This time around, we're going to be taking a closer in-depth look at one of the major parts of male to female transition...contra-hormonal therapy (CHT). I like that phrase more than just calling it hormone replacement therapy (HRT) because I am fancy and like big words. In reality, it all means the same thing...you're replacing the poison in your system (in my case, testosterone) with super happy girl juice (in my case)...estrogen and (sometimes) progesterone.
As we go through this essay, we'll be looking at how CHT/HRT affects and effects you, both in the short term and in the long term.
Without further ado to do, let's do the dew.
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What is the purpose of male-to-female contra-hormonal therapy?
I'm glad you asked!
The purpose of this form of HRT is to cause the development of the secondary sex characteristics of the desired sex, such as breasts and a feminine pattern of hair, fat, and muscle distribution. It cannot undo many of the changes produced by naturally occurring puberty, which may necessitate surgery and other treatments. The medications used in HRT of the MTF type include estrogens, antiandrogens, and progestogens.
While HRT cannot undo the effects of a person's first puberty, developing secondary sex characteristics associated with a different gender can relieve some or all of the distress and discomfort associated with gender dysphoria, and can help the person to "pass" or be seen as the gender they identify with. Introducing exogenous hormones into the body impacts it at every level and many patients report changes in energy levels, mood, appetite, etc. The goal of HRT is to provide patients with a more satisfying body that is more congruent with their gender identity.
This regimen does a number of things over varying lengths of time, and to differing degrees from person to person. A huge number of variables contribute to the efficacy of CHT/HRT; these include but are far from limited to, the following:
Age beginning CHT/HRT
Genetics
General health
Naturally occurring hormone levels (i.e., Julie already has sub normal serum testosterone prior to beginning any of her HRT)
Dosage and specific types of medications used
Methodology of intake
...
...prolly a dozen more variables I can't think of because damn it Jim I'm a transgirl not an endocrinologist!
Taking all of that into account, let's look at some of the amazing things hormones will do for me:
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EARLY EFFECTS: 1–3 months after starting CHT/HRT
• softening of skin
The uppermost layer of skin becomes thinner and more translucent. Spider veins may appear or be more noticeable as a result. Collagen decreases, and tactile sensation increases. The skin becomes softer, more susceptible to tearing and irritation from scratching or shaving, and slightly lighter in color because of a slight decrease in melanin.
Sebaceous gland activity lessens, reducing oil production on the skin and scalp. Consequently, the skin becomes less prone to acne. It also becomes drier, and lotions or oils may be necessary. The pores become smaller because of the lower quantities of oil being produced. Many sweat glands become inactive, and body odor decreases. Remaining body odor becomes less metallic, sharp, or acrid, and more sweet and musky.
There is a reason it's a cliché that we like moisturiser. That reason is we need it. Yeah, it smells awesome, and yeah it makes our gradually softer, smoother skin feel even more lovely, but without it out skin will crack and be very ouch-ridden indeed. I mean, not to the degree of Lady Cassandra from Doctor Who, but not in any happy way whatsoever.
More importantly, at least from a comfort level...sweat glands become less active, and we stop smelling like guys. That second one sounds weird, doesn't it? But it's true. There's no longer that sort of acidic man smell, and a softer, almost sweeter scent. And yeah, it gets more sensitive to the touch.
My understanding is that the skin even tastes different.
Not that I...you know...taste skin or anything.
* clears throat *
Anyway...
The skin change is a very cool and good thing, even for those of us who have semi-somewhat-almost-kinda-verging on ok-skin.
And despite the fact that this isn't happening...yet...I do love my moisturiser.
• decrease in muscle mass and increase in body fat
HRT causes a reduction in muscle mass and distribution towards female proportions.
Don't like your big muscular chest and shoulders? Can't stand your over-sized quads from leg press sets at 600 pounds? Don't worry, that will start reducing. No, you won't suddenly get smaller shoulders structurally...your bones aren't going to magically shrink. But without weight training, muscle definition will decrease. Muscle mass will decrease. You'll lose some of your blockish or possibly triangular shape (i.e., broad shoulders tapering to a thinner waist.
Now...if you're younger...if a transgirl is younger, and bone growth is not complete, some of what I just said does go out the window, because bones WILL adjust somewhat. The pelvis will widen, etc. But that is very much an age-specific thing. Once your bones have finished growing, outside of losing bone mass due to age or osteoporosis (yes, you need to make sure you take calcium and D3 supplements), your bones are your bones are your bones.
• redistribution of body fat to a more “feminine” pattern
The distribution of adipose (fat) tissue changes slowly over months and years. HRT causes the body to accumulate new fat in a typically feminine pattern, including in the hips, thighs, buttocks, pubis, upper arms, and breasts. (Fat on the hips, thighs, and buttocks has a higher concentration of omega-3 fatty acids and is meant to be used for lactation.) The body begins to burn old adipose tissue in the waist, shoulders, and back, making those areas smaller.
Do you want a booty?
You'll start getting one.
Hallelujah praise the lord.
You'll also get hippier (or, if you've never been hip, at least somewhat hip). You'll lose more of your thickness in your waist and shoulders, and pick up more in the thighs (replacing the muscle mass you'll be shifting) and breast areas. Basically? Welcome to puberty point two. If you're still in puberty point one, these changes will be much more dramatic...but it'll still be there for those of us who are full grown adults and ostensibly the captains of our fate. Obviously a load of other factors come into play here above and beyond age, but this is one area where we start seeing things that can really help with our image and dysphoria issues.
• decrease in sex drive
Some transgender women report a significant reduction in libido, depending on the dosage of antiandrogens. A small number of post-operative transgender women take low doses of testosterone to boost their libido. Many pre-operative transgender women wait until after reassignment surgery to begin an active sex life. Raising the dosage of estrogen or adding a progestogen raises the libido of some transgender women.
Welp.
See, here's the thing...and yes, I am obviously telling this from Real Life Adventures With Julie, issue 27: The TMI Special. It's now out at comic book stores everywhere, with 5 exclusive variant covers. Collect them all.
Julie is demisexual. This means that sexual attraction is a thing that can only happen with someone she is exceptionally close to. Demisexuality is part of the aesexual spectrum...it's a form of grey-ace sexuality. There are lots of times I didn't want sex even before starting meds. Wanna cuddle me, hug me, touch me, kiss me? Yes please, hell I'll even bring the strawberries, chocolate and salty chips.
Yes, when the mood strikes, I want it. Who doesn't?
But it doesn't drive me. And it drives me less now.
This obviously CAN be an issue. And there are ways of working with this. But absolutely it can be a very difficult issue to deal with if you are not on the aesexuality spectrum. It may be the cause of depression, anxiety and angst. I will never say otherwise. And I also know that the plural of anecdote is not data, but...I know a surprising number of transwomen (shock, I know), and they are on wildly different parts of the expressway. For some, the idea that they are not driven by the impulse to have sex is helpful, and they know that when the mood hits they're ready for where it follows. Others have told me post GCS that they enjoy getting to know and understand their changed body and how it reacts to things. And some have told me that they're just as easily turned on by a light breeze as ever.
So mileage may, and will, vary. Make cure to check your fluid levels at all times, and it's a good idea to keep an extra quart of oil in your trunk. Just in case.
Those may or may not be entendres. Not even double, because hey, do you expect anything other than by this point?
• fewer instances of waking up with an erection or spontaneously having an erection; some MTFs also find their erections are less firm during sex, or can’t get erect at all
Spontaneous and morning erections decrease significantly in frequency, although some patients who have had an orchiectomy still experience morning erections. Voluntary erections may or may not be possible, depending on the amount of hormones and/or antiandrogens being taken.
Oh the horror.
Actually, it's not really.
Ar at least, not for me.
Listen...I don't like thinking about them, OK? I don't like being reminded they're there. Imagine going through puberty certain that you'll wake up one day and your outie will finally have become the innie you know you're supposed to have...but it never does. It's not easy. It's not fun. I can, and probably will, write a whole piece on how much hell puberty was on me as changes happened to me that I couldn't control, that turned me into something I knew I wasn't, that I desperately tried to adjust to because I figured I had to and which drove me further down the pit to the point that I was looking into the abyss.
(Yes...as a teen I did read my Nietzsche, thank you for noticing.)
Being blessed with normally pre-HRT low serum testosterone, the whole erection thing has always been a bit of a sticky wicket, and that came with the frontal lobe knowledge that it was there and thus problematic. Not having it be an ur-drive for me? Not having that primal urge of MUST WANK NOW RARRRGH is an amazing thing. I can function and go for days and days without even once thinking 'Julie has penis, Julie must use.'
It's fucking LIBERATING.
The down side is, if the urge actually does hit, it's more difficult to get to the Summerlands. How and ever, I've found that eve when those urges hit, I don't need to, cos just the rest feels pretty damned good and I don't need to really go over the top.
• decreased ability to make sperm and ejaculatory fluid
HRT can cause infertility, eventually leading to chemically induced aspermatogenesis. The reversibility of this effect may depend on the duration of treatment. HRT of the MTF type is not a substitute for other birth control methods.
PLEASE NOTE AND THIS IS SO IMPORTANT I AM PUTTING THIS FIRST AFTER THE CLINICAL STUFF:
HRT is NOT a substitute for birth control!
I repeat:
HRT is NOT a substitute for birth control!
Yes, you can be transitioning to female, and on estrogen and spironolactone, and you can STILL get someone pregnant! Practice safe sex! In fact, not only is HRT not a replacement for safe sex, it does NOT protect you from venereal diseases! So...PRACTICE SAFE SEX!
Now...
There is a massive difference between puberty blockers and CHT/HRT. The idea of puberty blockers, and I am bringing this up because it seems to be a somewhat controversial thing among a certain subset of the community (read: conservative alt-right Whiteites), is that it stops the body's natural puberty process so a pre-teen or teen has the ability to work with their identity prior to puberty causing permanent changes to all the secondary sex characteristics we've talked about. Puberty blockers are 100% reversible, and they do not cause sterility.
Now, part deux...
The changes due to CHT/HRT, while in some cases reversible, because more murky here. It is possible that stopping HRT will bring back fertility and motive functioning spermatozoa. However, in many cases, infertility is permanent. The appearance of semen will change...it will become thinner, less milky, and lesser in productive volume. It will be harder to actually achieve ejaculatory orgasm. For me, this isn't even a thing...I very rarely feel the need or desire to actually peak in that manner, and the less I have to think about those bits the happier I am quite frankly. Ancillary to this, I was already sterile before any meds became involved, so the idea that I'd become sterile is more of a 'welp,' than a 'OMG BATTEN DOWN THE HATCHES THERE'S A STORM A BREWIN!'
If you think at some point that you want kids, and you are not sterile in advance of starting HRT, talk to your doctor about banking sperm. That way, when or if the day comes that you want to pass down your genetic legacy to a wee one, you can do so. I really recommend considering this...I know it's a cost, but if it's something you feel is important, do not remain quiet about it.
• emotional changes
This is important to mention: EMOTIONS ARE NOT PERSONALITY! Just because your emotions may (or may not) be affected by CHT/HRT that does not mean your personality will! Likes, dislikes, hobbies, interests, et cetera...all those things are determined by who you are, not what chemicals you have coursing through your system. So often I hear people freak that the whole person disappears and some stranger shows up in the same place, and that's really so far from the truth.
Do some people change things? I'm sure they do. I'm sure for some people, the cleaner the break from the past the easier it is to carry on in their proper gender. But it's not the hormones doing that...it's a conscious change. It's internal, sure...but don't blame it on estrogen and spiro, or testosterone.
Also, and this is equally important to mention...in fact, so much so that I am using this text from a booklet provided by Vancouver Coastal Health, Transcend Transgender Support & Education Society and Canadian Rainbow Health Coalition:
“Many people experience positive emotional changes with hormone therapy. But you’ll likely find, after the excitement wears off and you’ve incorporated the changes into your day-to-day life, that if you were shy you’re still shy, if you didn’t like your laugh you still don’t, and you’re still afraid of spiders. Whatever things you think of as your strengths and weaknesses will still be there. Hopefully, you will be happier, and that is good for anyone. Hormone therapy may help you to be more accepting of yourself. But if you are expecting that all your problems will pass away, and that everything is going to be easy emotionally and socially from here on in, you’re probably going to be disappointed.
This extends to mental health concerns as well. Trans people who were depressed because of gender dysphoria may find that taking hormones greatly alleviates their depression. However, if you have depression caused by biological factors, the stresses of transphobia or unresolved personal issues, you may still be depressed after you start hormones. Likewise, if you are having problems with drugs or alcohol, hormones will not necessarily get rid of those problems.”
HRT is a godsend. It truly is. But it is not a magic potion. It is not a cure all. It is a part...a VERY IMPORTANT PART...of proper health case for trans people. So many other things play a role too, and all need to be considered together holistically.
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GRADUAL CHANGES: 1-2 years after starting CHT/HRT
• nipple and breast growth
Breast, nipple, and areolar development usually takes 4–6 years to complete, depending on genetics, and sometimes as long as 10 years. It is normal for there to be a "stall" in breast growth during transition, or for one breast to be somewhat larger than the other. Transgender women on HRT often experience less breast development than cisgender women, and many seek breast augmentation; it is rare for an HRT patient to opt for breast reduction. Shoulder width and the size of the rib cage also play a role in the perceivable size of the breasts; both are usually larger in transgender women, causing the breasts to appear proportionally smaller. Thus, when a transgender woman opts to have breast augmentation, the implants used tend to be larger than those used by cisgender women.
Oh dear.
Breast growth.
How will I EVER manage having breasts.
Please wait as I LOL.
* LOLS *
There, better.
Results here vary. If you are young and starting HRT before puberty is over, you will have much more prominent results. Even taking that into consideration, estrogen will cause breath development and growth to anyone. Yes, many transwomen do opt to have augmentation done as well to help as the broader masculine skeletal framework means that breasts will seem smaller and further apart, but breasts will occur.
Some AMAB have breast development before any HRT...or even if they're cisgender and AMAB. Some medications can cause gynecomastia. Kleinfelter Syndrome, a kind of karotype trisomy (XXY male), can result in breast development, and I'm honestly not sure if this would be considered an intersex condition or not.
The point is, breast development happens. This is huge for us. It really is. The more our bodies redevelop to exhibit the characteristics we know they should have, the easier it is to manage all the beautiful side effects that come with our permanent subscription to trans life magazine, like dysphoria and depression and everything else. Those things never go away...not fully...but when things are rough, we do have boobs to play with.
• slower growth of facial and body hair
Body hair (on the chest, shoulders, back, abdomen, buttocks, thighs, tops of hands, and tops of feet) turns, over time, from terminal ("normal") hairs to tiny, blonde vellus hairs. Arm, perianal, and perineal hair is reduced but may not turn to vellus hair on the latter two regions (some cisgender women also have hair in these areas). Underarm hair changes slightly in texture and length, and pubic hair becomes more typically female in pattern. Lower leg hair becomes less dense. All of these changes depend to some degree on genetics.
There's not a single bad thing here. Really.
Listen...I know everyone's hair is different. Some women have very fine, light hair even if their head hair is thick and lush and black as a piece of volcanic glass. But when one considers that AMAB can often find themselves looking more like Gorilla beringei beringei than...well, not...anything we can do to lighten the texture, length, colour and density of body hair. It makes laser hair removal or electrolysis easier. When one considers the irritation of those procedures (skin reddening, inflammation, irritation, et cetera), anything that helps make it more tolerable is a positive.
And for those of us who don't want to buy stock in Nair or a razor blade company...or at least, not any more than we already have...this is a big plus. Plus no icky caustic chemicals sitting on your skin. Win win win.
• slowed or stopped “male”-pattern balding
Head hair may change slightly in texture, curl, and color. This is especially likely with hair growth from previously bald areas. Eyebrows, however, do not change because they are not androgenic.
Yay for the ending or slowening of MPB.
I know slowening is not a word. It is now.
Testosterone does horrible things to our hair. My hairline is making a strategic advance to the rear in the Caucasus on a daily basis. There is sweet fuck all I ca do about this. CHT will help slow or stop this.
Will lost hair grow back?
It depends.
Genetics play a huge part in this. I come back to that a lot. But it's true...your genes will contribute in a significant way to how well your receded hair grows back or not. Some people have exhibited some very nice, or even amazing results. Other people don't get much result at all. Anti-androgens such as spironolactone help block 5α-dihydrotestosterone (5α-DHT), a hormone that contributes to male pattern baldness. Combined, there's the potential for things to get better.
I'm still gonna rely on my wigs tho.
Even if I can finally pull my hair back in a tail now.
• decrease in testicular size
Testicle volume is reduced by about 25% with typical dosages and as much as 50% with higher dosages, especially after a year of HRT. When testosterone is dramatically reduced, spermatogenesis is halted almost completely, and when the cells that are involved in these processes go unused, they atrophy.
The prostate and bladder shrink. The line that runs down the underside of the penis and down the middle of the scrotum darkens. Minor water retention is likely, but spironolactone tends to counter this effect because it is a diuretic.
If your baby batter factory is making less product, it's gonna shut down manufacturing lines. It's as simple as that. This very much plays in with the things I discussed above with regard to decreased ability to make sperm and ejaculatory fluid, and so I'll repeat what I said there:
“If you think at some point that you want kids, and you are not sterile in advance of starting HRT, talk to your doctor about banking sperm. That way, when or if the day comes that you want to pass down your genetic legacy to a wee one, you can do so. I really recommend considering this...I know it's a cost, but if it's something you feel is important, do not remain quiet about it.”
Additionally, take it from someone on spiro...you will pee a lot. Add in the wonders of estrogen, and you will pee so much you'll be afraid that you'll dry up and blow away. Because spironolactone is a potassium sparing diuretic, you'll have the urge to eat lots of salty things to make up for the salt you're peeing out. Your fluid intake will go up (and it's a good idea to anyway, cos it's healthier for you), and you will pee a lot. A LOT. Get used to it. It's your new normal.
Oh...and you'll have to lay off the potassium. No more, or many many fewer, bananas. High potassium and electrolyte imbalance will cause nasty cramping. It's not fun. Be careful and smart.
Other side effects:
These are important to mention, even though these are side effects we don't want to see. My...your...body is going to go through a metric tonne of changes, and it's very important to understand that they may not all be wonderful. It's important to be aware of the following:
Estrogen can contribute to increased rates of blood clotting. Deep vein thrombosis occurs more frequently in the first year of treatment with estrogens.
Estrogens may increase the risk of gallbladder disease, especially in older and obese people.
Your metabolic rate may change, causing an increase or decrease in weight and energy levels, changes to sleep patterns, and temperature sensitivity.
Androgen deprivation leads to slower metabolism and a loss of muscle tone.
Migraines can be made worse or unmasked by estrogen therapy.
HRT in transgender women does not appear to increase the risk of breast cancer. Similarly to the case of breast cancer, prostate cancer is extremely rare in transgender women who have been treated with HRT for a prolonged period of time. But you will need to check your breasts regularly just like any cisgender/AFAB woman.
Estrogens can also cause prolactinomas. Milk discharge from the nipples can be a sign of elevated prolactin levels. If a prolactinoma becomes large enough, it can cause visual changes (especially decreased peripheral vision), headaches, depression or other mood changes, dizziness, nausea, vomiting, and symptoms of pituitary failure, like hypothyroidism.
There's a reason why once you're on HRT you get regular labs drawn and see your prescribing attending doctor frequently. It's not to get money out of you...it's to help monitor things, adjust dose as necessary, and to pick up issues before they become critical or terminal.
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This has been quite long, and there's a lot of clinical stuff in here, but it's all important to know. I get a lot of questions asking about how HRT makes someone feel, or what the side effects are, or 'have you woken up with a spontaneously generated vagina and uterus yet?' or 'my daughter identifies as a squirrel what HRT does she have to go on ha ha ha?' and I'm hoping that some of this is useful knowledge to have around, so when someone you know is going through this, you know some of what they may be feeling or experiencing.
And if you're one of those talking about squirrels, well...don't let the door hit ya where the lord split ya, as I say.
Thanks for making it all the way through this lengthy bit of info. I'll see you next time with more Trans 101 With Julie.
Au revoir. Auf wiedersehen. Adios. And other farewells as well.
(This is posted under the Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International (CC BY-NC-SA 4.0) license with the intent that you may share it if you have found it informative, helpful, or enlightening. You may use extracts, properly attributed, as part of your work as long is it is openly shared under similar license.)
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