Hormone Theraphy for MTF

Hormone therapy is a corner stone for medical transition. For many (but not all) trans people, hormone therapy is all they choose to do.

Terminology notes: In the medical literature, hormone therapy is often referred to as “cross-sex hormone therapy”. In the community I’ve seen it more often called HRT for short (and I’ve often called it that too). It’s important to note that trans hormone therapy may be different from the “hormone replacement therapy” used in cis men and cis women.

Which specific hormones get used depend on one’s health, age, and money. Some physicians choose to do a slow ramp up on dosage. Others do not. Your mileage will vary.
Hormones for adult trans women/people assigned male at birth

The modern classic hormone regime includes an estrogen and an anti-androgen. Why the anti-androgen? Well testosterone is very, very powerful stuff, far more powerful than estrogen. To overcome the effects of testosterone you’d need a very large dose of estrogen. We don’t want to do large doses of estrogen because of negative side effects and associated health risks. So both an estrogen and an anti-androgen are used.


Which Estrogen?

There are three common choices: orally/sublingually, intramuscular, and transdermal. Oral/sublingual is the most common and cheapest. These forms are also used for hormone replacement therapy for cis women.

Orally/Sublingually: The current estrogen of choice is 17β-estradiol. It comes as a pill which can be either swallowed or dissolved under the tongue. Common wisdom says under the tongue (sublingual) is safer for the liver, but that’s not a certainty. To my knowledge this is the cheapest form. Dosage is usually 1-4mg twice a day.

Intramuscular (e.g., estradiol valerate): Delivered as an injection that goes deep into muscle tissue (usually the thigh). Requires injection training, and you probably should carry paperwork if you’re traveling with injection supplies. Some people say they transition faster on injection, but I haven’t seen evidence supporting that. Dosing can be done weekly or biweekly. Women sometimes report that they start to feel moody or irritable towards the end of their injection cycle.

Transdermal (through the skin): Estrogen patches. Expensive if you don’t have insurance! But generally considered lowest risk, and provide the most consistent blood estrogen level. Patches are applied twice a week. Different brands of patch are different sizes and ability to stick to skin.

Other options may be available. I’ve seen estrogen sprays and creams advertised, but don’t know that they’re in use for trans care.

There are forms of estrogen which should not be used for transition. Premarin was originally used, but is currently not recommended because it’s high risk. Ethinyl estradiol, commonly found in birth control pills, is also higher risk than the estrogens listed above.

What health conditions may affect whether I can take estrogen or not?

The big ones are previous history of deep vein thrombosis (a kind of blood clot) and estrogen-sensitive cancers because they can be fatal. Tobacco smoking is a big No-No since it increases your risk for deep vein thrombosis. Other conditions which could be factors include high cholesterol or hypertriglyceridemia (high triglycerides), migraines and diabetes type 2. These other conditions may need to be controlled with medications or lifestyle changes before estrogen can be safely prescribed.

Which anti-androgen?

In the United States the anti-androgen of choice is spironolactone. This drug was used for many many years as a diuretic/antihypertensive for people in heart failure so it’s safety is very well established. It also happens to act as an anti-androgen and can feminize some on its own. Doses can be as high as 200-300mg per day, but high doses tend to have more side effects without more benefits.

The big side effect that people note about spironolactone is that it… well… it’s a diuretic. So lots of trips to the bathroom, lots of peeing. But as always, your mileage will vary.

Outside of the United States the anti-androgen of choice is cyproterone acetate. I can’t speak to it since I’ve never seen it myself. Let me know if you can!

What health conditions may affect whether I can take spironolactone or not?

A history of hyperkalemia is the big thing. Hyperkalemia means too much potassium in the blood, and can be life-threatening. Spironolactone likes to “hold on” to potassium, so blood tests are important to screen for hyperkalemia. You may need to avoid high-potassium foods like bananas, or you may not. It depends on how your body handles it all.

Other drugs that are used?

Finasteride is an anti-androgen used to slow/stop a receding hair line. Specifically, it blocks the conversion of testosterone to its more active form, dihydrotestosterone. Some trans women and trans men use it for receding hair line. Other trans women use it when other anti-androgens can’t be used for health reasons.

Progesterone is another drug which is sometimes used. Progesterone is another sex hormone found in high levels in female bodies. Its use in medical transition is currently debated. Some people use it for mood, libido, or breast development. Research supporting these claims is scarce, and progesterone comes with health risks.

Viagra is sometimes prescribed when there are significant erectile problems.

What are the major physical/emotional effects of HRT?

Breast growth, fat redistribution, decreased libido, (potential) decreased ability to have an erection, testicular shrinkage, skin softening. Facial hair may grow more slowly. HRT also has psychological effects but these are highly variable. Some report greater moodiness and ability to cry, others feel more calm. Spatial abilities may change. Sexuality may also shift – not just who you’re attracted to, but how you’re attracted and what you want to do in the bedroom. HRT can cause infertility, so if you want biological children you should bank sperm or conceive them before starting HRT.

What kind of blood test monitoring am I looking at here?

Your physician will likely want to do regular blood tests every couple of months in the beginning to make sure you’re staying healthy. The big things they’ll likely check include potassium levels (via a “complete metabolic panel” or CMP), lipids including cholesterol and triglycerides, and estrogen/testosterone levels (varies by physician). They’ll also want to check your prolactin level at least once, since HRT carries a risk of a type of growth called a prolactinoma. Other tests may also be done, depending on your health history. Other common tests include a complete blood count (CBC) which can detect anemia, and thyroid tests.

What about breast cancer?!

There’s a lot of fear about breast cancer. There are no large studies of breast cancer in trans women. A few case reports exist, but so far it doesn’t appear that trans women are at high risk for breast cancer. Ask your physician what level of screening is appropriate for you, but UCSF recommends the same level of screening as for cis women: yearly clinical breast exams and mammograms starting at age 50 unless you’re at high risk.

How big are my breasts going to get?

The “rule of thumb” is that you’ll likely be one cup size smaller than your closest women (genetic) relatives. This is by no means accurate, but is a fair place to start. Like all women, it’s a roll of the genetic dice.

What won’t HRT do?

HRT cannot change your bones. Your height will remain the same. Though the fat on top may redistribute, your hip bones and facial bones will stay the same. It cannot change the deepness of your voice, though you can change the way you use that voice. It cannot reverse a receding hair line or remove facial hair. There are surgeries which can help with some of these. Hair can be removed by electrolysis or laser. Facial feminization surgery is an option for women who can afford it. Voice surgery is also an option.

This is taking way too long. I want changes now!

Take a moment and breathe. I wish I could tell you there was a magic bullet here…. but there really isn’t. Consider hormone therapy like a second puberty – it will take years. There is no time deadline for transition, so relax. Take your time.

What if I choose to go off hormones?

You can do that! Some hormone changes are permanent – breast growth is the big one there. So you may need to bind or have breasts surgically removed if you don’t want them to show. As long as you still have testicles, many of the other changes (fat redistribution, softening of skin) reverse.

How will my hormones change after surgery?

Once your testes are removed, you will lose your major source of sex hormones. Anti-androgens are no longer needed, though some women choose to stay on spirolactone at a very low dose. You will likely need to stay on estrogen supplements for the rest of your life. Having no sex hormones is not good for bone health!

What can I do to minimize my risk factors?

Take care of yourself. Don’t use tobacco. Drink alcohol in moderation or not at all. Eat a healthy diet — not a lot of red meat, processed food or fast food but lots of fruits, vegetables and whole grains. Maintain a healthy weight – right in the Goldilocks zone, as it were. Avoid crash diets. Exercise!! Find something that works for you and do it. If that means walking on the treadmill while you play your favorite video game (like me when I started), then do it and have fun. If you have any family risk factors, be sure to tell your physician and ask them if they have any recommendations. And take care of your mental health. See a therapist if you need to. And don’t forget to practice safe sex.

What side effects should I call my doctor about?

In addition to the “usual” stuff, like high fever, chest pains, faintness, or any significant changes, there are certain symptoms you should definitely tell your doctor about. Vision changes, sudden headaches and sharp persistent leg pains should be called in. If you develop a rash or swelling after injecting estrogen, you should also tell your physician because that may be a sign you’re allergic to the oil the estrogen is suspended in.

For safety, read through the prescribing information packets that come with all your medications and familiarize yourself with the complete list of side effects to call your doctor about that’s included. If you lose the packet, the information is available from drugs.com.