Abstract
Purpose: Chronic gender-affirming hormone therapy (GAHT) with sublingual estradiol (SLE) has not been studied. We aimed to compare GAHT with SLE only, to combined oral (CO) estradiol and cyproterone acetate, in treatment-naive trans women.
Methods: Twenty-two trans women enrolled into either the CO arm or the SLE-only arm (0.5 mg four times daily) in this 6-month prospective study. Anthropometric and laboratory variables were collected at baseline and 3 and 6 months. At the study beginning and end, body composition was measured by dual-energy X-ray absorptiometry and bioelectrical impedance, and gender dysphoria, sexual desire, and function were assessed by validated questionnaires.
Results: Subjects in the SLE were older, 26.3±5.8 years versus 20.1±2.3 years, p=0.006. All anthropometric, body composition, and laboratory variables were identical at baseline. Although dysphoria appeared greater, and sexual function lower at baseline in the CO group, this canceled out after age adjustment. Both treatments induced similar biochemical and hormonal changes. Creatinine, hemoglobin and cholesterol decreased significantly, while testosterone was suppressed to the same level in both groups: 3.22 [1.47-5.0] nmol/L in the SLE group and 2.41 [0.55-8.5] nmol/L in the CO, p=0.65. Significant changes in body composition toward a more feminine body were noted in both groups. Dysphoria did not significantly improve in either group, while sexual desire and function decreased at six months in both, p<0.001.
Conclusions: Both treatments achieved similar clinical changes. At this stage, SLE, which repeatedly induces alarming excursions of serum estradiol throughout the day, appears to offer no advantage over the CO approach.
The main reason I hear people stating in favor of sublingual is that it is better for the liver, which those guys didn’t even study and wouldn’t have been able to with those sample sizes either…
And reducing CPA-intake is a pretty good reason to switch to SL in its own right, so this is all really non-convincing.
I think this conclusion is incredibly naïve given the dramatically increased bioavailability and significantly decreased side effects that sublingual administration has over oral estradiol. Flooding the liver through oral administration results in strain that is significantly reduced by sublingual administration, and the increased bioavailability alone accounted for comparable testosterone suppression without an anti-androgen at the same daily dosage. So on top of the decrease in liver damage by moving away from oral administration, this approach also does not account for the side effects of the anti-androgen. The miniscule sample size doesn’t do any favors to this study, either. The supposed “alarming excursions of serum estradiol” is solved simply by adjusting the dosage and spreading it out into more frequent doses throughout the day. It seems they did split the dosage into 4 doses for sublingual administration, but they are providing the same daily dosage despite significantly increased bioavailability of the sublingual route (which also accounts for the testosterone suppression). Additionally, a dosage of only 2mg of estradiol daily via oral administration is quite low for trans women.
I have a lot of problems with the conclusions of this study.
I’d like to link to a much more complete analysis of the sublingual route of administration for estradiol that analyzes a wide variety of sources (including the one linked in this post) for those interested in a more accurate picture of the benefits and shortcomings of sublingual administration:
An Exploration of Sublingual Estradiol as an Alternative to Oral Estradiol in Transfeminine People
Dysphoria did not significantly improve in either group, while sexual desire and function decreased at six months in both
💀
Why the skull?
Sexual desire & function decreasing is commonly seen as a negative thing, and dysphoria not improving is clearly negative - so I am attempting a kind of sympathetic humor at the unfortunate irony of a treatment being unsuccessful. It makes me sound monstrous, now that I have to explain it.
Thank you for explaining.
Personally we do not think desire decreases completely, but in our own experience it has changed and made us wish for different functioning. Perhaps we always had that to some degree but the problem is that medical science is not really a place for many of us to feel congruent in our desires and functioning, that is why it is a problem for many trans femmes, we believe.
As for functioning without the medical science currently able to provide us what we require, this can be true somewhat. However, it can be mitigated by alternative practices.
Personally, my desire pretty much disappeared… sometimes it super bothers me, especially since I know things need to stay engaged down there if I ever opt for certain surgeries. It’s not bothersome enough that I’ve seriously brought it up with my doctor, but I did ask to be prescribed progesterone to help as I’ve seen many anecdotes about it increasing sex drive and desire…zero change so far. I’d say it’s pretty nice for the most part as there’s this edge which is no longer there, buuuut I do sometimes miss actually feeling that type of desire. I have read that it just randomly returns eventually, so just doing my best to enjoy whatever this is for now 🤭
Progesterone can make desire or horniness return. However, in our experience and this might just be us it can bring with it a certain amount of dysmorphia.
Estrogen increased desire significantly for me, but I personally wish it had decreased desire and functioning. I like the atrophy (esp. when I started to think of myself in normative terms as a woman), and I would prefer a much lower libido, I think I would (selfishly) be happy with no libido.
Part of the problem with this study is that it has such a small sample size, dysphoria clearly decreases for many trans people when they take HRT and there are many, much larger and better studies showing this.
I don’t really follow what you mean about medical science and congruence with desire and function, or what you mean by alternative practices.
We mean that medical science cannot give us certain body parts that would increase sexual functioning such a clitoris, certain glands nor ovaries, a womb etc (yet) and by alternative practises we mean kink or possibly certain cultural practises like tantra etc.
A vaginoplasty absolutely can provide you with some of the anatomy like a clitoris and vagina … ovaries and a womb might be necessary for reproduction, but HRT substitutes for the ovaries and I don’t see how a womb necessarily increases sexual function in the sense that the researchers meant (which is the ability for arousal and orgasm).
I hear you about the womb, though - it’s painful to me in ways I don’t understand that I can never become pregnant. This is a bizarre change for me, since I have been very clear about not wanting children my whole life, and I felt the biological urge to reproduce only after taking estrogen. I completely understand why Lily Elbe tried (and tragically failed) to have a uterus surgically implanted.
Well, yes to a certain degree, however, most endogenic clitorises are inside the body and look like a wishbone in a way that no surgery or other medical procedures etc can currently do which is what we want, plus we believe ones created by vaginoplasty surgery don’t have the same number of nerve endings as endogenic ones. This is what we meant about sexual functioning as we want to be able to do all the things people who have them endogenically can do which isn’t possible sadly, we just feel empty and might still if we did have such surgeries.
Vaginas are similar in that we believe no current procedures can make them fully feel or function like endogenic ones inside, so we are hesitant about having surgery, it might help us, it might not.
Okay, fair about them only being needed for reproduction but we would very much like to be pregnant and would solve this situation we have gotten ourselves into where there’s probably no chance of having bio children any other way.
Yeah, we have seen that awful film about Lily Elbe, plus looked into it and it is possible but it would mean somebody with an endogenic womb dying currently as it is massive surgery and not sure whether the recipient would survive either. Given what happened to Lily Elbe, who knows. Guessing it would require some kind of crispr modification currently to be anywhere close to successful, even though that technology is nowhere near ready for that kind of modification.
We guess what we mean basically is that for us sexual functioning is tied very much to having certain body parts in an endogenic way because every time we think about any kind of sexual stuff currently we just get dysphoric and dysmorphic in a way that we aren’t sure would be solved by surgery completely.
We’re very glad if this doesn’t happen to other trans femmes though, because either it doesn’t or they don’t talk about it or they aren’t allowed to lest they get some transmisic somewhere to say some bullshit, for us though it hurts a lot and we’re glad if no others are going through this.
