For transfeminine people looking to medically transition, feminizing hormone therapy offers a chance to alleviate gender dysphoria in both the mental and physical sense.
Also known as feminizing hormone replacement therapy (HRT), the regime changes one's body through the introduction of hormones such as estrogen and progesterone while reducing the amount of androgen hormones like testosterone. This leads to changes in the body’s secondary sex characteristics like growing breasts and developing softer skin. For some people, feminizing HRT can make their body feel more in line with their mind.
“The course of treatment can vary for many, especially when it comes to feeling at home in one's body,” Dallas Ducar, CEO of Transhealth Northampton and a transgender nurse practitioner, told Them. “Importantly, some individuals may also notice emotional changes or changes in their libido.”
Are you considering feminizing HRT or wondering what effects it could have? Read this guide to answer frequently asked questions about the topic, such as: What is feminizing HRT? Is it for me? What will happen to my body on HRT? How do I take feminizing HRT? Will it cure my depression? And how do I access HRT?
What is feminizing hormone therapy?
There are two major components to feminizing HRT: the hormones themselves and hormone blockers, such as anti-androgens. These drugs work together to stimulate female puberty in your body, which can lead to the development of secondary sex characteristics such as breasts and the redistribution of body fat.
Estradiol is used as the feminizing hormone, as it is a synthetic version of the estrogen produced by human ovaries. Taking it can lead to breast growth, softening of the skin, and fat redistribution. For some transfeminine patients, doctors prescribe progesterone during parts of feminizing hormone therapy to increase breast growth and libido.
Anti-androgens are medications that block testosterone production in the body. They can cause shrinkage of the testicles, decreased libido, and thinning of body hair. There are multiple anti-androgen drugs that can be prescribed during feminizing HRT. The most common anti-androgen is Spironolactone, although Bicaludemide, Finasteride, and Dutasteride have also been known to be used.
Deciding whether or not to go on anti-androgen medications is a personal choice depending on how your medical transition is going.
“You do not necessarily need any medications, it all depends on your goals,” Ducar says. “You can decide to go on anti-androgen medications or not, but it depends on what you want as an outcome.”
How will feminizing hormone therapy affect my body?
The two different parts of feminizing HRT take on different functions during transition.
Estrogen will affect the body by:
- Softening the skin, which may cause it to bruise more easily
- Developing breasts
- Redistributing your fat toward your belly, hips, and legs
- Possibly causing mood swings or anxiety
Anti-androgen medication suppresses the body’s natural testosterone, which can cause:
- Thinning of facial and body hair
- Decrease in muscle mass
- Changes to your libido
- Reduction of penis and testicle size
- A decrease in the number of erections you experience
For transfeminine people on feminizing HRT, talking to your doctor about erectile dysfunction medication such as Viagra or Cialis can help offset a lack of erections when trying to stay sexually active. Such medicine has become much more easily available in recent years.
Feminizing HRT will also not completely eliminate facial hair, so those looking to remove hair from their face or body should consider laser hair removal. Using lasers, clinics can drastically reduce dark, thick hairs on the body. However, electrolysis – a procedure that gets to the roots of the hair – is needed to completely eliminate certain body hair. For people with melanated skin, laser hair removal requires an Nd:YAG laser to penetrate beyond the skin’s pigment.
There are risks associated with virtually every medical treatment, and feminizing HRT is no exception. It's important to note that multiple major medical associations maintain that HRT can be a medically necessary treatment to alleviate gender dysphoria, so the benefits can outweigh these risks.
Some of the possible risks of feminizing HRT include:
- Infertility
- Type 2 diabetes
- High triglycerides in your blood
- Heart disease
- Weight gain
- Stroke
It’s important to note that many of these risks, particularly blood clots, high triglycerides, and cardiovascular disease, are similar to the ones associated with HRT for cisgender people, such as cis women seeking treatment for menopause.
While there has been limited research linking feminizing HRT to higher rates of breast cancer in trans women compared to cis men, a 2019 study found this risk is still lower than that of cis women.
Because there is little long-term research on the bodily effects of feminizing HRT, it’s important to talk to your doctor before and during your treatment. Everyone’s body is different, so the risks vary.
How do I take feminizing hormone therapy?
HRT can be prescribed in different forms depending on your doctor’s advice.
Commonly, patients will begin by taking anti-androgen drugs to reduce testosterone levels before beginning to take estradiol orally, with regular testing to check hormone levels. Estradiol can also be taken transdermally via a patch, lotion, or spray, or via an injection. The precise method used depends on personal preference and on a doctor's guidance.
During the beginning of HRT, you will have follow-ups with a doctor approximately every three months to check hormone levels. Once this has stabilized, the length between visits increases.
People who inject can do so subcutaneously or intramuscularly. Subcutaneous injections are done with smaller needles, into the subcutaneous layer of tissue right under the skin. Intramuscular injections are done with larger needles, straight into the muscles below the skin.
Based on the method of taking estradiol, the frequency in which a patient administers the hormone may slightly vary. People who inject estrogen intramuscularly can do so weekly or bi-weekly, while hormones injected subcutaneously are done weekly because the fatty tissue they are injecting into does not hold onto the hormone for as long. However, at the end of the day, your schedule will depend on advice from your medical practitioner.
Other medications such as anti-androgens and progesterone come in pill form and should be taken regularly based on a schedule prescribed by a medical professional.
According to the Mayo Clinic, the initial effects of HRT should begin within weeks of starting your regimen. However, the full effects of hormone treatment will take over two years to manifest, so some patience is required.
Will HRT cure my depression?
For some trans people, going on HRT is a step in tackling the adverse mental health implications of gender dysphoria. Long-term data on the mental health impacts of HRT access is beginning to emerge, with studies showing that access to gender-affirming care can reduce risks of depression, anxiety, and even suicidal ideation. For those who start HRT as teens instead of waiting until they're adults, research also shows better mental health outcomes, including fewer thoughts of suicide, mental health disorders, and substance abuse disorders.
HRT should not be used as a substitute for any therapy or psychiatric care, but your therapist may suggest undergoing feminizing HRT in addition to whatever treatments you already have in place. Be sure to loop in psychologists and psychiatrists through your process to work together for the most productive outcomes.
Is feminizing hormone therapy for me?
This is a question no one can answer but yourself. Medically transitioning is not a requirement to be trans, as there are no formal requirements. For those questioning their own gender identity and have unanswered concerns about whether or not they are transfeminine, reading guides such as this one can help. Although transness is as old as history itself, the current language we use to describe it is less than 100 years old, so there is so much room to explore your identity, and say who you are. No one can take that away from you. If you say you’re trans, you are, with or without HRT.
If you feel you want to pursue feminizing HRT for your own transition, then it is for you.
“Each individual should reflect on their own goals of treatment and what they really want when considering HRT,” Ducar said about what a patient should do before considering whether to medically transition.
Ducar added that not everyone needs to go on feminizing HRT, and that you should only do so if you feel medically transitioning is that important for your transition goals.
How do I access feminizing hormone therapy? Is HRT covered by insurance?
Getting a prescription for HRT depends on a number of factors. First, it depends on the provider, the provider’s location, and if insurance covers the medication.
Ideally, when searching for HRT, patients will have done research online about the treatment’s effects and have some idea about what they are pursuing. A number of clinics in response have begun operating under the informed consent model.
According to the American Medical Association, informed consent is when “communication between a patient and physician results in the patient’s authorization or agreement to undergo a specific medical intervention.” This means that as long as a doctor provides patients with potential side effects and risks and a patient agrees to treatment, the doctor can provide it.
Many clinicians who do not follow the informed consent model require a referral letter and a formal diagnosis of gender dysphoria to start HRT. For many patients, this can be a time-intensive and prohibitive barrier to affirming care.
The informed consent model grew out of mistrust that transgender people have had for the medical establishment that has minimized their needs in the past, and has grown in recent years. There is no official, centralized database of informed consent clinics, but when researching a clinic that offers gender-affirming care, many websites will list that providers follow this model. If a clinic does not, it is a good idea to call ahead if you want to understand its methods.
Those who are still unable to find a provider in their area, or who are in situations where they have to hide their transition, tend to gravitate towards DIY HRT providers online. Understanding that access to transition-related care could be a life-or-death need, it is important to note that there are some risks of taking HRT without doctor supervision.
Ducar says that it is possible to cause an overdose on HRT, and that you could put yourself at risk for “breast cancer, stroke, blood clots, gallstones, and a range of heart issues” without being properly monitored.
“The most common testosterone-blocker, spironolactone, can cause dehydration and weaken the kidneys,” she added. “All of these are potential risks when not monitored by a provider, or someone trained and with access to a lab.”
Most major private insurers cover feminizing HRT, however, the types of care covered and possible exclusions may vary. As ring-wing lawmakers attack access to gender-affirming care through public insurers like Medicaid, coverage for feminizing HRT may change depending on your state.
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