Research about induction of lactation in transgender patients

Weimar 2023 California, USA: quotes and summary

Transgender woman (assigned male gender at birth) presented for induction of lactation

"For transgender and gender-diverse (TGD) parents, the ability to nourish their infants through production of their own milk may also be a profoundly gender-affirming experience.

"The patient was a nonsmoker and had no family history of venous thromboembolism. She took no other medications, including specifically over-the-counter medications which may prolong the QT nterval. Her physical examination at the initial consultation for lactation induction showed mature A-cup breasts with full rounded contour and excellent nipple maturation and protrusion.

Estradiol dosing of 4mg twice daily was selected to be relatively pharmacologically equivalent to the recommended ethinyl estradiol dose of 35mcg daily in the Newman-Goldfarb protocol (Newman, 2002-2019).

The patient underwent a diagnostic mammogram with ultrasound three weeks after initiation of the lactation induction protocol, both for routine breast cancer screening, as well as new development of right axillary discomfort. Images were notable for extremely dense breast tissue and were otherwise normal. Axillary discomfort spontaneously improved.

The patient reported that induction of lactation brought pragmatic and emotional benefits - helped the family manage sleep and fatigue.

Though the experiences of breast or chest feeding transgender and gender diverse parents (TGD) have much in common with those of cisgender people, there are unique considerations including

• Need for appropriate and affirming language

• Management of gender-affirming hormone therapy during the process.

Because participant expected to have minimal endogenous production of estradiol as a result of prior orchiectomy, rationale for continuing low-dose estradiol treatment during period of milk production was to minimize adverse effects, especially mental, from discontinuation of oestrogen treatment altogether, whilst avoiding impact on milk production.

Spironolactone or antiandrogen therapy was not indicated.

Weimer et al assessed one participant's milk and found values of fat, lactose, protein and calorie were comparable or even higher than those in term milk produced by cisgender women.

Trahair et al Durham 2024

50 year old assigned-male-at-birth transgender woman with medical history of discoid SLE and antiphosophlipid antibody and a surgical history of simple bilateral orchiectomy (2018) and full depth vaginoplasty (2019) No cigarette smoking, minimal alcohol.

Wished to breastfeed expected grandchild, and presented close to the daughter's due date. Wished to know the bond from breastfeeding, a desire which was supported by her daughter. Taking oestradiol 0.3 mg transdermal patch every 72 hours and micronized progesterone 200 mg oral once daily. Taking hydroxychloroquine sulfate daily.

Extensively counselled on increased risk of venous thromboembolism due to higher estrogen levels, age greater than 40, hypercoagulable disorder.

Started with increase estradiol dose to 0.4 mg transdermal patch every 72 hours, started manual pumping and nipple stimulation 3-4 times per day in five minute increments. Progesterone increased from 200 to 300 mg daily. Prescribed metoclopramide 10 mg tds. Told to start this one month after commencing estrogen and progesterone.

This patient pumped 5-6 times daily for 45 minutes per session, and began to experience spontaneous let down of milk, with a few drops of milk daily three weeks after adding domperidone.

She lactated for a total of two weeks and nursed the four month old infant on multiple occasions, with a peak milk production of 30 ml from larger R breast, 8 ml from smaller left breast. noticed breast maturation and filling in because of her treatment.

Stopped due to logistical barriers, such as needing to help with grandhild while daughter was pumping. Felt the breastfeeding from induction was a special experience. Felt female gender affirmation and full breast maturation.

Ikebukuro et al 2024 Japan: quotes and summary

There have been recent reports of lactogenesis in cissgender women who have had children through adoption or surrogacy. This study is only the seventh case report of induced lactation in transgender woman found in the research literature. The patient was a 50 year old transgender woman undergoing hormone therapy who asked to cofeed baby with pregnant partner.

The patient presented with her cisgender female partner in 19th week of pregnancy, conceived by sperm donation. The patient started Hormone therapy at age 40, and was currently taking estradiol 6 mg/day. Underwent orchidectomy at age 44.

Hormone levels were in the female cisgender E2 progsterone, prolactin range, with some insulin resistance. FBC lipids, E&LFTs nad

The patient was living with obesity. She had repeated normal ECGs prior to and during induction.

A regimen of estradiol, progesterone, and domperidone was initiated, accompanied by nipple stimulation. Treatment commenced with 6 mg estradiol and 10 domperidone.

There were concerns about the risk of leg venous thrombosis with high-dose estrogen and also about possible QTc abnormalities associated with domperidone, so careful monitoring occurred throughout induction, including by ECG. Blood tests were performed as an adjunct to screening for thorombosis by measuring D-dimer.

• On day 39 the patient commneced 100 mg progesterone.

• Day 46 commenced nipple stimulation (four times a day with breast pump, also 6 mg estrogen, 100 mg progesterone, 30 mg domperidone).

• On day 53 progesterone was increased to 200 ml, and on day 59 progesterone (to 300 mg) and domperidone (to 60 mg) were increased, estraodiol 6 mg continued.

• Day 63 added in 1 mg estradiol gel 500 mg progesterone 60 mg domperidone.

• Lactation was confirmed on day 63.

• Frequency of pumping increased to six times daily on day 99 and total oestrogen dose increased to 8 mg (2 mg gel). Pumping was increased to a total of 10 minutes each side. Transdermal estrogen was added to bring oestrogen concentration close to that of cisgender oestrogen concentration at that same gestational age. Transdermal rather than oral administration was chosen for estrogen administration to mitigate high risk of estradiol-induced venous thromboembolism.

• Subsequently increased to 8 mg estradiol, 500 mg progesterone, and 80 mg domperidone. Adjusted domperidone levels to maintain prolactin levels above 100 ng/l.

• Progesterone was discontinued on day 123 of teratment and estrogen dose reduced to 4 mg. Domperidone 80 mg continued to maintain hyperprolactinemia.

• After day 123 as progesterone and estrogen levels decreased, milk secretion increased to 30 mls milk/day.

• Baby was delivered on day 146. The patient reported 30 mls/milk production per day, 63 days after initiation of hormone therapy.

• On day 237, 3 months post delivery, domperidone tapered and breastfeeding discontinued after 3 months of direct breastfeeding. Patient found hypoestrogenic and hyperprolactinemiac state taxing.

Milk composition analysis showed protein very high at 123 and 126 days after start of treatment, high sIgA lactoferrin; calcium and zinc leels comrable with normal. That is, breastmilk composition was comparable with preterm infants.

Delgado et al 2023: quotes and summaries

A growing number of diverse familial structures wish to colactate their infant. For transgender and gender diverse (TGD) individuals, chestfeeding or breastfeeding may be within their goals of parenthood. There is limited evidence on how to induce lactation for a nongestational parent on gender affirming estrogen treatment.

There are a growing number of families formed by gender and sexual minorities. However, unfortunately the topics of pregnancy, childbirth, and parenting have often been bound to heteronormative norms and assumptions.

For transgender and gender diverse individuals, this can be compounded by a history of stigma and marginalization in health care.

Many diverse familial structures may have two parents who desire to colactate.

It's important to utilize gender inclusive language, varying from chestfeeding or breastfeeding as desired by any parent.

For transgender women on gender affirming treatment, the breast tissue develops radiographically and histologically indistinguable from cisgender women. The tissue goes through typical pubertal changes with estrogen called Tanner stages, leading to a breast tissue capable of lactating.

We report the case of a transgender woman who successfully underwent lactation induction following a protocol using the galactogue domperidone plus use of a breast pump. The patient had modifications to her hormone therapy with estrogen and progesterone while remaining on antiandrogen therapy with spironolactone. This study contains a description of the protocol, medications, laboratory monitoring, human milk analysis including macronutrients, oligosaccharides, and hormones.

40 year old transgender woman presented with cisgender wife, due date 6 months in future, patient hoping to assist her wife with breastfeeding. Had been on gender affirming hormone therapy since 35 years of age, currently on sublingual estradiol 4 mg twice daily, spironolactone 100mg bd, and progesteron 200 mg at bedtimes.

On physical examination her breasts were Tanner stage V with semiretracted nipples bilaterally. [Tanner scale stage 5: The areolar mound recedes into a single breast contour with areolar hyperpigmentation, papillae development, and nipple protrusion.]

Initial consultation: lactation induction protocols reviewed galactogue use discussed - domperidone counselling on risk of prolonged QTc with medication, requirement for ECG every 2 months. Commenced domperidone. Increased estradiol SL to 6 mg bd and progesteronte to 400 mg bdtime, continue on antiandrogen regimen.

One month followup:

• ECG QTc normal

• Spironolactone decreased to 100 mg daily and domperidone doubled.

Six weeks before due date medications changed to mimic delivery, including switching to transdermal estradiol and stopping progesterone. Encouraged to use electric pump every 3 hours for at least 5-7 minutes on each breast, or at least 6 sessions per day. Lactation consultant helped fit breast pump.

Baby born 4 days early by CS. Wife breastfed exclusively with patient assisting through bottle feeding. Patient able to give her baby at least one bottle of her own induced milk daily. Baby also needed formula feeding.

Patient had daily milk production of 74 ml. Milk production decreased in initial postpartum period due to caring for wife and baby. Milk supply increased with increased pumping. Began to breastfeed once daily. Continued domperidone throughout course of lactation at least 5 months.

7 month follow up, 14 days postdelivery, patient expressed wish to increase estrogen and sprionolactone back to pre-induction levels, which she did incrementally and which did not impact on milk. Milk volume peaked at 240 ml daily 3 months after birth as she continued to pump and breastfeed regularly.

Two months post birth milk collected for analysis. Values of protein, lactose, fat and calorie content were at or above standard term milk. HMO concentrations within normal mean range of mature human milk. Insulin, leptin, FGF-21 levels variable over the 8 weeks, but in line with previous studies. LH and FSH were undetectable.

Dropping estrogen levels and antiandrogen doses can increase the testosterone levels inducing gender dysphoria. Patient in this case continued to take spironolactone at a lower dose. When estrogen levels dropped, she did report rising dysphoria and increased the antiandrogen to achieve an estrogen predominant hormonal milieu.

No immediate change in milk volume but longer term effects of above changes not clear.

Amesfoort 2024 The Netherlands: quotes and summaries

37 year old transgender woman X (assigned gender male at birth, she/her) and her cisgender female partner presented asking that X be assisted to induce lactation.

The main motivation for lactation induction was to enhance parent–child bonding. Furthermore, they were planning to alternate chestfeeding to limit the burden, because the pregnant partner was experiencing some physical limitations.

The patient’s medical history was notable for gender incongruence. She was using gender affirming hormone therapy since October 2007 and had undergone a vaginoplasty in 2010, which was revised in 2011 and 2012. Her surgical history was also significant for an appendectomy because of appendicitis in 2010. The patient’s history was negative for smoking, alcohol and drugs.

Prior to initiating gender affirming hormone therapy she had cryopreserved her semen, which she and her partner used for her partner to conceive. At the time of her visit to the clinic she used estradiol gel 75ug per day, once daily.

On 1st June 2020, when her partner was approximately 14 weeks gestation, our patient started non-puerperal lactation induction. The first step was the use of a 150ug estradiol adhesive dermal patch once daily and 100 mg progesterone once daily orally.

Low milk production, and thus the possible inability of exclusive nursing were discussed with the patient. Hence, by shared decision making, the patient chose non-puerperal lactation induction.

After childbirth and delivery of the placenta, the levels of estrogen and progesterone drop drastically, allowing prolactin to trigger lactation.

Intake appointment in clinic before conception or in first trimester. Analyse risk factors, allergies, blood hormone levels

At end of first trimester (12-13 weeks gestation), after confirmation of viable pregnancy, increased estrogen dosage to 150 mcg once daily and commence progesteron to 100 mg once daily. This is ideally started 3-5 months prior to expected due state. Start stimulation of breast tissue by massaging, nipple stimulation.

At 17-18 weeks gestation, monitor blood hormone levels, increase estrogen to 250 mcg once daily

At 20 weeks gestation, start domepridone

At 21 weeks, double domperidone

At 23-24 weeks gestation monitor blood hormone levels, increase progesterone to 100 mg two times daily. Adjust estrogen dosage according to blood hormone levels

At 27-28 weeks of gestation monitor blood hormone levels, increase progeserone to 100 mg three times daily. Adjust estrogen to blood hormone levels

At least six weeks before expected due date, start manual breast pumping of breast to at least every 3-4 hours, at least once nightly

4-6 weeks before EDD decrease estrogen dose to 100 mcg once daily and discontinue progesterone

At onset of milk production decrease estrogen dosage to 50 mcg once daily. Use electric pump when milk volume icreases

After bith continue pumping including after feeds. Supplemental feedings with formula might be necessary.

Further details

Conception by cryopreserved sperm of transgender women (assigned male gender at birth AMAB, and affirm gender as female) patient and Intracytoplasmic Sperm Injection of cisgender female partner.

When partner was 14 weeks pregnant patient started non-puerperal lactation induction. Was using estradiol gel 75 mcg daily. Laboratory investigations re hormonal levels.

Used 150 mcg estradiol adhesive dermal patch once daily and 100mg progesterone once daily orally. Laboratory follow up after one month.

After three weeks, two pumps estradiol dermal spray (which equals approx 100mcg estradiol adhesive patch) added to estradiol treatment. Patient also started manual stimulation of the nipples and breast

Six weeks in she started domperidone 10mg four times daily orally

Seven weeks in domperidone dose doubled to 20 mg four times daily.

One week later progesterone dosage doubled to 100 mg twice daily orally.

Patient had gastrointestinal discomfort due to use of domperidone, which decreased over time.

Lactation consultant focussed on education about massaging of the breasts, pumping techniques, routines.

At nine weeks patient exxpressed first drops of fluid from her nipples. Laboratory results

Serum estradiol levels high, so esstradiol treatment decreased by 50 mcg to total of 200 mcg estradiol daily. Progesterone increased to three times daily.

Lab investigations a fornight later - at 11 weeks in.

Four months in, estradol dosage decreased by stopping the transdermal spray to a daily dosage of 1-- mcg estradiol daily.

One week later progesterone discontinued and patient started pumping every four hours including through night. A few droplets of milk released every time she pumped, to 2ml milk per day. Estradiol treatment decreased to 50mcg daily.

Investigations undertaken at 0, 10 days, 9 weeks, 11 weeks for estradiol, progesterone, testosterone, prolactin. At Week 0 also did: ASAT (SGOT), ALAT (SGPT), creatinine, cholsterol

Infant born by partner. Both continued or commenced pumping. Patient produced a maximum of 7 mls a day, enough for supplementary feeding. The infant had a short lingual frenulum and suckling problems. Patient weaned two weeks after birth because she experienced the frequent pumping to be exhausting and milk production to be low. Two weeks after the birth her estradiol dosage was increased to 100 mcg.

Patient reported that lactation induction did not have a significant effect on her gender identity, nor alter gender dysphoria. She reported "it was a pity" that the experience of long-term feeding had not been possible. She had fed a few times (or comforted the baby).

Patient started manual stimulation and expression 20 weeks prior to delivery, she only used breast pump three weeks before delivery (had meant it to be five weeks.) Most people advise six weeks of pumping.

Prenatal development of mammary tissue is similar in both males and females. In cisgender women breast development starts at pubery under influence of estrogen.

Breast of transgender women indistinguishable from cisgender women on radiography. However, clinically transsgender women may have smaller breast which may not reach full breast maturity, similar to Insufficent Glandular Tissue.

Selected references

Delgado D, Stellwagen L, McCune S, Sejane k, Bode L. Experience of induced lactation in a transgender woman: analysis of human milk and a suggested protocol. Breastfeeding Medicine. 2023;18(11):888-893.

Ikebukuro S, Tanaka M, Date M. Induced lactation in a transgender woman: case report. International Breastfeeding Journal. 2024;19(66):https://doi.org/10.1186/s13006-13024-00675-13004.

Trahair ED, Kokosa S, Weinhold A. Novel lactation induction protocol for a transgender woman wishing to breastfeed: a case report. Breastfeeding Medicine. 2024;19(4):DOI: 10.1089/bfm.2024.0012.

Van Amesfoort JE, Van Mello NM, Genugten RV. Lactation induction in a transgender woman: case report and recommendations for clinical practice. International Breastfeeding Journal. 2024;19(18):https://doi.org/10.1186/s13006-13024-00624-13001.

Weimer AK. Lactation induction in a transgender woman: macronutrient analysis and patient perspectives. Journal of Human Lactation. 2023;39(3):488-494.