Hormone Replacement Therapy (HRT) for transgender women (male-to-female or MTF) involves taking medications to induce feminine physical characteristics. This article provides an overview of the typical hormones and medications used in MTF HRT, the expected effects, potential side effects, and considerations.

Hormones & Medications:

  1. Estrogens: This is the primary feminizing hormone.
    • Types: The most commonly prescribed estrogens include oral estradiol, estradiol patches, and intramuscular estradiol valerate or cypionate injections.
  2. Anti-androgens: These block the effects of testosterone, enhancing the feminizing effect of estrogen.
    • Spironolactone: A commonly prescribed anti-androgen in the U.S.
    • Cyproterone acetate: Used in some other countries but not approved in the U.S.
    • GnRH agonists: These include medications like leuprolide or goserelin, which suppress testosterone production.
    • 5α-Reductase inhibitors: Such as finasteride or dutasteride, which prevent the conversion of testosterone to its more potent form, dihydrotestosterone (DHT).
  3. Progestogens: Their role in feminization is debated among experts, but they are occasionally prescribed.
    • Examples include micronized progesterone and medroxyprogesterone acetate.

Expected Effects:

  1. Breast development: Usually starts within a few months and can continue for several years.
  2. Softer skin: The skin becomes thinner and softer.
  3. Fat redistribution: Fat will begin to accumulate around the hips, thighs, and buttocks while reducing around the waist.
  4. Reduced muscle mass: Overall muscle mass and strength might decrease.
  5. Body hair reduction: Body hair growth rate slows down and becomes finer, but does not disappear entirely.
  6. Facial hair: May soften a bit but generally remains unaffected. Laser hair removal or electrolysis is typically required for removal.
  7. Sexual changes: Testicular volume reduces, spontaneous erections decrease, and overall libido may decrease.
  8. Hair: There might be some minimal regrowth or slowing of male pattern baldness, but estrogen won’t reverse significant hair loss.
  9. Emotional changes: Many people report mood swings or a change in emotional experience.

Potential Side Effects and Risks:

  1. Thromboembolic events: Blood clots in the legs or lungs.
  2. Cardiovascular risks: Potential increased risk of heart disease or stroke, especially with oral estrogens.
  3. Liver dysfunction: Especially associated with some synthetic estrogens or high doses of oral estrogens.
  4. Gallstones.
  5. High potassium levels: Associated with spironolactone use.
  6. Decreased libido.
  7. Depression.
  8. Weight gain.
  9. Electrolyte disturbances: With some anti-androgens.
  10. Breast cancer: While rare in transgender women, there’s a potential risk over extended periods.


  1. Baseline and Ongoing Monitoring: Regular check-ups are essential to monitor hormone levels, liver function, and overall health. Baseline measurements (before starting HRT) are important for comparison.
  2. Individual Differences: The effects of HRT can differ significantly based on genetics, age, and individual health factors.
  3. Fertility: Testosterone suppressors and estrogen can lead to sterility. Those considering future biological offspring should explore options like sperm banking before beginning HRT.
  4. Bone Density: Over time, especially without testosterone or if not on adequate estrogen, there’s a potential risk for decreased bone density.
  5. Duration: Some effects (like breast growth) are permanent, while others (like fat distribution) are reversible and will change if HRT is stopped.

HRT is a significant medical intervention, and the decision to start should be made with comprehensive information and medical guidance. Transgender individuals should work closely with a knowledgeable physician or endocrinologist and possibly a mental health professional to ensure the best care and outcomes.