Health

A Beginner's Guide to Hormone Replacement Therapy

Look into how your medication might interact. Get ready to interview your doctors. Go as slow or as fast as you want.
June 1, 2021, 6:30pm
A non-binary person injecting testosterone
Photo by Alyza Enriquez for The Gender Spectrum Collection

Navigating health care as a trans person is hard, especially with so many conflicting and wildly sensationalist stories out there about trans health care. When done right, many transition-related treatments, including hormone replacement therapy (HRT) or gender-affirming hormone therapy, are associated with overwhelmingly positive outcomes in terms of both physical and mental health. What’s actually dangerous is denying trans and nonbinary people the right to bodily autonomy and potentially life-saving health care. 

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When even basic access to care is difficult, the more granular questions about medical transition can feel hard to parse. But we’d like to help! VICE spoke to several experts on trans health care to clear up some of the most common nitty-gritty questions people might have about hormone therapy, even if they might already know the basics. (If you don’t yet know about them, a summary of the main effects of feminizing and masculinizing hormone therapies can be found here and here. Go read up—we’ll be here when you get back.)

How do I find an HRT provider to begin with?

One way to start is by asking your general practitioner for a referral to an HRT provider. Alex Iantaffi, a licensed marriage and family therapist, host of the Gender Stories podcast and co-author of the book How to Understand Your Gender: A Practical Guide for Exploring Who You Are, recommended connecting with your local trans community online. People in your area can provide much-needed information as to who your local competent providers are. Most major American cities have queer/trans community Facebook groups, with “Queer Exchange [insert your city here]” being the most prominent format. There are also online guides and databases of providers, including Transgender Care Listings, MyTransHealth, and Trans in the South. Alternatively, you can go straight to an endocrinologist or other HRT provider, like Planned Parenthood. 

Whatever route you choose, Iantaffi recommends taking some time to prepare “interview questions” for a potential provider to determine whether they’re the right choice for you. “If it feels too unsettling to talk with your provider alone, bring along someone you trust and who is able to advocate for you, should they need to,” Iantaffi added. 

What should I expect at my first appointment with an HRT provider?

Many HRT providers now operate off of the informed consent model. According to the American Medical Association Journal of Ethics, this method “seeks to better acknowledge and support patients’ right of, and their capability for, personal autonomy in choosing care options without the requirement of external evaluations or therapy by mental health professionals.” 

Informed consent is “trusting somebody to be the expert on their own body,” as Lola Pellegrino, who provides hormone therapy in the New York area, defined it. “We’re not there to be the gender police. We trust that they’re making the right decision for them, and we want to support them,” Pellegrino said. 

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At Planned Parenthood, a medical assistant will first take your general medical history if you’re totally new to hormones. A social worker or provider will explain the short- and long-term effects of HRT and a general timeline of changes, based on the World Professional Association for Transgender Health (WPATH) Standards of Care. The patient can then choose to sign or not sign the informed consent form, which will allow a provider to prescribe hormones. 

After doing some blood work to assess your baseline hormone levels, you’ll see a provider who will discuss the different types of HRT and their risks and benefits. Upon determining which care regimen is right for you, and sometimes doing tests to get more information to make sure HRT is safe for you, your provider will write you a prescription.

Not all hormone therapy providers practice informed consent. Joshua Safer is the former President of the U.S. Professional Association for Transgender Health and Executive Director for the Center of Transgender Medicine and Surgery at the Mount Sinai Hospital. He described his usual practice, based on the World Professional Association for Transgender Health Standards of Care (SOC), as “a bit of gatekeeping and a bit of informed consent, where we provide the patient information so they can join in the decision-making, and we follow best practices based on guidelines.”

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More explicitly, the main difference between these two models is that the SOC model requires a psychosocial assessment by a qualified mental health professional or other “appropriately trained” health care provider before hormones can be prescribed. According to the SOC, this assessment can consist of questions about “gender identity and gender dysphoria, history and development of gender dysphoric feelings, the impact of stigma attached to gender nonconformity on mental health, and the availability of support from family, friends, and peers.”  

“There are pros and cons of different approaches to discuss,” Safer said. “The plan is customized to the patient. And no signed form is required.”

Does insurance cover HRT? What if I don’t have insurance?

Insurance coverage for HRT can vary wildly depending on where you live, and depending on what kind of insurance you have. If you have private insurance, there are 24 states (plus D.C.) where trans exclusions in health insurance coverage are illegal. There are also 27 states and four territories where there are no laws in place prohibiting insurance discrimination against LGBTQ people. If you have Medicaid, there are 22 states, plus Puerto Rico and D.C., that explicitly cover transition-related health care, but also 11 states whose Medicaid policies exclude transition-related health care. You can find more specific details on coverage for your state at the Movement Advancement Project, and details on coverage under different plans at the Human Rights Campaign

If that wasn’t complicated enough: The Biden administration recently restored the Health Care Rights Law, also known as section 1557 of the Affordable Care Act, so that federal non-discrimination protections apply to gender identity and sexuality once again, as of May 10. (These protections were previously rolled back by the Trump administration.) The National Center for Transgender Equality also has a Know Your Rights guide to insurance discrimination

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If you don’t have insurance, it’s possible to pay out of pocket, though you’ll still need to have seen a provider and obtained a prescription. One 2019 study estimates that HRT costs for uninsured people can range from $970 to $3,200 a year, depending on whether you’re on estrogen or testosterone, and depending on your delivery method of choice. 

There are also a few startups that offer HRT out of pocket and virtually, including Folx Health and Plume, though they’re not currently available in all states. (Additionally, as Plume notes, because testosterone is a Schedule III controlled substance, these apps can only provide estrogen in select states.) 

Outside of startups, and more generally: Some clinics operate on a “sliding scale” model, meaning that they can offer medication at a price based on your income. “We really try to meet people where they’re at,” said Pellegrino. “If you don’t have insurance, some Planned Parenthood clinics have sliding scale medications on-site that we are able to give you.”

If you’re a minor, your access to care may be limited depending on what state you’re in, insurance or no insurance. Tennessee and Arkansas have both passed laws this year that criminalize the provision of gender-affirming care to those under 18; dozens of other states are considering similar legislation. Unfortunately, this means that unless you move states, you’ll likely have to wait until you’re of legal age to access care. 

What if I’m nonbinary or otherwise don’t identify with “MTF/FTM”? Does that affect my access to hormones? 

The short answer is no. “We have a ton of nonbinary trans patients,” said Pellegrino. “With HRT, you often cannot pick and choose your effects, but we can do our best to help maximize HRT for you and your goals.”

Microdosing” is the colloquial term for taking a lower dosage of hormones than a “typical” regimen, and one way that people undertake nonbinary medical transition. “You can have half-dose testosterone, or half the usual regimen used for feminizing,” said Safer. “That’s perfectly safe and perfectly reasonable. It’s really just a matter of customizing the regimen for the individual circumstance, whatever it is.” Safer warned, however, that many providers are still not educated about nonbinary identity, and many electronic medical systems still use binary language. “Nonbinary stories are rarer, and that may not be as automatic with certain providers who are less knowledgable,” said Safer. “There’s going to be a lag on that being as generalized.”

Tell me more about microdosing—is it only for nonbinary people? 

Microdosing hormones is increasingly popular among nonbinary/genderqueer people, but anyone can do it. There are misconceptions that a lower dose of hormones results in different effects than higher doses, but in reality, lower doses merely slow the onset of effects that would take place regardless. This means that it could be a good option for people who would prefer to take transition slower for any number of reasons.

“One of the things that is significant is most of the effects of testosterone are permanent, and most of the effects of estrogen tend to require continuing the medication to maintain,” said Pellegrino. In other words, if you stopped taking testosterone, your voice wouldn’t go back up and you would still grow facial hair. If you were on estrogen and a blocker and went off of those medications, your body hair would grow back; however, breast growth induced by estrogen is indeed permanent. 

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Some of Pellegrino’s transfeminine patients have expressed a desire to go on a testosterone blocker without taking estrogen, but she notes that this can present a “theoretical health concern” as your body would no longer be producing hormones, leading to potential bone loss. But the option doesn’t have to be written off entirely. “Talk to your doctor or provider about the long-term risk of bone health versus the benefits of what you want,” Pellegrino said, referring specifically to the numerous proven mental health and quality of life benefits that HRT can have. Just like any other medical decision, or even just getting a tattoo or piercing, there’s always a cost-benefit analysis to factor in.  

How can HRT affect mental health?

Because of the complexity of hormones and the lack of research about many aspects of trans health care, most providers can only offer observational insights, and even then, these observations are highly variable. “As a therapist, I have witnessed a broad range of reactions to HRT,” said Iantaffi. “There are stereotypes, such as testosterone making people angrier. These seem to be often based more on gender stereotypes than reality. In fact, several people feel more mellow when on testosterone. Generally, people feel more settled and confident in their own gender identity and expression when they go on HRT, and, often, their mental health improves.” 

Safer takes care to differentiate between treatment for gender dysphoria and treatment for potentially related mental health issues. “Transgender treatment is not a mental health concern; it’s dealing with people where there’s a disconnect between gender identity and some of the visible anatomy and we’re using hormones to change the body that you can see to match the gender identity,” said Safer. 

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“The mental health concerns that are associated with transgender people seem to mostly relate to not being treated or being neglected by the medical establishment,” said Safer. “The treatment… heavily ends up being legitimately mental health in the sense that we actually take care of people, [and] we’re respectful and thoughtful about their circumstances.”

Iantaffi agreed. “The barriers to care for transgender people are very real,” they said. “I want people to know that our fears are not paranoias, but rather a result of systemic discrimination within the health care system and beyond.”

Both Pellegrino and Iantaffi have observed that, upon starting HRT, patients often report feeling decreased rates of suicidality and depression. “Overall, people generally feel much, much better after HRT,” said Pellegrino. “On an individual level, it is a big change, so people often need support. It can be a mental health stressor—but so can getting married or losing a job or moving.”

“Anyone can benefit from therapy when something in their life changes. HRT is just one possible transition in life,” said Iantaffi. “There is not a simple narrative, in my experience, and a competent therapeutic space can give people the opportunity to explore what is going on for them.” 

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If you’re looking for a gender-affirming therapist, your local LGBTQ center will likely be happy to point you to resources to help you find one, and turning to your local LGBTQ Facebook groups can be a good option as well. If you’re a person of color who’d specifically like to see a QTPOC therapist, the National Queer & Trans Therapists of Color Network is exactly what it says on the tin. Psychology Today has a plethora of filters, including ones for trans and LGBTQ-allied providers. 

Are there any “side effects” to HRT that I should know about?

Professionals recommend quitting smoking tobacco across the board. “[In] studies on post-menopausal or perimenopausal cis women… the ones who smoke tobacco had reported less positive effects of estrogen than their [nonsmoking] counterparts,” said Pellegrino. “Definitely quit smoking if you’re going to take estrogen because it’s not going to work as well, beyond just the risks.” It’s also worth noting that both taking testosterone and smoking tobacco can raise red blood cell count, which can cause fatigue, shortness of breath, lightheadedness and several other potential adverse symptoms. 

Certain medications can interact negatively with estrogen. “There’s a whole list of medicines that are sensitive to this,” said Safer. “Men and women have fairly similar estrogen levels, so it may not make that much difference. But it’s certainly reasonable to maybe check the dosing of some medications and to see if you need just a slightly higher dose with those estrogens on board than you had otherwise,” he said. 

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Fewer drugs are known to interact with testosterone, but as with estrogen, you should talk with your doctor. You can also check for interactions with specific medications at the above links. 

A lot of other side effects are sadly under researched, but have been widely reported anecdotally, and some studies on cisgender HRT patients (yes, they exist) can likely also be extrapolated to apply to trans patients. Pellegrino said some of her patients, especially those taking estrogen, have reported that their senses of taste and smell have changed. Many feminizing patients report softer skin; conversely, masculinizing patients often report acne flare-ups. Some people taking estrogen also report poorer nail health, and some taking testosterone report thicker nails and skin; evidence shows that elevated hormone levels in pregnant women results in rapid nail growth. Both estrogen and testosterone therapy can cause bloating in the first year of treatment due to hormone fluctuation.

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Ultimately, in the absence of robust institutional research, your local communities, and also Reddit, will often be your best friends for information on some of these lesser-discussed effects.

How will HRT affect my reproductive capability?

“Pretty significantly,” said Safer. As with most other facets of trans health care, research is extremely limited, and individual results are highly variable. 

“With testosterone, we can’t tell you that you can get pregnant, but we also can’t tell you that you can’t get pregnant, which is incredibly annoying for everybody involved,” said Pellegrino, thanks to the limitations of available research focused on trans people.  

If someone who’s taking T does want to try to become pregnant, it’s worth noting that some studies suggest testosterone is a teratogen, or a substance that can cause birth defects. (Yes, this singular study was done with rats, but it’s classified as a Category X substance by the FDA regardless.) Pellegrino mentioned that most people will go off hormones “about six months” before trying to conceive, but your mileage may vary: There’s no standard “washout” period for testosterone prior to pregnancy

Fertility is likewise uncertain for people taking estrogen. “For trans women, knocking that testosterone way down with that estrogen regimen... means that there’s not gonna be [much] sperm growth,” said Safer. “If that person was interested in having kids with those sperm, then that is going to be much reduced by having a transfeminine regimen—although… it’s not foolproof. A few sperm might get through.” (Detransition, Baby, anyone?)

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If you know you want to have children in the future, you can bank your sperm or your eggs before beginning HRT, though these procedures can potentially be cost-prohibitive. Pellegrino recommended one sperm banking service called Dadi, which allows you to bank sperm from home. Banking eggs can be harder and more expensive, costing anywhere from $6,000 to $20,000 for a single cycle, not including yearly storage costs, and necessitates in vitro fertilization, which is also a famously pricey procedure

So much fertility care for trans patients is focused on pre-HRT preservative measures because of misconceptions that hormones are totally sterilizing, but more and more research is emerging that proves the contrary. “There's still no standardized method [for] people who have been on HRT [for] getting their fertility back, but there are now more options,” Pellegrino said.

A recent study found that people who stopped taking testosterone for an average of four months had fertility levels similar to cis women when undergoing fertility treatments. Another recent study found that it’s possible for some trans women to regain fertility after stopping hormones for five months, but the same study also found that another patient was unable to produce viable sperm after four months. 

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If you’re on testosterone and interested in breastfeeding, studies indicate that, while injectable testosterone increases testosterone levels in milk, infants aren’t affected “adversely” by it

What should I know about DIY hormonal transition?

People might DIY their transition for a number of reasons: they’re uninsured, have a (understandable) fear of discriminatory providers, or they live in an area where gender-affirming care is not readily available. 

While it is not recommended by medical professionals, many providers have empathy for those who choose to DIY. “I don’t think people would use combined hormonal contraceptive birth control pills knowing that they’re substantially more dangerous if the right kind of estrogen was available to them,” said Pellegrino. 

Ethinyl estradiol (the estrogen found in birth control pills) is highly thrombogenic, meaning that there’s a higher risk of blood clotting; studies have recommended that clinicians should avoid the usage of this particular estrogen. “If you’re trans and you’re using it to suppress your testosterone and you had no chance of getting pregnant anyway, then why bother using that particular estrogen? No need to have that extra clot risk,” said Safer. 

It’s nearly impossible to DIY testosterone, because the Drug Enforcement Administration classifies it as a Schedule 3/3N controlled substance. State laws regarding testosterone prescriptions vary widely, with some states requiring in-person visits before a prescription can be made, even during the pandemic. 

If you absolutely must DIY: Pellegrino recommended any of the numerous HRT protocols publicly available online such as UCSF’s Center for Transgender Excellence, Endocrine Society and TransLine. TransLine has links to many other HRT protocols used by medical providers across the nation. 

Am I too young/old to transition?

There’s no treatments available for prepubescent children, though they can transition socially. Once you hit puberty, you can go on blockers, which delay puberty until gender-affirming hormones can be administered. The Endocrine Society recommends that hormone therapy start at 16, but according to UCSF’s Center for Transgender Excellence, some clinics recommend determining hormone therapy on an individual basis, rather than by age.

As for older adults, Safer said that “There’s no absolute cutoff age for being aware that you’re trans and wanting to do something about it.” However, the effects of estrogen may vary. “There’s an age where, especially on the female side, you would not have natural hormones,” said Safer, referring to menopause, which can occur in your 40s or 50s. “For transgender women, the default is that we try to replicate that. If you’re older than [menopausal age], we try to block your testosterone so you can have some effect, and then you kind of enter the world of a menopausal woman in terms of your hormone profile,” Safer said.

The masculinizing hormone routine differs because cisgender men have testosterone throughout their lives. “For non-transgender guys, if they have low testosterone, we give them testosterone. So there really isn’t an age consideration there,” said Safer.

“You’re never too old. You can do it safely in both ways,” said Pellegrino. “I think our oldest patient is 83, and she’s living her life—she’s having a great time.” 

So: Start whenever you need to. As long as this guide may be, it’s certainly not exhaustive. There’s never a bad time to find an affirming doctor, or connect with your local or online trans community, to find the answers to whatever other questions you might have—and what you want to do with that information in the service of your health and happiness.

Follow James Factora on Twitter.

The images in this story are from The Gender Spectrum Collection, VICE's stock photo library featuring images of trans and non-binary models that go beyond the clichés. Learn more here.