All The E
Information on Gender Affirming Care with Estrogen, Progesterone, and T-Blockers
When you are considering taking gender affirming medicines, it is important to learn about some of the risks, expectations, long-term considerations, and medications associated with the transition from a testosterone predominant hormonal milieu to an estrogen and progesterone predominant hormonal milieu. Please read the following estrogen information to learn more, and/or watch the video. Also, this is just a general overview of possible changes: there is no one way to be trans!
It is very important to remember that everyone is different and that the extent and rate at which your changes take place while taking estrogen or other hormones depend on many factors. These factors include your genetics, the age at which you start taking hormones, and your overall state of health.
It is also important to remember that because everyone is different, your medicines or dosages may vary widely from those of your friends or what you may have read in books or online. Many people are eager for changes to take place rapidly. Please remember that you are going through a second puberty, and puberty normally takes several years for the full effects to be seen. Taking higher doses of hormones will not necessarily make things move more quickly — it may, however, endanger your health.
Effects of gender affirming medical care with estrogen
1) Physical Changes
Skin
The first changes you will probably notice are that your skin will become a bit drier and thinner. Your pores will become smaller, and there will be less oil production. You may become more prone to bruising or cuts. You may notice that you perceive pain or temperature differently or that things just “feel different” when you touch them. You will probably notice skin changes within a few weeks. In these first few weeks, you will notice that the odors of your sweat and urine change and that you may sweat less overall.
Breasts:
You will also notice small “buds” developing beneath your nipples within a few weeks of starting your estrogen treatment. These may be slightly painful (especially to the touch) and uneven between the right and left sides. This is normal and is the expected course of breast development. The pain will diminish somewhat over the next several months. Breast development is quite variable from person to person. Not everyone develops at the same rate, and most transfeminine people can expect to develop breasts based on their pre-existing genetics and duration of exposure to testosterone. Like the breasts of cis women, the breasts of transfeminine people vary in shape and size and are sometimes different sizes or shapes between the right and the left.
Weight:
Weight will begin to redistribute around your body. Fat will begin to collect around your hips and thighs, and the fat under your skin throughout your body will become a bit thicker, giving your arms and legs less muscle definition and a smoother appearance. Hormones will not have a significant effect on the fat in your abdomen. Your muscle mass will decrease, as will your strength (though you should continue to exercise to maintain your muscle tone and general health). Depending on your diet, lifestyle, genetics, and starting weight and muscle mass, you may gain or lose weight once you begin gender affirming treatment (GAT).
The fat under the skin in your face will increase and shift around to give your eyes and face a softer, fuller appearance. Please note that your bone structure (including your hips, arms, hands, legs, and feet) will not change if you have completed your endogenous (or first) puberty. The facial changes can take up to two years or more to see the final result; it is usually a good idea to wait at least two years after beginning HT before considering any gender affirming surgical facial procedures.
Hair:
The hair you may have on your body, such as your chest, back, and arms, will often decrease in thickness and may grow at a slower rate. However, it usually does not all go away, and most people need electrolysis or laser treatments to help reduce unwanted body hair. Your facial hair may thin and grow a bit slower, but it will rarely go away entirely without electrolysis or laser treatments. If you have had any scalp balding, this should slow or stop, though the amount that will grow back is variable.
2) Emotional Changes
Your overall emotional state may or may not change, and this varies from person to person. Puberty is a roller coaster of emotions, and second puberty during transition is no exception. You may find that you have access to a broader range of emotions or feelings, have different interests, tastes, or pastimes, or behave differently in relationships with other people. While psychotherapy is not for everyone, most people would benefit from a course of supportive psychotherapy while in transition to help explore these new thoughts and feelings and get to know their new selves. Most studies show a significant improvement in overall well-being after gender affirming hormone therapy begins. This is most likely due to the improved alignment of the physical body with the psychological gender identity.
3) Sexuality
Soon after beginning hormone treatment, you will notice a decrease in the number of erections that you have. When you do have an erection, it will be less firm and will not last as long. You may lose the ability to penetrate. You will still have erotic sensation and will still be able to orgasm. However, when you do orgasm, it may be “dry.” Sex may feel different. You may find that different sex acts or different parts of your body bring you erotic pleasure. Your orgasms will feel different, possibly with more of a “whole body” experience, less peak intensity, and longer duration. It is recommended that you explore and experiment with your new sexuality through masturbation, using sex toys such as dildos or vibrators, and involve your sexual partner(s).
Your testicles will shrink to less than half their original size or less. In nearly all cases, this does not affect the amount of scrotal skin available for future genital surgery, if that is desired.
4) Reproduction/ Fertility
You must assume that you will become permanently and irreversibly sterile within a few months of beginning hormone therapy. While some people may be able to maintain a sperm count on hormone therapy or have their sperm count return after stopping hormone therapy, you must assume that this will not be the case for you. If you think that there might be any chance that you may want to parent a child using your own sperm in the future, you should speak to the doctor about preserving your sperm in a sperm bank. This process generally takes 2-4 weeks and is rarely covered by health insurance. You should store your sperm before beginning any hormone therapy. All that said, many people stop hormones and go on to make biological children. However, there is just no way to know if you would be able to do that.
Additionally, even if you are on hormones, if you are having penetrative vaginal sex with a person who is able to become pregnant, you should always continue to use a birth control method to prevent unwanted pregnancy.
5) Medications used in Hormone Therapy
Hormone therapy for transfeminine people may include three main kinds of medicines: estrogen, testosterone blockers, and progesterone. SERMs are a fourth kind of medicine, which we discuss here.
Estrogen:
Estradiol is the hormone responsible for making bodies softer and curvier. It causes the physical changes of transition and many of the emotional changes. Estrogen is available in many forms: pills, injections, and preparations applied to the skin, including creams, gels, sprays, and patches.
Pills are convenient, cheap, and effective, but they are less safe after age 35 or if you smoke. Oral estradiol is more likely to cause blood clots. Generally, it is preferable to let the pill dissolve under your tongue (sublingual) rather than swallowing, to avoid metabolism through your liver.
Patches can be very effective and safe, but they may irritate your skin. Creams, sprays, and gels are effective and safe and absorb quickly into your skin. These are more expensive and generally not covered by most insurance plans.
Topical compounded estradiol cream is not covered by insurance. It costs approximately $25/month.
Estrogen-Related Health Risks:
Risks associated with estrogen include high blood pressure, blood clots, liver problems, stroke, and perhaps diabetes. There are not many long-term studies on the use of estrogen in transfeminine people, so there are potentially unknown risks, too. We may learn more about risks or side effects, particularly for long-term use of estrogen in the future. Contrary to what many may believe, only a very small amount of estrogen is needed to achieve the maximum effect. Taking very high doses of estrogen does not make changes happen more quickly, and it can be dangerous and harmful to your health.
There is not much scientific evidence about cancer risks in transfeminine people. We believe that your risk of prostate cancer will go down, but we are not sure, and therefore you will still need to be tested for that cancer when appropriate.
Your risk of breast cancer may increase slightly, although it will still be less than in a cis woman. Breast cancer screening with mammograms is recommended to begin between the ages of 40 and 50 for people who have been on hormones for more than three years.
If you have an orchiectomy (removing the testicles), your estrogen dose can be lowered. After testicle removal, you usually need much less estrogen to maintain your softer, curvier characteristics.
Estrogen can strain your liver and cause damage. Your doctor will periodically check your liver function, cholesterol levels, and blood sugar level (diabetes testing) to monitor your health while on estrogen therapy.
Testosterone blockers:
There are multiple options for testosterone blockers. Testosterone blockers (also known as anti-androgens) work in two main ways:
- By stopping your cells from using testosterone
- By preventing testosterone production in your body.
Most testosterone blockers are very safe. The three most commonly used in the United States are spironolactone, finasteride, and bicalutamide. To learn more about testosterone blocking medications, please see our article How do you know which T blocker to take?
Progesterone:
Progesterone is a source of constant debate among both transfeminine people and providers. Progesterone has multiple reported benefits: improved mood, sleep, and energy, more libido, better breast development, or better body fat redistribution and “curves.” There is very little scientific evidence to support these claims. However, some transfeminine people prefer to take progesterone and have seen some of these benefits. Your risk of blood clots, stroke, or cancer is lower when taking a natural form of progesterone than when taking a synthesized form but may be increased compared to not taking progesterone. There simply is not enough research in this area to predict your risk accurately. Progesterone is available in pill or cream form.
***Reversibility:
Many of the effects of hormone therapy are reversible if you stop taking them: how reversible depends on your length of treatment. Breast growth — and possibly sterility — are not reversible. If you have an orchiectomy (which is the removal of the testicles) or genital reassignment surgery, you will probably be able to take a lower dose of hormones and may not need testosterone blockers. However, hormones should continue to be taken, even at a low dose, after surgery until at least age 50 to protect your bones. Staying on hormones helps prevent osteoporosis, which is the weakening of the bones.
The usual blood test schedule is approximately every 3 months for 1 year, then every 6 months for 1 year, then yearly.
Taking more hormones will not make your changes progress more quickly and can be unsafe. Patience is vital. Remember that body changes in puberty take years to happen fully. It’s just as true for second puberty as it is for first puberty.
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