Male to Female Hormone Replacement Therapy aka Feminizing hormone therapy brings about changes in your physical body that are otherwise induced by female hormones during puberty. The goal is to match your gender identity and body (gender congruence). Another name for this therapy is cross-sex hormone therapy.
In this article, I’d like to walk you through the process, expectations, long term considerations, risks and the medications that are associated with your transition from that of a male to a female. I understand many people want to see rapid changes in their hormonal transformation, but it’s very important to keep in mind that the rate and extent to which the changes will occur in your body will depend on several factors like your age when you started the hormone replacement therapy, genetics and your health.
During the therapy, you will be given medication which will stop the action of the hormone testosterone. Additionally, you will also take hormone estrogen which will decrease the production of testosterone and induce the characteristics of feminine secondary sex. These changes can either be permanent or temporary, and you can either undergo the feminizing hormone therapy alone or along with feminizing surgery.
Why It Is Done
People undergo feminizing hormone therapy to change their hormone levels to match their inner gender identity. Typically these are individuals who are not happy with their gender because of the difference they face between their expressed and experienced gender, and the sex they have been assigned at birth (called gender dysphoria). In order to avoid any high risk, the main goal is to help maintain the level of hormone at a normal range for the target gender.
What Feminizing Hormone Therapy Can Do For You
- Reduce severity of gender dysphoria
- Reduce emotional and psychological distress
- Improve social and psychological functioning
- Improve overall quality of life
- Improve sexual satisfaction
It may be noted that the use of hormones has still not yet been approved by the Food and Drug Administration for treating gender dysphoria, but research shows that it can be effective and safe.
If hormone therapy is used on adolescents, it typically begins after the individual reaches the age of 16 years. The idea is to start the treatment before the individual develops his secondary sex characteristics so that teenagers can undergo puberty as their identified gender. This type of therapy is not used in children.
Not all trans-women can undergo feminization. Your doctor might not recommend feminizing hormone therapy if you:
- Have significant mental health problems
- Have or had hormone-sensitive cancer like prostate cancer
- Have thromboembolic diseases such as pulmonary embolism or deep vein thrombosis
Risks Of Male-To-Female Hormone Replacement Therapy
If you have any concerns or experience any changes in your body, always discuss it with your doctor. There are risks involved with this therapy, and it is very important for you to consider the risks before making the decision to undergo the therapy. Some common risks include:
- Blood clot in the lungs (pulmonary embolism) or in a deep vein (deep vein thrombosis) DVT
- Fat (lipid) in the blood called high triglycerides
- Elevated liver functions
- Weight gain
- Erectile dysfunction
- Decreased libido
- Hypertension (high blood pressure)
- Hyperkalemia (high potassium)
- Diabetes type II
- Cardiovascular risks
- Hyperprolactinemia or prolactinoma (a condition where an adenoma in the pituitary gland overproduces prolactin hormone
There has been no evidence so far on the risk of breast cancer.
Fertility and Hormonal Therapy
There is a very high chance that feminizing hormone therapy might decrease the level of fertility in you. For this reason, it is good to decide whether or not you want to have children in the future before you start the treatment. If you decide to have biological children of your own, discuss with your doctor about sperm cryopreservation (freezing your sperm).
Long-term use of hormones will further increase the risk of permanent infertility, especially if you have been taking the hormones before you hit puberty. There is a high chance that your testicular function might not recover enough to induce conception even after you have discontinued the hormone therapy.
Other estrogen side effects on trans-women include reduced ejaculation, libido and erectile function. You can take oral medications to improve the erectile function such as tadalafil (Cialis, Adcirca) or Sildenafil (Viagra).
How To Prepare for MTF HRT
Before you start the therapy, your doctor will conduct an overall health evaluation on you to address or rule out any medical conditions that might contraindicate or affect the treatment. The evaluation will include:
- Review of your personal medical history as well as that of your family
- Physical examination including that of your reproductive organs
- Lab tests on hormone prolactin, electrolytes, liver enzymes, blood count, blood sugar, and lipids
- Assessment of your immunizations
- Sex and age-appropriate screenings
- Identifying and managing HIV, STDs, alcohol abuse, drug abuse and tobacco use.
- Discussion on sperm cryopreservation (sperm freezing)
- Discussion on potentially harmful treatments such as self-castration, industrial silicone injections and unprescribed hormones
You might also undergo a mental health examination with a transgender health expert. The examination will assess:
- Your dysphoria and gender identity
- The impact of your gender identity in social environments, at home, school and work
- Issues related to relationship abuse, discrimination and stress over minority issue
- Mental health or other mood concerns
- Concerns over sexual health
- Risk-taking behaviors such as use of unapproved supplements or hormone therapy, silicone injections or nonmedical grade silicone injections
Individuals below 18 years of age should be accompanied by parents or guardians when consulting a doctor or mental health providers with specialization in pediatric transgender health to discuss the effects, possible complications and risks of gender transition.
What To Expect
Typically, you will begin the therapy with diuretic spironolactone (Aldactone) at 100 – 200 milligram dose per day. This will suppress testosterone production and block male sex hormone (androgen) receptors.
You will start taking estrogen following 6 – 8 weeks after the Aldactone. This will decrease the production of testosterone and induce the much-anticipated feminization. You can take estrogen through a variety of ways such as in skin preparation like gel, cream, patch or spray, pills, or even through injections.
If you have a family or personal history of venous thrombosis, avoid taking estrogen orally. If you want to take lower doses of estrogen and avoid using spironolactone, you can use gonadotropin-releasing hormone analogs (Gn-RH). However, Gn-RH analogs are costlier.
- Rogaine (topical minoxidil) or Propecia (Finasteride) or both for individuals suffering from male pattern baldness
- Micronized progesterone (reduced to minute particles) to enhance development of breast
Post Male-To-Female Hormone Replacement Therapy
After you start the feminizing hormone therapy, you will begin to see changes in your body in a matter of weeks or months, depending on your body and other factors that are unique to you. This is typically how your timeline might look:
- Decreased libido: One to three months into the treatment, you will notice a decrease in libido. Maximum effect can be seen at three to six months.
- Decreased erections: One to three months into the treatment, you will notice a decrease in spontaneous erections. Maximum effect can be seen at three to six months.
- Reductions in scalp hair loss: One to three months into the treatment, you will notice a decrease in scalp hair loss. Maximum effect can be seen at one to two years.
- Less oily, softer skin: Three to six months into the treatment, your skin will become softer and less oily.
- Testicular atrophy: Three to six months into the treatment, your testicles will begin to emaciate. Maximum effect can be seen at two to three years.
- Breast development: Three to six months into the treatment you will notice breast development. Maximum results can be seen in two to three years.
- Body fat redistribution: Three to six months into the treatment you will notice redistribution of fat in your body. Maximum results can be seen in two to five years.
- Reduction in muscle mass: Three to six months into the treatment you will notice a decrease in the muscle mass. Maximum effects can be seen in one to two years.
- Decreased hair growth in face and body: 6 to 12 months into the treatment, you will notice a decrease in body and facial hair growth. Maximum effects can be seen within three years.
Results of HRT
During the first 12 months of your hormone replacement therapy, you will have to see your doctor for checkups approximately every three months and anytime your hormone regimen changes. Your checkups will consist of:
- Documentation of physical changes
- Assessment of hormone concentration, taking care to achieve the desired results with the lowest dose possible
- Assess changes in your liver enzymes, blood count, blood sugar on fasting, lipids and electrolytes
- Assessment of stability in mental health
After your hormone replacement therapy, you will also require prentice care:
- Prostate Cancer Screening: Screening is done according to age appropriateness. The estrogen treatment will reduce your PSA by 50 per cent.
- Breast Cancer Screening: It consists of breast self-exams every month and age-appropriate mammography after 5-10 years of estrogen therapy.
- Supplementation: Intake of vitamin D and calcium supplementation along with examination of bone density.
How long does it take for male-to-female hormones to take effect?
A: Generally, you will start to notice changes in your body within three to six months. It will take approximately two years to see maximum results, but it varies from individual to individual.
Can I reverse the effects of male-to-female hormone therapy?
A: You can reverse most of the effects if you stop taking the hormones. However, if you have been taking it for years, it could be tricky. Sterility and breast growth cannot be reversed.
Does hormone replacement therapy shorten lives?
A: Hormone replacement therapy will not shorten lives.