Feminizing (MTF) Gender Affirming Hormone Therapy (GAHT) Guide
Background
I worked at a gender affirming clinic for nearly two years before leaving New Jersey. Being there is how I realized I myself am trans. For me, medically transitioning began a process of discovering sustainable self love. I love taking estrogen.
What is feminizing gender affirming hormone therapy?
Medical transition is one aspect of gender transition a trans person may decide to pursue. Feminizing therapy is for those assigned male at birth who identity as transfeminine, transwomen, or a whole host of other wonderful gender identities. The process involves taking the hormone Estradiol, often combined with Spironolactone, to increase the person’s blood levels of estrogen and decease their blood levels of testosterone. Increasing the levels of estrogen sparks changes to the body similar to puberty in cis gender women.
Much like there are cis women of all different body shapes, sizes, and types, the results of your feminizing hormone journey will vary.
Three major factors that affect the extent of your transition are
Age at time of medical transition
Genetics
Whether or not you have experienced male puberty
Not everyone should expect to pass as a cis woman from taking feminizing gender affirming hormone therapy (GAHT). Whatever your transition goals and results are, you are a valid trans individual.
What does informed consent model mean?
This is a way for medical providers to start you on gender affirming therapy without consulting a psychiatrist for a letter. Informed means you were told about the expected changes, risks, and side effects of the medication. Consent means you are able to make the decision on your own without a parent or legal guardian present. The provider will either obtain verbal consent or have you sign a consent form.
Generally speaking, most folks over 18 who made their own appointment, showed up to it, and expressed a desire to start feminizing hormones are able to consent. There are special instances where the medical provider may ask for a clearance letter from a specialist or psychiatrist. This is not intended to make getting hormones more challenging. The medical providers are under scrutiny of the federal government for providing medical transition care. They are protecting themselves and their patients.
How do I know hormones are right for me?
I tell my friends and patients the same things. You ever really know until you try. In my experience, within 12 hours of my first estradiol dose, I knew I had made the right choice. There are very few risks to trying feminizing hormone therapy. No medical provider should restrict your access based on desires to see how you like hormones before fully committing.
What changes does feminizing gender affirming therapy cause?
This is a list I have compiled myself from the research and anecdotal data from folks on feminizing hormone regimens. It is by no means comprehensive. Each person can expect a varying degree of some or all of these changes, based on their own unique makeup. Each person I talk to on feminizing hormone acquired some cool and random feature(s) because of their ‘mones.
Skin
Becomes less oily and more dry
You may be more prone to bruising and cutting
Changes in the sensations of pain, pressure, and temperature may occur
Body hair
Your hair may grow at a slower rate, it may grow in less thick
There is a possibility for scalp hair loss to be reversed
Chest tissue growth
This will happen to some extent on all feminizing regimens
Expect sensations of (mild) pain, fullness, and possibly lactation
Look to your mother’s breasts size for indications on how much growth you may achieve
Body composition changes
Changes to face structure
Folks on estradiol tend to gain a more rounded face, particularly the jaw
Estrogen will cause body fat to be deposited around the hips and buttocks as opposed to the stomach
Advice
Of all the changes, this category takes the longest time, be patient, and continue to take your estradiol
If it suits your goals, before starting hormones, under supervision of a medical provider, use caloric restriction to lose weight
This will reduce the size of fat tissue around your stomach, helping you achieve a flatter appearing abdominal region
Avoid weight cycling
ALL TRANSFEMININE BODIES ARE VALID!!!
Muscle mass changes
Upper body muscles may decrease in size and strength
Those of us on Estrogen notoriously experience difficulty opening jars
This muscle loss can be mitigated by resistance training
Lower body muscles such as the buttocks, hamstrings, and quadriceps may increase in size and strength
Especially in response to resistance training
Sexual changes
Decreased libido
Changes in size of the penis and testicles
Changes in sensation
The genitals can become quite sensitive
This may require changes to pleasure routines
Advice
Penis function is directly related to euphoria/dysphoria regarding your anatomy
You are a valid transfemme if you find euphoria having a penis
You are a valid transfemme if you pursue vaginoplasty
Emotional changes
You will experience changes to emotions that are broad and difficult to explain in a blog post
Increased spectrum of emotions
Crying
Increased empathy
The amazing thing about emotional changes is how they continue to grow and shift as you take your hormones
Mental health changes
Typically GAHT results in decreased rates of anxiety and depression
Risks of Feminizing Gender Affirming Hormone Therapy
Spironolactone can cause abnormal heart rhythms.
Estrogen can impact liver function.
GET YOUR LABS CHECKED
Compared to pre-transition hormone levels, your risk for blood clots is increased, but is not higher than a cis woman’s risk.
It is best not to consume tobacco while taking feminizing hormones.
Change to risk for cardiovascular disease.
Generally, people feel better in terms of anxiety, depression, and suicidal ideation after starting hormones.
There is a risk that starting a new medication can cause negative changes to mental health.
Hormone Regimens
The ideal hormone regimen is based on a person’s transition goals.
I refer to two general broad categories of regimens 1) nonbinary regimen, 2) transwoman regimen. These regimens are able to be tailored to the individual’s desires for feminizing characteristics.
Nonbinary regimen
Will likely lead to noticeable changes in skin, chest tissue growth, emotional changes, and sexual functioning.
The extent to which the changes occur vary by dosage and the factors above
Oral
2 to 4 mg Estradiol sublingual daily +
50-100 mg Spironolactone daily
Injectable
2 to 4 mg Estradiol injected intramuscular or subcutaneous once weekly +
50-100 mg Spironolactone daily
Transwoman reigmen
Oral
2 mg Estradiol sublingual twice daily +
100 mg Spironolactone daily
Injectable
2 to 4 mg Estradiol injected intramuscular or subcutaneous once weekly +
100 mg Spironolactone daily
Sublingual Estrogen
Do yourself a favor and place the pills under your tongue
They will dissolve
It increases the total amount of estrogen absorbed from the pill from 5% when swallowed to 10%
Take them twice daily, about 10-12 hours apart, to maximize your blood levels of estrogen
Injectable Estrogen
There are transfeminine folk who go their entire transition taking estradiol under the tongue
Injections are not for everyone, it involves drawing up and administering your medication with needles
Injectable Estrogen generally results in higher levels of Estrogen, over longer periods of time
If you are or a partner are able to reliably administer your E this way, trust me, and try it.
Progesterone
The research data for effectiveness of progesterone in transwomen is inconclusive.
Thus, we focus on the anecdotal evidence.
Progesterone is added to feminizing regiments to improve mood, libido, and fill out the shape of chest tissue.
Though it has many more benefits, you can read about here
A typical dose of progesterone is 100 mg or 200 mg once daily.
There is no proven benefit from cycling progesterone.
The current best practice is to delay progesterone until breast development has plateaued.
A GENERAL rule of thumb is starting 1-1.5 years after E levels have been consistently at goal.
Progesterone, when taken orally, causes drowsiness.
Please do not take it before driving or any other activities that require you being alert.
Progesterone may negatively impact mental health
This seems to be a higher risk when cycling the medication.
Checking Your Levels
There are two schools of thought regarding checking hormone levels
The first is not checking levels and letting the person be if they feel well and are experiencing feminization with no adverse side effects.
The second is to check levels at every 3 months for the first year, yearly thereafter if there is no dose adjustment, or as needed when the dose is adjusted.
It is so important to have labs checked if that is accessible to you. It is a way to get the most out of your transition. Plus your medical provider will assess your liver function too, which can be affected by feminizing hormones.
Needle Tips
For intramuscular injections you will need a 23 gauge, 1” needle to administer the hormones.
For subcutaneous inections you will need a 25 gauge, 5/8” needle to administer the hormones.
It has been recommended to me by trans elders to draw up your hormones with a 22” gauge needle. This prevents coring. Coring is when the needle breaks apart the cap of the hormone bottle, causing rubber to fall into the medication.
Needles from Amazon are affordable, but are not tested on humans.
MD supply has medical grade needles, requires a prescription.
For free or reduced cost injection supplies, check your area for a harm reduction program or needle exchange.
When in doubt, find other trans folks.
Do people regret medically transitioning?
In my experience as a health care provider one patient out of 400 discontinued gender affirming hormone therapy
The studies about regret and detransition are questionable in statistical significance
This subtack article is a phenomenal source for more information.
Is feminizing hormone therapy reversible?
To some extent, yes. There is little evidence on this. If you keep your innate gonads (penis and testicles) and stop your feminizing hormone therapy, the changes are likely reversible. It will take time for the body, emotions, and mind to return to the way it was prior to your medical transition.
Chest tissue growth is not reversible. If removal is desired it will require surgery.
Things I wish I was knew before I started medical transitioning…
People will drop out of your life without you having to do anything, simply because you are making a choice that will give you the confidence to consistently choose yourself, over people pleasing.
You will be unable to occupy spaces that require you to abandon yourself.
You did not have to know you were trans from an early age.
Using sex to dissociate is a symptom of gender dysphoria.
You will be called he/him and sir no matter how feminine you look.
Having tits is absolute euphoria.
How can I get started on feminizing GAHT?
There are two ways to go about this
Under the supervision of a medical provider
In your browser search “gender affirming clinic near me”
Use the LBGTQ+ healthcare directory to find a provider who prescribes hormones
Do It Yourself (DIY)
You can buy or make your own hormones and self administer
This is a perfectly valid way to transition
Please, when it doubt, seek a medical professional
More Resources
The University of California San Francisco guidelines for feminizing gender affirming hormone therapy
A comprehensive review of the literature for feminizing gender affirming hormone therapy