Experience of Induced Lactation in a Transgender Woman: Analysis of Human Milk and a Suggested Protocol

Abstract

Background:

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.

Case Presentation:

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. A description of the protocol, medications, laboratory monitoring, human milk analysis including macronutrients, oligosaccharides, and hormones is presented.

Discussion:

This is the fourth case to date known in the literature of a transgender woman with successful lactation induction, and the third case to remain on antiandrogen therapy during this process. Our report is the second to demonstrate comparable macronutrients, and the first to report on human milk oligosaccharides and hormones in induced milk compared with term human milk of a gestational parent.

Conclusions:

The opportunity to chestfeed or breastfeed an infant can be profound for many parents. Further research is needed to meet the needs of TGD individuals who wish to induce lactation as part of their parental goals.

Introduction

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.^1,2 In addition, health care spaces have traditionally not been welcoming and knowledgeable of diverse familial structures.³ For transgender and gender diverse (TGD) individuals, this can be compounded by a history of stigma and marginalization in health care.⁴

Recognizing and supporting all patients' goals in an affirming environment is key to improve health and well-being. With a growing number of TGD people interested in parenthood, many diverse familial structures may have two parents who desire to colactate.⁵ Utilizing gender inclusive language, varying from chestfeeding or breastfeeding as desired by any parent, and access to expert guidance is essential for supporting all families with their lactation goals. In addition, inducing lactation in a nongestational parent is becoming more common and is a pressing reproductive health issue.¹

There are well-known protocols for inducing lactation in cisgender females. The Newman–Goldfarb protocol is one of these, with recommendations to mimic the hormonal changes during pregnancy as the breast is prepared for lactation: Increase in prolactin with the use of a galactagogue, while also increasing progesterone and estrogen with a drop in the latter two during the postpartum period.⁶ These hormonal changes plus use of a breast pump to stimulate the breast have been successful in producing lactation in nonbirthing individuals.

For transgender women on gender affirming treatment, the breast tissue develops radiographically and histologically indistinguishable from cisgender women. The tissue goes through typical pubertal changes with estrogen called Tanner stages, leading to a breast tissue capable of lactating.⁷

Research has shown increase in interest from health care professionals and the community to learn more about chestfeeding and breastfeeding protocols specific to TGD individuals.⁸ The Academy of Breastfeeding Medicine recently published initial considerations on induced lactation for TGD individuals, an exciting initial step.² There is evidence online of providers assisting with lactation induction specifically for TGD people,⁸ although to date there have been only three published case reports documenting induced lactation in a transgender woman.^7,9,10 Our report presents a successful case of induced lactation in a transgender woman, plus analysis of induced milk macronutrients and oligosaccharides and the patient's perspective of this experience.

To our knowledge, only one prior case publication has analyzed the macronutrients of induced milk, demonstrating similar components to the milk of a gestational parent.⁹ Our report also examines the oligosaccharides present. Human milk oligosaccharides (HMOs) are complex indigestible sugars that represent the third most abundant group of molecules in human milk.

HMOs have several important benefits for the infant, including but not limited to preventing infections, assisting in differentiation and activation of immune cells leading to lower rates of inflammatory and allergic diseases, and reducing the risk of necrotizing enterocolitis, a common and often fatal condition experienced mostly by preterm infants.^11,12 Therefore, HMOs are an important constituent of human milk and its presence in a nonbirthing parent indicates the milk contains both nutritional and bioactive components.

The patient discussed in this report has given written consent and has reviewed the case before publication.

Case Presentation

We present the case of a 40-year-old transgender woman who presented to her primary care provider's office to discuss inducing lactation. The patient's wife, a cisgender woman, was pregnant with a due date 6 months in the future and the patient was hoping to assist her wife with breastfeeding during the postpartum period. She had been on gender affirming hormone therapy since age 35 years, currently on sublingual (SL) estradiol 4 mg twice daily (BID), spironolactone 100 mg BID, and progesterone 200 mg at bedtime.

She had also been taking finasteride 5 mg daily (QD) for hair loss prevention, which she stopped during lactation induction. In addition, her medical history was significant for attention-deficit/hyperactivity disorder, oral herpes simplex virus, erectile dysfunction, and allergies. Additional medications were all as needed and were held during this process. She was a nonsmoker, with rare alcohol use and no nonprescribed drug use. She had undergone facial feminization surgery but no breast surgeries. On physical examination, breasts were Tanner stage V with semiretracted nipples bilaterally.

Initial hormone panel showed an estradiol of 110 pg/mL and suppressed testosterone. The patient's prolactin was initially slightly elevated but normalized on repeat fasting draw. Table 1 gives results at initial and subsequent follow-up visits, following the format used in prior published lactation cases.⁹

Table 1.

Timeline of Medications, Study, and Lactation Results

Days relative to DD	DD −162 (08/23)	DD −132	DD −102	DD −51	DD −18	DD +10	DD +59	DD +131
Medications
Estradiol	4 mg SL BID	6 mg SL BID	6 mg SL BID	6 mg SL BID	25 mcg/d TD	25 mcg/d TD	2 mg SL QD	2 mg SL QD
Progesterone	200 mg QD	400 mg QD	400 mg QD	400 mg QD	Stopped
Spironolactone	100 mg BID	100 mg BID	100 mg QD	100 mg QD	100 mg QD	100 mg QD	100 mg BID	100 mg BID
Domperidone		10 mg BID ≥20 mg TID	20 mg QID	20 mg QID	20 mg QID	20 mg QID	20 mg QID	20 mg QID
Studies
EKG	QTc 430 msec	QTc 419 msec	QTc 419 msec		QTc 396 msec		QTc 410 msec
Prolactin (ng/mL)	25.1 ≥ 15.9		119	145		153	142
Estradiol (pg/mL)	110		143	195		<12	26
Progesterone (ng/mL)	1.6		4.6	2.7		0.5	0.2
Testosterone (ng/dL)	<6		<6	<6		249	<6
Lactation results
Breast pump frequency (24 hours)				Started DD −31 6 × daily	6 × daily +1 × nightly	3–4 × daily	6–8 × daily	6–8 × daily
Daily milk volume (24 hours)					18–40 mL	70–75 mL	177–240 mL	140–170 mL

BID, twice daily; DD, due date; EKG, electrocardiogram; QD, daily; QID, four times daily; QTc, corrected QT interval; SL, sublingual; TD, transdermal.

During the initial visit, previously documented lactation induction protocols⁶ were reviewed with the patient. The use of a galactogue was discussed, with options being metoclopramide and domperidone. Domperidone is not Food and Drug Administration approved in the United States. However, this medication has lower risks of side effects such as tardive dyskinesia, restlessness, and drowsiness. The patient preferred to use domperidone, which she obtained from a licensed Canadian pharmacy with a written physician's prescription.

She was also counseled on the risk of prolonged QTc with the medication and need for electrocardiogram monitoring every 2 months. Table 1 gives the titration schedule used and laboratory results. Additional medication changes at this visit included increase in estradiol SL to 6 mg BID and in progesterone to 400 mg at bedtime. She continued her antiandrogen regimen.

Results

At 1-month follow-up, the patient was tolerating the domperidone and changes in medications without side effects. Electrocardiogram showed a QTc within normal limits. At this visit, spironolactone was decreased to 100 mg QD and domperidone increased to goal of 20 mg four times daily (QID) as given in Table 1. Six weeks before due date, medications were changed to mimic delivery, including switching to transdermal estradiol and stopping progesterone. The patient was encouraged to use an electric pump every 3 hours for at least 5–7 minutes on each breast, or at least 6 sessions per day.

During this time, the patient also sought the expertise of a lactation consultant. She reported difficulties finding the right pump parts to match her breasts and found it beneficial to have assistance from the lactation consultant.

The patient's baby was born 4 days before due date through c-section for arrest of descent. The gestational parent and baby were both healthy. For convenience and to maintain the gestational parent milk supply, her wife breastfed exclusively with the patient assisting through bottle feeding. The patient reported being able to give her baby at least one bottle of her own induced milk daily. The baby also needed additional formula feeding initially while the gestational parent's milk supply was established.

At this time, the patient had a daily milk production of ∼74 mL. Her milk production decreased during the initial postpartum period, which she reported secondary to taking care of both her wife and baby after delivery. As she resumed additional pumping sessions, her milk production continued to increase as given in Table 1. Once her milk increased, she also added a breastfeeding session daily in addition to pumping.

At the 7-month follow-up visit, 14 days postdelivery, the patient expressed concerns with a testosterone-dominant hormonal milieu. She expressed the desire to increase estrogen and spironolactone. At this time, spironolactone was increased from 100 to 150 mg QD for 2 weeks. After monitoring there was no impact on milk supply, she increased back to 100 mg BID. In addition, estradiol was switched from patch to 2 mg SL. The patient's volume peaked at 240 mL daily 3 months post due date as she continued to pump and breastfeed regularly.

Starting 63 days post due date, the patient began weekly milk collection for analysis. Given milk macronutrients vary throughout the day, the patient was instructed to pool milk expressions over the course of 24 hours into one 200 mL high-density polyethylene bottle. Each container transfer of milk can leave behind residual fat, and thus calories. Therefore, the samples were expressed and transferred one time. Before milk was frozen, she mixed the full 24-hour pool thoroughly and poured off all but 60 mL for her baby's feedings. The remaining sample was frozen.

Eight samples were shipped to the University of California Health Milk Bank (UCHMB) on dry ice and stored at UCHMB at −25°C until analysis. The samples were warmed to 45°C and agitated by hand before analysis. Milk samples were analyzed on a FOSS FT1 milk analyzer (Hilleroed, Denmark), a Fourier transform infrared technology instrument with high levels of accuracy. Samples were run twice, and a mean result was provided. Total calories were calculated using the Atwater General equation (4 kcal/g for protein, 4 kcal/g for carbohydrates, and 9 kcal/g for fat) and reported as kcals per ounce (30 mL).

HMOs were measured at the University of California, San Diego, using an established method.¹³ The concentrations of five hormones (fibroblast growth factor [FGF]-21, leptin, insulin, follicle-stimulating hormone [FSH], and luteinizing hormone [LH]) were measured using an MSD U-PLEX Metabolic Group 1 immunoassay (Meso Scale Diagnostics, Rockville, MD, USA) according to manufacturer's instructions. Table 2 gives these values along with the average nutritional values of term milk compiled from systematic reviews.^14,15

Table 2.

Milk Macronutrients, Calories, Human Milk Oligosaccharide, and Hormone Profile Compared to Standard Term Milk

	Days relative to DD								Standard term milk ^a
	DD +83	DD +90	DD +97	DD +104	DD +111	DD +118	DD +125	DD +130	At least 70–84 days post delivery
Protein (g/dL)	1.1	1.2	1.2	1.2	1.2	1.1	1.1	1.2	0.9–1.2
Lactose (g/dL)	7.4	7.4	7.3	7.3	7.3	7.4	7.3	7.3	6.7–7.8
Fat (g/dL)	4.0	3.3	4.1	4.0	3.8	3.9	4.2	4.1	3.2–3.6
Calories (kcal/30 mls)	21	19	21	21	20	20	21	21	65–70 Kcals/dL = 19.5–21 Kcals/30 mLs
24 hour Milk Production (mL)	145	80	130	145	140	140	160	170

									At least 15–30 days post delivery
HMO (g/L)	7	7	7	7	8	7	7	7	10–17
2’-fucosyllactose (mg/L)	473	535	521	488	487	481	450	494
3-fucosyllactose (mg/L)	1,360	1,454	1,404	1,385	1,418	1,601	1,532	1,571
Difucosyllactose (mg/L)	155	167	163	139	155	145	147	136
3’-siallylactose (mg/L)	104	99	97	109	118	114	100	100
6’-siallylactose (mg/L)	182	176	156	144	159	129	117	129
Lacto-N-tetraose (mg/L)	1,095	1,028	1,072	1,128	1,070	1,043	990	1,052
Lacto-N-neotetraose (mg/L)	66	64	61	76	74	57	50	67
Lacto-N-fucopentaose-I (mg/L)	215	218	248	244	259	217	212	242
Lacto-N-fucopentaose-II (mg/L)	1,277	1,320	1,316	1,336	1,397	1,364	1,313	1,379
Lacto-N-fucopentaose-III (mg/L)	15	13	15	14	33	13	11	14
Sialyllacto-N-tetraose b (mg/L)	94	82	85	87	115	83	79	76
Sialyllacto-N-tetraose c (mg/L)	92	88	74	72	109	64	60	67
Difucosyllacto-N-tetrose (mg/L)	533	536	577	562	573	534	511	521
Lacto-N-hexaose (mg/L)	68	67	64	60	103	57	56	56
Disialyllacto-N-tetraose (mg/L)	263	217	238	241	292	232	213	205
Fucosyllacto-N-hexaose (mg/L)	264	248	215	241	274	185	172	196
Difucosyllactose (mg/L)	186	163	184	194	236	192	168	174
Fucosyl-disialyllacto-N-hexose (mg/L)	456	544	457	455	535	423	423	473
Disialyllacto-N-hexaose (mg/L)	168	164	148	138	175	114	111	116
FGF-21 (pg/mL)	27.0	6.8	7.3	22.5	9.0	8.2	13.8	12.7
Leptin (μIU/mL)	59.1	33.1	39.6	26.5	27.9	20.2	30.6	27.1
Insulin (μIU/mL)	53.7	50.3	38.5	40.3	41.4	45.4	45.3	62.3
FSH (pg/mL)	^a	^a	^a	^a	^a	^a	^a	^a
LH (pg/mL)	^a	^a	^a	^a	^a	^a	^a	^a

Note: The values reported are mean values. Standard term milk.^14,15

Below assay detection range.

FGF, fibroblast growth factor; FSH, follicle-stimulating hormone; HMO, human milk oligosaccharide; LH, luteinizing hormone.

The nongestational parent's milk showed values of protein, lactose, fat, and calorie content that were at or above the standard term milk. HMO concentrations were within the normal mean range of mature human milk. Insulin, leptin, and FGF-21 levels were variable over the 8 weeks, but in line with previous studies.^16–18 LH and FSH were below detection limit.

Patient perspective

Making milk for my daughter has been beautiful and empowering. Whether I am nursing her or feeding her expressed milk in a bottle, I feel a wonderful connection with her and I am proud that my body and hard work can help her grow and stay healthy. My milk contributions also reduced the burden of care for my wife in the early days and nights, which was a great relief for us after her difficult labor. I still dealt with challenges such as making time to pump, finding pump parts that fit my body, and dealing with inexperience or hostility from hospital staff about feeding my milk to my daughter during the postpartum days in the hospital.

At the time of writing, the patient continues on domperidone, and her baby is 5 months old. She plans on continuing to breastfeed and pump until the baby is at least 6 months old and will wean thereafter.

Discussion

Inducing lactation in the nongestational parent has become more common. Specifically, lactation induction for TGD individuals has additional considerations, such as modification of hormone affirming therapy and access to a provider knowledgeable on modifying cisgender protocols for this population. For the patient in this case, she has a long-standing relationship with her primary care physician who also prescribes her gender affirming treatment, streamlining this process.

To our knowledge, this is only the second case in the literature to report on the macronutrients of induced milk⁹ and the first to present data on the HMO and hormone content from a nongestational parent also on gender affirming hormone treatment. As reported, the induced milk was as robust in protein, calories, fat, lactose, and HMOs as term milk from a gestational parent. The prior report also documented comparable levels of macronutrients in the induced milk of a transgender woman compared with those in standard term milk.^9,14

Although HMO profile varies from person to person, the overall HMO content of this induced milk is comparable with standard term human milk. These results show that induced milk from a TGD nongestational parent also produces adequate nutrients for a growing infant. LH and FSH levels were below detection range, suggesting very low, if any, levels of these hormones. This may be due to the hormone therapy suppressing LH and FSH production in transgender women.¹⁹

Breastfeeding can be a gender affirming practice for transgender women.²⁰ However, given the changes in the hormonal milieu, for those who have not had gender affirming genital reconstruction, dropping the estrogen levels and antiandrogen doses can increase the testosterone levels inducing gender dysphoria. The patient in this case continued to take spironolactone at a lower dose, similar to prior case reports.^7,10 When estrogen levels dropped, she did report rising dysphoria and a desire to reincrease the antiandrogen to achieve an estrogen predominant hormonal milieu.

A known metabolite of spironolactone, canrenone is excreted in human milk. Data are scarce on this issue, but one case study demonstrated that only 0.2% of the parental daily dose is excreted and has not been shown to be clinically significant.²¹ The World Health Organization has also deemed this medication to be safe while breastfeeding.²² The patient's milk production did not decrease immediately after resumption of higher spironolactone and estrogen levels. However, there was a drop in volume within the month after this change, making it unclear whether there is a definitive causal relationship. Given our results, an important consideration would be discussing benefits and risks of continuing the same dose of antiandrogen throughout the chestfeeding or breastfeeding process.

In addition, the patient disclosed discrimination at the hospital when trying to feed her milk to her newborn. For diverse familial structures within the lesbian, gay, bisexual, transgender and queer community, having a sensitive and supportive health care team may considerably change the experience during pregnancy, postpartum, and lactation periods. Some have suggested creating a birth and lactation plan before delivery that includes the goals of both parents, and having access to a support group of other colactating parents.⁵ As for any new parents, questions arise during this time and having a health care team who understands the realities of their family can make a difference.²³ The patient in this case also reported that access to a lactation consultant made a significant impact in her lactation success.

Limitations

The amount of milk production by the patient in this report would not be enough to solely sustain an infant's nutritional needs. However, since the patient was cofeeding with the gestational parent, this amount aligned with her breastfeeding goals. For this patient, considerations may include reduced pumping sessions around delivery while in the hospital and time constraints with newborn's needs. The prior three published case reports discuss similar findings.^7,9,10 Additional research is needed to highlight potential limitations specific to this population.

Regarding milk analysis, the 24-hour pooled milk volumes were estimated from observation of bottle volume markings that may have a small margin of error. In addition, the milk had undergone multiple freeze–thaw cycles, therefore, the reported hormone content is likely lower than if it had been analyzed fresh.

Conclusions

Induction of lactation may be chosen in multiple diverse familial structures for a nongestational parent. For families who colactate, the experience can be rewarding for both parents and having access to adequate lactation support can make a significant impact. Development of specific regimen guidelines with exact dosing of hormones for inducing lactation in TGD individuals will foster needed progress in this field. Chestfeeding or breastfeeding can be for many a transformative experience of parenthood. Further research is needed for health care providers to engage productively with all families in meeting their lactation goals.

Footnotes

Acknowledgments

We thank the patient described in this case, for her willingness to share her experience for the benefit of clinicians and the community at large. We also thank Amy K. Weimer, MD, for her guidance and expertise on inducing lactation in transgender women.

Authors' Contributions

D.D. contributed to conceptualization and writing—original draft, methodology, and data curation. L.S., S.M., and L.B. were involved in data curation, formal analysis, and writing—review and editing. K.S. was in charge of data curation and formal analysis.

Disclosure Statement

The author was the treating physician for the patient in this case study.

Funding Information

No funding was received for this article.

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