Accurate information on hormones and their effects on trans-women specifically seems difficult to find. Specialists use hormones to lessen the distress caused by Gender Dysphoria in some trans-women. That stated, I keep seeing so many people attempting Do-It-Yourself hormone therapies. Hormones control literally your entire life. Every aspect of your bodily functions comes from hormone impulses released by various glands, and attempting to manipulate them without medical supervision risks ruining that.
Medical Readiness Before Hormones
You should know before you read on that I am not a medical professional. The following outline details research combined with my own experiences. Always consult your own doctor before you begin any sort of medical changes or treatments, especially hormones. That stated, your doctor would do something like the following.
Physical Readiness
Initially, your physician or provider will ask you about your personal and family medical history. They need to know if taking hormones will place you at risk for blood clots, hormone-sensitive cancers, and impulse control issues. For your safety, and that of those around you, tell your doctor the truth about everything.
Next, your provider should give you a thorough physical exam. This should include an external assessment of your reproductive organs, immunizations, and age-appropriate screenings (like prostate and testicular cancer). Then, they should conduct a series of blood and urine tests to check lipids, blood sugar, blood count, liver enzymes, electrolytes, and the hormone prolactin. Additionally, you may request a baseline Estradiol, Testosterone (Free & Total), LH, and FSH count.
Before your provider issues any referrals for insurance, they should also discuss the effects on your fertility. Namely, within the first three weeks, hormone therapy sterilizes most patients.
Finally, your provider should issue you a referral to a psychologist, gender therapist, or mental health provider.
Psychological Readiness
In order to begin most treatments for Gender Dysphoria, you should have at least two psychological evaluations. Depending on whether or not you already have a mental health provider, you may have to undergo several sessions. These include establishing rapport, confirming your diagnosis, treating other conflicting conditions, and managing your expectations.
These sessions can take anywhere from a few weeks, to several years depending on your personal readiness. I suggest reading through the Psychology posts to help prepare you for these evaluations.
Your second provider can, based on your readiness, probably provide your second evaluation within one three hour session. The primary mental health provider can usually facilitate that by providing a letter in advance to the second evaluator, detailing your history with them.
Endocrinology
With both letters of recommendation from your mental health providers, your primary provider can write you a referral to an endocrinologist. Of note, do not settle for an internal medicine provider. While they specialize in many disciplines and can treat most illnesses, they do not usually appreciate the nuances of endocrinology.
First, your Endocrinologist will review the labs that you did initially, and if needed get your baseline hormones. Then, they should start you on the lowest dosage based on your initial results. After your first three months, your endocrinologist should order a second set of labs similar to the first. Depending on those results, they may or may not adjust your dosage. At this stage, you want to track your weight, moods, libido, hydration, blood pressure, exercise, and eating habits. While that seems like a lot, if you experience any problems, it allows the endocrinologist to pinpoint the issue much quicker.
Barring any complications within you first six to nine months, prepare to see some steady changes.
Types of Hormone Therapies Used
As of 2021, the medical community commonly uses seven different methods of hormone delivery for trans-women. The following table can help understand the differences.
| Intramuscular Injection | Using a longer needle to inject the medication deep into the muscles to deliver it straight to the bloodstream. |
| Orally | Swallowing the pill whole and letting it start to work from your stomach. |
| Subcutaneous Implant | Implanting a pellet directly between the muscle and skin using an injector or surgery to give a constant dose over a long period of time. |
| Subcutaneous Injection | Injecting with a shorter needle into the tissue layer between the skin and the muscle to deliver the medication slower. |
| Sublingual Delivery | Dissolving the pill underneath your tongue to allow the mucus there to activate it. |
| Transdermal Gel | Massaging a gel onto a specific area to absorb the medication through your skin. |
| Transdermal Patch | Putting on a sticky thing that feels like a Band-Aid, and allows the medication to absorb directly through the skin into the bloodstream. |
Maintaining Realistic Expectations
First off, hormones can make gender dysphoria less severe. They reduce distress, improve psycho-social function, increase sexual satisfaction, and generally benefit your quality of life. However, you cannot classify hormones as a magical solution. The risk of blood clots, cardiovascular disease, high blood pressure, and diabetes should give you pause. Your medical team should eliminate those in the comprehensive evaluation beforehand. They should also help you decide which delivery method might work best for you depending on your tolerance, lifestyle, and medical conditions.
1-3 Months: Starting Hormones
If you think of it in terms of puberty, this equates to Tanner Stage I. Changes in the first few months come slowly. As your body begins adjusting, your skin begins to soften and oil production lessens a lot. Facial and body hair may begin to slightly soften.
No one seems certain about how or if hormones affect libido. Some people report a decrease in Libido, others claim it spikes. Both remain a high possibility, and this requires more study. However, within the first month, ejaculate will begin to thin slightly with decreased sperm production.
Probably the fastest and most notable change comes from your thoughts. Your thoughts begin to clear up, and you may notice your productivity skyrockets. You may also find yourself crying more often. Then, mood swings begin to hit you a little more often, which may include depression, sadness, and anger. Some things that bothered you in the past might suddenly seem less important. A feeling of ease or euphoria might set in.
3-6 Months: Early Changes From Hormone Therapy
Sometime between your third and sixth month, you’ll begin to feel a layer of subcutaneous fat filling in under your now softer skin. Around the same time, you may notice a painful itch or burn under your areola. This marks the beginning of your breast tissue growth. In tanner stages, this equates to stage II more or less.
Muscle mass begins to shrink noticeably during this stage. Additionally, fat begins to collect ever so slightly in your hips, thighs, face, and abdomen.
The initial euphoria and emotional highs begin to balance out. Your emotions will still intensify slightly.
6 – 12 Months: Slowing Changes
As your body begins normalizing to the hormone therapy, the subcutaneous layer of fat becomes more obvious. Things like the shape of your hips, breasts, face, tummy, and butt change dramatically. Your muscle tone also changes to a softer shape. Maintaining a healthy lifestyle at this point makes a world of difference for the better.
Breast development, in particular enters the equivalent of Tanner Stage III. Most websites and some Reddit threads will tell you not to expect your beasts to grow any further, don’t listen. Your breast development depends on your genes. At this point, speaking to your mother can provide vital insight to your expectations. On average, trans-women have the genetic material to grow to the size of their mother. This depends heavily on age, lifestyle, and your Endocrinologist.
Not everyone, but most trans-women become fully sterile at this point. Libido, however, remains a varied mystery, as some trans-women become much more sexually active, and some don’t.
Mental and emotional health begin to become more fragile around this time as well. Because of the changes to your physical body, it’s easy to feel like everyone is out to get you. First off, people worry far to much about themselves to worry about you. Secondly, please discuss your feelings with your mental health provider. They can help you work though this tedious period.
1 – 2 Years: The Second Half
During your second year on Hormones, most changes to your body begin to finalize. At this point, your skin, body hair, and muscles will match a biological female. This applies to challenges like weight gain, emotional cycles, bloating, dryness, and hair as well. Learning to take care of yourself should remain a priority for your physical health.
Some breast growth may continue at this point, hopefully bringing you into Tanner Stage IV development. At this point 99% of trans-women should expect to stop growing/developing. Tanner Stage V in a biological female occurs during pregnancy. Studies currently show that while inducing lactation may occur, the science still needs fine-tuning.
***Let me know if you think I should include the current studies here.***
Mental and emotional health during this stage should being to improve substantially. At this point, Psychologists can and will usually recommend any further treatments desired, though keep in mind, most additional treatments require two letters of recommendation.
2 – 5 Years: Continuing Hormones
Most, if not all changes that happen, occur within the fist two years. However, the health benefits of continuing hormone therapy remain a topic of study. At this point, most trans-women fade into the world, indistinguishable from everyone else, and happily live out their lives.
Hormones and Limitations
The male skeletal structure remains completely unaltered. You will not get shorter, your feet will not shrink, and your pelvis will not widen. While some trans-women report a shift in their sizes, this happens because of ligaments and muscles in their feet and spinal column.
Hormone therapy cannot reverse male pattern baldness, nor can it stop facial hair altogether. It will make the hair softer, making various forms of hair removal easier. To learn more about growing hair, check here.
Your voice pitch, tone, and volume remain unaffected. In order to effectively feminize your voice, speech therapy, YouTube videos, and some apps provide a solid guide. It does take lots of practice, with the shortest being around six weeks, and most programs averaging about three to four months.
Women’s Health Issues Caused by Hormones
Due to the unique nature of trans-women, a combination of health-related issues come up. Understanding the dynamics of those can help prevent serious problems later.
Breast Health
Many medical professions disagree on the timing merits of mammograms for trans-women. My Endocrinologist recommended one for me after my first year of Hormone Therapy. Internal medicine and my Primary Care Manager (PCM) both said they wouldn’t refer me. A few months later, while conducting a regular self-check, I found a lump on my left breast. Both of my providers dismissed it, but my PCM referred me to an ultrasound to try and stop my constant concern. The ultrasound tech found the lump, but because of its size, dismissed it as nothing.
At that point, I met with my Endocrinologist, and she conducted a quick check. She immediately contacted my PCM, and I received a mammogram a couple of days later, confirming that there was an issue (link to full story).
Sharing this story, I cannot stress enough the importance of regular self-checks and trusting your instincts.
Vitamin Deficiencies
While not unique to trans-women, vitamin deficiencies can cause a ton of avoidable problems. Taking a multi-vitamin formulated for women of your age group will lower your risk of bone density issues, and avoidable immune deficiencies.
Prostate Health on Hormones
Despite a nearly 50% shrinkage, trans-women still require regular prostate screenings. Your medical provider should track them ordinarily, but never take that for granted. Ask, and if necessary, keep a record for yourself.
References
- Coleman, Eli, et al. “Standards of Care for the Health of Transsexual, Transgender, and GenderNonconforming People.” World Professional Association for Transgender Health (WPATH), World Professional Association for Transgender Health (WPATH), 2012, https://www.wpath.org/publications/soc.
- Deutsch, Maddie. “Information on Estrogen Hormone Therapy | Transgender Care.” UCSF Transgender Care, The Regents of the University of California, July 2020, https://transcare.ucsf.edu/article/information-estrogen-hormone-therapy.
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