Ginger (Zingiber officinale Roscoe) is a flowering plant in the family Zingiberaceae whose rhizome, ginger root or simply ginger, is widely used as a spice or a folk medicine.

It is a herbaceous perennial which grows annual stems about a meter tall bearing narrow green leaves and yellow flowers. Ginger is indigenous to south China, and was spread eventually to the Spice Islands, other parts of Asia and subsequently to West Africa and the Caribbean. Ginger was exported to Europe via India in the first century AD as a result of the lucrative spice trade. India is now the largest producer of ginger.

Other members of the family Zingiberaceae include turmeric, cardamom, and galangal. The distantly related dicots in the genus Asarum are commonly called wild ginger because of their similar taste.

Etymology

The origin of "ginger" is from the mid-14th century, from Old English gingifer, from Medieval Latin gingiber, from Latin zingiberi, from Greek zingiberis, from Prakrit (Middle Indic) singabera, from Sanskrit srngaveram, from srngam "horn" + vera- "body", from the shape of its root. But this may be Sanskrit folk etymology, and the word may be from an ancient Dravidian name that also produced the Malayalam name for the spice, inchi-ver, from inchi "root." cf. gin (v.). The word apparently was readopted in Middle English from Old French gingibre (modern French gingembre).

Horticulture

Ginger produces clusters of white and pink flower buds that bloom into yellow flowers. Because of its aesthetic appeal and the adaptation of the plant to warm climates, ginger is often used as landscaping around subtropical homes. It is a perennial reed-like plant with annual leafy stems, about a meter (3 to 4 feet) tall. Traditionally, the rhizome is gathered when the stalk withers; it is immediately scalded, or washed and scraped, to kill it and prevent sprouting. The fragrant perisperm of Zingiberaceae is used as sweetmeats by Bantu, also as a condiment and sialogogue.

Production

From 1585, Jamaican ginger was the first oriental spice to be grown in the New World and imported back to Europe.

In 2012, India, with over 33% of the global production, now leads in growing ginger, replacing China, now in second position (about 20%), followed by Nepal (about 12%), Nigeria and Thailand (each about 7%) and Indonesia (about 5%).

Uses

Ginger produces a hot, fragrant kitchen spice. Young ginger rhizomes are juicy and fleshy with a very mild taste. They are often pickled in vinegar or sherry as a snack or cooked as an ingredient in many dishes. They can be steeped in boiling water to make ginger tea, to which honey is often added; sliced orange or lemon fruit may be added. Ginger can be made into candy, or ginger wine, which has been made commercially since 1740.

Mature ginger rhizomes are fibrous and nearly dry. The juice from ginger roots is often used as a spice in Indian recipes and is a common ingredient of Chinese, Korean, Japanese, Vietnamese, and many South Asian cuisines for flavoring dishes such as seafood, meat, and vegetarian dishes.

Fresh ginger can be substituted for ground ginger at a ratio of six to one, although the flavors of fresh and dried ginger are somewhat different. Powdered dry ginger root is typically used as a flavoring for recipes such as gingerbread, cookies, crackers and cakes, ginger ale, and ginger beer.

Candied ginger, or crystallized ginger, is the root cooked in sugar until soft, and is a type of confectionery.

Fresh ginger may be peeled before eating. For longer-term storage, the ginger can be placed in a plastic bag and refrigerated or frozen.

Regional use

In Indian cuisine, ginger is a key ingredient, especially in thicker gravies, as well as in many other dishes, both vegetarian and meat-based. Ginger also has a role in traditional Ayurvedic medicine. It is an ingredient in traditional Indian drinks, both cold and hot, including spiced Masala chai. Fresh ginger is one of the main spices used for making pulse and lentil curries and other vegetable preparations. Fresh ginger together with peeled garlic cloves is crushed or ground to form ginger garlic masala. Fresh, as well as dried, ginger is used to spice tea and coffee, especially in winter. Ginger powder is used in food preparations intended primarily for pregnant or nursing women, the most popular one being katlu, which is a mixture of gum resin, ghee, nuts, and sugar. Ginger is also consumed in candied and pickled form. In Bangladesh, it is finely chopped or ground into a paste to use as a base for chicken and meat dishes alongside onion and garlic.

In Japan, ginger is pickled to make beni shoga and gari or grated and used raw on tofu or noodles. It is made into a candy called shoga no sato zuke. In the traditional Korean kimchi, ginger is either finely minced or just juiced to avoid the fibrous texture and added to the ingredients of the spicy paste just before the fermenting process.

In Burma, ginger is called gyin. It is widely used in cooking and as a main ingredient in traditional medicines. It is consumed as a salad dish called gyin-thot, which consists of shredded ginger preserved in oil, with a variety of nuts and seeds.

In Thailand it is called ??? khing and is used to make a ginger garlic paste in cooking.

In Indonesia, a beverage called wedang jahe is made from ginger and palm sugar. Indonesians also use ground ginger root, called jahe, as a common ingredient in local recipes.

In Malaysia, ginger is called halia and used in many kinds of dishes, especially a soup.

In the Philippines, it is a common ingredient in local dishes, and it is brewed into a tea called salabat.

In Vietnam, the fresh leaves, finely chopped, can be added to shrimp-and-yam soup (canh khoai m?) as a top garnish and spice to add a much subtler flavor of ginger than the chopped root.

In China, sliced or whole ginger root is often paired with savory dishes such as fish, and chopped ginger root is commonly paired with meat, when it is cooked. Candied ginger is sometimes a component of Chinese candy boxes, and an herbal tea can be prepared from ginger.

In the Caribbean, ginger is a popular spice for cooking and for making drinks such as sorrel, a drink made during the Christmas season. Jamaicans make ginger beer both as a carbonated beverage and also fresh in their homes. Ginger tea is often made from fresh ginger, as well as the famous regional specialty Jamaican ginger cake.

On the island of Corfu, Greece, a traditional drink called ??????????? (tsitsibira), a type of ginger beer, is made. The people of Corfu and the rest of the Ionian islands adopted the drink from the British, during the period of the United States of the Ionian Islands.

In Arabic, ginger is called zanjabil and in some parts of the Middle East, gin?gayu (???). The Hebrew name for the spice, zangevil, is a variation on the name. A ginger tea that is spicy and stimulating is made.

In Western cuisine, ginger is traditionally used mainly in sweet foods such as ginger ale, gingerbread, ginger snaps, parkin, ginger biscuits, and speculaas. A ginger-flavored liqueur called Canton is produced in Jarnac, France. Ginger wine is a ginger-flavored wine produced in the United Kingdom, traditionally sold in a green glass bottle. Ginger is also used as a spice added to hot coffee and tea.

Nutritional information

Composition and safety

In a typical spice serving amount of one US tablespoon or 5 g, ginger powder provides negligible content of essential nutrients, with the exception of the dietary mineral manganese, which is present in the Daily Value amount of 79%.

If consumed in reasonable quantities, ginger has few negative side effects. It is on the FDA's "generally recognized as safe" list, though it does interact with some medications, including the anticoagulant drug, warfarin.

Allergic reactions to ginger generally result in a rash. Although generally recognized as safe, ginger can cause heartburn, bloating, gas, belching, or nausea, particularly if taken in powdered form. Unchewed fresh ginger may result in intestinal blockage, and individuals who have had ulcers, inflammatory bowel disease, or blocked intestines may react badly to large quantities of fresh ginger. It can also adversely affect individuals with gallstones. There are suggestions that ginger may affect blood pressure, clotting, and heart rhythms.

Products of Chinese origin found in Taiwan contained ginger contaminated with diisobutyl phthalate, causing some 80,000 nutritional supplement capsules made with imported ginger powder to be seized by the Public Health Department of Taiwan in June 2011.

Medicinal use and research

According to the American Cancer Society, ginger has been promoted as a cancer treatment "to keep tumors from developing," but "available scientific evidence does not support this." They add: "Recent preliminary results in animals show some effect in slowing or preventing tumor growth. While these results are not well understood, they deserve further study. Still, it is too early in the research process to say whether ginger will have the same effect in humans."

In limited studies, ginger was found to be more effective than placebo for treating nausea caused by seasickness, morning sickness, and chemotherapy, although it was not found superior to placebo for pre-emptively treating postoperative nausea. Some studies advise against taking ginger during pregnancy, suggesting that ginger is mutagenic, though some other studies have reported antimutagenic effects.

Chemistry

The characteristic odor and flavor of ginger is caused by a mixture of zingerone, shogaols, and gingerols, volatile oils that compose one to three percent of the weight of fresh ginger. In laboratory animals, the gingerols increase the motility of the gastrointestinal tract and have analgesic, sedative, antipyretic, and antibacterial properties. Gingerols can inhibit growth of ovarian cancer cells in vitro. [6]-gingerol (1-[4'-hydroxy-3'-methoxyphenyl]-5-hydroxy-3-decanone) is the major pungent principle of ginger.

Ginger contains up to 3% of a fragrant essential oil whose main constituents are sesquiterpenoids, with (-)-zingiberene as the main component. Smaller amounts of other sesquiterpenoids (?-sesquiphellandrene, bisabolene, and farnesene) and a small monoterpenoid fraction (?-phelladrene, cineol, and citral) have also been identified.

The pungent taste of ginger is due to nonvolatile phenylpropanoid-derived compounds, particularly gingerols and shogaols, which form from gingerols when ginger is dried or cooked. Zingerone is also produced from gingerols during this process; this compound is less pungent and has a spicy-sweet aroma. Ginger is a minor chemical irritant and, because of this, was used as a horse suppository by pre-World War I mounted regiments for feaguing.

Ginger has a sialagogue action, stimulating the production of saliva, which makes swallowing easier.

Folk medicine

One traditional medical form of ginger historically was called 'Jamaica ginger'; it was classified as a stimulant and carminative and used frequently for dyspepsia, gastroparesis, slow motility symptoms, constipation, and colic. It was also frequently employed to disguise the taste of medicines.

Studies are inconclusive about the effects of using ginger for nausea or pain associated with various ailments. Side effects, mostly associated with consuming powdered ginger, are gas, bloating, heartburn and nausea.

One clinical trial showed ginger to be no better than a placebo or ibuprofen for treatment of osteoarthritis.

Similar ingredients

Myoga (Zingiber mioga Roscoe) appears in Japanese cuisine; the flower buds are the part eaten.

Another plant in the Zingiberaceae family, galangal, is used for similar purposes as ginger in Thai cuisine. Galangal is also called Thai ginger, fingerroot (Boesenbergia rotunda), Chinese ginger, or the Thai krachai.

A dicotyledonous native species of eastern North America, Asarum canadense, is also known as "wild ginger", and its root has similar aromatic properties, but it is not related to true ginger. The plant contains aristolochic acid, a carcinogenic compound. The United States Food and Drug Administration warns that consumption of aristolochic acid-containing products is associated with "permanent kidney damage, sometimes resulting in kidney failure that has required kidney dialysis or kidney transplantation. In addition, some patients have developed certain types of cancers, most often occurring in the urinary tract."

See also

• Bu Zhong Yi Qi Wan - contains ginger material
• Kaempferia galanga
• Xiao Yao Wan - contains ginger material

References

 This article incorporates text from a publication now in the public domain: Ward, Artemas (1911). The Grocer's Encyclopedia. 

External links

• The dictionary definition of ginger at Wiktionary
• Media related to Ginger at Wikimedia Commons
• Data related to Zingiber officinale at Wikispecies
• Zingiber officinale List of Chemicals (Dr. Duke's)

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The combination of the drugs phentermine and topiramate extended-release (ER) (trade name Qsymia kyoo-sim-EE-uh) is a medication used for weight loss. In clinical trials, phentermine/topiramate ER was associated with modest but statistically significant weight loss when compared with placebo. This weight loss was associated with improvements in weight-related comorbidities such as improved glycemia, decreased blood pressure, and improved cholesterol.

Phentermine/topiramate ER was developed by Vivus, Inc., a California pharmaceutical company. Phentermine is a sympathomimetic amine which acts as an appetite suppressant and stimulant. Topiramate is an anticonvulsant that has weight loss side effects. The exact mechanism of action for both drugs is unknown.

In 2012 the U.S. Food and Drug Administration approved phentermine/topiramate ER as an adjunct to a reduced-calorie diet and increased physical activity for chronic weight management in adults with an initial body mass index (BMI) of at least 30 kg/m², or at least 27 kg/m² (overweight) in the presence of at least one weight-related comorbidity such as hypertension, type 2 diabetes mellitus, or dyslipidemia. Phentermine/topiramate ER is available in certified retail pharmacies nationwide and also available through a certified mail-order pharmacy network. Approval was denied by European regulatory authorities, who cited potential risk to the heart and blood vessels, psychiatric side effects, and cognitive side effects in explaining their decision.

Medical uses

In clinical trials, people treated with the highest dose of phentermine/topiramate ER in combination with a program of diet and exercise lost 10% to 11% of their body weight compared to 1% to 2% for those who received placebo. In addition, 62% to 70% of subjects receiving the recommended dose or top dose of phentermine/topiramate ER achieved >=5% weight by week 56 (ITT-LOCF) compared to 17% to 21% of those receiving a sugar pill.

Adverse effects

In clinical trials, the most common adverse events which occurred at a rate >=5% and >=1.5 times placebo included paraesthesia (tingling in fingers/toes), dizziness, dysgeusia (altered taste), insomnia, constipation, and dry mouth.

In the U.S., the drug label contains warnings for increased heart rate, suicidal behavior and ideation, glaucoma, mood and sleep disorders, creatine elevation, and metabolic acidosis. Some of these warnings are based on historical observations in epilepsy patients taking topiramate. The FDA is requiring the company to perform a post-approval cardiovascular outcomes trial, due in part to the observation of increased heart rate in some people taking the drug in clinical trials.

Pregnancy

Phentermine/topiramate ER can cause fetal harm. Data from pregnancy registries and epidemiology studies indicate that a fetus exposed to topiramate in the first trimester of pregnancy has an increased risk of oral clefts (cleft lip with or without cleft palate). If a patient becomes pregnant while taking phentermine/topiramate ER, treatment should be discontinued immediately, and the patient should be apprised of the potential hazard to a fetus. Females of reproductive potential should have a negative pregnancy test before starting phentermine/topiramate ER and monthly thereafter during phentermine/topiramate ER therapy. Females of reproductive potential should use effective contraception during phentermine/topiramate ER therapy.

Contraindications

Phentermine/topiramate ER is contraindicated in pregnancy, glaucoma, hyperthyroidism, during or within 14 days of taking monoamine oxidase inhibitors, and in patients with hypersensitivity or idiosyncrasy to sympathomimetic amines. Phentermine/topiramate ER can cause an increase in resting heart rate.

Risk Evaluation and Mitigation Strategy (REMS)

Phentermine/topiramate ER was approved with a REMS program to ensure that benefits of treatment outweigh the risks. Because of the teratogenic risk associated with phentermine/topiramate ER therapy, phentermine/topiramate ER is distributed via certified pharmacies.

Approval history

In December 2009 VIVUS, Inc. submitted a new drug application (NDA) to the FDA and on March 1, 2010, VIVUS, Inc. announced that the FDA accepted the NDA for review.

In October 2010, the FDA announced its decision to not approve phentermine/topiramate ER in its current form and issued a Complete Response Letter (CRL) to VIVUS due to lack of long-term data and concerns about side effects including elevated heart rate, major adverse cardiovascular events, and birth defects.

The FDA expressed concerns about the potential for phentermine/topiramate ER to cause birth defects and requested that Vivus assess the feasibility of analyzing existing healthcare databases to determine the historical incidence of oral cleft in offspring of women treated with topiramate for migraine prophylaxis (100 mg).

In October 2011, VIVUS resubmitted the NDA to the FDA with responses to the issues addressed in the CRL. The FDA accepted the NDA in November 2011.

On September 18, 2012, Qsymia became available on the US market.

References

External links

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Weight loss, in the context of medicine, health, or physical fitness, refers to a reduction of the total body mass, due to a mean loss of fluid, body fat or adipose tissue and/or lean mass, namely bone mineral deposits, muscle, tendon, and other connective tissue. Weight loss can either occur unintentionally due to malnourishment or an underlying disease or arise from a conscious effort to improve an actual or perceived overweight or obese state. "Unexplained" weight loss that is not caused by reduction in calorific intake or exercise is called cachexia and may be a symptom of a serious medical condition. Intentional weight loss is commonly referred to as slimming.

Unintentional

Characteristics

Unintentional weight loss may result from loss of body fats, loss of body fluids, muscle atrophy, or even a combination of these. It is generally regarded as a medical problem when at least 10% of a person's body weight has been lost in six months or 5% in the last month. Another criterion used for assessing weight that is too low is the body mass index (BMI). However, even lesser amounts of weight loss can be a cause for serious concern in a frail elderly person.

Unintentional weight loss can occur because of an inadequately nutritious diet relative to a person's energy needs (generally called malnutrition). Disease processes, changes in metabolism, hormonal changes, medications or other treatments, disease- or treatment-related dietary changes, or reduced appetite associated with a disease or treatment can also cause unintentional weight loss. Poor nutrient utilization can lead to weight loss, and can be caused by fistulae in the gastrointestinal tract, diarrhea, drug-nutrient interaction, enzyme depletion and muscle atrophy.

Continuing weight loss may deteriorate into wasting, a vaguely defined condition called cachexia. Cachexia differs from starvation in part because it involves a systemic inflammatory response. It is associated with poorer outcomes. In the advanced stages of progressive disease, metabolism can change so that they lose weight even when they are getting what is normally regarded as adequate nutrition and the body cannot compensate. This leads to a condition called anorexia cachexia syndrome (ACS) and additional nutrition or supplementation is unlikely to help. Symptoms of weight loss from ACS include severe weight loss from muscle rather than body fat, loss of appetite and feeling full after eating small amounts, nausea, anemia, weakness and fatigue.

Serious weight loss may reduce quality of life, impair treatment effectiveness or recovery, worsen disease processes and be a risk factor for high mortality rates. Malnutrition can affect every function of the human body, from the cells to the most complex body functions, including:

• immune response;
• wound healing;
• muscle strength (including respiratory muscles);
• renal capacity and depletion leading to water and electrolyte disturbances;
• thermoregulation; and
• menstruation.

In addition, malnutrition can lead to vitamin and other deficiencies and to inactivity, which in turn may pre-dispose to other problems, such as pressure sores.

Unintentional weight loss can be the characteristic leading to diagnosis of diseases such as cancer and type 1 diabetes.

In the UK, up to 5% of the general population is underweight, but more than 10% of those with lung or gastrointestinal diseases and who have recently had surgery. According to data in the UK using the Malnutrition Universal Screening Tool ('MUST'), which incorporates unintentional weight loss, more than 10% of the population over the age of 65 is at risk of malnutrition. A high proportion (10-60%) of hospital patients are also at risk, along with a similar proportion in care homes.

Causes

Disease-related

Disease-related malnutrition can be considered in four categories:

Weight loss issues related to specific diseases include:

• As chronic obstructive pulmonary disease (COPD) advances, about 35% of patients experience severe weight loss called pulmonary cachexia, including diminished muscle mass. Around 25% experience moderate to severe weight loss, and most others have some weight loss. Greater weight loss is associated with poorer prognosis. Theories about contributing factors include appetite loss related to reduced activity, additional energy required for breathing, and the difficulty of eating with dyspnea (labored breathing).
• Cancer, a very common and sometimes fatal cause of unexplained (idiopathic) weight loss. About one-third of unintentional weight loss cases are secondary to malignancy. Cancers to suspect in patients with unexplained weight loss include gastrointestinal, prostate, hepatobilary (hepatocellular carcinoma, pancreatic cancer), ovarian, hematologic or lung malignancies.
• People with HIV often experience weight loss, and it is associated with poorer outcomes. Wasting syndrome is an AIDS-defining condition.
• Gastrointestinal disorders are another common cause of unexplained weight loss - in fact they are the most common non-cancerous cause of idiopathic weight loss. Possible gastrointestinal etiologies of unexplained weight loss include: celiac disease, peptic ulcer disease, inflammatory bowel disease (crohn's disease and ulcerative colitis), pancreatitis, gastritis, diarrhea and many other GI conditions.
• Infection. Some infectious diseases can cause weight loss. Fungal illnesses, endocarditis, many parasitic diseases, AIDS, and some other subacute or occult infections may cause weight loss.
• Renal disease. Patients who have uremia often have poor or absent appetite, vomiting and nausea. This can cause weight loss.
• Cardiac disease. Cardiovascular disease, especially congestive heart failure, may cause unexplained weight loss.
• Connective tissue disease
• Neurologic disease, including dementia
• Oral, taste or dental problems (including infections) can reduce nutrient intake leading to weight loss.

Therapy-related

Medical treatment can directly or indirectly cause weight loss, impairing treatment effectiveness and recovery that can lead to further weight loss in a vicious cycle.

Many patients will be in pain and have a loss of appetite after surgery. Part of the body's response to surgery is to direct energy to wound healing, which increases the body's overall energy requirements. Surgery affects nutritional status indirectly, particularly during the recovery period, as it can interfere with wound healing and other aspects of recovery. Surgery directly affects nutritional status if a procedure permanently alters the digestive system. Enteral nutrition (tube feeding) is often needed. However a policy of 'nil by mouth' for all gastrointestinal surgery has not been shown to benefit, with some suggestion it might hinder recovery.

Early post-operative nutrition is a part of Enhanced Recovery After Surgery protocols. These protocols also include carbohydrate loading in the 24 hours before surgery, but earlier nutritional interventions have not been shown to have a significant impact.

Some medications can cause weight loss, while others can cause weight gain.

Social conditions

Social conditions such as poverty, social isolation and inability to get or prepare preferred foods can cause unintentional weight loss, and this may be particularly common in older people. Nutrient intake can also be affected by culture, family and belief systems. Ill-fitting dentures and other dental or oral health problems can also affect adequacy of nutrition.

Loss of hope, status or social contact and spiritual distress can cause depression, which may be associated with reduced nutrition, as can fatigue.

Intentional

Intentional weight loss is the loss of total body mass as a result of efforts to improve fitness and health, or to change appearance through slimming.

Weight loss in individuals who are overweight or obese can reduce health risks, increase fitness, and may delay the onset of diabetes. It could reduce pain and increase movement in people with osteoarthritis of the knee. Weight loss can lead to a reduction in hypertension (high blood pressure), however whether this reduces hypertension-related harm is unclear.

Weight loss occurs when the body is expending more energy in work and metabolism than it is absorbing from food or other nutrients. It will then use stored reserves from fat or muscle, gradually leading to weight loss.

It is not uncommon for some people who are at their ideal body weight to seek additional weight loss in order to improve athletic performance or meet required weight classification for participation in a sport. Others may be driven to lose weight to achieve an appearance they consider more attractive. Being underweight is associated with health risks such as difficulty fighting off infection, osteoporosis, decreased muscle strength, trouble regulating body temperature and even increased risk of death.

According to the U.S. Food and Drug Administration (FDA), healthy individuals seeking to maintain their weight should consume 2,000 calories (8.4 MJ) per day.

According to the Dietary Guidelines for Americans those who achieve and manage a healthy weight do so most successfully by being careful to consume just enough calories to meet their needs, and being physically active.

Low-calorie regimen diets are also referred to as balanced percentage diets. Due to their minimal detrimental effects, these types of diets are most commonly recommended by nutritionists. In addition to restricting calorie intake, a balanced diet also regulates macronutrient consumption. From the total number of allotted daily calories, it is recommended that 55% should come from carbohydrates, 15% from protein, and 30% from fats with no more than 10% of total fat coming from saturated forms. For instance, a recommended 1,200 calorie diet would supply about 660 calories from carbohydrates, 180 from protein, and 360 from fat. Some studies suggest that increased consumption of protein can help ease hunger pangs associated with reduced caloric intake by increasing the feeling of satiety. Calorie restriction in this way has many long-term benefits. After reaching the desired body weight, the calories consumed per day may be increased gradually, without exceeding 2,000 net (i.e. derived by subtracting calories burned by physical activity from calories consumed). Combined with increased physical activity, low-calorie diets are thought to be most effective long-term, unlike crash diets, which can achieve short-term results, at best. Physical activity could greatly enhance the efficiency of a diet. The healthiest weight loss regimen, therefore, is one that consists of a balanced diet and moderate physical activity.

Weight gain has been associated with excessive consumption of fats, sugars, carbohydrates in general, and alcohol consumption. Depression, stress or boredom may also contribute to weight increase, and in these cases, individuals are advised to seek medical help. A 2010 study found that dieters who got a full night's sleep lost more than twice as much fat as sleep-deprived dieters.

The majority of dieters regain weight over the long term.

Therapeutic techniques

The least intrusive weight loss methods, and those most often recommended, are adjustments to eating patterns and increased physical activity, generally in the form of exercise. The World Health Organization recommended that people combine a reduction of processed foods high in saturated fats, sugar and salt and caloric content of the diet with an increase in physical activity.

An increase in fiber intake is also recommended for regulating bowel movements.

Other methods of weight loss include use of drugs and supplements that decrease appetite, block fat absorption, or reduce stomach volume.

Bariatric surgery may be indicated in cases of severe obesity. Two common bariatric surgical procedures are gastric bypass and gastric banding. Both can be effective at limiting the intake of food energy by reducing the size of the stomach, but as with any surgical procedure both come with their own risks that should be considered in consultation with a physician.

Dietary supplements, though widely used, are not considered a healthy option for weight loss. Many are available, but very few are effective in the long term.

Virtual gastric band uses hypnosis to make the brain think the stomach is smaller than it really is and hence lower the amount of food ingested. This brings as a consequence weight reduction. This method is complemented with psychological treatment for anxiety management and with hypnopedia. Research has been conducted into the use of hypnosis as a weight management alternative. In 1996 a study found that cognitive-behavioral therapy (CBT) was more effective for weight reduction if reinforced with hypnosis. Acceptance and Commitment Therapy ACT, a mindfulness approach to weight loss, has also in the last few years been demonstrating its usefulness.

Crash dieting

A crash diet is the willful restriction of nutritional intake (except water) for more than 12 waking hours. The desired result is for the body to burn fat for energy and thereby lose a significant amount of weight in a short time. Crash dieting can be dangerous to health and this method of weight loss is not recommended by physicians.

According to the Academy of Nutrition and Dietetics, "If the diet or product sounds too good to be true, it probably is. There are no foods or pills that magically burn fat. No super foods will alter your genetic code. No products will miraculously melt fat while you watch TV or sleep." Certain ingredients in supplements and herbal products can be dangerous and even deadly for some people.

Weight loss industry

There is a substantial market for products which promise to make weight loss easier, quicker, cheaper, more reliable, or less painful. These include books, DVDs, CDs, cremes, lotions, pills, rings and earrings, body wraps, body belts and other materials, fitness centers, personal coaches, weight loss groups, and food products and supplements.

In 2008 between US$33 billion and $55 billion was spent annually in the US on weight-loss products and services, including medical procedures and pharmaceuticals, with weight-loss centers taking between 6 and 12 percent of total annual expenditure. Over $1.6 billion a year was spent on weight-loss supplements. About 70 percent of Americans' dieting attempts are of a self-help nature.

In Western Europe, sales of weight-loss products, excluding prescription medications, topped £900 million ($1.4 billion) in 2009.

See also

References

External links

• Weight loss at DMOZ
• Health benefits of losing weight By IQWiG at PubMed Health
• Weight-control Information Network U.S. National Institutes of Health
• Nutrition in cancer care By NCI at PubMed Health
• Unintentional weight loss

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Body contouring is any procedure that alters the shape of different areas of the body. Body contouring after massive weight loss refers to a series of procedures that eliminate and/or reduce excess skin and fat that remains after previously obese individuals have lost a significant amount of weight, in a variety of places including the torso, upper arms, chest, and thighs.

History

Obesity is in epidemic proportions in the US and many parts of the world. It is defined as a condition where a person's body mass index (BMI) is 30 or greater. BMI is calculated by dividing the patient's weight in kilograms by their height in meters, squared. Normal weight individuals have a BMI that ranges from 18 to 25. Overweight people have a BMI from 26 to 30, with 30 and above people considered obese. Once the BMI reaches 35 and above, patients are considered morbidly obese. From a BMI of 30 and above a person's life span is shortened. In addition, obesity negatively affects the economic health of a society as well as other aspects of adult and child health, often for life. Childhood obesity is on the rise in Europe as well.

Bariatric surgery

In response to a serious obesity crisis, medical science has devised a handful of bariatric (obesity treatment) surgeries, including gastric bypass, stomach stapling, lap banding, stomach reduction and other techniques that reduce the amount of food the stomach can hold. For instance, in the United States, the American Society of Bariatric Surgery (ASBS) reports that the year 2000 saw an estimated 37,700 surgeries to restrict the size of a patient's stomach. But in 2006, the most recent year for which statistics are available, there were 177,600 such operations. Usually, by 18 months after the surgery, patients report having lost anywhere from 45 to 136 kg (100 to 300 pounds).

Body lifting

Food-restriction operations to the stomach have several side effects. One such undesirable side effect that is very bothersome and visible is the loose, hanging skin that covers much of a weight loss patient's body. Because hundreds of pounds have stretched the patient's skin to the maximum, it has lost its elasticity and the ability to spring back. Instead, the newly slimmed patient must deal with so much extra hanging skin, he or she can actually stumble on an overhanging panniculus, the large apron of skin hanging from the stomach that can cover the pubis and groin areas. Notably, many extra inches (and sometimes, feet) of floppy skin hang from the upper arms, the chest, the stomach, the upper thighs and buttocks.

Most people who have lost massive amounts of weight complain about the difficulty of getting their fleshy arms into sleeves and their excess stomach skin tucked into clothing. Most women in this state condition require a mastopexy, or breast lift, often in conjunction with breast implants. Men who have body shaping surgery usually undergo male breast reduction surgery to remove the pendulous skin hanging from their chests.

The extra rolls and sheets of skin rub against each other, creating many spots of irritation and leading to hygienic difficulties. The masses of excess skin also make any form of exercise difficult.

While the procedure is expensive, often running in the neighbourhood of US$20,000-50,000 for an entire body, it usually leaves long, visible scars on the arms, chest, stomach and legs. Most surgeons break the surgical task into an upper, and a lower, body lift. A lower body lift removes the sagging skin on the back, abdomen, buttocks and thighs while the upper body procedure removes loose skin from the arms, breasts and chest.

Potential risks and side-effects

Body lifting is not lightly undertaken. The process requires a commitment on the part of the patient who must stay with the program through bariatric surgery, during the 18 months required for weight loss, then the body contouring procedures and recovery. Often, beginning to end takes three years. A single body lifting operation can require seven to 10 hours under general anesthesia, blood transfusions and often, another surgeon to assist. Plastic surgeons advise patients that body shaping is not an obesity operation. A patient who is more than 50 percent over his or her ideal weight must first drop as many pounds as possible before proceeding. Other medical considerations the plastic surgeon must take into account include scars already present on the body, current medical conditions like heart disease or bleeding disorders, and if the patient smokes. Other possible risks include infections and reactions and complications due to being under anesthesia for longer than six hours. The patient may also experience seroma, a buildup of fluid; dehiscence (wound separation) and deep vein thrombosis (blood clots forming in the legs.) Rare complications include lymphatic injury and major wound dehiscence. The hospital stay for the procedure can require from one to four days while recovery can require about a month for a total body lift. Essentially, the patient trades "skin for scars". But skin relaxation is always a risk and may not be stopped with a single procedure. Reputable plastic surgeons will explain all the risks and complications in full to their patients and even encourage a second or third consultation visit with other plastic surgeons to get additional views on such a major undertaking.

Body lifting surgical procedures

While body shaping can be done in one marathon session, it is usually broken into one to three surgical stages, with the patient under general anesthesia. But if the patient is a smoker, has a history of deep venous thrombosis or clotting disorders along with a high BMI and other medical risk factors, the surgeon will probably insist on doing several short procedures in a hospital setting to insure maximum safety for the patient.

The following are the individual components of body contouring:

Arm lift or brachioplasty. The extra flesh on the arms of bariatric patients virtually always appears on the underside of the upper arm and is sometimes referred to as "bat wings". Surgeons make incisions made from the armpit to the elbow to remove the skin and create a more pleasing contour. Consequently, surgeons open the arm on its underside so that the resulting scar is fairly well hidden. A brachioplasty procedure can employ some liposuction after the incision is made. With the arm opened, the surgeon pulls the skin tight and then trims away the excess skin which, depending on the patient, can be a pound of skin per arm or more.

Breast lift or mastopexy. By trimming excess tissue from the upper breast, the surgeon can move breasts which usually droop to the umbillicus to a more upright and full position. The procedure also often requires an implant to make up for lost fat and tissue inside the breast. Scars on women are almost always hidden inside the area covered by the bra.

Stomach lift or abdominoplasty. Excess skin hanging down over the pubic region is often the distorting feature that most concerns and bothers patients. The stomach pannus retains moisture, and causes rashes due to skin rubbing against itself which usually leads to poor hygiene. While the surgical procedure to remove it is known as a panniculectomy, there is often more work to be done for patients who suffer from large amounts of hanging skin. To provide improved contours on the waist, back and flanks, surgeons sometimes perform a belt lipectomy, (also known as a torsoplasty or a circumferential lipectomy). The incision goes all the way around the patient's midsection at the level of the lower waist. The surgeon uses more liposuction on the stomach and flanks while trimming excess skin from the patient's back and sides as well. The abdominoplasty and belt lipectomy incisions are placed so that the resulting scar is hidden within most underwear and swimsuits.

Lower body lift trims excess skin on the buttocks and thighs. For an inner thigh lift, the surgeon makes an incision high on the inner leg, starting near the groin and continuing down to the knee. Some fat may be removed with liposuction. The surgeon then removes excess skin and redrapes the remaining skin before closing the long incision, leaving the patient with tighter and more attractive thighs.

The outer thigh and buttock can be lifted through a hip-to-hip incision across the back, above the buttocks.

Nonsurgical methods

Nonsurgical body contouring is a rapidly growing field. Common methods used include low-level laser therapy (LLLT), cryolipolysis, radiofrequency energy, suction massage, and high-frequency focused ultrasound.

Now, doctors are able to use non-invasive technology to achieve a reduction in size of certain body areas, increased tone in lax or redundant skin and a diminished appearance of cellulite.

Usual results

While considered major surgery, the outcome of body shaping can require several months to see the full effects of the procedure.

When researchers at the University of Pittsburgh enrolled 18 bariatric patients just before the subjects decided to undergo body contouring, their average age was 46, plus or minus ten years. The researchers studied the patients' body perception, quality of life and mood at three and six months after the body contouring procedures. They found the subjects' quality of life improved and significantly enhanced their moods which had remained stable at the six-month point. Most body lifting patients return to non-strenuous work in about two to three weeks.

Except for brachioplasty, virtually all body shaping procedures require the patient to wear a support or compression garment for two to six weeks. The garment speeds and aids in healing.

Patients can usually drive again within one to three weeks, depending on the extent of the surgery, their health and general robustness.

See also

• Liposuction
• Bariatrics

References

Further reading

• Soldin, M; Mughal, M; Al-Hadithy, N (2014). "National Commissioning Guidelines: Body contouring surgery after massive weight loss". Journal of Plastic, Reconstructive & Aesthetic Surgery 67 (8): 1076-81. doi:10.1016/j.bjps.2014.04.031. PMID 24909630. 
• Hasanbegovic, E; Sørensen, JA (2014). "Complications following body contouring surgery after massive weight loss: A meta-analysis". Journal of Plastic, Reconstructive & Aesthetic Surgery 67 (3): 295-301. doi:10.1016/j.bjps.2013.10.031. PMID 24211118. 
• Azin, A; Zhou, C; Jackson, T; Cassin, S et al. (2014). "Body contouring surgery after bariatric surgery: A study of cost as a barrier and impact on psychological well-being". Plastic and Reconstructive Surgery 133 (6): 776e-82e. doi:10.1097/PRS.0000000000000227. PMID 24867737. 
• Hurwitz, Dennis J. Total Body Lift: Reshaping the Breasts, Chest, Arms, Thighs, Hips. Waist, Abdomen & Knees after Weight Loss, Aging & Pregnancies. New York: M.D. Publish. 
• Capella, Joseph; Rubin, Peter; Sebastian, Jeffrey. Body Contouring Surgery After Weight Loss. Omaha, NE: Addicus Books. 
• Jalian, HR; Avram, MM (2012). "Body contouring: The skinny on noninvasive fat removal" (PDF). Seminars in Cutaneous Medicine and Surgery 31 (2): 121-5. doi:10.1016/j.sder.2012.02.004. 

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Hormone replacement therapy of the male-to-female type is a type of hormone replacement therapy for transgender and transsexual people. It changes the balance of sex hormones in the body. Some intersex people also receive HRT, either starting in childhood to confirm the assigned sex, or later, if this assignment has proven to be incorrect.

Its purpose is to cause the development of the secondary sex characteristics of the desired sex. It cannot undo many of the changes produced by the first natural occurring puberty, which may necessitate surgery and/or epilation (see below).

Formal requirements for HRT

The requirements for hormone replacement therapy vary immensely, often psychological counseling is required.

Under WPATH guidelines the Mental Health Provider requires individuals to satisfy two sets of criteria -- eligibility and readiness -- to undertake any stage of transition including hormone replacement therapy. Eligibility involves the patient meeting requirements from a major diagnostic tool, such as the ICD-10, DSM-IV-R or the DSM-V. ICD-10 requirements are for either Transsexualism or Gender identity disorder of childhood.

The ICD-10 criteria for Transsexualism include the individual having a transsexual identity of over 2 years, a strong and persistent desire to live as a member of the opposite sex, usually accompanied by the desire to make their body as congruent as possible with the preferred sex through surgery and hormone treatments. These individuals cannot be diagnosed with Transsexualism if it is believed to be a result of another mental disorder, or a genetic, intersex or chromosomal abnormality.

The ICD-10 criteria for Gender identity disorder of childhood in males include the individual being pre-pubescent and having intense and persistent distress about being a boy. The distress must be present for at least six months. The child must either:

1. Have a preoccupation with stereotypic female activities, as shown by crossdressing, simulating female attire, or an intense desire to join in the games and pastimes of girls, rejecting male games and pastimes.
2. Have persistent denial relating to their male anatomy. This can be shown through believing they will grow up to be a woman, that their penis or testes is disgusting or will disappear, or that it would be better not to have a penis.

The DSM-IV-R criteria for Gender Identity Disorder includes four main criteria. The DSM-IV-R also requests that the individual's sexuality is noted.

Strong and persistent cross-gender identity

In children this may be demonstrated by them meeting four or more of the following criteria:

1. An insistence that one is or desires to be the other sex.
2. Girls(MTFs) must display a preference crossdressing or simulating female attire, and boys(FTMs) must persistently wear only stereotypical male clothing.
3. Persistent fantasies of being the other sex, or strong and persistent preference for cross-sex roles in make-believe play.
4. Intense desire to participate in stereotypical games of the other sex.
5. Strong preference for playmates of the other sex.

Adolescents and Adults must display a persistent desire to be the other sex, frequent passing as the other sex, desire to live or be treated as the other sex, or the conviction that they have the typical feelings and reactions of the other sex.

Persistent discomfort with their sex or a sense of inappropriateness in the gender role of that sex

In boys this may manifest as an assertion that their penis or testes are disgusting or will disappear, or asserting that it is better not to have a penis.

In adults and adolescents this manifests as a preoccupation with removing primary or secondary sex characteristics, such as a demand for surgery or hormone replacement therapy.

The disturbance must not be concurrent with a physical intersex condition

The disturbance causes clinically significant distress or impairment in social, occupations or important areas of functioning

The DSM-V moves from Gender Identity Disorder to Gender Dysphoria to avoid the implication that gender nonconformity is in itself a mental disorder, but a similar entry remains in the DSM-V so that individuals may still seek treatment. The DSM-V, unlike the DSM-IV and ICD-10, separates Gender Dysphoria from sexual paraphilias, and diagnoses on the basis of a strong desire that one has feelings and convictions typical of the other sex, or that one strongly desires to be treated as the other sex or be rid of one's sex characteristics.

The readability of patients to transition is also relevant to undertake hormone replacement therapy, which includes the patient's likelihood to take hormones in a responsible manner, have made progress in mastering other identified problems that leads to improving or continuing stable mental health, and have had further consolidation of gender identity during psychotherapy or Real Life Experience of their desired gender role.

Some organizations still require a period of time living as the desired gender role, based on standards such as the Standards of Care for the Health of Transsexual, Transgender, and Gender Nonconforming People (WPATH). This period is sometimes called the Real Life Experience (RLE). The Endocrine Society in 2009 specified that individuals should either have a documented 3 months Real Life Experience or a period of psychotherapy of length specified by the mental health provider, usually a minimum of 3 months.

Some people, especially individuals from the transgender community, say that RLE is psychologically harmful and is a form of "gatekeeping" -- effectively barring people from transitioning for as long as possible, if not permanently.

Some individuals choose to self-administer their medication ("do-it-yourself"), often because available doctors have too little experience in this matter, or no doctor is available in the first place. Sometimes, trans persons choose to self-administer because their doctor will not prescribe hormones without a letter from the patient's therapist stating that the patient meets the diagnostic criteria for GID and is making an informed decision to transition. Many therapists require at least three months of continuous psychotherapy and/or a real life test in order to write such a letter as is suggested in the HBIGDA Standards of Care. As many individuals must pay for evaluation and care out-of-pocket, expense can also be prohibitive to pursuing such therapy.

However, self-administration of certain hormones (namely ethinyl estradiol) and anti-androgens (namely cyproterone acetate, flutamide, and nilutamide) is potentially dangerous and can cause an elevation in liver enzymes.

Medical contraindications

• Absolute: history of estrogen-sensitive cancer (for example breast cancer), history of thromboembolic disease (unless provided with concurrent anti-coagulation therapy), or history of macroprolactinoma. In such cases the patient should be concurrently followed by an oncologist, hematologist or cardiologist, or neurologist, respectively.
• Relative: Liver, kidney, or heart disease and stroke (or any of the risk factors for heart disease: high cholesterol, diabetes, obesity, smoking); Strong family history of breast cancer or thromboembolic disease; Gallbladder disease; circulation or clotting conditions such as peripheral vascular disease, polycythemia vera, sickle cell anaemia, paroxysmal nocturnal hemoglobinuria, hyperlipidemia/hypercholesterolemia, hyperlipoproteinaemia, hypertension, factor V leiden, prothrombin mutation, antiphospholipid antibodies, anticardiolipin antibodies, lupus anticoagulants, plasminogen or fibrinolysis disorders, protein C deficiency, protein S deficiency, or antithrombin III deficiency.

Types of therapy

Estrogens

• The dosages used are often higher than replacement doses for natal women, although the official guideline for endocrinologists recommends "maintain[ing] sex hormone levels within the normal range for the person's desired gender". Usually the dosage is reduced after an orchiectomy (the removal of the testes) or sex reassignment surgery. However, the practice of lowering estrogen doses after such operations has been carried over from the days when very high doses of estrogen were required to decrease testosterone since antiandrogens were not used. In fact, high doses (though using a less potent estrogen, estradiol, that is endogenous to the human body rather than the risky ethinyl estradiol and conjugated estrogens used in the past) are recommended during the first ten or so years of HRT to fully develop, with or without having had an orchiectomy or sex reassignment. After usually ten years or so the dosages can be reduced.
• Many different variations of estradiol exist as well as other types of estrogens although the ones most commonly used are either micronized estradiol, estradiol acetate, estradiol valerate, estradiol cypionate, estradiol enanthate, conjugated estrogens, and esterified estrogens.
• Injectable, implanted, nasal, oral, sub lingual, gel, spray, and transdermal patch formulations are available.
• As dosage increases, risks increase as well. Therefore, those with relative contraindications should start at lower doses and increase dosage more gradually.

Progestogens

• Progestogens include progesterone and progestins (synthetic analogs of progesterone or 17?-hydroxyprogesterone). There are oral, sublingual, suppository, gel, and injectable formulations available.
• Progestogens, in conjunction with prolactin, are involved in the maturation of the lobules, acini, and areola during pregnancy, which are mammary structures that estrogen has little to no effect on. However, there is at present no clinical evidence that either progesterone or progestins enhance breast size, shape, or appearance in either trans women or cisgender women, and one study found no benefit to breast hemicircumference over estrogen alone in a small sample of trans women given both an estrogen and an oral progestogen (usually 10 mg/day medroxyprogesterone acetate). However, the authors of the paper state that the sample size was too small to make any definitive conclusions, and that further studies should be carried out to confirm whether progestogens do significantly affect breast size and/or shape in trans women or not. As of 2012, no additional study has looked at the issue again.
• Progestogens are involved in fat distribution, increase female libidinal feelings, increase appetite, slight increase in skin oil, increases blood flow to the skin, increases the ability to sweat and lose extra heat, increase in body temperature enabling one to better tolerate the cold, healthier nails, produce a sense of calm and promote sleep, and increase energy. However, progestogens may increase skin oil and libido too much for some and there may be acne breakouts due to the increase in skin oil. In addition, these effects may actually be the result of androgenic action, which may be undesirable for most trans women.
• Progesterone in particular is essential for bone health and seems to have a role in skin elasticity, and nerve tissue. Other effects that have been seen with progesterone in particular (not the synthetics) include reducing spasms and relaxing smooth muscle tone, gallbladder activity is reduced, bronchi are widened (helps respiration), an anti-inflammatory agent and reduces the immune response, normalizing blood clotting and vascular tone, zinc and copper levels, cell oxygen levels, and use of fat stores for energy. Progesterone also assists in thyroid function and bone building by osteoblasts.
• Progestins (synthetic progestogens) are associated with an increased risk in breast cancer, which is not seen with progesterone (a bioidentical or natural progestogen).

Antiandrogens

• Spironolactone is the most frequently used antiandrogen in the United States because it is relatively safe and inexpensive. Cyproterone acetate is more commonly used outside of the US.
• Spironolactone is a 'potassium-sparing diuretic' that is also used to treat low-renin hypertension, edema, hyperaldosteronism, and low potassium levels caused by other diuretics. It can cause high potassium levels, hyperkalemia, and is therefore contra-indicated in people with renal failure or who otherwise have elevated potassium levels. Spironolactone prevents the formation of testosterone in the testis (though not in the adrenals) by inhibiting enzymes involved in its production and is an androgen receptor antagonist (prevents androgens from binding to androgen receptors).
• Cyproterone acetate is derived from 17? hydroxyprogesterone and suppresses gonadotropin levels (which in turn reduces testosterone levels), blocks androgens from binding to androgen receptors, and is a weak progestin. It has been used to treat prostate cancer. If used long-term in dosages of 150 milligrams or higher it can possibly lead to liver damage or failure.
• Other antiandrogens include bicalutamide, flutamide, and nilutamide. Unlike the two medications above, these do not lower testosterone levels but rather prevent testosterone and dihydrotestosterone from binding to androgen receptors. Because these have a weak action at the brain they do not lower libido or decrease erections. Two other antiandrogens that are rarely prescribed are ketoconazole and cimetidine. Ketoconazole has been used in those with prostatic cancer and hirsutism. Cimetidine has also been used in hirsutism. Ketoconazole has the potential of liver toxicity over long-term use and cimetidine is a relatively weak antiandrogen.
• Certain antiandrogens do not lower testosterone levels or prevent its action upon tissues but rather its metabolite, dihydrotestosterone (DHT), from forming. These medications can be used when the patient has male-pattern hair loss (androgenetic alopecia) and/or an enlarged prostate (benign prostatic hyperplasia). DHT contributes to the manifestation and exacerbation of both. Two medications are currently available to prevent the creation of DHT, finasteride and dutasteride. DHT levels can be lowered up to approximately 60-75% with the former depending upon dosage and up to 93-94% with the latter.

GnRH analogues

• In both sexes, the hypothalamus releases GnRH (gonadotropin-releasing hormone) to stimulate the pituitary to produce LH (luteinizing hormone) and FSH (follicle-stimulating hormone) which in turn cause the gonads to produce sex steroids. In adolescents of either sex with relevant indicators, GnRH analogues, such as goserelin acetate can be used to suspend the advance of sex steroid-induced, inappropriate pubert changes for a period without inducing any changes towards the sex with which the patient currently identifies. GnRH agonists work by initially over stimulating the pituitary then rapidly desensitizing it to the effects of GnRH. After an initial surge, over a period of weeks, gonadal androgen production is greatly reduced. On the other hand, GnRH antagonists act by blocking the action of GnRH in the pituitary. There is considerable controversy over the earliest age, and for how long it is clinically, morally and legally safe to do this. The previous, sixth edition of the World Professional Association for Transgender Health Standards of Care permit from Tanner stage 2, but do not allow the addition of hormones until 16, which could be five or more years. The sex steroids do have important other functions. Also, some skeletal changes (such as increased height), which may be considered masculine, are not hindered by GnRH analogues.
• GnRH analogues are often prescribed to prevent the reactivation of testicular function where surgeons require the cessation of estrogens prior to surgery.
• The high cost of GnRH analogues is often a significant factor.

Effects of HRT

Overview

For trans women, taking estrogens causes among other changes:

• The growth of breasts, with accompanying enlargement of the nipples.
• Redistribution of body fat.
• Thinning of skin.

For male-to-female transgender people, HRT often includes antiandrogens in addition to the estrogens and progestogens mentioned above.

HRT does not usually cause facial hair growth to be impeded or the voice to change.

Partially reversible changes

• Breast development (may need reconstructive surgery to reverse the effect)
• Infertility, eventually leading to chemically induced aspermatogenesis. The reversibility of this effect depends on the length of time and effects of androgen suppressing substances. Androgen suppressing drugs are not a substitute for other birth control methods.

Reversible changes

• Decreased libido
• Redistribution of body fat (most of time)
• Reduced muscle development
• Various skin changes
• Significantly reduced and lightened body hair
• Change in body odor and sweat production
• Less prominence of veins
• Ocular changes
• Reduced gonadal "gonads" size

The psychological changes are harder to define, because HRT is usually the first physical action that takes place when transitioning and the act itself of beginning HRT has a significant psychological effect, which is difficult to distinguish from hormonally induced changes.

What HRT cannot change

• HRT cannot reverse bone changes that have already been established by puberty. Consequently, total height, the length of the arms, legs, hands, and feet, and the width/size of the shoulders and rib cage are all not affected by HRT. However, details of bone shape change throughout life, with bones becoming heavier and more deeply sculptured under the influence of androgens, and HRT will prevent such changes from developing any further.
• The width of the hips are not affected in individuals in whom epiphyseal closure (fusion and closure of the ends of bones, which prevents any further lengthening) has taken place, an event which occurs in most people between 18 and 25 years of age. In addition, already established changes to the shape of the hips cannot be reversed by HRT whether epiphyseal closure has taken place yet or not.
• Already established changes to the sculpture of the bone structure of the face are not affected by HRT, nor is the prominence of the thyroid cartilage (Adam's apple) affected. These changes may be reversed by surgery (facial feminization surgery and tracheal shave, respectively) instead.
• During puberty, the voice deepens in pitch and becomes more resonant, effects which are permanent and are not affected by HRT. Voice therapy and optionally surgery may be used instead to achieve a more female sounding voice.
• Facial hair develops during puberty, and this is a change that is only slightly affected by HRT. Facial hair may be near-permanently removed with laser hair removal or permanently with electrolysis instead.

Cardiovascular

• The most significant cardiovascular risk for transgender women is the pro-thrombotic effect of estrogens (Increased blood clotting.) This manifests most significantly as an increased risk for thromboembolic disease: deep venous thrombosis (DVT) and pulmonary embolism (PE) which occurs when DVTs break off and migrate through the venous system to the lungs. It is important for any person on female hormones to immediately seek medical care if she develops pain or swelling of one leg (especially calf) as this is the predominant symptom of a DVT, or if she develops symptoms of PE: chest pain, shortness of breath, fainting, or palpitations (even without leg pain or swelling).
• In practice this becomes very important to transgender women undergoing surgery. Ethinyl and conjugated oral estrogens should be withheld for a week before and until two weeks after surgery.
• DVTs occur more frequently in the first year of treatment with estrogens. However this may represent a 'screening by treatment' of patients who may have genetic predispositions to thromboembolic disease, with those who are more likely to develop DVTs doing so early on in therapy. However, if patients have a family history of thromboembolic disease, screening for known disease may be appropriate.
• DVT risk is higher with oral estrogen (particularly ethinyl estradiol and conjugated estrogens) rather than injectable, transdermal, implantable, and nasal estrogens.
• DVT risk also increases with age and with smoking, so many clinicians advise using the safer estrogen formulations in patients who smoke or are older than age 40.
• If screening is undertaken for known pro-thrombotic mutations such as Factor V-Leiden, antithrombin III, and protein C or S deficiency, it should be done so to increase the safety of hormonal therapy and not as a screen for who may undertake hormonal therapy. Given that the risk of warfarin treatment in a relatively young, well-informed, and otherwise healthy population is quite low and that the risk of adverse physical and psychological outcome for untreated transgender patients is high, a prothrombotic mutation is not an absolute contraindication for hormonal therapy. (See: Levy, et al. "Endocrine Intervention for Transsexuals" Clin Endo 2003. 59:409-418.)
• The antiandrogen bicalutamide is associated with an increased risk of heart failure when used as monotherapy (without any other drugs). A study of prostate cancer patients also showed an increased number of deaths unrelated to cancer among patients taking 150 mg/day bicalutamide. This prompted Health Canada to withdraw its approval for 150 mg bicalutamide as monotherapy. The increased death rate has not been observed where bicalutamide was combined with a method of reducing androgen production. The exact reasons for the heart failure and deaths have not been completely determined, however a likely cause is acute adrenal insufficiency and hypotension due to the action of DHT during episodes of bicalutamide withdrawal. Because bicalutamide is extremely lipophilic, it is difficult to avoid periods of low serum concentration due to the uptake of bicalutamide into fat cells.

Hair

• Current facial hair is only slightly affected (some reduction in density, coverage, and slower growth) by antiandrogens. Those who are less than a decade past puberty and/or whose race generally lacks a significant amount of facial hair will have better results with antiandrogens. Those taking antiandrogens will have better results with electrolysis/laser hair removal than those who are not. If one is still in their teens or early twenties, there will be prevention of new facial hairs from developing if testosterone levels are within the female range.
• Body hair (chest, periareolar, shoulders, back, abdomen, buttocks, thighs, tops of hands, tops of feet) will, over time, turn from terminal ("normal") hairs to vellus hairs (very tiny, blonde "baby" hairs). Hair on the arms, perianal, and perineal will reduce but may not turn to vellus hair on the latter two regions (some natal females also have some hair in these areas). Underarm hair will slightly change in texture and length, pubic hair becomes more typically female in pattern. Lower leg hair becomes less dense in concentration. All depend upon genetics.
• Head hair may slightly change in texture, curl, and color (new hairs that is, not hair that has already formed and reached the surface prior to HRT), this is especially likely with hair growth from previously bald areas.
• Eyebrow hair becomes less "bushy" or scattered.

Urogynecological effects

• Transgender women report a sometimes significant reduction in libido, all depending on the dosage of antiandrogens. A small number of post-operative transsexual women may take small amounts of testosterone to boost the libido. Many pre-operative transsexual women simply wait until after sex-reassignment surgery to begin an active sex life (due to how they feel towards their genitals and/or an aversion to other sex acts) and for newly post-operative women how satisfied they are with the results. Raising estrogen dosage or adding a progestogen has also raised the libido of some trans women.
• Spontaneous and morning erections decrease in frequency significantly, however some who have had an orchiectomy still experience morning erections. Voluntary erections may or may not be possible depending on the amount of hormones and/or antiandrogens being taken; it varies a lot depending on individual biochemistry, dosing, and anatomy.
• Testi volume is reduced by about 25% with typical dosages and as much as 50% in higher dosages, especially after a year of HRT. This is in response to the decrease in Leydig cells, Sertoli cells, and interstitial tissue, which produce both sperm and testosterone. When testosterone is dramatically reduced spermatogenesis is halted almost completely, when the cells that are involved in these processes go unused they atrophy (shrink).
• The prostate shrinks.
• The bladder shrinks.
• The line that runs down the underside of the penis and down the middle of the scrotum, the peno-scrotal raphe (where the urogenital folds fused early in the womb), will darken.
• Minor water retention is likely. (If spironolactone is used as an antiandrogen then it will tend to counter this effect, since it is a diuretic.)

Childbearing

• Childbearing, as experienced by cisgender women, is speculative with current technology. Pre-operative sperm banking can be done, however, allowing artificial insemination to be used to produce genetic offspring with someone else at a later date. Medical advances in the near future may one day make this possible by using a donor uterus long enough to carry a child to term as anti-rejection drugs do not seem to affect the fetus. As of now, the first uterine transplant, done on October 4, in Sweden proved to be successful. The DNA in a donated ovum can be removed and replaced with the DNA of the receiver. Further in the future stem cell biotechnology may also make this possible, with no need for anti-rejection drugs.

However, a problem may arise with the structure of hip bones, since cisgender women generally have larger hip bones to accommodate pregnancy.

Bone

• Both estrogens and androgens are necessary in all humans for healthy bone. (Young healthy women produce about 10 mg of testosterone monthly. Higher bone mineral density in males is associated with higher serum estrogen.)
• Bone is not static. It is constantly being reabsorbed and created. Osteoporosis results when bone formation occurs at a rate less than bone reabsorption.
• Estrogen is the predominant sex hormone that slows bone loss (even in men.)
• Both estrogen and testosterone help stimulate bone formation (T, especially at puberty.)
• The hips will rotate slightly forward due to changes in the tendons so hip discomfort is not uncommon.
• If estrogen therapy is conducted prior to the pelvis ossification that occurs around the age of 25, the pelvic outlet and inlet open slightly. This widening will also widen the femora as they are connected to the pelvis. The pelvis will still have some masculine characteristics by default but the end result will be wider hips than a normal male and closer to a cis female.

Drug interactions

• Any drug can cause adverse reactions with other medications so it is wise to check with a doctor or pharmacist when starting any new medication.
• Of the estrogen formulations commonly used, ethinyl estradiol (commonly found in birth control pills) has the greatest number of adverse reactions.

Skin

• The uppermost layer of skin, the stratum corneum, becomes thinner and therefore more translucent and pinkish (spider veins may appear or be more noticeable), less collagen, more susceptible to tearing and irritation from scratching or shaving, increased tactile sensation, and slightly lighter in color due to a slight decrease in melanin (pigment).
• Skin becomes softer.
• Sebaceous gland activity (which is triggered by androgens) lessens which lowers the amount of sebum (oil) production on the skin and scalp, consequently the skin becomes less prone to the formation of acne due to the less quantity of oil that is produced. Dry skin becomes a problem and lotions and oils may be necessary.
• The skin's pores become smaller due to the low quantities of sebum produced
• Body odor (skin, sweat, and urine) will become less "metallic," "sharp," or "acrid" and more "sweet" and "musky."
• Many apocrine glands (type of sweat glands) become inactive and body odor decreases. Sebum also contributes to body odor, the production of which is reduced by antiandrogens (as described above).
• More subcutaneous fat tissue accumulates. This gives a more puffy/softer appearance. Consequently dimpling, or cellulite, will be more apparent on the thighs and buttocks due to this along with the thinness of the skin.
• Susceptibility to sunburn increases possibly due to the thinner skin and/or less skin pigment.
• Because of the increase in adipose tissue in the hips, thighs, and rear, stretch marks (striae distensae) may appear on the skin in these areas.

Ocular changes

• The lens of the eyes changes in curvature.
• Due to decreased androgens, the meibomian glands (a.k.a. tarsal, palpebral, or tarsoconjunctival glands. A type of sebaceous gland on the upper and lower eyelids that open at the edges of the lids) produce less oil (oil that makes up the lipid layer of tear film which prevents the evaporation of the watery layer beneath) and a tendency for dry eyes may be a problem.

Senses

• Sensitivity to male body odor(s) (including male pheromones) may be positively correlated with elevated estrogen levels. Overall, olfactory senses may increase.

Mammary gland development

• Breast, nipple, and areolar development takes 4-6 years to complete depending upon genetics, and sometimes as long as 10 years. It is normal for there to be a "stall" in breast growth during transition, or for the size of one breast to be a little bigger than the other. Transwomen who undergo HRT often experience breast development which is below the comparable cis female norm (many seek breast augmentation); it is rare for an HRT patient to opt for breast reduction. The size of the rib cage and shoulder width also play a role in the perceivable "size" of the breasts; both characteristics are usually smaller in cis females, i.e., if a cis female and a trans female were to have the same cup size, the transwoman's breasts would most likely appear smaller. Thus when a trans woman opts to have breast augmentation, the implants used are, on the average, larger than those commonly used by cis females.
• The nipples often become more sensitive to stimulation.
• Many women in clinical trials used stem cells from fat to regrow breasts from total mastectomies. This would replace the need for artificial implantation.
• As in a genetic woman during puberty, ducts and coopers ligaments will develop under the influence of estrogen. Progesterone will cause the actual milk sacks (alveoli) to grow and develop and given the right stimuli, the breasts can lactate as in a cis woman.

Adipose tissue distribution

• Fat distribution in the body slowly changes over months and years. The body will now tend to accumulate new adipose tissue (fat) in a typically female pattern. This includes the hips, thighs, rear, pubis, upper arms, and breasts. The body will now tend to use/burn the old adipose tissue in the waist making the waist appear smaller as well as on the shoulders and back.
• Subcutaneous adipose tissue increases in the face (cheeks and lips) making the face appear puffier, appears to "round out" the face, and the face appears less "drawn" or "hollow" with slightly less emphasis on the jaw due to the lower portion of the cheeks having filled in.
• Gleuteofemoral fat ( fat on hips, thighs and buttocks) will begin to accumulate. This fat has a higher content of omega-3 fatty acids and its purpose is to be used for lactation.

Gastrointestinal

• Estrogens may predispose to gallbladder disease - especially in older and obese people.
• Estrogens (especially oral forms) may cause elevations in transaminases (liver function tests) indicating liver toxicity. LFTs should therefore be periodically monitored in transgender women.

Neurological/Psychiatric

• Mood changes can occur, such as the development of depression. However, many trans women report significant mood-lifting effects from HRT as well. In addition, the risk of depressive side effects is more particularly common in those who take progestins. Medroxyprogesterone acetate, in particular, has been shown to cause depression in certain individuals, perhaps due to its possible effect on dopamine levels; though, this effect may be largely reliant on its strong inhibitory effects on sex hormone production.
• Migraines can be made worse or unmasked by estrogen therapy.
• Estrogens can induce the development of prolactinomas, which is why prolactin levels should periodically be monitored in transgender women. Milk discharge from the nipples can be a sign of elevated prolactin levels. If a prolactinoma becomes large enough, it can cause visual changes (especially decreased peripheral vision), headaches, mood changes, depression, dizziness, nausea, vomiting, and symptoms of pituitary failure like hypothyroidism.
• Some people have noticed a feeling of calmness/self-contentment after starting HRT.
• Recent studies have indicated that cross-hormone therapy in trans women may result in a reduction in brain volume towards female proportions.

Metabolic

• Estrogen therapy causes decreased insulin sensitivity which places transgender women at increased risk of developing type II diabetes.
• One's metabolism slows down and one tends to gain weight, lose energy, need more sleep, and become cold more easily. Due to androgen deprivation a loss of muscle tone, a slower metabolism, and physical weakness becomes more evident. Building muscle will take more work than before. The addition of a progestogen may increase energy although an increase in appetite may be seen as well.

Hormone levels

During HRT, especially in the early stages of treatment, blood work should be consistently done to assess hormone levels and liver function. It is suggested by Endocrine Society that individuals have blood tests every 3 months in the first year of Hormone Replacement Therapy for Estradiol and Testosterone and monitor Spironolactone, if used, every 2-3 months in the first year.

The optimal ranges listed for estrogen only apply to individuals taking bioidentical hormones (i.e., estradiol, including esters) and do not apply to those taking synthetic or other non-bioidentical preparations (e.g., ethinyl estradiol or conjugated equine estrogens (Premarin)). While the ranges given are optimal, Endocrine society further state that Estrogen levels of 200pg/ml ought not to be exceeded.

There should also be medical monitoring, including complete blood counts, renal and liver function, lipid and glucose metabolism, as well as monitoring prolactin levels, body weight and blood pressure.

See also

• Hormone replacement therapy (transgender)
• Hormone replacement therapy (female-to-male)

References

External links

• Hembree W, Cohen-Kettenis P, Delemarre-van de Waal H, Gooren L, Meyer III W, Spack N, Tangpricha V, Montori V (September 2009). "Endocrine Treatment of Transsexual Persons: An Endocrine Society Clinical Practice Guideline" (PDF). The Endocrine Society/Journal of Clinical Endocrinology & Metabolism. Retrieved 20 July 2011. 
• Dahl M, Feldman J, Goldberg J, Jaberi A, Bockting W, Knudson G, Goldberg J (January 2006). "Endocrine Therapy for Transgender Adults in British Columbia: Suggested Guidelines" (PDF). Vancouver Coastal Health Authority. Retrieved 20 July 2011. 
• Tom Waddell Clinic Transgender Protocol - MTF and FTM clinical protocols aimed at providers
• Moore E, Wisniewski A, Dobs A (August 2003). "Endocrine treatment of transsexual people: a review of treatment regimens, outcomes, and adverse effects". J. Clin. Endocrinol. Metab. 88 (8): 3467-73. doi:10.1210/jc.2002-021967. PMID 12915619. Retrieved 31 October 2013. 

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