Recommended Supplements for FTM and MTF

While natural health supplements marketed to “women” and “men” are widely available, these labels can be alienating to important and significant populations of people. To someone who identifies as a trans woman or nonbinary, taking a “men’s” vitamin daily for their biology may feel like yet another betrayal to their identity. Inclusivity is important to your health. Feeling seen and heard is important to your health. 

As humans, many of our nutritional needs are the same, regardless of gender or biological sex. However, there are some unique needs of the biologically male and female systems, some due to size and structure, but mostly due to differences in hormones. This means that when a person prepares for transition through gender-affirming hormone treatment, their nutritional needs will transition too. If they also undergo gender-affirming surgery, there are additional nutritional concerns to be addressed for a healthy and speedy surgical recovery. 

It is important that we are all able to take care of our unique and individual, physical bodies without feeling mislabeled. While we wait for the inclusivity of our greater health community to broaden, Naturopathic Doctor Kristen McCormack has offered some excellent, thoughtful recommendations for natural vitamin, mineral, and herbal supplements that may benefit people undergoing male to female (MTF) or female to male (FTM) transitions.

Addressing MTF Concerns 

Weight Gain

When transitioning to a female physiology, therapies typically include hormonal treatment with estrogen and progesterone. One biological benefit to added estrogen is the protective effect it has on bone health [1]. Unfortunately, as estrogen begins to outweigh testosterone in the system, weight gain typically ensues. Estrogen favors energy storage, and this weight gain is generally associated with an increase in fat mass [2]. While you can try to embrace this change as just another element of womanhood, it does have a history of triggering disordered eating.

If weight gain is a health concern as you transition from male to female biology, take a close look at the nutrition requirements for a woman of your height and structure. You may find that the total calories you need each day are lower than they once were. There will also be slight differences in requirements for specific nutrients. One excellent way to be sure you are getting adequate, balanced nutrition without going over your daily caloric needs is to replace one meal a day with a nutritional shake or smoothie powder. Metabolic Detox® Complete powder is a great allergen-, dairy-, soy-, and gluten-free choice and doubles as your daily multivitamin/mineral supplement. It tastes great alone but also blends nicely with fruit and greens for an even more nutritious meal.  

Changing Nutritional Needs (Beware Iron)

A daily multivitamin is a healthy choice for most people. Trans women should be wary of added iron in “women’s” multivitamins. Iron is often added for those who become iron deficient due to menstruation, during pregnancy, or while lactating. As it is possible to have too much dietary iron, check with your doctor and analyze recent blood work before taking a supplement with added iron. A general multivitamin/mineral formula, such as Basic Maintenance®, is probably a more suitable choice.  

Triglycerides, Cholesterol, and Heart Disease

The risk of death from cardiovascular disease is more common in biological males than females. As such, it was long believed that female hormones must somehow offer cardiovascular protection. Studies involving transgender subjects have shown this is not necessarily the case [3]. In fact, the combination of estrogen and anti-testosterone treatment has been shown to cause an increase in triglycerides and blood pressure, an increase in subcutaneous and visceral fat, and a decrease in insulin sensitivity [3]. All of these factors increase a person’s risk for cardiovascular disease. 

In comparison, testosterone treatment increased subjects’ triglycerides and decreased their HDL, but FTM treatment did not affect blood pressure, fat distribution, LDL cholesterol, or insulin sensitivity [3]. 

When undergoing MTF transition, it is especially important to nurture your body in a way that protects and supports your cardiovascular system. Omega-3 fatty acids, like those found in cold water ocean fish or fish oil supplements, such as Mega Omega™, are an excellent promoter of a healthy cardiovascular system. Epidemiological and clinical evidence suggests that there is a significant inverse association between long-term intake of Omega-3s, specifically eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA), and mortality associated with cardiovascular disease [4-6]. Studies have also been conducted to measure the effects of EPA and DHA on serum lipids, plasma, platelet fatty acids, and fasting glucose concentrations. DHA has been shown to cause an increase in HDL cholesterol (good cholesterol), EPA increases fasting glucose concentrations, and both EPA and DHA have been shown to decrease triacylglycerols [7].

Other heart-healthy supplements that can be taken in conjunction with a daily multi include CoQ10 and curcumin. Curcumin specifically is an excellent choice to support healthy blood glucose levels if insulin sensitivity appears to become an issue [8].

Addressing FTM Concerns

Acne

In the short term, testosterone treatment will likely lead to an increase in muscle mass, fat loss, and increased facial and body hair growth [9,10]. Unfortunately, it may also be accompanied by cranial hair loss and acne [9]. Acne is often triggered by a sudden change in hormones as sebum production is significantly increased in facial hair follicles in response to testosterone [11]. Luckily this effect is not a lasting one for most people. In one study of FTM trans people, acne peaked at 6 months of testosterone treatment and was no longer visible for most subjects after long-term treatment [9]. 

While this effect will vary from person to person, having a comprehensive natural skincare routine may help to minimize the appearance of acne. Look for products that contain niacinamide, the physiologically active form of niacin or vitamin B3. Niacinamide is an anti-acne ingredient as it reduces the production of sebum [12]. It also up-regulates the production of new skin cells, supports sun damage repair, and provides potent anti-inflammatory activity [12]. Metabolic Maintenance’s “Naturally Clear® is a line of natural skincare products that all contain niacinamide, along with a range of other natural ingredients to benefit different skin types. 

Bone Loss/Osteoporosis

Although few studies have analyzed the long term effect of testosterone treatment on osteoporosis in trans men, estrogen is a known protector of bone density. Due to this factor, and studies showing increased bone turnover in trans men on testosterone therapy [10], it is reasonable to hypothesize that the risk of osteoporosis may increase due to FTM gender affirmation. Osteoporosis occurs when the creation of new bone doesn’t keep up with the breakdown of old bone, resulting in decreased bone mineral density (BMD). It is associated with back pain, stooped posture, and a higher risk of fracture. One setback is that the scoring for osteoporotic diagnosis is based on sex, and it is unclear whether the diagnoses of trans people on hormone therapy or post-gonadectomy should be calculated based on their gender identity or their biological sex at birth [13]. 

Regardless of terminology, bone health is important to our longevity as we age. Loss of estrogen dominance may have a detrimental effect on bone density and strength, especially if we are not meeting nutritional demands for bone health. Many people know that healthy bones require calcium and vitamin D, but a 2-year, double-blind, placebo-controlled study that measured spinal bone loss in postmenopausal people showed that calcium (as calcium citrate/malate) plus trace minerals (zinc, manganese, and copper) was far more effective in maintaining BMD than calcium alone [14]. A bone support supplement, such as Metabolic Maintenance’s Rebuild® or Rebuild® Plus formulas (depending on your vitamin D levels), could be the help you need to keep bones strong into your golden years.

Triglycerides, Cholesterol, and Heart Disease

The risk for stroke and myocardial infarction (heart attack) is significantly higher for trans women than for trans men [15]. However, hormone therapy for trans men has been shown to increase blood pressure, triglycerides, and LDL (bad cholesterol), while decreasing HDL (good cholesterol) compared to cisgendered men of the same age group [15]. All of these factors increase a person’s risk of developing cardiovascular disease. 

Omega-3 fatty acids are fantastic cardiovascular support nutrients as described above. Another heart supportive nutrient available in supplement form is coenzyme Q10, also known as ubiquinone or CoQ10. Coenzyme Q10 is a mitochondrial coenzyme, essential for the production of cellular energy (ATP), and a powerful antioxidant [16]. Our bodies make it naturally, but production tends to slow down as we age. Through its central role in energy production, CoQ10 promotes the healthy function of cells that need and use a lot of energy such as those of the heart, blood vessels, muscles, and kidneys [17]. It also inhibits LDL oxidation and thus the progression of atherosclerosis [17]. CoQ10 decreases proinflammatory cytokines and decreases blood viscosity [16,17]. Together, all of these actions make CoQ10 an ideal supplement for people with either past or potential heart failure and coronary artery disease.

Mental Health

Mental health is by no means a trans-specific issue, but statistics show a significant amount of physical and psychological abuse is experienced by trans people, which can be directly related to the development of depression and alarmingly high rates of suicide [18]. Additionally, there is evidence to suggest that low testosterone levels may be associated with depression [19]. Due to this relationship, MTF transition may come along with new, low feelings as your body adjusts to its new hormonal levels. The protective factors that serve as the best predictors against suicide in the trans community have been analyzed to be social support from friends and family, and a generally optimistic attitude and personality [18]. 

These are not problems that can be solved with nutrition alone. However, multiple studies have demonstrated the connection between the quality of our diets and mental health. By doing our best to supply body systems with the proper nutrition, we make available all of the molecules needed to naturally support the brain and body through change and transition. A high-quality diet has been connected to lower rates of depression and lower suicidal risk [20]. 

Gut Health

The gut in particular has been dubbed “the second brain” and the gut-brain-axis is gaining the attention it receives from researchers in both alternative and western medical fields. There are more than one million neurons making up the “enteric nervous system” of the gut, which is more neurons than the spinal cord or the peripheral nervous systems [21]. The enteric nervous system uses more than 30 neurotransmitters, including serotonin, melatonin, and acetylcholine, just like the brain, and 95% of the body’s serotonin is actually located in the gut [21]. In fact, because antidepressant medications such as selective serotonin reuptake inhibitors (SSRIs) increase serotonin levels, they often provoke gastrointestinal issues as a side effect [21]. Stress, in the form of physical or psychological trauma, anxiety, and depression can all have a negative effect on the health of the gut, and in turn, the health of the gut can have an effect on these mental conditions [22].  

The trillions of bacteria in the gut “communicate” with enteric nervous system cells (which they greatly outnumber) and can have an effect on mood. Helpful, healthy bacterial species, known as probiotics, promote more than just good digestion. Among their many benefits, probiotics have been shown to reduce feelings of anxiety, depression, among other mental health issues, and increase a self-reported quality of life [20]. Certain probiotic species have been linked directly to increased serotonin levels [23].

The health and proliferation of probiotic bacteria do require input other than probiotics alone. Probiotic microorganisms feed on non-digestible fiber oligosaccharides, also known as prebiotics. If a person’s diet is low in oligosaccharide fiber, a prebiotic supplement compliments a probiotic supplement to support the survival of a healthy gut microbiome. Metabolic Maintenance offers excellent options for both probiotic and prebiotic supplements in the BioMaintenance™ line.

Aside from incorporating pre- and probiotics, the health of the gut can be supported with certain dietary choices and a healthy lifestyle.

Methylfolate

Due to severe consequences of folate deficiency, especially for fetal development, common food items like bread, rice, and cereals are often “fortified” with folic acid. Relatively recently, however, it was discovered that a significant portion of our population does not process synthetic folic acid properly, due to a mutation in the MTHFR gene . As folate plays a key role in methylation, and therefore the production of neurotransmitters such as serotonin, dopamine, and norepinephrine [19], people with this genetic mutation may be more likely to experience a low mood and other symptoms due to low folate status. Luckily, L-methylfolate, the activated form of folate, is now available as a nutritional supplement. L-Methylfolate is the active ingredient in the medical food Deplin®, often prescribed as a complement to antidepressant medication. L-Methylfolate bypasses the activation process that folic acid must go through, and is ready to use in all bodies, regardless of one’s MTHFR variant. 

Methylation and the production and processing of neurotransmitters all require vitamins B-6 and B-12 in addition to folate [19]. Be sure these cofactors are also plentiful in your diet or daily supplement regimen to get the most from methylfolate.

References

  1. Cauley, Jane A. “Estrogen and bone health in men and women.” Steroids 99 (2015): 11-15.
  2. Anthony J. O’Sullivan, Allison Martin, Mark A. Brown, Efficient Fat Storage in Premenopausal Women and in Early Pregnancy: A Role for Estrogen, The Journal of Clinical Endocrinology & Metabolism, Volume 86, Issue 10, 1 October 2001, Pages 4951–4956, https://doi.org/10.1210/jcem.86.10.7941
  3. Elbers, Jolanda MH, et al. “Effects of sex steroids on components of the insulin resistance syndrome in transsexual subjects.” Clinical endocrinology 58.5 (2003): 562-571.
  4. Horrocks, Lloyd A., and Young K. Yeo. “Health benefits of docosahexaenoic acid (DHA).” Pharmacological research 40.3 (1999): 211-225.
  5. Yokoyama, Mitsuhiro, et al. “Effects of eicosapentaenoic acid on major coronary events in hypercholesterolaemic patients (JELIS): a randomised open-label, blinded endpoint analysis.”The Lancet 369.9567 (2007): 1090-1098.
  6. Kwak, Sang Mi, et al. “Efficacy of omega-3 fatty acid supplements (eicosapentaenoic acid and docosahexaenoic acid) in the secondary prevention of cardiovascular disease: a meta-analysis of randomized, double-blind, placebo-controlled trials.” Archives of internal medicine 172.9 (2012): 686-694.
  7. Mori, Trevor A., et al. “Docosahexaenoic acid but not eicosapentaenoic acid lowers ambulatory blood pressure and heart rate in humans.” Hypertension 34.2 (1999): 253-260.
  8. Den Hartogh, Danja J., Alessandra Gabriel, and Evangelia Tsiani. “Antidiabetic Properties of Curcumin I: Evidence from In Vitro Studies.” Nutrients 12.1 (2020): 118.h
  9. Wierckx, Katrien, et al. “Short‐and long‐term clinical skin effects of testosterone treatment in trans men.” The journal of sexual medicine 11.1 (2014): 222-229.