Hormone replacement therapy (male-to-female)

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Hormone replacement therapy (HRT) for transgender and transsexual people changes the balance of sex hormones in their bodies. Some intersex people also receive HRT, either starting in childhood to confirm the sex to which they were assigned, or later, if this assignment has proven to be incorrect.

Its purpose is to cause the development of the secondary sex characteristics of the desired sex. It cannot undo many of the changes produced by the first natural occurring puberty, which may necessitate surgery and/or epilation (see below).

Formal requirements for HRT[edit]

The requirements for hormone replacement therapy vary immensely, often at least a certain time of psychological counseling is required. Some organizations still require a period of time living as the desired gender role, based on standards such as the Standards of Care for the Health of Transsexual, Transgender, and Gender Nonconforming People. This period is sometimes called the Real Life Experience (RLE). Some people, especially individuals from the transgender community, say that RLE is psychologically harmful and is a form of "gatekeeping" — effectively barring people from transitioning for as long as possible, if not permanently.[who?]

Some individuals choose to self-administer their medication ("do-it-yourself"), often because available doctors have too little experience in this matter, or no doctor is available in the first place. Sometimes, trans persons choose to self-administer because their doctor will not prescribe hormones without a letter from the patient's therapist stating that the patient meets the diagnostic criteria for GID and is making an informed decision to transition. Many therapists require at least three months of continuous psychotherapy and/or a real life test in order to write such a letter as is suggested in the HBIGDA Standards of Care. In these circumstances, the individual may self-administer until they can get these authorizations, feeling that they shouldn't have to wait for a medical professional to be convinced of their situation. In addition, as many individuals must pay for evaluation and care out-of-pocket, expense can also be prohibitive to pursuing such therapy.

However, self-administration of certain hormones (namely ethinyl estradiol) and anti-androgens (namely cyproterone acetate, flutamide, and nilutamide) is potentially dangerous and can cause an elevation in liver enzymes.[1]

Medical contraindications[edit]

Types of therapy[edit]




GnRH analogues[edit]

Effects of HRT[edit]


For trans women, taking estrogens causes among other changes:

For male-to-female transgender people, HRT often includes antiandrogens in addition to the estrogens and progestogens mentioned above.

HRT does not usually cause facial hair growth to be impeded or the voice to change.

Partially reversible changes[edit]

Reversible changes[edit]

The psychological changes are harder to define, because HRT is usually the first physical action that takes place when transitioning and the act itself of beginning HRT has a significant psychological effect, which is difficult to distinguish from hormonally induced changes.

What HRT cannot change[edit]



Urogynecological effects[edit]



Drug interactions[edit]


Ocular changes[edit]


Mammary gland development[edit]

Adipose tissue distribution[edit]




Hormone levels[edit]

During HRT, especially in the early stages of treatment, blood work should be consistently done to assess hormone levels and liver function.

Israel et al. have suggested that for pre-castration MTF individuals, therapeutic estrogen levels should optimally be above the normal female range but not more than twice the maximum for the female range, and testosterone levels should optimally fall within the normal female range. However, before castration, it may prove difficult to the extent of being impractical to fully suppress testosterone levels, in which case they may be allowed to fall between the high female and low male ranges instead. In post-castration MTF persons, Israel et al. recommend that both estrogen and testosterone levels fall exactly within the normal female ranges. See the table below for all of the precise values they suggest.[61]

HormoneBio. female ref. rangeBio. male ref. rangeOptimal trans. female (MTF) rangeOptimal trans. male (FTM) range
Estrogen (total)40–450 pg/ml< 40 pg/ml400–800 pg/ml (pre-castration)
40–400 pg/ml (post-castration)
< 400 pg/ml (pre-castration)
< 40 pg/ml (post-castration)
Testosterone (total)25–95 ng/dl225–900 ng/dl95–225 ng/dl (pre-castration)
25–95 ng/dl (post-castration)
225–900 ng/dl (pre-castration)
225–900 ng/dl (post-castration)

The optimal ranges listed for estrogen only apply to individuals taking bioidentical hormones (i.e., estradiol, including esters) and do not apply to those taking synthetic or other non-bioidentical preparations (e.g., ethinyl estradiol or conjugated equine estrogens (Premarin)).

Male and female reference ranges for hormones and other compounds are not exact and usually vary slightly depending on the source referenced. The same applies to optimal MTF (and FTM) ranges, naturally.

See also[edit]


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