Is spironolactone bad for HRT

Common questions about hormone therapy

What should be used to lower testosterone levels?

While spironolactone is primarily used to lower testosterone levels in the USA, cyproterone acetate (Androcur®) is mainly used in Europe. Both substances are artificial descendants of progesterone, so-called progestins, which have a testosterone-suppressing and antagonistic effect, i.e. counteracting testosterone. Spironolactone tends to be less effective in terms of its affinity for the testosterone receptor. There are almost no comparative studies that provide an advantage or Show disadvantage of one therapy compared to the other. With cyproterone acetate, increased liver toxicity has been reported as a possible side effect. However, this occurs extremely rarely with the dosages used in transsexuality. Alternatively, a suppression of the sex hormones can also be achieved with the administration of so-called GnRH analogues. These are usually injected at monthly intervals and, in contrast to cyproterone acetate and spironolactone, only work centrally and not peripherally. Possibly they are better tolerated with regard to psychological side effects, since they cannot theoretically act like the progestins on other receptors in our brain that are e.g. connected to the stress system.

Is Progesterone Necessary in Trans Women?

There is general consensus that additional progesterone administration is not necessary and may only increase the rate of side effects. In women, progesterone can have an effect on the differentiation of the mammary gland tissue, but it does not appear to have any effect on breast volume as such, which is in the foreground in male-to-woman transsexuals. In hormone therapy for postmenopausal women, progesterone increases the risk of breast cancer and the rate of cardiovascular disease. Little is known about possible psychological effects. In women, however, progesterone can promote the development of depression. Some sufferers want sequential estrogen and progesterone administration to mimic a female cycle. Here, too, it must be remembered that up to 60% of women of childbearing age are not subject to such a cycle because they use hormonal contraception. Finally, it must also be mentioned that the antiandrogens cyproterone acetate (Androcur®) and spironolactone as progestins can, by definition, bind to the progesterone receptor and thus develop a corresponding effect.

Should the estradiol be given as a tablet or through the skin?

Most of the data on the advantage of transdermal (= absorption through the skin) versus oral (= as a tablet) supply come from studies on postmenopausal women who have received hormone therapy. Transdermal administration means that there is a lower risk of blood clots forming. Every hormone that is swallowed is largely broken down by the liver and thus leads to liver strain. There are also studies in trans women which have found indications of increased blood clotting ability during oral intake. In principle, transdermal administration is particularly recommended for older people (> 40 years) and if there are other existing risk factors for thrombosis or pulmonary embolism (e.g. with nicotine consumption).

What influence do the sex hormones have on the psyche?

There are different statements about the effects of sex hormones on the psyche, which are probably primarily due to the fact that there are very large inter-individual differences here. Just as with other women, for example, hormonal contraception can have positive as well as negative effects on the psyche, or mood swings can occur in the context of the female cycle, the effects of opposite-sex hormone therapy are individually different and difficult to predict. However, in 80% of cases, hormone therapy leads to an improvement in mood and quality of life. It must be added that in some patients, after a so-called honey moon period of up to a year, the mood can worsen again. Testosterone can lead to excessive sexuality or more aggressive behavior.

Testosterone in Trans Women?

Even if the thought seems absurd at first glance, it must be taken into account that the male sex hormone testosterone is also formed in the ovaries and adrenal glands in other women. Trans women usually have testosterone levels below those of postmenopausal women after their testicles have been removed. In individual cases it may therefore be advisable to initiate a low-dose testosterone substitution based on the female organism (e.g. with 25 mg TestoGel spread over 5-7 days) after the gender reassignment operation has been carried out in the case of libido disorders or a deterioration in mood.

Why do the dosages differ depending on how the estrogens are used?

The dosage form plays a decisive role in the dosage of estradiol. When absorbed through the intestines, much of the hormones are broken down by the liver before they can reach the bloodstream. Therefore the required doses are higher here. When given as a gel, they are already lower (1mg≙0.75mg). In the case of patches, much lower doses are necessary because they contain so-called absorption enhancers, which improve the absorption capacity, so that, for example, only 0.05 mg of estradiol are released daily.

What actually happens in the "menopause" of trans women?

There are no clear recommendations for this, but it is known that the risk of developing cardiovascular diseases increases with age when taking hormone therapy. Therefore, it should be considered whether from the age of 50, if therapy has been used for many years, at least a reduction in the sex hormone dose should take place.

Breast growth is not enough, what can I do?

In breast growth, as in other women, a very strong hereditary component also appears to play a role. Taking sex hormones beyond the recommended maximum dose does not lead to any additional breast growth and only increases the rate of side effects. If other measures, such as consistent hormone therapy, do not achieve at least an A-cup over a longer period of time, according to the latest legal situation, there is an obligation to reimburse the health insurance companies for surgical breast augmentation.

What are the effects of the hormones on hair?

In trans women, the combined estradiol-antiandrogen therapy can usually achieve a significant reduction in body hair. However, in the majority of cases, additional epilation measures are necessary in the face area in order to achieve a satisfactory result. In trans men, there is usually a significant increase in body and facial hair in the course of hormone therapy. Here, too, there is a restriction that the individual extent of hairiness is mostly genetic and is therefore not primarily due to the hormone dose. Androgenetic alopecia (hair loss of the male type) often occurs as an undesirable effect in the course of the disease. If necessary, this can be treated with local or systemic therapies.

What are the pros and cons of the different testosterone supplements?

Testosterone as an injection lasting several weeks or several months is very practical and widely used. Especially with the short-acting preparations that are used every 2-4 weeks, however, there may be an excessive testosterone increase shortly after the injection. Against the end of the interval there is a risk of undersupply. These strong fluctuations can be perceived by some patients and have a particularly negative effect on the psyche. With the preparations that are only used every few months, the fluctuations are less pronounced. The restriction here is that if you initially choose these preparations, the hormones remain in the body for several months and, in the event of any intolerance, the negative effects last for a correspondingly long time. The gel formulations allow the most constant effective levels to be achieved in the blood. The disadvantage is the lower practicality due to the necessity of daily application. In addition, a certain "hormone hygiene" must be observed. There should be no close physical contact with children or women for at least 2 hours after application, as hormone transmission can still take place through clothing. Recently, preparations that can be used under the armpits have also become available which have a lower risk of contamination for outsiders, but which have not yet been used in therapy for trans men.

Matthias Auer