Transgender Health Before and After MTF HRT

Understanding Physical and Emotional Changes Related to Hormone Replacement Therapy for Transgender Patients

The World Professional Association for Transgender Health (WPATH) provides essential guidelines for the treatment of gender dysphoria in the Standards of Care (SOC) document.

For some transgender patients, the ultimate goal is plastic surgery. However, this is not the goal for all individuals struggling with gender identity. Instead, most seem to be content with gender affirming hormone therapy.

Regardless of the ultimate goal, what is absolutely essential is to understand what treatments are available and when are ideal times to begin these treatments—bearing in mind that starting feminizing hormone therapy later than usual is still an option, the same for surgical treatments.

What we hope to achieve with this article is a deeper understanding of the types of changes that can be explicitly expected in relation to feminizing hormone therapy for transgender patients. This can be either for transgender women, gender expansive, or non-binary individuals who seek to feminize their bodies that were assigned male at birth.

Gender Affirming Hormone Therapy – A Quick Overview

Gender affirming hormone regimens are common treatments for transgender women. Hormone therapy is divided into two categories: fully reversible interventions and partially reversible interventions.

Fully reversible interventions can generally start as soon as signs of puberty appear. It is, however, advised that puberty persists to Tanner Stage 2 before puberty delaying hormone therapy is started. The purpose for delaying puberty would be twofold. First, it would give adolescents more time to decide whether they want to undergo gender affirmation therapies and stop irreversible changes from occurring while this decision is being made.

This, of course, means that only puberty delaying hormone therapy can take place during this time, and no gender affirming hormone therapy should begin during this time as some of it is only partially reversible.

The WPATH SOC indicates explicitly that hormone therapy needs to be individualized and adapted for each case, as the needs for each person will vary.

Expected Changes

The following changes associated with feminizing hormone therapy tend to optimize within two years of commencing treatment.

Erectile function and testicular size tend to decrease, along with sperm production. As a result, there is some degree of breast growth. Due to this breast development, it is common for doctors to suggest a minimum of one year on feminizing hormone therapy before attempts are made at gender affirming surgery. Therefore, it is beneficial to observe the full extent of breast development in the context of what can ultimately be expected in conjunction with breast augmentation surgery.

Furthermore, there is an increased body fat percentage compared to muscle mass. Therefore, body fat and muscle mass distributions will also change during the course of feminizing hormone therapy.

Softening of the skin as well as changes in facial and body hair growth will change. Male pattern baldness also stops (if it has already started) or will be prevented.

These changes are bought on by a combination of effects from the estrogen hormone therapy as well as anti-androgens that affect testosterone production. All of these changes combined tend to result in a noticeable feminizing appearance of the body.

The onset and progression of changes might vary from one individual to the next. So, for example, if the patient is on higher levels of anti-androgens it will have a different timeline than lower levels of anti-androgens. And the same would be true for estrogen therapy.

Puberty Suppression

Adolescents with male genitalia are given gonadotropin-releasing hormone suppressants, and usually also progestins or other medications that stop testosterone production or neutralize testosterone. Monitoring and regular blood tests by a pediatric endocrinologist are necessary during this time to manage appropriate height, bone density, etc. This sort of treatment does not cause many direct changes but will stop things like facial hair growth or the development of other secondary sex characteristics.

Commonly, the age by which most transgender individuals begin partially reversible hormone therapy is around the age of 16 years. This is where more notable changes to physical appearance can be noted, and secondary sex characteristics can be seen to present in accordance with the preferred gender identity characteristics.

Although it is not a requirement, it is advised that adolescents see a mental health professional during this time to help them cope with physical changes. While the changes might be welcome, this is usually a difficult time and can be extra challenging for a transgender individual. In addition, feminizing hormone therapy can also lead to confusing emotional reactions.

Estrogen Hormone Therapy

The use of Ethinyl Estradiol is not recommended anymore due to the increased risk of venous thromboembolism. It is believed that transdermal estrogen hormone therapy is a better option.

Anti Androgen Therapy

It is decidedly best to combine anti-androgen therapy with estrogen hormone therapy in order to minimize the amount of estrogen needed for desired results.

HRT for Gender Nonconforming People

Hormone therapy is not only reserved for someone wanting to transition from male to female. In addition, there are options available for those who are gender nonconforming.

With any hormone therapy, clinicians are expected to sit down with their transgender patient and establish the extent of changes that are expected for their gender identity and then come up with a plan for hormone therapy based on these expectations along with the mental health conditions and medical history that the individual faces. In addition, there are some cases where there might be restrictions on what hormone therapy can be administered due to increased risks of cardiovascular disease, blood clots, etc.

Stopping Hormone Therapy

There are not many situations that would result in someone being expected to stop their feminizing hormone therapy entirely. Although, there are some instances where it might be necessary.

Firstly, the individual might want to stop their hormone therapy.

This can be due to numerous reasons. They could struggle with side effects, such as weight gain, depressive symptoms, decreased sexual desire, and decreased sexual function that might be unwanted. If an individual is relatively young, they might decide not to go through with the feminizing hormone therapy after spending some time on puberty suppression hormones.

People might develop concerning signs of deep vein thrombosis or other serious side effects from altered hormone levels.

Another reason an individual might need to stop hormone therapy is that they want to have a biological child. This is entirely possible for transgender people who have not undergone bottom surgeries yet. While trans women at this point in time are not able to fall pregnant, they can produce sperm that can result in pregnancies of either transgender men or cisgender women. Feminizing hormone therapy interferes with sperm production, so this might be a reason to stop hormone treatment for a while until a pregnancy can be confirmed before starting hormone therapy up again.

When starting feminizing hormone therapy, the doctors would have discussed which physical changes are reversible and which are not. Transgender women who want to stop hormone therapy will need to be reminded of this. Support can be given to manage any further gender dysphoria associated with incomplete and unsatisfactory gender transition.

Persistent Gender Dysphoria

Should an individual continue to experience high and persistent levels of gender dysphoria that do not diminish despite changes bought on by feminizing hormone therapy, a clinician might suggest further intervention. It is not uncommon for gender dysphoria to be managed by an interdisciplinary team as opposed to a single clinician.

Gender dysphoria is quite serious, and there is an expectation that some anxiety will be diminished through feminizing hormone therapy and the understanding that this is only one step and that further efforts are still to come should the individual wish to take them.

If there is a need for psychological support, the clinician should be comfortable suggesting this to a patient. The ultimate goal would be the best possible physical and psychological outcome for the patient.

Prolonged Estrogen Hormone Therapy

Reaching a menopausal age

A factor that many transgender individuals might not necessarily consider when they are only beginning estrogen hormone therapy is what the treatment will look like over time. In cisgender women, female hormones decline over time, and the reproductive system naturally slows as the levels of sex hormones decrease with age. Therefore, it is likely that hormone levels in transgender women will be suitably adjusted as they reach menopausal ages. Androgen production in their own bodies will likely lower at that age as well, which might cause problems if higher doses of female hormones are not adjusted. It could further increase the risks of cardiovascular disease.

Furthermore, a naturally decreased libido can also be expected as age progresses. And while there is a slightly increased risk of breast cancer (which can affect anyone regardless of assigned gender, including cisgender men), luckily, however, feminizing hormone therapy lowers the risk of prostate cancer.

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