Some effects of feminizing hormone therapy include:

No one can predict how fast, or how much change will happen after starting hormone therapy. Changes are often more noticeable for people who begin the process when they are younger. It’s also important to know that some effects may not be reversible once you have started hormone therapy.

To ensure you are getting a safe dose of hormones to help meet your goals of gender affirmation, your Care Pathway Center team will check on you often to help you understand your body’s response to the hormones.

During your first year on hormone therapy lab work must be done every 3 months. Your Care Pathway Center case manager will remind you when it is time for lab work. It is important that you complete your lab work when required.

Estrogen is the sex hormone that causes physical characteristics that are typically feminine. We can prescribe it as:

• A topical patch applied to the skin that is changed once or twice a week (recommended for women over 40 or those who have certain medical conditions)
• An oral pill taken once or twice a day
• An injection every one or two weeks

Care Pathway Center does not prescribe estrogen implantable pellets.

How to inject intramuscularly

How to inject subcutaneously

Androgen blockers can reduce the effects of testosterone on the body. Androgen is the male sex hormone (testosterone). These medications may also be described as:

• Antiandrogens
• Testosterone blockers

Spironolactone is the androgen blocker most used in the United States. It is relatively safe and effective at blocking the effects of testosterone. Estrogen and androgen blockers are most effective when taken together. Androgen blockers lower testosterone levels. This allows the estrogen to cause more feminizing changes.

Hormone therapy doses (amounts) vary from person to person. How much you take will depend on:

• How your body reacts to the hormones
• Your treatment goals. People have a wide range of goals related to how they want to look and feel.

Talk with your Care Pathway Center team about your desired outcomes. Together we will develop a hormone therapy plan to help you achieve your goals safely and ensure that your hormones are in a healthy range for you.

Taking higher doses of hormones than prescribed:

• Does not increase the effects or make the changes occur faster
• Can increase the risk that you will develop serious side effects

If you are receiving estrogen injections, your labs need to be drawn halfway between your injection dates. To make sure we have an accurate result, your labs should be drawn in the morning, before 9 a.m. Your Care Pathway Center case manager will contact you to review the results. At that time, your hormone dose may be adjusted to help you continue to reach your gender affirming goals. After your first year on hormone therapy, you may need less frequent lab work.

Everyone responds differently to hormone therapy. Some people may experience side effects.

Most side effects are mild. Others are more serious. We don’t yet know all of the side effects of taking hormones or hormone blockers for a long time. In rare cases, they can cause severe complications.

Using hormones and hormone blockers for the purpose of gender affirmation is an off‐label use. This means that:

• It has not been approved by the Food and Drug Administration (FDA)
• The medicine and dose recommended for you is based on your healthcare provider’s judgment and experience

Before we prescribe hormones or hormone blockers, we will talk to you about:

• The risks and side effects
• How to lower your risk of serious side effects
• Identifying early signs of serious side effects so we can address them

Estrogen and hormone blockers can interact with other drugs and substances and cause medical problems that can be life-threatening. We need to know everything you take or use, including:

• Prescription medications
• Alcohol
• Diet supplements
• Herbs
• Other hormones
• Nonprescribed legal or illegal drugs
• Nicotine products

We need to know this information for your safety. This will not affect your ability to receive medical care.

Estrogen is associated with a risk of blood clots. Blood clots can cause a number of problems including:

• Chronic problems with veins in the legs
• Heart attack
• Blood clot in the lung (pulmonary embolism). This may cause permanent lung damage or death.
• Stroke. A severe stroke can cause permanent brain damage or death

There are a number of ways to reduce your risk:

• Stop smoking. Smoking greatly increases your risk for developing blood clots, especially if you are over age 40. We strongly recommend that you stop smoking completely if you want to start taking estrogen. We can help you quit
• Use the estrogen patch. People who receive estrogen through a patch on the skin are less likely to develop blood clots
• Get blood tests. We will order lab tests to monitor your blood levels of estrogen. Keeping those levels in the normal range can reduce the risk of a blood clot

Common side effects of estrogen include:

• Mood changes. Many people notice that they feel more emotional after starting estrogen. However, if you feel depressed or hopeless, please let us know so that we can offer support and treatment
• Nausea and vomiting. Some people report this when they begin taking estrogen. Nausea can occur if we adjust your dose. We can treat these symptoms by reducing the dose or prescribing a different form of estrogen. Anti-nausea medication may also help
• Headaches or migraines. This symptom is more likely to develop in people who already have migraines. It’s important that you let us know about your migraines before you begin estrogen hormone therapy or if you develop them after you start estrogen hormone therapy

Less common side effects of estrogen include:

• Abnormal liver blood tests. This is rare. We will monitor your liver function before starting hormone therapy. Let us know if you have a history of liver problems
• Diabetes. This is more likely if you have other risk factors for diabetes, like a family history of diabetes or obesity
• High blood pressure and heart disease. We will check your blood pressure before starting hormone therapy and while you continue taking hormone therapy. We can work with you to control high blood pressure with diet, lifestyle changes, and/or medication
• Noncancerous tumor of the pituitary gland. This is very rare and it’s not yet known if taking estrogen increases this risk. It is not usually life-threatening but can damage vision and cause headaches. Estrogen can cause your pituitary gland to produce more of the hormone prolactin. We can monitor the level of prolactin to screen for problems with the pituitary gland

Spironolactone affects the balance of water and salts in the kidneys. This may:

• Increase the amount of urine you produce
• Increased thirst
• Reduce blood pressure
• Rarely, increased potassium levels in the blood. This can cause heart rhythm changes that may be life‐threatening.

Androgen blockers can sometimes make it difficult to determine the results of prostate cancer tests. If you are over 50 years old or have a strong family history of prostate cancer, we will schedule annual prostate checks as recommended by guidelines.

Other side effects of lowered testosterone may include:

• Decreased libido
• Decreased frequency and quality of erections
• Fatigue
• Depressed mood
• Low bone density

To get the best and safest results from feminizing hormone therapy, it’s important for you to:

• Take your hormones/hormone blockers as prescribed. Taking more than prescribed won’t make the changes faster or more noticeable. We will prescribe you hormone therapy based on your goals and what is safest for you. Everyone’s body responds differently to hormone therapy
• Avoid taking any other hormones that are not prescribed by Care Pathway Center. Once we start you on hormone therapy, you will need to agree to not use hormones or hormone blockers from any other source
• Tell your Care Pathway Center team if you have any problems or are unhappy with your hormone therapy
• Follow through with all scheduled physical exams and blood tests to check for any side effects
• Let your Care Pathway Center team know if you have or develop any of the conditions that make it risky to take hormones or hormone blockers. Your healthcare provider can determine whether it’s safe to start or continue them, and may suggest you lower the dose or stop taking the estrogen and/or hormone blockers. This may happen if the side effects are severe or there are health risks that cannot be controlled
• Stop smoking. Quitting smoking will lower your risk of developing blood clots and reduce your risk for developing cardiovascular disease
• If you decide to stop taking hormone therapy, please discuss it with your Care Pathway Center team

It is important to keep others safe from your hormones and hormone blockers:

• Do not share your hormones with anyone
• Keep your hormones in a safe location away from children
• Do not share needles with anyone or use them more than once. Dispose of needles properly in a sharps container

Having less testosterone in your body will affect your fertility in different ways. You may – or may not – be able to produce sperm mature enough to cause pregnancy. It is possible these changes will be permanent.

If you’re having sex that could result in a pregnancy, continue using birth control if pregnancy is not desired. Hormone therapy is not a form of contraception.

Talk to us about any plans or hopes you have about starting a family, so we can discuss your options. You might consider collecting and freezing sperm if you’re interested in having biologically related children in the future. The best time to store sperm is before you start hormone therapy.

You may have a range of feelings about the changes you experience after starting feminizing hormone therapy.

• It can be a relief to be recognized and accepted in your affirmed gender
• It can also be challenging if other people do not respond to you the way that you want and deserve to be treated

There are many resources to help you find support as you transition. We can help connect you to local support groups, online forums, community groups, events, and other resources.