Transgender Hair Transplant and Medical Treatments

The journey through the gender confirmation process can be long and emotional but, in the end, it is often one of the most rewarding steps our patients take in their lives. It involves an experienced team of physicians and surgeons to transition a patient safely so the medical and surgical stages should be coordinated at all times. Transgender hair surgery is often one of the most special and effective phases of the process.

Some masculine and feminine patients might be unsure about the idea of taking medications for the gender transition and confirmation process. The first step is to meet with your gender confirmation physician and complete the basic evaluations to determine medical treatments that would be required in your individual case. It is up to each patient to decide when to schedule an appointment with a board-certified surgeon, like Dr. Manu Gujrati, that is experienced in performing surgical gender confirmation hair procedures. Patients can discuss their concerns and personal goals with the doctor as well as ask any questions they have about how the procedure is performed. In addition, the doctor can review the risks and benefits of gender transition surgery and suggest any medical alternatives before the final gender transition treatment decision is made by the patient and the surgeon.

Transgender Women

There are multiple medical treatment options available for transgender women, or trans-feminine people or MTF, which bring about a successful outcome for the patient. The most commonly used medications during the transition process for transgender women are estrogens and anti-androgens (discussed below).

Estrogen

The administration of estrogen is able to lower serum testosterone levels as well as raise serum estradiol levels. Estrogen can be administered via oral, intramuscular, transdermal, sublingual or subcutaneous methods. Estrogen can result in the development of typical female secondary sex characteristics (that are largely reversible) such as the growth of breasts, softer skin, a decrease in muscle mass, female-pattern fat distribution and testicular and penile atrophy which might lead to erectile dysfunction and infertility. Some trans-women also report a decreased libido and changes in their emotions on a regular basis.

There are some adverse effects that can be the result of having an estrogen treatment:

• Elevated blood pressure
• Higher risk of thrombosis
• Impact on fertility (estrogen is not an effective method of contraception)
• Elevated transaminases (high level of certain liver enzymes)

Patients that want to enjoy a higher pitch to their voice, less facial hair, changes in their facial bone structure or a reversal of male-pattern baldness need to seek out other treatment options. Some of the most common methodologies include voice training, facial feminization surgery, laser hair removal or a hair transplant.

Anti-Androgens

Anti-androgens (such as finasteride, dutasteride, spironolactone (SPL), and flutamide) are commonly used in trans-women who have not yet undergone or do not plan to have an orchiectomy (where one or more testicles are removed). These medications are taken to block the effects of testosterone, and its more powerful form dihydrotestosterone (DHT), which leads to a decrease in body hair and male erectile function. In turn, this allows any estrogen that is administered to promote the development of female secondary sex characteristics.

Almost as important are the effects of these drugs in preserving hair growth on the scalp and preventing typical male-pattern baldness (Androgenetic Alopecia also known as AGA). AGA is actually caused by dihydrotestosterone (DHT) (and not testosterone itself). Finasteride (which is also known as Propecia) and dutasteride are the most effective drugs at blocking the production of DHT in the body. Dutasteride is typically 4-5 times more effective than finasteride.

Spironolactone (SPL or Aldactone) and Flutamide have blocking properties against the androgen receptor itself and get in the way of DHT binding to it. However, neither are complete blockers and their effectiveness is in the mild to moderate level.

GnRH Agonists (i.e. Lupron)

This is another medical option (besides anti-androgens) that can be used to block endogenous testosterone production and is administered every few months in an intramuscular manner. While it is quite successful at blocking overall levels of testosterone, it is rarely covered by insurance which means patients have to pay for it out of pocket.

Progesterones

A medical option performed to slightly activate the androgen receptors in order to improve both the libido and mood of a person. In addition, they can be used to maximize the amount of breast growth enjoyed by a patient (although this might be the result of weight gain). There have been some studies that have shown a possibility of an increased risk of cardiovascular disease, VTE (blood clots in the veins) and/or breast cancer with its use.

Transgender Males

When it comes to the transition process for transgender males, or trans-masculine people or FTM, physicians and surgeons can use a variety of medical and surgical techniques to achieve a successful transition for the patient.

Testosterone

The most common medication used by physicians for the transition process is testosterone. There are multiple reasons that the use of testosterone is ideal for patients transitioning from female to male:

• Lowers serum estradiol levels
• Raises the levels of serum testosterone
• Promotes the development of typical male secondary sex characteristics

In addition, the use of testosterone on FTM patients provides several permanent changes:

• Increase in facial hair growth
• Increase in the growth of body hair
• Deeper voice
• Thicker structure to the facial bones
• Clitoral enlargement (clitoromegaly)

The administration of testosterone can be achieved by a pill (oral), an injection (intramuscular), a patch or cream (transdermal) or even as a small implant (subcutaneous).

Patients should be aware of some adverse effects that can happen during testosterone treatment:

• Elevated blood pressure
• Elevated glucose
• Worsening lipid profile
• Acne
• Impact on fertility (although it does not stop ovulation so pregnancy can still occur)
• Temporary vaginal atrophy
• Temporary increased muscle mass

Finasteride and Dutasteride

Finasteride (known as Propecia) and dutasteride are very effective drugs that can be used to prevent the occurrence of male-pattern baldness in transgender men since it only blocks dihydrotestosterone (DHT) (and not testosterone itself). Patients should be aware that the use of finasteride or dutasteride can decrease the amount of secondary hair growth as well as slow the amount of clitoromegaly (since those are at least partially related to DHT).

Transgender Hair Transplant Myths

There seems to be a common misconception among patients that the anti-androgen spironolactone (SPLCTN) blocks all testosterone production in the body and that is why it is a popular choice for male-to-female (MTF) transgender confirmation.

This premise is incorrect because, as shown above, there are far more effective drugs available for the act of blocking testosterone production or the activation of the androgen (male sex hormone) receptor. The use of SPLCTN is possibly so popular because it is inexpensive to purchase, has few side effects and offers some mild benefits to the gender confirmation process.