Talk:Pharmaceutical feminizing HRT

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Starting Off

Your first order of business is to get bloodwork done. See Blood tests and staying safe for where to order bloodwork and how to interpret it. If you think you ever want biological kids of your own, you should bank sperm before or immediately after starting HRT. You'll become temporarily infertile a month or two into HRT, and permanently infertile around 9 months in on average, I've heard. Going off hormones to bank later is not fun, and dysphoria may be much worse than it was before you started HRT. See Fertility (AMAB) for more info.

Basic regimen overview

Generally speaking, most feminizing HRT regimens will include an anti-androgen, to suppress the effects of testosterone on the body, alongside some form of estrogen and potentially some form of progestogen. This is analogous to the treatment of AFAB people suffering from conditions such as PCOS. However if an orchiectomy has been preformed then treatment with an anti-androgen may no longer be necessary, and AFAB people who wish to still be on estrogen but have had a hysterectomy will also need this regimen. Though if ovaries are intact simply stopping testosterone intake can often allow AFAB people to feminize through the usual aromatase pathway.

Risk minimalization


  • Bioidentical 17β-estradiol is preferable over common xenoestrogens like ethinyl estradiol
  • Transdermal routes of administration like patches or gel
  • Higher levels of hormones can increase risks, especially when exceeding cis levels of hormones
  • People with conditions that can be affected by estrogen should start at lower doses
    • Some of the conditions that could be exacerbated by estrogen:


  • Spironolactone
    • can cause hyperkalemia
    • can lower blood pressure
  • Cyproterone acetate
    • is hepatoxic
    • can cause depression
    • can cause fatigue/drowsiness
  • 5-alpha reductase inhibitors


Feminizing regimens in WPATH SOC


Use of oral estrogen, and specifically ethinyl estradiol, appears to increase the risk of VTE. Because of this safety concern, ethinyl estradiol is not recommended for feminizing hormone therapy. Transdermal estrogen is recommended for those patients with risks factors for VTE. The risk of adverse events increases with higher doses, particular those resulting in supraphysiologic levels (Hembree et al., 2009). Patients with co-morbid conditions that can be affected by estrogen should avoid oral estrogen if possible and be started at lower levels. Some patients may not be able to safely use the levels of estrogen needed to get the desired results. This possibility needs to be discussed with patients well in advance of starting hormone therapy.

Androgen reducing medications (“anti-androgens”)

A combination of estrogen and “anti-androgens” is the most commonly studied regimen for feminization. Androgen reducing medications, from a variety of classes of drugs, have the effect of reducing either endogenous testosterone levels or testosterone activity, and thus diminishing masculine characteristics such as body hair. They minimize the dosage of estrogen needed to suppress testosterone, thereby reducing the risks associated with high-dose exogenous estrogen (Prior, Vigna, Watson, Diewold, & Robinow, 1986; Prior, Vigna, & Watson, 1989). Common anti-androgens include the following:

  • Spironolactone, an antihypertensive agent, directly inhibits testosterone secretion and androgen

binding to the androgen receptor. Blood pressure and electrolytes need to be monitored because of the potential for hyperkalemia.

  • Cyproterone acetate is a progestational compound with anti-androgenic properties. This

medication is not approved in the United States because of concerns over potential hepatotoxicity, but it is widely used elsewhere (De Cuypere et al., 2005).

  • GnRH agonists (e.g., goserelin, buserelin, triptorelin) are neurohormones that block the

gonadtropin releasing hormone receptor, thus blocking the release of follicle stimulating hormone and luteinizing hormone. This leads to highly effective gonadal blockade. However, these medications are expensive and only available as injectables or implants.

  • 5-alpha reductase inhibitors (finasteride and dutasteride) block the conversion of testosterone

to the more active agent, 5-alpha-dihydrotestosterone. These medications have beneficial effects on scalp hair loss, body hair growth, sebaceous glands, and skin consistency.

Cyproterone and spironolactone are the most commonly used anti-androgens and are likely the most cost-effective.


With the exception of cyproterone, the inclusion of progestins in feminizing hormone therapy is controversial (Oriel, 2000). Because progestins play a role in mammary development on a cellular level, some clinicians believe that these agents are necessary for full breast development (Basson & Prior, 1998; Oriel, 2000). However, a clinical comparison of feminization regimens with and without progestins found that the addition of progestins neither enhanced breast growth nor lowered serum levels of free testosterone (Meyer III et al., 1986). There are concerns regarding potential adverse effects of progestins, including depression, weight gain, and lipid changes (Meyer III et al., 1986; Tangpricha et al., 2003). Progestins (especially medroxyprogesterone) are also suspected to increase breast cancer risk and cardiovascular risk in women (Rossouw et al., 2002). Micronized progesterone may be better tolerated and have a more favorable impact on the lipid profile than medroxyprogesterone does (de Lignières, 1999; Fitzpatrick, Pace, & Wiita, 2000).

Effects and side effects

Effects and side effects in WPATH SOC

Risks Associated with Hormone Therapy.
Bolded items are clinically significant [1]
Risk Level Risks
Likely increased risk * Venous thromboembolic diseaseA
* Gallstones
* Elevated liver enzymes
* Weight gain
* Hypertriglyceridemia
Likely increased risk with
presence of additional risk factorsB
* Cardiovascular disease
Possible increased risk * Hypertension
* Hyperprolactinemia or prolactinomaA
Possible increased risk with
presence of additional risk factorsB
* Type 2 diabetesA
No increased risk or inconclusive * Breast cancer
A Risk is greater with oral estrogen administration than with transdermal estrogen administration.
B Additional risk factors include age.
Effects and Expected Time Course of Feminizing Hormones [2]
Effect Expected Onset Expected Maximum Effect
Body fat redistribution 3-6 months 2-5 years
Decreased muscle mass/
3-6 months 1-2 yearsA
Softening of skin/
decreased oiliness
3-6 months unknown
Decreased libido 1-3 months 1-2 years
Decreased spontaneous
1-3 months 3-6 months
[Erectile] dysfunction variable variable
Breast growth 3-6 months 2-3 years
Decreased testicular volume 3-6 months 2-3 years
Decreased sperm production variable variable
Thinning and slowed growth
of body and facial hair
6-12 months > 3 yearsB
[Androgenetic alopecia] No regrowth, loss
stops 1-3 months
1-2 years
A Significantly dependent on amount of exercise.
B Complete removal of male facial and body hair [may require] electrolysis, laser treatment, or both.



  1. | Standards of Care for the Health of Transsexual, Transgender, and Gender Nonconforming People (page 40)
  2. | Standards of Care for the Health of Transsexual, Transgender, and Gender Nonconforming People (page 38)