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. 

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:

"Social Side Effects [of Hormones]. There are often important social effects from taking hormones which the patient must consider.  These include relationship changes with family members, friends, and employers.  Hormone use may be an important factor in job discrimination, loss of employment, divorce and marriage decisions, and the restriction or loss of visitation rights for children."

Before taking female hormones it is also necessary to carefully consider several other important points:

Many girls have over- optimistic expectations about the effects of hormones.

Firstly, why do you really want to start taking them?  The results of  prolonged use of hormones such as Estrogens 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.

Types of Hormone
Estrogens
Estrogen (or 'Oestrogen' in British English) is the most important female hormone taken by transsexual male-to-female women.

Estrogens 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 Estrogens 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, Estrogens participate in the monthly menstrual cycle that prepares the body for a possible pregnancy, and they also participate in the pregnancy if it occurs. 

Estrogens also have several non-reproductive effects, for example: 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; they promote blood clotting and lower the risk of heart disease, and they help to maintain good blood flow in the brain.

In terms of the specific biochemicals contained in Estrogen-based hormone preparations, there are three main categories of interest to transsexual women:

• conjugated Estrogens - from natural sources e.g. Premarin, from pregnant mares’ urine.
• oestradiol valerates - synthetic copies of vegetable (yam or soya) Estrogen.
• phyto-Estrogens - from plants, e.g. Ogen.

For hormone therapy both synthetic and natural Estrogens are commercially available.  Synthetic Estrogens are generally cheaper but more prone to side effects than are natural Estrogens.  Products based on phyto-Estrogens 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 Estrogens, 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 Estrogen measurements are meaningless in someone taking, say, Premarin.

Progesterone
Progesterone is another steroid "female hormone".  It is secreted by the corpus luteum and by the placenta, is responsible for preparing the body (in particular the uterus) for pregnancy and if pregnancy occurs, maintaining it until birth.  Progesterone is very important during pregnancy and pregnant women have lots of progesterone, which helps their bodies support the developing baby.  Progesterone has an effect on the brain, where it acts as a mild anaesthetic, presumably helping to reduce the pain of periods and even childbirth.  Progesterone is included in HRT for post-menapousal women as it lowers the risk of uterine cancer.  

In the late 20th century there was a huge debate about whether transsexual women needed progesterone given that they do not have a uterus and can't become pregnant.  In addition, studies suggested that the physical feminisation of a transwomen from taking hormones was just associated with Estrogen.  As a result there was a great reluctance by doctors to prescribe progesterone to transwomen as it appeared to be unnecessary. Nevertheless, many transwomen who were taking progesterone (prescribed or obtained surreptitiously) insisted that it was beneficial to both their physical and mental wellbeing.
 
It now seems probable that apart from its obvious effect on the uterus, progesterone has many effects on other tissues in the body, some having nothing to do with sex and reproduction.  For example increased libido and sex drive, and deeper sleep with more vivid dreams.  The revised medical consensus is that progesterone is important since it is obviously part of the general hormonal cocktail in XX women, thus transsexual women are now recommended to take progesterone along with their Estrogen.   Progesterone administered with Estrogen appears to help promote breast growth: Estrogen 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 Estrogen also seems to reduce the risk of fibrosis, cysts, and cancer from administration of Estrogen 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 Estrogen dosage in pre-op TS women, as well as improving libido and overall energy level.

Androgens
The principal androgen (male sex hormone) is testosterone.  This steroid hormone is mostly manufactured by the interstitial (Leydig) cells of the testes and therefore men have much more testosterone than women.  Testosterone is one of the hormones that make men look different from women, secretion of testosterone increases sharply at the start of a boy's puberty and this is responsible for the development of the male secondary sexual characteristics such as beards and deeper voices.  Testosterone is also essential for the production of sperm by men.

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 Estrogen. 

Anti-androgens
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.

The most commonly used antiandrogens are spironolactone (brand name Aldactone), flutamide (Eulexin) and cyproterone acetate (Androcur).  Spironolactone, in a dosage of 25 to 100 mg administered twice daily, is often favoured because of it's safety, availability and low cost.  Flutamide is usually given in a dosage of 250 mg twice daily, and cyproterone is given in a dosage of 25 to 50 mg per day. 

Most post-SRS transwomen don't need an anti-androgen, but a few find finasteride to still be useful, this reduces residual testosterone producrtion by the prostate.

Rimal Ali Shah is a transwoman of modest height (5ft 7, 170 cm) and weight (120lbs, 54kg.  She claims that her very feminine and well endowed appearance is soley from hormones, and that she has had no surgery. (Pakistan)

Puberty
Puberty is largely initiated and controlled by the sex hormones.

   
Effects of Hormone Treatment
A post male puberty male-to-female transsexual who commences female hormone treatment is effectively triggering some aspects of a second, female type, puberty in her body.

In general, the increased estrogen 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 estrogen 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.

Likely effects and timeline of a man beginning estrogen hormones after puberty

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).     

Desired Characteristic	Effects of Hormone Treatment	Possible or Additional Treatments
Female type skull shape and facial features	None	Facial feminisation surgery - jaw, brow ridges, skull shape, ...
Smaller nose	None	Rhinoplasty surgery
Softer, clearer skin with no acne or spots	Considerable improvement	Deep chemical skin peel, aka skin resurfacing
Smaller teeth	None	Dental surgery to improve teeth
Smaller hands and feet	None	None
Reduced height	None	None
Broader pelvis	None	None
Stop facial beard hair growth	Little or no effect	Electrolysis and laser treatment
Thick female type scalp hair and forehead hairline	Hair loss ceases, slight reversal of balding	Wig, hair implants, some medications (e.g. Minoxidil) may help slightly
Female pubic hair pattern.  Hairless trunk and limbs.	Substantial improvement after prolonged treatment	Electrolysis and laser treatment
Higher pitched feminine voice	None	Voice training, voice change surgery
Reduction of "Adams Apple"	None	Thyroid cartilage reduction surgery, aka tracheal shave
Slimmer neck	No effect not ascribable to dieting	None
Breast development	Variable, from slight to substantial breast development  (Note 1)	Mammoplasty (breast implants)
Female type body shape (including generous hips, buttocks & thighs)	Variable, slight to substantial subcutaneous fat redistribution after prolonged treatment	Fat transfer, implants
Small waist	May actually increase unless supported by dieting and exercise	Dieting and exercise, liposuction, lower rib removal
Reduced weight	Negligible (Note 2)	Dieting and exercise
Reduced muscular development	Some reduction	None
Reduced penis and testes	Substantial to significant reduction (not necessarily good if SRS is planned)	Surgery
Good mental health	Depression may occur	Therapy, support of friends and family, anti-depressants
Menstrual cycle	PMS and Hot Flashes only (Note 3)	None
Female hormones don't alter the underlying skeleton of an adult transsexual woman but can significantly change the external appearance. Notes: 1.  Breast development will vary considerably depending on the individuals genetic make-up and the time from puberty.  Early hormone treatment (by age 18) will typically result in breasts about one bra-cup size less than the girl's mother and sisters. 2. Estrogen hormones help to deposit fat, and on a male type skeleton this can result in a larger rather than reduced waist line. Sensible dieting and suitable exercising (e.g. aerobics, not power lifting!) is essential for developing a female type figure and body shape.  Although their fat distribution may change, in the long-term few transwomen seem to substantially reduce either their weight or their waistline. 3. Periods and menstruation are impossible even for a post-SRS transwomen.  However, transwomen will suffer from Pre Menstrual Syndrome (PMS) and Hot Flashes if they choose to stop taking Estrogen for 1 week in every 4 week period.  These unpleasant effects - and associated "bad moods" - can be avoided by maintaining a continuous hormone dosage.

Continuous female hormone treatment at the levels recommended for a MTF transsexual can result in a flacid and shrinking penis in just weeks.

Maintaining Male Libido
The taking of significant amounts of female hormones by a man will reduce his sexual "potency" to zero within two or three months.  The long-term use of hormones inevitably means a greatly shrunken penis, an inability to have erections, and the probability of permanent infertility after about two years. 

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. 

"Female" type fat deposit areas Nikki began hormones in her mid-teens, 20 years later her female type fat distribution is evident.  (USA) Charlie Craggs posted this photo age 28, after 5 years on hormones. (UK)

Weight, Muscle Loss and Fat Re-Distribution
One very visible effect associated with the long-term use of female hormones by a male-to-female woman is changes to her fat distribution and muscles - and thus to her appearance. 

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 Estrogen.

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.

Hormones, a good diet and exercise will radically change a transwoman's body, but a male-type skeleton can't be totally hidden.

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. 

Transgender artist Zackary Drucker has photographed the evolution of her body since beginning hormones and transitioning age 23.  Shown age 30. (USA)

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.

Attractiveness
Women with high levels of Estrogen tend to benefit in terms of attractiveness from a facial appearance aspect - healthier looking, fuller lips, better skin quality, less unwanted facial hair, etc.  However good makeup and 'facial maintenance' can achieve the same - and thus totally negate these advantages.

Reality Check Time Some women choose to begin hormone therapy for what may be the wrong reasons, and perhaps with unrealistically high expectations of what the results will be.  It's essential to be realistic about what hormones and feminisation surgery can do.  Many of the transsexual woman featured in magazines, newspapers, on talk shows, and other media are exceptional in their looks, and would probably very feminine without any hormones or surgery.  Beautiful women are [mostly] born so, not made.

The left hand picture is perhaps OTT, but the reality is that passable transsexual women such as Ha Ri-su (right) are the lucky exceptions, not the rule... perhaps rather more typical in appearance are the two ladies below whom I tried to randomly select:

(Above) Judith Kerr, once John Kerr, and (left) Susan Watson, once James Watson

I used to recommend here browsing the pages of Vicki Rene's "The Prettiest of the Pretty" website, this Geocities website was essential reading in the late 1990's.  Sadly. Vicki departed this world in 2011.

A composite image showing the effect of Estrogen levels as a child on the face of a post-puberty woman.  Left is with low levels and right with high.

No Miracles
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. 

A 58 year old transwoman after two years of hormone treatment.

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". 

Estrogen can be taken in pill, injection, or skin patch (shown) form.

Modes of Delivery
There are five ways of taking hormones:

• oral (tablet)
• transdermal (skin patch or cream/gel)
• implant (pellet inserted under skin)
• injection (e.g. intramuscular testosterone)
• vaginally (cream or tablets)

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 Estrogen preparations are not a source of whole-body hormone replacement, but help to treat vaginal dryness and assist with dilation in post-SRS women.

Hormone Therapy Products
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:

Prempak C 0.625 mg Prempak C 1.25 mg Tridesta Trisequens Trisequens Forte Cycloprogynova 1 mg Cycloprogynova 2 mg Estrapak Estracombi Climaval 1 mg Climaval 2 mg Premique Cycle Premique Nuvelle Kliofem Livial Premarin 0.625 mg Premarin 1.25 mg

Evorel 25 mcg/50 mcg Evorel 75 mcg/100 mcg Progynova 1 mg (skin patch) Progynova 2 mg (skin patch) Estraderm 25 mcg (skin patch) Estraderm 50 mcg (skin patch) Estraderm 100 mcg (skin patch) Zumenon 1 mg Zumenon 2mg Ethinyloestradiol (BP tablets in a bottle) Micronor Oestrogel (skin gel) Provera (progesterone) Duphaston (progesterone)

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.
 

Hormone Regime's for Transsexual Women (c.2000)
Many options for Estrogen therapy exist for use in hormonal reassignment therapy, and the doses used are generally at least 2-3 times higher than doses used for hormone replacement therapy in postmenopausal women.   

In 2000 oral Estrogen was by far the most commonly used medication as this was relatively inexpensive and easy to obtain, often even without a prescription.  Two forms of estrogen were used - conjugated equine estrogen (Premarin) or ethinyl estradiol (Estinyl).  The latter is very potent in its feminisation effects, but it's a synthetic compound and since about 2010 has ceased to be recommended for the treatment of transwomen as at the necessary dosage levels too many patients were suffering contradictions.  It has effectively been replaced by estrodial, a bio-identical compound that is much closer to the hormones naturally produced by the human body.

For transgender women older than 40, or heavy smokers, transdermal estradiol patches (e.g. Alora, Climera, Esclim, Estraderm, Vivelle, Vivelle-Dot) were recommended, although these were more costly than oral pills.

PO qd = one tablet by mouth once a day
IM q2wks = Intra musuclar injection fortnightly

A minority of transwomen (about a third) also took anti-androgen agents in combination with Estrogens in hormonal reassignment therapy to further decrease male secondary sexual characteristics. These anti-androgen agents block thge "male" hormone testosterone from binding to the androgen receptor of cells - preventing the resulting masculisation. 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.

It's important to note there a suspicion (not backed by any formal medical studies) that high doses of anti-androgens's can cause incomplete breast development, and the dose taken should never exceed recommended maximums.

For a comprehensive consideration of typical hormone regime's for transsexual women at this time,  I doubt if there is a better resource on the web than the article on Dr Anne Lawrence's Transsexual Women's Resources site. 

 

Hormone Regime's for Transsexual Women (c.2020)

The last twenty years have seen a slow but ultimately substantial change in the hormone regimen taken by transwomen.  Most obvious is the move away from taking estrogen oraly, to the use of injections - with Estrodiol Valerate heavily preferred.  If this is impossible then Estradiol transdermal patches have become the second choice, with oral pills a last resort.  The change is because injections and patches put far less strain on organs such as the liver, which when taking high-levels very long-term is an important health consideration.  

A new development is the emergence of Gonadotropin-releasing hormone agonists, these directly block the bodies production of testosterone.  A majority of transwomen now take these or anti-androgens in addition to estrogen - a "combined" regimen.  This is partially due the most common age in the west for starting hormones has moved from the 30-39 cohort to the 20-29 cohort, when the body is still amenable to change. 

The table below shows gender affirming drugs for a transwomen that are recommended in the 2020 medical paper Assessment and Hormonal Management in Adolescent and Adult Trans People, With Attention for Sexual Function and Satisfaction With Attention for Sexual Function and Satisfaction, by T'Sjoen G, Arcelus J, De Vries ALC, Fisher AD, Nieder TO, Özer M, et al.

 

Progesterone

The use of a progesterone such as Provera - the subject of much debate in 2000 - still remains unresolved. Whilst many transwomen take these, some doctors remain unconvinced of the benefits.  However, the  Assessment and Hormonal Management study mentioned above indicates that progestins (e.g. Lynestrenol and CPA) appear to attenuate hormonal effects in at least adolescent transgirls.

 

hCG
Human chorionic gonadotropin (hCG) is a hormone produced by women during pregnancy. As a prescription medication, it is usually taken as an injection to help to treat fertility issues in cis women.  However some transwomen also take hCG.  The primary benefit seems to be weight loss - transwomen report losing up to 2lb/1kg  a week after starting hCG, without any other changes to their diet or life style.   A secondary benefit (or disadvantage) is that it helps to maintain male libido and sexual function after starting female hormone therapy - i.e. taking Estrogen and anti-androgens. 

A transwoman showing her positive pregnancy test after being injected with hCG by Dr Mujajati Aaron!

However, hCG medications are expensive.  Typically three injections of 1000 units are recommended each week.  At retail prices, this will cost $300-400 a month using branded hCG medications such as Pregnyl or Novarel.  Most transwomen can't justify or afford this long-term.

There is an unexpected side-effect from taking hCG.  Pregnancy tests work by detecting the presence of hCG in a woman's urine, and transwomen taking high doses of hCG will test positive as pregnant! 

 

Hormone Replacement Therapy after SRS/GCS
When the testes are removed (orchiectomy, gonadectomy) during Gender/Sex Re-assignment Surgery or a bilateral orchidectomy (also known as gonadectomy) is performed, immediate long-term female hormone replacement therapy (HRT) is needed in order to prevent menopausal symptoms and to protect the skeleton from osteoporosis.  Clearly transwomen should follow the advice of their physicians regarding post-GCS HRT, but as a guideline, the National Osteoporosis Society (UK) advises that the minimum daily dose to maintain bone density in normal adult post-menopausal women is thought to be 0.625 mg conjugated Estrogen (e.g. Premarin) or 2 mg oestradiol by mouth, or a 50 micrograms oestradiol skin patch.

While the warnings cannot be emphasised enough, and they are certainly not a magical potion, hormones have nevertheless helped to transform the lives of a million+ transsexual women in a way that was unimaginable just 50 years ago.

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.

 

Risks
The "Standards of Care" states that:

"The administration of hormones is not to be lightly undertaken because of their medical and social risks.  .....  cigarette smoking, obesity, advanced age, heart disease, hypertension, clotting abnormalities, malignancy, and some endocrine abnormalities may increase side effects and risks for hormonal treatment. Therefore, some patients may not be able to tolerate cross-sex hormones. However, hormones can provide health benefits as well as risks.  Risk-benefit ratios should be considered collaboratively by the patient and prescribing physician."

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:

Thrombophlebitis or thromboembolic disorders Cerebro-vascular or coronary artery disease Undiagnosed abnormal genital bleeding Benign or malignant liver tumour

Relative contraindications which increase the risk of complications developing include:

Age over 45 Diabetes Hypertension Smoking Gallbladder disease Gestational cholestasis History of renal disease Impaired liver function Hyperlipidemia

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:

Elevated blood pressure Benign liver tumour Hepatitis Pulmonary embolism Thrombophlebitis Gallbladder disease Carcinoma of the breast (Breast Cancer) or other Estrogen-dependent neoplasia

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 Estrogen. The risks of complications developing can be significantly reduced by leading a healthy lifestyle, for example:

Don't Smoke Drink alcohol only in moderation Eat healthily Drink plenty of water Exercise regularly Avoid high stress levels Take the minimum hormone dosage necessary to achieve/maintain benefits No drug abuse

Long Term Risks
There is only very limited information based on direct studies about the risks transsexual women face due to long-term Estrogen and progesterone-based hormone therapy.  Assumptions have generally been for the worst, but that is gradually changing as additional relevant research slowly appears.

Medical opinion in the late 1990's was that the very high levels of hormone therapy required in a pre-SRS woman would inevitably be associated with health risks in the long-term - more than two years - and that these risks increased with the age of the patient.  SRS or an orchiectomy was thus essential to allow 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.  The use of modern bio-identical rather than synthetic hormones further reduces health risks.  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 evidence so far is unfortunately slightly 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!

A 31-year old transwoman after 7 years taking hormones - no surgery.

In addition to the primary feminisation effects, long-term Estrogen therapy may actually have some benefits for the body of the male-to-female transsexual woman.  For example some research on transsexual women indicates that long term Estrogen-based hormone replacement therapy (HRT) protects the trans women against heart disease but slightly increases the risk of breast cancer, while other research suggests that provided they are conservatively treated with Estrogens 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.  On balance, 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 - superficially good news until you realise that 2.6% of women die from breast cancer, compared to under 0.1% of men.

Two reports published in the Journal of the American Medical Association on 3 July 2002 unfortunately contained further bad news.  A study of 16,600 genetic post-menopause women taking a combination of conjugated Estrogen (e.g. Premarin) and medroxyprogesterone acetate (e.g. Provera)  - a very common regimen for transwomen - found that the therapy lowered the risk of hip fracture, a measure of osteoporosis, but 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. 

Trace Lysette credits hormones for her substantial breast development and excellent figure and claims to have had no plastic surgery.

There have been subsequently ore positive reports.  For example an article in the 24 February 2015 issue of the Journal of Clinical and Translational Endocrinology are actually very positive for transwomen.  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
A post-SRS transsexual woman on long-term hormone therapy is far closer to a natal woman than a man where many health matters are concerned.  A few examples:

• She must regularly examine her breasts for odd lumps, secretions from the nipple, and changes in the shape of one breast.

• Breast cancer is a serious risk.  As a rough guideline, any transwoman over age 45 and ten years plus on Estrogen hormones should get a mammogram every two years - it could be lifesaving.

• Maité (formerly Alexandre) Schneider started hormones age 18, Shown age 21 before SRS. (Brazil)

  Whilst she can't get cervical cancer, if she is sexually active, she should still get a Papanicolaou test (aka Pap or smear test) every two years to identify abnormal conditions and infections

• A bi-annual vaginal examination is recommended to detect growths or other abnormalities 

• Many transwomen suffer from vaginal irritation and malodorous vaginal discharge

• Urinary tract infections are common in transwomen, particularly if sexually active

• Transwomen have a greatly increased likelihood of suffering from fibromyalgia, a condition resulting in muscular pain and genera fatigue which is rare in men

• Osteoporosis - weakened bones and increased risk of breakages - is more likely

• A significantly increased likelihood of suffering from migraines (x3 according to one study)

• Drastic mood swings and depression (which had never been experienced by the suffer before SRS)

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.

 

Bioidentical Hormones

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 is 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, happily, become apparent that transwomen who require only a modest boost to their estrogen levels in order to stay healthy post-GRS 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.

	Leora Moore Pre-SRS Daily: 8 mg Estrofem 0.5 mg Dutasteride 200 mg Spirolacatone 200 mg Microgest (1st 10 days of the month)		Rachel Saunders Pre-SRS Daily: 1.25 mg Premarin.
	Natta Klomklao Pre-SRS: Diane 35 Post SRS: Daily: Premarin and 10mg estradiol valerate Weekly: 250mg hydroxyprogesterone-Caproate injections		Julie Pre-SRS: Initially: Daily 10 mg Permarin; Weekly injection of 300 mg  spiro, proscar and prometrium. Currently: Daily 2.5 mg Premarin Weekly:  injection of 1CC of 40mg per ml of Del-estrogen
	Jhenna Kelly Taylor 100mg Androcur & Estradam daily.		Barbie Pre-SRS: Twice monthly injections of 40 mg Estradiol Valerate and 150 mg Depo-Provera.
	Nun Umdomsak Pre-SRS: Diane 35 tablet & 1.25mg Premarin daily; Post SRS: 10mg Progynon Depot & 250mg Prolution Depot combined injection.		Vanessa Lopez Pre-SRS: Premarin.  Post SRS: 1 mg Androcur every second day.
	Jessica Pre-SRS: 2.5mg Premarin/day 10mg/ml IM (shot) weekly Estradiol Valerate (40mg/ml month) 300 mg Spiro/dy Post-SRS: 0.65 Premarin daily 10mg/ml Estradiol Valerate every 10 days (30mg/mo)		Kira Post-orchiectomy: 1ml Estradiol Valerate injection monthly

 

Obtaining Drugs without Prescription
Most countries require a doctors prescription for the purchase of female hormones and anti-androgens from a local pharmacy.  However in the 'noughties' it was very easy to obtain hormones - often quite cheaply - via the internet without a 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. 

Singer Dana International started hormones age c.17.  It's unlikely they were obtained with a prescription.

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:

• Calvizie (http://www.anagen.net/salusin.htm) - Implies that they are an Italian company.  Offers hormones and antiandrogens useful to transsexual women.

• Inhouse Pharmacy (http://www.inhousepharmacy.vu) - Nominally based in the Republic of Vanuatu in the South Pacific.

• Pharmacy Network (http://www.pharmacy-network.com) -  They claim to be based in Europe, India and the Far East (Malaysia?).  Very expensive.

• Medica International Pharmaceuticals (http://www.medica-ch.com) - Claims to be based in Switzerland.

And for optimists seeking a non-prescription herbal solution:

• The Phoenix Project (http://www.myevanesce.com/) - Run by a transsexual woman in the USA, will ship internationally.

  Professor Marie-Pier Ysser, formally the showgirl "Bambi".  Shown age 40, after 20 years of hormone therapy.

Important Notes:

1. I have not personally used any of the above companies, and make no personal recommendation about the quality of their service.

2. Be warned that the cost of drugs on these sites is often much higher (double, treble, ...) than what you would pay in a local drug store/pharmacy if presenting a prescription. .

3. After a clampdown on the personal importation of prescription drugs by the FDA, women in the USA face possible customs detention and non-delivery of their orders.

4. Because of known customs problems, companies may not take orders which require shipping to some countries (e.g. Sweden and USA).

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.

 

My Experience
Hormones are not magical pills that will turn the average XY man into the Next Top Model, but they are an essential aid for a successful MTF transition.  However, they are not to be taken lightly.  In my experience, after just a few weeks on hormones I would lose all sex drive and become incapable of an erection, which may disappoint some readers who've watched far too many she-male videos starring men with generous breast implants!  The recommended regimen for a pre-GCS transwoman will certainly result in sexual impotency within a month or two, followed eventually by hormonal castration, whilst often irreversable physical changes such as obvious breast development (gynecomastia) will occur within a year.

I'm not a doctor and you should seek professional medical advice and supervision before starting hormone therapy.  However, I know that the reality is that many transgirls still go DIY, and indeed the hormone regimen I followed for many years was self developed.  It is based partially upon trial and error experiences from when I started to take feminizing hormones in 1994, and partially upon research dating back to 1997.  I include it on this site only for interest, and without prejudice.

 

More Information
For those that want to learn a lot more about hormones, here are two good links:

• FAQ: Hormone Therapy for M2F Transsexuals

• Hormone Therapy