Transgender Hormone Replacement Therapy – HRT Guide 101 (Oestrogen & Testosterone)
What are hormones?
There are many different hormones produced in the body by a system of glands. These release hormones directly into the bloodstream so that they are carried all round the body. Among these are the sex hormones: the male hormone, testosterone, produced by the testes; and the female hormone, oestrogen, produced by the ovaries.
Men also have a small amount of female hormone because some testosterone is converted into oestrogen. In both men and women, the adrenal glands, which sit on top of the kidneys, produce small quantities of testosterone. So all men and women naturally produce both testosterone and oestrogen.
What effects do naturally produced hormones have?
Broadly speaking, testosterone has masculinising effects, and oestrogen has feminising effects.
Along with genetic factors, sex hormones affect the development of the reproductive system, the brain and physical characteristics such as height and build, the way fat is distributed in your body and your muscle bulk.
Before birth, in boys, a strong form of testosterone prompts the development of the penis and testicles. Without this input of testosterone, girls develop the clitoris and labia, ovaries, uterus and vagina.
At puberty, sex hormones prompt the development of what we call ‘secondary’ sex characteristics. In girls these include breasts, periods, a more rounded shape, underarm hair and an inverted triangle of pubic hair; in boys they include facial and body hair, a prominent Adam’s apple, a deepening of the voice, an enlargement of the penis and testicles, erections, a diamond shape of pubic hair and increased height and muscle bulk.
Throughout life, sex hormones help to support the reproductive systems and general health and wellbeing. As we get older, hormones naturally diminish.
What is the aim of hormone therapy for trans people?
The aim of hormone therapy is to make you feel more at ease with yourself, both physically and psychologically.
You may be experiencing discomfort because you are not happy with your male or female appearance; or maybe you are not comfortable in your gender role as a man or as a woman. Perhaps both these factors – your appearance and your gender role – are in conflict with your inner sense of being a man or a women (your gender identity).
You may have lived with this conflict for many years and be desperate to get some help.
If this is how you are feeling, hormone treatment (testosterone if you are a trans man, and oestrogen if you are a trans woman) may help to overcome your distress. This kind of treatment is sometimes referred to as ‘cross-sex’ hormone therapy.
In addition, to testosterone or oestrogen, hormone ‘blockers’ may be taken in the early stages of treatment to interrupt the hormone production of your own body, so that the prescribed hormones can be more effective.
Hormone therapy is usually the first treatment that trans people want to have and, for some, it may be the only treatment they need. Some people find that they get sufficient relief from taking hormones so that they do not need to change their gender role or have surgery.
What physical effects will hormone treatment have on me?
If you are a trans woman, cross-sex hormones will be helpful in making your appearance more feminine; if you are a trans man they will make your appearance more masculine. However, whether you are a trans man or a trans woman, you will need to be realistic about the extent of the changes you can expect. Although hormones taken in adulthood can help to keep your bones healthy, they cannot alter your skeletal shape or your height.
In trans women, oestrogen has subtle feminising effects:
• Fat may be distributed on the hips.
• The size of the penis and testicles may be slightly reduced.
• Some trans women find that erections and orgasm are harder to achieve.
• Muscle bulk and power may be reduced.
• Breasts may feel tender and lumpy and may sometimes increase modestly in size.
• The growth of facial and body hair may become weaker. This is regarded by many trans women as helpful in supporting the hair removal process using electrolysis and/or laser treatment and other hair removal techniques.
• Male pattern baldness may be slowed or stopped, but is not necessarily reversed.
It should be noted that for trans women there is no noticeable effects on voice feminization with hormone treatment; for most trans women it is often recommended that you seek vocal coaching for a more passable feminine voice.
In trans men, testosterone may cause the following effects:
• It promotes beard and body hair growth.
• Male pattern baldness may develop.
• The clitoris increases slightly in size.
• Libido may be heightened.
• Muscle bulk increases.
• The voice deepens, but not usually to the pitch of other men.
• Periods will stop, although there may be some breakthrough bleeding requiring adjustment of dosage.
• Some individuals develop acne.
The way you respond to hormone treatment will help you and your doctor decide if it is right for you. If the effects are unhelpful or even unpleasant, this could indicate that this treatment is not right for you.
You can stop taking hormones at any time.
On the other hand, if you start to feel better, psychologically and physically, this is a good sign that continuing with hormone therapy will benefit you, and that your treatment is on the right track. You and your doctor will still need to be sure about this because further treatment will cause some or all of the physical changes mentioned above. Some of these begin to happen after a few months and may be irreversible, such as the deepening of the voice in trans men and breast growth in trans women. However, most changes are slow to develop.
In fact, trans people sometimes feel frustrated by the slow pace of change brought about by hormone treatment. Remember that, as with puberty, physical changes are spread over a few years, so high doses of hormones do not necessarily produce better or quicker results. For instance, the adult breast shape of non-trans women is only achieved after several years of exposure to oestrogen during puberty, and they have very different breast sizes. It is similar for trans women, some of whom will never develop anything more than very small breasts.
If you are a trans man, you may actually find that taking excessive testosterone is counter productive, since the body’s natural mechanisms may convert some of the testosterone to oestrogen.
Teenage trans people
If you are a teenage trans person, you may feel a strong sense of conflict between appearance and gender identity during puberty when your body is developing into an adult shape. Hormone blockers can help at this time by temporarily suppressing the more obvious changes to your body. This provides a breathing space for you to decide how you want to live as an adult.
Will I always have to take hormones?
Yes, you will need to take hormones for the rest of your life if you want to maintain the feminising effects of oestrogen or the masculinising effects of testosterone.
If, at any stage, you decide to have your testes (trans women) or your ovaries (trans men) removed by surgery:
• Your dose of hormones will usually be reduced but it should still be enough to produce the effects that you need and to keep you well, and to protect you against osteoporosis (thinning of the bones) as you get older, and
• If you are still on hormone blockers, you will stop taking them altogether.
What are the risks of hormone treatment?
Ideally, medical treatment should be based on scientific evidence, but there is little research about the use of cross-sex hormones. Guidance is therefore provided, which may be used flexibly, taking account of your particular needs and keeping the risk to your health as low as possible.
Hormone treatment for trans people at reasonable dosages is remarkably safe. The hormone products that you will be prescribed are very like the natural hormones produced by the body. Most people taking hormones do not experience any major problems.
However, all medication has potential side effects, and some people may have serious adverse reactions to it. You need to be aware of the possible risks, however remote, before deciding to start treatment.
The most serious risks when taking oestrogens are:
• Deep vein thrombosis (DVT)
• Pulmonary embolism (block in a blood vessel in the lungs)
• Altered liver function.
The most serious risk when taking testosterone is:
Polycythaemia (over-production of red blood cells).
The risk of developing complications from hormone treatment is relatively small and is less common if your general health is good.
Thrombosis in trans women is more likely to occur within the first year of treatment, particularly if you are taking a hormone called ethinylestradiol.
There are far fewer risks of thrombosis with oestradiol, which is the product most widely prescribed for trans women now.
The way you take the hormones can also make a difference to how your body reacts. Those who may be more at risk, for example those over 40 years old, may be advised to use hormone patches so that the medication is absorbed through the skin. Compared with pills, gel or injections, hormone patches provide a more gradual release of hormones into the bloodstream, which the body is able to tolerate more easily.
Why do I need to be monitored?
Monitoring your health will help your doctor to ensure that your body is absorbing the medication. It can also help your doctor to identify any health problems early so that, if necessary, your hormone treatment can be adjusted and/or additional medication may be prescribed.
It is very important that you give full details to your doctor of any history you and/or your family have of breast cancer or circulatory or liver disorders. This does not mean that you cannot have hormone therapy, but your doctor will be able to advise you on the available treatment options, and the follow-up monitoring, to suit your particular needs.
A healthy lifestyle is important. You should eat sensibly and take regular exercise. Drug taking, excessive alcohol consumption and obesity are all factors that can undermine your hormone treatment and heighten the risk of complications, which may affect your chances of having surgery. Smoking, in particular, is a significantly greater risk to you than hormone treatment. In addition, if you are a trans woman and you are taking oestrogen, smoking reduces its feminising effects.
Your doctor should give you advice about how to address other health concerns and may give you information about support groups.If you are on medication for other conditions, for instance antiretroviral drugs for HIV, you need to tell your doctor. However, being HIV positive is not a reason for you to be refused hormone treatment. Monitoring of your blood pressure, regular blood tests and, possibly, scans of your bones, breasts and pelvis may be undertaken, usually by your GP.
It is important for you to understand that e with regular monitoring, you may still experience adverse side effects. If, at any time, you experience chest pain or breathlessness, discomfort in the calf or unusually frequent and/or severe headaches, you should seek urgent medical help.
Will I need to stop taking hormones before surgery?
Major surgery always involves a level of risk. When you are thinking about having surgery, you may wish to discuss with your own doctor the benefits of coming off hormones for a few weeks.
To minimise the risk of blood clots forming, it is recommended that trans women stop taking oestrogen for four to six weeks before any operation. There is no absolutely safe length of time, and surgeons and anaesthetists may have different views on how long to stop for. They will take into account your general health and whether or not you smoke or are overweight.
You may start your treatment again a couple of weeks after surgery as long as you are up and about, unless your surgeon advises you otherwise. During the time that you are not taking oestrogen in the lead-up to your operation, you may want to start (or continue) to take hormone-blocking medication to suppress testosterone, to discourage any facial hair from growing back.
Trans men are not always required to stop taking hormones before surgery. However, testosterone may make you more likely to bleed, so you will need to be guided by your surgeon and anaesthetist.
Both trans men and trans women may have blood tests before surgery to check their general health and to note any tendency to form clots or to bleed.
Trans women: Feminising medication (Oestrogen)
• Oestradiol-based formulations are naturally occurring oestrogen
• Oestradiol patches (best for those over 40, smokers or those with circulatory problems; least risk)
• Oestradiol gel (applied to skin; also low risk)
• Oestradiol/oestradiol valerate (taken in pill form; some risk)
• Conjugated equine oestrogen (from mares’ urine; taken in pill form; more risk. Some people regard the method of collection from horses as unethical)
• Ethinylestradiol (not recommended; taken in pill form; most risk of side effects)
Medication to reduce testosterone effects:
This treatment will not be necessary in all cases. All these products are effective and each will be suitable for some service users.
• Cyproterone acetate is preferred by some service users because it is in pill form and is therefore easily administered. It works by blocking testosterone receptors, and it is effective against androgen (testosterone) produced by the adrenal glands, as well as that produced by the testes. Heavy alcohol use reduces its effectiveness.
• Spironolactone (taken in pill form) is a well-tolerated and effective anti-androgen.
• Goserelin or leuprorelin is administered by subcutaneous (under the skin) depot injection. It is preferred by some doctors because it is believed to have fewer side effects. It does not block testosterone produced by the adrenal glands, but this is not essential.
• Finasteride (taken in pill form) reduces the effect of male hormones and promotes a modest regrowth of hair on the head if the hair follicles have not been inactive for too long. It is not possible to reverse significant hair loss.
• Progesterone is not usually prescribed for this condition. It increases the risk of thrombosis and other side effects. Although it can reduce the effect of testosterone if taken in high doses, it can also, paradoxically, inhibit the action of oestrogen and may therefore have anti-feminising effects, such as increasing libido and causing facial hair regrowth.
Trans men: Masculinising medication (Testosterone)
Testosterone is usually administered by way of intramuscular or subcutaneous injection every two to three weeks. One of the testosterone products delivered in this way is licensed in the UK for use in trans people. Other methods of administering testosterone are now available, so service users have more choice.
These methods include patches and gels (via the skin), and Buccal:
• Testosterone esters (injected)
• Testosterone enanthate (injected; for those with a peanut allergy)
• Testosterone undecanoate (preferably injected; also available in tablet form)
• Testosterone gels (applied to the skin daily)
• Testosterone patches (applied to the skin daily)
• Buccal testosterone (pill held in the mouth between the cheek and the gum until it dissolves and testosterone is absorbed through the mucous membrane).
Medication to lower oestrogen levels:
This medication is not always regarded as necessary because testosterone alone can be very effective for many trans men. Both Goserelin and Leuprorelin may be administered by subcutaneous depot injection. These products do not block the testosterone produced by the adrenal glands and they are believed to have few side effects.
Trans women voice feminization:
There are 7 important steps that are the foundation to creating your passable female voice. Please read our article on voice feminization which gives instruction and detail about the techniques and steps required to help you achieve your feminine voice.
Do not miss our popular article ‘10 Tips to Feel Like a Girl Prior and During Transgender Transition‘, this article has some great advice and tips for beating gender dysphoria whilst going through the seemingly endless process of transgender transition, it’s a good read.
Further Reading: You may wish to take a look at our article which discusses ‘What is Transgender?‘. This article contains an excellent video and references to transgender material and definition of being a transgender individual.