Feminizing (MTF) Gender Affirming Hormone Therapy
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.
Introduction
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.
How do I know hormones are right for me?
I tell my friend 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.
Some Changes to Expect
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.
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
Any body fat you gain after starting hormones will deposit around the hips and buttocks rather than the stomach.
Over the timeframe of months to years, your body will take on a feminine shape.
Advice
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!!!
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
Emotional changes
You will experience changes to emotions that are broad and often difficult to explain in a blog post. The amazing thing about the emotional changes is how they continue to grow and shift as you take your hormones.
Increased spectrum of emotions
Crying
Increased empathy
Typically GAHT results in decreased rates of anxiety and depression
Each person experiences their own unique combination of these changes and other changes.
I feel like every person I talk to on feminizing hormone acquired some cool and random feature(s) because of their ‘mones.
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
Medicine has little to no idea about the role of progesterone in transfeminine folk.
The data we use is mostly anecdotal.
Progesterone is often taken to improve mood, libido, and fill out the shape of chest tissue.
It will serve you best to wait 1-1.5 years after your E levels are at goal, to achieve maximum chest growth, before starting progesterone.
Please take your Progesterone orally, not rectally.
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
If you remain with the genitals you were born with, there is a chance that you may stop feminizing hormone therapy, and return to pre-transition hormone levels.
Most changes will likely reverse over time.
Chest tissue growth cannot be reversed.
This subtack article is a phenomenal source for more information.
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.
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