Hi ,
Thanks for writing in to us.

Humira (adalimumab) is a recombinant human IgG1 monoclonal antibody specific for human tumor necrosis factor (TNF). It works well for conditions like Crohn's disease.

Estrace (estradiol) is a form of estrogen, a female sex hormone produced by the ovaries.

I would like to make you aware that there is no serious interaction between Humira and Estrace documented in medical literature to the best of my knowledge.

Following side effects can be caused by Estrace:
Sudden numbness or weakness, especially on one side of the body;
Nausea, vomiting, loss of appetite, increased thirst, muscle weakness, confusion, and feeling tired or restless;
Feeling like you might pass out;

The tiredness and extreme fatigue may be discussed with your doctor before going off Estrace.

I hope this answers your question,
Write back in case of doubts,
Dr. A. Rao. Kavoor.

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Hi,
Thanks for writing in.

I will answer your queries as below:

Can you advise of the longterm risks of taking Estrace?

There are a few long term risks associated with continued Estrace (estrogen) use:
1.     Taking estrogen increases the risk of blood clots. Blood clots can cause death, permanent lung damage (clot in the lungs), permanent brain damage (stroke), heart attack, or chronic problems with the veins in your legs. The risk of blood clots is much higher for smokers, especially those who are age 40 or higher. The danger is so high that some doctors will not prescribe estrogen if you are a smoker; most will only prescribe you a low dose as long as you are still smoking.
2.     Taking estrogen changes the way your body metabolizes and stores fat. Taking estrogen can increase deposits of fat around your XXXXXXX organs, which is associated with increased risk for diabetes and heart disease.
3.     Estrogen also increases the risk of gallstones, which can block your gallbladder. If you have chest or abdominal pain, you should see a medical professional right away.
4.     Estrogen can cause increased blood pressure. This can be counteracted by taking it with spironolactone, which tends to lower blood pressure.


Liver issues and Estrace (history of hepatitis):

Estrogens may be poorly metabolized in patients with impaired liver function. For patients with a history of cholestatic jaundice associated with past estrogen use or with pregnancy, caution should be exercised and in the case of recurrence, medication should be discontinued. Liver function tests need to be done and results to be discussed with your doctor regularly.


Can you advise what can be expected after going off hormones?

If you stop taking the medication, most of the changes will reverse themselves. There are two types of changes that may be permanent: breast growth and sterility. Estrogen causes permanent nipple development and breast growth. Even if you stop taking estrogen, breast tissue will not go away and your nipples will not shrink.


Does the body and mind readjust? How long will it take to rebalance the body?

Starting Estrace:
Bringing the mind and body closer together eases gender dysphoria and can help trans people feel better about their bodies. People who have had gender dysphoria often describe being less anxious, less depressed, calmer, and happier when they start taking hormones. For some people this psychological change happens as soon as they start taking hormones, and for others it happens as physical changes happen. The degree and rate of change depends on factors that are different for every person, including your age, the number of hormone receptors in your body, and how sensitive your body is to the medication. There is no way of knowing how your body will respond before you start hormones.

Some physical characteristics aren’t changed by hormone therapy, or are only slightly changed. This includes aspects of your body that develop before birth (penis, sex chromosomes, etc.) and also physical characteristics that developed from the increase in testosterone at puberty. Hormone therapy may make facial and body hair grow more slowly and be less noticeable, but hair will not go away completely. “Feminizing” hormone therapy does not change voice pitch or speech patterns. Speech therapy can help change pitch and other aspects of speech associated with sex/gender. Some MTFs have surgery on their vocal cords or the surrounding cartilage to try to further raise voice pitch.

Stopping Estrace:
Even if you stop taking estrogen, breast tissue will not go away and your nipples will not shrink. Sudden changes in dosage of estrogens, either increasing or decreasing, have been known to produce severe mood changes. Lethargy, depression, anxiety, difficulty in concentration, headaches, abdominal cramping, nausea, and other symptoms have been noted for periods of days or weeks.

I hope this answers your question,
Write back in case of doubts,

If you do not have further queries, I request you to please close this thread and post a feedback.
Dr. A. Rao. Kavoor.

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Hi,
Thanks for writing in.

I will answer your queries as below:

1. Can you advise of the link between going off hormones and osteoporosis? Does estrogen preserve bone strength? If there is a link between going off hormones and osteoporosis, what measures can be taken to reduce the risk of osteoporosis? Is there an additional risk from an orchiedectomy and osteoporosis? What can be done to minimise the risk of osteoporosis?

After removal of the testicles the body is only producing a tiny amount of testosterone, so the dosage of estrogen is usually cut in half and anti-androgens greatly reduced or stopped. Your friend will need to stay on estrogen or another form of medication for the rest of their life to preserve bone strength. The doctor may also suggest that your friend take Calcium and bone density. Stopping estrogen, taking too low a dose, or stopping and restarting can
negatively affect bone density.
• Studies of MTFs who were taking estrogen found no negative changes to bone density. Researchers concluded that taking estrogen compensated for the decrease in testosterone.
• It is not clear whether just taking an anti-androgen (e.g., spironolactone) without estrogen is safe in terms of bone density.
Non-trans men who have low testosterone have higher risk of osteoporosis. Decreasing the body’s testosterone without increasing the estrogen could cause similar problems in MTFs.


2. Regarding enhanced breast and nipple size from estrogen, after going off hormones, is it possible to have surgery to reduce breast size? If so, what kind of surgery? Or does the breast size shrink naturally after going off hormones?

There are surgeries to reduce breast size. This is the same as done in males who develop gynecomastia. Fluid is inserted by creating a port and then aspirated through a pump. Breast size does not shrink after going off hormones.

3. In going off estrogens, do the risks of taking estrogens reverse immediately? For example, the deposits of fat around the XXXXXXX organs? There is much diabetes in the family.

Your friend will have to allow some time for the risks associated with estrogens to reverse, a few months perhaps. There is no rule book to suggest the exact time necessary for that to happen. Subsequently risks associated due to conditions arising from estrogen intake also decline with time.

4. As another question, how does going off hormones affect sex drive, if at all? Please keep in mind there is an orchiedectomy. Does going off hormones affect the ability to have an erection? I am aware of sterility – fortunately, there was sperm banking prior to hormones.

After going off hormones, your friend might notice improvement of your erectile function, sex drive though can vary from patient to patient. Glad to know that sperm banking was done.

I hope this answers your queries,
Write back in case of doubts,

If you do not have further queries, I request you to please close this thread and post a feedback.
Dr. A. Rao. Kavoor.

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Hi ,
Thanks for writing back.

Let me answer your queries as follows

1.     Can you advise which medication(s) (aside from Calcium and bone density after going off hormones?

Bisphosphonates are a class of drugs that can be given for prevention of osteoporosis. These need to be taken as per instructions.

2.     If sudden decreases or increases in hormone dosage affect mood, anxiety, etc, - what would happen if the endocrinologist slowly decreased the dosage? Are there still mood swings?

The increase or decrease in hormones act differently in all people. Mood swings can occur if the total amount of hormones in body is altered. Please remember that there is very little testosterone without testis.

3.     After three years on hormones, the breasts have probably grown to maximum size –and will nor shrink after hormones. Being on hormones, longterm, creates health risks. The health risks of staying on hormones are further complicated by age(mid-30’s) smoking, and general health,(Crohn’s and Humira). What would be the benefit of staying on hormones?

As I have discussed the risks in the first reply, the benefits of staying on estrogen as follows.
Bringing the mind and body closer together eases gender dysphoria and can help trans people feel better about their bodies. People who have had gender dysphoria often describe being less anxious, less depressed, calmer, and happier when they start taking hormones.
Prevention of osteoporosis.

4.     If it is a psychological benefit to staying on hormones, how do hormones affect the mind? And being off hormones, after being on hormones for three years, how does that affect the mind?

A person with a mood problem is like a human roller coaster. One minute he's up, the next minute he's down. He never seems to be able to get off the ride. His mood swings are intense, sudden and out of control. Chronic and severe mood swings are a psychological disorder, a health problem every bit as real as a physical ailment. Other mind related problems include Sleep Disorders, Difficult Concentrating, Memory Lapses and Dizziness.

Hope your query is answered.

Dr A Rao Kavoor

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Brief Answer:
Detailed answers to questions on hormones

Detailed Answer:
Hi ,
Thanks for writing in again


I would throw some light on the questions asked by you.

1.     I am unclear. Do men who have an orchidectomy (for medical reasons) also have the risk of osteoporosis? Or is it unique to trans men who take hormones? Do hormones on their own create a risk of osteoporosis? Or is it the orchidectomy?

There is significant increase in osteoporosis risk in males who have an orchidectomy fop medical reasons like prostate cancer. It is due to decreased androgens. It is the hormone imbalance which causes osteoporosis. As androgens are associated with testis, orchidectomy is causing hormonal deprivation.

2.     My question is – do hormones in and of themselves- affect mood? In other words, do hormones affect the brain in such a way that mood is affected? (irrespective Trans or non-trans?)

Yes, hormones affect mood by their action on the brain, irrespective of trans or non trans. This is seen in female, trans population and also being studied in males.

3.      Also, life seems to be far more difficult as a trans MTF. Employment is far more difficult to access. Relationships have to be negotiated on a different footing, and are more difficult. Friends cannot relate in the same way. It becomes a far more lonely existence, particularly when begun in the mid-thirties. As well, there are health concerns. What other options can you suggest ?

I support your concern on points raised by you regarding employment, relationships, friendships and health matters. In my opinion, your friend must take an informed decision on living the life he/ she would like to. You are a very concerned friend and could help him have a few sessions with psychiatrists and psychologists and coming to a conclusion on his acceptance or refusal of complete gender reassignment. There are many self help and support groups online and in Canada. You could associate your friend with them and XXXXXXX many more like minded people.

Hope your query is answered.

Dr A Rao Kavoor

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Brief Answer:
Estrace protects from osteoporosis

Detailed Answer:
Hi ,
Thanks for writing in again.

Glad to know that you find my answers informative.
I would like to clarify your doubts as below.

1.I am still a bit unclear.
Do hormones -Estrace- create a risk of osteoporosis? This is irrespective of an
orchidectomy. If so, is this the reason given to stay on hormones ?

Estrace is estrogen. Estrogen protects women from having osteoporosis at younger age. In post menopausal females, it is the lack of estrogen which causes osteoporosis.

In males, androgens like testosterone protect the males from have osteoporosis. As there is no significant hormonal decline in males at older age, testosterone is produced and this protects men from osteoporosis.

After orchidectomy, there is decline in production of testosterone and males after orchidectomy dont generate testosterone. This causes osteoporosis. This is the reason to stay on estrace after orchidectomy in males.

2. After starting hormones for a while the person suffered from depression. The person had been in the creative fields for years - and did not feel "creative" any more. Does the depression have to do with the hormones and their interaction with the brain and the system?

There is a lot of interaction between hormone levels and mood variations. Your friend might need a psychiatry consultation to express his difficulties in relationships and mood changes in detail. Mental health in transgenders is an important matter under research.

Hope your query is answered.

Dr A Rao Kavoor

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