Hormone Replacement Therapy for Transgender People: What to Know

In the United States, 1 in every 200 people identifies as transgender. Hormone replacement therapy (HRT) helps people transition their bodies to align with their gender identity.

What is HRT?

Hormone replacement therapy is receiving hormones to change your body to fit your gender identity physically. This can be done as a stand-alone process or as a pre-surgical plan. There are two types of HRT for transgender people. Estrogen is given as a feminizing hormone and testosterone as a masculinizing hormone.

People who receive HRT to help them transition often report an improved quality of life and decreased stress surrounding their appearance. Doctors take several precautionary steps to ensure receiving HRT is safe for you.

Before your treatment begins, your doctor ensures the following:

• You are at least 18 years old.
• Able to make your own informed decisions.
• Performs a thorough exam.
• Collects blood work.

As support for the LGTBQI+ community grows, the progress toward better medical care for individuals will too. While some clinics may require a referral letter before starting hormone therapy, many clinics that now specialize in transgender care will use informed consent. Informed consent is an agreement to sign saying you understand the risks and benefits of the treatment.

People under 18 who wish to receive HRT may receive analogs to suppress puberty until they are of age to receive HRT. For many transgender people, HRT is important for transitioning and developing traits to make them comfortable with their gender identity. Fortunately, many people who start hormone treatment early when transitioning are shown to have improved mental health.

HRT for transgender women

Treatments for males transitioning to females (MTF) use testosterone blockers and estrogen hormones. Goals for estrogen treatment in transgender women is to decrease their testosterone levels to 30-100 ng/dl and increase their estradiol levels to <200 pg/ml by receiving estrogen and anti-androgen.

Treatment includes an anti-androgen (testosterone blocker) such as spironolactone, Cyproterone acetate, or gonadotropin-releasing hormone antagonists (GnRH).

Estrogen treatment can include oral estrogen, intramuscular estrogen (injection in the muscle), or transdermal (on the skin) estrogen. Dosages may vary depending on the route and hormone levels in your blood.

During treatment for transfeminine patients, expect to be seen by your doctor every three months for the first year, then every 6 to 12 months after that to assess how your treatment is going. During these check-ups, your doctor will also monitor your testosterone levels, prolactin levels, and other blood levels. For people with prostates, prostate check-ups for cancer should be screened appropriately.

While undergoing treatment with female hormones, your body will undergo several changes:

Some people may notice changes right away, and physicians may suggest waiting before receiving surgeries to see what needs to be changed. However, it is important to note that these changes can take years to develop and vary from person to person.

HRT for transgender men

Treatments for females transitioning to males (FTM) include testosterone medication. The goal of testosterone treatment for transmasculine patients is to increase their testosterone levels to a range of 300-1000 ng/dl.

Testosterone treatments can be injected or transdermal. Injections can be made either intramuscularly or subcutaneously (under the skin).

Depending on the route, the dosing can be 50-200mg per week, 100-200 mg every two weeks, or 1000 mg every 12 weeks.

Transdermal treatment can be administered as a 1% gel or a testosterone patch. The gel releases 2.5-10 g daily, and the patch 2.5-7.5 mg daily.

The type of treatment depends on your hormone levels and tolerance levels to get you to the desired outcome. The doctors will monitor you closely and regularly during treatment to ensure safety.

During your appointments, the doctor will want to see you every three months for the first year, then every 6-12 months. They will check the progression of your testosterone levels, the adverse effects you may be experiencing, and other blood levels. For patients that have breasts and cervixes, these body parts will also be screened appropriately.

While undergoing treatment with male hormones, your body will go through several changes, including:

Some people may notice changes right away, and physicians may suggest waiting before receiving surgeries to see what needs to be changed. However, it is important to note that these changes can take years to develop and vary from person to person.

Risks of receiving HRT

As with most medications, there are side effects and risks to receiving HRT. New studies have shown that HRT increases people's risk of heart attacks, strokes, and cardiovascular disease. Different treatments present different risks, including:

Risks of testosterone treatment:

• High red blood cell count.
• Excess of acne.

Risks of estrogen and spironolactone treatment:

• Blood clots.
• Stroke.
• Dehydration.
• Elevated potassium levels.
• Excess urination.

Smoking further increases the risk of blood clots and stroke while taking estrogen treatment and should be stopped before receiving HRT.

Are there emotional changes with HRT?

Emotional changes should be expected when introducing hormones, such as during HRT, into the body. These dynamic shifts can present in many ways, including changes in feelings, interests, and sexuality. Hormone replacement therapy can be a long journey and sometimes may feel overwhelming. During these changes, it is essential to make sure you have a sound support system or a therapist to speak to who knows what you are going through. If you are feeling any changes in your mood, make sure to talk with your physician about it.

Emotional changes can include:

• Depression.
• Anxiety.
• Mood changes and fluctuations.

Does HRT cause fertility changes?

While receiving HRT —and even after — it may still be possible to get pregnant or to impregnate someone. Depending on your sexual activity preferences, you may still need to use birth control to prevent pregnancy. However, hormone replacement therapy lessens the chances of becoming pregnant or impregnating someone else. Even after you think you have stopped producing sperm or eggs, pregnancy may still be possible. If you and your partner are looking to have children in the future, it is possible to save eggs and sperm with specialty clinics.