Welcome to Trans Tuesday! Today we’re covering a big topic that affects so many trans people: HORMONE REPLACEMENT THERAPY. But right up front, you need to know this essay is also about PATIENCE.
To be sure we’re all on the same page right from the start, you do not have to be on (or even want) hormone replacement therapy (HRT) to be trans.
It’s a huge part of medical transition for those of us who want and need it, but not every trans person does. And it’s not wanting HRT or medical transition that makes you trans, it’s how you feel on the inside.
But for those of us, like me, for whom it’s a huge part of our transitions, what’s it like? Well the difficulty in answering is that hormones affect literally every body differently. Some of us can be on the exact same dose with the exact same delivery method, and have wildly different results.
It’s very often a game of trial and error, and finding what combo of things gives us what we need. There are things hormones can do, and might do, and won’t do, but not everyone’s experience is the same.
Please please keep that in mind. I don’t want you going to another trans person who says they were affected differently, or coming to me saying, “but Jane said X!” Hormones are just wonky like that, because human bodies are… fun?
Also, as I am not an endocrinologist or doctor of any kind, I can’t give you the kind of information they can. For example, there are medical reasons why some people can’t be on HRT, but I don’t know what all of those reasons may be.
I just want you to understand how unique this is to every trans person. We all have our own experiences with it and we’re all on our own journeys. Okay? Okay.
While trans HRT sends a human body through a second puberty, it does not undo the effects of the first, wrong puberty. But physically and emotionally, it absolutely sends you through another one.
HRT consists of two main portions… usually one medication to block the testosterone or estrogen that your body produces, and one medication to introduce the other one into your system. Not everyone is on both, for medical or personal or other reasons.
A testosterone blocker in an adult trans woman suppresses said hormone in the body.
This can lead to slower-growing, and/or thinner, and/or less BODY HAIR growth, and can even halt or slow male pattern baldness, and sometimes even cause minor breast growth.
Reducing testosterone in AMAB (assigned male at birth) folks can also lead to a decrease in muscle mass (more on this in a bit), a shrinking of the penis and testicles, and infertility. Though there have been a couple studies that indicate fertility may return if T-blockers are stopped, but that hasn’t been really confirmed yet. (More on the dangers of a lack of medical studies done on trans HRT in a bit.)
And the problem with testosterone, for we trans ladies who transition as adults, is once you go through testosterone-induced puberty… you can’t undo most of those changes. The voice deepens, the shoulders broaden, the jaw becomes more defined, facial hair starts growing, you get taller.
There are some things we can do to try to change or mitigate these things, but not all of them. There’s no way to make your shoulders less broad. You can’t NOT be as tall as you are (mostly… again, more on this later).
I went through three years of gender affirming voice therapy to help me sound less like a cis man and more like me (see the three-part series on TRANS VOICES. It was a ton of hard work I put in on trying to change the way I talk and how I sound.
And if you are a cis woman, imagine how you’d feel if your body did those things, and how much it would feel like your body betrayed you and made the world see you as someone you’re not. And the horror of not being able to stop it as your body keeps making those changes. Really think about how that would make you feel…. watching facial and body hair grow, seeing your jaw and shoulders widen, hearing your voice deepen.
Congratulations! You just got the tiniest experience of GENDER DYSPHORIA. Now imagine it all day long for every day of your life. And you will instantly see why getting trans kids on perfectly safe and reversible puberty blockers before that happens is vital and lifesaving. Again see TRANS KIDS AND THE INTAKE EXAM.
What happens for trans ladies when estrogen is introduced into our bodies? It can also slow/thin body and facial hair growth, and it definitely promotes breast growth (but how much varies wildly). It also shifts the way your body carries fat.
Did you know cis men and women carry fat in different places in their bodies? SCIENCE, BITCHES. So when a trans lady goes on estrogen, it will shift where fat gets stored and carried under the skin and can lead to a softer, rounder appearance. This includes a softening of the skin and facial features, and a softening or rounding of the hips and butt
You can see in my FOUR YEARS OUT AND ON HRT CHECK-IN timeline photo that not only did HRT give me a whole new face, it changed my eye color. Many trans people report that happening, but as far as I know there have been no studies done on why or how that happens.
But this study mentions there are estrogen receptors in the eyes! So it’s not nonsense.
But guess what? You also get emotional changes, because hormones and puberty are fun. The emotional/mood changes also definitely vary from person to person. If someone is getting an injection once a week, the day they take it their body is getting a flood of hormones, and if your dose isn’t high enough to maintain a constant level, the last day or two before an injection can be awful… filled with mood swings and hot flashes (ask me how I know).
I did not at all expect the mental changes that would come with HRT. The calm, the peace, the feeling of wholeness and fullness and of being me that would come with being on the right hormone for my body. “Night and day” doesn’t even begin to describe the difference, it’s like life in my body went from absolute zero to the surface of the sun (complimentary).
And in fact, this was illustrated all too clearly to me when I lost the mental changes HRT had given me. I was initially on estrogen pills, but a couple years into medical transition they just stopped working for me entirely. My estrogen levels plummeted, I was getting almost nothing from them, my testosterone rose (estrogen and testosterone fight each other in the body, when one rises the other usually falls), and life became awful again. I talked about this in detail in TRANSITION SETBACKS.
And what this taught me was how much I need my HRT. Even if I never get another physical benefit from it, the emotional gains and stability it provides me are so much of what keeps my dysphoria at bay. And without it, it felt like my very identity was being stripped away from me. My personality, my thoughts, my feelings, my everything. Not being on it is not an option.
But let’s talk more about those physical changes from estrogen!
Some trans ladies have noticed that after being on HRT for a long time, their feet are a little smaller, maybe they’re not quite as tall. Again, it shifts everything in your body. But not the same way for everyone! I lost half a shoe size pretty early into HRT, and that’s stayed consistent. But alllllso…
I lost an inch and a half in height! A lot of trans women report this happening, possibly just from tendons and muscles shifting, or loss of muscle mass, or who knows. But I’m a little salty about it, I liked being 6’2”! Alas.
Also, my hips have rotated. It hurt like hell when it was happening (slowwwwwly, over many months). It’s something that happens to cis women when they go through puberty, too. And I have evidence, because the measurement across my hips hasn’t changed, but I can’t pull some skirts over my hips like I used to be able to (which is how I figured this out). I talked about that, again, in my FOUR YEARS OUT AND ON HRT CHECK-IN.
I’ve also finally seen some butt growth (see that four year retrospective) and a lot more breast growth, and that’s all from switching my estrogen from pills to injections, and also due to taking my progesterone (another hormone I take) sublingually… which basically no doctor will tell you to do, but other trans ladies sure will (see ANECDOTAL TRANS HEALTHCARE for more).
Also, let me tell you… growing boobs HURTS LIKE A MOTHERFUCKER?
I know lots of cis ladies complain about bras, but frankly they were vital for me because they’d act like a shield to protect my boobs from being touched. BY ANYTHING. Getting dressed and my hand brushed one? AGONY.
Rolling over in bed was a nightmare, because I’m a side sleeper so as soon as the side of a boob hit the mattress I’d nearly scream in pain. And it means they’re growing, so yay!
But auuuuuuuuuugh the pain. And again not every trans woman gets the same results (just like cis ladies when they go through puberty). Also there’s no timeframe for when it all happens!
I saw decent breast growth in a matter of months (if not a ton), but some ladies take years. It took me one thousand days of HRT (mostly with estrogen and progesterone pills) to get to a B cup bra, but then only a few months from there to get to a C cup (with estrogen injections and sublingual progesterone).
One trans lady I know had B cups for ten years and then suddenly they grew to D cups. Why must bodies be this way? Seems inefficient!
I mentioned that loss of muscle mass definitely happened, so let’s talk about that. I’m still kinda buff (in my own estimation) and I love my biceps, but I have to work harder now than I did before to keep them looking the same. In fact, I have to work twice as hard to see the same results as I did before HRT. (All my exercising was one of the first things I did to transition before I could medically or socially transition, see BODY HACKING for more.)
Jars I never once struggled to open before now give me fits. I just can’t do some of the physical things I could before, even with my pretty biceps (they are indeed pretty, I assure you… see that four year retrospective and peep ‘em for yourself).
As to my body changing the way it stores fat, I’ve definitely noticed that too. There’s a spot in my lower abdomen, below my stomach, that has been flat as a wall my entire life. But on cis ladies it’s often softer and rounded there? Do you know what I mean?
Anyway! I’ve got that. And having a face that looks like me is the biggest hit of GENDER EUPHORIA ever! And cis folks, that’s something you can (and likely do) experience, so check out that link. It’s the. Most. Amazing. Feeling. Ever.
And one of the earliest changes I experienced from HRT was my smell! I just smell like a girl now, and did as of a few months in, and that was absolutely wild.
It also cratered my libido for a while, but adding progesterone into my HRT definitely brought that back.
Let me quickly note that for people on masculinizing HRT, the effects they might see are the opposite of what I’ve described for feminizing HRT… body hair and facial hair growth, a deepening of the voice, facial and body fat redistribution (the opposite of the way transfem folks like me experience it) increased muscle mass, change in body odor, possible hairline recession, and an increased libido.
But as far as the changes from my HRT go, I want more. I want SO MUCH MORE. Yes, good, keep going body! But there’s literally nothing I can do to speed it along. And that’s where patience comes in, because HRT isn’t a switch you flip.
It’s a process, and it’s slow as hell, and it’s just going to do what it’s going to do and at its own pace. And you have no idea what you’re going to get, or when you’ll get it. You have to live with getting incrementally closer to your goal, day by day.
You can see it starting. You can see it getting closer. Almost agonizingly close, after spending so long being so far away. All you want to do is sprint to the finish line. But you can’t, even if you wanted to! You’re stuck crawling like a snail.
There’s no magic shortcut. We’re trapped in bodies that were forced to change against our will (see TRANS TRAUMA 2: SOCIETAL GASLIGHTING), and changing them into one that is one we feel at home in can be a painfully slow process.
And that’s made worse about the issue I briefly touched on before, there being so few medical studies done on trans people, much less run by trans people. This is because we’re such a small percentage of the population we’re not, I dunno, “medically lucrative” enough, I guess, for a lot of studies to be done on us. So there’s a lot we just don’t know, and a lot of doctors operating on thirty-year old information.
That can lead to problems, like a lot of endocrinologists wanting to keep trans women’s estrogen levels artificially low, based on dangers that occurred with high levels of estrogen from old forms of HRT that are no longer used. It’s not profitable or pressing enough for a lot of them to stay up to date on things, because they treat so few trans patients (comparatively to their cis patients). But when you look at modern data, or let trans doctors lead the way, they often argue that trans women’s estrogen levels are absolutely fine anywhere in the normal cis feminine range.
And these guidelines are mostly all set, in the US, based on WPATH (World Professional Association for Transgender Health) standards, and also guidelines of the Endocrine Society. Those standards are occasionally revised, but they are still mostly set by cis people and also have terribly transphobic origins (see TRANSMEDICALISM and WPATH version 1).
As one example, the trans clinic at UCSF recommends a dose of up to 20 mg estradiol valerate for trans women on injections, but WPATH maxes out at half that.
SIDEBAR: there is some indication the UCSF trans clinic website may be down and/or have been removed due to capitulation with fascism. Here’s the archive.org version just in case. Preserve trans science.
And in fact, the UCSF guidelines state that for trans women, “Maintaining estrogen levels in the physiologic range for menstruating non-transgender women minimizes risks and side effects, and makes sense clinically.”
Multiple studies have shown that for cis women going through puberty, and for adult cis women, their normal estrogen levels can range up to 300 pg/mL (picograms per milliliter).
But many endocrinologists (a few of my past ones included) pitch a fit when you go over 200. Why? Because with older, more dangerous forms of HRT, going over 200 was exceptionally risky. It’s not so much anymore! But most of them want to stick to WPATH/Endocrine Society guidelines.
When you look at trans doctor-led healthcare, like Folx, they say, “We typically are looking for levels in a range from 50 to 500 pg/mL. … We think people using GAHT [gender-affirming hormone therapy] may need and deserve wider ranges than their cisgender peers. The typical estradiol range for cis women is 100-350 pg/mL. We use a broader range for GAHT.”
So in addition to sometimes having to even fight to access HRT if we’re not in a location with informed consent (where you can say “I understand and consent to this medication”) and we have to prove we are who we say we are just to get a cis doctor to agree to put us on HRT (again, see TRANS KIDS AND THE INTAKE EXAM), we often then have to fight with our doctors about not keeping our estrogen levels artificially low.
And let me remind you that every drug used in hormone replacement therapy was developed for cis people. For cis men dealing with hair loss, for cis women going through menopause, and more. That they’re used to great effect for trans people is wonderful, but is not why they were designed or exist. And this isn’t remotely the only medical stuff that cis people get which trans people use too. Please see CIS PEOPLE GET GENDER AFFIRMING HEALTHCARE TOO to learn all about the myriad other things tons of cis people do and are fine with, but then suddenly balk when trans people want gender affirming care too. Don’t be a hypocrite.
And yes, it’s remarkably safe, and in fact every major medical association approves of hormone replacement therapy for trans folks and trans kids (who only get blockers to prevent the wrong puberty, which can be stopped at any time and then puberty proceeds as normal). Read more here: Medical Association Statements in Support of Health Care for Transgender People and Youth
Every trans and nonbinary person does what we can to try to feel more like our real selves. For many of us that involves HRT.
And we do it because we must, because it’s better than the alternative.
Every out trans person you meet decided climbing this almost insurmountable hurdle was better than the pain we were living through before. It’s a slog, and it’s tough going, especially if you’re on HRT. But the rewards are worth it. If we’re lucky, gender euphoria waits on the other side!
And for the trans people that aren’t out yet, or can’t be, that want HRT but can’t access it yet… I know how tough it is, but you can do it. I did, and you can too. Don’t give up. Hold on. Whenever you’re ready, we’ll be here to help you along.
Tilly Bridges, end transmission.
tillysbridges@gmail.com
ADDENDUM 5/8/25
I should have mentioned this in the main essay, but HRT also changed the way I experience the way I’m attracted to women, and the way I feel romantic love for my wife.
Someone asked if I could explain it, but I’m not sure I can. I don’t have words to describe how it chanted, but I thought about it for an entire day, and this was the closest I could come up with (and it applies to the change in both how I experience romantic love, and how I am attracted to women).
It’s like… my love for my wife was a freight train barreling through the countryside with blinders on, chasing a single infinite end point.
And now it’s a soft hot air balloon ride on a warm sunny day where the horizon goes on to infinity and I can see the entire world.
Maybe that will make sense to or help someone else out there.
