MTF Self Medication Guide
While we would never advise self-medication of feminizing hormone therapy without guidance from a licensed healthcare provider, we understand that not everyone has access to this kind of healthcare. We also understand that gender dysphoria associated with primary and secondary sex characteristics can be a danger in and of itself. Therefore, we provide this guide to those with no other options.
This article will specifically focus on a (feminizing) male to female transition, but there is also information available for female to male transitions.
We would also like to state that this article was not written by a medical professional and comprises information from various similar sources online. Therefore, if any adverse effects are experienced, it might be best to consult a doctor. Also, remember that doses given here are approximations, and your individual case might need different dosages for various reasons.
A Few Words on Terminology
Please note that the use of terms such as “male to female” or other uses of words like “male” and “female” often suggest a gender binary approach, which is something that we do not have here. Such terminology is used purely to indicate the appearance of primary and secondary sex characteristics and is not meant to suggest gender binary ideals. We respect and value the amazing diversity of gender identity, and this article will hopefully help someone to embrace their gender identity and combat gender dysphoria.
We would also like to indicate that any information provided for transgender women can also be applied to gender nonconforming people who would like to undergo feminizing hormone therapy by minimizing male secondary sex characteristics.
Gender Affirming Hormone Therapy at a Glance
The purpose of gender affirming hormone therapy is to reduce secondary sex characteristics of an assigned gender and increase secondary sex characteristics of a preferred gender.
So in an MTF transition for trans women, this would involve a lessening of facial hair growth, stimulating breast growth, decreasing muscle mass, and feminizing of the face and other parts of the body, among other things.
This type of transformation entails an increase in estrogen production and a decrease in testosterone production. This is achieved through administering medications like Ethinyl estradiol and anti-androgens. In most cases, you would take both estrogen supplements like Ethinyl estradiol, in conjunction with anti-androgens. Although if you have already undergone an orchiectomy, you will likely only need an estrogen supplement as the removal of the testes dramatically affects the production of testosterone sex hormone.
Feminizing Hormone Therapy Overview and Testosterone Production
The most important thing that you need to take note of here, as briefly mentioned in the previous section, is that there is a difference between the medications that you take if you have not had any bottom surgery yet and the medication that you will take if you have had an orchiectomy.
Before this surgery, you will need a combination of estrogen therapy (for example, Ethinyl estradiol) and anti-androgen therapy. After the surgery, you might not need anti-androgens; in fact, as with some cisgender women, you might end up having too little testosterone production following this surgery and might need to take low dose testosterone for a while to stabilize hormones, but this will not have a negative effect on your transition seeing as a certain level of testosterone is normal in all women and is necessary to maintain secondary sex characteristics associated with femininity.
Taking estrogen therapy will reduce the production of gonadotropin-releasing hormone by the pituitary gland. However, taking estrogen therapy on its own will likely not cause the changes you are looking for as transgender women or gender nonconforming people. And taking only anti-androgen therapy can cause severe side effects associated with bone density.
Although with all medical treatment, there is a risk of side effects, we often have to weigh risks up against issues that can be caused by gender identity problems such as gender dysphoria. Leaving something like an incongruent gender identity unaddressed can have terrible effects on transgender health.
Secondary Sex Characteristics
What changes once I start feminizing hormone therapy?
Many things will change, and these changes occur gradually. It is noted that there is no set timeline for these changes as they tend to vary significantly from one individual to another. They are also not entirely related to hormone levels, and it is essential that you not exceed doses of any sex hormone without consulting a licensed healthcare professional.
Some breast development will occur. However, most people report having an a-cup or small b-cup size within six months. Most surgeons would advise waiting at least one year before considering breast augmentation surgery so that the full extent of breast development can be considered.
Body hair growth will alter to appear more feminine. In addition, male pattern baldness can decrease due to redistribution of hair growth.
You can also expect decreased muscle mass within the first year. Many people also report a sharp decrease in physical strength associated with decreased muscle mass. This is accompanied by a redistribution of body fat that will help to physically appear more feminine.
Physical and emotional changes are often welcomed during the transition, but we also need to be aware of some changes that might be unpleasant.
A decreased libido can sometimes occur, and erectile dysfunction is common, although orgasm is still possible. Should you wish to maintain an erection, then taking Viagra is an option but should be discussed with a licensed healthcare provider due to the risks involved with taking Viagra.
There might also be abnormalities in liver enzymes which can be pretty bad. In this case, you will likely need to alter your dosage or change the brand of medication that you are using.
Mood swings can also increase with estrogen therapy, but this is likely temporary and can also be managed with a brand change, etc. It is important to note that even cisgender women who take estrogen therapy can experience associated mood swings, and it is managed the same way.
Another common side effect of estrogen treatment for both transgender women and cisgender women is an increased risk of high blood pressure. Again, this can be managed by changing your estrogen dose, brand or, adding blood pressure stabilizing treatment to your regimen.
Weight gain can also be a common side effect of hormone replacement therapy. This can usually be managed with lifestyle and dietary changes (also remember that people who were assigned male at birth intake much more calories than people who were assigned female at birth, and if you start hormone therapy, then you need to adjust your diet to fit the appropriate hormone levels).
Overall Health Considerations following Feminizing Hormone Therapy
Although feminizing hormone therapy and gender affirming surgery will likely be a largely positive experience and will have significant benefits for your self-esteem and your overall well-being, there are still some things you need to remember to look out for. First, it is essential to remember that all aspects of transgender health need to be addressed in your hormone therapy plan. Starting hormone therapy can be great for your mental health, but there are several physical and emotional changes that you will need to be prepared for as trans women. Some of them will be very welcome (for example, breast development), while others might be far less so (for example, weight gain).
Most transgender women still have their prostate, so remember to look for signs of prostate cancer. It might be a good idea to go for prostate cancer screening still occasionally. However, there is some scientific evidence that transgender women have a lower risk of prostate cancer than cisgender men.
You will also need to be on the lookout for breast cancer. Some hormone therapies can increase your risk of breast cancer very slightly; although it is uncommon, we also need to remember that anyone can get breast cancer, even cisgender men. So regardless of breast development or breast augmentation surgery, cancer is still a natural and normal possibility for anyone, even transgender women.
Some hormone regimens can cause a slightly elevated risk of cardiovascular disease, so it is good to go for regular screenings and maintain a healthy lifestyle. This will also help fight possible weight gain and can decrease the risk of breast and prostate cancer.
Regardless of the risk of cardiovascular disease, it is always a good idea to maintain a healthy lifestyle and exercise regularly. It will also help your body optimize the hormone therapy you are already receiving. Aside from the positive effect that a healthy lifestyle has on cardiovascular disease, it can also help combat the risk of venous thromboembolism and stabilize liver enzymes. In addition, hormone therapy also causes an increased risk of mood instabilities in transgender women, which regular exercise and a healthy lifestyle will also help to minimize.
Medications and Dosage
Two anti-androgen options seem to be more widely used than others. These are:
- Cyproterone Acetate at 100mg – 150mg daily, taken orally. This one seems to carry an increased risk of depressive symptoms, and should this side effect occur, the medication is often changed.
- Spironolactone – 100mg- 200mg daily, taken orally. This one might be a good option if you have high blood pressure or are concerned about blood clots or venous thromboembolism as it is a potassium-sparing diuretic.
Other options include:
- Medroxyprogesterone – 5mg – 10mg daily, taken orally, or 150mg monthly via intramuscular injection.
- Nilutamide – 300mg daily, taken orally. This one can cause androgen production in rare cases, so it is usually not the first choice.
- Flutamide – 250mg three times daily, taken orally. This one can also potentially cause androgen production, so it is not the first choice.
- Ethinyl Estradiol – 100micrograms daily, taken orally. Most effective and easy to come by. It can be in the form of an oral contraceptive pill.
- Conjugated Equine Estrogens – 5mg t- 10mg daily, taken orally. This one is usually not advised as it increases the risk of thrombosis.
- 17ß Estradiol – 2mg – 8mg daily, taken orally, or 200mg monthly intramuscular injection, or 50 – 100micrograms transdermally. This is a synthetic hormone therapy. This option appears to be the most expensive.
- Estriol – 4mg – 6mg daily, taken orally. High doses are necessary for gender affirming hormone therapy.
When self-medicating feminizing hormone therapy, it is best to monitor your sex hormones at home. There are home testing kits available to monitor sex hormones, for example, a serum estradiol test. Within the first year, testing of hormone levels is usually done every three months, and after the first year, they can be done at 6 – 12 month intervals.
Remember, your goal is to maintain a physiologic female range, and if you are over the age of 40, you might need to aim more for ranges typical in postmenopausal women. Increasing doses will not speed up your gender transition and will likely have serious complications. Remember then also that postmenopausal women have lower hormone therapy requirements. This might mean lower doses of anti-androgens are required, depending on your situation.
Transdermal estrogen therapy is often the most expensive form of hormone therapy and might not be indicated for self-medication due to high costs.
Stopping Hormone Therapy
There are not many instances where you would need to stop gender affirming hormone therapy. It is far more likely that dosage or brand would be adjusted in the case of side effects. In terms of transgender health, hormone therapy is a well-researched and generally safe treatment for transgender women.
If you are experiencing side effects or other health concerns, it might be better to consult a healthcare provider before resolving to stop hormone therapy entirely. Feminizing hormone therapy should be your first port of call and is an essential aspect of transgender health.
Some people who experience gender dysphoria might have contraindications for estrogen use, in which case you would require more anti-androgen medications to maintain the desired levels of hormones. Therefore, it is essential to find the right anti-androgen for you. What works well for one might not work nearly as well for another. Generally speaking, it is advised to start with the most widely used anti-androgen. Then, if that one is causing side effects or otherwise not having the desired effect of feminizing hormone therapy, you attempt the next anti-androgen down the list, and so on.
If you are experiencing persistent problems, you might need to seek professional assistance concerning feminizing hormone therapy. In addition, if you do experience severe adverse effects from self-medication with any sex hormone for gender dysphoria, it might be necessary for you to consult with a healthcare professional.
Mental Health Conditions
It is essential to acknowledge that mental health conditions are common in transgender women, as it would be with the rest of the transgender community. The main reason for this is prolonged gender dysphoria and likely social ridicule.
However, regardless of the cause, any comorbid mental health condition will also require treatment, and it might be best to see a doctor about mental health concerns. Some of the medications associated with feminizing hormone therapy can worsen or produce, on its own, symptoms of depression. There is also a risk that feminizing hormone therapy can aggravate existing mood disorders. Therefore, there might be a need for additional medication to manage symptoms associated with mental health conditions for some time. But this should not, on its own, be a contraindication for feminizing hormone therapy unless the symptoms are particularly severe.
You will need to be aware of some general risk factors before starting any self medical treatment.
One of the most significant risks associated with hormone therapy, especially with estrogen therapy, is high blood pressure and blood clots, which is a risk that both transgender women and cisgender women, or anyone else on this spectrum, will face when taking such hormone treatments.
Another significant risk that is common for anyone taking estrogen therapy is an increased risk of depression-like symptoms. Again, suppose the dosage is correct, and your body adjusts appropriately to hormone therapy. In that case, symptoms like that can decrease quite quickly, but it is imperative to be aware of them and to know that you need to try and get insight from a doctor if these symptoms are pervasive.