Taking estrogen, whether alone as monotherapy or in combination with an anti-androgen, often makes erections less firm and less frequent. Libido may drop, and genitals may shrink, too. Not everyone wants this. (More on what to expect when starting estrogen is on our All The E page and our Gettin’ Nerdy about Gettin’ Curvy blog.)
We have options for this! We can:
- decrease, stop, or change antiandrogens
- allowing higher testosterone levels in the body by slightly decreasing estrogen
- add a PDE5 inhibitor
- add transdermal testosterone to the genitals or systemic testosterone
- don’t forget to check full medication list for any that effect erectile function
NOTE: QueerCME is geared for a clinical audience. We may be using medical terminology such as
“PRN” (short for the latin phrase “pro re nata” which means “as the need arises” or, “when you need it.”
“Transdermal” – absorbed through the skin (see Transdermal Testosterone: Everything You Need to Know.)
“Endogenous” – means “created by the body” as compared to “exogenous,” which means “added to the body
“PD5E inhibitor“ – medications which help spontaneous erections happen and help erections last longer. These chemicals inhibit an enzyme (PDE5) which causes relaxation of the muscles in blood vessels, which lets blood drain from erectile tissue. If this enzyme is stopped/lowered, those muscles stay, (ahem) stiffer longer, keeping blood in erectile tissues. Examples of PD5E medications are well known: sildenafil (Viagra,) vardenafil (Levitra,) tadalafil (Cialis,) avanafil (Stendra.)
So here’s our QueerCME tiktok on
Erections and Genital Size When Taking Estrogen
(Original tiktok link here.)
Video Transcript
um
so preserving erectile function while taking estrogen therapy or preserving um
or minimizing size loss
the channels can be something patients can be interested in
um this is a question that comes up often
I have a step wise approach to this um
and typically think about them in order of the steps
as they apply to that patient’s individual treatment plan
but the steps don’t have to be linear
typically I can talk through the whole process of patients
and we move through the parts that feel right for them
after they hear the choices um
and options
but first step I usually think about is decreasing or stopping an anti androgen
um or at most changing it
um so finasteride and Lupron tend to have the most effect on erections um
based on research and CIS people and in my clinical experience with trans people
um and then um
Spiro is probably next
and then bicalutamide seems to have the least effect on erections
and so um that tends you I go with that
um and then uh
the next step should be allowing like
permissively let higher levels of testosterone right,
cause stopping the anti androgen isn’t
probably gonna significantly change our testosterone levels um
well Lupron stopping Lupron would but um
if it’s an oral anti antigen um
probably won’t significantly change our testosterone levels right
finasteride, dutasteride, bicalutamide don’t affect testosterone levels
and spirinolactone in the presence of estrogen doesn’t affect them a ton
um
and so slightly decreasing the estrogen dose and allowing
allowing the endogenous system to make a little bit more hormones can help
if someone’s interested in doing that one
not always sometimes
um and then uh
yeah and I’m also thinking about a PDE5 um inhibitor
so like I typically use tadalafil most frequently
um couple reasons
I either use the daily dosing options
you can do like um 2.5 to um 5 mg um daily
uh the research is up to five
I have done up to 10 daily
and someone um
who’s young and always healthy
and are trying to prevent drinkers for a period of time
um but that is not a research based um
and the counseling on risk gets a little murkier
um and then um for PRN use I use as
I like that daily dosing option with tadalafil
um but then I also like PRN use of it a little better than
so in other words just because you have that longer window
um
that PRN use isn’t gonna help reduce shrinkage though
so that that’s just for a erectile function
um support and then um and then I think about um
transdermal testosterone applied directly to the genitals
um or supplemental testosterone just taken systemically
so couple options there
um like to be clear sometimes you’ve asked for topical testosterone
there’s no such thing as topical hormones
hormones are absorbed well through the skin
and get distributed throughout the bloodstream
so um transdermally applied testosterone to the generals
will increase full body exposure to testosterone to some degree um
we too think you know
the application site for hormones
gets a little extra exposure or oomph when we apply them that way right
we see this when we um
um get more body hair at the site of the Androgel application
and people taking testosterone therapy
and so um if you’re gonna do that um
transdermal testosterone – I am typically using a compounded preparation
you don’t wanna use the retail Androgels or generics because they have alcohol
that would feel pretty uncomfortable on the genitals um
so you get a compounded cream usually 10% testosterone compounded cream um
alternatively um
I’ve also just had patients uh
use the intramuscular oil um
rub directly onto the shaft of the general
so just draw up like you know um
0.1 mLs and um
not inject it, just ah
squish it out of the syringe and rub it on the shaft of the genitals um
obviously they’re dosing it when we’re doing it that way
it’s a little more vague and un unknowable
the frankly
compounding pharmacy’s concentrations in their products vary incredibly widely
cause they’re not regulated in the same ways that retail products are
and so it doesn’t necessarily feel like that a difference
um
and then some patients just actually take a little supplemental testosterone um
right so do a systemic injection um
once a week um
yeah and so those are all the options
and um I have patients take
some patients take systemic testosterone who still have testicles
even I’m just cause it feels less um
dysphoria producing
for them to take testosterone and lower their estrogen
and let their body make more of it
um that’s totally fine um
to the steps I use
I feel like there was something else I was thinking when I started this video
hmm
libido right
approaching libido can be a little different than approaching erectile function
and general use
so that’s something to keep in mind
some of these might help
some of them might not
um
and then the other thing obviously I’m looking at is their other medication list
um right
are they on other medications that are affecting erectile function
and is there any chance that they can tape her down on those or come off of them