女性化激素療法
系列條目 |
跨性別專題 |
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女性化激素療法(英語:feminizing hormone therapy)是一種性別肯定激素治療(GAHT)及性別重置療法,旨在將跨性別者的第二性徵從男或中性轉變為女性氣質[1][2][3][4][5][6]。用於治療跨性別女性和非二元跨女個體。根據個人需要和偏好,一些人,特別是雙性人,但也包括一些雙性戀者,也會採取這種形式的治療。
該療法的目的是引起患者希望成為的性別的第二性徵的發育,例如乳房發育,女性化的毛髮、脂肪和肌肉分布等。它無法消除自然青春期產生的許多變化,這可能需要手術和其他治療來逆轉(見下文)。用於女性化激素療法的藥物包括雌激素、抗雄激素、孕激素和促性腺素釋素(GnRH調節劑)。
女性化激素療法已被證明可能緩解與性別不一致相關的痛苦或不適[7]。
要求
[編輯]許多醫生按照世界跨性別人士健康專業協會(WPATH)的護理標準(SoC)模式運作,要求跨性別者接受心理治療並提供心理治療師的推薦信,以便獲得激素治療[8]。其他醫生按照知情同意模式運作,除了同意之外,對性別肯定激素治療(GAHT)沒有任何要求[8]。某些不受監管的互聯網網路藥房也出售用於GAHT的藥物,無需處方,一些跨性別女性購買這些藥物並使用自己動手(DIY)或自我用藥的方法自行治療[9][10]。許多跨性別者在"/r/TransDIY"和"/r/MtFHRT"等Reddit社區討論和分享有關DIY激素治療的信息[9][10][11][12]。許多跨性別者轉向DIY激素療法的一個原因是,由於在世界某些地區(例如英國),看醫生的費用通常很高,而且限制性標準使一些人沒有資格接受治療[9][10]。
GAHT的可用性在全世界各個國家有所不同[8]。
藥物
[編輯]藥品 | 商品名 | 類型 | 途徑 | 劑量[b] |
---|---|---|---|---|
雌二醇 | 多種 | 雌激素 | 口服 | 2–10毫克/日 |
多種 | 雌激素 | 舌下 | 1–8毫克/日 | |
康美華(Climara)[c] | 雌激素 | 透皮貼片 | 25–400微克/日 | |
迪維舒凝膠(Divigel)[c] | 雌激素 | 透皮凝膠 | 0.5–5毫克/日 | |
多種 | 雌激素 | 皮下植入 | 50–200毫克每6–24個月 | |
戊酸雌二醇 | 補佳樂(Progynova) | 雌激素 | 口服 | 2–10毫克/日 |
補佳樂(Progynova) | 雌激素 | 舌下 | 1–8毫克/日 | |
Del雌激素(Delestrogen)[c] | 雌激素 | 肌肉注射,皮下注射 | 2–10毫克/周或 5–20毫克每2周 | |
環戊丙酸雌二醇 | 狄波-雌二醇(Depo-Estradiol) | 雌激素 | 肌肉注射,皮下注射 | 2–10毫克/周或 5–20毫克每2周 |
二丙酸雌二醇 | Agofollin | 雌激素 | 肌肉注射,皮下注射 | 2–10毫克/周或 5–20毫克每2周 |
苯甲酸雌二醇 | 保女榮-B(Progynon-B) | 雌激素 | 肌肉注射,皮下注射 | 0.5–1.5毫克每2–3日 |
雌三醇 | 歐維婷(Ovestin)[c] | 雌激素 | 口服 | 4–6毫克/日 |
螺內酯 | 安體舒通(Aldactone) | 抗雄激素 | 口服 | 100–400毫克/日 |
醋酸環丙孕酮 | 色普龍(Androcur) | 抗雄激素; 孕激素 |
口服 | 5–100毫克/日 |
色普龍長效(Androcur Depot) | 肌肉注射 | 300毫克/月 | ||
比卡魯胺 | 康士得(Casodex) | 抗雄激素 | 口服 | 25–50毫克/日 |
恩扎盧胺 | 安可坦(Xtandi) | 抗雄激素 | 口服 | 160毫克/日 |
促性腺激素釋放激素類似物 | 多種 | 促性腺激素釋放激素調節劑 | 多種 | 多變 |
噁拉戈利 | Orilissa | 促性腺激素釋放激素拮抗劑 | 口服 | 150毫克/日或 200毫克每日兩次 |
非那斯特萊 | 保法止(Propecia) | 5α還原酶抑制劑 | 口服 | 1–5毫克/日 |
度他雄胺 | 安福達(Avodart) | 5α還原酶抑制劑 | 口服 | 0.25–0.5毫克/日 |
孕酮 | Prometrium[c] | 孕激素 | 口服 | 100–400毫克/日 |
醋酸甲羥孕酮 | 普維拉(Provera) | 孕激素 | 口服 | 2.5–40毫克/日 |
狄波-普維拉(Depo-Provera) | 孕激素 | 肌肉注射 | 150毫克每3個月 | |
狄波-皮下普維拉104(Depo-SubQ Provera 104) | 孕激素 | 皮下注射 | 104毫克每3個月 | |
己酸羥孕酮 | 普羅路通(Proluton) | 孕激素 | 肌肉注射 | 250毫克/周 |
地屈孕酮 | 達芙通(Duphaston) | 孕激素 | 口服 | 20毫克/日 |
屈螺酮 | Slynd | 孕激素 | 口服 | 3毫克/日 |
多潘立酮[d] | 嗎丁啉(Motilium) | 催乳素釋放劑 | 口服 | 30–80毫克/日[e] |
各種不同的性激素藥物用於跨性別女性的女性化激素療法[13][8][3][4]。其中包括雌激素,用於誘導女性化並抑制睾酮水平;抗雄激素,如雄激素受體拮抗劑、抗促性腺激素、GnRH調節劑和5α還原酶抑制劑,以進一步對抗睾酮等雄激素的作用;以及孕激素,以獲得各種可能但不確定的益處[13][8][3][4]。雌激素與抗雄激素聯合使用是跨性別女性女性化激素療法的主流[46][47]。
雌激素
[編輯]![](http://upload.wikimedia.org/wikipedia/commons/thumb/7/7d/Estradiol_and_testosterone_levels_with_a_single_intramuscular_injection_of_320_mg_polyestradiol_phosphate_in_men.png/350px-Estradiol_and_testosterone_levels_with_a_single_intramuscular_injection_of_320_mg_polyestradiol_phosphate_in_men.png)
![](http://upload.wikimedia.org/wikipedia/commons/thumb/3/31/Testosterone_levels_as_a_function_of_estradiol_levels_during_oral_estradiol_therapy_in_transgender_women.png/350px-Testosterone_levels_as_a_function_of_estradiol_levels_during_oral_estradiol_therapy_in_transgender_women.png)
雌激素是女性體內主要的性激素,負責發育和維持女性的第二性徵,如乳房、寬臀部及女性的脂肪分布模式[4]。雌激素通過結合併激活雌激素受體(ER)發揮作用,ER是它們在體內的靶點[50]。有多種不同形式的雌激素可供醫學使用[50]。跨性別女性最常用的雌激素包括雌二醇,它是女性體內最主要的天然雌激素,以及雌二醇酯,如戊酸雌二醇和環戊丙酸雌二醇,它們是雌二醇的前體藥物[13][4][50]。用於絕經期激素治療(MHT)的結合型雌激素(普力馬),以及用於避孕藥的炔雌醇,過去曾用於跨性別女性,但由於其血栓和心血管問題的風險較高,現在不再推薦,也很少使用[4][13][8][5]。雌激素可通過口服、舌下含服、透皮/外用(通過貼片或凝膠)、直腸、肌肉或皮下注射或植入的方式給藥[50][51][52][53][54]。首選腸外(非口服)途徑,因為這樣血凝塊和心血管問題的風險可最小或可忽略不計[5][55][56][57][58]。
除了產生女性化外,雌激素還具有抗促性腺激素作用,抑制性腺產生性激素[51][49][59]。雌激素主要負責抑制跨性別女性的睾酮水平[51][59]。雌二醇水平在200 pg/mL及以上,可抑制睾酮水平約90%,而雌二醇水平在500 pg/mL及以上,可抑制睾酮水平約95%,或達到與睾丸切除術和GnRH調節劑相當的程度[60][61]。較低的雌二醇水平也可以顯著抑制睾酮的產生,但不完全[49]。當單獨的雌二醇不足以抑制睾酮水平時,可以使用抗雄激素來抑制或阻斷殘留睾酮的作用[51]。口服雌二醇往往難以充分抑制睾酮水平,因為所產生的雌二醇水平相對較低[49][62][63]。
在睾丸切除術(手術切除性腺)或性別重置手術前,用於跨性別女性的雌激素劑量通常高於用於順性別女性的替代劑量[64][65][66]。這有助於抑制睾酮水平[65]。內分泌學會(2017)建議將雌二醇水平大致維持在絕經前婦女的正常平均範圍內,約100至200 pg/mL[13]。然而他們指出,這種生理水平的雌二醇通常無法將睾酮水平抑制到女性範圍內[13]。2018年考科藍的一項綜述計劃對將跨性別女性雌二醇水平保持在較低水平提出質疑,這會導致睾酮水平的不完全抑制,並且需要加入抗雄激素[67]。綜述計劃指出,高劑量的非經腸雌二醇已知是安全的[67]。內分泌學會本身建議注射會導致雌二醇水平明顯超出正常女性範圍的雌二醇酯劑量,例如每周10 mg戊酸雌二醇肌肉注射[13]。單次注射,雌二醇峰值水平約為1,250 pg/mL,7天後200 pg/mL左右[68][69]。當在睾丸切除術或性別重置手術後,不再需要抑制性腺睾酮時,可以減少雌激素的劑量[5]。
抗雄激素
[編輯]抗雄激素是防止體內雄激素作用的藥物[70][71]。雄激素,如睾酮和雙氫睾酮(DHT),是有睾丸個體的主要性激素,負責發育和維持男性的第二性徵,如低沉的聲音、寬闊的肩膀和男性化的毛髮、肌肉和脂肪分布[72][73]。此外,雄激素刺激性慾和自發勃起的頻率,並導致痤瘡、體臭和雄激素依賴性脫髮[72][73]。它們還在乳房中有功能性抗雌激素作用,並阻止雌激素介導的乳房發育,即使在低水平時也如此[74][75][76][77]。雄激素通過結合併激活雄激素受體發揮作用,雄激素受體是它們在體內的靶點[78]。抗雄激素阻止雄激素與雄激素受體結合,和/或阻斷或抑制雄激素的合成,達到抗雄激素目的[70]。
直接阻斷雄激素受體的抗雄激素稱為雄激素受體拮抗劑或阻滯劑,而抑制雄激素酶促生物合成反應的抗雄激素稱為雄激素合成抑制劑,抑制性腺中雄激素產生過程的抗雄激素稱為抗促性腺激素[71]。雌激素和孕激素是抗促性腺激素,因此是功能性抗雄激素[51][79][80][81]。在跨性別女性中使用抗雄激素的目的是阻斷或抑制單雌激素無法抑制的殘留睾酮[51][70][59]。如果睾酮水平在正常女性範圍內或接受了睾丸切除術,則不一定需要額外的抗雄激素治療[51][70][59]。然而,睾酮水平在正常女性範圍內,但仍持續存在雄激素依賴性皮膚和/或頭髮症狀(如痤瘡、皮脂溢、油性皮膚或頭皮脫髮)的個體仍可能受益於服用抗雄激素,因為抗雄激素可以減輕或消除這些症狀[82][83][84]。
甾體抗雄激素
[編輯]甾體抗雄激素是在化學結構上類似於甾體激素如睾酮、孕酮的抗雄激素[85]。它們是跨性別女性中最常用的抗雄激素藥物[8]。螺內酯(安體舒通)相對安全且價格低廉,是在美國最常用的抗雄激素藥物[86][87]。醋酸環丙孕酮(安得卡)未在美國上市,但在歐洲、加拿大和世界其他地區廣泛使用[8][70][86][88]。醋酸甲羥孕酮(普維拉,狄波-普維拉)是一種類似的藥物,在美國有時用於代替醋酸環丙孕酮[89][90]。
![](http://upload.wikimedia.org/wikipedia/commons/thumb/1/17/Testosterone_levels_with_estradiol_alone%2C_estradiol_plus_spironolactone%2C_and_estradiol_plus_cyproterone_acetate_in_transfeminine_people.png/350px-Testosterone_levels_with_estradiol_alone%2C_estradiol_plus_spironolactone%2C_and_estradiol_plus_cyproterone_acetate_in_transfeminine_people.png)
螺內酯是一種抗鹽皮質激素(鹽皮質激素受體的拮抗劑)和保鉀利尿劑,主要用於治療其他利尿劑引起的高血壓、水腫、高醛固酮和低鉀等,以及其他用途[92]。螺內酯作為一種抗雄激素,最初是一種無意發現的次要作用[92]。它主要通過作為雄激素受體拮抗劑,發揮抗雄激素作用[93]。該藥物也是一種弱甾體生成抑制劑,可抑制雄激素的酶促合成[94][93][95]。然而,這種作用的效力很低,螺內酯對激素水平的影響參差不齊[94][93][95][96][97]。在任何情況下,通常螺內酯不會改變睾酮水平[94][93][95][96][97]。對跨性別女性的研究發現,螺內酯不會改變[49]或降低睾酮水平[91]。螺內酯一般認為是一種相對較弱的抗雄激素[98][99][100]。它廣泛用於治療女性的痤瘡、毛髮過度生長和雄激素過多症,因女性的睾酮水平遠低於男性[96][97]。由於其抗鹽皮質激素活性,螺內酯具有抗鹽皮質激素的副作用[101],可導致高鉀血症[102][103]。螺內酯導致的高鉀可能導致住院和/或死亡[102][103][104],但在服用螺內酯的人群中,若本身沒有風險因素,高鉀風險似乎很小[97][105][106]。因此,在大多數情況下可能不需要監測血鉀水平[97][105][106]。已發現螺內酯可降低高劑量口服雌二醇的生物利用度[49]。儘管廣泛使用,由於螺內酯用於該目的各種缺點,近來有人質疑,在跨性別女性中是否應將此藥用作為抗雄激素藥物[49]。
醋酸環丙孕酮是一種抗雄激素和孕激素,可用於治療多種雄激素依賴性疾病,也可用作避孕藥中的孕激素[107][108]。它主要作為抗促性腺激素起作用,其次是其強效孕激素活性,並強烈抑制性腺生產雄激素[107][59]。已發現5至10 mg/天劑量的醋酸環丙孕酮可將男性的睾酮水平降低約50至70%[109][110][111][112],而100 mg/天的劑量可降低約75%[113][114]。25 mg/天的醋酸環丙孕酮和適量雌二醇的組合可將跨性別女性的睾酮水平抑制約95%[115]。與雌激素聯合使用10、25和50 mg/天醋酸環丙孕酮均顯示出相同程度的睾酮抑制[116]。除了抗促性腺激素的作用外,醋酸環丙孕酮還是一種雄激素受體拮抗劑[107][70]。然而,這種作用在低劑量時相對微不足道,在用於治療前列腺癌的高劑量醋酸環丙孕酮中(100-300 mg/天)時更為重要[117][118]。醋酸環丙孕酮可導致肝酶升高和肝損傷,包括肝功能衰竭[70][119]。然而,這主要發生在服用非常高劑量醋酸環丙孕酮的前列腺癌患者身上;跨性別女性尚未報告肝毒性[70]。醋酸環丙孕酮還有其他多種副作用,如疲勞和體重增加,以及如血栓和良性腦瘤等風險[59][70][120]。在醋酸環丙孕酮治療期間,建議定期監測肝酶和催乳素水平。
醋酸甲羥孕酮是一種與醋酸環丙孕酮有關的孕激素,有時作為後者的替代[89][90]。在美國專門用作醋酸環丙孕酮的替代品,因為醋酸環丙孕酮尚未批准用於醫療用途且無法獲得[89][90]。醋酸甲羥孕酮抑制跨性別女性的睾酮水平,效果與醋酸環丙孕酮類似[90][49]。已發現口服醋酸甲羥孕酮可在20至100 mg/天的劑量範圍內,將男性的睾酮水平抑制約30至75%[121][122][123][124][125]。然而,與醋酸環丙孕酮相比,醋酸甲羥孕酮不同時是雄激素受體拮抗劑[50][126]。醋酸甲羥孕酮的副作用和風險與醋酸環丙孕酮相似,但與肝臟問題無關[127][101]。
許多其他孕激素和抗促性腺激素也用於抑制男性的睾酮水平,並且可能對跨性別女性也有用[128][129][130][131][132][133][134]。單獨使用孕激素通常能夠將男性的睾酮水平抑制最多約70%至80%,在以足夠高的劑量使用時能達到略高於女性/去勢水平[135][136][137]。足量孕激素與極小劑量雌激素(例如,每天口服0.5-1.5 mg雌二醇)的組合在抗促性腺激素作用方面具有協同作用,並且能夠完全抑制性腺睾酮的產生,從而降低睾酮水平到女性/去勢範圍[138][139]。
非甾體抗雄激素
[編輯]非甾體抗雄激素是非甾體類抗雄激素,因此在化學結構方面與甾體激素無關[85][140]。這些藥物主要用於治療前列腺癌[140],但也用於治療痤瘡、面部/體毛過度生長和女性高雄激素水平等其他目的[17][141][142][143]。與甾體抗雄激素不同,非甾體抗雄激素對雄激素受體具有高度選擇性,可作為純雄激素受體拮抗劑[140][144]。然而,與螺內酯類似,它們不會降低雄激素水平,而是僅通過阻止雄激素激活雄激素受體來發揮作用[140][144]。非甾體抗雄激素是比甾體抗雄激素更有效的雄激素受體拮抗劑[85][145],因此,與GnRH調節劑一起,在前列腺癌的治療中已在很大程度上取代了甾體抗雄激素[140][146]。
已用於跨性別女性的非甾體抗雄激素包括第一代藥物氟他胺(優力霉)、尼魯米特(Anandron,Nilandron)和比卡魯胺(可蘇多)[17][22][5][3][147]:477。存在更新且更有效的第二代非甾體抗雄激素藥物,如恩雜魯胺(安可坦)、阿帕魯胺(安列康)和達洛魯胺(Nubeqa),但由於沒有仿製藥且尚未用於跨性別女性,因此價格非常昂貴[148][149]。氟他胺和尼魯米特具有相對較高的毒性,包括相當大的肝損傷和肺病風險[150][141]。由於其風險,現在已經限制且不鼓勵在順性別和跨性別女性中使用氟他胺[17][141][5]。臨床上氟他胺和尼魯米特已在很大程度上被比卡魯胺取代[151][152],到2000年代中期,比卡魯胺占美國非甾體抗雄激素處方的近90%[153][144]。相對於氟他胺和尼魯米特,以及與醋酸環丙孕酮相比,比卡魯胺具有出色的耐受性和安全性[154][155][156]。它對女性幾乎沒有副作用[142][143]。然而,儘管比卡魯胺的耐受性和安全性大大提高,但仍有很小的肝酶升高風險,並且與非常罕見的肝損傷和肺病病例有關[17][150][157]。
對於希望保持性慾、性功能和/或生育能力的跨性別女性來說,相比於抑制睾酮水平並能極大破壞這些功能的抗雄激素,如醋酸環丙孕酮和GnRH調節劑等,比卡魯胺等非甾體類抗雄激素可能是一個特別有利的選擇[158][159][160]。然而,雌激素會抑制睾酮水平,高劑量會顯着破壞性慾、功能和生育能力[161][162][163][164]。此外,長期暴露後,雌激素對性腺功能和生育能力的破壞可能是永久性的[163][164]。
GnRH調節劑
[編輯]GnRH調節劑是抗促性腺激素,因此是功能性抗雄激素[165]。在男性和女性中,下丘腦都會產生促性腺激素釋放激素(GnRH),並誘導垂體分泌兩種促性腺激素,黃體生成素(LH)和促卵泡激素(FSH)[165]。促性腺激素向性腺發出信號,以製造睾丸激素和雌二醇等性激素[165]。GnRH調節劑結合併抑制GnRH受體,從而阻止促性腺激素釋放[165]。因此,GnRH調節劑能夠完全關閉性腺性激素的產生,並且可以將男性和跨性別女性的睾酮水平降低約95%,或與手術去勢相當[165][166][167]。GnRH調節劑通常也稱為GnRH類似物[165]。然而,並非所有臨床使用的GnRH調節劑都是GnRH的類似物[168]。
GnRH調節劑有兩種類型:GnRH激動劑和GnRH拮抗劑[165]。這些藥物對GnRH受體具有相反的作用,但矛盾的是具有相同的治療效果[165]。GnRH激動劑,例如亮丙瑞林(柳菩林)、戈舍瑞林(諾雷德)和布舍瑞林(舒攝癌),是GnRH受體超激動劑,其作用是使GnRH受體深度脫敏,從而使受體失去功能[165][166]。這是因為GnRH通常以脈衝形式釋放,但GnRH激動劑持續存在,這導致受體過度下調,並最終完全喪失功能[169][170][165]。在治療開始時,由於GnRH受體的急性過度刺激,GnRH激動劑與激素水平的「耀斑」效應有關[165][171]。在男性中,LH水平增加高達800%,而睾酮水平增加至基準的約140%至200%[172][171]。然而,GnRH受體逐漸脫敏。睾酮水平在大約2到4天後達到峰值,在大約7到8天後恢復到基準水平,並在2到4周內降至去勢水平[171]。抗促性腺激素如雌激素和醋酸環丙孕酮,以及非甾體抗雄激素如氟他胺和比卡魯胺,可以預先使用或同時使用,以減少或預防由GnRH激動劑引起的睾酮激增影響[173][172][174][175][51][176]。與GnRH激動劑相比,GnRH拮抗劑,例如地加瑞克(輔美康)和惡拉戈利(艾伯維),通過與GnRH受體結合但不激活它來發揮作用,從而將GnRH從受體中置換出來並阻止其激活[165]。與GnRH激動劑不同,GnRH拮抗劑沒有初始激增效應。治療效果立竿見影,性激素水平在幾天內降至去勢水平[165][166]。
GnRH調節劑對跨性別女性抑制睾酮非常有效,並且在伴隨雌激素治療性激素缺乏時幾乎沒有副作用[13][177]。然而,GnRH調節劑往往非常昂貴(在美國,通常為每年10,000美元至15,000美元),並且經常被醫療保險拒絕[13][178][179][180]。GnRH調節劑治療遠不如手術去勢經濟,而且從長期來看也不如手術去勢方便[181]。由於成本原因,許多跨性別女性買不起GnRH調節劑,必須使用其他通常不太有效的睾酮抑制選擇[13][178]。而在英國,GnRH激動劑被規定為跨性別女性的標準做法,英國國民保健署(NHS)給付這些藥物[178][182]。這與歐洲其他地區和美國形成鮮明對比[182]。GnRH調節劑的另一個缺點是它們中的大多數是肽並且沒有口服活性,需要通過注射、植入或鼻噴霧給藥[174]。然而,非肽類和口服活性GnRH拮抗劑惡拉戈利(艾伯維)和瑞盧戈利(Relumina)分別於2018年和2019年推出用於醫療用途。但它們受到專利保護,並且與其他GnRH調節劑一樣,目前非常昂貴[183]。
無論性別,對於符合相應指標的青少年,GnRH調節劑可用於在一段時間內阻止不希望的青春期變化,亦不會誘導患者當前的認同性別發生任何變化。GnRH調節劑在臨床、道德和法律上安全的最早年齡,以及使用多長時間上,存在相當大的爭議。世界跨性別人士健康專業協會第六版的護理標準允許從譚納階段II開始使用GnRH調節劑,但直到16歲才允許使用激素,期間可能跨越五年或更長時間。除了在青春期中的作用外,性甾醇還有其他重要的功能,一些可能被認為是男性化的骨骼變化(如身高增加)不受GnRH調節劑的阻礙[來源請求]。
5α還原酶抑制劑
[編輯]5α還原酶抑制劑是5α還原酶的抑制劑,是一種特異性雄激素合成抑制劑[184][185]。5α還原酶是一種酶,負責將睾酮轉化為更有效的雄激素雙氫睾酮(DHT)[184][185]。5α還原酶有三種不同的亞型,1、2和3型,這三種亞型在體內表現出不同的表達模式[184]。相比睾酮,DHT作為雄激素受體激動劑,效力高出2.5到10倍[184][185][186]。因此,5α還原酶可顯著增強睾酮的作用[184][185]。然而,5α還原酶僅在特定組織中表達,如皮膚、毛囊及前列腺,因此,睾酮轉化為DHT僅發生在身體的某些部位[184][185][187]。此外,男性的總DHT和游離DHT的循環水平非常低,分別約為睾酮的1/10和1/20[185][188][184],並且DHT在各種組織中被有效地滅活為弱雄激素,例如肌肉、脂肪及肝臟[184][166][189]。因此人們認為,DHT作為一種全身性雄激素的作用很小,而更多的是作為一種以組織特異性方式局部增強睾酮雄激素作用的手段[184][190][191]。在男性生殖系統發育和維持(特別是陰莖、陰囊、前列腺和精囊)、男性型面部/體毛生長和頭皮脫髮中,5α還原酶將睾酮轉化為DHT的過程起着重要作用,但在男性化的其他方面幾乎沒有作用[184][185][187][192][193]。除了5α還原酶參與的雄激素信號傳導外,它還分別將孕酮和睾酮等甾體激素轉化為別孕烷醇酮和雄烷二醇等神經甾體[194][195]。
5α還原酶抑制劑包括非那雄胺和度他雄胺[184][185]。非那雄胺是2型和3型5α還原酶的選擇性抑制劑,而度他雄胺是5α還原酶的所有三種亞型的抑制劑[184][196][197]。非那雄胺可以將循環DHT水平降低多達70%,而度他雄胺可以將循環DHT水平降低多達99%[196][197]。相反,5α還原酶抑制劑不會降低睾酮水平,實際上可能會略微增加[13][49][59][198]。5α還原酶抑制劑主要用於治療良性前列腺增生症,即前列腺因DHT的刺激變得過大並導致令人不快的泌尿生殖系統症狀的病症[196][199]。它們還用於治療男性和女性的雄激素依賴性頭皮脫髮[200][201][202]。這些藥物能夠防止男性進一步的頭皮脫髮,並可以恢復一些頭皮的毛髮密度[200][201][203]。相反,5α還原酶抑制劑在治療女性頭皮脫髮方面的有效性尚不清楚[202][185]。這可能是因為女性的雄激素水平要低得多,它們在頭皮脫髮中的作用可能不那麼重要[202][185]。5α還原酶抑制劑也用於治療女性多毛症(身體/面部毛髮過度生長),對這種適應症非常有效[204]。已發現度他雄胺在治療男性頭皮脫髮方面明顯比非那雄胺更有效,這歸因於其更完全地抑制5α還原酶並進而減少DHT的產生[205][206][140]。除了抗雄激素用途外,5α還原酶抑制劑還發現可以減少女性經前煩躁症的不良情感症狀[207][208]。這被認為是由於5α還原酶抑制劑在月經週期的黃體期中阻止了孕酮轉化為別孕酮[207][208]。
5α還原酶抑制劑有時與雌激素和/或其他抗雄激素聯合使用,作為跨性別女性女性化激素治療的組成部分[4][209][66]。它們的有益效果可能僅限於改善頭皮脫髮、體毛生長以及可能的皮膚症狀,如痤瘡[210][8][211][66]。然而,很少有人對5α還原酶抑制劑在跨性別女性中進行臨床研究,其在該組中的有效性和安全性的證據有限[209][31]。此外,5α還原酶抑制劑僅具有輕微和特異性的抗雄激素活性,不推薦作為一般抗雄激素藥物[31]。
5α還原酶抑制劑副作用最小,男性和女性都能很好地耐受[212][213]。在男性中,最常見的副作用是性功能障礙(發生率0.9-15.8%),其中可能包括性慾下降、勃起功能障礙和射精減少[212][213][214][215][216]。男性的另一個副作用是乳房變化,例如乳房脹痛和男性乳腺發育(發生率2.8%)[213]。由於雄激素和/或神經甾醇水平降低,5α還原酶抑制劑可能會略微增加抑鬱的風險(發病率約為2.0%)[215][217][218][212][195]。有報道稱,即使在停用5α還原酶抑制劑後,仍有一小部分男性可能會出現持續的性功能障礙和不良情緒變化[216][219][217][220][215][214][195]。5α還原酶抑制劑對男性的一些可能的副作用,例如男性乳房發育症和性功能障礙,實際上是許多跨性別女性可喜的變化[17]。無論如何,在跨性別女性中使用5α還原酶抑制劑時可能需要謹慎,因為這個群體已經處於抑鬱和自殺的高風險中[221][59]。
孕激素
[編輯]孕酮是一種孕激素,是女性體內兩種主要性激素中的另一種[174]。主要參與女性生殖系統、月經週期、妊娠、哺乳的調節[174]。孕酮的非生殖作用是相當微不足道的[222]。與雌激素不同,孕酮不參與女性第二性徵的發育,因此被認為不會導致女性個體女性化[8][90]。就孕酮對女性的影響而言,一個特別令人感興趣的領域是乳房發育[223][224][225]。雌激素負責乳腺管和結締組織的發育以及女孩青春期乳房脂肪的沉積[223][224]。相反,高水平的孕酮與其他激素如催乳素一起,是懷孕期間乳腺泡成熟的原因[223][224]。這樣可以在分娩後進行哺乳和母乳餵養[223][224]。雖然孕酮在懷孕期間會導致乳房發生變化,但在停止母乳餵養後,乳房會退化並恢復到懷孕前的組成和大小[223][226][224]。每次懷孕,小葉泡的成熟都會重新發生[223][224]。
孕激素有兩種類型:孕酮,它是體內天然及生物相同的激素;和孕激素類,它們是合成孕激素[50]。臨床上使用的孕激素有幾十種[50][227][228]。某些孕激素,即醋酸環丙孕酮及醋酸甲羥孕酮,如前所述,由於其抗促性腺激素作用有助於抑制跨性別女性的睾酮水平,因此被高劑量用作功能性的抗雄激素[89][90]。但除了睾酮抑制的具體作用外,目前沒有其他跨性別女性可使用孕激素的適應症[8]。因此,在跨性別女性中使用孕激素是有爭議的,且不作為常規處方推薦使用[8][5][6][229][31][230]。除孕酮、醋酸環丙孕酮和醋酸甲羥孕酮外,據報道在跨性別女性中使用的其他孕激素包括己酸羥孕酮、地屈孕酮、醋酸炔諾酮和屈螺酮[231][232][31][233][5][234]。一般來說,孕激素類在很大程度上具有與孕激素相同的作用,理論上任何孕激素類都可以用於跨性別女性[50]。
跨性別女性使用孕激素的臨床研究非常有限[8][225]。一些患者和臨床醫生根據傳聞和主觀主張認為,孕激素可能會帶來益處,例如改善跨性別女性的乳房和/或乳頭髮育、情緒和性慾[4][3][225]。目前沒有臨床研究支持此類報告[8][4][225]。沒有臨床研究評估跨性別女性使用孕酮的情況,只有幾項研究比較了跨性別女性使用孕激素(特別是醋酸環丙孕酮和醋酸甲羥孕酮)與不使用孕激素的情況[225][235][177]。儘管這些研究的結果質量有限,但報告稱孕激素對跨性別女性的乳房發育沒有益處[225][177][229]。在有限的臨床經驗中也是如此[236]。這些報告與完全雄激素不敏感綜合徵女性的正常甚至高於平均水平的乳房發育一致,這些女性缺乏孕激素,且在組織學檢查中沒有發現乳腺小葉泡發育[74][237]。值得注意的是,構成小葉泡組織的上皮組織通常(在懷孕和哺乳期之外)僅占乳房組織的10%至15%[238][239][240][241]。儘管孕酮對乳房發育的影響尚不確定,但由於乳房局部液體瀦留,孕酮被認為會在月經週期引起可逆的乳房增大[242][243]。這可能會產生誤導性的乳房生長外觀,並可能導致跨性別女性使用孕酮改善乳房大小和/或形狀流言[242][243]。
孕激素在乳房中具有一定抗雌激素作用,例如降低雌激素受體的表達及增加雌激素代謝酶的表達[244][245][246][247],因此已用於治療乳房疼痛和良性乳腺疾病[248][249][250][251]。直到接近青春期結束時,女性青春期的孕酮水平通常都不會顯着增加,而此時順性別女孩的大部分乳房發育已經完成[252]。此外,有人擔心在乳房發育過程中過早接觸孕激素是非生理性的,可能會影響最終的乳房發育結果,儘管這一概念目前仍處於理論階段[17][225][253]。儘管孕激素在青春期乳房發育中的作用尚不確定,但孕酮對於懷孕期間乳腺小葉泡成熟至關重要[223]。因此,任何希望哺乳或母乳餵養的跨性別女性都需要孕激素[43][254][225]。一項研究發現,在接受雌激素和高劑量醋酸環丙孕酮治療的跨性別女性中,組織學檢查發現乳腺小葉肺泡完全成熟[255][256][257]。然而,隨着醋酸環丙孕酮的停藥,小葉泡發育逆轉,這表明持續的孕激素暴露對於維持組織是必要的[255]。
就孕激素對性慾的影響而言,一項研究評估了使用地屈孕酮來改善跨性別女性的性慾,但沒有發現任何益處[233]。另一項研究同樣發現,口服孕酮並不能改善順性別女性的性功能[258]。
孕激素可能有副作用[229][31][50][227][259][53]。口服孕酮具有抑制性神經甾體作用,可產生鎮靜、情緒變化和酒精樣作用等副作用[50][260][261]。許多孕激素具有脫靶活性,例如雄激素、抗雄激素、糖皮質激素和抗鹽皮質激素活性,這些活性同樣會產生不良副作用[50][227]。此外在絕經後婦女中,與單獨使用雌激素治療相比,在雌激素治療中添加孕激素會增加血栓、心血管疾病(如冠心病和中風)和乳癌的風險[262][31][229][263]。雖然不知道孕激素的這些健康風險是否同樣發生在跨性別女性中,但不能排除它們確實如此[262][31][229]。高劑量孕激素會增加良性腦腫瘤的風險,包括催乳素瘤和腦膜瘤[264][265]。由於其潛在的有害影響和缺乏支持的益處,一些研究人員認為,除了抑制睾酮的目的外,孕激素通常不應用於或提倡在跨性別女性中使用,或僅應在有限的時間內使用(例如,2-3年內)[262][229][5][6][230]。相反,其他研究人員認為,跨性別女性使用孕激素的風險可能很小,鑑於潛在的益處(儘管是假設的益處),應在需要時使用[3]。一般來說,一些跨性別女性對孕激素的影響反應良好,而另一些則反應消極[3]。
孕酮最常口服[50][263]。然而,口服孕酮的生物利用度非常低,即使在高劑量下也只產生相對較弱的孕激素作用[266][267][263][268][269]。與孕激素相一致,但與孕激素類相反,即使在高劑量下口服孕酮也對男性沒有抗促性腺激素作用[260][270]。孕酮也可以通過各種非腸道(非口服)途徑服用,包括舌下、直腸和肌肉或皮下注射[50][250][271]。這些途徑沒有口服孕酮的生物利用度和功效問題,因此可以產生相當大的抗促性腺激素和其他孕激素作用[50][268][272]。由於吸收問題,透皮孕酮效果不佳[50][250][269]。孕激素類通常口服[50]。與孕酮相比,大多數孕激素類具有較高的口服生物利用度,並且可以通過口服產生完全的孕激素作用[50]。一些孕激素類,例如醋酸甲羥孕酮和己酸羥孕酮,通過或可以通過肌肉內或皮下注射替代給藥[273][250]。幾乎所有孕激素類,除地屈孕酮外,都具有抗促性腺激素作用[50]。
雜項
[編輯]催乳藥如外周選擇性D2受體拮抗劑和催乳素釋放劑多潘立酮等催乳劑可在希望母乳餵養的跨性別女性中用於誘導泌乳[274][275][43]。在成功之前,需要延長雌激素和孕激素聯合治療以使乳房的小葉泡組織成熟[254][43][276][255]。有幾篇關於跨性別女性哺乳和/或母乳餵養的報道[277][278][254][276][43][279][280]。
相互作用
[編輯]許多用於女性化激素治療的藥物,如雌二醇、醋酸環丙孕酮和比卡魯胺,都是CYP3A4和其他細胞色素P450酶的底物。因此,CYP3A4和其他細胞色素P450酶的誘導劑,如卡馬西平、苯巴比妥、苯妥英鈉、利福平和貫葉連翹等,可能會降低這些藥物的循環水平,從而降低它們的作用。相反,CYP3A4和其他細胞色素P450酶的抑制劑,如西咪替丁、克催瑪汝、葡萄柚汁、伊曲康唑、酮康唑和利托那韋等,可能會增加這些藥物的循環水平,從而增加它們的作用。細胞色素P450誘導劑或抑制劑與女性化激素治療同時使用可能需要調整藥物劑量。
效果
[編輯]跨性別女性激素治療的影響範圍取決於所使用的特定藥物和劑量。無論如何,激素治療對跨性別女性的主要影響是女性化和去男性化,具體如下:
效果 | 效果發生的預期時間[a] | 效果最大化的預期時間[a][b] | 激素治療停止後的持久性 |
---|---|---|---|
乳腺發育和乳頭/乳暈增大 | 2–6個月 | 1–3年 | 通過手術可逆 |
鬍鬚/體毛變稀疏/生長減緩 | 4–12個月 | >3年[c] | 可逆 |
男性模式脫髮的停止/逆轉 | 1–3個月 | 1–2年[d] | 可逆 |
皮膚變軟/油質和痤瘡減少 | 3–6個月 | 未知 | 可逆 |
脂肪組織以一種女性模式重新分布 | 3–6個月 | 2–5年 | 可逆 |
肌肉質量/力量下降 | 3–6個月 | 1–2年[e] | 可逆 |
骨盆變寬和變圓[f] | 不明確 | 不明確 | 永久 |
心境、情緒性和行為變化 | 不明確 | 不明確 | 可逆 |
性衝動減少 | 1–3個月 | 3–6個月 | 可逆 |
自發性/夜間陰莖勃起減少 | 1–3個月 | 3–6個月 | 可逆 |
勃起功能障礙和少精液症 | 1–3個月 | 多變 | 可逆 |
精子產量/生育能力下降 | 未知 | >3年 | 可逆或永久[g] |
睾丸變小 | 3–6個月 | 2–3年 | 未知 |
陰莖變小 | 無[h] | 不存在 | 不存在 |
前列腺變小 | 不明確 | 不明確 | 不明確 |
聲音變化 | 無[i] | 不存在 | 不存在 |
腳註和來源
腳註:
來源: |
身體變化
[編輯]乳房發育
[編輯]乳房、乳頭和乳暈的發育差異很大,這取決於遺傳、身體成分、GAHT起始年齡和許多其他因素。對於某些人來說,發育可能需要幾年到近十年的時間。然而,許多跨性別女性報告稱,在過渡期間,乳房通常會出現發育「停滯」或明顯的乳房不對稱。接受GAHT的跨性別女性通常比順性別女性經歷更少的乳房發育(特別是如果在年青成年後開始)。由於這個原因,許多人尋求隆胸或自體脂肪填充。選擇縮胸的跨性別患者很少見。肩寬和胸腔的大小對乳房的可感知大小也有影響;在跨性別女性中,兩者通常都較大,導致乳房成比例地縮小。因此,當跨性別女性選擇隆胸時,使用的植入物往往比順性別女性使用的更大。[290]
在接受GAHT的跨性別女性中,與青春期的順性別女性一樣,乳腺導管和乳房懸韌帶在雌激素的影響下發育。孕酮會導致乳囊(乳腺泡)發育,在正確的刺激下,跨性別女性可能會分泌乳汁。此外,HRT通常會使乳頭對刺激更敏感。
跨性別女性的乳房發育在激素治療開始後的兩到三個月內開始,並持續長達兩年[291][211]。身體質量指數較高的跨性別女性的乳房發育似乎更好[291][211]。因此,在激素治療的早期階段增加一些體重可能有利於較瘦跨性別女性的乳房發育[291][211]。不同的雌激素,如戊酸雌二醇、結合雌激素和炔雌醇,似乎在跨性別女性乳房大小上的效果相同。突然停止雌激素治療與溢乳(哺乳)有關[291][211]。
皮膚變化
[編輯]皮膚的最上層,即角質層,變得更薄、更透明。結果,蜘蛛靜脈可能會出現或更明顯。膠原蛋白減少,觸覺增加。皮膚變得更柔軟[292],更容易因抓撓或剃鬚而撕裂或受刺激,且由於黑色素略有減少,因此顏色略淺。
皮脂腺活動(由雄激素觸發)變少,皮膚和頭皮上的油脂產生減少。因此,皮膚變得不太容易長粉刺。它也會變得更乾燥,可能需要使用乳液或油[290][293]。由於產生的油量較少,孔隙變得更小。許多大汗腺——一種汗腺——變得不活躍,體味減少,變得不那麼刺激而變得溫和[來源請求]。
隨着皮下脂肪的積累[290],凹陷或脂肪團在大腿和臀部變得更加明顯。這些區域的皮膚上可能會出現妊娠紋(擴張紋)。皮膚更容易曬傷,可能是因為皮膚較薄且色素較少[來源請求]。
頭髮變化
[編輯]抗雄激素僅輕微影響現有的面部毛髮;患者可能會看到生長緩慢,密度和覆蓋率有所降低。那些青春期過去不到十年和/或缺乏大量面部毛髮的人可能會有更好的結果。服用抗雄激素的患者在電解和激光脫毛方面往往比不服用的患者有更好的效果[來源請求]。在十幾歲或二十出頭的患者中,如果睾酮水平在正常女性範圍內,抗雄激素會阻止新的面部毛髮發育[290][293]。
隨着時間的推移,體毛(胸部、肩膀、背部、腹部、臀部、大腿、手背和腳背)從末端(「正常」)毛髮變成細小的金色毳毛。手臂、肛周和會陰部的毛髮減少,但後兩個區域可能不會變成毳毛(一些順性別女性在這些區域也有毛髮)。腋毛的質地和長度略有變化,陰毛在圖案上變得更像典型女性。小腿毛變得不那麼濃密。所有這些變化都在一定程度上取決於遺傳因素[290][293]。
頭髮的質地、捲曲和顏色可能會略有變化。以前禿頂的區域頭髮尤其可能發生再生長[來源請求]。眉毛不會改變,因為它們不是雄激素毛髮[294]。
眼睛變化
[編輯]眼睛晶狀體的曲率發生變化[295][296][297][292]。由於雄激素水平降低,瞼板腺(上下眼瞼邊緣張開的皮脂腺)產生的油脂較少。因為油會阻止淚膜蒸發,所以這種變化可能會導致眼睛乾澀[298][299][300][301][302]。
脂肪變化
[編輯]脂肪組織的分布在數月和數年內緩慢變化。HRT導致身體以典型的女性模式積累新的脂肪,包括臀部、大腿、臀部、恥骨、上臂和乳房。身體開始燃燒腰部、肩部和背部的舊脂肪組織,使這些區域變小。[290]
臉頰和嘴唇的皮下脂肪增加,使臉看起來更圓,隨着臉頰下部的填充,下巴不再那麼突出。[來源請求]
骨骼/骨架變化
[編輯]不受影響的特徵
[編輯]GAHT不會逆轉青春期已經確立的骨骼變化。因此,除上述原因外,它不會影響身高,手臂、腿、手和腳的長度,或肩膀和肋骨。然而,骨骼形狀的細節在一生中都會發生變化,骨骼在雄激素的影響下變得更重、雕刻得更深,而GAHT確實阻止了這種變化的進一步發展。
對於已經發生骨骺閉合(骨骼末端融合及閉合,防止進一步延伸)的個體,髖部的寬度不受影響。這發生在大多數18到25歲之間的人身上[來源請求]。無論是否發生骨骺閉合,GAHT都不能逆轉已經確定的臀部形狀變化[來源請求]。有研究表明,只有在青春期早期進行青春期阻滯療法/HRT的人,其(髖骨)骨骼與其認同性別相接近[303],如果是青春期晚期,則骨骼形狀與指派性別相差不大。
面部骨骼結構的既定變化也不受HRT的影響。絕大多數顱面變化發生在青春期。相比之下,青春期後的成長要慢得多,而且細微[304]。同樣不受影響的是甲狀軟骨(喉結)的突出。這些變化可以通過手術逆轉(分別是面部女性化手術和喉結縮小術)。
在青春期,聲音音調變低,變得更加洪亮。這些更改是永久性的,不受GAHT的影響,可以通過聲音手術部分逆轉。通過語音治療也可以獲得更女性化的聲音。
面部毛髮在青春期發育,僅受GAHT輕微影響。然而,它可以通過激光脫毛幾乎永久消除,或通過電解永久消除。[來源請求]
心理變化
[編輯]女性化激素療法的心理影響比身體變化更難定義。因為激素治療通常是性別轉換的第一步,開始它的行為具有顯着的心理影響,這很難與激素引起的變化區分開來。
情緒變化
[編輯]跨性別女性的激素治療會改變情緒和幸福感。[305]
性變化
[編輯]一些跨性別女性報告性慾顯著降低,具體取決於抗雄激素的劑量[306]。少數術後跨性別女性服用低劑量的睾酮來提高她們的性慾。增加雌激素的劑量或添加孕激素會提高一些跨性別女性的性慾[來源請求]。
自發和晨勃的頻率顯著降低,儘管一些進行了睾丸切除術的患者仍會出現晨勃。自願性勃起是可能的或不能的,這取決於所服用的激素和/或抗雄激素的量[來源請求]。
尚未研究且難以估計管理長期激素治療的方案,因為尚未有關於長期使用激素治療的研究[262]。然而,根據目前對性腺激素在順性別男性和女性性功能影響的了解,可以推測這些療法對跨性別者的效果[307]。
首先,如果要在女性化的性別轉變中降低睾酮,很可能會抑制性慾和性喚起;或者,已在一些對順性別女性的研究中發現,如果高劑量的雌激素對性慾產生負面影響,則可假設雄激素與高水平的雌激素結合會加劇這種結果[307]。不幸的是,迄今為止還沒有任何隨機臨床試驗研究跨性別激素治療的類型和劑量之間的關係,因此它們之間的關係仍不清楚[307]。通常,女性化性別轉變使用的雌激素比絕經後婦女HRT的推薦劑量高2至3倍[262]。藥代動力學研究表明,這些增加的劑量服用後可能會導致血漿雌二醇峰值更高;但是,長期副作用尚未研究,並且該途徑的安全性尚不清楚[262]。
與任何藥物或激素療法一樣,存在潛在的副作用,在跨性別激素療法的情況下則是包括性功能的變化。它們能夠通過各種副作用直接或間接地顯著影響性功能,例如腦血管疾病、肥胖和情緒波動[307]。此外,一些研究發現女性化激素治療後會出現糖尿病,這會損害性反應[來源請求]。無論個人及其醫生選擇採取何種途徑,同時考慮激素治療的醫療風險以及患者的心理需求很重要[來源請求]。
大腦變化
[編輯]幾項研究發現,跨性別女性的激素治療會導致大腦結構向女性方向改變[308][309][310][311][312]。此外,研究發現,跨性別女性的激素治療會導致認知任務的表現,包括視覺空間、語言記憶和語言流暢度,向更女性化的方向轉變[308][305]。
不利影響
[編輯]心血管影響
[編輯]跨性別女性最顯著的心血管風險是雌激素的凝血作用。最明顯地表現為靜脈血栓(VTE)的風險增加:深靜脈血栓(DVT)和肺栓塞(PE)的形成,後者由DVT的血凝塊脫落並遷移到肺部時形成。DVT的症狀包括一條腿的疼痛或腫脹,尤其是小腿。PE的症狀包括胸痛、氣短、暈厥和心悸,有時不伴有腿痛或腿脹。
VTE更常發生在雌激素治療的第一年。口服非生物相同的雌激素(如炔雌醇和結合雌激素)的VTE風險高於通過注射、透皮、植入和鼻內等途徑的非腸道雌二醇製劑[313][314][315][316][317][318][319][320][321][322][323][164][324][325][326][327][328][57][329][330][331][332]。VTE風險也隨着患者年齡和吸煙因素的增加而增加,因此許多臨床醫生建議吸煙者和40歲以上患者中使用更安全的雌激素製劑[來源請求]。此外,孕激素會增加VTE風險,並且風險隨雌激素和孕激素劑量而增加[來源請求]。肥胖也會增加VTE的風險[來源請求]。雌激素增加VTE的風險被認為是由於它們對肝臟蛋白質合成,特別是對凝血因子產生的影響[50]。與雌二醇相比,非生物相同的雌激素,例如結合雌激素,尤其是炔雌醇,對肝臟蛋白質合成的影響程度較生物相同的雌激素明顯不成比例[50]。此外,口服雌二醇對肝臟蛋白質合成的影響比經皮或其他非腸道雌二醇途徑增加4到5倍[50][333]。
由於華法林(用於治療血栓)在相對年輕且健康的人群中風險較低,而未經治療的跨性別患者產生不良生理和心理後果的風險很高,因此血栓前突變(如第五凝血因子萊頓突變,抗凝血酶III和蛋白質C或S缺乏症)不是激素治療的絕對禁忌症。[211]
美國2018年一項對2842名跨女個體進行的群組研究,平均隨訪時間為4.0年,觀察到與順性別參考人群相比,VTE、中風和心肌梗死發作的風險增加[334][335][17][56]。使用的雌激素包括口服雌二醇(1至10 mg/天)和其他雌激素製劑[56]。其他藥物,例如螺內酯等抗雄激素藥物也有使用[56]。
2019年一項系統綜述和元分析發現,跨性別女性接受女性化激素治療後,VTE的發病率為每1000人年2.3人[336]。相比之下,一般人群的發病率為每1000人年1.0-1.8人,而服用避孕藥的絕經前婦女的發病率為每1000人年3.5人[336][337]。納入研究中的VTE發生率存在顯著異質性,元分析無法在雌激素類型、途徑、劑量、同時使用抗雄激素或孕激素,或對應於已知VTE危險因素的患者特徵(例如,性別、年齡、吸煙狀況、體重)之間進行亞組分析[336]。由於納入了一些使用炔雌醇(更容易形成血栓,已不再用於跨性別女性)的研究,研究人員指出,其中的VTE風險可能被高估了[336]。
2016年一項專門評估口服雌二醇的研究,在676名平均接受1.9年治療的跨性別女性中,VTE的發生率僅為一人,組發生率0.15%,每10,000人年7.8起[338][339]。使用的口服雌二醇劑量為2至8 mg/天[339]。幾乎所有跨性別女性也服用螺內酯(94%),一小部分人服用非那雄胺(17%),不到5%的人還服用孕激素(通常是口服孕酮)[339]。這項研究的結果表明,口服雌二醇的跨性別女性VTE發生率較低[338][339]。
胃腸道影響
[編輯]雌激素可能會增加膽囊疾病的風險,尤其是在老年人和肥胖人群中[292]。還可能表現出肝毒性,增加轉氨酶水平,尤其是在口服時[來源請求]。
代謝變化
[編輯]患者的基礎代謝率可能會發生變化,從而導致體重和能量水平的增減、睡眠模式及溫度敏感性的改變[來源請求]。雄激素剝奪會導致新陳代謝減慢及肌張力下降。需要更多的鍛煉才能增加肌肉。添加孕激素可能會提高耗能水平,儘管它也可能會增加食慾[來源請求]。
骨骼變化
[編輯]對所有人來說,為了維持骨骼健康,雌激素和雄激素都是必需的。健康的年輕女性每月會產生約10 mg睾酮[來源請求],而男性較高的骨礦物質密度與較高的血清雌激素水平有關。雌激素和睾酮都有助於刺激骨骼形成,尤其是在青春期。雌激素是減緩骨質流失的主要性激素,與性別無關。
癌症風險
[編輯]關於跨性別女性接受激素治療是否會增加乳腺癌風險的研究參差不齊[341][342][343][344]。兩項群組研究發現,與順性別男性相比風險沒有增加[342][343],而另一項群組研究發現風險增加了近50倍,因此乳腺癌的發病率介於順性別男性和順性別女性之間[344][341]。沒有證據表明跨性別女性罹患乳腺癌的風險高於順性別女性[345]。截至2019年,已有20例跨性別女性罹患乳腺癌的報告[341][346]。
在患有男性乳腺發育的順性別男性中,尚未發現患乳腺癌的風險增加[347]。有人提出,相比於46,XX核型(兩條X染色體),46,XY核型(一條X染色體和一條Y染色體)可能更能抵禦乳腺癌[347]。患有克氏綜合徵(47,XXY核型)的男性會導致雄激素缺乏症、雌激素過多症和非常高的男性乳腺發育發生率(80%),與核型男性(46,XY)相比,患乳腺癌的風險顯著增加(20至58倍),更接近核型女性(46,XX)的水平[347][348][349]。核型男性、克氏綜合徵男性和核型女性的乳腺癌發病率分別約為0.1%[350]、3%[348]和12.5%[351]。患有完全雄激素不敏感綜合徵(46,XY核型)的女性從未出現男性性徵,且具有完整正常的女性形態,包括乳房發育[352],也尚未有報道患乳腺癌[72][353]。特納綜合徵(45,XO核型)女性患乳腺癌的風險似乎也顯著降低,但這可能與卵巢衰竭和性腺功能減退,而不是與遺傳有關[354]。
在已切除性腺長期接受雌激素治療的跨性別女性中,前列腺癌極為罕見[13][355][356]。儘管多達70%的男性在80多歲時出現前列腺癌[152],文獻僅報道了少數跨性別女性罹患前列腺癌的案例[13][355][356]。因此,根據雄激素導致前列腺癌發展的事實,GAHT似乎對跨性別女性的前列腺具有高度保護作用[13][355][356]。
跨性別女性接受激素治療會增加某些類型的良性腦腫瘤(包括腦膜瘤和催乳素瘤)風險[357]。這些風險主要與醋酸環丙孕酮的使用有關[357]。
雌激素和孕激素可引起催乳素瘤,這是一種良性的、分泌催乳素的垂體腫瘤[來源請求]。乳頭溢乳可能是催乳素水平升高的標誌。如果催乳素瘤足夠大,將導致視覺變化(尤其是周邊視力下降)、頭痛、抑鬱或其他情緒變化、頭暈、噁心、嘔吐和垂體功能衰竭的症狀,如甲狀腺機能低下症。
監測
[編輯]在女性化激素治療的早期階段,尤其應經常進行血液檢查以評估激素水平和肝功能。內分泌學會建議患者在HRT的第一年中,每三個月進行一次血液檢查,以檢測雌二醇和睾酮;如果使用螺內酯,則在第一年中每兩到三個月監測一次[13]。總雌二醇和總睾酮水平包括(但不限於)以下推薦範圍:
來源 | 位於 | 總雌二醇 | 總睾酮 | 參考 |
---|---|---|---|---|
內分泌學會 | 美國 | 100–200 pg/mL | <50 ng/dL | [13] |
世界跨性別人士健康專業協會(WPATH) | 美國 | 「[T]雄激素水平[...]低於正常女性範圍上限,雌二醇水平在絕經前女性範圍內,但遠低於超生理水平。」「[M]維持患者所需性別表達的生理範圍內的水平(基於完全女性化/男性化的目標)。」 | [8] | |
跨性別健康卓越中心(UCSF) | 美國 | 「對跨性別者激素水平的解釋尚無證據基礎;非跨性別者的生理激素水平用作參考。」 「鼓勵提供者諮詢他們當地的實驗室,以獲得『男性』和『女性』的激素參考水平,[範圍可能會有所不同],然後再根據激素性別應用正確的範圍解釋當前的結果,而不是登記時的性別。」 | [3] | |
芬威健康 | 美國 | 100–200 pg/mL | <55 ng/dL | [358] |
卡倫洛德 | 美國 | 「一些指南建議在雌激素治療的基線和整個監測過程中檢查雌二醇和睾酮水平。我們還沒有發現常規激素水平的臨床用途可以證明費用是合理的。然而,我們認識到,個別提供者可能會根據需要或在患者需要的指導下調整他們的處方和監測做法。」 | [359] | |
國際計劃生育聯合會(IPPF) | 英國 | <200 pg/mL | 30–100 ng/dL | [360] |
國民保健署(NHS)基金會信託 | 英國 | 55–160 pg/mL | 30–85 ng/dL | [361][362][363][364] |
英國皇家精神科醫學院(RCP) | 英國 | 80–140 pg/mL | 「遠低於正常男性範圍」 | [14] |
溫哥華沿海衛生(VCH) | 加拿大 | ND | <45 ng/dL | [5] |
雌激素的最佳範圍僅適用於服用雌二醇(或雌二醇酯)的個體,不適用於服用合成或其他非生物同質製劑(例如結合型雌激素或炔雌醇)的個體。[13]
醫生也建議進行更廣泛的醫療監測,包括全血細胞計數,腎功能、肝功能、脂質和葡萄糖代謝檢查,及監測催乳素水平、體重和血壓。[13][359]
如果催乳素水平大於100 ng/mL,則應停止雌激素治療,並在6至8周後重新檢查催乳素水平[359]。如果催乳素水平仍然很高,則應對垂體進行MRI掃描,以檢查是否存在催乳素瘤[359]。否則,可以以較低劑量重新開始雌激素治療[359]。醋酸環丙孕酮與催乳素水平升高尤其相關,停用醋酸環丙孕酮會降低催乳素水平[365][366][367]。與醋酸環丙孕酮相比,雌激素和螺內酯治療與催乳素水平升高無關[367][368]。
歷史
[編輯]有效的女性性激素藥物,包括雄激素、雌激素和孕激素,在1920年代和1930年代首次面世[369]。丹麥內分泌學家Christian Hamburger於1953年發表了對跨性別女性進行激素治療的最早報告之一[370]。他的一位病人是克里斯汀·約根森(Christine Jorgensen),他從1950年開始開始治療[371][372][373][374]。Hamburger、德裔美國內分泌學家哈里·本傑明(Harry Benjamin)和其他研究人員在1960年代中後期發表了關於跨性別女性激素治療的其他報告[375][376][377][378][379][380]。然而,到1950年代後期,本傑明就有數百名跨性別患者[90],早在1940年代末或1950年代初,他就為跨性別女性提供激素治療[381][382][383][371]。無論如何,Hamburger據說是第一位用激素療法治療跨性別女性的人[384]。
首批跨性別診所之一由約翰斯·霍普金斯大學醫學院於1960年代中期設立[385][90]。到1981年,已有近40個這樣的中心[386]。當年發表了其中20個中心激素治療方案的綜述[375][386]。由克里斯托弗·約翰·杜赫斯特(Christopher John Dewhurst)主持的第一屆性別認同國際研討會(International Symposium on Gender Identity)於1969年在倫敦舉行[387],而約翰斯·霍普金斯大學出版社於1969年出版了第一本關於跨性別主義的醫學教科書,題為《跨性別主義和性別重置》(Transsexualism and Sex Reassignment),由理查德·格林(Richard Green)和約翰·曼尼(John Money)編輯[388][389]。這本教科書包括一章由哈里·本傑明和Christian Hamburger撰寫的激素治療章節[380]。哈里·本傑明國際性別焦慮症協會(HBIGDA),現稱為世界跨性別人士健康專業協會(WPATH),於成立1979年,同年發布了第一版護理標準[371]。內分泌學會於2009年發布了跨性別者荷爾蒙護理指南,並於2017年發布了修訂版[375][390][13]。
跨性別女性的激素治療最初是使用高劑量雌激素,口服雌激素如結合型雌激素、炔雌醇和己烯雌酚,以及腸外雌激素如苯甲酸雌二醇、戊酸雌二醇、環戊丙酸雌二醇和十一烷酸雌二醇[378][379][380][386]。有時還包括孕激素,例如己酸羥孕酮和醋酸甲羥孕酮[370][378][379][386][391][37][392]。抗雄激素和孕激素醋酸環丙孕酮於1977年首次用於跨性別女性[393][394]。螺內酯是另一種抗雄激素,於1986年首次用於跨性別女性[395][391][285][396]。到1990年代初,抗雄激素已在跨性別女性的激素治療中得到廣泛應用[37][262][397]。引入抗雄激素後,跨性別女性的雌激素劑量減少了[來源請求]。炔雌醇、結合雌激素和其他非生物相同的雌激素從2000年左右開始停止用於跨性別女性,轉而使用雌二醇,因為它們有更大的血栓和心血管風險[286][340][336]。
參見
[編輯]參考文獻
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如前所述,CPA會導致血漿睾酮水平的不完全抑制,降低約70%並保持在去勢值的三倍左右。[Rennie等人]發現CPA與極低劑量(0.1 mg/d)的DES聯合使用可以非常有效地去除血漿睾酮和組織中的雙氫睾酮雄激素。[...]該方案結合了兩種化合物的睾酮降低作用,因此只需少量雌激素即可將血漿睾酮降低至接近去勢水平。(CPA, as mentioned earlier, leads to an incomplete suppression of plasma testosterone levels, which decrease by about 70% and remain at about three times castration values. [Rennie et al.] found that the combination of CPA with an extremely low dose (0.1 mg/d) of DES led to a very effective withdrawal of androgens in terms of plasma testosterone and tissue dihydrotestosterone. [...] this regimen combines the testosterone-reducing effects of two compounds, therefore, only small amounts of estrogen are required to bring down plasma testosterone to approximately castrate levels.)
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[醋酸甲羥孕酮]使血漿睾酮水平暫時降低至略高於去勢男性的水平。當以40 mg tid的劑量使用時,與0.5–1.5 mg/d的雌二醇聯合使用,可協同抑制垂體促性腺激素,並將血漿睾酮維持在去勢水平長達一年。([Megestrol acetate] produces a transient reduction in plasma testosterone to levels somewhat higher than those in castrated men. When used in a dose of 40 mg tid, in combination with estradiol 0.5–1.5 mg/d, it acts synergistically to suppress pituitary gonadotropins and maintain plasma testosterone at castration levels for periods up to one year.)
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非甾體抗雄激素包括氟他胺、尼魯米特和比卡魯胺,它們不會降低雄激素水平,可能對想要保持性慾和生育能力的個體有利[9]。(Non-steroidal antiandrogens include flutamide, nilutamide, and bicalutamide, which do not lower androgen levels and may be favorable for individuals who want to preserve sex drive and fertility [9].)
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傳統上,建議患者在開始異性激素治療之前冷凍保存精子,因為隨着時間的推移,高劑量雌激素治療可能會降低精子活力(Lubbert等,1992)。然而,由於研究有限,雌激素治療導致的生育力下降仍有爭議。(Traditionally, patients have been advised to cryopreserve sperm prior to starting cross-sex hormone therapy as there is a potential for a decline in sperm motility with high-dose estrogen therapy over time (Lubbert et al., 1992). However, this decline in fertility due to estrogen therapy is controversial due to limited studies.)
- ^ Payne, Anita H.; Hardy, Matthew P. The Leydig Cell in Health and Disease. Springer Science & Business Media. 2007-10-28: 422–431 [2022-01-14]. ISBN 978-1-59745-453-7. (原始內容存檔於2020-07-27).
雌激素是下丘腦-垂體-睾丸軸的高效抑制劑(212-214)。除了它們在下丘腦和垂體水平的負反饋作用外,還可能對睾丸產生直接抑制作用(215,216)。[...][用雌激素治療的]睾丸組織學顯示曲細精管紊亂、空泡化和管腔缺失,以及精子發生的區室化。(Estrogens are highly efficient inhibitors of the hypothalamic-hypophyseal-testicular axis (212–214). Aside from their negative feedback action at the level of the hypothalamus and pituitary, direct inhibitory effects on the testis are likely (215,216). [...] The histology of the testes [with estrogen treatment] showed disorganization of the seminiferous tubules, vacuolization and absence of lumen, and compartmentalization of spermatogenesis.)
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雌激素主要通過下丘腦-垂體水平的負反饋來減少LH分泌和睾丸雄激素合成。[...]有趣的是,如果不間斷地暴露,3年後停止雌激素治療,血清睾酮可能會保持在去勢水平長達3年。這種長期抑制被認為是雌激素對睾丸間質細胞的直接影響所致。(Estrogens act primarily through negative feedback at the hypothalamic-pituitary level to reduce LH secretion and testicular androgen synthesis. [...] Interestingly, if the treatment with estrogens is discontinued after 3 yr. of uninterrupted exposure, serum testosterone may remain at castration levels for up to another 3 yr. This prolonged suppression is thought to result from a direct effect of estrogens on the Leydig cells.)
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[...]在第一次注射亮丙瑞林之前進行雌激素或抗雄激素治療可能會降低[治療開始時由睾酮「爆發」引起的症狀風險](16)。([...] estrogen or antiandrogen treatment prior to the first leuprolide injection may reduce [the risk of symptoms caused by the testosterone "flare" at the initiation of treatment] (16).)
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[...]建議在為男性到女性的跨性別者開具口服非那雄胺的處方時要謹慎,因為該藥物與誘發抑鬱、焦慮和自殺意念有關,這些症狀在性別不安患者中尤為常見,他們已經處於高風險中[9]。([...] caution is recommended while prescribing oral finasteride to male-to-female transsexuals, as the drug has been associated with inducing depression, anxiety and suicidal ideation, symptoms that are particularly common in patients with gender dysphoria, who are already at a high risk.[9])
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有人建議在每個雌激素治療周期的最後一周添加孕激素,以形成更圓潤的乳房,而不是這些患者中出現的錐形乳房,但我們無法檢測到乳房輪廓在有沒有孕激素情況下的差異。(It has been suggested that progestins be added during the last week of each cycle of estrogen therapy in order to develop more rounded breasts rather than the conical breasts many of these patients develop, but we have been unable to detect any difference in breast contour with or without progestins.)
- ^ Morris JM. The syndrome of testicular feminization in male pseudohermaphrodites. Am. J. Obstet. Gynecol. 1953-06, 65 (6): 1192–1211. PMID 13057950. doi:10.1016/0002-9378(53)90359-7.
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.
脂肪細胞占人體乳房的大部分,而上皮細胞僅占人體乳房體積的約10%。(Adipocytes make up the bulk of the human breast, with epithelial cells accounting for only approximately 10% of human breast volume.)
- ^ Howard BA, Gusterson BA. Human breast development. Journal of Mammary Gland Biology and Neoplasia. 2000, 5 (2): 119–37. PMID 11149569. S2CID 10819224. doi:10.1023/A:1026487120779.
在基質中,纖維和脂肪組織的數量增加,成人非哺乳期乳房由80%或更多的基質組成。(In the stroma, there is an increase in the amount of fibrous and fatty tissue, with the adult nonlactating breast consisting of 80% or more of stroma.)
- ^ Sperling, Mark A. Pediatric Endocrinology. Elsevier Health Sciences. 2014-04-10: 598– [2022-01-14]. ISBN 978-1-4557-5973-6. (原始內容存檔於2022-04-30).
雌激素刺激乳頭生長,乳腺終末導管分支發展到形成導管的階段,脂肪基質生長至構成乳房質量的約85%。[...]初潮前後,當末端導管分支形成多個盲囊芽時,乳腺小葉出現。這些效果是由於有孕酮存在。[...]完整的小泡發育通常僅在懷孕期間,在額外的孕酮和催乳素的影響下發生。(Estrogen stimulates the nipples to grow, mammary terminal duct branching to progress to the stage at which ductules are formed, and fatty stromal growth to increase until it constitutes about 85% of the mass of the breast. [...] Lobulation appears around menarche, when multiple blind saccular buds form by branching of the terminal ducts. These effects are due to the presence of progesterone. [...] Full alveolar development normally only occurs during pregnancy under the influence of additional progesterone and prolactin.)
- ^ Hagisawa S, Shimura N, Arisaka O. Effect of excess estrogen on breast and external genitalia development in growth hormone deficiency. Journal of Pediatric and Adolescent Gynecology. 2012, 25 (3): e61–3. PMID 22206682. doi:10.1016/j.jpag.2011.11.005.
雌激素刺激乳頭的發育,從乳腺導管分叉到小管形成階段的過程,及脂肪基質生長至構成乳房質量的約85%。(Estrogen stimulates growth of the nipples, progression of mammary duct branching to the stage at which ductiles are formed, and fatty stromal growth until it constitutes about 85% of the mass of the breast.)
- ^ 242.0 242.1 Lee-Ellen C. Copstead-Kirkhorn; Jacquelyn L. Banasik. Pathophysiology - E-Book. Elsevier Health Sciences. 2014-06-25: 660– [2022-01-14]. ISBN 978-0-323-29317-4. (原始內容存檔於2021-04-14).
在整個生育期,一些女性在月經開始前的每個月經周期後期都會注意到乳房腫脹。在月經周期的這個階段,乳房組織的保水和隨後的腫脹被認為是由於高水平的循環孕酮刺激了乳房的分泌細胞。(Throughout the reproductive years, some women note swelling of the breast around the latter part of each menstrual cycle before the onset of menstruation. The water retention and subsequent swelling of breast tissue during this phase of the menstrual cycle are thought to be due to high levels of circulating progesterone stimulating the secretory cells of the breast.12)
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在實驗上,我已經能夠誘導一名男性異裝癖者的泌乳,該男性異裝癖者的睾丸在幾年前已被切除,其乳房在很長一段時間內使用芪雌酚和乙炔雌酮,發育已良好[9]。1955年7月9日,皮下植入600 mg雌二醇,每周注射50 mg孕酮,持續四個月。下個月每天注射10 mg二丙酸雌二醇和50 mg孕酮。這些注射又持續了一個月,將孕酮增加到每天100 mg。然後停用兩種激素,逐日增加劑量注射催乳素和生長激素,持續四天;同時,患者每天使用吸乳器四次,每次5分鐘。在此期間,乳腺靜脈明顯增大,在第六天和第七天收集到了1到2 mg乳狀液體。(Experimentally I have been able to induce lactogenesis in a male transvestite whose testes had been removed some years before and whose breasts had been well developed over a long period with stilbestrol and ethisterone.9 In July, 1955, 600 mg. of estradiol was implanted subcutaneously and weekly injections of 50 mg. of progesterone were given for four months. For the next month daily injections of 10 mg. estradiol dipropionate and 50 mg. progesterone were given. These injections were continued for another month, increasing progesterone to 100 mg. daily. Both hormones were then withdrawn, and daily injections of increasing doses of prolactin and somatotropin were given for four days; at the same time, the patient used a breast bump four times daily for 5 minutes on both sides. During this time the mammary veins were visibly enlarged and on the sixth and seventh days 1 to 2 cc. of milky fluid was collected.)
- ^ 255.0 255.1 255.2 Kanhai RC, Hage JJ, van Diest PJ, Bloemena E, Mulder JW. Short-term and long-term histologic effects of castration and estrogen treatment on breast tissue of 14 male-to-female transsexuals in comparison with two chemically castrated men. The American Journal of Surgical Pathology. 2000-01, 24 (1): 74–80. PMID 10632490. doi:10.1097/00000478-200001000-00009.
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- ^ Worsley R, Santoro N, Miller KK, Parish SJ, Davis SR. Hormones and Female Sexual Dysfunction: Beyond Estrogens and Androgens--Findings from the Fourth International Consultation on Sexual Medicine. J Sex Med. 2016-03, 13 (3): 283–90. PMID 26944460. doi:10.1016/j.jsxm.2015.12.014.
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- ^ 269.0 269.1 Hermann AC, Nafziger AN, Victory J, Kulawy R, Rocci ML, Bertino JS. Over-the-counter progesterone cream produces significant drug exposure compared to a food and drug administration-approved oral progesterone product. J Clin Pharmacol. 2005, 45 (6): 614–9. PMID 15901742. S2CID 28399314. doi:10.1177/0091270005276621.
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- ^ Unfer, Vittorio; di Renzo, Gian; Gerli, Sandro; Casini, Maria. The Use of Progesterone in Clinical Practice: Evaluation of its Efficacy in Diverse Indications Using Different Routes of Administration. Current Drug Therapy. 2006, 1 (2): 211–219. ISSN 1574-8855. doi:10.2174/157488506776930923.
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- ^ Paynter MJ. Medication and Facilitation of Transgender Women's Lactation. J Hum Lact. 2019-03, 35 (2): 239–243. PMID 30840524. S2CID 73466659. doi:10.1177/0890334419829729.
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- ^ 276.0 276.1 Kozlov GI, Mel'nichenko GA, Golubeva IV. Sluchai laktorei u bol'nogo muzhskogo pola s transseksualizmom [Case of galactorrhea in a transsexual male patient]. Probl Endokrinol (Mosk). 1985, 31 (1): 37–8 [2022-01-14]. ISSN 0375-9660. PMID 4039061. (原始內容存檔於2022-04-21) (俄語).
[...]進行了外生殖器去勢和女性化整形手術[...]手術後一段時間,患者對生活重新產生了興趣。經過手術和荷爾蒙矯正後,患者不可抗拒地發展出母性本能。未婚,患者獲准領養孩子,模擬懷孕,帶着兒子從婦產醫院出院。從「出生」後的第一天開始,溢乳急劇增加,出現自發流出乳汁,伴溢乳(+++)。嬰兒一直母乳餵養到6個月大。[...]我們的信息是文獻中第二例有關男性易性症患者溢乳的描述。R.[Flückiger]等人於1983年首次描述了這種類型(6)。這一觀察結果證明了泌乳發育機制與一個人的遺傳性別相獨立,並且對男性發生藥物性溢乳的可能性感到擔憂。([...] castration and feminizing plastic surgery of the external genitalia was performed [...] Some time after the operation, the patient developed a renewed interest in life. After the surgical and hormonal correction, the patient irresistibly developed maternal instincts. Unmarried, the patient obtained permission for the adoption of a child, simulated pregnancy, and was discharged from the maternity hospital with a son. From the first days after the 「birth」, galactorrhea sharply increased, and spontaneous outflow of milk appeared, with galactorrhea (+++). The baby was breastfed up to 6 months of age. [...] Our message is the second in the world literature describing galactorrhea in a male patient with transsexualism. The first description of this kind was made in 1983 by R. [Flückiger] et al. (6). This observation demonstrates the independence of the mechanism of lactation development from one’s genetic sex and is alarming with regard to the possibility of drug-induced galactorrhea development in men.)
- ^ Foss, GL. Abnormalities of form and function of the human breast. Journal of Endocrinology. 1956-01, 14 (1): R6–R9 [2022-01-14]. (原始內容存檔於2022-01-14).
基於催乳理論,並受到Lyons、Li、Johnson&Cole[1955]在雄性大鼠中成功產生泌乳的激勵,嘗試在男性異裝癖者中啟動催乳。六年前,該患者接受了雌激素治療。然後切除睾丸和陰莖,並通過整形手術構建人造陰道。該患者在1954年9月植入了500 mg雌二醇,在1955年7月植入了600 mg。然後每天注射二丙酸雌二醇和孕酮,持續6周,使乳房發育更加快速。停止該治療後立即每天注射催乳素22·9 mg,連續3天無效。每天服用雌二醇和孕酮的第二個月後,聯合注射催乳素和生長激素,持續4天,並通過吸乳器進行抽吸,每天4次。在第4天和第5天,從右側乳頭擠出幾滴初乳。(Based on the theories of lactogenesis and stimulated by the success of Lyons, Li, Johnson & Cole [1955], who succeeded in producing lactation in male rats, an attempt was made to initiate lactogenesis in a male transvestist. Six years ago this patient had been given oestrogens. Both testes and penis were then removed and an artificial vagina was constructed by plastic surgery. The patient was implanted with 500 mg oestradiol in September 1954, and 600 mg in July 1955. The breasts were then developed more intensively with daily injections of oestradiol dipropionate and progesterone for 6 weeks. Immediately following withdrawal of this treatment, prolactin 22·9 mg was injected daily for 3 days without effect. After a second month on oestradiol and progesterone daily, combined injections of prolactin and somatotrophin were given for 4 days and suction was applied by a breast pump-four times daily. On the 4th and 5th days a few drops of colostrum were expressed from the right nipple.)
- ^ Harold Gardiner-Hill. Modern Trends in Endocrinology. Butterworth. 1958: 192 [2022-01-14]. (原始內容存檔於2022-04-21).
最近,Foss(1956)嘗試在一名被閹割的男性異裝癖者中開始哺乳。給他植入了500 mg的雌二醇,10個月後,又植入了600 mg的雌二醇,隨後每天注射二丙酸雌二醇和黃體酮,持續6周。停藥後立即每天注射22·9 mg催乳素,連續3天,但沒有效果。在每天用雌二醇和黃體酮治療的第二個月後,他被給予催乳素和生長激素聯合注射4天,每天使用吸乳器抽吸4次。在第四天和第五天,從右側乳頭擠出幾滴初乳。這是現代激素知識在男性中的一個可能應用,值得進一步試驗。(Recently, an attempt has been made by Foss (1956) to initiate lactation in a castrated male transvestist. He was given an implant of 500 milligrams of oestradiol, and 10 months later, a further 600 milligrams of oestradiol, followed by daily injections of oestradiol dipropionate and progesterone for 6 weeks. Immediately after withdrawal of this treatment, 22·9 milligrams of prolactin were injected daily for 3 days but without effect. After a second month of treatment with oestradiol and progesterone daily, he was given combined injections of prolactin and somatotrophin for 4 days, suction with a breast-pump being employed 4 times daily. On the fourth and fifth days a few drops of colostrum were expressed from the right nipple. There is a possible application here of modern hormone knowledge to man, and further trials would be of interest.)
- ^ Edward Flückiger; Emilio Del Pozo; Klaus von Werder. Prolactin: Physiology, Pharmacology, and Clinical Findings. Springer-Verlag. 1982: 13 [2022-01-14]. ISBN 978-3-540-11071-2. (原始內容存檔於2022-04-28).
[...]對男性變性者的觀察(Wyss和DelPozo未發表)表明,在人類男性中也可以類似地實現泌乳誘導。[...]([...] An observation (Wyss and Del Pozo unpublished) in a male transsexual showed that induction of lactation can be similarly achieved in the human male. [...])
- ^ Carla A. Pfeffer. Queering Families: The Postmodern Partnerships of Cisgender Women and Transgender Men. Oxford University Press. 2017: 19– [2022-01-14]. ISBN 978-0-19-990805-9. (原始內容存檔於2022-04-21).
僅僅2年後,溫弗瑞進行的另一次採訪,引發了許多觀眾相同的反應。在2010年的這一集中,女同性戀夥伴克里斯汀·麥金博士和麗莎·博茨抱着他們的雙胞胎嬰兒時喜極而泣。再一次,當人們發現美麗的克里斯汀是一位男到女變性人,曾經是一位英俊的軍官克里斯時,觀眾的下巴都掉了下來,而麗莎使用克里斯汀在性別確認手術之前儲存的精子生下了她們的親生孩子[10]。當溫弗瑞觀看克里斯汀母乳餵養她們孩子的視頻時,溫弗瑞的下巴差點撞到地板上(這一集在網上稱為「成為自己孩子父親的媽媽」)。[...](Just 2 years later, Winfrey would feature another interview that elicited many of the same audience reactions. In this 2010 episode, lesbian partners Dr. Christine McGinn and Lisa Bortz beamed with joy as they held their infant twins. Again, audience members' jaws dropped when it was revealed that beautiful Christine was a male-to-female transsexual who used to be a handsome military officer Chris, and that Lisa had given birth to the couple's biological children using sperm Chris banked prior to gender confirmation surgeries.10 And it was Winfrey's chin that nearly hit the floor as she watched video of Christine breastfeeding the couples' children (the episode is referred to online as "The Mom Who Fathered Her Own Children"). [...])
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擴展閱讀
[編輯]- Gooren LJ, Giltay EJ, Bunck MC. Long-term treatment of transsexuals with cross-sex hormones: extensive personal experience. J. Clin. Endocrinol. Metab. 2008-01, 93 (1): 19–25. PMID 17986639. doi:10.1210/jc.2007-1809
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- Fabris B, Bernardi S, Trombetta C. Cross-sex hormone therapy for gender dysphoria. J. Endocrinol. Invest. 2015-03, 38 (3): 269–82. PMID 25403429. S2CID 207503049. doi:10.1007/s40618-014-0186-2.
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- Wesp LM, Deutsch MB. Hormonal and Surgical Treatment Options for Transgender Women and Transfeminine Spectrum Persons. Psychiatr. Clin. North Am. 2017-03, 40 (1): 99–111. PMID 28159148. doi:10.1016/j.psc.2016.10.006.
外部連結
[編輯]- Hembree WC, Cohen-Kettenis PT, Gooren L, Hannema SE, Meyer WJ, Murad MH, Rosenthal SM, Safer JD, Tangpricha V, T'Sjoen GG. Endocrine Treatment of Gender-Dysphoric/Gender-Incongruent Persons: An Endocrine Society Clinical Practice Guideline (PDF). J. Clin. Endocrinol. Metab. 2017-11, 102 (11): 3869–3903 [2021-10-15]. PMID 28945902. S2CID 3726467. doi:10.1210/jc.2017-01658. (原始內容 (PDF)存檔於2021-04-15).
- Coleman, E.; Bockting, W.; Botzer, M.; Cohen-Kettenis, P.; DeCuypere, G.; Feldman, J.; Fraser, L.; Green, J.; Knudson, G.; Meyer, W. J.; Monstrey, S.; Adler, R. K.; Brown, G. R.; Devor, A. H.; Ehrbar, R.; Ettner, R.; Eyler, E.; Garofalo, R.; Karasic, D. H.; Lev, A. I.; Mayer, G.; Meyer-Bahlburg, H.; Hall, B. P.; Pfaefflin, F.; Rachlin, K.; Robinson, B.; Schechter, L. S.; Tangpricha, V.; van Trotsenburg, M.; Vitale, A.; Winter, S.; Whittle, S.; Wylie, K. R.; Zucker, K. Standards of Care for the Health of Transsexual, Transgender, and Gender-Nonconforming People, Version 7 (PDF). International Journal of Transgenderism. 2012, 13 (4): 165–232 [2021-10-16]. ISSN 1553-2739. S2CID 39664779. doi:10.1080/15532739.2011.700873. (原始內容 (PDF)存檔於2021-04-12).
- Deutsch, Madeline. Guidelines for the Primary and Gender-Affirming Care of Transgender and Gender Nonbinary People 2nd. University of California, San Francisco: Center of Excellence for Transgender Health: 28. 2016-06-17 [2022-01-14]. (原始內容存檔於2022-05-11).
- Dahl, M; Feldman, JL; Goldberg, J; Jaberi, A. Endocrine Therapy for Transgender Adults in British Columbia: Suggested Guidelines (PDF). Vancouver Coastal Health. 2015 [2018-08-15]. (原始內容 (PDF)存檔於2018-08-16).
- Bourns, Amy. Guidelines and Protocols for Comprehensive Primary Care for Trans Clients (PDF). Sherbourne Health Centre. 2015 [2018-08-15]. (原始內容 (PDF)存檔於2020-05-10).
- Transgender HRT Research Repository (頁面存檔備份,存於網際網路檔案館)
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