feminising hormones

oestrogen

what is it & how is it used?

Oestrogen is the main hormone responsible for promoting female characteristics. It works directly on tissues in your body (e.g. makes breasts develop) and indirectly suppresses your testosterone. We often aim for oestradiol levels of 250-600 pmol/L and total testosterone levels of < 2 nmol/L, however, these goals vary from person to person.

oestrogen options

  • Brand: Progynova/Zumenon

    Timing: daily

    Pros: most common, simple to take

    Cons: higher clotting risk than transdermal options

  • Brand: Estradot

    Timing: twice a week

    Pros: not daily application, lower clotting risk

    Cons: potential skin irritation from patch, bad if you sweat a lot

  • Brand: Sandrena gel

    Timing: daily

    Pros: lower clotting risk

    Cons: risk of gel getting onto others

  • Compounded oestradiol is available from certain pharmacies in Australia, but levels vary, and this preparation is not recommended.

  • Subdermal oestradiol implants are fused crystalline hormone pellets prescribed by a doctor that you will need to have manufactured by a compounding chemist. Oestradiol implants can vary from 50-100 mg pellets. Pellets are replaced every 6-24 months, depending on how you respond. The insertion procedure takes approximately 20 minutes.

Transdermal (via the skin) oestrogen is less likely to cause blood clots than oral oestrogen, so for this reason, it is usually recommended for anyone over age 40, a smoker, or otherwise at risk for blood clots. Also, transdermal oestrogen tends not to elevate triglycerides (a type of fat in the blood) as much as oral oestrogen, so it is recommended if you are at risk of a heart attack or stroke.

changes on oestrogen

The purpose of feminising hormone therapy is to bring together the mind and body to lessen gender dysphoria. Every person will experience change to a different extent and at a different rate depending on various factors. This can include your age, the number of hormone receptors in your body, and how responsive your body is to oestrogen. There is no way of knowing how your body will respond to hormones before starting.

Oestrogen affects the entire body. It’s not possible to pick some changes and not others.

    • calmer mood, more emotional range

    • softening of skin

    • decrease in sex drive

    • fewer instances of waking up with an erection or spontaneously having an erection; some trans women also find their erections are less firm during sex or can’t get erect at all

    • decreased ability to make sperm and ejaculatory fluid*

    • decrease in muscle mass and increase in body fat

    • redistribution of body fat to buttocks and hips

    • breast tenderness and swelling

    • breast growth (may take 2-3 years)

    • reduction in size of penis & testicles

    • reduced facial and body hair

    • slowing of male pattern baldness

    • infertility

Breast and nipple growth starts early but is usually gradual – it can take two years or more for breasts to reach their maximum size. As in non-trans women, there is significant variation in how large breasts grow from estrogen. In many trans women, breasts do not grow beyond an A or B cup.

Most of the effects of hormones happen in the first two years. You will usually have a review one month after starting hormones or changing your dose, then every three months in the first year. After dosing is stable, review appointments usually occur every six months.

At appointments in the first two years, your doctor will likely:

  • look at your facial/body hair and, if you shave, ask how quickly your hair grows back

  • ask about changes to your breast development and testicular size

  • ask about changes to your sex drive, erections, or other sexual changes

  • order a blood test to see what your hormone levels are

  • ask how you feel about the changes that have happened thus far

permanent changes

Most of the changes brought on by feminising hormone therapy are not permanent.  If you stop taking the medication, most of the changes will reverse.  The two changes which may be permanent are

1.  Breast growth

  • this can happen even if you are only taking anti-androgens, although, without oestrogen, it is usually minor and reversible

  • oestrogen causes permanent nipple development and breast growth

  • even if you stop taking oestrogen, breast tissue will not go away, and nipples will not shrink

2.  Infertility

  • both anti-androgens and oestrogen affect your production of sperm

  • long-term effects on fertility are not fully understood

  • the ability to make sperm may not come back even if you stop taking the medication

  • it is strongly recommended that you discuss options for sperm banking before starting hormone therapy

risks & side effects

The medical effects and safety of feminising hormones are not fully understood.  There may be long-term risks that are not yet known. Many known risks of hormones can be reduced by creating a hormone combination tailored to you and having periodic blood tests to monitor potentially risky conditions.

smoking

Stopping smoking is the number one thing you can do to reduce your risk of blood clots and heart disease (and also make it possible to increase the amount of oestrogen that can safely be prescribed).

blood clots

Taking oestrogen increases the risk of blood clots. The increase in risk is around 3-4 times your background risk of getting a blood clot, probably in the order of 1%. Blood clots can cause death, permanent lung damage, stroke, heart attack, and chronic leg vein problems.  The risk of blood clots is much higher for smokers, especially those aged 40 or higher.  The danger is so high that some doctors will not prescribe oestrogen if you are a smoker; most will only prescribe a low dose if you are still smoking.  The risk of blood clots may be reduced by taking oestrogen via skin patch, cream or gel (rather than pill/injection) and a lower dose of oestrogen.

body fat

Taking oestrogen changes the way your body metabolises and stores fat.  This can increase fat deposits around your internal organs, which is associated with an increased risk for diabetes and heart disease. Oestrogen is likely to cause some increase in weight. Oestrogen also increases the risk of gallstones, especially at higher doses.  You should see a doctor immediately if you have chest or abdominal pain. 

blood pressure

Oestrogen can cause increased blood pressure. 

nausea & vomiting

Rarely, oestrogen can cause nausea and vomiting. This is similar to morning sickness in pregnant women. This is usually an early side effect that resolves quickly.

headache

Estrogen can also cause headaches or migraines. If you are getting frequent headaches/migraines or the pain is unusually bad, talk to your doctor.

prolactinoma

With breast growth, there is often an increase in milky discharge from the nipples (galactorrhoea).  This is caused by oestrogen stimulating the production of prolactin, which stimulates breast ducts to produce milk.  It is unknown whether this increases the risk of non-cancerous tumours of the pituitary gland (prolactinoma).  Prolactinoma is not life-threatening but can cause vision damage and headaches.  A blood test will show a very high level of prolactin if it is suspected.

breast cancer risk

It is not known how much oestrogen increases the risk of breast cancer in trans people, but the evidence suggests that it causes the same risk as is naturally present in cis women.  There have been cases of trans people who have developed breast cancer after starting hormones.  Risks are increased if you have a family history, have been taking oestrogen and progestagens for more than 5 years, are age 50+, or are overweight.  For this reason, it is recommended that you learn how to do regular self-breast examinations and start having mammograms when directed by your doctor.

anti-androgens

The role of androgen blockers (or anti-androgens) is to suppress the production of testosterone and/or block its effects on the body. Not all people want or need anti-androgens. For some people, oestrogen alone may suppress testosterone adequately. For those wishing to preserve erections, either oestrogen alone or a low-dose anti-androgen can be used.

Cyproterone acetate

Cyproterone is the most commonly prescribed form of androgen blocker in Australia. ‘Cypro’ is not commonly prescribed in the U.S. due to FDA restrictions, but it is a safe and effective androgen blocker. Cyproterone is quite potent, so only small doses are needed to block testosterone. It’s a good option for people who want to cease erections. There is a rare risk of liver inflammation; however, this is usually due to much higher doses.

Spironolactone

The second most commonly prescribed form of androgen blocker in Australia is Spironolactone. ‘Spiro’ is a potassium-sparing diuretic that can cause increased urination, dry mouth and postural dizziness. It is taken twice a day. You can (rarely) have problems with high levels of potassium in the blood (this can cause changes to your heart rhythm and can be life-threatening).  You will need regular checks of your potassium and kidney function while on Spiro.

Anti-androgens are usually prescribed in addition to oestrogen, as the two have complementary effects. They can be prescribed alone for those people who want to reduce masculine characteristics for a more androgynous appearance and avoid feminisation. However, taking blockers without oestrogen for extended periods of time could lead to osteoporosis (low bone density) and other adverse health effects.

changes on anti-androgens

Oestrogen affects the entire body. It’s not possible to pick some changes and not others.

    • decreased testosterone in the body

    • decrease in sex drive

    • fewer instances of waking up with an erection or spontaneously having an erection; some trans women also have difficulty getting an erection even when they are sexually aroused

    • decreased ability to make sperm and ejaculatory fluid

    • slower growth of facial and body hair

    • slowed or stopped balding

    • slight breast growth (reversible in some cases, not in others)

progesterone

There are mixed opinions about using progesterone.  Most trans health programs worldwide don’t recommend it due to the lack of evidence that it adds to feminisation and known side effects (depression, moodiness, weight gain, increased blood fats, blood clot risk). Progesterone is sometimes cited as enhancing breast growth, and many people are keen to try it.  There is no evidence that it does more than make your breasts painful and swollen and is unlikely to make a big difference to breast growth. Many people like to try progesterone, which is a reasonable approach.

what hormones won’t change

hormone therapy won’t solve all body image problems

The point of hormone therapy is to feel more comfortable with your body by bringing your physical characteristics closer to your internal sense of self. This can increase self-esteem and make you feel more confident and attractive. However, the changes may not necessarily meet your expectations. It can be hard to separate gender dysphoria from body image problems, and counselling can help achieve greater self-acceptance.

hormone therapy won’t make you into somebody else

Many people experience positive emotional changes with hormone therapy.  But after the excitement wears off and you’ve incorporated the changes into your daily life, you’ll likely find that your personality remains unchanged.  Whatever you see as your strengths and weaknesses will still be there.  Hopefully, you will be happier and more accepting of yourself, but if you expect all of your problems to disappear, you may be disappointed.

This extends to mental health concerns as well.  People who were depressed because of gender dysphoria may find that taking hormones improves their depression.  However, if you have depression caused by biological factors, the stresses of transphobia, or unresolved personal issues, you may still be depressed after you start hormone therapy.  

hormone therapy won’t provide you with a perfect community

For some trans people, hormone therapy is a ritual affirming that they are who they say they are.  Making physical changes is a way to bring who you are to the rest of the world so that other people can see it.  This process of self-emergence can be very liberating, but it does not guarantee that you will find acceptance or understanding.

When starting hormones, there can be a drive to find other people who have gone through similar experiences.  There are a lot of very cool trans people to talk with about hormones, but having taken hormones doesn’t automatically make trans people welcoming, approachable or sensitive.  Being realistic about the likelihood that you will sometimes feel lonely and alone after you start taking hormones is part of emotionally preparing for hormone therapy.

hormone therapy won’t remove all “male”/”masculine” aspects of your body.

Some physical characteristics aren’t changed by hormone therapy or are only slightly changed.  This includes aspects of your body that developed before birth (penis, sex chromosomes) and physical characteristics that developed from increased testosterone at puberty.

  • Hormone therapy may make facial and body hair grow slower and be less noticeable, but the hair will not completely disappear.  Electrolysis and laser will be necessary for more permanent hair removal.

  • Baldness may slow down or stop, but bald areas will not regrow hair.  Some people use wigs, while others get hair transplants.

  • Hormones do not change voice pitch or speech patterns - speech therapy can help.  

  • Once your bones have stopped growing after puberty, hormones will not change their size or shape.  No treatments will reduce your height or the size of your hands and feet.  Facial feminising surgery (FFS) can be used to change the shape of your skull and facial features, and to reduce a prominent Adam’s apple.

  • Although sperm production is affected by hormones, there may still be a chance that you could make somebody pregnant, so you may need to consider birth control options.

  • Being on hormones does not decrease the risk of sexually acquired infections, including HIV, and condoms should still be worn.  Feminising hormones can make erections less firm, increasing the risk of condom leakage.