Hormones

Hormones 101

  • For many trans and gender diverse people, hormonal affirmation is an important part of how we see, care for, and envision ourselves.

    Exactly what this means can vary from person to person, and there is no one correct path to hormonal affirmation. Using hormones doesn’t make you the woman, man, or non-binary person you already are but most trans or gender diverse people using gender affirming hormones report high levels of satisfaction.

    For people who experience dysphoria, hormones often alleviate this.

    TransHub uses the terms ‘masculinising’ and ‘feminising’ hormones to describe the physical effects of hormonal affirmation, recognising that not everybody will use them with the intention of masculinising or feminising, and that bodies are not inherently masculine or feminine due to their hormonal makeup.

    These terms are imperfect descriptors for categories of hormones and their effects, but do not intend to denote the specific genders.

  • What are hormones?

    Hormones are chemical messengers that exist in most bodies, sending signals throughout the endocrine system and brain that tell different parts of the body how to function.

    Hormones Australia writes that “[hormones] are signals that tell the body to act in a certain way. Hormones are recognised by their target receptors in a “lock and key” system. Each hormone (key) fits exactly into its receptor (lock). Only those parts of the body that have the receptor (lock) can respond to the hormone (key). This is why hormones affect some parts of the body, but have no effect on others.”

    Cisgender and some intersex people have bodies that produce hormones, and those hormones affect their bodies in ways that are usually in line with how they see themselves. For trans people, our bodies produce hormones that can create changes that we don’t like, or make us feel uncomfortable, dysphoric, or like our bodies are rebelling against us.

    If sought, hormonal affirmation is relatively simple, can create a lot of change from a small amount of input, and our communities have been doing it for a long time, so we have a good understanding that it’s effective and safe.

    GPs are able to initiate and continue gender affirming hormonal therapy for people age 18 and above.

Risks associated with hormone therapy. Bolded items are clinically significant.

  • Likely increased risk

    Feminising hormones:

    - Venous thromboembolic disease
    - Gallstones
    - Elevated liver enzymes
    - Weight gain
    - Hypertriglyceridemia
    -     Cardiovascular disease

    ***

    Masculinising hormones:

    - Polycythemia
    - Weight gain
    - Acne
    - Androgenic alopecia (balding)
    - Sleep apnea

  • Possible increased risk

    Feminising hormones:

    - Hypertension
    - Hyperprolactinemia or prolactinoma
    - Type 2 diabetes

    ***

    Masculinising hormones:

    - Elevated liver enzymes
    - Hyperlipidemia
    - Destabilisation of certain psychiatric disorders
    - Cardivascular disease
    - Hypertension
    - Type 2 diabetes

  • No increased risk or inconclusive

    Feminising hormones:

    - Breast cancer

    ***

    Masculinising hormones:

    - Loss of bone density
    - Breast cancer
    - Cervical cancer
    - Ovarian cancer
    - Uterine cancer

Hormones - Masculinising

  • Hormonal gender affirmation is an important part of many trans and gender diverse people’s lives. Masculinising hormones are typically used by trans people who were presumed female at birth (PFAB), including men and non-binary people.

    Masculinising hormones are testosterones. The physical and psychological effects testosterone has on the body depend on the type of testosterone prescribed as well as personal factors including your age, body, hormonal history, any existing contraindications, and what you want to take. Generally though, using testosterone is a very effective way of masculinising your body.

    TransHub uses the terms masculinising and feminising hormones to describe the effects that hormonal affirmation has on bodies, but not to describe the genders of the people using them. You can be a man who uses masculinising hormones, you can also be non-binary and use masculinising hormones as well, there is no one correct form of hormonal therapy. Being on testosterone isn’t the thing that makes you, you. Who you are is always valid.

  • Testosterone

    Testosterone is a sex hormone (steroid hormone) that influences fat cells, bones, some muscles, skin, and hair. Testosterone can also affect mood, energy levels, and sex drive.

    Some people will take a full dose of testosterone, and others a low dose, or somewhere between the two. Some will prefer a longer cycle between injections or applications, others will find a shorter cycle fits best. Talk with your doctor about the outcomes you want, and you can work with them to find the dose that feels right for you.

    If you’re on a particular dose and it doesn’t feel like it’s working or feeling right, you can ask to change it up or try something new - no one is in your body but you.

  • Testosterone is usually taken in one of the following forms:

    Injections - an intramuscular injection administered regularly, either by a medical practitioner, or by you or a friend who has been shown how to do injections.

    This could be either Reandron (3 monthly), Primoteston (fortnightly), or Sustanon. Some forms of testosterone injection are covered on the PBS.

    Gels and creams - a cream or gel that is applied to the skin daily as directed. Some testosterone gels and creams are covered on the PBS.

    Implants - testosterone pellets that are inserted into the body and can last for several months. Implants are not covered on the PBS and can only be manufactured by a compounding chemist.

  • Typical changes from Testosterone (varies from person to person)

    1-3 months after starting testosterone:
    - decreased estrogen in the body
    - increased sex drive
    - vaginal dryness
    - lower growth (clitoris) - typically 1–3 cm
    - increased growth, coarseness, and thickness of hairs on arms, legs, chest, back, & abdomen
    - oilier skin and increased acne
    - increased muscle mass and upper body strength
    - redistribution of body fat to the waist, less around the hips

    ***

    1-6 months after starting testosterone:
    - menstrual periods stop

    ***

    3–6 months after starting testosterone:
    - voice starts to crack and drop within first 3–6 months, but can take a year to finish changing

    ***

    1 year or more after starting testosterone:
    - gradual growth of facial hair (usually 1–4 years)
    - possible male-pattern balding

Hormones - Feminising

  • Hormonal gender affirmation is an important part of many trans and gender diverse people’s lives. Feminising hormones are typically used by trans people who were presumed male at birth (PMAB), including women and non-binary people.

    There are several hormones that come under the category of ‘feminising hormones’. The physical and psychological effects that feminising hormones have on the body depend on the type prescribed as well as personal factors including your age, body, hormonal history, any existing health issues, and what you want to take.

    TransHub uses the terms masculinising and feminising hormones to describe the effects that hormonal affirmation has on bodies, but not to describe the genders of the people using them. You can be a woman who uses feminising hormones, you can also be non-binary and use feminising hormones as well, there is no one correct form of hormonal therapy. Being on feminising hormones isn’t the thing that makes you, you. Who you are is always valid.

  • Estrogen

    Estrogen is the primary feminising hormone used by trans women and non-binary people (PMAB). Estrogen affects many parts of the body, including fat cells, bones, some muscles, skin, and hair.

    Estrogen can also affect mood, with low estrogen levels linked to reduced mood. Talk with your doctor about the outcomes you want, and you can work with them to find the dose that feels right for you. If you’re on a particular dose and it doesn’t feel like it’s working or feeling right, you can ask to change it up or try something new too - no one is in your body but you so it’s important to listen to what your body is telling you. Some people will take a higher dose of estrogen, and others a lower dose, or somewhere between the two.

    Some research suggests an increased risk of blood clots and other health issues as a result of taking estrogen. There is limited research including trans women, which shows estrogen hormonal therapy (especially oral estrogen) can increase your cardiovascular risk to that of cis women.

    It is recommended that levels are monitored at baseline, every 3-4 months for the first year, and then annually once your estradiol and testosterone levels are adequate and stable. This includes a full blood count, renal and liver function, blood pressure and lipids, and blood glucose for patients with risk factors.

  • Estrogen Regimens

    Estrogen is usually taken in one of the following forms:

    • Pills - Taken either orally, or sublingually (dissolves beneath the tongue or between the cheek and gums). Doses usually start with 2-6mg estradiol valerate tablets daily, increasing to up to 8mg as needed.
    • Patches - Placed onto the surface of the skin. Doses are usually between 100–150 μg/24 hours changed twice weekly
    • Gels - Estrogen gels are less common in Australia than other methods.
    • Injections - Injectable estrogen is less common in Australia than other methods.
    • Implants - Available through particular doctors. Subdermal estradiol implants are fused crystalline hormone pellets prescribed by a doctor that you will need to have manufactured from a compounding chemist. Estradiol implants can vary from 50-200 mg pellets, with between 50-100 mg generally considered a preferred dose. Pellets are replaced every 6-24 months, depending on how you respond. The insertion procedure takes approximately 15 minutes.

  • Typical Changes from Estrogen (varies from person to person)

    1-3 months after starting estrogen:

    - softening of skin
    - decrease in muscle mass and increase in body fat
    - redistribution of body fat to buttocks and hips
    - decrease in sex drive
    - fewer instances of waking up with an erection or spontaneously having an erection; some trans women also find their erections are less firm during sex, or can’t get erect at all
    - decreased ability to make sperm and ejaculatory fluid

    ***

    Gradual changes (maximum change after 1-2 years on estrogen):

    - nipple and breast growth
    - slower growth of facial and body hair
    - slowed or stopped balding
    - decrease in testicular size

  • Androgen Blockers / Anti-Androgens

    The role of androgen blockers (or anti-androgens) is to suppress production of testosterone and/or block its effects on the body.

    These include:

    • Cyproterone acetate - the most commonly prescribed form of androgen blocker in Australia. ‘Cypro’ is not commonly prescribed in the U.S. due to FDA restrictions, but it is a safe and effective form of androgen blocker.
    • Spironolactone - the second most commonly prescribed form of androgen blocker in Australia. ‘Spiro’ is a potassium sparing diuretic, which can result in needing to go to the bathroom more than usual.
    • Finasteride / Duasteride - far less commonly used. They work by blocking conversions of testosterone to the androgen dihydrotestosterone, and are sometimes prescribed to men (trans and cis) for male-pattern baldness.
    • Bicalutamide - an emerging non-steroidal anti-androgen that works by blocking the androgen receptor. This is not PBS-listed.

  • Typical Changes from Anti-Androgens (varies from person to person)

    1-3 months after starting anti-androgens:

    - decreased testosterone in the body
    - decrease in sex drive
    - fewer instances of waking up with an erection or spontaneously having an erection; some trans women also have difficulty getting an erection even when they are sexually aroused
    - decreased ability to make sperm and ejaculatory fluid

    ***

    Gradual changes (maximum change after 1–2 years on anti-androgens)

    - slower growth of facial and body hair
    - slowed or stopped balding
    - slight breast growth (reversible in some cases, not in others)