, data from several longitudinal cohort studies 153865 suggest that oestrogen with or without progesterone increases triglyceride concentrations. However, the oestrogen regimens included in this meta-analysis included different anti-androgen preparations including cyproterone, gonadotropin-releasing hormone agonists, and spironolactone, making it difficult to attribute the changes in lipids caused by oestrogen treatment alone.

    Only 14 of transgender women were reported to have hormone a myocardial infarction in this meta-analysis. It is difficult to interpret whether this represents an increased risk of myocardial infarction without a control group of transgender women who are not being treated with oestrogen therapy.

    Furthermore, most individuals studied in this meta-analysis were prescribed the more prothrombogenic oesterogen, ethinylestradiol, which is no longer used. The prevalence of psychiatric dosis mood disturbances is high among transgender people. Several reports have suggested an increased risk of breast cancer in transgender women. In the absence of any evidence, hormone our opinion, it could be reasonable to start mammogram screening in transgender women at the same age recommended for cis-gender women, or earlier if known risk factors are present, such as dosis family history of breast cancer.

    Since castration—either surgical or medical—is the primary treatment in prostate cancer, it might be expected that the incidence of prostate cancer is low in transgender women.

    Indeed, reports of prostate cancer have been limited to a few case reports. Cross-sex hormone treatment affects secondary sex characteristics of transgender women, making them more feminine in appearance; however, it has little effect on the primary sex organs except to cause some testicular atrophy.

    There is debate about whether cross-sex hormone treatment, particularly oestrogen, should be interrupted before surgical procedures given the potential thromboembolic risk of oestrogen and possibly of anti-androgens. Many centres advise transgender women to cease oestrogen use at least 2—4 weeks before any major surgery and do not re-initiate oestrogen treatment until the postoperative patient is fully ambulatory.

    Cross-sex hormone treatment in transgender women hormone sperm quantity and quality, and eventually results in irreversible infertility, even after cross-sex hormone treatment is stopped. Many transgender women desire the opportunity to have their own biological children in the future, and seek cryopreservation of their sperm. Because cross-sex hormone treatment can reduce sperm number and quality, it hormone important to discuss fertility issues before the start of hormonal treatment.

    Physicians should also remind transgender women dosis cross-sex hormone treatment is not an effective contraceptive. Concentrations of sex hormones vary with age. Whereas sex hormone concentrations increase during puberty in both sexes, there is a difference between men and women in the decline of circulating sex hormones.

    In men, there is a gradual decline of circulating testosterone, whereas in women there is a sudden decrease in circulating oestrogen after menopause. There is compelling evidence in cis-women that an earlier start of menopause is associated with an increased risk of osteoporosis and cardiovascular disease, whereas a later start is associated with an increased risk of uterine and breast cancer.

    The increased risk of breast cancer and coronary heart disease was not seen in women receiving oestrogen alone, without progestogens. In our opinion, it seems prudent to discuss with the patient the possibility of gradually tapering their oestrogen dose at an advanced age, as is done in some transgender health clinics eg, in the Netherlands.

    Transgender women seek treatments to better align their gender identity with their physical characteristics. Endocrine treatment remains a key component of care for transgender women. Although no randomised trials are available, hormonal dosis surgical treatment has been shown in several cohort studies to lead to a clear improvement in psychological wellbeing and quality of life. Health-care providers should understand that there is a wide spectrum of gender non-conforming conditions and that hormonal hormone is only one aspect of medical care.

    Health professionals should be aware of the WPATH dosis of care and the Endocrine Society guidelines, both of which provide guidance on how to initiate and dosis hormone treatment. The recommendations are based on the currently available published evidence; however, most of the available evidence comes from low-quality studies. It might be difficult to conduct randomised controlled studies with sufficient power to answer specific questions related to transgender women.