The postoperative transgendered patient is a very special person with her own unique set of issues. For many male to female transgendered patients, gender reassignment surgery (GRS) is the ultimate goal, the moment when you really cross the river. But one of my post-op patients summed it up perfectly. "The surgery is the easy part,” she said, “it's what happens afterward that brings the real challenge, when they drop you over the edge of a cliff and you start screaming for a parachute."
Not all transgendered patients undergo GRS, but for those that do so, there can be some hefty challenges, both physical and emotional. Major problems that are too often addressed with addictive sedatives or mind-numbing antidepressants, drugs that, despite often being effective, frequently fuel mind fog, weight gain, and even diabetes, while destroying sexual function. Better treatments are available; user-friendly ones, even sex-friendly ones and ones that really work, based on hormones. And you won't find these treatments in rigid protocols, medical cookbooks or the frozen bibles of managed care; you will only find them with the help of real experts in the field. That's why we at the O'Dea Medical Hormone Center decided to put a special emphasis on postoperative care; not only the care of your vagina but of your brain, your mind, your bones, your heart, your metabolism and even your sanity.
A large proportion of transgendered women, once they go through the gender reassignment process, suffer greatly from anxiety, panic attacks, mood swings and depression, not because of who they are but because of what they are failing to get, which is optimal, or what I call "Precision Hormone Therapy". And since society loves to criticize anything that deviates from the mainstream, it blames the patient herself and her life choices. But the patient is not at fault here; instead it is her new hormonal profile or the lack of one. The proof of this is that the self-same suite of problems that the post GRS trans-woman experiences are just as commonly seen in genetic women who, for whatever reason, have had their ovaries removed prematurely. The problem then, is neither social nor sexual, but quite obviously hormonal.
The best way to make sense of the post GRS problem is by looking at what actually happens during transgender surgery, and discovering to what degree it mimics the hormonal changes that occur in the genetic woman when she loses her ovaries. In essence it all boils down to (1) removal of both testicles (aka castration) and (2) generation of a surgical vagina out of the tissues that used to comprise the male genitals. Both the new vagina and the patient's body at large are now forced to exist in a hormone depleted world.
Many post GRS trans-women feel that with their testicles removed and a vagina added, this is all the femininity they need, particularly those who have already obtained breast implants and silicone injections, and consider themselves fully feminized as a result. But whereas the surgery removes their masculine hormones, it does nothing to supply them with feminizing ones. This is a dangerous road to travel, this road that lacks feminizing hormones, since it so often leads to severe depression and frequent suicides. And far too often on the basis of conscious or subconscious bias the problems the post operative patient faces are blamed on the patient herself, rather than any external force, such as a hormonal one.The fact is that once the trans-woman recovers physically from surgery, she is on her own. Whether operated on overseas or in the US, she becomes medically abandoned, isolated and thoroughly under treated. And this is not always the surgeons fault. The patient herself may feel that having a vagina is all that it takes to make her a woman.
She doesn't realize that many patients have the surgery far too early, before their bodies have become even halfway feminized, and that adequate hormone therapy may continue to further feminize them for as long as five years after surgery. She is generally not aware that following surgery she is now a castrated person and that the only significant way her body can get hormones is from the outside. She doesn’t know that castration in both women and men promptly leads to an enormous increase in a wide variety of serious issues, including chronic diffuse body pain, headache, back pain, so called “fibromyalgia” and “myofascial pain syndrome,” fatigue, insomnia, irritable bowel syndrome, depression, anxiety, suicide, memory loss and cognitive dysfunction, and early heart disease as well as osteoporosis, dementia, and premature aging, both internally and cosmetically. In addition, in those with a family history of diabetes and therefore a special vulnerability toward it, surgical castration is followed by a dramatic increase in insulin resistance, weight gain and diabetes risk. These problems are by no means imaginary or psychological.
Let's take a real example, involving an actual patient and her true story. Wendy (a fictitious name to protect her privacy) had reassignment surgery in her mid twenties, some 17 years ago, and she took 2mg of estradiol by mouth for years following. Finally she came to see us complaining of a lack of sex drive, premature physical aging, depression and anxiety, despite being married to a wonderful and supportive husband and having two lovely children. Everything should have been incredible, but it wasn't. In addition, she said that over the years she had lost about 50% of her vaginal depth and never experienced orgasms. I felt that Wendy was severely underhormonized and her hormonal balance was also completely off. We changed Wendy to a better form of estradiol, given by the non-oral route, and combined it with other hormones, and she did extremely well. Her figure improved with a narrower waist, fuller breasts and buttocks and the loss of 12 pounds in body weight. Her face looked younger with wrinkle reversal. Now she became much more easily aroused sexually, and her vagina was becoming self-lubricating. Whereas before she had been sexually disinterested she was now far more sexually eager and aware. Orgasms went from never to within about 2 to 3 minutes. Most amazing of all however, was what Wendy had to say about her surgical vagina. Over a twelve month period of time she had already recovered about 80% of her lost vaginal depth.
So transsexual surgery is the easy part, whereas it's how you take care of your new body and your new mind afterwards that forms the real challenge. The post operative trans woman truly needs ongoing enlightened hormonal care for the rest of her life for several major reasons. First of all, if, as so often is the case, she had her surgery too soon, a fair amount of feminization still needs to take place before she has maxxed-out her feminine potential. Second of all, her vagina is a hormone dependent organ and it needs to be sustained, for sexual and physical comfort and enjoyment. The GRS vagina is more than some purposeless ornament, it is (or should be) a living, vital, moist, self-lubricating, highly sensitive source of immense sexual pleasure. Thirdly her sexual interest, orgasmic potential and drive are hormone dependent because of the influences of sex hormones on the brain. Fourthly her general physical health is put at risk by hormone depletion, just as the heart health of older men goes bad after their testicles are removed in the treatment of prostate cancer. And finally she critically needs a healthy hormone profile for the maintenance of her mental health.
Crossing the gender river and achieving one's goal should make the trans woman feel at her best ever. Far too often this doesn't happen but with Precision Hormone Therapy it really can. Hormones, in the right hands and the proper blends, are the only road to true feminization. They have the power to eliminate mood disorders, depression, anxiety and the need for psychiatric drugs. Over the long term they offer protection against heart disease, diabetes, obesity and premature aging. But Precision Hormone Therapy requires expert care and it cannot be purchased online from an off-shore pharmacy, it requires delivery from a real expert.
John O'Dea, MD is an endocrinologist who has been treating transgendered patients and hormonally disrupted genetic women for many years. His prime focus is the effects of sex hormones on brain and mind. His Los Angeles area location is situated in Marina Del Rey, about ten minutes north of LAX and he also offers services in the San Francisco, San Jose and Las Vegas areas.
John O'Dea, MD