Feeling hormonal

A decision to delist hormone replacement therapy (HRT) products from the Ontario Drug Benefits Plan (ODBP) as of Mar 1 due to the associated health risks for menopausal women is raising questions about what is known about the risks for trans women using the same products.

“The [medical] evidence is sparse and thus, no specific recommendations were made regarding the therapeutic role of these products in the transsexual patient group,” says Ontario Ministry Of Health And Long-term Care media relations coordinator David Jensen.

For trans women accessing hormones through ODBP, there’s now another administrative hoop to jump through. Physicians are required to make a written request for their patient’s HRT through the ministry’s Individual Clinical Review mechanism. Requests will be reviewed on a case-by-case basis, says Jensen.

The lack of substantive research on the risks for trans women is in part because of the relatively small population for clinical trials and in part because of prejudice, says Anna Travers, LGBTT [lesbian, gay, bisexual, transsexual, transgendered] services program manager at Toronto’s Sherbourne Health Centre. Collection of statistical information is also made more difficult due to the variety of hormones available and varied methods of administering them.

The decision to delist HRT from ODBP was based on two studies: one from Women’s Health Initiatives (WHI) and the other called the Heart And Estrogen/Progestin Replacement Study (HERS), both of which indicated that the risks of long-term use of HRT outweigh the benefits for menopausal women. Risks identified for bio women include increased rate of coronary events, breast cancer, dementia, stroke, blood clots and abnormal vaginal bleeding. In fact, both studies demonstrated that even short-term use (under a year) had an increased risk for cardiovascular events.

These findings, however, can’t be applied directly to the trans experience because the risk-benefit ratio and physiological interactions are different in trans women than they are in menopausal women. Rebecca Allison, a US cardiologist and trans woman, writes that, for most trans people, “the benefits [of HRT] outweigh the potential risks, even taking into account the results of the WHI study.”

So what are the risks for trans women? What little we do know indicates that for trans people on hormones — both female-to-male (FTM) and male-to-female (MTF) — adverse side effects include increased risks of blood clotting, stroke, cardiac events, decreased insulin sensitivity, high blood pressure, weight gain and liver and gall bladder problems.

For MTFs on estrogen, progestins and/or anti-androgens permanent effects include breast development and nipple enlargement, and reversible effects include the redistribution of body fat, reduced muscle development, reduced body hair and less prominent veins. Adverse side effects may include depression, high blood pressure, migraines, liver and gall bladder problems and a potential increased risk of breast cancer.

Despite the risks, health service organizations specializing in providing hormone treatment to trans people, such as Sherbourne Health Centre and San Francisco’s Tom Waddell Health Center, believe HRT to be generally safe for trans people, particularly with ongoing medical monitoring.

“What we do know is that when hormones are properly administered and monitored, there haven’t been a lot of really serious side effects,” says Travers.

Potential adverse effects can also be ameliorated through the method of administering, which include injection, patch or oral. For example, using a transdermal patch may reduce the impact on the liver and the risk of pulmonary embolism. Appropriate dosages are also key to minimizing negative effects, says Travers.

So what makes taking HRT worth the risks for the trans women?

“Imagine your mind as a jigsaw puzzle that won’t fit properly and you don’t understand why,” says trans woman Ilsa Hunter, “and then suddenly everything fits into place and you can finally see yourself for who you are.

“To be fair, hormones aren’t happiness in a bottle. But for all the problems I have, hormones have put a small part of me at peace.”

“I think the perspective of most trans people [is that] going on hormones is just an obvious and happy step to take,” says trans woman Rebecca Hammond. “It’s analogous to asking the question, ‘Was going through puberty worth the risks?’ The uncertainty I don’t think has stopped a single transsexual from going on hormones.”

What is abundantly clear is that risk factors for heart disease — cigarette smoking, high cholesterol, diabetes, high blood pressure, obesity, age and family history — need to be assessed for anyone using hormones. Cardiovascular risks are more than additive and thus any of these factors can significantly increase risk with hormone use. Regular monitoring is also essential, including blood tests, bone density scans and general health assessments.

“Not everyone can use them, so we must know the individual health status,” says Travers. “What ultimately minimizes health risks is access to good healthcare.”