Feminizing Hormones

No matter what the gender, babies mostly develop the same way in the womb for the first 5-7 weeks. Hormones are the chemical magic that cause bodies to grow differently, both in the womb and during puberty. For those who suffer from gender dysphoria, hormone replacement therapies (HRT) present a second chance at puberty. A way to change their bodies to line up better with the gender they identify with and experience. This time, we’ll talk about “feminizing hormones” and what they do.

Disclaimer : I am not a medical professional. I sometimes crumble up stale cookies, pour milk on them, and eat them like cereal. Leave actual medical advice to the folks with letters after their names. I’ll try to balance medical research, personal experience, and anecdotal evidence from others to give y’all a good overview of the options out there. Also, this is very NSFW.

What does feminizing mean?

Feminine means different things to each person that uses the term. For now, we’ll be using the word feminizing and HRT to refer to the process of changing a body to look more like the typical cis-female body: softer facial features, curvier form, wider hips, smaller and smoother muscles, and larger breasts. Not all trans folks want these things, but hopefully anyone who does can get the info they want and need here.

We’ve just covered some of the things HRT does, but there are more. For example, HRT also leads to softer skin, slower and thinner body hair growth, a more pear-shape distribution of body fat, and a sweeter body odor. These are mostly pluses for those starting feminizing HRT. The folks on r/transtimelines have provided many examples of the results of medically transitioning. However, there are also risks of reduced upper body strength, libido, and sex drive. Also, anyone even slightly interested in having children one day should look into long-term fertility options (for many AMAB folks, that means storing a semen sample in a sperm bank).

Before we get ahead of ourselves, there are things HRT won’t do. Hormones will not change someone’s bone structure, so there are limits on how much their body shape can change. Similarly, the Adam’s apple won’t shrink, and voices won’t get any higher on their own. Those on HRT won’t grow a uterus or start having menstrual cycles. And while some people see male pattern baldness slow down, there’s no guarantee it will stop completely or that any lost hair will grow back. I call hormones magic, but they do have limits.

The lineup

The specific medications and dosages may vary by physician and patient, but HRT generally has two main goals. First, slow down typically “male” hormones (more accurately called androgens). Next, crank up the typically “female” hormones (such as estrogen). Those will combine to stimulate something like puberty in a cis woman.

Antiandrogens

Sometimes called androgen blockers, these medications lower testosterone levels. This is what leads to reduced muscle mass, the slowing and thinning of body hair, changes in body odor, and softer skin and facial features. Many folks, including myself, also report a sense of calm. In fact, one of the most common antiandrogens was originally prescribed to reduce blood pressure.

That blocker is called Spironolactone. Most people on HRT use some dosage of Spiro. For most people, spiro is tolerable and relatively safe. It does affect the water and salt balance in the kidneys, though. This means it’s important to watch out for high potassium levels, getting blood tests as regularly as you can. Also, it makes some people need to pee more. When dehydration mixes with lower blood pressure, some folks experience lightheadedness or even fainting. Keep an eye out for the side-effects and keep in close touch with your doctor.

If you’re curious about how Spiro feels emotionally, here’s what I wrote in my own journal after starting it.

So, here’s the thing. I’ve struggled with anxiety for many years. Anxiety felt like my thoughts were being shaken and thrown about, like a cup of water in a car on a bumpy road. Everything felt fast and agitated, ready to spill over at any time and splash wildly all around. It was too much for me because adding stress was like pouring more water in the cup, only making the overflow more prominent and violent.

Spiro changed that. It felt like someone had stopped shaking the cup, like the car had rolled onto smooth pavement. Now it might be stirred and sloshed around, but it felt smoother. Most of the time, I felt like that cup was less than half-filled, very calm and controlled. I only panicked when additional stress nearly filled my glass. I could hold more in without losing it, and when I did, it would be less. I just had less nagging fears and anxieties running in the back of my head than I did before.

Meds affect everyone differently, so feel free to share your own experiences in the comments.

Estrogen

While antiandrogens may cause small feminizing changes (getting rid of testosterone lets naturally-occuring estrogen in the body do its thing), estrogen treatments spark the largest visible changes. Estrogen changes where fat is distributed in the body, leading to breast development and widening hips.

For whatever reason, many transitioning folks become obsessed with breasts. Now, personally I give them a “B+, would recommend” because they’re fun, they make me feel feminine, and they’re a couple of the best things about sex. However, HRT rarely grants folks with bounteous bosoms. Usually folks’ breasts on HRT mature to about a III or IV on the Tanner Scale (see below), just short of where they may have developed to had they grown up as a cis-woman. For most, this is around a B cup or smaller, though there are exceptions.

A chart of the five Tanner stages of breast development, showing progressively larger, prominent, and rounder breasts.

The Tanner Scale illustrated by M•Komorniczak via Wikimedia Commons under [CC BY-SA 3.0]

Growth also occurs very slowly. After a few months, it may begin to hurt after the first feeling of tightness of the skin and tenderness under the nipple. Then growth tends to happen in spurts. While everyone’s different, there tend to be milestones in growth every three months or so, with the entire process taking 1-2 years to reach a final size. Breasts can also grow a little bit more after bottom surgeries.

Now, let’s talk about the emotional parts of taking estrogen. Just like with meds used for mental health, medicine doesn’t really change your personality. It changes what you feel, and your personality handles and adapts to what it experiences. As for what those experiences are, here’s the continuation of my journal entry from earlier.

So what does Estrogen feel like? Well, I think the water somehow has…pressure. I feel fuller, like there’s something deep underneath my feelings that has swollen. My normal register of feeling is now on top of an expanding balloon underneath. The water is just as calm, but there’s just consistently more of it than ever. And it has a feeling like heat. Like a warm balloon filling and pressuring out my normal emotions. Even though I’m still pretty calm, the glass is nearly full, so adding anything to the glass guarantees some spills. It feels like I have less time for things to build up before the cup is full.

I felt myself become overwhelmed very quickly today, and it scared me a little. Feelings just felt bigger in general. Sadness is more sad, joy is happier. It has more body to it, and it’s kind of nice. It’s just a lot to take in.

Estrogen isn’t a drug you take lightly, though. Its side effects include increased risks of headaches, heart disease, blood pressure, and gallstones. In particular, estrogen is linked with risks of blood clots, especially in people who smoke or have smoked. Most people are told to quit smoking before starting for that reason. Doctors also aren’t 100% sure how estrogen may affect the risk of breast cancer.

These aren’t all the side effects, and please don’t take the word of someone who ate brownies for breakfast this morning. I’m also not trying to keep anyone from taking estrogen. But it’s worth keeping the dangers in mind before you make a big decision.

People take estrogen (estradiol is the generic prescription name) in multiple ways. The most common method is by pill, but it can also be administered by patches or injections. Pills are relatively cheap and easiest. Dissolve them under the tongue, rather than swallowing them, to reduce the amount of toxins entering the liver. Injections are believed to have a lower clotting risk, but require the use of needles. Patches have even less of a clotting tendency, but can be tricky to keep on and can get expensive. Again, consult one of those folks with cool scrubs and lab coats to figure out what works best.

Honorable mentions

The most common combination for HRT is Spiro for the anti-androgen and estradiol (usually as a pill) for feminization. However, here are a couple more (though nowhere near an exhaustive list of) relatively common additional medications.

Finasteride is another androgen blocker. It’s sometimes used for folks who don’t react well to spiro. Plus finasteride is FDA-approved for treating male pattern baldness, which is the other reason it’s sometimes included in some people’s treatments.

Progesterone, another important hormone in the cis-female reproductive system, is ocassionally used to stimulate breast growth. However, there are often risks associated with it that can outweigh the benefits. It’s not the most common treatment.

Getting treatment

Two prescription bottles and an open palm of a hand with three white pills and two smaller blue pills.

Spiro and Estradiol in their natural habitat: a dirty bathroom counter.

This will eventually become at least two separate articles in the future, trust me. For now, let’s stick to two questions: “How much will it cost?” and “Where can I go to get HRT?”

Costs vary widely between pharmacies, and dosages are different for everybody. However, for one month of 200mg/day of Spiro, I’ve generally seen it cost around $30 without insurance (in the US). Estrogen tablets cost about the same for 4mg/day for a month. With insurance, however, these can each drop to the $10-15 range. Insurance is yet another article, but here are a few plans that should cover HRT.

As for where somebody can go, there are generally two paths: 1) giving a physician/endocrinologist a therapist’s letter approving the treatment or 2) visiting an informed consent clinic.

The first option involves seeing a counselor for a few months (anywhere from 3-6 months) to work through the decision of beginning a medical transition. Once the therapist and patient agree it’s the best course of action, they are given a letter to take to a physician or endocrinologist. From there, the doctor can consult with them on treatments and prescribe medication. This deliberate walk-through can be helpful for some. For others, it can be a dreadfully slow and expensive process, sometimes all too open to abuse by transphobic therapists and physicians.

Informed consent clinics cut to the chase. Appointments offer an in-depth consultation and blood tests to assess risks and help a the patient make an informed decision on whether to sign the consent form. From there, the clinic can offer treatment and prescribe meds relatively quickly. This can save a lot of time, money, and heartache. They are also often more receptive to nonbinary and gender-nonconforming individuals seeking treatment. However, these sites can be hard to find or get to depending on where you live.

There is a third option: doing it yourself. If I had lawyers, they would be screaming at me to tell you not to do this, and I would never recommend it to anyone. The other methods are often cheaper and are so much safer under supervision. That being said, if someone were to hypothetically ignore my advice and do it anyway, there’s probably some things they should keep in mind. And maybe some people they should talk to. They should hypothetically stay safe and be very careful.

Should I medically transition?

Transition photos:  u/hatespoonu/khelek41u/ashleyj0nes,
u/jossgossu/una_lady_troubridgeu/koffee_kat

Nobody can decide this for you. You don’t have to transition if you don’t want to, can’t afford it, or can’t access it. If you have problems with dysphoria, there are other ways you can go about it. Ultimately, the question you need to ask is “Will my life be better after starting this?” For me, I like hormones for the way it makes me feel, rather than how it helps me look. Consider why you want this. If it’s to make your life happier, healthier, and fuller, then go for it. The biggest sign of success in the pictures above are the smiles, not just the bodies.

Transitions also take time, with results often taking a year or two. This is puberty all over again, and nobody changes completely overnight. But you’ll have times where you look in the mirror and spot the growth. The day will come when you look at yourself and smile. Hold on and be patient. You are beautiful the entire winding way of your transition, even through your awkward second adolescence. Meds won’t make you love your body, but hopefully they can help make it easier.

I’ll leave you with the words of my mentor: You have to go at your own pace. There will be people that say you’re moving too fast, no matter what rate you go. There may even be people that rush you. Screw them. It’s your body, and you have to do whatever makes your life better. I believe in you. It may not get easier, but you’ll get better at it all in time.

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