Gender-affirming hormone therapy (GAHT) is a treatment in which people take hormones such as estrogen or testosterone, or hormone blockers, that help achieve physical characteristics that are more masculine or feminine. Hormone therapy for transgender and gender-fluid people can improve mental well-being and quality of life by more closely aligning someone’s outer appearance with their gender identity. 

Helene Hedian, director of clinical education at the Center for Transgender and Gender Expansive Health, discusses hormone replacement therapy for gender affirmation. 

What is gender-affirming hormone therapy?

GAHT uses medicine to replace or suppress the hormones your body makes, typically estrogen and testosterone, that influence your outward appearance after puberty. During puberty, your body increases production of hormones that cause either feminine or masculine characteristics to become more pronounced. These include a lowered voice, body hair, increased muscle mass or breast growth.

If your body has gone through puberty but you haven’t had genital surgery, taking GAHT can suppress some physical traits created by your body’s hormones. If you have had genital surgery, taking GAHT replaces hormones that your body no longer makes, which is important for bone health.

Prescribed by a primary care provider or endocrinologist, GAHT can be part of a presurgical plan or a stand-alone service for adult patients.

Which hormones are used during GAHT? 

• Estrogen-based therapy: Typically taken via a skin patch, pill, gel or injection, this medicine blocks testosterone production and adds estrogen for breast growth and fat redistribution.
• Testosterone therapy: Typically administered via injection in the stomach or in the muscles of the glutes or thigh, this medicine adds testosterone.
• Hormone blockers: Drugs that block the body’s own testosterone production

Who may be a candidate for gender-affirming hormone therapy?

Hormone therapy may be part of a transition for gender-fluid individuals. It may be used in conjunction with transgender surgical procedures, but these procedures are not a requirement for receiving GAHT.

Patients interested in hormone therapy for gender affirmation must meet the following criteria: 

• Have a diagnosis of gender dysphoria or incongruence from an experienced health professional 
• Be able to make an informed decision and consent to treatment 
• Have a thorough discussion about medical history, including mental health history, with your doctor and receive a physical exam to identify any conditions that could affect your GAHT treatment 

What to expect when starting hormone therapy for gender affirmation

You can expect to have several follow-up visits with your doctor. Most likely, you’ll meet every three months for the first year, every six months for the second year, and yearly from then on. GAHT for gender affirmation is a lifelong treatment for some people. Other people may take hormones for a period of time, until they achieve their desired changes, then stop.

Are the changes from GAHT permanent?

Some changes from hormones are permanent. For example, people who take feminizing hormones experience breast development, which will not go away if they later stop hormones. People who take masculinizing hormones experience several permanent changes — voice deepening, facial and body hair growth, scalp hair loss, and clitoral enlargement — which will not go away if they later stop hormones. Other changes are reversible. The long-term effects of hormone therapy on a person’s fertility are not fully understood.

Below is a typical timetable of changes for feminizing and masculinizing hormone therapy. Patients who have nonbinary physical goals may take lower doses of hormones. At lower doses, you can expect slower physical changes than what is listed in the chart.

Physically

For Female Characteristics

For Male Characteristics

Source: Standards of Care for the Health of Transgender and Gender Diverse People, Version 8

Emotionally

During gender-affirming hormone therapy, you will go through what is called a “second puberty.” This means that the same emotional struggles that your first puberty may have brought — mood swings, anxiety and depression — are possibilities as an adult during your second puberty. It is important to discuss your mental health with your doctor so that they can best support you. Also, having a community of support through family, friends or individuals with similar experiences will help. You can see if there are resources available in your city or town, or online, that connect you with people also going through GAHT.

Risks of Gender-Affirming Hormone Therapy

While the risks of untreated gender dysphoria can be severe, there are also risks with taking hormones. You should discuss how these risks might impact your personal health with your doctor.

• Only take gender-affirming hormones that are prescribed by a medical doctor. Taking hormones not prescribed to you can lead to serious health risks.
• Depending on preexisting conditions and age, you may be at a higher risk of serious cardiac events, such as heart attacks, strokes and pulmonary embolism.

Can you smoke or vape while on hormone replacements?

Smoking and vaping can have negative effects on your health, especially when taking estrogen as part of hormone replacement therapy. Using nicotine products while taking estrogen can increase the risk of blood clots, strokes and heart attacks. 

Fertility Preservation

Hormone replacement therapy may impact future fertility, so it’s important to discuss options with your doctor if you’d like to have a biological child. There are several fertility preservation options to consider.

Preventative Care After GHAT

After starting gender affirming hormone therapy, you’ll still need to take care of every organ you have. Preventive care and regular screenings are essential for good health, and early detection and screenings can mean more successful treatment. These can include:

• Mammograms
• Prostate screenings
• Pap Smears (if you have a cervix)
• DEXA (bone density) tests

Patients with a history of blood clots may need to take anticoagulants or antiplatelets. Patients at risk of osteoporosis may need bone mineral density screening before starting hormones. Talk to your doctor about the right interventions for you.

Supporting a Loved One During Gender-Affirming Hormone Therapy

Transgender and gender-fluid people are more likely than cisgender people to experience poor mental health and need support from their community.

If someone you love is undergoing gender-affirming hormone therapy, you may have questions and concerns about the process. You may consider:

• Joining a family support group or online discussion space
• Showing your support by using the name and pronouns your loved one has asked you to use for them
• Discussing the treatment options with your loved one and if they agree, your loved one’s doctor, so that you can help support them in their transition