For people born with testes who want hormonal treatment for trans feminine or non-binary gender affirming care, estrogen (estradiol) has been the work horse with or without medication that blocks testosterone (anti-androgens). Adding progesterone to the mix has not commonly been done. However, if we think about what ovaries make, we know that ovaries make both estrogen and progesterone.
Huh, where did the progesterone go in gender affirming care?
Ovaries and bodies with ovaries make 3 highly functional forms of estrogen (E1, E2, E3) and 10-15 minor forms of estrogen. They also make 1 highly functional form of progesterone (P4) and about 9 minor forms.
So why don’t we use more progesterone?
There was a study, called the Women’s Health Initiative, in the 90s that raised some concerns that progesterone in post menopausal cis woman increased the rates of cardiac events, strokes, pulmonary emboli, and invasive breast cancers. Bad news bears!
EXCEPT!
The study used a totally different form of progesterone and was done in a totally different population.
Furthermore, while the increases were clinically significant, they were minor numbers over all and did NOT effect overall rates of death amongst the study groups. While extrapolation of this data to trans woman is questionable at best, this data scared providers off of prescribing progesterone.
Where we are now with progesterone:
Where we are with lots of gender affirming care:
- we don’t have a lot of research in transgender people
- we extrapolate data from studies using cis people, and
- we utilize expert opinion and our understanding of pathophysiology to make our best educated guesses.
I know!
I want more science too.
We do know that having enough progesterone during a cis woman’s menstruating years reduces her risk of cardiovascular disease, osteoporosis, and breast cancer later on in life.
We do know that estrogen and progesterone work hand in hand and some times in opposition to bring about these health benefits.
We do know that progesterone is needed for the later stages of breast development in cis woman (Tanner 4-5).
We do know that progesterone has significant mood effects.
For trans women or trans femme people, we think progesterone may:
- bring about more rapid feminization
- help create larger, more developed breasts
- reduce testosterone production
- improve bone health
- improve cardiovascular health
- improve sleep and hot flashes
Some risks may include:
- may cause some mood symptoms
- may causes liver, cardiovascular, and cancer risk increase
- (weird right, but we just don’t have great science here)
- We know that it is protective against these things in people with ovaries (i.e., people with ovaries with less progesterone throughout their life have higher rates of cardiovascular disease and breast/ovarian cancer)
- We know that SYNTHETIC progestins caused increases in strokes, heart problems, and blood clots
- BUT micronized progesterone, which is BIOIDENTICAL, does not seem to have these effects
This is why we AVOID SYNTHETIC PROGESTERONE
At QueerDoc, we aim to INDIVIDUALIZE your gender affirming treatments to your gender expression goals, so we might not recommend progesterone for everyone, but we do talk about it as one of the potential treatments for all of our trans feminine / non-binary femme patients.
THERE IS NO ONE WAY TO BE TRANS. THERE IS NO ONE WAY TO BE A WOMAN OR TO BE FEMME.
Progesterone may or may fit with your goals. That being said, ovaries make estrogen and progesterone, so why wouldn’t we prescribe you both if your gender identity and gender expression goals are congruent with the things that ovaries make happen????
Check out our Progesterone Handout for further reading or book now to learn more about how QueerDoc works!
