Want to Start Estrogen-Based Hormone Therapy? Here's What to Know

If you're interested in estrogen-based gender-affirming therapy, you can easily connect with a care team via telemedicine.
Image Credit: Renata Angerami/E+/GettyImages

Getting on hormones is one of the most common goals transgender and gender non-conforming people have once they've decided to transition. Indeed, gender-affirming hormone therapy (GAHT) is a popular form of gender-affirming care, says Jerrica Kirkley, MD, CMO and co-founder of Plume, which provides this type of care via telemedicine.

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"It is estimated that about 80 percent of the gender-diverse community desires to be on GAHT," Dr. Kirkley says. "In general, it helps support alignment between one's gender experience and outward expression, which can look very different for different people."

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Male-to-female (MtF) is a term used by some but not all folks who desire to undergo estrogen-based therapy. "Many folks on estrogen-based therapy don't identify as feminine or female," Dr. Kirkley says. "We use the term 'estrogen-based gender-affirming hormone therapy' to encompass the wide breadth of gender identity, including non-binary, genderqueer, agender, gender-fluid and other identities."

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Using the right terminology is just one part of understanding estrogen-based gender-affirming hormone therapy. Knowing what hormones are involved, what changes to expect and having a general timeline in mind are also important components of successfully achieving your hormone therapy goals.

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What Is Estrogen-Based GAHT?

While some people use the term hormone replacement therapy (HRT) to describe this part of medically transitioning, the more accurate term is gender-affirming hormone therapy, or GAHT.

"Technically, HRT describes providing hormones to folks who are no longer producing adequate quantities of the hormones they predominantly produce from birth," Kirkley says. "This is therapy typically provided to cisgender individuals," such as women going through menopause.

Michelle Forcier, MD, MPH, a clinician with Folx Health, explains that GAHT for trans-femme patients (sometimes referred to as feminizing hormone therapy) involves using bio-identical hormones to support gender identity and expression.

Transgender or gender-non-conforming youth usually take a different approach.

"Transgender youths who have not started or completed puberty can receive 'puberty blocker' medication, which suppresses the release of sex hormones, including testosterone for some and estrogen for others," Mary Jacobson, MD, ob-gyn and chief medical advisor at telemedicine company Alpha Medical, tells LIVESTRONG.com.

Who Is Estrogen-Based GAHT Right For?

Most transgender folks who go on GAHT do so to try to alleviate the cognitive dissonance they feel between their true identity and their bodily experience. Hormones are a great way to get one's body in line with their identity.

"Patients who seek gender-affirming care are often experiencing gender dysphoria or 'psychological distress' due to incongruence between gender assignment and identity," Dr. Jacobson says.

"In addition to helping obtain an internal alignment, for some, it can also be helpful for safety reasons to be recognized as their known gender and have alignment with legal documents in regards to gender marker and name change," Dr. Kirkley adds.

Those who know they are transgender, gender-diverse or nonbinary are typically thoughtful and sensitive about their options before deciding to go on hormones or make any life-altering medical decisions when it comes to their gender identity, Dr. Forcier says. They seek out GAHT in order to live their most authentic and healthful lives.

"Persons who identify as gender-diverse or transgender often do quite a bit of research on their own about what this means and what options for care exist," she adds. "Thoughtful and sensitive evaluation and prescribing make these hormones even safer and more effective."

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Which Hormones Are Involved?

While estrogen is the main hormone used in GAHT, there are other hormones involved. "The general approach of feminizing hormone therapy is to combine an estrogen with an androgen blocker, and in some cases a progestogen," which produces a similar effect to the natural female hormone progesterone in the body, Dr. Jacobson says.

"Estradiol is the specific type of estrogen that is prescribed for GAHT," Dr. Kirkley says.

Brand names for estradiol include Delestrogen, Yuvafem and Vivelle-Dot. It can be taken as a pill, injection, patch or gel, Dr. Forcier says.

Dosing and frequency is different for every patient based on their individual goals, Dr. Kirkley says. "Generally speaking, tablets are taken anywhere from one to three times per day, injections are given once weekly and patches are placed once or twice weekly depending on the formulation," she adds.

Estradiol isn't the only medication providers prescribe, though. "We also prescribe 'testosterone-blocking' medications to help block the 'masculine' changes that testosterone induces," Dr. Kirkley says. These don't have to be prescribed with estradiol, but they can be helpful depending on the patient's goals.

What Kind of Transition Timeline Is Typical for Folks Taking Estrogen?

Timeline of Bodily Changes While on Estrogen Therapy

Expected Onset

Max Effect

Mental health benefits

Immediate

Lifetime

Breast development

3 to 6 months

2 to 3 years

Body fat redistribution

3 to 6 months

2 to 5 years

Decreased muscle mass and strength

3 to 6 months

2 to 5 years

Genitalia changes

3 to 6 months

2 to 3 years

Skin (softer, less oil and acne)

3 to 6 months

unknown

Voice

Not affected

Not affected

Body hair thins and grows slower on face

6 to 12 months

3 years

Decreased sex drive and erectile dysfunction

1 to 3 months

3 to 6 months

Source: Dr. Jerrica Kirkley

Some changes happen very quickly during hormone therapy, while others can take a couple of years to show, Dr. Forcier says.

"Earlier effects start within the first three to six months and may include skin that becomes less thick and oily," she notes. "It will include some early growth of breast tissue called 'breast budding.' Sexual desire and drive, as well as erectile and sexual function, change due to lack of testosterone."

Changes to body shape tend to take longer, while changes to one's voice or skeletal structure do not happen during GAHT.

"The thing that surprised me the most was the appearance of a cycle around six months [into therapy] that involved breast tenderness and major mood swings," says Dyzee, a Utah-based Airsoft influencer and transgender woman who started hormone therapy about 10 months ago. "I even get cramps where it feels like my muscles around my groin...will ache for like 30 seconds to a minute quite severely. The cycle lasts five to six days for me about every three weeks, and from what I've read, it happens for almost all of us every three to five weeks to varying degrees."

For Maria Maughan, an operator with TTM Technologies, the most surprising thing that happened to her after starting estrogen therapy was "basically having a second puberty. I did ​not​ expect to behave like a teenager again for the first few months," she says. "I heard it was a roller coaster, but damn."

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Which Parts of GAHT Are Permanent?

Many transgender people seek GAHT for the near-permanent changes it causes. However, there's only one change that will stick even if the person stops taking hormones.

"Many of the effects of hormone therapy are reversible if the person stops taking them," Dr. Jacobson says. "The degree to which they can be reversed depends on the length of time taking them. Some breast growth and possibly reduced or absent fertility are not reversible."

If breast development isn't desired, Dr. Forcier says, the person might take a low dose of estradiol or other medications to meet their gender goals.

How Does Estrogen Therapy Affect Mental Health?

Now that we've covered how transitioning can affect a person's physical health, what about their mental health? What kinds of changes can someone expect mentally? Both Drs. Kirkley and Forcier have seen great results in their practice.

"Our patients often tell us how much more confident they feel and that they feel less anxious and depressed," Dr. Kirkley says. "Many note that they are more active in their communities and doing things like exercising and eating healthier. Many describe it as a '180' from where they were before starting GAHT. "

Along with being more community-oriented, using hormones to transition can have a huge effect on your self-esteem as well.

Acceptance does wonders for one's confidence and self-esteem.

"If you are acknowledged and accepted, by yourself and others, that is a huge boost for self-esteem, self-love and self-confidence," Dr. Forcier says. "Taking gender-affirming hormones is an empowering and biologic way to move toward a better match of a person's identity with their internal hormone environment and their externally presented self."

Dr. Jacobson says gender-affirming hormone therapy tends to reduce anxiety, depression and distress in most patients.

Dyzee says going on estrogen changed her life: "The best thing for me was the disappearance of my social anxiety," she says. "My spouse used to have to fight tooth and nail to get me to leave the house even for short periods of time pre-transition, but now I ​love​ being in social situations. I finally feel like I'm not watching every move I make to make sure I seem as masculine as possible."

Maughan says she also noticed a great change in her mental health once she started estrogen-based therapy.

"Before I started HRT, my anxiety would manifest itself unexpectedly, and I would instantly snap from a happy to angry person and I would turn into the worst version of me," Maughan recalls. "Everyone viewed me as a powder keg and felt like they were walking on eggshells around me. Upon starting HRT, my anxiety disappeared and I turned into someone that my friends and family were happy to be around. I'm constantly told by my children that it was the best thing I ever did."

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