Estrogen-Based Hormone Therapy

Some trans and gender diverse people benefit from gender-affirming hormone therapy to promote physical characteristics reflective of one’s gender identity or gender expression.
Estrogen, often in combination with a testosterone blocking medication, is used to reduce testosterone-related features, induce estrogen-related features and relieve distress related to gender. This page sets out the advantages and disadvantages, expected effects, and potential risks of common estrogen, testosterone blocker and progesterone therapies. The list of therapies is not exhaustive. Talk to your health care provider to determine the best fit for you.
Common therapies

Your health care provider will help you tailor your hormone therapy to meet your goals, health needs and budget. Your hormone therapy may include any of the following:

  • estrogen alone
  • estrogen and testosterone blockers
  • estrogen and testosterone blockers and progesterone
  • testosterone blockers alone (this is not safe for long periods of time)

Common estrogen therapies

Oral estrogen 

  • brand name: Estrace 
  • description: a pill you swallow or dissolve under your tongue each day
  • advantages: less expensive (around $14 a month)
  • disadvantages: higher cardiovascular risk for people over 40, especially with other risk factors

Estrogen patch 

  • brand names: Estradot, Estraderm, Oesclim
  • description: a patch you wear on your skin that gets changed twice a week
  • advantages: lower cardiovascular risk for people over 40, especially with other risk factors
  • disadvantages: more expensive (around $25 a month). some people have a skin reaction to the adhesive in the patch

Injectable estrogen (estradiol valerate)

  • description: a substance you inject every week or two (sometimes twice weekly)
  • advantages: possibly lower cardiovascular risk for people over 40, especially with other risk factors
  • disadvantages: requires a compounding pharmacy, more expensive and less widely available, some people find injections to be painful.

Common testosterone blocker therapies

Spironolactone 

  • brand name: Aldactone
  • description: a pill that you swallow once or twice a day
  • advantages: most common because it’s less expensive ($22 a month) and usually well tolerated
  • disadvantages: some people find pills hard to swallow. may make you have to pee more often and may require dietary restrictions

Cyproterone 

  • brand name: Androcur
  • description: a pill that you swallow once a day
  • advantages: potent testosterone blocker
  • disadvantages: more expensive (around $50 a month). may cause liver inflammation, especially in higher doses, and depression

Finasteride 

  • brand name: Proscar
  • description: a pill that you put under your tongue once a day or every other day. Will not suppress testosterone levels on its own
  • advantages: can help slow hereditary hair loss
  • disadvantages: costs around $60 a month

Common progesterone therapies

The role of progesterone is not well understood. Most guidelines do not recommend the use of it as part of a standard regimen but discuss the possibility of using it as an adjunctive medication for a period of time.

Benefits may include positive effects on the development of the nipple and areola and improved libido, but this is unproven. 

Common side effects include weight gain, edema, lipid changes and depression. Taking progesterone along with estrogen as compared to taking estrogen alone may increase health risks. 

Medroxyprogesterone 

  • brand name: Provera
  • description: a pill you take daily
  • advantages: widely available and less expensive
  • disadvantages: thought to be higher risk

Micronized progesterone 

  • brand name: Prometrium
  • description: a pill you take daily
  • advantages: thought to be lower risk than medroxyprogesterone
  • disadvantages: more expensive at about $90 a month
These therapies are also known as feminizing hormones. To be more inclusive of diverse gender identities, we are using language that focuses on anatomy, treatments and presenting concerns, rather than gender. 

Effects

Expected effects of estrogen-based hormone therapies

Breast development

  • usually starts in 3 to 6 months
  • breasts reach full size in 2 to 3 years
  • size varies; A or B cup size is typical
  • a  permanent change

Body fat redistribution

  • usually starts in 3 to 6 months
  • reaches maximum effect in 2 to 5 years
  • less fat on abdomen
  • more fat on buttocks, hips and thighs
  • not a permanent change if you stop taking hormones

Reduced muscle mass & strength

  • usually starts in 3 to 6 months
  • reaches maximum effect in 1 to 2 years
  • reduced muscle and strength in upper body
  • not a permanent change if you stop taking hormones

Softening of skin

  • usually starts in 3 to 6 months
  • skin will be softer and less oily
  • not a permanent change if you stop taking hormones

Less facial & body hair

  • usually starts in 6 to 12 months
  • maximum effect in more than 3 years
  • body hair will appear less noticeable
  • body hair will grow more slowly
  • facial hair may grow more slowly and appear less noticeable, but will not go away
  • if you have scalp hair loss, it may slow down
  • hair that has already been lost likely will not grow back
  • not a permanent change if you stop taking hormones

Reduced sex drive

  • usually starts in 1 to 3 months
  • reaches maximum effect in 1 to 2 years
  • less spontaneous physical arousal
  • not a permanent change if you stop taking hormones

Fertility

  • timeline varies
  • sperm may no longer reach maturity
  • won’t produce as much semen
  • may not be able to get hard enough for penetrative sex
  • may become permanently unable to make someone pregnant (but birth control is still recommended)

Smaller gonads (testes)

  • usually starts in 3 to 6 months
  • maximum effect in 2 to 3 years
  • may shrink down to half their initial size
  • may or may not be a permanent change if you stop taking hormones

Emotional changes

  • overall emotional state may or may not change; this varies from person to person
  • may experience a narrower or wider range of emotions or feelings

External video resource

A presentation by Dr. Maddie Deutsch, from the Center of Excellence for Transgender Health.

Risks

Risks associated with estrogen-based hormone therapies

With estrogen-based hormone therapies, there is: 

  • a likely increased risk of serious blood clots (venous thromboembolic disease), gallstones, elevated liver enzymes, weight gain and hypertriglyceridemia (risk factor for heart disease and pancreas problems)
  • a likely increased risk (with presence of additional risk factors) of cardiovascular disease
  • a possible increased risk of high blood pressure (hypertension), hyperprolactinemia or prolactinoma 
  • a possible increased risk (with presence of additional risk factors) of type 2 diabetes

There is either no increased risk of breast cancer or the research is inconclusive. 

Mood changes are variable; they may be positive or negative, or may have an adjustment period. Many people experience positive mood changes after starting hormone therapy. Any mood changes that cause you concern should be discussed with your primary care provider.

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