To Transgender Women Wanting to Take Hormones

By Ms. Juicy Queen Bee

From PHN Issue 46, Spring/Summer 2021

I’ve been on my treatment for over 3 years. Here are some tips:

  1. Wait, don’t rush—let the process take its course.
  2. The doctor is actually doing what you go through on the street, checking your mental health to find out what psychological help you may need and to make sure you are prepared.
  3. Most people think getting on the hormones they’re going to get the result they want ASAP, but it may take some patience, or it may not be exactly the result you want.
  4. When you start taking estrogen, you may find that your mood swings change and your emotional state changes.
  5. The older you start, the higher you are at risk for certain health issues.
  6. If you take certain medications, you may not be able to take hormones until they replace them, or you may need to take the medications differently.

Feminizing hormone therapy: A guide to the medications, body effects, and health risks you should know about
Adapted from Insider Health, reviewed by a medical expert in October 2020
Feminizing hormone therapy can involve taking estrogen and anti-androgen hormones. An anti-androgen is any drug that blocks the production of male sex hormones, mainly testosterone.

“We’re increasing estrogen levels while also decreasing testosterone levels,” says Ravi Iyengar, MD, a doctor at Rush University Medical Center with expertise in transgender medicine.

Ultimately, the target is to lower the patient’s testosterone levels to that of the typical cisgender female range, which is around 30 to 100 ng/dL. The following medications are usually used:

  • Estradiol. This estrogen hormone is taken in a pill, gel, patch, or injectable form. Daily oral doses of estradiol fall around 2 to 4 mg daily, according to a 2019 study, though the dose can increase up to 8 mg. Users take the dose for as long as they want to see feminizing effects in their bodies.
  • Spironolactone. The most commonly used androgen blocker for feminizing hormone therapy, spironolactone is taken orally once or twice a day, at doses of 100 to 200 mg.

How might your body change? What to expect
“In general, hormone therapy is not quick to act. It’s a process, and it does take a couple of years,” Iyengar says. Here is a general timeline and description of the changes you might expect from feminizing hormone therapy:

  • Body fat redistribution. Body fat moves toward the hips, legs, cheeks, and face to create a more feminine fullness.
  • Breast growth. Fat will also appear on the breasts, and you may be able to form an “A” cup or a small “B” cup, though results are highly variable and can 12 differ for everyone. You will also develop mammary and ductal tissue, which is important to note because you will require breast cancer screenings in the future.
  • Hair and skin differences. Your facial or body hair will become finer. Any receding hairlines or balding on top of the head will stop. Your skin will also become softer and less oily.
  • Decreased sperm count. Estrogen drugs and spironolactone can lower sperm count, making it potentially more difficult to produce biological children.

To develop the right treatment plan for you, talk with your doctor about what you’d like to gain from feminizing hormone therapy and your preferred timetable. You can adjust your dosage accordingly.

How should you prepare? Health risks to know
The lower your dose of feminizing hormones, the slower the changes you’ll see in your body. However, this doesn’t necessarily mean that higher doses cause faster changes, and they may even endanger your health.

In fact, high doses of estrogen can increase the risk of blood clots, stroke, and estrogen-related tumors, according to a 2018 study. That’s why blood tests are important before going on feminizing hormone therapy.

“Every person is unique based on their own health factors and their family history,” says Amy Weimer, MD, a primary care physician in transgender care at UCLA Health. “But at the very baseline, we typically check blood count and a liver and kidney panel, then may check tests for cholesterol or diabetes or occasionally hormone levels as well.”

Blood clots are a risk with estrogen therapies, says Joshua Safer, MD, an endocrinologist at the Center for Transgender Medicine and Surgery at Mount Sinai Hospital. However, they’re not common. A 2017 study found that blood clots form within roughly 2 of 1,000 people on feminizing hormone therapy.

Those taking spironolactone must also know their baseline potassium levels. Spironolactone is known as a potassium-sparing diuretic, meaning it prevents the body from having low potassium levels. The drug blocks the hormone aldosterone, which causes the kidneys to pass fluid while keeping potassium.

In some cases, potassium could build up to higher than normal levels in a condition called hyperkalemia, though it is also rare. You should check in with your doctor if you experience the following symptoms of hyperkalemia:

  • Muscle weakness, numbness, or tingling
  • Nausea or vomiting
  • Heart palpitations
  • Shortness of breath
  • Chest or muscle pain

Weimer also says there are a few medical cases where feminizing hormone therapy may be harmful to your health, such as if you have signs of breast cancer, colorectal cancer, or any cancer sensitive to estrogen.

While feminizing hormone therapy comes with some health risks, for some people, not receiving this treatment can be even more harmful. “It is, for many people, a lifethreatening condition to continue without access to hormone therapy,” Weimer says.

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