Hormone replacement therapy (male-to-female)

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Hormone replacement therapy (HRT) for transgender and transsexual people changes the balance of sex hormones in their bodies. Some intersex people also receive HRT, either starting in childhood to confirm the sex to which they were assigned, or later, if this assignment has proven to be incorrect.

Its purpose is to cause the development of the secondary sex characteristics of the desired sex. It cannot undo many of the changes produced by the first natural occurring puberty, which may necessitate surgery and/or epilation (see below).

Formal requirements for HRT[edit]

The requirements for hormone replacement therapy vary immensely, often at least a certain time of psychological counseling is required.

Under WPATH guidelines the Mental Health Provider requires individuals to satisfy two sets of criteria - eligibility and readiness - to undertake any stage of transition including hormone replacement therapy. Eligibility involves the patient meeting requirements from a major diagnostic tool, such as the ICD-10, DSM-IV-R or the DSM-V. ICD-10 requirements are for either Transsexualism or Gender identity disorder of childhood.[1]

The ICD-10 criteria for Transsexualism include the individual having a transsexual identity of over 2 years, a strong and persistent desire to live as a member of the opposite sex, usually accompanied by the desire to make their body as congruent as possible with the preferred sex through surgery and hormone treatments. These individuals cannot be diagnosed with Transsexualism if it is believed to be a result of another mental disorder, or a genetic, intersex or chromosomal abnormality.

The ICD-10 criteria for Gender identity disorder of childhood in males include the individual being pre-pubescent and having intense and persistent distress about being a boy. The distress must be present for at least six months. The child must either:

  1. Have a preoccupation with stereotypic female activities, as shown by crossdressing, simulating female attire, or an intense desire to join in the games and pastimes of girls, rejecting male games and pastimes.
  2. Have persistent denial relating to their male anatomy. This can be shown through believing they will grow up to be a woman, that their penis or testes is disgusting or will disappear, or that it would be better not to have a penis.

The DSM-IV-R criteria for Gender Identity Disorder includes four main criteria. The DSM-IV-R also requests that the individual's sexuality is noted.

Strong and persistent cross-gender identity.[edit]

In children this may be demonstrated by them meeting four or more of the following criteria:

  1. An insistence that one is or desires to be the other sex.
  2. Boys must display a preference crossdressing or simulating female attire, and girls must persistently wear only stereotypical male clothing.
  3. Persistent fantasies of being the other sex, or strong and persistent preference for cross-sex roles in make-believe play.
  4. Intense desire to participate in stereotypical games of the other sex.
  5. Strong preference for playmates of the other sex.

Adolescents and Adults must display a persistent desire to be the other sex, frequent passing as the other sex, desire to live or be treated as the other sex, or the conviction that they have the typical feelings and reactions of the other sex.

Persistent discomfort with their sex or a sense of inappropriateness in the gender role of that sex.[edit]

In boys this may manifest as an assertion that their penis or testes are disgusting or will disappear, or asserting that it is better not to have a penis.

In adults and adolescents this manifests as a preoccupation with removing primary or secondary sex characteristics, such as a demand for surgery or hormone replacement therapy.

The disturbance must not be concurrent with a physical intersex condition.[edit]

The disturbance causes clinically significant distress or impairment in social, occupations or important areas of functioning.[edit]

The DSM-V moves from Gender Identity Disorder to Gender Dysphoria to avoid the implication that gender nonconformity is in itself a mental disorder, but a similar entry remains in the DSM-V so that individuals may still seek treatment.[2] The DSM-V, unlike the DSM-IV and ICD-10, separates Gender Dysphoria from sexual paraphilias, and diagnoses on the basis of a strong desire that one has feelings and convictions typical of the other sex, or that one strongly desires to be treated as the other sex or be rid of one's sex characteristics.

The readability of patients to transition is also relevant to undertake hormone replacement therapy, which includes the patient's likelihood to take hormones in a responsible manner, have made progress in mastering other identified problems that leads to improving or continuing stable mental health, and have had further consolidation of gender identity during psychotherapy or Real Life Experience of their desired gender role.[3]

Some organizations still require a period of time living as the desired gender role, based on standards such as the Standards of Care for the Health of Transsexual, Transgender, and Gender Nonconforming People (WPATH). This period is sometimes called the Real Life Experience (RLE). Endocrine Society in 2009 specified that individuals should either have a documented 3 months Real Life Experience or a period of psychotherapy of length specified by the mental health provider, usually a minimum of 3 months.[3]

Some people, especially individuals from the transgender community, say that RLE is psychologically harmful and is a form of "gatekeeping" — effectively barring people from transitioning for as long as possible, if not permanently.[who?]

Some individuals choose to self-administer their medication ("do-it-yourself"), often because available doctors have too little experience in this matter, or no doctor is available in the first place. Sometimes, trans persons choose to self-administer because their doctor will not prescribe hormones without a letter from the patient's therapist stating that the patient meets the diagnostic criteria for GID and is making an informed decision to transition. Many therapists require at least three months of continuous psychotherapy and/or a real life test in order to write such a letter as is suggested in the HBIGDA Standards of Care. In these circumstances, the individual may self-administer until they can get these authorizations, feeling that they shouldn't have to wait for a medical professional to be convinced of their situation. In addition, as many individuals must pay for evaluation and care out-of-pocket, expense can also be prohibitive to pursuing such therapy.

However, self-administration of certain hormones (namely ethinyl estradiol) and anti-androgens (namely cyproterone acetate, flutamide, and nilutamide) is potentially dangerous and can cause an elevation in liver enzymes.[4]

Medical contraindications[edit]

Types of therapy[edit]




GnRH analogues[edit]

Effects of HRT[edit]


For trans women, taking estrogens causes among other changes:

For male-to-female transgender people, HRT often includes antiandrogens in addition to the estrogens and progestogens mentioned above.

HRT does not usually cause facial hair growth to be impeded or the voice to change.

Partially reversible changes[edit]

Reversible changes[edit]

The psychological changes are harder to define, because HRT is usually the first physical action that takes place when transitioning and the act itself of beginning HRT has a significant psychological effect, which is difficult to distinguish from hormonally induced changes.

What HRT cannot change[edit]



Urogynecological effects[edit]



Drug interactions[edit]


Ocular changes[edit]


Mammary gland development[edit]

Adipose tissue distribution[edit]




Hormone levels[edit]

During HRT, especially in the early stages of treatment, blood work should be consistently done to assess hormone levels and liver function. It is suggested by Endocrine Society that individuals have blood tests every 3 months in the first year of Hormone Replacement Therapy for Estradiol and Testosterone and monitor Spironolactone, if used, every 2–3 months in the first year.[3]

HormoneEndocrine Society [64]Royal College of Psychiatry [65]
Estradiol Level (pg/ml)Less than 200pg/ml80-140pg/ml
Testosterone Level (ng/dl)Less than 55 ng/dl"Well below normal male range"

The optimal ranges listed for estrogen only apply to individuals taking bioidentical hormones (i.e., estradiol, including esters) and do not apply to those taking synthetic or other non-bioidentical preparations (e.g., ethinyl estradiol or conjugated equine estrogens (Premarin)). While the ranges given are optimal, Endocrine society further state that Estrogen levels of 200pg/ml ought not to be exceeded.[66]

There should also be medical monitoring, including complete blood counts, renal and liver function, lipid and glucose metabolism, as well as monitoring prolactin levels, body weight and blood pressure.[67]

See also[edit]


  1. ^ "ICD-10 Diagnostic Codes". ICD-10:Version 2010. Retrieved 2014-06-08. 
  2. ^ "DSM-V Fact Sheet". Retrieved 2014-06-08. 
  3. ^ a b c Hembree, Wylie, C; Cohen-Kettenis, Peggy; Delemarre-van de Waal, Henriette; Gooren, Louis; Meyer III, Walter; Spack, Norman; Tangpricha, Vin; Montori, Victor (September 2009). "Endocrine Treatment of Transsexual Persons: An Endocrine Society Clinical Practice Guideline". Clinical Endocrinology & Metabolism. 94(9): 11. Retrieved 2014-06-07. 
  4. ^ Becerra Fernández A, de Luis Román DA, Piédrola Maroto G (October 1999). "Morbilidad en pacientes transexuales con autotratamiento hormonal para cambio de sexo" [Morbidity in transsexual patients with cross-gender hormone self-treatment]. Medicina Clínica (in Spanish; Castilian) 113 (13): 484–7. PMID 10604171. 
  5. ^ Hembree, W. C.; Cohen-Kettenis, P.; Delemarre-van de Waal, H. A.; Gooren, L. J.; Meyer, W. J.; Spack, N. P.; Tangpricha, V.; Montori, V. M. (2009-09-01). "Endocrine Treatment of Transsexual Persons:An Endocrine Society Clinical Practice Guideline" (pdf). Journal of Clinical Endocrinology & Metabolism. The Journal of Clinical Endocrinology & Metabolism. pp. 3132–3154. doi:10.1210/jc.2009-0345. Retrieved 31 October 2013. 
  6. ^
  7. ^ a b Meyer WJ, Webb A, Stuart CA, Finkelstein JW, Lawrence B, Walker PA (April 1986). "Physical and hormonal evaluation of transsexual patients: a longitudinal study". Archives of Sexual Behavior 15 (2): 121–38. doi:10.1007/bf01542220. PMID 3013122. 
  8. ^ Stelmanska, Ewa; Kmiec, Zbigniew; Swierczynski, Julian (2012). "The gender- and fat depot-specific regulation of leptin, resistin and adiponectin genes expression by progesterone in rat". The Journal of Steroid Biochemistry and Molecular Biology 132 (1-2): 160–167. doi:10.1016/j.jsbmb.2012.05.005. ISSN 0960-0760. 
  9. ^ Friess E, Tagaya H, Trachsel L, Holsboer F, Rupprecht R (May 1997). "Progesterone-induced changes in sleep in male subjects". The American Journal of Physiology 272 (5 Pt 1): E885–91. PMID 9176190. 
  10. ^ Montplaisir J, Lorrain J, Denesle R, Petit D (2001). "Sleep in menopause: differential effects of two forms of hormone replacement therapy". Menopause 8 (1): 10–6. doi:10.1097/00042192-200101000-00004. PMID 11201509. 
  11. ^ Söderpalm AH, Lindsey S, Purdy RH, Hauger R, Wit de H (April 2004). "Administration of progesterone produces mild sedative-like effects in men and women". Psychoneuroendocrinology 29 (3): 339–54. doi:10.1016/S0306-4530(03)00033-7. PMID 14644065. 
  12. ^ van Broekhoven F, Bäckström T, Verkes RJ (November 2006). "Oral progesterone decreases saccadic eye velocity and increases sedation in women". Psychoneuroendocrinology 31 (10): 1190–9. doi:10.1016/j.psyneuen.2006.08.007. PMID 17034954. 
  13. ^ Schumacher M, Guennoun R, Ghoumari A, et al. (June 2007). "Novel perspectives for progesterone in hormone replacement therapy, with special reference to the nervous system". Endocrine Reviews 28 (4): 387–439. doi:10.1210/er.2006-0050. PMID 17431228. 
  14. ^ Golparvar M, Ahmadi F, Saghaei M (January 2005). "Effects of progesterone on the ventilatory performance in adult trauma patients during partial support mechanical ventilation" (PDF). Archives of Iranian Medicine 8 (1): 27–31. 
  15. ^ Fournier A, Berrino F, Riboli E, Avenel V, Clavel-Chapelon F (April 2005). "Breast cancer risk in relation to different types of hormone replacement therapy in the E3N-EPIC cohort". International Journal of Cancer. Journal International Du Cancer 114 (3): 448–54. doi:10.1002/ijc.20710. PMID 15551359. 
  16. ^ Stripp B, Taylor AA, Bartter FC, et al. (October 1975). "Effect of spironolactone on sex hormones in man". The Journal of Clinical Endocrinology and Metabolism 41 (4): 777–81. doi:10.1210/jcem-41-4-777. PMID 1176584. 
  17. ^ Pozzi AG, Ceballos NR (August 2000). "Human chorionic gonadotropin-induced spermiation in Bufo arenarum is not mediated by steroid biosynthesis". General and Comparative Endocrinology 119 (2): 164–71. doi:10.1006/gcen.2000.7509. PMID 10936036. 
  18. ^ Canosa LF, Ceballos NR (August 2001). "Effects of different steroid-biosynthesis inhibitors on the testicular steroidogenesis of the toad Bufo arenarum". Journal of Comparative Physiology. B, Biochemical, Systemic, and Environmental Physiology 171 (6): 519–26. doi:10.1007/s003600100203. PMID 11585264. 
  19. ^ Boisselle A, Dionne FT, Tremblay RR (July 1979). "Interaction of spironolactone with rat skin androgen receptor". Canadian Journal of Biochemistry 57 (7): 1042–6. doi:10.1139/o79-131. PMID 487244. 
  20. ^ Tremblay RR. (May 1986). "Treatment of hirsutism with spironolactone". Clinics in Endocrinology and Metabolism 15 (2): 363–371. doi:10.1016/S0300-595X(86)80030-5. PMID 2941190. 
  21. ^ Biffignandi P, Molinatti GM. (1987). "Antiandrogens and hirsutism". Hormone Research 28 (2–4): 242–249. doi:10.1159/000180949. PMID 2969862. 
  22. ^ Loy R, Seibel MM (December 1988). "Evaluation and therapy of polycystic ovarian syndrome". Endocrinology and Metabolism Clinics of North America 17 (4): 785–813. PMID 3143568. 
  23. ^ Yamasaki K, Sawaki M, Noda S, et al. (February 2004). "Comparison of the Hershberger assay and androgen receptor binding assay of twelve chemicals". Toxicology 195 (2-3): 177–86. doi:10.1016/j.tox.2003.09.012. PMID 14751673. 
  24. ^ Kaiser E, Gruner HS (1987). "Liver structure and function during long-term treatment with cyproterone acetate". Archives of Gynecology 240 (4): 217–23. doi:10.1007/BF02134071. PMID 2955749. 
  25. ^ Willemse PH, Dikkeschei LD, Mulder NH, van der Ploeg E, Sleijfer DT, de Vries EG (March 1988). "Clinical and endocrine effects of cyproterone acetate in postmenopausal patients with advanced breast cancer". European Journal of Cancer & Clinical Oncology 24 (3): 417–21. doi:10.1016/S0277-5379(98)90011-6. PMID 2968261. 
  26. ^ Hinkel A, Berges RR, Pannek J, Schulze H, Senge T (1996). "Cyproterone acetate in the treatment of advanced prostatic cancer: retrospective analysis of liver toxicity in the long-term follow-up of 89 patients". European Urology 30 (4): 464–70. PMID 8977068. 
  27. ^ Watanabe S, Cui Y, Tanae A, et al. (September 1997). "Follow-up study of children with precocious puberty treated with cyproterone acetate. Ad hoc Committee for CPA". Journal of Epidemiology 7 (3): 173–8. doi:10.2188/jea.7.173. PMID 9337516. 
  28. ^ Migliari R, Muscas G, Murru M, Verdacchi T, De Benedetto G, De Angelis M (December 1999). "Antiandrogens: a summary review of pharmacodynamic properties and tolerability in prostate cancer therapy". Archivio Italiano Di Urologia, Andrologia 71 (5): 293–302. PMID 10673793. 
  29. ^ Laron Z, Kauli R (July 2000). "Experience with cyproterone acetate in the treatment of precocious puberty". Journal of Pediatric Endocrinology & Metabolism. 13 Suppl 1: 805–10. doi:10.1515/JPEM.2000.13.S1.805. PMID 10969925. 
  30. ^ Giordano N, Nardi P, Santacroce C, Geraci S, Gennari C (September 2001). "Acute hepatitis induced by cyproterone acetate". The Annals of Pharmacotherapy 35 (9): 1053–5. doi:10.1345/aph.10426. PMID 11573856. 
  31. ^ Lin AD, Chen KK, Lin AT, et al. (December 2003). "Antiandrogen-associated hepatotoxicity in the management of advanced prostate cancer". Journal of the Chinese Medical Association 66 (12): 735–40. PMID 15015823. 
  32. ^ Savidou I, Deutsch M, Soultati AS, Koudouras D, Kafiri G, Dourakis SP (December 2006). "Hepatotoxicity induced by cyproterone acetate: a report of three cases". World Journal of Gastroenterology 12 (46): 7551–5. PMC 4087608. PMID 17167851. 
  33. ^ "Standards of Care for the Health of Transsexual, Transgender, and Gender Nonconforming People". 7th version. World Professional Association for Transgender Health. p. 18. Archived from the original on 2012-09-20. Retrieved 31 October 2013. 
  34. ^
    • Henriksson P, Eriksson A, Stege R, et al. (1988). "Cardiovascular follow-up of patients with prostatic cancer treated with single-drug polyestradiol phosphate". The Prostate 13 (3): 257–61. doi:10.1002/pros.2990130308. PMID 3211807. 
    • von Schoultz B, Carlström K, Collste L, et al. (1989). "Estrogen therapy and liver function--metabolic effects of oral and parenteral administration". The Prostate 14 (4): 389–95. doi:10.1002/pros.2990140410. PMID 2664738. 
    • Asscheman H, Gooren LJ, Eklund PL. (September 1989). "Mortality and morbidity in transsexual patients with cross-gender hormone treatment". Metabolism: Clinical and Experimental 38 (9): 869–873. doi:10.1016/0026-0495(89)90233-3. PMID 2528051. 
    • Aro J, Haapiainen R, Rasi V, Rannikko S, Alfthan O (1990). "The effect of parenteral estrogen versus orchiectomy on blood coagulation and fibrinolysis in prostatic cancer patients". European Urology 17 (2): 161–5. PMID 2178941. 
    • Henriksson P, Blombäck M, Eriksson A, Stege R, Carlström K (March 1990). "Effect of parenteral oestrogen on the coagulation system in patients with prostatic carcinoma". British Journal of Urology 65 (3): 282–5. doi:10.1111/j.1464-410X.1990.tb14728.x. PMID 2110842. 
    • Aro J (1991). "Cardiovascular and all-cause mortality in prostatic cancer patients treated with estrogens or orchiectomy as compared to the standard population". The Prostate 18 (2): 131–7. doi:10.1002/pros.2990180205. PMID 2006119. 
    • Henriksson P, Stege R (1991). "Cost comparison of parenteral estrogen and conventional hormonal treatment in patients with prostatic cancer". International Journal of Technology Assessment in Health Care 7 (2): 220–5. doi:10.1017/S0266462300005110. PMID 1907600. 
    • Henriksson P (Jan–Feb 1991). "Estrogen in patients with prostatic cancer. An assessment of the risks and benefits". Drug Safety 6 (1): 47–53. doi:10.2165/00002018-199106010-00005. PMID 2029353. 
    • Caine YG, Bauer KA, Barzegar S, et al. (October 1992). "Coagulation activation following estrogen administration to postmenopausal women". Thrombosis and Haemostasis 68 (4): 392–5. PMID 1333098. 
    • Stege R, Sander S (March 1993). "[Endocrine treatment of prostatic cancer. A renaissance for parenteral estrogen]". Tidsskrift for Den Norske Lægeforening (in Norwegian) 113 (7): 833–5. PMID 8480286. 
    • Stege R, Carlström K, Hedlund PO, Pousette A, von Schoultz B, Henriksson P (September 1995). "[Intramuscular depot estrogens (Estradurin) in treatment of patients with prostate carcinoma. Historical aspects, mechanism of action, results and current clinical status]". Der Urologe. Ausg. A (in German) 34 (5): 398–403. PMID 7483157. 
    • Cox RL, Crawford ED (December 1995). "Estrogens in the treatment of prostate cancer". Journal of Urology 154 (6): 1991–8. doi:10.1016/S0022-5347(01)66670-9. PMID 7500443. 
    • Henriksson P, Carlström K, Pousette A, et al. (July 1999). "Time for revival of estrogens in the treatment of advanced prostatic carcinoma? Pharmacokinetics, and endocrine and clinical effects, of a parenteral estrogen regimen". The Prostate 40 (2): 76–82. doi:10.1002/(SICI)1097-0045(19990701)40:2<76::AID-PROS2>3.0.CO;2-Q. PMID 10386467. 
    • Hedlund PO, Henriksson P (March 2000). "Parenteral estrogen versus total androgen ablation in the treatment of advanced prostate carcinoma: effects on overall survival and cardiovascular mortality. The Scandinavian Prostatic Cancer Group (SPCG)-5 Trial Study". Urology 55 (3): 328–33. doi:10.1016/S0090-4295(99)00580-4. PMID 10699602. 
    • Hedlund PO, Ala-Opas M, Brekkan E, et al. (2002). "Parenteral estrogen versus combined androgen deprivation in the treatment of metastatic prostatic cancer -- Scandinavian Prostatic Cancer Group (SPCG) Study No. 5". Scandinavian Journal of Urology and Nephrology 36 (6): 405–13. doi:10.1080/003655902762467549. PMID 12623503. 
    • Scarabin PY, Oger E, Plu-Bureau G (August 2003). "Differential association of oral and transdermal oestrogen-replacement therapy with venous thromboembolism risk". Lancet 362 (9382): 428–32. doi:10.1016/S0140-6736(03)14066-4. PMID 12927428. 
    • Straczek C, Oger E, Yon de Jonage-Canonico MB, et al. (November 2005). "Prothrombotic mutations, hormone therapy, and venous thromboembolism among postmenopausal women: impact of the route of estrogen administration". Circulation 112 (22): 3495–500. doi:10.1161/CIRCULATIONAHA.105.565556. PMID 16301339. 
    • Ockrim J, Lalani el-N, Abel P (October 2006). "Therapy Insight: parenteral estrogen treatment for prostate cancer--a new dawn for an old therapy". Nature Clinical Practice Oncology 3 (10): 552–63. doi:10.1038/ncponc0602. PMID 17019433. 
    • Basurto L, Saucedo R, Zárate A, et al. (2006). "Effect of pulsed estrogen therapy on hemostatic markers in comparison with oral estrogen regimen in postmenopausal women". Gynecologic and Obstetric Investigation 61 (2): 61–4. doi:10.1159/000088603. PMID 16192735. 
    • Hemelaar M, Rosing J, Kenemans P, Thomassen MC, Braat DD, van der Mooren MJ (July 2006). "Less effect of intranasal than oral hormone therapy on factors associated with venous thrombosis risk in healthy postmenopausal women". Arteriosclerosis, Thrombosis, and Vascular Biology 26 (7): 1660–6. doi:10.1161/01.ATV.0000224325.96659.53. PMID 16645152. 
    • Hedlund PO, Damber JE, Hagerman I, et al. (2008). "Parenteral estrogen versus combined androgen deprivation in the treatment of metastatic prostatic cancer: part 2. Final evaluation of the Scandinavian Prostatic Cancer Group (SPCG) Study No. 5". Scandinavian Journal of Urology and Nephrology 42 (3): 220–9. doi:10.1080/00365590801943274. PMID 18432528. 
    • Canonico M, Plu-Bureau G, Lowe GD, Scarabin PY (May 2008). "Hormone replacement therapy and risk of venous thromboembolism in postmenopausal women: systematic review and meta-analysis". BMJ 336 (7655): 1227–31. doi:10.1136/bmj.39555.441944.BE. PMC 2405857. PMID 18495631. 
  35. ^ "Casodex monograph" (PDF). Retrieved 14 June 2008. 
  36. ^ Iversen P, Johansson JE, Lodding P, et al. (November 2004). "Bicalutamide (150 mg) versus placebo as immediate therapy alone or as adjuvant to therapy with curative intent for early nonmetastatic prostate cancer: 5.3-year median followup from the Scandinavian Prostate Cancer Group Study Number 6". The Journal of Urology 172 (5 Pt 1): 1871–6. doi:10.1097/01.ju.0000139719.99825.54. PMID 15540741. 
  37. ^ "Important Safety Information Regarding Casodex 150 mg". Retrieved 14 June 2008. 
  38. ^ Rossi R, Zatelli MC, Valentini A, et al. (December 1998). "Evidence for androgen receptor gene expression and growth inhibitory effect of dihydrotestosterone on human adrenocortical cells". The Journal of Endocrinology 159 (3): 373–80. doi:10.1677/joe.0.1590373. PMID 9834454. 
  39. ^ a b c d e f g Asscheman H, Gooren LJ (1992). "Hormone Treatment in Transsexuals". Retrieved 13 June 2008. 
  40. ^ a b c Giltay EJ, Gooren LJ (August 2000). "Effects of sex steroid deprivation/administration on hair growth and skin sebum production in transsexual males and females". Journal of Clinical Endocrinology and Metabolism 85 (8): 2913–21. doi:10.1210/jc.85.8.2913. PMID 10946903. 
  41. ^ Doctors plan uterus transplants to help women with removed, damaged wombs have babies - Associated Press
  42. ^ Fageeh W, Raffa H, Jabbad H, Marzouki A (March 2002). "Transplantation of the human uterus". International Journal of Gynaecology and Obstetrics 76 (3): 245–51. doi:10.1016/S0020-7292(01)00597-5. PMID 11880127. 
  43. ^ Del Priore G, Stega J, Sieunarine K, Ungar L, Smith JR (January 2007). "Human uterus retrieval from a multi-organ donor". Obstetrics and Gynecology 109 (1): 101–4. doi:10.1097/01.AOG.0000248535.58004.2f. PMID 17197594. 
  44. ^ Nair A, Stega J, Smith JR, Del Priore G (April 2008). "Uterus transplant: evidence and ethics". Annals of the New York Academy of Sciences 1127: 83–91. doi:10.1196/annals.1434.003. PMID 18443334. 
  45. ^ Kirk, MD, Sheila (1999). Feminizing Hormonal Therapy For The Transgendered (1999 Edition). Pittsburgh, PA: Together Lifeworks. p. 38. 
  46. ^ Leach NE, Wallis NE, Lothringer LL, Olson JA (May 1971). "Corneal hydration changes during the normal menstrual cycle--a preliminary study". The Journal of Reproductive Medicine 6 (5): 201–4. PMID 5094729. 
  47. ^ Kiely PM, Carney LG, Smith G (October 1983). "Menstrual cycle variations of corneal topography and thickness". American Journal of Optometry and Physiological Optics 60 (10): 822–9. doi:10.1097/00006324-198310000-00003. PMID 6650653. 
  48. ^ Gurwood AS, Gurwood I, Gubman DT, Brzezicki LJ (January 1995). "Idiosyncratic ocular symptoms associated with the estradiol transdermal estrogen replacement patch system". Optometry and Vision Science 72 (1): 29–33. doi:10.1097/00006324-199501000-00006. PMID 7731653. 
  49. ^ Kirk, MD, Sheila (1999). Feminizing Hormonal Therapy For The Transgendered (1999 Edition). Pittsburgh, PA: Together Lifeworks. p. 56. 
  50. ^ Krenzer KL, Dana MR, Ullman MD, et al. (December 2000). "Effect of androgen deficiency on the human meibomian gland and ocular surface". The Journal of Clinical Endocrinology and Metabolism 85 (12): 4874–82. doi:10.1210/jcem.85.12.7072. PMID 11134156. 
  51. ^ Sullivan DA, Sullivan BD, Evans JE, et al. (June 2002). "Androgen deficiency, Meibomian gland dysfunction, and evaporative dry eye". Annals of the New York Academy of Sciences 966: 211–22. doi:10.1111/j.1749-6632.2002.tb04217.x. PMID 12114274. 
  52. ^ Sullivan BD, Evans JE (December 2002). "Complete androgen insensitivity syndrome: effect on human meibomian gland secretions". Archives of Ophthalmology 120 (12): 1689–1699. doi:10.1001/archopht.120.12.1689. PMID 12470144. 
  53. ^ Cermak JM, Krenzer KL, Sullivan RM, Dana MR, Sullivan DA (August 2003). "Is complete androgen insensitivity syndrome associated with alterations in the meibomian gland and ocular surface?". Cornea 22 (6): 516–21. doi:10.1097/00003226-200308000-00006. PMID 12883343. 
  54. ^ Oprea L, Tiberghien A, Creuzot-Garcher C, Baudouin C (October 2004). "Influence des hormones sur le film lacrymal" [Hormonal regulatory influence in tear film]. Journal Français D'ophtalmologie (in French) 27 (8): 933–41. doi:10.1016/S0181-5512(04)96241-9. PMID 15547478. 
  55. ^ Cite error: The named reference Meikle2009 was invoked but never defined (see the help page).
  56. ^ Kirk, MD, Sheila (1999). Feminizing Hormonal Therapy For The Transgendered (1999 Edition). Pittsburgh, PA: Together Lifeworks. p. 52. 
  57. ^ Harel Z, Biro FM, Kollar LM (May 1995). "Depo-Provera in adolescents: effects of early second injection or prior oral contraception". The Journal of Adolescent Health 16 (5): 379–84. doi:10.1016/S1054-139X(95)00094-9. PMID 7662688. 
  58. ^ Archer B, Irwin D, Jensen K, Johnson ME, Rorie J (1997). "Depot medroxyprogesterone. Management of side-effects commonly associated with its contraceptive use". Journal of Nurse-midwifery 42 (2): 104–11. doi:10.1016/S0091-2182(96)00135-8. PMID 9107118. 
  59. ^ Civic D, Scholes D, Ichikawa L, et al. (June 2000). "Depressive symptoms in users and non-users of depot medroxyprogesterone acetate". Contraception 61 (6): 385–90. doi:10.1016/S0010-7824(00)00122-0. PMID 10958882. 
  60. ^ Ott MA, Shew ML, Ofner S, Tu W, Fortenberry JD (August 2008). "The influence of hormonal contraception on mood and sexual interest among adolescents". Archives of Sexual Behavior 37 (4): 605–13. doi:10.1007/s10508-007-9302-0. PMC 3020653. PMID 18288601. 
  61. ^ St-André M, Stikarovska I, Gascon S (February 2012). "Clinical Case Rounds in Child and Adolescent Psychiatry: De Novo Self-Mutilation and Depressive Symptoms in a 17-year-old Adolescent Girl Receiving Depot-Medroxyprogesterone Acetate". Journal of the Canadian Academy of Child and Adolescent Psychiatry 21 (1): 59–62. PMC 3269252. PMID 22299016. 
  62. ^ Gupta ML, Tandon P, Barthwal JP, Gupta TK, Bhargava KP (November 1983). "Role of catecholamines in the central actions of medroxyprogesterone acetate". Experimental and Clinical Endocrinology 82 (3): 380–3. doi:10.1055/s-0029-1210303. PMID 6228435. 
  63. ^ Hulshoff, Cohen-Kettenis et al. (July 2006). "Changing your sex changes your brain: influences of testosterone and estrogen on adult human brain structure". European Journal of Endocrinology 155 (Suppl 1): 107–114. doi:10.1530/eje.1.02248. ISSN 0804-4643. 
  64. ^ Hembree, Wylie, C; Cohen-Kettenis, Peggy; Delemarre-van de Waal, Henriette; Gooren, Louis; Meyer III, Walter; Spack, Norman; Tangpricha, Vin; Montori, Victor (September 2009). "Endocrine Treatment of Transsexual Persons: An Endocrine Society Clinical Practice Guideline". Clinical Endocrinology & Metabolism. 94(9): 18. Retrieved 2014-06-07. 
  65. ^ Wylie, Kevan; Barrett, James; Besser, Mike; Bouman, Walter; Brain, Caroline; Bridgman, Michelle; Clayton, Angela; Green, Richard; Hamilton, Mark; Hines, Melissa; Ivbijaro, Gabriel; Khoosal, Deenesh; Lawrence, Alex; Lenihan, Penny; Ivbijaro, Del; Ralph, David; Reed, Terry; Stevens, John; Terry, Tim; Thom, Ben; Thornton, Jane; Walsh, Dominic; Ward, David (2014). "Good Practice Guidelines for the Assessment and Treatment of Adults with Gender Dysphoria". Sexual and Relationship Therapy (Taylor & Francis) 29: 35. 
  66. ^ Hembree, Wylie, C; Cohen-Kettenis, Peggy; Delemarre-van de Waal, Henriette; Gooren, Louis; Meyer III, Walter; Spack, Norman; Tangpricha, Vin; Montori, Victor (September 2009). "Endocrine Treatment of Transsexual Persons: An Endocrine Society Clinical Practice Guideline". Clinical Endocrinology & Metabolism. 94(9): 22. Retrieved 2014-06-07. 
  67. ^ Hembree, Wylie, C; Cohen-Kettenis, Peggy; Delemarre-van de Waal, Henriette; Gooren, Louis; Meyer III, Walter; Spack, Norman; Tangpricha, Vin; Montori, Victor (September 2009). "Endocrine Treatment of Transsexual Persons: An Endocrine Society Clinical Practice Guideline". Clinical Endocrinology & Metabolism. 94(9): 22–23. Retrieved 2014-06-07. 

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