Feminizing Hormone Therapy

What is feminizing hormone therapy?

Feminizing hormone therapy (FHT) is a gender-affirming hormonal therapy (GAHT). It uses certain manufactured hormones to reduce traditionally masculine features and develop physical female characteristics.

You may choose to use feminizing hormone therapy as a stand-alone therapy. Or you may use it in combination with other types of gender-affirming medical care, like surgery and voice therapy.

The process of transitioning from your sex assigned at birth to your identified gender is as unique as you are. It’s deeply personal, and you know what’s right for you. But if you’re considering feminizing hormone therapy, it’s best to work with a healthcare provider who specializes in it. Together, you can make sure the process is medically safe for you and that it can help you reach your desired goals.

What type of healthcare provider should I see for feminizing hormone therapy?

Many healthcare providers can help you, particularly ones specializing in transgender health. You may work with one or more of the following providers:

• Primary care physician.
• Endocrinologist.
• Gynecologist.
• Urologist.
• Mental health professional, like a psychologist or a psychiatrist.

You might want to look for providers who have certification through organizations like the World Professional Association for Transgender Health (WPATH) Gender Education Institute (GEI).

How does feminizing hormone therapy work?

Feminizing hormone therapy involves the use of prescription medications. It always includes the use of estrogen (estradiol). Depending on your goals, your healthcare provider may prescribe it in combination with a testosterone‐blocking, or antiandrogen, medication (like spironolactone). Occasionally, providers may also prescribe synthetic progesterone. But the data on the safety and benefits of progesterone use is limited.

Estradiol comes in many forms, including:

• Pills.
• Injection.
• Skin patch.

You may decide to take either estradiol or antiandrogens, or both. You and your provider will also discuss the dose ranges to start with. Some people want to begin this therapy at the typical starting dose, as they desire maximal transition changes. Others want more gradual changes, have concerns about side effects or drug interactions or simply desire more androgynous characteristics. Together, you and your provider will determine the type and dose that’s right for you.

Your provider will check your hormone levels regularly with blood tests to make sure they’re in the desired and healthy range. After reaching the desired results, you may take a lower dose for the rest of your life to maintain the changes.

Feminizing hormone therapy for adolescents

Adolescents going through puberty who meet the criteria to receive feminizing hormone therapy typically start with puberty blockers before taking estrogen. But this depends on several factors, including state laws and various health considerations.

What changes does feminizing hormone therapy cause?

Feminizing hormone therapy produces changes in certain secondary sex characteristics. These are the physical features that aren’t directly involved with reproduction, like facial hair, breast size, and muscle and body fat distribution. Secondary sex characteristics typically arise during puberty.

Antiandrogen therapy blocks testosterone production, which affects secondary male sex characteristics. Changes from antiandrogen therapy typically include:

• Decreased muscle mass.
• Thinning and/or slowed growth of facial and body hair.
• Decreased sex drive (libido).
• Fewer spontaneous erections.
• Smaller testicles.

Estrogen (estradiol) promotes secondary female sex characteristics. Changes from estrogen therapy typically include:

• Softer skin and decreased oiliness.
• Increased body fat storage in your hips, buttocks and face.
• Breast growth.

It’s important to note that feminizing hormone therapy doesn’t change the pitch or sound of your voice. But other options may help alter your voice, like voice feminization surgery and voice therapy.

How soon will I notice changes in my body?

The changes from feminizing hormone therapy come about at different rates and depend on various factors. Your healthcare team will explain what changes to expect and when to expect them.

Most people experience desired physical changes within the first three to six months of starting feminizing hormone therapy. It typically takes 18 to 24 months to achieve the full effect. But remember that everyone’s body is different. Try to give yourself — and your body — grace if the changes don’t happen as fast as you’d like.

How do I prepare for feminizing hormone therapy?

You’ll need to take several steps to prepare for feminizing hormone therapy. Your healthcare team will be by your side throughout this process. Don’t hesitate to ask questions or raise any concerns.

Mental health evaluation

One of the criteria for starting feminizing hormone therapy is having a diagnosis of persistent gender dysphoria or gender incongruence.

You’ll likely meet with a mental health professional for this. They use criteria in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) to make a diagnosis of gender dysphoria. The International Classification of Diseases (ICD-11) gives specific diagnostic criteria for gender incongruence.

Your healthcare team will also want to make sure that any other mental health conditions you have (like depression, anxiety or an eating disorder) are well-managed before starting feminizing hormone therapy.

Education and informed consent

Another criterion for receiving hormone therapy is being of the age of legal medical consent and having sufficient mental capacity to give informed consent. There are extra requirements for adolescents who haven’t reached the legal age of consent. These laws vary by state in the U.S.

Your healthcare team will explain how feminizing hormone therapy works and what to expect. Together, you’ll discuss reasonable expectations and the timeline of anticipated physical changes. You’ll also review the risks and benefits of the therapy.

Checking your physical health

Your provider will want to check for conditions that feminizing hormone therapy can make worse, like a history of:

• Thromboembolic diseases (like deep vein thrombosis and pulmonary embolism) and/or risk factors for them.
• Hormone-sensitive cancers.
• Coronary artery disease.
• Cerebrovascular disease.
• HIV.
• Hyperprolactinemia.
• Hypertriglyceridemia.
• Gallstones.
• Liver disease.
• Neurological conditions, like seizures.

They’ll also do a physical exam and may recommend some tests to assess your overall health, like:

• A1C.
• Basic metabolic panel.
• Complete blood count.
• Urinalysis.
• Lipid panel.
• Liver function tests.

What are the benefits of feminizing hormone therapy?

Feminizing hormone therapy is an effective medical therapy. It can lead to significant improvements in mental, physical and sexual well-being for transgender women and gender nonconforming people.

Having physical attributes that match your gender identity can help improve your self-esteem and self-image. These factors contribute to a better quality of life.

What are the potential side effects of feminizing hormone therapy?

Estrogen and anti-androgen therapy may increase your risk of:

• Venous thromboembolism.
• Infertility.
• High potassium (hyperkalemia).
• Hypertriglyceridemia.
• Weight gain.
• Cardiovascular and cerebrovascular disease.
• Meningioma.
• Excessive peeing (polyuria) and dehydration.
• Gallstones.
• High blood pressure.
• Erectile dysfunction.
• Type 2 diabetes.
• Osteoporosis and osteopenia.
• Hyperprolactinemia.

The level of increased risk for these conditions varies based on a few factors. Your healthcare team will go over them with you before you start hormone therapy. They’ll also let you know what signs to look for and when to seek medical care if any of these conditions develop.

How do I lower my risk of complications?

Steps you can take to stay healthy while on feminizing hormone therapy include:

• Seeing a healthcare provider experienced in transgender health and gender-affirming hormonal care.
• Taking your hormone therapy medications as prescribed.
• Going to follow-up appointments.

When should I see my healthcare provider?

You’ll need to see your healthcare provider for follow-up visits and if any complications develop.

Follow-up visits for feminizing hormone therapy

You’ll have several follow-up appointments with your healthcare provider after you start hormone therapy. This is so they can track your response to the therapy. Care also includes tests (like blood tests) to check your hormone levels and check for signs of complications. Occasionally, you may need a bone density test (DEXA scan).

In general, you can expect to see your provider:

• Every three months during the first year of hormone therapy.
• Every six to 12 months after that.

When to seek help for complications

Certain side effects of estrogen and antiandrogens can be signs of complications. Some can become severe or need immediate medical attention. Call your healthcare provider if you experience:

• Bulging eyes.
• Dizziness.
• Hives and swelling.
• Itchy skin.
• Joint pain.
• Muscle weakness.
• Tingling in your arms or legs (peripheral neuropathy).
• Vomiting.
• Yellowing of your skin or eyes (jaundice).

Can I undergo feminizing hormone therapy without help from a healthcare provider?

Taking estradiol, progesterone or antiandrogens without a healthcare provider’s guidance is dangerous. A healthcare provider will ensure you receive the correct dose for your needs. This helps you achieve the best possible results and avoid complications.

A note from Cleveland Clinic

Living with gender dysphoria can be distressing and isolating. Femininizing hormone therapy is one of many options that can help address these issues by matching your appearance with your authentic gender identity. Know that you won’t be alone during this process. A healthcare team specializing in transgender care will be by your side to answer any questions about hormone therapy and what to expect.