Will Powers method of hormonal transitioning

A method for transgender hormone therapy.

This document is meant to be an easy to process summary of Dr Will Powers MTF method to get an idea. Please contact me for any required edits.

References

Dr Will Powers website: https://powersfamilymedicine.com/

Youtube lecture (2h): Healthcare of the transgender patient and the Powers Method of Hormonal Transitioning (v. 5.4, somewhat outdated)

Powerpoint: version 6.0, version 7.0 (only changes preview), v7 (leak), v7 (leak 2)

v7 “leaks”: SHBG for target hormone levels

Reddit: r/DrWillPowers/ and reddit wiki

Summary

(edited version from a message on reddit here)

• [ref] are research paper references
• [will] are links to Will Powers messages
• [wiki] are links to Wikipedia articles

General goals

1. Focus on side-effects reduction.
2. Tailored to each individual based on lab results.
3. Patient choice.
4. Monotherapy when possible.
5. Monitoring for stalls.
6. Bioindentical as much as possible.
7. Adapt based on new research, ideas and data.

FTM & MTF

Uses bioidentical E or T only. Provides less to no side-effects compared to synthetics.

1. Lupron for postponing puberty.
2. Lupron must be followed up on with proper nutrition and lab levels so patients don’t have health problems later or sooner in life.

FTM

1. He uses almost any form of bioidentical T because they work well as shots.
2. He’ll only use finasteride topically.
3. Uses topical potent T on crotch to help grow the micro penis to hopefully non-microsized.
4. Uses… something on face to grow beard in a year compared to cis males taking years.

MTF

Image referenced from wikipedia (haven’t verified original sources)

1. Pill estrogen swallowed for 6–12 months until Tanner 3 (end of bud formation).
2. E2/E1 (estradiol/estrone) ratios may suck but this is OK (mimics early puberty in girls as to adrenal estrone before ovaries boot).
3. May be put on Bicalutamide at this time as anti-androgen. But will be pulled off later. Comparaison with other AA on here: [wiki].
4. Switch to estrogen injections (in order to bypass first pass metabolism in liver) to change E2/E1 ratio in favour of E2 (estradiol) because E1 (estrone) has 4% potency compared to E2. (300 pg/ml estradiol ~ 10mg estradiol, 100 pg/ml estrone , 10–30 ng/dl testosterone)
5. After Tanner 2 is finished, use rectal micronized progesterone as AA (acts as antagonist to GnRH which brings LH and FSH levels to zero and stops testosterone production in the gonads (but keeps production of adrenal T).
6. Aim for 2% free E2 (In plasma, estradiol is largely bound to SHBG, and also to albumin. Only a fraction of 2.21% (± 0.04%) is free and biologically active) [wiki]

Latest additions (v7 “leaks”)

Here are the latest changes published by Dr Powers:

• 2020–06–14 Target: LH & FSH zero, highest free E pre boron [will]
• 2021–01–09 Target: highest value without triggering SHBG [will]
• 2021–01–20 Weight cycling (within safe limits !) to redistribute fat [will]

Notes

• Some people have way higher levels of estrone to estradiol ratios (20x more estrone) and this could be linked to a genetic mutation also explaining the person’s transness.
• High estrone levels seem to be bad (correlation to breast cancer, could increase thrombotic risk).
• He may also introduce pills to women who took shots first but didn’t develop as much as they thought they would, it’s another theory about depleted estrogen “reservoir” in body.
• 300 pg/ml estradiol is not high (pregnancy levels in cis-woman can approach 8000 pg/ml). Cis-woman routinely spike level of E2 at 300–600pg/ml for a week. Patients feel better at this level.
• Topical testosterone on post-op transwoman (issues of vaginal depth, skin suppleness).
• Use Bicalutamide before “test withdrawal” before blockers are removed to see if T level stays down without risking T effect (facial hair regrowth).
• It seems that estradiol values above 700pg/ml make SHBG go crazy and free E2 drops. [will]

Boron

• 3–12mg / day to increase free E2. Should not be given until LH and FSH are zero and T between 10/20 ng/dl. [will]
• Increases availability of present sex hormone (favors T over E 2:1) [ref]
• boron-containing compounds may beneficially modulate estrogen receptors [ref]
• increases bioavailability of pre-hormone D3 [ref]

Opinions and misc

This is a small compilation of opinions and common sense ideas gathered by reading posts online. If anyone has facts about these, please comment and I’ll edit.

• From testimonies online, it seems that starting slow and carefully measuring lab levels is both the safest and probably best route in terms of transition results.
• There is no need to change a formula that works: as long as transition progress has not stalled, there is no reason to change the medication. This is in contradiction with v6 to take progesterone at start of Tanner III but is a hunch on v7 ?