Hormone Therapy and MTF SRS: How They Work Together

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The synergism of hormone therapy and MTF SRS in the opposite ‘natural’ direction is a well-documented fact. These components complement one another in various aspects and contribute to the complex treatment and rehabilitation of the transsexual (transfeminine) patients. Recognition of this by the medical community and the law has been thoroughly tested in many international epidemiological and legal studies. The association of such data became the basis of the conceptual framework on the treatment of trans people from a harmonization point of view. This paper summarizes the potential medical basis of their synergism. These issues include changes in androgen and estrogen metabolism hormones before and after SRS, the effect on the mental state and psycho-emotional regulation of a person, as well as other restoration and reproof functions, including hormonal metabolic mechanisms.

Hormone therapy and MTF SRS is a necessary component of both male-to-female HRT and sex reassignment surgery (SRS) or facial feminization surgery (FFS). Its relevance has been increased by the relaxation of the WPATH-issued criteria for legal gender recognition of transgender patients. Currently, both healthcare providers and international health insurance companies are no longer allowed to force or show trademark ‘moral dilemmas’ in refusing hormone therapy coverage to their patients on the waiting list. Public health issues must celebrate the reassessment of hormone therapy which is now more included in the standard HRT and gender surgery package of care.

What is the Impact of Hormone Therapy on Gender Dysphoria and the Transitioning Process?

Hormones before and after SRS therapy is a vital element in facilitating the transitioning process of male-to-female transsexuals. Psychological changes begin after the initiation of hormone therapy, and exacerbation of gender dysphoria is common following the onset of psychological effects. The predominantly feminizing regimens used in hormone therapy for cross-sex hormone reassignment (CSHR) are guided by the World Professional Association for Transgender Health (WPATH) Standards of Care. They are designed to improve the potential for masculinization of the body, although they may also be chosen to feminize psychological or social function. The WPATH Standards of Care also include diagnostic goals in the selection of CSHR, such as puberty delay or puberty suppressant medication.

The hormone regimens are used in an attempt to make the physical characteristics of male-to-female transsexuals congruent with their HRT and gender surgery identity. The physical and emotional changes a male-to-female individual will experience depend in part on whether or not they have had previous puberty. If hormone therapy is administered as a sole agent without additional medical or surgical interventions, it may provide moderate improvement of gender dysphoria. Feminine-associated changes are stage one in the four stages of the male-to-female transition process, where stage one involves hormones before and after SRS therapy changes of the body, and stages two to four involve different aspects of gender-affirming surgery, such as pre-operation, the operation, and the healing process.

Surgical Techniques in Male-to-Female Sex Reassignment Surgery

The irreversibility and complexity of surgical transition in male-to-female HRT and sex reassignment surgery (SRS) require specialized surgical procedures and carefully carried out intra-operative techniques. Meticulously planning and safely conducting a variety of procedures sequentially and concurrently are essential considerations for optimal outcomes. As the general and genital anatomy of candidates seeking SRS may vary widely, many technical considerations should be made during an evaluation. While guidelines for standards of care are generally recognized for SRS, it should be noted that some countries such as the United States and Australia do not require reconstructive HRT and gender surgery. Surgery is an option, and most insurance and reimbursement considerations have chosen not to include this as necessary treatment due to personal convictions. 

All surgical techniques in the male-to-female SRS include steps followed in the order as follows: 1) removal of the penis and testicles – scrotectomy; 2) creation of the neovagina; and 3) fashion of a natural-looking clitoris.

There are multiple methods in each of these steps, and the surgeon will usually discuss the options with the patient, when applicable. Foremost in her/his and the surgical team’s priority is the attention to safety, as with any surgical procedure. Surgical procedures to create the neovagina are often referred to as vaginoplasty and frequently use the penile inversion technique. These procedures generally use the penile skin cut open from top to bottom, leaving a portion at the base of the penis intact. This remaining portion becomes the clitoris, which is often sensitive for intercourse although not generally for erotic sensation unless activated or redeveloped. A second vaginoplasty technique uses a section of the colon to create an additional neovagina after native penile skin removal. An element of this technique may be used when a longer length of vaginal canal is desired. In other conditions, the penile skin may be too unhealthy to use for the procedure. In essence, the penile shaft skin removed to help in the formation of the initial neovagina heals in about the same fashion as elsewhere on the body and develops about 80% of its length and 80-100% of its width. In these cases, a laparoscopic or non-laparoscopic assisted colovaginoplasty may be offered as an option (See Good Practice Point II). Foreskin skin, skin grafts, and/or the remnants of the glans may be used with or without the penile skin during (co-) surgery techniques and makeup in order to create and/or enhance the neovaginal canal, clitoris, and external female genitalia aesthetic results. Further discussion may be found on the risks and complications of surgery. The clitoris is an erogenous structure resulting from the glans penis otherwise known as the head of the penis. Sometimes sensation from the clitoral remnants decreases in the months following surgery, and all or part of its erotic sensation may temporarily decrease or temporarily or permanently increase. In the event of removal, anesthetic or no local sensation may be expected during intercourse. An unsatisfactory surgical result may also impact in the urologic or gynecologic management of the neovagina. Consultation with a surgeon at a later time is important if clinical symptoms of urologic or gynecologic problems can be identified.

Preoperative and Postoperative Hormone Therapy in MTF SRS

For MTF transsexuals (TS), the male-to-female HRT and sex reassignment surgery (SRS) is known as the medical gold standard. Both preoperative and postoperative hormone therapy are indispensable, and they have their respective targets. Preoperative hormone therapy is to establish a feminine hormone environment. It can relieve patients’ gender dysphoria, promote patients’ secondary sexual characteristics reconstruction, and serve as a psychotherapy alternative. Moreover, the adequate use of estrogen can soften patient’s scrotum and penis skins, and enable the development of neovagina and the health of vulvar skin. Therefore, related medical literature has delineated the timing of penile inversion vaginoplasty (PIV) in the context of time-experienced hormones before and after SRS therapy. Some reports suggest that hormone therapy could be started for at least one year before SRS. However, there is no consensus about the duration of preoperative hormone therapy in MTF TS.

Postoperative hormone therapy plays a vital role in assisting neovagina recovery and maintaining both subcutaneous tissue and submucosal layer of the neovagina after SRS. However, related research is scarce, and most of these concentrate on clinical case summaries. Currently, there is a lack of documentation focusing on cisgender and transgender individuals’ neovagina recovery and the complete combination of postoperative hormone therapy with the MTF SRS. Further scientific inquiry regarding postoperative hormone therapy may offer vital perspective that could inform effective strategies to optimize the SRS effect and also reduce some avoidable surgical risks. Consequently, in order to guide surgeons to optimize the SRS effect and decrease surgical complications, postoperative hormone therapy needs to be explored via a multi-center study with a broader sample size.

What are the Psychological and Physiological Benefits of Combining Hormone Therapy with MTF SRS?

It is logical to consider facilitating the experiences of trans people whose romantic life has been affected in some way. Although some trans women do in fact have some kinds of relationships, the most common type of interaction for trans women as a group is prostitution. As an SRS surgeon, the goal is to improve the physical appearance and psychological well-being of patients. It is only logical that this concern also extends to the interpersonal realm. Many trans women believe that undergoing both an MTF sex reassignment and facial feminization surgery is the only appropriate course of treatment. Trans women who undergo both treatments notice quick improvements in their interpersonal interactions. They are generally treated with more kindness and respect by men once they look like women.

Combining hormones before and after SRS therapy can provide trans women with psychological and physiological benefits. The scientific literature holds much evidence that hormone therapy can significantly improve the mental state, self-concept, and interpersonal interactions of MTF transsexuals. Bibliographic studies suggest that hormone therapy alone can alleviate some of the sufferers, but that its effects are significantly multiplied when combined with sex reassignment. If hormone therapy and SRS treatment work together (the sum of their respective effects), the entire treatment becomes a kind of neurological, psychological, aesthetic, and hormonal transformation to which trans people can easily become accustomed.

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