Table of ContentsView AllTable of ContentsEffects of Estrogen TreatmentMethods for Taking EstrogenTypes of EstrogensRisks and BenefitsTreatment and Gender Surgery
Table of ContentsView All
View All
Table of Contents
Effects of Estrogen Treatment
Methods for Taking Estrogen
Types of Estrogens
Risks and Benefits
Treatment and Gender Surgery
Transgender women and transfeminine people are persons who were assigned male at birth, yet identify as women or as having a gender identity that is predominantly feminine. Transgender or trans people represent a group that includes not just transgender women but also non-binary people who have a more feminine gender identity than the one that is expected for their recorded sex at birth.
This photo contains content that some people may find graphic or disturbing.See PhotoSDI Productions / Getty Images
This photo contains content that some people may find graphic or disturbing.See Photo
This photo contains content that some people may find graphic or disturbing.
Not every transgender person deals with their gender dysphoria in the same way. However, for many people, hormone therapy can help them feel more like themselves. For transmasculine people, this involves testosterone treatment. Testosterone is a type of androgen (male sex hormone). For transfeminine people, this usually involves a combination of androgen blockers (also known astestosterone blockers) and estrogen treatment.
Androgen blockers are a necessary part of estrogen treatment for transfeminine people because testosterone acts more strongly in the body than estrogen does. Therefore, in order for transfeminine people to experience the effects of estrogen treatment, they must block their testosterone. The most common medication used to block testosterone is spironolactone or “spiro.”
Some also have their testicles removed (orchiectomy) so that they can take a lower dose of estrogen and not need an androgen blocker. This is because testosterone is primarily produced in the testicles.
The purpose of estrogen treatment for transfeminine people is to cause physical changes that make the body more feminine. The combination of an androgen blocker with estrogen can lead to the following types of desired changes in the body:
All of these are changes that can reduce gender dysphoria and improve quality of life. There are also some changes that occur that are less obvious. Some of these, like a reduction in testosterone, fewer penile erections, and a decline in blood pressure are generally considered to be positive changes. Others, like decreased sex drive and changes in cholesterol and other cardiovascular factors, may be less desirable.
The physical changes associated with estrogen treatment may start within a few months. However, changes can take two to three years to be fully realized. This is particularly true for breast growth. As many as two-thirds of transgender women and transfeminine people are not satisfied with breast growth and may seek breast augmentation. Research suggests that this procedure depends on a number of factors including when hormone treatment is started and how fully testosterone is suppressed.
Insurance for Gender Confirmation Surgery
When used for gender-affirming care, estrogen is available in different formulations:
The choice of estrogen is not just a matter of preference. Different forms of estrogen are absorbed and distributed throughout the body differently—some more efficiently and less problematically than others.
Oral estrogen is one such example.
When many oral drugs are swallowed, they are taken directly to the liver to be metabolized (broken down) before being released in general circulation to exert their intended action.
The problem with estrogen is that the liver is very effective in removing much of the active hormone from circulation. This is known as the “first-pass effect” in which liver metabolization reduces the concentration of circulating drug.
As a result, you need to take higher doses of oral estrogen, sometimes 10 to 20 times higher, in order for there to be enough active estrogen in the body. At this dose, estrogen can cause complications, likehigh triglycerides,gallstones, and an increased risk of heart disease andvenous thromboembolism(blood clots in veins).
The same does not apply to other forms of estrogen. For instance, sublingual estrogen tablets dissolved under the tongue can largely sidestep the first pass and go directly into the bloodstream. As a result, they are less likely to cause the same complications as oral estrogen.
Estrogen injections also go directly into circulation, resulting in greater bioavailability (more active drug entering circulation) at lower doses. Because of this, an estrogen injection may only require 1 to 20 milligrams (mg)per weekcompared to oral estrogen which may require 2 to 8 mgper day.
In addition to the different routes of administration of estrogen treatment, there are also different types of estrogens used for treatment. These include:
Endocrine Society guidelines specifically suggest that oral ethinyl estradiol should not be used in transfeminine people. This is because oral ethinyl estradiol is the treatment most associated with thromboembolic events such as deep vein thrombosis, heart attack, pulmonary embolism, and stroke.
No matter what type of estrogen treatment is used, monitoring is important. The doctor who prescribes your estrogen should monitor the levels of estrogen in your blood.
The testosterone levels should also be the same as for premenopausal cisgender women (less than 50 nanograms per deciliter). However, androgen levels that are too low may lead to depression and generally feeling less well.
By Route of Administration
In general, transdermal or injected estrogen treatment is thought to be safer than oral treatment. This is because there is no hepatic first pass effect. Topical and injectable estrogens also need to be taken less often, which may make dealing with them easier. However, there are downsides to these options as well.
It is easier for people to maintain steady levels of estrogen on pills than with other forms of estrogen. This can affect how some people feel when taking hormone treatment. Since levels of estrogen peak and then decline with injections and transdermal (patch/cream) formulations, it can also be harder for doctors to figure out the right level to prescribe.
In addition, some people experience skin rashes and irritation from estrogen patches. Injections may require visiting the doctor regularly for people who are not comfortable giving them to themselves.
By Type of Estrogen
Oral ethinyl estradiol is not recommended for use in transgender women because it is associated with an increased risk ofblood clots. Conjugated estrogens are not used frequently, as they may put women at a higher risk of blood clots and heart attacks than 17B-estradiol, and they also cannot be accurately monitored with blood tests.
Risk of thrombosis (blood clots) is particularly high for those who smoke. Therefore, it is recommended that if smokers wish to be on estrogen therapy, they use transdermal 17B-estradiol (patch) if that is an option.
Transgender women and nonbinary feminine people who are considering surgery should discuss the risks and benefits of discontinuing their estrogen treatment with their surgeon. For some, discontinuing estrogen is no big deal. For others, it can be extremely stressful and cause an increase in dysphoria. For such people, surgical concerns about blood clotting may be manageable using postoperativethromboprophylaxis. (This is a type of medical treatment that reduces the risk of clot formation.)
However, individual risks depend on a number of factors including the type of estrogen, smoking status, type of surgery, and other health concerns. It is important that this be a collaborative conversation with a doctor. For some, discontinuing estrogen treatment may be unavoidable. For others, risks may be managed in other ways.
A Word From Verywell
Transgender women and nonbinary feminine people taking estrogen treatment should be aware that they will need many of the same screening tests as cisgender women. In particular, they should follow the same screening guidelines for mammograms. This is because their breast cancer risk is much more similar to cisgender women than it is to cisgender men.
Research shows that any person with a prostate, including trans women on estrogen, can still get prostate cancer. However, there is currently no consensus on guidelines for how to screen for prostate cancer in this population and more research is needed in this area.
Estrogen’s Effect on the Body
7 SourcesVerywell Health uses only high-quality sources, including peer-reviewed studies, to support the facts within our articles. Read oureditorial processto learn more about how we fact-check and keep our content accurate, reliable, and trustworthy.Hembree WC, Cohen-Kettenis PT, Gooren L, et al.Endocrine treatment of gender-dysphoric/gender-incongruent persons: an Endocrine Society clinical practice guideline.J Clin Endocrinol Metab. 2017;102(11):3869-903. doi:10.1210/jc.2017-01658Seal LJ, Franklin S, Richards C, Shishkareva A, Sinclaire C, Barrett J.Predictive markers for mammoplasty and a comparison of side effect profiles in transwomen taking various hormonal regimens.J Clin Endocrinol Metab. 2012;97(12):4422-8. doi:10.1210/jc.2012-2030University of California, San Francisco.Overview of feminizing hormone therapy.Unger CA.Hormone therapy for transgender patients.Transl Androl Urol.2016 Dec;5(6):877–884. doi:10.21037/tau.2016.09.04MedlinePlus.Could you have low testosterone?.Boskey ER, Taghinia AH, Ganor O.Association of surgical risk with exogenous hormone use in transgender patients: a systematic review.JAMA Surg. 2019;154(2):159-69. doi:10.1001/jamasurg.2018.4598Tangpricha V, den Heijer M.Oestrogen and anti-androgen therapy for transgender women.Lancet Diabetes Endocrinol. 2017;5(4):291-300. doi:10.1016/S2213-8587(16)30319-9Additional ReadingStreed CG Jr, Harfouch O, Marvel F, Blumenthal RS, Martin SS, Mukherjee M.Cardiovascular disease among transgender adults receiving hormone therapy: a narrative review. Ann Intern Med. 2017;167(4):256-67. doi:10.7326/M17-0577
7 Sources
Verywell Health uses only high-quality sources, including peer-reviewed studies, to support the facts within our articles. Read oureditorial processto learn more about how we fact-check and keep our content accurate, reliable, and trustworthy.Hembree WC, Cohen-Kettenis PT, Gooren L, et al.Endocrine treatment of gender-dysphoric/gender-incongruent persons: an Endocrine Society clinical practice guideline.J Clin Endocrinol Metab. 2017;102(11):3869-903. doi:10.1210/jc.2017-01658Seal LJ, Franklin S, Richards C, Shishkareva A, Sinclaire C, Barrett J.Predictive markers for mammoplasty and a comparison of side effect profiles in transwomen taking various hormonal regimens.J Clin Endocrinol Metab. 2012;97(12):4422-8. doi:10.1210/jc.2012-2030University of California, San Francisco.Overview of feminizing hormone therapy.Unger CA.Hormone therapy for transgender patients.Transl Androl Urol.2016 Dec;5(6):877–884. doi:10.21037/tau.2016.09.04MedlinePlus.Could you have low testosterone?.Boskey ER, Taghinia AH, Ganor O.Association of surgical risk with exogenous hormone use in transgender patients: a systematic review.JAMA Surg. 2019;154(2):159-69. doi:10.1001/jamasurg.2018.4598Tangpricha V, den Heijer M.Oestrogen and anti-androgen therapy for transgender women.Lancet Diabetes Endocrinol. 2017;5(4):291-300. doi:10.1016/S2213-8587(16)30319-9Additional ReadingStreed CG Jr, Harfouch O, Marvel F, Blumenthal RS, Martin SS, Mukherjee M.Cardiovascular disease among transgender adults receiving hormone therapy: a narrative review. Ann Intern Med. 2017;167(4):256-67. doi:10.7326/M17-0577
Verywell Health uses only high-quality sources, including peer-reviewed studies, to support the facts within our articles. Read oureditorial processto learn more about how we fact-check and keep our content accurate, reliable, and trustworthy.
Hembree WC, Cohen-Kettenis PT, Gooren L, et al.Endocrine treatment of gender-dysphoric/gender-incongruent persons: an Endocrine Society clinical practice guideline.J Clin Endocrinol Metab. 2017;102(11):3869-903. doi:10.1210/jc.2017-01658Seal LJ, Franklin S, Richards C, Shishkareva A, Sinclaire C, Barrett J.Predictive markers for mammoplasty and a comparison of side effect profiles in transwomen taking various hormonal regimens.J Clin Endocrinol Metab. 2012;97(12):4422-8. doi:10.1210/jc.2012-2030University of California, San Francisco.Overview of feminizing hormone therapy.Unger CA.Hormone therapy for transgender patients.Transl Androl Urol.2016 Dec;5(6):877–884. doi:10.21037/tau.2016.09.04MedlinePlus.Could you have low testosterone?.Boskey ER, Taghinia AH, Ganor O.Association of surgical risk with exogenous hormone use in transgender patients: a systematic review.JAMA Surg. 2019;154(2):159-69. doi:10.1001/jamasurg.2018.4598Tangpricha V, den Heijer M.Oestrogen and anti-androgen therapy for transgender women.Lancet Diabetes Endocrinol. 2017;5(4):291-300. doi:10.1016/S2213-8587(16)30319-9
Hembree WC, Cohen-Kettenis PT, Gooren L, et al.Endocrine treatment of gender-dysphoric/gender-incongruent persons: an Endocrine Society clinical practice guideline.J Clin Endocrinol Metab. 2017;102(11):3869-903. doi:10.1210/jc.2017-01658
Seal LJ, Franklin S, Richards C, Shishkareva A, Sinclaire C, Barrett J.Predictive markers for mammoplasty and a comparison of side effect profiles in transwomen taking various hormonal regimens.J Clin Endocrinol Metab. 2012;97(12):4422-8. doi:10.1210/jc.2012-2030
University of California, San Francisco.Overview of feminizing hormone therapy.
Unger CA.Hormone therapy for transgender patients.Transl Androl Urol.2016 Dec;5(6):877–884. doi:10.21037/tau.2016.09.04
MedlinePlus.Could you have low testosterone?.
Boskey ER, Taghinia AH, Ganor O.Association of surgical risk with exogenous hormone use in transgender patients: a systematic review.JAMA Surg. 2019;154(2):159-69. doi:10.1001/jamasurg.2018.4598
Tangpricha V, den Heijer M.Oestrogen and anti-androgen therapy for transgender women.Lancet Diabetes Endocrinol. 2017;5(4):291-300. doi:10.1016/S2213-8587(16)30319-9
Streed CG Jr, Harfouch O, Marvel F, Blumenthal RS, Martin SS, Mukherjee M.Cardiovascular disease among transgender adults receiving hormone therapy: a narrative review. Ann Intern Med. 2017;167(4):256-67. doi:10.7326/M17-0577
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