A Crash Course in Hormones and HRT for Transgender People Part 1

Since the beginning, this has been one of our most requested and anticipated articles. So, finally, we are getting to the subject that draws scrutiny and derision- as well as some very questionable practices. Of course, that subject is HRT or Hormone Replacement Therapy. You deserve and need to know what you are getting into and what to expect. As with any medical procedure, you need to be educated and understand what will be happening with your body. And hopefully, you won’t choose to make some of the terrible mistakes that some trans people do.

*This information is no substitute for, or pretends to be, medical advice. I am a web developer and writer, not a medical professional. Any information here is presented based on research and experience. However, we stress that you speak to your medical provider about any questions you have and before you begin treatment.

What are Hormones?

Hated science class? Well tough falsies because one- science rocks, and two- you wouldn’t work on a carburetor if you didn’t know what it did or how it worked. So tough it out and learn about your body.

Here’s the quick answer, hormones are one of the three main components of what makes up the physical facets of gender. Chromosomes and gonads are the other two. The rest of what you think is male or female is really a secondary gender marker and can honestly occur in men or women. Some women have square jaws, some men develop breasts. What can I say? Bodies are weird that way.

For men, the hormones consist of Testosterone and its derivative 5alpha-dihydrotestosterone (DHT). Strong stuff, which we will get to later. For women you are looking at Estrogen and progesterone, which are no slouch themselves. However, in HRT the effect and scope of change is very different. But we will get into that later.

So What Do Hormones Do?

Often, we see gender attributed solely to chromosomes, and don’t hear as much about hormones. However, it is these hormones that set many of the secondary gender markers like body hair, voice pitch, etc. And so for those wishing to attain certain visual characteristics, hormones are a must.

Hold up keyboard warriors, that isn’t to say that being gender non-conforming or being trans means you HAVE to undergo HRT (Hormone Replacement Therapy), or that it is a requirement of transition. For health, financial, religious, or personal reasons- there are many people who opt to be non-op or non-hrt or both. Some people identify as transgender and don’t transition. It’s all valid, of course. But somethings just won’t happen without HRT.

TransgenderCare.com offers this explanation:

Testosterone and its potent derivative 5alpha-dihydrotestosterone (DHT) induce penile growth and secondary sex characteristics as sexual hair, deepening of the voice, a muscular build and the greater average height in males in comparison to the females. In girls, estrogens in conjunction with Progestogens induce breast formation and a fat distribution predominantly around the hips; subcutaneous fat padding produces a softness of the body configuration and of the skin. The skin in women is further generally less oily than in men; the latter on the basis of activation of the sebaceous glands by androgen.

So puberty comes along, and blammo- secondary gender markers all up in the joint. Up until puberty, we generally have to go out of our way to express our gender identity. As we saw in “Stranger Things” a preteen girl with a shaved head and neutral clothing had no problem passing as male (unintentionally). And it was even harder in the past when everyone pretty much put all kids in the same clothes- mostly dresses. Aside from a primary gender marker like genitalia to discern out- there is little difference outwardly.

So What Does that Mean to Me?

Me, me, me. That’s all you talk about. Well, to answer your question, it means that we are attempting to induce secondary gender markers and traits after puberty- to varying degrees of time. Or, we are trying to hold off puberty and avoid having these hormones start doing their remodeling work in the first place so that HRT can be begun. In many cases we are looking to also minimize unwanted gender markers as well as making changes to the body.

In the case of trans women, we are looking to not only block testosterone and DHT but also introduce estrogen or progesterone into the body. We will talk a bit more about how exactly this is done a bit later. Seriously, buckle up, it’s a long article.

So if that is your goal in mind, then HRT might be your ticket. Of course, there are some things to consider when starting HRT.

Some Things to Consider When Starting HRT

I know, great literary transition. Call me Hemingway.

So, the first thing you have to know is this- there is a process to medical transition. If you want to use medical procedures to alter your body, you have to go through the proper channels. If you were curious, they also won’t do spinal surgery without going through all the steps either. They generally like to check some boxes first.

The biggest thing is a letter from a therapist. Pretty much any Endocrinologist (think “hormone doctor”) is going to look at you vacantly and play out the movie “Diner” in their head while you talk if you try to go in and talk to them about HRT without a letter from your therapist recommending you for hormones. That’s because they tend to like their job. And performing a procedure on someone that hasn’t been properly checked out amounts to malpractice. So you will have to obtain a letter before an endocrinologist will see you.

Ah, the golden letter. What many transgender people seek, it is seen as a magical ticket that opens up the doors to the rest of your life. That’s right, one letter can change your life. So, for the life of me, I don’t understand why so many people think they can just call a therapist and ask them to write a letter or go to one session and get one. This is a big step- one that can have some irreversible effects. And, frankly, I’d be leery of any professional therapist handing out letters like a vending machine. We call those “letter factories”.

Generally, the rule for both therapists and Endocrinologists is one year of therapy to begin HRT. That’s when you can usually expect to get a letter. It might not be consecutive, or with the same therapist. But you at least need to show you’ve put in some consistent effort and made a commitment to this.

The letter itself is usually pretty straightforward. It essentially says that they’ve seen you for however long and that they’ve found you to be of sound mind and rational enough to make this decision. So that everyone can see it isn’t symptomatic of another condition. Usually, it is also covered that you are not being coerced in any way into this decision and you are doing it of your free will. Also, that it is not sexually motivated.

Once you have this letter, you will get referred to an Endocrinologist. This is either done through your regular doctor, a clinic like planned parenthood or directly from your therapist (ONLY if they are a psychiatrist).

The endocrinologist will run several tests to make sure that you are healthy and suitable for HRT. This will include a medical history and a good amount of blood work. After you get the all clear, your endocrinologist will sit down and work out a plan with you for your treatment including schedule, exact medication, and dosages.

For the record- we won’t be talking about dosages here. It’s considered a no-no. You need to stick to the dosage you are given. Even if you feel it isn’t happening fast enough and your friend is on a higher dosage than you. Just know that you are on the right dosage for you, and if you aren’t then your doctor will adjust that. Taking too much, or an incorrect dosage can lead to blood clots, strokes, seizures, taking not good blood thinners and death. Did you come all this way to wind up like that? Read more at http://sideeffectsofxarelto.org/current-xarelto-lawsuits/ and think.

Do I Have to be on HRT Forever?

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Unfortunately, the answer is yes. You will be on HRT for the rest of your life. Some of the effects of hormone replacement therapy are reversible and you will wind up right back where you started if you quit. You will need to discuss this further with your endocrinologist.

What Will I Be Taking?

This is entirely dependent on what your endocrinologist prescribes for you. But here are the types of hormones you can expect to receive:

Male to Female

• Estrogens
  The most commonly prescribed estrogens in HRT for transgender women are micronized estradiol, certain estradiol esters such as estradiol valerate and estradiol cypionate (which are prodrugs of estradiol), and conjugated equine estrogens (Premarin). Estrogens may be administered orally, nasally, sublingually, by intramuscular injection, from an implant, or transdermally (via gel, spray, or patch).
• Progestogens
  Progestogens include progesterone and progestins (synthetic progestogens). Progestogens commonly prescribed for transgender women include progesterone, cyproterone acetate, and medroxyprogesterone acetate. They may be administered orally, sublingually, rectally (by suppository), transdermally (in gel form), or by intramuscular injection.
• Anti-Androgens
  Anti-androgen medications work by blocking the effects of testosterone. For example, they will help slow male-pattern baldness, reduce growth of facial hair, and stop spontaneous/morning erections. They are not needed if one has undergone a bilateral orchidectomy (removal of both testicles).Anti-androgen drugs are often prescribed in addition to oestrogen, as the two have effects that complement each other. Taking anti-androgens reduces the amount of oestrogen you need to get the same effects, which minimizes the health risks associated with high doses of oestrogen. Anti-androgen drugs can be prescribed alone for those who want to reduce ‘masculine’ characteristics for a more androgynous appearance, as it’s less ‘feminizing’ than oestrogen.
  • Steroidal
    The most commonly used antiandrogens for trans women are steroidal: spironolactone and cyproterone acetate. Spironolactone, which is relatively safe and inexpensive, is the most frequently used antiandrogen in the United States. Cyproterone acetate, which is unavailable in the United States, is more commonly used in the rest of the world.
  • 5α-Reductase inhibitors
    Certain antiandrogens do not reduce testosterone or prevent its action upon tissues, but instead prevent its metabolite, dihydrotestosterone (DHT), from forming. These medications can be used when the patient has male-pattern hair loss and/or an enlarged prostate (benign prostatic hyperplasia), both of which DHT exacerbates. Two medications are currently available to prevent the creation of DHT: finasteride and dutasteride. DHT levels can be lowered up to 60–75% with the former, and up to 93–94% with the latter. These medications have also been found to be effective in the treatment of hirsutism in women.
  • Non-Steroidal
    Non-steroidal antiandrogens used in HRT for trans women include flutamide, nilutamide, and bicalutamide, all three of which are primarily used in the treatment of prostate cancer.[45][46] Unlike steroidal antiandrogens such as spironolactone and cyproterone acetate, these drugs are pure androgen receptor antagonists. They do not lower androgen levels; rather, they act solely by preventing the binding of androgens to the androgen receptor.
  • GnRH analogues
    In both sexes, the hypothalamus produces gonadotropin-releasing hormone (GnRH) to stimulate the pituitary gland to produce luteinizing hormone (LH) and follicle-stimulating hormone (FSH). This in turn cause the gonads to produce sex steroids such as androgens and estrogens. In adolescents of either sex with relevant indicators, GnRH analogues such as goserelin acetate can be used to stop undesired pubertal changes for a period without inducing any changes toward the sex with which the patient currently identifies.
  • GnRH agonists
    GnRH agonists work by initially overstimulating the pituitary gland, then rapidly desensitizing it to the effects of GnRH. After an initial surge, over a period of weeks, gonadal androgen production is greatly reduced. Conversely, GnRH antagonists act by blocking the action of GnRH in the pituitary gland.

Female to Male

• Androgens
  A natural or synthetic compound, usually a steroid hormone, that stimulates or controls the development and maintenance of male characteristics. This is usually just generically referred to as “T” or testosterone.
• GnRH agonists
  In all people, the hypothalamus releases GnRH (gonadotropin-releasing hormone) to stimulate the pituitary to produce LH (luteinizing hormone) and FSH (follicle-stimulating hormone) which in turn cause the gonads to produce sex steroids. In adolescents of either sex with relevant indicators, GnRH agonists, such as nafarelin can be used to suspend the advance of sex steroid induced, inappropriate pubertal changes for a period without inducing any changes in the gender-appropriate direction. GnRH agonists work by initially over stimulating the pituitary then rapidly desensitizing it to the effects of GnRH. Over a period of weeks, gonadal androgen production is greatly reduced.
• Progestin injections
  Depo-Provera (depot medroxyprogesterone acetate, or DMPA) may be injected every three months just as it is used for contraception. Generally, after the first cycle, menses are greatly reduced or eliminated. This may be useful for transgender men prior to initiation of testosterone therapy. These work to help eliminate menstruation and acts as birth control.
• Supplements
  Andro ‘Pro-hormones’: Androstenedione, 4-androstenediol, 5-androstenediol, 19-androstenediol, and 19-norandrostenediol are sold as supplements that are purported to increase serum testosterone, increase muscle mass, decrease fat, elevate mood, and increase sexual performance (i.e. many of the effects transgender men seek with androgen therapy). However, there is no good medical evidence that the pro-hormones do any of these things. However, there is evidence that ingestion of these substances can cause elevated estrogen levels, and decreases in HDL (good) cholesterol.

What Will Change?

This will vary depending on dosage, length on therapy, and whether you are a trans male or female.

Female to Male

• deepening of the voice,
• growth of facial and body hair
• male pattern baldness (in some individuals)
• an enlargement of the clitoris
• growth spurt and closure of growth plates if given before the end of puberty
• possible shrinking and/or softening of breasts, although this is due to changes in fat tissue
• increased libido
• redistribution of body fat
• cessation of ovulation and menstruation
• further muscle development (especially upper body)
• increased sweat and changes in body odor
• prominence of veins and coarser skin
• acne (especially in the first few years of therapy)
• alterations in blood lipids (cholesterol and triglycerides)
• increased red blood cell count

Male to Female

• Breast development and enlargement
• Softening and thinning of the skin
• Decreased body hair growth and density
• Redistribution of body fat in a feminine pattern
• Decreased muscle mass and strength
• Widening of the hips (if epiphyseal closure has not yet occurred; see below)
• Decreased acne, skin oiliness, scalp hair loss, and body odor
• Decreased size of the penis, scrotum, testicles, and prostate
• Suppressed or abolished spermatogenesis and fertility
• Decreased semen production/ejaculate volume
• Changes in mood, emotionality, and behavior
• Decreased sex drive and incidence of spontaneous erections

Potential Side Effects

Male to Female

• Blood Clots
• Prolactinoma
• Gallstones
• Possible Risk of Cancer
• Heart Disease
• Infertility

Special note about Spironolactone
Spironolactone is often prescribed in MTF therapy for pre-op trans women. It’s used off-label to this end, as it is usually prescribed for high blood pressure or edema. It is a diuretic that expels water and holds on to potassium. However, you can hold on to too much potassium and wind up with a life threatening situation. So you have to make sure you have your levels closely monitored.

Female to Male

• Heart disease
• Stroke
• Diabetes
• Increased red blood cells and hemoglobin
• Onset or worsening of headaches and migraines
• Cancer
• Mental Health

That’s a very broad overview to start, what questions do you have that you would like answered in part 2? We will be covering supplements, online ordering, administering medication, and more. Let us know what you want in the comments below.