What is Feminizing Hormone Therapy?

Feminizing hormone therapy (also referred to as cross-sex hormone therapy), alters your hormone levels to match your gender identity. People who seek feminizing hormone therapy are often experiencing gender dysphoria, which is distress that is caused by a discrepancy between a person’s gender identity and that person’s sex assigned at birth. Feminizing hormone therapy induces physical changes in your body caused by female hormones during puberty (secondary sex characteristics) to promote the matching of your gender identity and your body (gender congruence). To avoid excess risk, the goal is to maintain hormone levels in the normal range for the target gender.

Feminizing hormone therapy can:

  • Make gender dysphoria less severe
  • Reduce psychological and emotional distress
  • Improve psychological and social functioning
  • Improve sexual satisfaction
  • Improve quality of life

What are the Risks?

Because feminizing hormone therapy can adversely affect your fertility and sexual function and cause other health problems, it is important to consult your doctor in order to weigh the risks and benefits.

Complications of feminizing hormone therapy might include:

  • A blood clot in a deep vein (deep vein thrombosis) or in a lung (pulmonary embolism)
  • High triglycerides, a type of fat (lipid) in your blood
  • Gallstones
  • Weight gain
  • Elevated liver function tests
  • Decreased libido
  • Erectile dysfunction
  • Infertility
  • High potassium (hyperkalemia)
  • High blood pressure (hypertension)
  • Type 2 diabetes
  • Cardiovascular disease, when at least two other cardiovascular risk factors are present
  • Excessive prolactin in your blood (hyperprolactinemia) or a condition in which a noncancerous tumor (adenoma) of the pituitary gland in your brain overproduces the hormone prolactin (prolactinoma)

How Do I Prepare?

Prior to commencing feminizing hormone therapy, your doctor will evaluate your health to rule out or address any medical conditions that might affect or contraindicate treatment. The evaluation might include:

  • A review of your personal and family medical history
  • A physical exam, including an assessment of your external reproductive organs
  • Lab tests measuring your lipids, blood sugar, blood count, liver enzymes, electrolytes and the hormone prolactin
  • A review of your immunizations
  • Age- and sex-appropriate screenings
  • Identification and management of tobacco use, drug abuse, alcohol abuse, HIV and other sexually transmitted infections
  • Discussion about sperm freezing (sperm cryopreservation)
  • Discussion about use of potentially harmful treatment approaches, such as unprescribed hormones, industrial-strength silicone injections or self-castration

In addition, you may also need a mental health evaluation by a provider with expertise in transgender health. The evaluation might assess:

  • Your gender identity and dysphoria
  • The impact of your gender identity at work, school, home and social environments, including issues related to discrimination, relationship abuse and minority stress
  • Mood or other mental health concerns
  • Sexual health concerns
  • Risk-taking behaviors, including substance use and use of nonmedical-grade silicone injections or unapproved hormone therapy or supplements
  • Protective factors such as social support from family, friends and peers
  • Your goals, risks and expectations of treatment and your future plans for your care

What Can I Expect During the Procedure?

Typically, during feminizing hormone therapy, you’ll be given medication such as the diuretic spironolactone (Aldactone) to block the action of the hormone testosterone. After six to eight weeks you’ll also be given the hormone estrogen to decrease testosterone production and induce feminine secondary sex characteristics. Changes caused by these medications can be temporary or permanent. Feminizing hormone therapy can be done alone or in combination with feminizing surgery.

Additional therapies might include:

  • Progesterone that’s been reduced to tiny particles (micronized), which might improve breast development
  • Finasteride (Propecia) or topical minoxidil (Rogaine) or both for people prone to male-pattern baldness

What Results Can I Expect?

During your first year of feminizing hormone therapy, it is recommended that you see your doctor approximately every three months for checkups, as well as anytime you make changes to your hormone regimen. Your doctor will:

  • Document your physical changes
  • Monitor your hormone concentration, and use the lowest dose necessary to achieve desired physical effects
  • Monitor changes in your lipids, fasting blood sugar, blood count, liver enzymes and electrolytes that could be caused by hormone therapy
  • Monitor your mental health stability

After feminizing hormone therapy, you will also need routine preventive care, including:

  • Breast cancer screening. This includes monthly breast self-exams and age-appropriate mammography screening after five to 10 years of estrogen therapy.
  • Supplementation. This includes standard calcium and vitamin D supplementation, along with bone density assessment according to the female age-appropriate recommendations.
  • Prostate cancer screening. This should be done according to age-appropriate recommendations. With estrogen treatment, your PSA is expected to decrease by about 50 percent.