The effects of hormones

Taking oestrogen reduces your blood pressure. Or not.

There was a study published in 2015 of 23 trans women and 34 trans men commencing hormone treatment, measuring blood pressure, BMI, lipids and sex hormone levels at the start of treatment and six months after. Trans men continued menstruating throughout the time. The trans women’s blood pressure reduced from 130 to 120.

When a doctor takes my blood pressure I become tense, and they tell me this may give a falsely high result. Trans women beginning treatment are likely to relax. They are on their way, so their stress will reduce. So blood pressure reduces. These people are undergoing such an extreme life change that it is impossible to isolate one possible cause of change of blood pressure. “The study had insufficient power to detect other associations,” the summary says, and I wonder, decades after doctors started giving us hormones, that so little has been done to find what they do to us.

I wanted to read the article Priorities for Transgender Medical and Health Care Research, but it will be published on 1 April.

From 2007, there is an NHS leaflet, addressed to both trans men and women. The aim of hormone therapy is to make you feel more at ease with yourself, both physically and psychologically. That is, the fact of taking hormones, whatever effect they have physically, affirms your transition so makes you feel better. Some people find that they get sufficient relief from taking hormones so that they do not need to change their gender role or have surgery. I had decided to transition: I am transsexual, therefore I will transition to expressing female. A more fluid way of proceeding, trying things out, would have been better. I railroaded myself.

Hormones will affect your appearance, but you need to be realistic (the leaflet says). Fat may be redistributed, hair loss may reduce though probably not significantly reverse, facial hair may be easier to electrolyse, you may grow breasts though that might take years- ten years, in my case. You may have blood clots in brain, heart or veins: a woman I met in Thailand had a stroke a few months later. You should stop smoking, which increases risk: I was told you could not have hormones until you stopped.

If you start to feel better this is a good sign that you are having the right treatment. However, I railroaded myself. I committed to the whole thing. Moving forward on that track made me feel better, because I thought I had the solution, waiting at the end of the track.

You may find erection and orgasm harder to achieve. You may become infertile: it is not known when. You may become less interested in sex. This was a good thing for me, as I was so thoroughly ashamed of it, but I might have found better ways of living with it.

It is unethical and impossible to conduct a study comparing transition with other modes of treatment. People wait for years to see an NHS psychiatrist, and have definite ideas of what treatment we want. From Lili Elbe onwards, doctors have seemed delighted to have a subject they could try things out on, rather than merely wanting to find the best way to help, which might be to do nothing.

“You will need to take hormones for the rest of your life.” I was told I had to, to avoid the risk of osteoporosis.

Study: Effects of Cross-Sex Hormone Treatment on Transgender Women and Men.

Patient leaflet– A guide to hormone therapy for trans people, pdf.

norah-neilson-gray-self-portrait-1918

Gender psychiatrist

I am one person. This is not immediately obvious.

Penny Lenihan, at Charing Cross, is my eighth psychiatrist. I liked her practical manner, and she shook me up, so that I don’t want to go where I am going this weekend. Cos it ain’t competent me that is going, but shit me, shit me who does fuck all and whom I despise. She observed me communicating calmly and well, and me weeping in anger frustration and sadness, and said “You compartmentalize”.

And I think that’s a bad thing, and I should stop, and I don’t even know what she means by it, particularly. One of my thoughts was that this is a good experience, because however unsettled I feel now I might get to better ways of coping. And now I think that I might bring things to consciousness: see what I am doing, see I have choices.

I got a different view of Serra Pitts. Dr Lenihan has some familiarity with my case, because she has been supervising Serra, who was a trainee and is no longer working with the clinic. I was unaware Serra was a trainee. It is “contrary to protocols” that trainees work with patients privately after sessions at the clinic end. Dr Lenihan will see that the new trainees are aware of the protocols, she says drily. And now I see, yes, that is appropriate; and Serra just not turning up for work does not mean Serra having great difficulty but Serra doing something any employer would object to.

We started by discussing what hormones I was on. She saw no reason for me to be on norethisterone, and did not think my emotional issues were anything to do with hormone doses, though she did want me to see the endocrinologist.. This morning I have been entirely miserable about that: so much of what I have done over the last four years to get my head together has been at best useless. So we were off to a bad start: I thought I would be discharged. She asked if I had been offered group therapy. Well, no; I would be willing to attend but needed it sold to me: what might I gain? So the offer of groups appeared rescinded, because I was insufficiently enthusiastic, and I was confused.

Like many group patients, I like to imagine I am better than the people I would meet in the group; and perhaps fear opening up to them.

Serra told me that the clinic is under great pressure to put patients through, and achieve desired outcomes. I should come knowing what I wanted to get out of it.

So because my emotional issues are not particularly related to transsexuality, she will refer me to my local CMHT. Yes, I do know that means Community Mental Health Trust. I know what they will say: “Sorry, we have no funding”. Well, I am not a risk of killing someone, and if I were they could always leave me to the prison system.

So I gave myself permission not to go to the AM clerks’ conference, and considered the possibility that I would be still tearful, there, and actually disrupt it, rather than merely gain nothing and give nothing to it; and decided that the risk was worth it, and that I could get there without undue difficulty, and would just go.

Antoine Caron, The Triumph of Winter

Norethisterone III

How does synthetic progesterone, Norethisterone, affect my mood? I can only find out by varying what I take.

My retired doctor friend said an option would be to take norethisterone all the time. When my levels change, then my moods will. I could cut it out, continue on the current regime of twelve days in every four weeks, or take it all the time. The GP was happy to prescribe norethisterone: it is oestradiol which causes the elevation in risk of deep vein thrombosis and so heart attack, stroke, pulmonary embolism etc. I can do what I like with norethisterone.

The norethisterone I take is licensed as a contraceptive. I did not think my risk of pregnancy was that high, but there you go. It is a dose a third of what I was taking, so I have to take three pills: I heard that contraceptives had far higher doses of hormones than HRT, which is not true of these pills: you have to go into these things in great depth or just do what feels right, and trust. I don’t know that an in depth understanding of current endocrine theory would help me make better decisions. I also see that norethisterone is used to delay bleeds or mitigate heavy periods, which might seem to contradict what I had heard, that it is used in HRT to precipitate a bleed; but different doses may have different effects in different situations.

The first thing I decided to do was take it all the time. I wanted greater control; and I wanted to see what effects altering what I take might have; but I am not sure I want to reduce my emotional lability. When it’s good, it’s really good. My friend said that menopause was a relief, as she got her analytic mind back. During her period, it left.

I want the intensity of feeling, because it feels good, and may help me understand my desires. I find myself swayed by attraction and aversion rather than calm analytic thought, and that feels like me making the decisions.

And on Sunday night I sent off an email. I reacted rather than responding. I did not improve the situation, and may have made it worse. I made a politic decision: rather than saying “I am angry” I wrote “I am distressed”, because that gets more sympathy, even though as I read on facebook “Angry is Sad’s bodyguard” and my choice of word was calculated- analytic enough. The communication I had received was badly expressed, but it was a lot less offensive when it was explained to me than it had seemed. That is, there are risks; however my feeling angry sad or fearful is usually a good thing, and not to be feared.

Rousseau, Jungle at the Equator

Letting off steam

Trouble with hormones. Man cycling on the pavement of Midland Road, which has little vehicular or pedestrian traffic, a wide pavement and low kerb so you can fairly easily move on and off the pavement on a bicycle. Being in an arsey sort of mood, I think to myself “It’s a road vehicle,” and walk so as to force him to the edge of the pavement. He wobbles on the edge, passes me, and shouts abuse: “Slut!” he shouts. “Slut! Slut!” Quotidian human interaction…

Here am I on the green pills, which may or may not cause emotional lability, and my emotional reaction shows in my face and actions. Sometimes I am upset, and I start to cry (Oh God, I think, why can I not get this sentence out? Such frustration!) and sometimes I get angry. There is a rational basis, an explicable factual stimulation behind both responses, the world is not as I want it to be, do you want it to change too, can we make it better? The crying produces “there there” noises and offers of help and sympathy- still frustrated, I think No! Under this I am sensible- and the anger produces an equal and opposite reaction, or sometimes expressions of hurt from others which get sympathy and I am the Bad Person.

It is so frustrating! If only I could choose: calm, rational explanation; turn on the waterworks to elicit, “Oh! How can we help? What can we do?” Anger just at the right moment…

Arse excelled himself. (Quakers do not know whom I mean.) Now, when exactly the same circumstances are about to arise, I think, surely he will not do it again? Fearing that he will, I find anger and irritation rising, and wonder if I will be able to resist the sarky remarks which he just might take as a challenge. I know a soft answer turneth away wrath, and it is oestrogen I am on, and still.

Or, total bore whose topics of conversation with me, when I fail to avoid her, are what a wonderful Ally she is and what right-on opinions she has about LGBT (which I feel is my topic, and I don’t want to talk about it except when I do) and ghastly sympathy about how awful it must be to wear a wig, be unemployed etc. Actually, wearing a wig is like having your own hair: sometimes I love it, sometimes I think Oh God I look like a man! It looks like a wig! I look terrible! To which the appropriate answer- most women understand this- is “You look beautiful. Of course I mean that. I would not say it if I didn’t mean it…”

So I shouted at her, making my aim about which I was really stressed less likely to be achieved, making me less able to contribute to achieving it, and making me the bad person. Yes, I know I upset people. Sometimes I regret that, and sometimes I just regret the results.

Feuerbach, Medea

Norethisterone II

I am on my period. Sort of, anyway…

For some years a trans woman I met put a rubber bladder inside her knickers for five days each month, filled with a red concoction of the consistency of menstrual blood, which would leak out into a sanitary towel. I thought this entirely bizarre, but she wanted to have part of the experience of menstruating. Of course, her period was generally in her control.

I seem to have greater emotional lability when on Norethisterone acetate, twelve days in 28. The moments which most embarrass me over the last three months have taken place on the green pills. But then I started them on Tuesday last week, and have felt good. Planning my trip to Luton from Richmond was a pain: will I find three separate entrances to public transport, in streets I do not know, in five minutes? Will any of them be late so that I have less time? Even on the bus, I was stressed.

I keep thinking of an archetypal human conflict with the woman on the bus. She sat beside me holding the bar in front, so I had to ask her to let me out, twice. When I got off she caught my eye, standing in the street- she got off, she had time, I had no need to get up so quickly. Or, I have a right to get up early if it makes me feel better. Each irritated the other, and she caught my eye and pulled a face at me. Of such minor triumphs good morale is made.

Meeting a friend. She texted, don’t be angry that I am late. Oh, Darling, I thought, I expected you to be late, I am quite mellow. The food was poor: edible but dry and boring, in small quantities. Now, I have a letter about my last meeting with Stuart Lorimer of Charing Cross GIC, and I am not reading it. I glance at it, read a sentence, get worked up about what it says, leave it. Perhaps I will sit down with it, it says nothing I do not know, though the differences between his understanding and mine irk me.

Flirting with the woman at the station ticket office. I have noticed her, either butch lesbian or possibly a woman who likes to “wear the trousers” with sissy men; and on Friday she said “That’s £9.60, Honey”. Ooh. Yesterday she admired my necklace, so I took off a matching earring to show her.

With that friend, I got to the theatre just before the lights went down: not bad seats, actually, and quite on time.

So I do need to manage stress, or I could be a stress monster. But the risk of shouting at someone might be worth it, if I could enjoy the heightened sensibility the rest of the time.

Ingres, Venus Diomede

Norethisterone

Should I be taking norethisterone? It is synthetic progesterone, and (if the difference between the green pills and the white pills means what I think it means) I take it twelve days in every 28. Why should a trans woman take hormones, anyway? What good do they do?

My friend is a retired doctor, as is her husband. I wanted to discuss my emotional lability, and the possibility of a hormonal effect on that, with a friend before the psychiatrist in November. She thought her husband would be more up to date on endocrinology. I thought, oh, do I have to? Telling a friend is one thing, telling yet another person that I have never met-

I cycled by country roads, luckily picking the right private farm road, and entered their beautiful house. The garden is glorious. I meet this man, and really do not want to. We shake hands. Over lunch I admire the art work- this 4′ high fish is welded together of bicycle parts- and having sensed my discomfort she suggests he go out of the room, she could consult him if she really needs to: yet such was his gentle charm that now I would like him present.

The whole problem is life passing me by (does everyone think that, or only most of the people most of the time?) while I sit at home with little motivation and no felt ability to earn money to support myself. And I feel so lonely yet want to hide away. But the smaller problem, which might be addressed by hormone adjustment, is my emotional lability. I would like to discuss this with you without bursting into tears. I would like to discuss Quaker problems with an overseer without crying or getting angry.

He says, there is not always a medical solution, and one of the GP’s roles is to protect patients from specialists. An endocrinologist will seek a hormonal solution, a psychiatrist a psychiatric one. Mmm, sometimes leave well alone is the best answer. I started the norethisterone after the endocrinologist saw blood results, and after the psychiatrist suggested testosterone for motivation.

Godward, an Offering to VenusHe says, the point of norethisterone in HRT is that oestradiol alone risks cancer of the lining of the womb, and norethisterone clears it out reducing that risk. So there should be no need in me. Now, I wonder, what of motivation, did the specialist know something he did not? Or not? One of his patients on norethisterone had been quite unreasonable emotionally- he happened to see it, she admitted it- and on this sample size of one he was wary of it. Though proper peer reviewed studies may be no more reliable.

There you go. One possible thing worth trying. Not an answer, even though hormones affect mood: premenstrual syndrome is not merely a male chauvinist myth, and I feel, well, premenstrual. I could try and see if I felt more labile when taking the green pills.

We discussed my wider issues. On defences, he noticed that when I seemed to be coming to an important point, I would digress into a long story.

I feel valued. I feel cared for. It was lovely, talking of my stuff to sympathetic hearers for two hours.

 

Oestradiol

Why should I be taking hormones? Dr Lorimer’s answer was, to prevent osteoporosis. Now, I have no wish to have a break as easily as I now have a bruise, but don’t think that is a huge risk. What Dr Lorimer said makes no sense to me, and is inconsistent with what he said before: I said I was lacking in energy, and he proposed testosterone. I said I would agree, if it would get me more motivated. His endocrinologist colleague proposed instead norethisterone, synthetic progesterone. It is indicated for heavy periods, not something I have suffered from.

Yet it could be that the only reason to take oestradiol indicated by studies sufficient to back licensing a preparation, is to avoid osteoporosis.

Oestrogen is so important to the culture. The name comes from Eastre, Germanic Goddess of Spring and fertility, from which we get the word Easter. The suffix is from the Greek for Begetter. Women have strong feelings about HRT, not all related to peer-reviewed double blind large-scale studies, and doctors’ recommendations for it seem to change by fashion as much as rational prognosis.

I could, I suppose, find out about the differences between oestradiol and oestrogen, norethisterone and progesterone; normal levels in pre- and post-menopausal women; and documented effects on such things as felt energy levels, emotional lability, and motivation. The problem is that I don’t believe finding these things out will give me any more control over those things.

I don’t know whether they affect the softness of my skin or levels of facial or body hair. I have grown breasts because I take hormones, but I don’t think they are growing now.

I like to think I would like a rational reason for taking, or ceasing to take, my pills. In cis women, they increase the risk of breast cancer and stroke. Yet I don’t look for one, perhaps because I do not believe it. It felt like I became hugely labile when I came off them suddenly, but I was stressed at the time and going back on did not seem to change things. I can’t be certain of anything.

So I keep taking the tablets. Perhaps they are a symbol of my femaleness, a link to womanhood. I feel my feminine character is more important. I like to think I don’t need a symbol.

Ostara, Johannes Gehrts

Hormone history

Pissarro, still life painting with apples and pitcher I cannot see how the advice I was given about hormones, or the decisions I took, could have been better; yet with hindsight I wish they had been otherwise.

When I decided to transition, it seemed possible to me that I would revert within five years; yet the only way I could get to the point of committing to presenting male was trying the alternative. If I never tried transition, it would always be the siren path. I have not reverted, and have no desire to, twelve years on. I started taking Ovran, which has now been discontinued, the sort of dose of oestradiol that women take as HRT, and Oestrogel, absorbed through the skin. Soon after I started taking spironolactone, a testosterone suppressant, prescribed by my private psychiatrist Russel Reid. I heard on Radio 4 that some men are so concerned about hair loss that they take this, illegally sourced. It can cause irreversible damage to the testicles, and breast development.

Pissarro, still life with peoniesI asked my GP to refer me to a local endocrinologist. He had seen my trans friend, and without expertise in trans issues had read up a bit. He tripled my hormone dose, and gave me gosarelin implants, which suppress testosterone more comfortably. They are given to sufferers from prostate cancer. The tripling was to stimulate breast growth, which did not impress me much, and I stayed on that dose until it was suddenly cut to zero. My feelings went wild: though I had had periods of emotional lability before, it was then that I became completely self-conscious of them. I went back on 2mg, then 4mg, then 6mg, and my lability continued.

Eventually I got referred to Charing Cross, and though I have not seen their specialist endocrinologist, he has looked at blood tests. He has halved my dose of oestradiol and put me on Elleste duet, which includes a synthetic progesterone- norethisterone acetate. My oestrogen levels are “normal”. Progesterone might make me feel a bit more energetic and motivated, was the thought. I take it twelve days in 28, and notice that my breasts are slightly tender then.

Well, what’s normal, and how does it matter? Normal for a woman after menopause: contraceptive pills have far higher doses of hormone. If your blood sugar is not “normal”, you can develop diabetic retinopathy- go blind- or follow the path unconsciousness- coma- death. “Normal” oestrogen levels seem less important than that, but- I don’t know. As for energy levels and motivation, some people do what I do plus a full time job. Rationally I see it would be better to be doing more, but I am reasonably content with watching TV and reading a bit, blogging a bit. Perhaps, if I had a partner supporting me, I would be looking for other excuses reasons for my lassitude, such as chronic fatigue syndrome. I manage not to be emotionally labile by excluding everything from my life, and hiding at home. I have not been meditating. I knelt, just now, and rather than concentrating on my breath my mind went wild, thinking of an experience yesterday with exasperation and sadness. Should I try once again to pass through the lability?

Confusion and clarity

Klee- Oriental pleasure garden, in partG was excited by the first meeting of the Green Party in Swanston, and wanted to do something for it. Oh, remember Advices and Queries- don’t work too much? What is it? Eventually I find the quote:

 
Attend to what love requires of you, 

which may not be great busyness.

I have not actually read Advices and Queries for a long time, and sat with it at the start of Meeting, in love again with its sonorous phrases:

 This.

This.

This.

Are you?

One thing which makes it beautiful is its clarity. Are you honest and truthful in all you say and do? Do you maintain strict integrity in business transactions and in your dealings with individuals and organisations? I have always sought clarity. I sought it in the law, though in practice I found pseudo-clarity, like this:

Work done in expectation of payment means more than a mere hope that payment will be made at a future date. There should be a probability rather than just a possibility that a payment will be made. If a person reasonably expects payments for work done then the condition is satisfied. However, if the person knew before starting the work that payment was unlikely to be made, the remunerative condition is not satisfied.

That’s the Tax Credits Technical Manual. If you specify every possible situation, the thing which must be done will always be clear. However, in my experience Real Life brings hopeless confusion to it, and the desperate efforts to answer every question merely increases complexity and confusion- as if confusion were the real goal, with the apparent clarity only an excuse to blame others for it.

It seemed to me in meeting that the answer is Love, not Fear. If I did that job I am considering applying for, or A’s job, in fear, I could never assuage my fear. Am I doing it right, and is my job safe? Am I caring properly for the thing entrusted to me, and is it safe? Yet if I did it in Love- what will build this up, what will make it more beautiful, I could get endless joy from it. Then K ministered, and said how pleased he was to go to the Green Party meeting- I was delighted to see him there- and of his desire for a politics of hope.

I had a lovely meeting. Love, not fear. Then we had our business meeting, and S resigned her membership. On Friday, S and I had had coffee together with Quakers, and discussed what more she could do in the Society, so this was a shock. After, E asked “Are you alright?” and I started crying, angry that I was so upset. I should not be emotionally labile like this after the endocrinologist adjusted my hormone dose.

It seemed to me after that I have created my safe space in my living room, and the Quaker meeting, and I explore other potential safe spaces such as Greenbelt, yet even in the Quaker meeting I am not safe from painful change I cannot control.