The information on this site is not meant to replace individual medical consultation with your doctor. Please speak with your medical provider about any medical interventions you are interested in.
How It Works
Estrogen is a naturally occurring hormone in all people. It promotes development of traditionally “feminine” secondary sex characteristics, including softer skin, breast development, and fat distribution around hips and buttocks. At certain levels, it also suppresses estrogen production. Therefore, it prevents traditional “feminine” development and function, such as formation of body curves and menstruation [“having periods”].
Depending on one’s gender identity and developmental goals, estrogen can improve an individual’s feelings about their body. When indicated and appropriate, gender-affirming hormone therapy has been shown in multiple studies to have a protective effect on mental health and wellness.
Readiness
It is important to note that assessing if gender medical treatments, like hormones, are right for someone and if that person is ready to start is complicated. Every program has it’s own policies about making decisions about when it is appropriate to start gender medical treatments based on one’s cognitive, emotional, and physical development using a family-centered approach for shared decision-making.
What to Expect
Effects of estrogen typically become noticeable within months and may take several years for full effect. You will need to continue feminizing hormone therapy for the rest of your life to keep all the desired effects. Some changes will go away if you stop taking estrogen (reversible effects). Some changes will be permanent even if you stop taking estrogen (irreversible effects). You are NOT locked into a decision to take estrogen, and if it is not working for you, please let your provider know so we can discuss options.
| Reversible | Irreversible |
|---|---|
| • Decreased skin oiliness, acne, and softer skin (3-6mo) • Slowing of balding (6-12mo) • Thinning of body and facial hair (6-12mo) • Decreased muscle mass and upper body strength (3-6mo) • Redistribution of fat to the hips and buttocks (3-6mo) • Possible decrease in erectile function – difficulty becoming aroused, maintaining erection, and/or achieving orgasm/ejaculation • Change in or decrease in libido (sex drive) • Emotional changes, broadening of emotional range (1-3mo)* | • Breast development, nipple enlargement (3- 6mo start, max growth by 2-3yr) |
What it Won’t Do: raise voice pitch; dramatically reduce facial hair or reverse established baldness; start a menstrual cycle or remove a penis; or alter body skeleton including hands, feet, and height, and neck cartilage.
Important Considerations
We are still learning about the use of Estrogen in transgender and gender diverse individuals and the risks are not fully understood. Gender-affirming hormones are not FDA-approved but are commonly used off-label for gender-affirming care and have been for over 50 years.
- Possible benefits: Patients may find improved cholesterol levels, decreased risk for cardiovascular disease, and less hereditary balding. However, these things can still be heavily influenced by genetics.
- Blood Clots: Estrogen increases the risk for blood clots, which can affect the heart, lung, or brain. People with certain conditions, such as migraines, blood clotting disorders, history of stroke or heart attack may have an even higher risk of blood clots.
- Smoking nicotine or other substances increases your risk of blood clots and heart disease. If you use nicotine and are interested in starting estrogen, we recommend that you stop using nicotine. We can give you options and resources to help you quit using nicotine.
- Cancer: The effect of estrogen on the risks for cancers is multifactorial and still being researched. Family history, tobacco use, obesity, and lifestyle all increase the risk of adult cancers. There is currently no evidence that people taking estrogen have an increased risk of cancer compared to cisgender women.
- Regret: Due to estrogen having irreversible effects and the degree of any effect being based on genetic, there is a risk that you may not like the outcome. Research shows that later regret is rare, but it does sometimes happen. It is important that if you do not like the effect that you are getting, you let your provider know right away. No one is “locked into” any treatment or decision.
Fertility
Estrogen may affect fertility (the ability to have a child biologically related to you). We recommend that you talk to a fertility expert and consider banking your sperm prior to starting estrogen. There have been select cases where people have stopped estrogen and had successful natural or assisted reproduction, but also anecdotal cases of infertility that may or may not have been related to estrogen.
Estrogen does not provide birth control. If you are having sex with a partner who could become pregnant (i.e., has a uterus and eggs) you should use another form of birth control. Estrogen will not prevent transmission of sexually transmitted infections.
Mental Health
Most people using estrogen for gender affirmation report feeling better on hormones. Many people do note feeling more emotional, experiencing larger fluctuations in mood, and crying more easily than before. You will still be you and will acclimate to the way estrogen affects your mood and thinking. Let your providers know how you are doing—they are here for you and can connect you to mental health services.
Dosing
Dosing is guided by desired physical effects, any emotional concerns, and achieving blood estrogen levels of someone your age assigned female at birth (typically, 100 – 350 ng/dL). There are limitations in how much effect you might have based on your genes and where you are developmentally. Note that everyone breaks down estrogen at a different rate, so if you break it down slowly, you may be on a lower dose than someone who breaks it down quickly. Some people may simply desire a lower level for a more androgynous appearance. Removing the testes or using other medications (i.e., puberty blockers) may change the estrogen dose needed.
Follow-up and Labs
Follow up every 3-4 months for 1-2 years, then 1-2 times a year
- Physical examination (Genital and breast exams are not required if they cause significant distress and there is no concern.)
- Labs may include estradiol or testosterone levels (to help guide dose adjustments), as well as metabolic and other liver tests)
How it’s Given
Estrogen is available in the following forms. Insurance coverage may require preauthorization.
- Pills: 17β estradiol tablets are placed either under tongue (sublingual) for 30 minutes or swallowed. Sublingual administration avoids metabolism by the liver and increases safety profiles.
- Transdermal: Estrogen patches placed on the skin and changed once or twice weekly.
- Injection: Intramuscular injections given every week to every two weeks at home or by a nurse in a doctor’s office.
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