Estrogen therapy is a hormone and sex reassignment therapy used in facilitating conversion of transgender individuals from masculine to feminine. The purpose of estrogen therapy is to stimulate formation of secondary sex features of the desired female sex such as fat and muscle distribution, breasts growth of feminine hair pattern. Introducing exogenous estrogen hormone impacts a person’s body at every level leading to notable changes in dimensions such as mood, energy levels and appetite ( Unger, 2016) . Estrogen male to female therapy feminizes patients through suppression of masculinizing features. Exogenous estrogen therapy suppresses secretion of gonadotropin leading to reduced production of androgen through a negative feedback loop. Estrogen therapy may fail to suppress all masculinizing characteristics and carries several risks during and after uptake of the exogenous hormone.
Role, risks/benefits of estrogen therapy for male to female transgender transition
Estrogen therapy plays a role in feminizing male patients by inducing formation of breasts, triggering reduction of male hair growth pattern and changing fat distribution. Additionally, estrogen hormone therapy minimizes secretion of gonadotropin from a male’s pituitary gland consequently leading to suppression of androgen production. The therapy performs an important role in transition through blocking hormone testosterone action. During male to female transition, estrogen therapy significantly decreases generation of testosterone and triggers manifestation of feminine secondary characteristics. The estrogen therapy lowers masculine hormonal levels to match the female gender identity.
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Estrogen therapy improves the transgender individual’s quality of life. Longitudinal studies indicate that estrogen therapy affects sexual function and mood positively ( Nikkelen et al., 2018) . Individuals with major depression experience reduced SERT reduction through SERT binding in the brain. The individual’s quality of life improves by gaining a more satisfying boy that is aligned to one’s gender identity. Estrogen hormone therapy has been found to have positive effects on physiologic stress. A study by Chipkin and Kim (2017) evaluated 70 transgender patients who were undergoing hormone therapy and measured the patient’s cortisol and stress levels before and 12 months after starting estrogen uptake. The study reported that after starting estrogen therapy, perceived stress and cortisol levels reduced significantly. Oestrogen therapy makes gender dysphoria less severe, improves social and psychological functioning and can enhance sexual satisfaction.
Estrogen feminizing therapy is associated with an increased thrombotic risk. A blood clot may develop in a deep vein or in lung leading to pulmonary embolism. Estrogen therapy increases the risk of having high triglycerides which is a type of fat in a person’s blood. Additional risks include formation of gallstones, weight gain, elevated liver function tests, decreased libido, erectile dysfunction and infertility ( Nikkelen & Kreukels, 2018) . An individual partaking the hormone also faces the risks of developing hyperkalemia, hypertension, type 2 diabetes, cardiovascular diseases and excessive prolactin in a person’s blood.
Alternatives to Estrogen Therapy
A person intending to transition from male to female can opt for feminizing surgery in lieu of estrogen therapy. The surgery encompasses procedures that alter a person’s appearance in an attempt to match one’s body to the preferred female gender identity. Feminizing surgery may involve top surgery to promote breast augmentation, bottom surgery to eliminate testicles (orchiectomy) and create a vagina a process called vaginoplasty ( Hadj-Moussa et al., 2018) . The surgery can also involve body contouring and facial procedures to enhance feminine appearance. The procedure also entails movement of hairline to create a smaller forehead, augmenting cheek bones and lips, resizing and reshaping chin as well as skin lightening. Anti-androgen therapy is a second alternative which involves uptake of spironolactone and cyproterone to lower testosterone concentration ( Tangpricha & den Heijer, 2017) .
Role that hormones play in sexual drive for male to female transgender patients
Uptake of female estrogen hormone when transitioning to female can trigger decreased sexual drive characterized by low libido and erectile dysfunction. The estrogen intake can alter the way an individual experiences sexual arousal. A study published in 2016 reported that 62.4% of surveyed transwomen reported a significantly decreased sexual desire after estrogen hormone therapy ( Selix & Rowniak, 2016) . The estrogen can trigger spontaneous and responsive sexual desire. In some cases, estrogen intake can lead to a feeling of hypersexuality a condition characterized by dysfunctional pre-occupation with sexual fantasy, obsessive pursuit of casual sex, romantic intensity, compulsive masturbation and pornography. Estrogen therapy can alter orgasms, making one feel different physically. The treatment in some people can lead to multiple but less intense orgasms as well as satisfying and affirming sex. The sexual drive in transgender females differs and varies from one person to another since some people experience hypo or hyper sexuality after taking in estrogen.
Plan for evaluation and management for Julie
Evaluation of Julie’s case will entail clinically checking the estrogen doses she has been taking to determine if the side effects are caused by low or a higher dosage. Julie will be subjected to estrogen test to determine her estradiol levels. Evaluation plan will aim at determine Julie’s causes of low estrogen therapy compliance. Hormone testing will determine level of serum testosterone which ought to be <50 ng/dl. The serum estradiol test will determine if Julie’s level is below of higher than the recommended range of 100-200 pg/ml. Management of the difficulty in compliance, facial hair growth and decreased sexual drive will entail recommending an alternative option which is a combination of feminizing surgery and Anti-androgen therapy in place of estrogen therapy. Facial and body contouring procedures will permanently rid the facial hair growth. Julie will be subjected to spironolactone doses and be monitored every 3 months to check her sexual drive improvement.
References
Chipkin, S. R., & Kim, F. (2017). Ten most important things to know about caring for transgender patients. The American journal of medicine , 130 (11), 1238-1245.
Hadj-Moussa, M., Ohl, D. A., & Kuzon Jr, W. M. (2018). Feminizing genital gender-confirmation surgery. Sexual medicine reviews , 6 (3), 457-468.
Nikkelen, S. W., & Kreukels, B. P. (2018). Sexual experiences in transgender people: the role of desire for gender-confirming interventions, psychological well-being, and body satisfaction. Journal of sex & marital therapy , 44 (4), 370-381.
Selix, N. W., & Rowniak, S. (2016). Provision of patient ‐ centered transgender care. Journal of midwifery & women's health , 61 (6), 744-751.
Tangpricha, V., & den Heijer, M. (2017). Oestrogen and anti-androgen therapy for transgender women. The Lancet Diabetes & Endocrinology , 5 (4), 291-300.
Unger, C. A. (2016). Hormone therapy for transgender patients. Translational andrology and urology , 5 (6), 877.
