/user/Head_Juggernaut_6582/ Saturday, April 24, 2021 at 3:06:27 AM EDT

3 year update

This is my update after 3 years of medical transition and FFS. I’m mid to late 30s, and I’m a doctor.

The very personal part of this update is going to be brief, because I feel I can’t offer anything super unique there. It’s been a struggle to fit transition related tasks around family/professional life, but I somehow did it. My partner and I are still together and making plans for the near, medium, and distant future. It all feels very settled. I still have bad days, but I’m post-FFS and all my facial hair is gone so I’m just kind of being myself these days.

What I can offer you is my unique perspective as a doctor going through this process. I can also give you some of the fruits of my personal research and opinions on how to optimize a transition. So here are my thoughts, in no particular order:

Hormones

I think there is something to starting slow. I started with sublingual, 2 then 4 mg, then transitioned to EV 20mg/ml at 0.5 ml/week for a total of 10mg/week. Results with fat redistribution have been good. I had big mood swings early on, but it’s levelled out. I like the convenience of not having to let a pill dissolve under my tongue as well.

I know there is some controversy about hormone cycling in the community. I have done this by doing half an injection one week and 1.5x an injection the next, followed by two weeks of regular injection, and I did feel more breast sensitivity at points. There are no studies around cycling HRT in trans women or trans men that I can find, but the fact is, receptor downregulation happens. Almost every hormone in the human body has downregulation of its receptors as a feature. It was assumed for a long time, and has been shown to happen in mice and some human tissue. Do with this information what you will, and know if you choose to cycle hormones there is at least some science behind it and it’s not just some “trying to replicate periods” thing.

Edit: I should explain what receptor downregulation is. Your body has estrogen receptors on and in its cells -- on the surface, but more importantly on the surface of the nucleus inside the cell. This is where the estrogen you take attaches to, which then instructs the cell to make more or less of specific proteins, ultimately resulting in things like breast tissue growth, softer skin etc.

Your body strives for homeostasis in pretty much all things, which is a state of very little change. It's kind of a default setting for safety reasons. If a particular hormone gets too high in the blood, your body reduces the number of receptors expressed on and in the cells so that you don't get some kind of runaway overreaction from rising hormone levels. This is in fact how GnRH agonists work -- they blast the pituitary gland with so much of something that looks like GnRH that they become desensitized to it. So theoretically, having super high E all the time can reduce the number of receptors available to bind to, which means making less of desirable proteins etc. What is the effect of this on transition as a whole is unknown. I'd have to do some more research to find out how quickly the number of available receptors rebounds.

Breast growth

I honestly don’t believe that breast tissue growth stops at 1 or 2 years. Those who stick around the community sometimes report a growth spurt 3, 4, or 5 years in. My cis friends tell me their breasts didn’t really fill out until they were in their mid to late 20s, so give it time. Weight gain is a factor here too, which I’ll discuss later. Breasts are mostly fat.

Hips/fat redistribution.

Hips are fat. Hips are fat. Hips are fat. I can’t say that enough. The pelvic bone width difference between those who underwent puberty on T vs E is about two finger widths, on average. It’s noticeable but it’s not all the difference.

Going to get a little judgey here… I came across a site from a trans woman who had transitioned long ago and who I guess is rather famous in the community? Her advice was that you won’t get hip growth, and fat redistribution was way overblown, so just live with it. Thing is, she had less body fat as a trans woman than I have ever had living as a guy. I would have killed for that muscle definition in my gym-going days. So of course she isn’t going to get hips from fat redistribution, because there is no fat. If being that lean is your thing then go for it, but I feel like it’s kind of a classic transition mistake. Cis women are like 20-30% body fat, not 10%. I know you want your shoulders to shrink, but that takes time or possibly clavicle shortening. So you’re better off increasing your body fat to grow hips.

Here is one cis woman’s before and after from intermittent fasting:

https://i.imgur.com/0btKc0F.jpg

Starts with hips wider than shoulders, ends with shoulders much wider than hips. Of course this an extreme, but it shows my point: hips are fat. Look at any skinny model on a clothing site. No fat, no hips. Look at a very overweight cis woman. No, her hip width isn’t bone -- a human being with a pelvic width of 30” would not be capable of bipedal motion. It’s all fat. It’s kind of astonishing that this is still a debate. Hips. Are. Fat.

So why can’t some of us get hips? On to the next point.

Fat storage: hypertrophy vs hyperplasia

Hypertrophy refers to the growth of existing cells. Hyperplasia is the creation of new cells. You might have heard hypertrophy in relation to muscle growth. It’s generally thought that we have X number of cells in our muscles, and working them out increases the size of those cells. Some research indicates there may be a tiny bit of hyperplasia, but it’s overwhelmingly hypertrophy causing the growth.

So what about fat? If you have extra calories, your body stores it as fat. If you have existing fat cells, it’s much more efficient to stuff it there causing hypertrophy of those existing cells than it is to make new cells. If you run out of room in your existing cells, that’s when your body turns to hyperplasia and starts making new fat cells. If you gain weight on T it’s going to store it on your tummy, potentially making new cells there if it needs to. When you lose weight, those existing cells simply shrink, but don’t die. This is all a bit hand wavey, as there will be overlap in these processes and any number of variables that are difficult to track (does speed of fat gain influence hypertrophy vs hyperplasia etc.) How hormonal transition affects the balance between hypertrophy and hyperplasia is unknown. It may be slightly more preferential to create new fat cells on your hips even if there is room on your tummy, once you’re under E. What is this mix? 70% hypertrophy and 30% hyperplasia? More or less of one or the other? Nobody knows even with cis people, so it's a complete mystery with trans people. Point is, to gain hips you may need to exceed the existing fat storage capacity of your body to some degree in order to form new fat cells on your hips, and you need to do this with good E levels.

What was my experience with this? I did get some fat on my thighs and my butt under T, but I never stored fat on my hips under T, so I likely didn’t have that many fat cells hanging out there. I used to poke my thumb into the side of my hip just over the trochanter to see how far it would sink in. When I started HRT, it was pretty much just skin there. Now it sinks in a good inch. I took measurements throughout transition to track this as well, though not as often as I should have. I measured hip circumference as well as hip width by putting my butt against the wall and using pencils to carefully mark the maximum width point, kind of in the saddle bag area.

• Time: 152lbs Start to Now 178lbs
• Chest: 36" to 39"
• Waist: 29.5" to 32.5"
• Hip Circumference: 36" to 41.5"
• Standing Hip Width: 13.125" to 15.5"
• Waist to Hip Ratio: 0.82 to 0.78

That last standing hip width measurement is the same as my biacromial distance, that is, the distance between the lateral edge of the acromion process of the shoulder. I definitely did not have miracle bone growth in my hips, as I measured the distance between my anterior superior iliac spines (ASIS) and it did not change at all.

To get this growth, I had to fill the fat storage capacity of my butt, thighs, and some of my tummy. I would describe myself as “chubby” right now, and would like to lose some weight. But, I have no muscle definition, and my hips are pretty wide. We’ll see how much of it I retain in each area when I start losing.

So anyway, you want that waist to hip ratio of 0.75 or lower for that typically feminine look. I believe 0.7 is considered the “most attractive” WHR for women. Without more fat on your hips you’ll never approach that. You have to get it there somehow, then optimize your WHR. Once you start losing weight you should lose more from your tummy, just by virtue of hormonal distribution. If you want to take a more extreme route, CoolSculpting can apparently destroy fat cells, so that is an option you can try if you’re unhappy with distribution after gaining weight. No experience with this myself though.

Some general info on hypertrophy vs hyperplasia https://link.springer.com/article/10.1007/s00125-018-4732-x

Evidence of fat cell hyperplasia continuing into adulthood (previously this was disputed) https://www.pnas.org/content/107/42/18226

Muscle loss: you can botox any muscle in the human body

Here’s something I’ve never seen anyone else talk about: you can botox and shrink any muscle in the human body. More on this later, just trying to pique your interest.

I lost a lot of muscle early on in transition. I was never huge, but after about 8 months I tried on some old guy clothes with structure (a couple of jackets) and they were hanging off my shoulders. Muscle loss continues at a very slow pace, and I’m told it can even increase after orchiectomy/bottom surgery, even with complete suppression of T otherwise.

My biceps and triceps have remained stubborn, mostly in shape rather than overall size. I still had a big ball of bicep when I flexed my arm from hours in the gym. I thought surely there’s a better way, so I started doing some research after learning about botox treatments for jaw slimming. Why could that not be applied to other muscles in the body, I thought?

I found that botox is starting to be used for the trapezius, and in some places, for the deltoids and triceps. Google “barbie arms botox” to get an idea of what people are doing. The results aren’t super dramatic in cis women, but I think that depends on how hypertrophied the treated muscle is, and under what circumstances it got that way. Think of it like this: a masseter muscle is under a load of 1.0, just your regular load of chewing food and talking. Whatever 1.0 is for you. Once the botox wears off, the muscle rebounds slightly under this load. Similarly if you’re treating a cis woman’s arms who just wants them smaller, but has never really worked out. Think of it like if an average person broke their arm -- there’s quite a bit of atrophy after 6 weeks in a cast, but it builds back up rather quickly under normal use.

Now consider what happens if you were a bodybuilder and you broke your arm. The load on your arms is probably 2.0 or 3.0 or more of what a regular person does, with your heavy gym routine. So if you break it, it atrophies, but it’s never going to build back up to where it was unless you go back to the gym and put it under load of 2.0 or 3.0. If you gave up bodybuilding at that point and only had a load of 1.0, you’ll likely end up with a normal looking arm.

So, with that in mind, I started messaging places that do botox asking if they could do this. I found one, and started with my biceps. It was 4 injection points of 10 units in each bicep, for a total of 40 units per arm. Within a couple of days my bicep was just floppy tissue. It’s been about 3 months, and it was enormously effective in shrinking it. My best flex is just flat across the bicep. It is still regaining a little mobility but I don’t expect it will come back to where it was. I’ll update you as time passes. I’ve lost about 1” on each arm so far. As a side note, the arms are a key fat storage location for women. Your muscles might shrink but the measurement can stay the same as fat piles up on your tricep and round the whole arm. I can definitely pinch a good amount of fat there now. Here is an MRI of a healthy young man and young woman's arm compared. Size difference is there, but composition is the major difference.

Some things to know: do this with a doctor. It’s not common, and a knowledge of anatomy is required. Infiltrate too deep and you can hit some major arteries or nerves. This also isn’t cheap. Botox is $10/unit where I am. Might be less or more where you are. You might have trouble finding someone to do it. I emailed several botox places and was told it’s not something they do. Finally found one who would do it, but I had to get my hands on a copy of the bible of botox injection, available here:

https://www.amazon.ca/Pictorial-Atlas-Botulinum-Toxin-Injection/dp/1850971757

And I brought this with me to show them what to do. It’s possible that they were more willing to listen to me based on my medical knowledge so your mileage may vary.

You have to be careful about what you treat at one time. I think the safe maximum dose is 400 units in any 3 month period, so don’t go thinking you’ll just treat your whole upper body at once. Also realize that you need to be functional. Treating the biceps muscle and completely paralysing it is fine, because you have residual function by the brachialis muscle. If you were to, say, treat the long head of your tricep, your posterior deltoid, and maybe your trapezius all at once, you might find you cannot lift your arm over your head.

Also note I mentioned heads of the tricep. Many muscles have multiple heads (tricep has 3, deltoid has 3) and these can be treated individually depending on your needs.

This made a huge difference for me, dysphoria wise. And the nice thing about it is that it’s not like FFS where you have to pay it all at once. You can do just one muscle, and maybe even just one side at a time if you really want to. You can also start low on units and come back in a week if you don’t have the desired effect. Once you have a baseline of how much it took for effect on one muscle, you can use this research on the relative sizes of muscles in the upper body to ballpark the next set of injections.

Edit: I've had my deltoids done as well, 10 units in each head. I think I might need a little more for the effect so I'll be going back for a few more units in each head. After that, long head of the triceps, then lats/pecs.

Edit 2: Went back for another 10 units in each head for a total of 60 units per side. The deltoid has shrunk tremendously and my triceps are now the part that sticks out furthest from my body.

Be aware that there are risks associated with botox use.

Here’s a link to part of a book a chapter called Body Contouring with Botulinum Toxin in the book Botulinum Toxin for Asians. To give you an idea of efficacy, 75 units in the deltoid resulted in a 31.4% decrease in size on MRI in a cis woman. I would expect it to be a greater drop in a muscle with acquired (not congenital) hypertrophy, as they state here:

The effects of BoNT-A in body contouring begin to appear 2 weeks after the injection, become prominent after 1 month, and approach the maximum level after 2–3 months. After 6 months the muscle volume begins to redevelop partially and completely recover to the original state after 9–12 months. However, minimizing the use of the corresponding muscles can slow down the recovery process. Conversely, excessive use of the corresponding muscles can cause the muscle volume to recover more quickly as if undergoing rehabilitation physical therapy. If the muscle volume is large congenitally, the muscle volume recovers more easily due to homeostasis.

However, acquired form of muscle hypertrophy through exercise does not easily recover to the original state as long as exercise for the corresponding muscles is avoided.

So, don't hit the upper body weight hard and the reduction should be permanent. I suspect that after some time and in the absence of testosterone, you can even go back to upper body weights without much risk of becoming too bulky again. Honestly that is something I'd like to do, because lifting weights is so good for your overall health.

Don't expect overnight results from botox! If you google onset time, you'll find a lot of things about how fast it works for wrinkles in the face. That means that paralysis or partial paralysis has taken effect, resulting in the cosmetic improvement of skin texture, but it does not mean atrophy is happening. For larger muscles the onset time is slower. One reference I found said 1-2 weeks for muscle weakness to start, with improvement in appearance at 2-3 months. This is about what I saw with my biceps -- immediate weakening, but longer until the muscle actually shrank.

The other classic way to lose muscle is to do a caloric deficit, tonnes of cardio, and low protein. This worked for me somewhat, but didn’t change the contour of muscles the way botox did. I also had another problem with my hair because of this…

Hair

Take care of your hair. My hair story is pretty dramatic. It was quite thin on top with a badly receded hairline. I tried minoxidil for 2.5 years pre-HRT and got no response. I was also on Finasteride for over a year of that time, and dutasteride for about 5 months. After HRT I had dramatic regrowth on top, almost completely filling in. Hairline improved a little but did not move down. When I had FFS, I had a hairline advance, which helped, but I’ll still need transplants. I thought post surgery was a good time to give up on minoxidil because it didn’t appear to do anything, and I didn’t want to worry about getting around sutures. Following that, I had massive hair shedding, to the point where it was very thin on top. What happened? Some obvious possibilities:

• A scalp advance involves dissecting back on the scalp almost to the crown. This disturbs blood supply, and can cause something called anagen effluvium, which is an immediate shed of shocked hair in that area. This can be an effect of scalp surgeries and I think this happened to me.
• Separately from anagen effluvium, telogen effluvium is a shedding process that starts generally 6 weeks to 3 months after a major shock like starting some medications, surgery, or anesthesia for long periods. I had 2 of those risk factors.
• It’s possible that minoxidil magically started working after 2 years and I lost what I did because I quit minoxidil. I haven’t restarted, because honestly I hate applying it every day and it takes 2 hours to dry. If I don’t get good regrowth I’ll consider switching to oral minoxidil instead.

Ferritin and hair

One other possibility is this, connected to that low protein muscle losing diet… my post-surgery blood work revealed a ferritin of 7. What is ferritin? It’s a measure of the amount of iron that your body has in storage. Low ferritin means low iron. This can happen from losses, which is generally caused by menstruation, GI, or surgical blood loss, or it can be from reduced intake. I didn’t lose enough in surgery to account for this, so I think I screwed myself with my low protein (and very unintentionally by extension) low iron diet for many months, sometimes with a great caloric deficit. And low iron is also a trigger for telogen effluvium, and regrowth from this often only starts 6 months after coming back to good ferritin levels. What is a good level? A GP will probably tell you something like 20 to 200. Some derms will tell you 50 to stop shedding and 70 or 100 for good regrowth. I can tell you that below a ferritin of 50, there is a 50% chance that your bone marrow contains no stored iron, which is like, bad.

Iron is used for many things in the body. Generally a GP will only think about your hemoglobin, and tell you you’re fine if you’re not anemic. Anemia is a late finding of iron deficiency, and there are many other processes in the body that may be shut down/restricted when iron is low. Hair is one of those things. Iron deficiency without anemia just happens to be a thing many GPs don’t know about. Here is some good info from an internist who knows all about it.

Anyway, if you have some hair loss, iron probably isn’t your issue -- but optimizing it is part of making sure you get the most of any regrowth you’re going to experience under HRT. I think whatever else happened with anagen or telogen effluvium, the low ferritin made it worse or stunted regrowth. My ferritin is now at a good level so I’m just going to have to wait another 4-6 months for the hair to cycle and see if it grows back like it did before, or if minoxidil really did start working for me and I need to go back on that. That was long, but I think it’s worth mentioning, because I know a lot of trans women go vegan or very low protein in transition in order to maximize muscle loss. It’s possible to do that safely but few ever do. So be careful, and if you find yourself falling asleep from fatigue at 8 pm every night, maybe get that ferritin checked.

FFS

FFS is great. I had pretty much the works: hairline, brow, nose, lip lift, chin/jaw, and tracheal shave. I think I will need some revisions, but those were included in the cost. It’s made a huge difference for me. After a couple of years of HRT I was passing without makeup but I wanted it to be a no-effort foolproof thing. I think I’ve done that.

FFS is not a one day surgery. It is a 1 year long surgery. Your results early on are so different than what you end up with. Tissue has to be a bit overcorrected to account for sagging. My lip lift was unnaturally high for months, but drops over time to where it should be. A good surgeon knows this. Swelling also persists for a very long time.

So expect to hate the results. Initially I thought, "My god, I've ruined my face." And my wife later admitted to me that her first thought was, "My god, you've ruined your face." lol. So be prepared for that. It takes along time for swelling to come down.

Voice

Voice is hard. Work at it every day. Don’t go falsetto, that doesn’t work and doesn’t sound right. Pitch is important but not the main thing -- listen to some celebs with lower voices. Reducing chest resonance is key. I spent a lot of time with my hand on my chest or on the bony part of my nose, trying to discern where I was producing sound. If you can get some sessions with an SLP who works with trans women, this is useful. I pass on the phone all the time, people assume I have a husband and/or ask about my pregnancy status for things. Still thinking about voice surgery though, because I’m a low-maintenance gal and I just don’t want to have to think about it ever.

Mannerisms/walking

Something else I thought of. Your mannerisms are important. Generally women keep limbs closer to their bodies. Elbows tucked in at your sides while you're sipping coffee, things like that. The best tip I have heard for walking is don't think about swaying your hips, think about keeping your shoulders still, and the rest follows.

I would add that I think muscle loss assists in all of this. Having just treated my deltoids with botox, my arms naturally come in more. Before, it was easy to drink a cup of coffee with my elbow poking out. Now it's exhausting. Same with my biceps -- treating them made my arms more relaxed and swingy at my sides, rather than slightly flexed.

Hair removal

Laser hair removal is permanent. The only reason people think it isn't is when cis women have it done, they have increasing T later in life that activates new follicles, leading people to think it's not permanent. It's not the same follicles coming back to life, it's new ones being activated. We've probably activated every single follicle on our faces already, so once they get blasted, they're gone. I found that Diode Laser really effective, Alexandrite super effective, and that IPL was very painful and a waste of money. Research shows they're all equally effective, but it probably depends on skin type.

Electrolysis is good to clean it up but takes a lot of time. Skill really varies here. I had a local place that was nice, but slow, and relatively cheap. I found one in another city that was about 3 times the price but honestly about 6 times faster. If you're in Canada, I've had luck with Jade Electrolysis They have done my whole face in about 3 hours, and less time each time. They are good about applying the numbing cream and covering it with saran wrap, then only exposing the part they're working on. They also have the option of having a nurse inject lidocaine, but I haven't found that necessary. Also they can even do nose hair! Just something else to take care of.

Start your hair removal early. It makes a huge difference, just by itself.

Summary

That’s all I’ve got for now. If you have any questions I’ll do my best to answer them. Also I should say that I've kind of moved away from trans spaces, like a lot of trans people do later in transition. Life takes over. I thought I should pop back in because I had something unique to contribute, and I encourage you all to do the same thing when you are further along in transition.

Edit: added some details on receptor downregulation, mannerisms, FFS recovery, hair removal.