You are seeing Julie, a 31 yr old male to female transgender patient. Julie reports she has been having difficulty being compliant with her oral estrogen therapy and questions what alternative approaches to her estrogen therapy are available. She is concerned about her continued significant facial hair growth, and decreased sexual drive. She is afraid that if she continues to have these symptoms that she will be less desirable to her partner and their relationship will deteriorate.

You are seeing Julie, a 31 yr old male to female transgender patient. Julie reports she has been having difficulty being compliant with her oral estrogen therapy and questions what alternative approaches to her estrogen therapy are available. She is concerned about her continued significant facial hair growth, and decreased sexual drive. She is afraid that if she continues to have these symptoms that she will be less desirable to her partner and their relationship will deteriorate.

You are seeing Julie, a 31 yr old male to female transgender patient. Julie reports she has been having difficulty being compliant with her oral estrogen therapy and questions what alternative approaches to her estrogen therapy are available. She is concerned about her continued significant facial hair growth, and decreased sexual drive. She is afraid that if she continues to have these symptoms that she will be less desirable to her partner and their relationship will deteriorate.

The case study depicts Julie, a 31-year-old male to female transgender patient with compliance difficulties with oral estrogen therapy. She inquires about alternative approaches to estrogen therapy.  In addition, Julie expresses concerns about continued significant facial hair growth and decreased sexual drive, making her less desirable to her partner and affecting their relationship. The purpose of this paper is to discuss the role and risks/benefits of estrogen therapy, alternatives to estrogen therapy, and the role of hormones in sexual drive.

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Estrogen Therapy

Estrogen therapy is the mainstay of Gender-affirming hormonal treatment (GAHT) used in transgender women. The desired effects include the development of secondary female characteristics like breast growth and female body composition. Exogenous estrogen is administered to feminize patients by suppressing gonadotropin secretion of the breast from the pituitary gland, resulting in decreased androgen production (Defreyne et al., 2020). The benefits of Estrogen therapy in transgender women include initiating breast growth, increasing body fat, slowing the growth of body and facial hair, and reducing the testicular size and erectile function.  In addition, hormone therapy improves the quality of life of transgender patients and has positive effects on mood (Haupt et al., 2020). However, estrogen is associated with cardiovascular health risks like deep venous thrombosis and heart diseases in transgender women, particularly those taking Ethinyl estradiol (Swe et al., 2022).

Alternatives to Estrogen Therapy

Anti-androgen treatments are the recommended alternatives to estrogen therapy including Cyproterone acetate (CPA), GnRH-a, 5α-reductase inhibitors, and spironolactone. Androgen suppression and feminization are the main goals of anti-androgen treatments. CPA blocks the testosterone receptor and acts as synthetic progesterone causing suppression of the hypothalamic-pituitary-gonadal axis (Glintborg et al., 2021). GnRH-a inhibits the pituitary-gonadal axis and suppresses gonadal sex hormone levels but maintains adrenal androgen production.  In addition, 5α-reductase inhibitors like finasteride are used to hinder the conversion of testosterone to the more active dihydrotestosterone. Spironolactone is an androgen and progesterone receptor antagonist. It blocks the binding of dihydrotestosterone to its androgen receptor, inhibiting androgen effects (Glintborg et al., 2021). Progesterone is also used as an alternative to estrogen due to its feminizing effect. It inhibits the hypothalamic-pituitary-gonadal axis and improves breast development.

Role That Hormones Play In Sexual Drive For Male to Female Transgender Patients

            Testosterone has a key role in sexual arousal in birth-assigned men. However, the use of hormonal therapy in transgender women affects their sexual drive by decreasing their sexual desire. During the withdrawal of testosterone, transgender women experience a decrease in the level of sexual desire (Defreyne et al., 2020).  The decreased sexual drive is attributed to the suppression of testosterone. Therefore, Julie’s decreased sexual drive can be linked to oral estrogen therapy.

Plan for Evaluation and Management for Julie

Julie’s treatment will be changed from oral estrogen to a parenteral formulation: Estradiol valerate (Delestrogen) 10 mg IM every two weeks. The parenteral formulation aims at improving adherence.  Estrogen alone is usually not adequate to attain desirable androgen suppression, and adjunctive anti-androgenic therapy is usually needed (Haupt et al., 2020). The patient will be prescribed CPA 2 mg to reduce the facial hair growth

Conclusion

Exogenous estrogen helps to feminize patients, while anti-androgens are used as adjuncts to suppress masculinizing features in transgender women. However, exogenous estrogen is associated with cardiovascular side effects. The suppression of testosterone in transgender women lowers their sexual drive.

References

Defreyne, J., Elaut, E., Kreukels, B., Fisher, A. D., Castellini, G., Staphorsius, A., … & T’Sjoen, G. (2020). Sexual desire changes in transgender individuals upon initiation of hormone treatment: results from the longitudinal European network for the investigation of gender incongruence. The Journal of Sexual Medicine, 17(4), 812-825. https://doi.org/10.1016/j.jsxm.2019.12.020

Glintborg, D., T’Sjoen, G., Ravn, P., & Andersen, M. S. (2021). Management of endocrine disease: Optimal feminizing hormone treatment in transgender people. European Journal of Endocrinology, 185(2), R49-R63.

Haupt, C., Henke, M., Kutschmar, A., Hauser, B., Baldinger, S., Saenz, S. R., & Schreiber, G. (2020). Antiandrogen or estradiol treatment or both during hormone therapy in transitioning transgender women. The Cochrane database of systematic reviews, 11(11), CD013138. https://doi.org/10.1002/14651858.CD013138.pub2

 Swe, N. C., Ahmed, S., Eid, M., Poretsky, L., Gianos, E., & Cusano, N. E. (2022). The effects of gender-affirming hormone therapy on cardiovascular and skeletal health: A literature review. Metabolism Open, 100173. https://doi.org/10.1016/j.metop.2022.100173

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You are seeing Julie, a 31 yr old male to female transgender patient. Julie reports she has been having difficulty being compliant with her oral estrogen therapy and questions what alternative approaches to her estrogen therapy are available. She is concerned about her continued significant facial hair growth, and decreased sexual drive. She is afraid that if she continues to have these symptoms that she will be less desirable to her partner and their relationship will deteriorate.

Discuss the role, as well as the risks/benefits of estrogen therapy for male to female transgender transition and maintenance.

Discuss alternatives to estrogen therapy.

Discuss the role that hormones play in sexual drive for male to female transgender patients

Outline your plan for evaluation and management for Julie