Important Disclaimer: The first version of this page was written in 2001 when I was collating a mass of information and trying to decide whether to finally make a life changing decision. I'm not a medical professional and the content does NOT constitute Medical Advice. I disclaim any responsibility for extracts that have appeared elsewhere that might imply that it does. Also, I cannot accept any responsibility for any medication that a reader may take. Such treatment should always be done done under the supervision of a qualified medical professional.
All animals have hormones. Hormones are chemical messengers that travel through the blood and turn body functions on or off. For example, some hormones tell your heart to beat faster when you get scared while others control fat deposition. Hundreds of hormones are in our body's, carrying many different messages.
For male-to-female transsexual women, taking hormones becomes part of their daily routine. Although the amounts taken can be reduced after sex re-assignment surgery, it will still be necessary for them to take hormones every day for the rest of their lives in order to remain healthy. It must be emphasised that some of the effects of long term hormone use are irreversible, at least without surgery; hormones are not something that can be experimented with. The widely followed HBIGDA Standards of Care of Gender Identity Disorders Version 6, warns that:
Before taking female hormones it is also necessary to carefully consider several other important points:
Firstly, why do you really want to start taking them? The results of prolonged use of hormones such as oestrogens at medicinal levels are obvious and permanent. Taking female hormones makes no sense unless you are seeking permanent and irreversible body feminisation. In particular breast development can soon become a source of embarrassment for some one still living as a man, it will not shrink significantly when the hormones are stopped, and may eventually require surgical removal (gynecomastia).
Secondly, there are serious medical risks associated with long term hormone use, although admittedly recent studies seem to show that these risks are much less than previously thought, for example post-operative MTF women seem to be no more at risk of getting breast cancer than genetic women on HRT.
Thirdly, there are considerable costs associated with hormone treatment, particularly if "natural" hormones are preferred over much cheaper "synthetic" hormones which are thought to have higher risks of side effects and complications. The cost of hormones varies hugely from country to country, but if you are paying yourself then $100/€100 a month is about the minimum budget for hormones and antiandrogens when pre-SRS, perhaps halving after surgery. This may not sound too much, but it must be maintained month after the month, and the total annual expenditure can be a significant burden, particularly for young women on low salaries and pensioners.
Finally it is necessary to be realistic about what feminising hormones can do, they are not some magic potion. Also the effects take a long time to realise - it's at least two to three years before maximum effects are achieved.
Oestrogens are steroid "female hormones" produced in large quantities by the ovaries of women, however they are also produced in small quantities by the testes of men. During a girl's puberty it's a flood of oestrogens that are responsible for the development of female secondary sexual characteristics such as breast enlargement, broadening of the pelvis and fat deposition around the hips. In a sexually mature woman with female reproductive organs, oestrogens participate in the monthly menstrual cycle that prepares the body for a possible pregnancy, and they also participate in the pregnancy if it occurs.
Oestrogens also have several non-reproductive effects: they are mental tonics and have anti-depressive effects; they antagonize the effects of the parathyroid hormone, minimizing the loss of calcium from bones and thus helping to keep bones strong; and they promote blood clotting and may lower the risk of heart disease (although a recent study has questioned this) .
In terms of the specific biochemicals contained in oestrogen-based hormone preparations, there are three main categories of interest to transsexual women:
For hormone therapy both synthetic and natural oestrogens are commercially available. Synthetic oestrogens are generally cheaper but more prone to side effects than are natural oestrogens. Products based on phyto-oestrogens are available in health food shops but are not subject to licensing or standardisation of their active constituents, and are usually of very low, and possibly ineffective dose - the sweeping claims made by manufacturers of such products should treated with great scepticism.
Most of the preparations that are licensed for use as female hormone therapy (these may be conjugated oestrogens, but are usually based on oestradiol valerates) are only available by doctor’s prescription. Oestradiol valerate is the only form of hormone therapy that can be measured in blood, so blood oestrogen measurements are meaningless in someone taking, say, Premarin.
In the transsexual woman progesterone administered with oestrogen appears to help promote breast growth: oestrogen stimulates cell mitosis and growth of the ductal system, while lobular development and differentiation seems to be dependent on progesterone (breast fat accretion seems to require both). Progesterone consistently administered with oestrogen also seems to reduce the risk of fibrosis, cysts, and cancer from administration of oestrogen alone.
There are some prescription HRTs available that are based on synthetic progestogens (chemicals that have progesterone-like actions), e.g. Provera and Duphaston. True, non-synthetic, progesterone (as opposed to a progestin) is very rarely reported to have any adverse effect, and seems to provide a healthier balance for an aggressive oestrogen dosage in pre-op TS women, as well as improving libido and overall energy level.
One of the well-known effects of testosterone is that it stimulates muscle growth. For this reason, some athletes and body builders (both male and female) take testosterone or similar drugs - called "anabolic steroids" - to help them build bigger, bulkier muscles. Conversely in pre-SRS transsexual women it is highly desirable to block the muscle building and other masculinising effects of androgens such as testosterone which are produced by the testes, and to a lesser extent the adrenal cortex. This can be most safely and effectively fought by taking an "anti-androgen" drug, rather than by trying to overwhelm the effects of androgens by mega-dosing with oestrogen. The Spironolactone and Finasteride anti-androgens are very commonly prescribed and taken by pre-SRS transwomen, transsexual women older than 25 or so seem to find taking an anti-androgen to be much more effective and important than those who are younger. Most post-SRS transwomen don't need an anti-androgen, but a few find Finasteride to still be useful.
In a transsexual woman the surgical removal of the testes either during sex re-assignment surgery or by a bilateral orchidectomy (castration) is highly desirable because of the virilizing effects of the testosterone they produce. Without the testes present, not only can smaller doses of female hormones can be administered but unopposed by testosterone this will often have a greater feminising effect on the body than before.
Puberty is largely initiated and controlled by the sex hormones.
Puberty can be defined as the biological developments which change boys and girls from physical immaturity to biological maturity, and many of the differentiations in outward appearance and body shape between men and women occur or develop further during puberty. Unfortunately for a male-to-female transsexual, an inappropriate male puberty sets a physical mountain that can never be full conquered.
A lot more information about puberty and its effects is are described in a separate article which can be found here.
of Hormone Treatment
In general, the increased oestrogen and progesterone blood levels resulting from the female hormone treatment will stimulate and promote the growth of female secondary sexual characteristics (breasts, fat distribution, pubic hair pattern, ...). Body shape is controlled by oestrogen so its use stimulates a female body shape to develop, and the woman's body shape and "figure" will become far closer to female norms in proportions.
The effects of female hormone treatment will vary considerably by individual, and can take 2 to 5 years to fully achieve. In order to maximise the physical effects and benefits, hormone treatment should be begun as young as possible, before the body has completely matured and can no longer develop in response to stimuli. The greatest maximum effect occurs if hormonal treatment begins before a male puberty - there is a lower maximum otherwise.
If the testes have been removed in infancy or early childhood (usually because the child has been identified as intersex or AIS, and a female gender has been agreed with the parents), hormone therapy is usually started at the age of about 10 or 11, in order to initiate a female puberty. Unfortunately of course this ideal situation is very rare - the average 'western' transwoman is in her 30's before she commences hormone treatment. If a male puberty has already occurred, whilst female hormone therapy will cause a reduction in the levels of 'male' androgens such as testosterone, this will have little or no effect on most of the already developed of male secondary sexual characteristics (e.g. deepening of voice, facial hair, narrow pelvis, ...). The longer after male puberty (which typically ends by age 18) that female hormone therapy is started the less effective it will be - but not on a linear scale, the effects tail-off rapidly as time since puberty increases. For example, a woman starting hormones at age 20 may experience good breast development and a near cessation of facial hair growth, the same woman starting treatment at 30 will get considerably less breast development and only a slight reduction of facial hair growth, while if she started at 40 the effects will be less again, but not so significantly.
The following table shows the effects of female hormone treatment begun after male puberty has completed (i.e. after about age 17).
Maintaining Male Libido
For various reasons some male-to-female transsexuals wish to preserve their ability to have a penal erection, sexual intercourse and ejaculate, whilst still feminising their body. This is rather a contradiction but stop-start hormone treatment (a month on, a month off...) and the use of drugs such as Viagra can result in a uneasy compromise.
Weight, Muscle Loss and Fat Re-Distribution
In one study, profound changes in weight and fat distribution were observed in 20 MTF transsexuals after taking hormones for just 12 months. A marked increase in subcutaneous fat deposition was observed, reaching near female norms in the arms, abdomen, hips, thighs, etc. Other studies support these findings. It's also become clear that transsexual women on hormones loses muscle mass, in particular there is likely to be a large decrease in thigh muscle, instead a considerable subcutaneous fat deposit is accumulated in this area - this is a typically female characteristic as the thigh is not a primary site for fat storage in men.
As well as hormones, a doctor may be able to recommend other drugs to aid fat redistribution and weight control. One such drug is Metformin (one brand being Glucophage). Although normally associated with diabetes, it's now also considered useful for aiding and enhancing the body fat redistribution (including limbs and face) of transsexual women taking oestrogen.
Despite a loss of several kilogram's of muscle mass, adult male-to-female transsexuals actually have a tendency to gain weight after starting hormones as they put on so called "reproductive fat". An overall gain of 4-5kg (10-12 lbs) seems typical - the largest fat deposition occurs on the hips and thighs, with a typical gain of 4-5 cm (2 inches) in hip measurement. Whilst there are far smaller deposits on the abdomen, this can still result in a 2-3 cm (1 inch) increase in waist measurement - with unfortunately little net improvement in the waist-hip ratio (WHR), a key physical "female indicator" that's subconsciously observed by other people.
The problem for most transwomen is that their underlying male type skeleton is differently shaped from genetic woman, and thus achieving phenotype female fat deposits will not still result in a hour glass or even pear-shape figure. Some transwomen do attempt to compensate for this fundamental problem by augmenting the size of their hips and buttocks with butt implants or even dangerous silicone injections. Liposuction body contouring is another common quick-fix option used by many transwomen these days; however, it is not a substitute for weight reduction - particularly in an obese individual.
The tendency of male to female transsexuals to gain weight is best countered by appropriate exercising and dieting. This will assist and magnify the effects of drugs in developing a female type figure and body shape - a moderately active metabolism means that typically "male fat" on areas such as the stomach will be burnt up while female-type fat on areas such as the buttocks will still be deposited.
Exercising should emphasise burning calories and general toning rather than aim to maintain or even increase physical strength, so daily sessions of aerobics, swimming or cycling are appropriate, but not power lifting, weights or even circuit training. Happily, once lost, it is almost impossible for a transsexual women to regain excessive "male" type muscle in areas such as the biceps if post-SRS or taking hormones and anti-androgens.
After transition most MTF women at least temporarily reduce their calorie intake by a huge amount - perhaps a third based on anecdotal evidence. A few diet to such an excessive degree that it becomes an eating disorder with malnutrition and osteoporosis. This may result in irreversible bone loss, psychological abnormalities and death.
After the initial period of rigorous restriction (Atkin's et al), dieting really means a permanent change of eating habits, the aim is simply to adopt a healthy balanced diet that's relatively low in fat. A good rule of thumb is to eat no more than 2000 calories per day if your height no more than 66 inches (168 cm), adding 50 calories for each inch above that. If you are exceptionally active or very heavily built then adding a few hundred extra calories a day may be appropriate.
While female-type peripheral fat deposits on the bottom, legs and arms are not closely associated in women with increased health risks (heart disease, diabetes, ... ), excess fat around the waist strongly is. Thus shifting fat from the waist to elsewhere in the body is win-win situation for the transsexual woman. Basically a good figure is a healthy figure, which is why women with good figures are more attractive to men!
The final objective is a weight close to a female rather than male norm for the transwoman's height and build, however it is necessary to accept that most transwomen are physically more heavily built and thus heavier than genetic women of the same height. Also, unfortunately the underlying constraints of a male type skeleton make figures with a WHR of 0.7 or less very rare in transwomen, and a WHR of about 0.8 is very good.
Sense of Smell
It's long been accepted that the sense of smell of men and women differs, and that "female intuition" is often due to them being able to detect odours consciously or subconsciously that men can't. This ability is particularly heightened when fertile, when women have an extraordinary ability to determine if a potential sexual partner is married! The most well know manifestation of this difference was the discovery in the 1960's that "male pheromones" can stimulate the arousal and sexual interest of a woman, and a whole industry has since developed selling men expensive aftershaves and oils that claim to include such pheromones.
The reality is that male sweat and semen includes in tiny quantities a steroid called androstadienone (AMD). Tests have shown that smelling this stimulates in women (only) a part of the brain called the hypothalamus, causing physiological responses of a sexual nature. Men don't have this response, instead their hypothalamus reacts to a female pheromone called estratetraenol (EST) which is found in a woman's urine. However medical studies have found that transwomen who have been taking oestrogen hormones for at least two years can switch to a female typical sense of smell, and their hypothalamus reacts to AMD rather than EST, or at least reaches an intermediate position. This finding is very important as it shows biological sex actually changing from male to female in a transwoman. Other such instances - for example the development of glandular breast tissue or the appearance of squamous cells in the lining of a neo-vagina - are far less clear cut.
Two composite female faces without makeup, the left is
with high oestrogen levels and the right with low.
The visible changes in physique and appearance resulting from extended female hormone treatment can vary from extraordinarily successful to rather disappointing. The vast majority of transwomen are somewhere in between these two poles.
Social media is filled with transgender women claiming a miraculous feminisation of their body after just a few months on hormones, often accompanied by a photo showing breast cleavage that Kim Kardistan or (for an older generation!) Pamela Anderson would be proud of. I was watching a mid-day time-filler television show when they had as a guest a transgender woman willing to answer "intrusive" questions from callers. I was dubious about some of her answers but choked when she said that her feet had reduced by 3 shoe sizes because taking female hormones had changed the shape of her foot muscles! That is simply impossible.
It is important to remember the limitations of hormones - they cannot change a skeleton, nor can they reverse ageing. For example the pelvis of an average adult woman is significantly different from that of an average adult man - with effects which range from gait to appearance in a bikini - and these can't be overcome by hormones, or even with dangerously drastic measures such as silicone injections.
Hormones can greatly assist the transition of a short and lightly built young man in to an attractive young woman, but hormones (nor anything else) cannot turn a tall, rugged, heavily built, balding, and elderly man in to a pretty and petite girl. Such a man is always going to have difficulty passing successfully as a woman, indeed even after all available hormonal and surgical treatment, the brutal reality is that he may still appear to strangers as a man in drag with "boobs stuck on".
The doses provided by skin patches, implants and injections are lower than those of tablets because they do not involve the hormone passing through the liver - where a significant amount of an orally administered hormone will be metabolised and lost. So it is possible to directly compare the headline dosage figures on the packets. Vaginal oestrogen preparations are not a source of whole-body hormone replacement, but help to treat vaginal dryness and assist with dilation in post-SRS women.
There are a lot of hormone products on the market and finding the right one can be difficult. The questionnaire for The Million Women Study lists the following common UK preparations:
What suits one person will not suit another. There are really no
guidelines other than just to keep trying different preparations until you
find one that suits you.
Regime's for Transsexual Women
PO qd = one tablet by mouth once a day
IM q2wks = Intra musuclar injection fortnightly
Important: Ethinyl Estrodial is no longer recommended for the treatment of transwomen
Anti-androgen agents are often used in combination with oestrogens in hormonal reassignment therapy to further decrease male secondary sexual characteristics. These anti-androgen agents presumably exert their action by lowering serum testosterone levels and by blocking testosterone binding to the androgen receptor. Effective agents include spironolactone, progesterone, testosterone uptake inhibitors, growth hormone releasing antagonists, and cyproterone. Potential benefits include mild to modest breast development, the softening of body and facial hair, decreased progression of male pattern baldness, and decreased erections.
For a comprehensive consideration of typical hormone regime's for transsexual women I doubt if there is a better resource on the web than the article on Dr Anne Lawrence's Transsexual Women's Resources site.
Replacement Therapy after SRS
Finding the right dose is a matter of balancing symptomatic relief (hot flushes, mood problems etc.) and osteoporoisis and cardiovsacular protection, against the risks such as breast cancer that are often associated with higher dosages. The taking of female hormones by a male-to-female transsexual has associated risks which can in extreme cases can be life threatening.
When considering the use of female hormones, absolute and relative contraindications (undesirable conditions) must be considered. Absolute contraindications which should prevent the commencement of female hormone treatment include:
Relative contraindications which increase the risk of complications developing include:
Once on female hormone treatment, development of any of the following conditions should cause the transsexual woman to immediately seek the advice of a physician. These contraindications include:
As with any medication if you notice unexplained changes in your health notify your physician. The woman should report to her physician immediately the occurrence of nausea, vomiting, breast lumps, abnormal bleeding, leg cramps, water retention, headache, dizziness and light-headedness. Cigarette smoking is known to increase the risk of side effects with synthetic estrogens, and this may also occur with natural oestrogen.
The risks of complications developing can be significantly reduced by leading a healthy lifestyle, for example:
Medical opinion has long been that the very high levels of hormone therapy required in a pre-SRS woman who has not had an orchiectomy will inevitably be associated with health risks in the long term - more than two years - and that these risks increase with the age of the patient (particularly if over 40). SRS or an orchiectomy allows a radical reduction in hormone intake, indeed the endocrinology and hormone regimen of post-SRS women is very similar to post-menopause women on HRT, however transsexual women who had SRS at an early age have the complication of needing to take HRT for a very much longer period of their lives than most women, so unknown side effects may yet emerge.
The news seems to be improving but is often contradictory, for example one large scale study found no evidence that transsexual women taking hormones are likely to die any younger than the general population, but another found that their mortality rate increased.
In addition to the primary feminisation effects, it now seems that long-term oestrogen therapy may actually have some benefits for the body of the male-to-female transsexual woman. The very limited research available seems to show that post-SRS transsexual women are no more at risk of breast cancer then genetic XY women on HRT. But the evidence is unfortunately slightly contradictory - some research on transsexual women indicates that long term oestrogen-based hormone replacement therapy (HRT) protects the women against heart disease but slightly increases the risk of breast cancer, while other research suggests that provided they are conservatively treated with oestrogens then they may actually may run a smaller risk of breast malignancy than genetic females because the mammagenesis (breast development) is initiated later in life.
Two reports published in the Journal of the American Medical Association on 3 July 2002 unfortunately contained some bad news. A study of 16,600 genetic post-menopause women taking a combination of conjugated oestrogen (e.g. Premarin) and medroxyprogesterone acetate (a progestin, e.g. Provera) had found that HRT did lower the risk of hip fracture, a measure of osteoporosis, but it raised the number of strokes by 41%, heart attacks by 29%, and breast cancer cases by 26%. It should be pointed out that the overall risk of these events is still low absolutely, the figures represent for every 10,000 women taking HRT about 7 extra heart "events", 8 more breast cancer cases, and 8 more strokes per year.
However, recent reports such as an article in the 24 February 2015 issue of the Journal of Clinical and Translational Endocrinology are actually very positive for trans women. If the patient follows the hormone approach found in both the World Professional Association for Transgender Health (WPATH) Standards of Care of 2011 and The Endocrine Society Guidelines of 2009, long-term transgender hormone therapy is safe for most situations. There appears to be no increased risk of cancer, whilst the previously reported increased risk of blood clots and liver damage seems to be primarily associated with ethinyl estradiol, a potent and cheap synthetic hormone that is particularly suited for oral delivery as a tablet. Until about 2010 it was a common component of feminizing hormone therapy for transgender women, but given the risks that have been identified it is no longer recommended for this purpose, with estradiol having largely superseded it. However ethinyl estradiol is still widely used in contraceptive pills and for female hormone replacement therapy. It is thus quite easy to obtain and still commonly used for self-medication by transwoman - I can only say here that please avoid a daily dosage above the 0.5 mg considered to be "high" in contraceptive pills.
Other Health Considerations
Another very serious problem for transwomen is the reluctance of GP's in the UK and Ireland to treat a patient when they discover that she is post-operative transsexual. In Ireland, (based upon personal experience in 2009), no health insurance company will accept a new customer who is a post-SRS transwoman.
In the late 1990's there became a huge interest in bioidentical hormones derived from plants that that are very similar to the estrogen and progesterone hormones produced by the human body. It was widely felt that these were somehow safer and less risky than than so called synthetic hormones. In practice this is a hugely complex subject and not one that I'm qualified to comment on. Nevertheless most post-menopausal women taking HRT are now prescribed patches releasing bioidentical hormones such as estradiol or estriol. It's also become apparent that post-GRS women who require only a modest boost to their estrogen levels in order to stay healthy can also economically and conveniently use such patches.
Example Hormone Regimes
(Please contact me if you wish your details to be added)
Warning:Some of the hormone regimes stated below seem to be excessively high, overdosing on hormones will not have any additional physical feminisation effects but does have very serious and dangerous health risks. Hormones should only be prescribed and taken under qualified professional supervision.
Drugs without Prescription
Since the early 2000's custom authorities around the world (including the USA and UK) have tightened up immensely on the importation of prescription drugs. Although the importation of prescription medication is still legal in many of the same countries (including the UK, USA, France, Spain, Hong Kong, Japan, S. Korea, and India) provided that the medication is for personal use and it's not a controlled substance - the barriers preventing this are now high. For example in Ireland the delivery of drugs will be automatically blocked by the Irish Tax and Customs service, and the package only released upon providing evidence of a prescription and the payment of VAT plus an administration fee.
Over the years many on-line pharmacies have been suggested to me as being prepared to ship hormones internationally without prescription, but this is a moving target and "buyer beware" is a vital consideration. E.g. Pharmacy Care New Zealand was an excellent source for several years, before going off-line in 2001 and then reappearing in 2003 as a scam. Another consideration is that prices have increased immensely since c.2000 - trying to buy drugs without a prescription can cost many times more than with a prescription, with no guarantee you will ever actually get them.
As a result of the customs clamp down, most of the international online pharmacies I once listed here have closed. For the very brave, the few web sites that I believe still operate include:
And for optimists seeking a non-prescription herbal solution:
If you have had experience ordering hormones from the Internet and can perhaps recommend another company, or have had a bad experience with one listed above, please let me know so that I can update this section.
you have any questions, please feel free to email
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Copyright (c) 2013, Annie Richards
Last updated: 22 September, 2013