Trans women and trans people are people whose gender was assigned male at birth, but they exist as women. Trans people represent a group that includes not only trans women, but also non-persons with a gender identity that is more feminine than the sex recorded at birth. The term “transfeminine” is an umbrella term that includes trans women and non-binary women. Many trans people experience what’s called gender dysphoria — discomfort caused by people’s bodies not matching their sense of identity.
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Not every trans person deals with their gender dysphoria in the same way. However, for many people, hormone therapy can help them feel more like themselves. For the trans-male population, this involves testosterone therapy. For transgender people, this usually involves a combination of testosterone blockers and estrogen therapy.
Effects of estrogen therapy
Testosterone blockers are a necessary part of estrogen therapy for transgender people because testosterone works more strongly in the body than estrogen. Therefore, in order for transgender people to experience the effects of estrogen therapy, they must block their testosterone. The most common drug used to block testosterone is spironolactone, or “spironolactone.” Some people also have their testicles removed (orchiectomy) so they can take lower doses of estrogen without the need for testosterone blockers.
The purpose of estrogen therapy for transgender people is to cause physical changes that make the body more feminine. The combination of testosterone blockers and estrogen can cause the following types of expected changes in the body:
- breast development
- Body and facial hair reduction
- Redistribution of body fat
- soften and smooth skin
- reduce acne
- Slow or stop scalp baldness
All of these are changes that can reduce gender dysphoria and improve quality of life. There have also been some less obvious changes. Some of these, such as decreased testosterone, decreased penile erection, and decreased blood pressure are generally considered positive changes. Others, such as decreased libido and changes in cholesterol and other cardiovascular factors, may be less than ideal.
Physical changes associated with estrogen therapy may begin within a few months. However, changes may take two to three years to fully materialize. This is especially true for breast growth. As many as two-thirds of trans women and trans women are dissatisfied with breast growth and may seek breast augmentation. Research shows that this process depends on many factors, including when hormone therapy is started and how much testosterone is suppressed.
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How to take estrogen
Estrogen can be taken in a number of different ways. People receive estrogen through pills, injections, patches, and even topical creams. It’s not just a matter of preference. The way people take estrogen affects some of the risks of estrogen therapy—the way estrogen is absorbed by the body varies depending on how it is taken.
Much of the research on the risks of estrogen therapy has focused on oral estrogens — those taken by mouth. Studies have found that oral estrogen appears to increase the risk of some problematic side effects compared with topical or injectable estrogen. This is because ingested estrogen affects the liver as it passes through this organ during digestion.
This is called the liver first-pass effect, and it’s not a problem with estrogen therapy that isn’t taken in pill form. Liver first-pass effects lead to changes in many physiological markers that affect cardiovascular health.
These changes can lead to increased blood clotting and decreased cardiovascular fitness. If at all, they appear less frequently with non-oral estrogens. Therefore, parenteral estrogen may be a safer option.
It is important to note that most of the research on the safety of estrogen therapy has been conducted in cisgender women taking oral contraceptives or hormone replacement therapy. This can be problematic because many of these treatments also contain progesterone, and the type of progesterone in these preparations has also been shown to affect cardiovascular disease risk. Transgender women and transgender people are generally not treated with progesterone.
types of estrogen
In addition to the different routes of administration of estrogen therapy, there are different types of estrogen used in therapy. These include:
- Oral 17B-estradiol
- Oral conjugated estrogen
- 17B-estradiol patches (usually changed every three to five days)
- Estradiol valerate injection (usually every two weeks)
- Estradiol Cypionate Injection (every to two weeks)
The Endocrine Society guidelines specifically recommend that oral ethinyl estradiol should not be used in transgender 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.
Monitoring is important regardless of the type of estrogen therapy used. The doctor who prescribes estrogen should monitor the level of estrogen in your blood.
The goal is to make sure your estrogen levels are similar to those of premenopausal cisgender women, around 100 to 200 picograms per milliliter (pg/mL). Your doctor will also need to monitor the effects of your anti-androgens by checking your testosterone levels.
Testosterone levels should also be the same as in premenopausal cisgender women (less than 50 ng/dL). However, too low androgen levels can lead to depression and generally not feeling well.
risk and benefit
By way of management
In general, topical or injectable estrogen therapy is considered safer than oral therapy. This is because there is no hepatic first-pass effect. Topical and injectable estrogens also need to be taken less often, which may make it easier to deal with them. However, these options also have drawbacks.
People are more likely to maintain stable estrogen levels on pills than other forms of estrogen. This can affect how some people feel while receiving hormone therapy. Because estrogen levels peak and then drop with injectable and transdermal (patch/cream) formulations, it is also difficult for doctors to determine the correct levels to prescribe.
Additionally, some people experience rashes and irritation from estrogen patches. Estrogen creams can be difficult to handle for people who live with other people who may be exposed through contact with treated skin. For those who are reluctant to inject themselves, injections may require regular doctor visits.
By estrogen type
Oral ethinyl estradiol is not recommended for transgender women because it increases the risk of blood clots. Conjugated estrogens are not often used because they may put women at higher risk for blood clots and heart disease than 17B-estradiol, and they cannot be accurately monitored with blood tests.
The risk of thrombosis (blood clots) is especially high for people who smoke. Therefore, smokers are advised to always use transdermal 17B-estradiol if given the choice.
Treatment and Gender Surgery
Currently, most surgeons recommend that trans women and transgender people stop taking estrogen before undergoing gender-affirming surgery. This is because there may be an increased risk of blood clots caused by estrogen and post-operative inactivity. However, it is not clear whether the advice is necessary for everyone.
Transgender and nonbinary women who are considering surgery should discuss the risks and benefits of discontinuing estrogen therapy with their surgeon. For some people, stopping estrogen is not a big deal. For others, it can be extremely stressful and lead to increased restlessness. For these individuals, surgical concerns about blood clotting can be resolved with postoperative thromboprophylaxis. (This is a medication that reduces the risk of clot formation.)
However, individual risk depends on many factors, including the type of estrogen, smoking status, type of surgery, and other health problems. Importantly, this is a collaborative conversation with the physician. For some people, stopping estrogen therapy may be inevitable. For others, risk can be managed in other ways.
Transgender and nonbinary women on estrogen therapy should be aware that they need to undergo many of the same screening tests as cisgender women. In particular, they should follow the same mammogram screening guidelines. This is because their risk of breast cancer is more similar to that of cisgender men than cisgender women.
On the other hand, transgender women and women taking estrogen do not need prostate cancer screening until after age 50. Prostate cancer appears to be fairly rare among trans women who have gone through a medical transition. This may be due to reduced testosterone in their blood.
Effects of estrogen on the body