What is HRT, or hormone therapy?
Research shows that hormone therapy (often called “HRT”) and gender-affirming care save lives. Gender-affirming care is health care that affirms people to live authentically in their genders, no matter the gender they were assigned at birth or the path their gender affirmation (or transition) takes. It allows each person to seek only the changes or medical interventions they desire to affirm their own gender identity, and hormone therapy (“HRT” or gender-affirming hormone therapy) may be a part of that.
Overwhelming evidence shows that such care greatly improves health outcomes for trans people. The evidence, and our lived experiences, show that when trans people get the gender-affirming care we need, the high rates of depression, anxiety, and suicide attempts that burden our community decrease substantially.
For more research on the health benefits of gender-affirming care visit our blog.
Gender-Affirming Hormone Therapy (GAHT) 101
Gender-affirming hormone therapy (GAHT) more accurately describes the use of hormones by the trans community versus hormone replacement therapy (HRT). Read on to understand the background of “HRT.”
What is HRT, or hormone therapy? Let’s break down what HRT means, why there is a move towards more accurately calling it gender-affirming hormone therapy (GAHT), why it’s important, and the main medications that constitute HRT, or GAHT: estrogen, androgen blockers, and testosterone.
First, let’s talk about HRT. HRT, or hormone therapy, broadly describes medical therapy that helps to encourage physical changes in the body to live our authentic selves in respect to our gender identity or lack thereof. HRT technically stands for hormone replacement therapy, commonly attributed to the process of prescribing primarily estrogen to postmenopausal cisgender women. It has also been used to describe the prescription of testosterone to cisgender men with low testosterone levels. The term HRT has been adopted by the trans community to describe the process of gender-affirming hormone therapy (GAHT). Hormone therapy is one aspect of gender-affirming care, the evidence-based model practiced by Plume that allows each person to seek only those interventions they desire to affirm their own gender identity, whether that be a trans, non-binary, gender fluid, or other gender identity.
Access to gender-affirming care, including hormone therapy, is lifesaving for those of us who need it. This care is considered standard of care and a medical necessity by nearly every major medical association in the United States due to the overwhelming evidence that it greatly improves health outcomes for our community. When we get the care we need, the high rates of depression, anxiety, and suicide attempts that burden our community decrease substantially[^1] .
It’s worth noting that GAHT isn’t a part of every person’s gender journey, and for those of us who do find that GAHT helps to live authentically, there’s no one size fits all approach. While there are standard medications and protocols our health care providers use to ensure safe and effective care, each person’s dose, route, and frequency of meds like testosterone or estrogen is individual.
We have more detailed information about starting estrogen, T blockers, and testosterone available on our website, but below are some of the main GAHT meds and their basic info.
Estrogen: Estrogen is a naturally occurring hormone that is typically produced in all bodies, but in different amounts for different bodies. For GAHT, we prescribe synthetic bioidentical estrogen, also known as 17-beta estradiol. Estrogen can be taken through three main routes: a tablet under your tongue, a weekly shot (usually into the thigh muscle), or a patch once or twice a week. Most people first start noticing changes from estrogen at around 2-3 months with chest development and nipple tenderness. Mental health, especially anxiety and depression, can also improve soon after starting estrogen. Some of the other changes that occur more gradually include body fat redistribution to the outside of the body (hips, thighs and glutes), softer and less oily skin, thinning and slowed growth of coarse body and facial hair, decreased libido and sexual function, and decrease in size of some parts of the genitals. Most folks will max out on physical changes after taking estradiol for 2-5 years, at which point it is typically continued to maintain the changes that have occurred. With a GoodRx coupon, estrogen generally costs between $8 to $110 a month, depending on your dose and route. For more info on estrogen from Plume, click here.
Progesterone: Progesterone is another hormone that can be used in HRT. We unfortunately don’t have any evidence to show that progesterone causes significant changes within gender-affirming care, mostly because the studies have not been done. While the research is lacking, there are a fair amount of folks who feel that it helps with things like breast development, including rounding out the breasts and areolar development, adding fullness to the hip area, and possibly improving mood and increasing libido. It appears to be safe, so if you want to try it, there doesn’t appear to be much risk. At Plume, we prefer to use bioidentical progesterone, called micronized progesterone or Prometrium (the brand name). Progesterone is usually taken as a capsule swallowed in the evenings before bed. For more info on progesterone from Plume, scroll to the bottom here.
Testosterone or androgen blockers: Testosterone is a type of androgen, so these medications are sometimes referred to as testosterone blockers or androgen blockers. It is important to know that estrogen, and not testosterone blockers, is primarily what lowers testosterone in the body. T blockers block the effects of testosterone in different ways, but do not typically have a direct lowering effect. They either directly block the testosterone receptors or block the conversion of testosterone to dihydrotestosterone (DHT), a more potent form of testosterone. In fact, often at least initially, they increase the levels of testosterone in the body because there is more floating around with nothing to do, since most of the receptors are blocked. Once the T drops to very low levels, such as less than 30 (T is usually somewhere between 400-800 pre-hormone therapy for most folks), most people don’t need to be on T blockers anymore, because there is hardly any T to block anymore! Whether to go on T blockers or not is totally up to you. You could be on none, one or multiple at the same time depending on your personal situation. Some T blockers we use include spironolactone, or “spiro” for short, and finasteride or dutasteride, or more specifically “DHT” blockers. For more info on T blockers from Plume, click here.
Testosterone: Testosterone (often called “T”) is a naturally occurring hormone that is typically produced in all bodies, but in different amounts for different bodies. For HRT, we prescribe synthetic testosterone, a version very similar to the testosterone all bodies naturally make. T is usually taken via a weekly shot, which results in the fastest changes, but can also be administered through a daily gel, or a patch. Most folks will start to notice changes like lower voice, facial hair growth, and stopping of monthly bleeding at around 2-3 months. Some folks notice feeling better emotionally shortly after starting T – in particular, decreased anxiety and increased confidence. Some other physical changes that occur more gradually include body fat redistribution, increased muscle mass, increased and darker facial and body hair growth, broadening of shoulders, more angular eyes and face, increase in libido, enlargement of some genital parts and deepening of the voice. Most folks will max out on physical changes somewhere between 2-5 years after starting T. With a GoodRx coupon, T generally costs between $15 to $60 a month, depending on your dose and route. For more info on T from Plume, click here.
[^1]: Murad MH, Elamin MB, Garcia MZ, et al. Hormonal therapy and sex reassignment: a systematic review and meta-analysis of quality of life and psychosocial outcomes. Clin Endocrinol (Oxf). 2010;72(2):214‐231. doi:10.1111/j.1365-2265.2009.03625.x