How to Start Hormone Replacement Therapy (Male to Female)

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The decision to start male-to-female hormone replacement therapy (HRT) can be an exciting choice. For many people, hormone treatment is the first step to transitioning physically into a female body. First, you will need to find a doctor who can prescribe you female hormones. You will take these hormones by patch, pill, or injection. As your body begins to change, you may need to manage side effects or reduce unwanted features. After a few years on hormones, you can begin to consider surgery.

Part 1
Part 1 of 4:

Getting Medical Treatment

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  1. Ask your primary care doctor if they can offer you HRT. Some physicians can provide HRT. In most cases, however, they will refer you to an endocrinologist, which is a doctor who specializes in hormones. If you do not have a primary care doctor, you can find your closest endocrinologist by going here: https://www.aace.com/ .
    • Contact your local LGBT support organization to see if they have any recommendations for a good doctor.
    • Some Planned Parenthood locations in the US offer HRT.
  2. Your doctor will talk to you about the changes, side effects, and processes of undergoing HRT. They may also provide pamphlets and other reading material. Go through these carefully. Once you are certain that you want to continue, sign a document giving informed consent to the doctor to proceed.
    • Most doctors will only provide HRT to people 18 or over. Older adolescents may be able to undergo therapy with their parent or guardian’s permission. Talk to your doctor for more information.
    • HRT will increase your risk of blood clots, cancer, and stroke.
    • After a few months on HRT, you will become irreversibly sterile. If you would like to preserve sperm to have a child some day, talk to your doctor about your options.
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  3. Some doctors may require “proof” that you are comfortable living as a female and that you are able to make the decision to undergo HRT. To do this, you may need to show that you have lived for 12 months as a woman. If you are working with a therapist, you can also have them provide a reference for you. [1]
    • Some doctors may require that you undergo a psychological evaluation by a therapist. They can refer you to a therapist or you can provide your own.
    • Not all doctors will require this step. That said, many will try to make sure that you have thought through the decision carefully.
    • If you're unable to undergo HRT for any reason, seek out what you can do to live more fully in your authentic gender when and wherever you feel safe doing so.
  4. Hormone therapy can increase the risk of certain medical problems, and it may interfere with certain medications. Give your doctor a full report of your entire medical history, including any past hormone treatments and current medications.
    • Inform your doctor if you or your family have a history of breast cancer, if so you may not be a candidate for hormonal therapy.
    • Inform your doctor about any history of cardiovascular problems (such as heart disease, high blood pressure, or heart attacks), deep vein thrombosis, blood clots, or liver disease. Hormone therapy may increase your risk of these.
    • Make sure to tell your doctor about your mental health history as well, including any history of depression, bipolar disorder, or psychosis.
  5. These tests will help your doctor find the right medication and dosage for you. It will also ensure that you are healthy enough for hormone therapy. Your blood may be sent to a lab or tested at the office to check for:
    • Blood count, blood lipid, and blood glucose levels
    • Liver function
    • Diabetes
    • Testosterone levels
  6. You will be prescribed a form of estrogen to introduce female hormones into your body, as well as an anti-androgen to reduce male hormones. In rare cases, you may be given progesterone as well. [2]
    • Estrogen includes estradiol, estriol, and estrone. It is the “female” hormone. Estrogen comes in pill, patch, or injection form.
    • Anti-androgens (sometimes known as androgen blockers or antagonists) will reduce the effect of testosterone (the "male" hormone) in your body. The most common form is Spironolactone, which comes in pill form.
    • Progesterone may sometimes be used if estrogen is not working in your body. That said, it is not commonly prescribed due to the high risk of side effects.
  7. HRT can cost up to $1,500 USD a year. Some insurance plans may cover the treatment, but others may not. If you have insurance, talk to your provider to see if they will cover your treatment. If not, start saving up money.
    • Most people who start HRT will be on it for the rest of their lives. Start budgeting to include HRT as part of your lifestyle.
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Part 2
Part 2 of 4:

Taking Your Medications

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  1. Estrogen is sometimes given as a skin patch. Follow the instructions on the label of your prescription to apply the patch. In most cases, you will apply the patch to dry, clean skin twice a week. [3]
    • Patches are best for women over 40, smokers, and anyone at higher risk of developing blood clots.
  2. Estrogen is sometimes delivered in pill form instead. Furthermore, your anti-androgens may come in pill form. Read the instructions on your medication carefully. Some pills may need to be taken every day while others will be taken every other day. [4]
    • Pills may have varying levels of risk and effectiveness.
    • Never take more than your prescribed dose of hormones. Taking more hormones will not speed up your transition, but it can increase your risk of complications.
  3. Ask your doctor to show you the proper way to inject. Before you inject, clean the syringe and your skin with an alcohol wipe. Insert the tip into the medicine bottle and hold it upside down to fill it. Press down on the plunger to fill it. Make sure to tap the syringe and press down on the plunger to release any air bubbles before injecting it. [5]
    • Injections deliver higher doses of estrogen, but they can also increase the risk of blood clots significantly.
  4. Every person develops differently on HRT. Some may take longer than others to develop feminine features. It is important you monitor your health for any potential side effects. Call your doctor if you notice: [6]
    • Abdominal pain
    • Nausea or vomiting
    • Headaches or migraines
    • Skin rash
  5. The doctor may test your hormone levels and monitor for any side effects, such as diabetes or kidney and liver issues. Your doctor may decide to increase your estrogen or anti-androgen doses. After the first year, your doctor may only need to monitor you every 6-12 months. [7]
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Part 3
Part 3 of 4:

Managing Physical Changes

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  1. Quit smoking. Smoking can reduce the effects of estrogen and increase your risk of complications. If you smoke cigarettes, talk to your doctor about quitting.
  2. HRT may reduce your sex drive and libido. If you are currently in a relationship, talk to your partner about your needs and desires. Make sure that they understand that your sex drive may decrease. If necessary, you both may want to attend couples counselling to help you work through it together.
    • For some people, the lack of sex drive will last for as long as they take HRT.
  3. Estrogen will change the way that your body distributes fat and muscle. Women generally are less muscular than men. That said, muscle tone is important to general health. Keep exercising to maintain a healthy muscle tone. [8]
  4. Estrogen will cause the hair on your back, face, and arms to thin, but it will rarely take it away completely. To remove hair from these areas, book an appointment with a dermatologist or plastic surgeon for electrolysis or laser hair removal treatments. It may take several treatments to remove hair completely. [9]
    • The average cost of laser hair removal is $235 USD per session. [10]
    • The average cost of electrolysis is between $50-100 USD an hour.
  5. HRT can help you feel at peace with your gender identity. That said, you may have mood swings or other side effects during this time. Tell your friends and family what to expect as you go through HRT. Ask them to help support you through the process.
    • If you are not already going through therapy, you may want to find a mental health professional who can provide support during the process.
    • Many LGBT centers offer support groups for people who are currently going through or considering HRT.
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Part 4
Part 4 of 4:

Taking the Next Steps

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  1. It can take up to 2 years for the full bodily effects of hormone therapy to take effect. Your breasts, hips, and face may not completely feminize until this time, and it may take a while for fat to redistribute in your body as well. [11]
    • It used to be that people needed to spend a certain amount of time living publicly in their affirmed gender before going on hormones or being on hormones a certain length of time before having surgery, but it is now understood that these guidelines can be overly limiting and are not a fit for everyone.
  2. While your risk of breast cancer is still lower than a cisgender woman, your risk will still increase. After a few years on hormones, go to your doctor for annual breast cancer screenings. [12]
  3. Not everyone on HRT decides to get gender reassignment surgery, but if this option feels right to you, talk to your doctor to determine what is the best step for you. Gender reassignment surgery will remove your male genitals and reform them into female organs. [13]
    • The removal of your testicles is a procedure called orchiectomy. After this procedure, you can start taking a lower dose of estrogen.
    • Other surgeries that you might consider include facial feminization surgery (plastic surgery that will make your face look more feminine) and breast augmentation (to give you a fuller bosom).
  4. In some cases, insurance may cover gender reassignment surgery, but it usually won’t cover feminization procedures or breast augmentation. These procedures can be very expensive. [14]
    • Gender reassignment surgery may start at $30,000 USD.
    • Facial feminization can start at $5,000 USD and go all the way up to $20,000.
    • The cost of breast augmentation can vary widely but in general it can cost up around $4,000 USD.
  5. Because hormones can increase the risk of blood clots, your doctor may advise you to stop taking them for 4-6 weeks before surgery takes place. You may need to wait a few weeks after the surgery to start taking them again.
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Navigate Your Gender Transition with this Expert Series

Transitioning is a big process with many potentially confusing and difficult steps. Don't worry, we're here to guide you every step of the way with these expert articles.
1
Adjust to Being a Boy when You Really Want to Be a Girl
2
How to Become a Woman: Male to Female Transition
3
Start Hormone Replacement Therapy (Male to Female)
4
Know if You Should Transition
5
Know if You Are Transgender
6
How to Deal With Gender Dysphoria: Mental Health, Gender Expression & Medical Treatments

Expert Q&A

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  • Question
    What is the first step in starting HRT?
    David Nazarian, MD
    Board Certified Internal Medicine Physician
    Dr. David Nazarian is a board certified Internal Medicine Physician and the Owner of My Concierge MD, a medical practice in Beverly Hills California, specializing in concierge medicine, executive health and integrative medicine. Dr. Nazarian specializes in comprehensive physical examinations, IV Vitamin therapies, hormone replacement therapy, weight loss, platelet rich plasma therapies. He has over 16 years of medical training and facilitation and is a Diplomate of the American Board of Internal Medicine. He completed his B.S. in Psychology and Biology from the University of California, Los Angeles, his M.D. from the Sackler School of Medicine, and a residency at Huntington Memorial Hospital, an affiliate of the University of Southern California.
    David Nazarian, MD
    Board Certified Internal Medicine Physician
    Expert Answer
    Meet with a doctor and take a closer look at your medical history and family history (especially when it comes to cancer). Your doctor will make sure that all of your labs are normal and that you've completed your preventative screening tests.
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  • Question
    Does having HRT help you lose weight?
    David Nazarian, MD
    Board Certified Internal Medicine Physician
    Dr. David Nazarian is a board certified Internal Medicine Physician and the Owner of My Concierge MD, a medical practice in Beverly Hills California, specializing in concierge medicine, executive health and integrative medicine. Dr. Nazarian specializes in comprehensive physical examinations, IV Vitamin therapies, hormone replacement therapy, weight loss, platelet rich plasma therapies. He has over 16 years of medical training and facilitation and is a Diplomate of the American Board of Internal Medicine. He completed his B.S. in Psychology and Biology from the University of California, Los Angeles, his M.D. from the Sackler School of Medicine, and a residency at Huntington Memorial Hospital, an affiliate of the University of Southern California.
    David Nazarian, MD
    Board Certified Internal Medicine Physician
    Expert Answer
    People do usually lose weight when they do hormone replacement therapy—men specifically, but also women. After all, hormones help the body function better, improve your metabolism, give you more energy, and help slow down the aging process.
    Thanks! We're glad this was helpful.
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  • Question
    Can I start hormone replacement therapy?
    Inge Hansen, PsyD
    Clinical Psychologist
    Dr. Inge Hansen, PsyD, is the Director of Well-Being at Stanford University and the Weiland Health Initiative. Dr. Hansen has professional interests in social justice and gender and sexual diversity. She earned her PsyD from the California School of Professional Psychology with specialized training in the area of gender and sexual identity. She is the co-author of The Ethical Sellout: Maintaining Your Integrity in the Age of Compromise.
    Inge Hansen, PsyD
    Clinical Psychologist
    Expert Answer
    Whether and when to take hormone replacement therapy is a deeply personal choice. You should take hormones when you’ve fully researched your options, feel that hormones are a positive next step for you, and you are okay with the fact that the effects are not fully reversible should you stop taking them.
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      Tips

      • You can stop hormone replacement at any time, and this is done for a variety of reasons. For instance, some people only desire a partial effect from hormones, or they need to pause hormones because they are hoping to bring back fertility, or they are having unintended side effects from their hormones.
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      Warnings

      • You may experience mood swings while on HRT.
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      • HRT can increase your risk of stroke, cancer, blood clots, and breast cancer.
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      • Taking hormones without a doctor’s supervision or prescription can be extremely dangerous.
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      • It’s always a good idea to seek guidance from your doctor before stopping hormones, and to be aware that some effects of hormones will reverse (or at least partially reverse) if you stop taking them, while other effects are more permanent.
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      Expert Interview

      Thanks for reading our article! If you'd like to learn more about Hormone replacement therapy, check out our in-depth interview with David Nazarian, MD .

      References

      1. ↑ https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5182227/
      2. ↑ https://apps.carleton.edu/campus/gsc/assets/hormones_MTF.pdf
      3. ↑ https://apps.carleton.edu/campus/gsc/assets/hormones_MTF.pdf
      4. ↑ https://apps.carleton.edu/campus/gsc/assets/hormones_MTF.pdf
      5. ↑ http://www.trans-health.com/2001/safety-guidelines-for-injecting-hormones/
      6. ↑ https://apps.carleton.edu/campus/gsc/assets/hormones_MTF.pdf
      7. ↑ https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5182227/
      8. ↑ https://transcare.ucsf.edu/article/information-estrogen-hormone-therapy
      9. ↑ https://transcare.ucsf.edu/article/information-estrogen-hormone-therapy
      1. ↑ https://www.webmd.com/beauty/laser-hair-removal#2
      2. ↑ https://transcare.ucsf.edu/article/information-estrogen-hormone-therapy
      3. ↑ https://transcare.ucsf.edu/article/information-estrogen-hormone-therapy
      4. ↑ https://apps.carleton.edu/campus/gsc/assets/hormones_MTF.pdf
      5. ↑ https://www.teenvogue.com/story/transgender-operations-hormone-therapy-costs

      About This Article

      Article Summary X

      Hormone replacement therapy is an exciting part of your transition, and by working closely with your doctors, you can get started as soon as you’re ready. Some physicians can provide hormone replacement therapy, but if yours is unable to, ask them to refer you to an endocrinologist. To start your hormone therapy, you’ll generally need to be 18 and understand all of the risks and side effects involved with the treatment. Some doctors may also require you to live as a female for 12 months before they start you on hormone replacement therapy to make sure you’ll be able to live with the treatment. Hormone replacement therapy can take the form of estrogen patches that you place on your skin, pills, or regular injections. For more tips, including how to deal with side effects of hormone replacement therapy, read on.

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