Some time ago, one of my patients introduced me to “The Powers Method” of hormone transition for transgender patients. “The Powers Method” was created by Michigan based family practitioner Dr. Will Powers. Dr. Powers primarily treats transgender patients in his practice. Over the years, he has been brave enough to change his practice standards when he repeatedly saw better results through different dosing and medication regimens. His treatment of transgender patients looks very different today from the mainstream guidelines produced by the WPATH and UCSF.
Prescribing in a manner different from the WPATH and UCSF guidelines is a scary thought for me! There are only a few areas of my life where I am a pioneer (I went to Burning Man before most anyone else, as an example), but for the most part, I am fairly conservative with change. I am particularly conservative with medical change because I don’t particularly like to experiment on myself and my patients. I prefer the test of time for the best interventions to reveal themselves.
But so much of what Dr. Powers’ says makes sense! Dr. Powers graciously produced terrific free downloadable presentations about his method. He also has a two-hour video lecture going through the presentation as well. His presentation is full of excellent citations and he makes some really great points from the lens of biochemistry and physiology.
Bicalutamide for breast development
One of the medications Dr. Powers uses to promote fuller breast development in transwomen is an androgen receptor blocker called bicalutamide (generic name is Casodex). Bicalutamide is used primarily for the treatment of advanced prostate cancer. One of the major side effects of concern is inflammation of the liver (hepatitis), as evidence by increased liver enzymes. The study that the UCSF guidelines quote as their reason for avoiding bicalutamide looked at 3000 advanced stage prostate cancer patients. The study notes that they cannot definitively say that the increased liver enzymes were from the Casodex, although it is likely that for at least some of these patients, the medication was the cause (PMID: 8560681). I do, however, find it difficult to apply these results from advanced cancer patients to my fairly healthy trans patients. The one study that we do have using bicalutamide in 23 transwomen did not show elevated liver enzymes (PMID: 30612811). The major side effect from the medication? Breast development.
What about the risks?
Let’s just say that bicalutamide carries a significant risk of elevated liver enzymes. Do you know what else carries a very clear risk of elevated liver enzymes? Tylenol. Tylenol is one of the absolute worst medications for the liver and I can buy it everywhere. There are many medications that carry the risk of liver strain actually, and we have a very reliable lab test to watch and observe how the liver is tolerating a medication.
Do you know what else carries significant risk? Untreated gender dysphoria. Transgender students attempt suicide at a rate of 35% (PMID: 30677012). Transgender veterans fair even worse, with up to 66% of them having attempted or planned their suicide at some point in their lives (PMID: 26878597). And speaking of risks, we should also consider the risks of breast augmentation. According to the medical database, UpToDate, breast augmentation results in a non-infectious complication rate between 10.3-17.4%. The rate of infection ranges from 8.9 to 9.3%. And spironolactone, the main anti-androgen recommended by the WPATH and UCSF, also carries its own risk of side effects, including some animal studies showing that it may promote tumor growth.
Physicians have a long history within the transgender community as being “gate-keepers”, something patients must tolerate to get access to life-saving medical interventions. And for me, I see similarities between this history and physicians that are unwilling to consider the use of bicalutamide and other alternative dosing styles. The fact that I have a pharmaceutical medication that may offer my patients an alternative to breast augmentation surgery is something all my transwomen deserve to know about. I believe strongly in informed consent and they deserve to be informed about this option!
I am grateful for the work of the WPATH and UCSF and I think their guidelines have opened up avenues of care for many providers. It can be overwhelming to know where to turn when you start this work. And, I think we need to keep exploring and advancing our field, so our patients get the absolute best assortment of choices to navigate their transition. And for that reason, I am grateful for physicians like Dr. Will Powers for being pioneers in this field.
About the author: Dr. Lauren Gresham is a naturopathic physician and Certified Community Health Educator practicing in North Seattle. Her areas of emphasis are transgender care, sexual medicine and cardiovascular disease. Please feel free to reach out if you have any questions by calling us at 206.542.4325.