Today I am celebrating 1 year on hormone replacement therapy (HRT)! It was one of the better decisions I have ever made and I think more people should make it. Here is how it has gone for me so far.
This post contains
- detail of my medications
- the physical effects I expected and how I experienced them
- the psychological changes that HRT has effected
- some additional changes which are not known to be from HRT, but which might be
- my future plans
- my special thanks to people I cannot personally tell
Note
Some effects of HRT cannot be described without fairly explicit physical detail. I will write a separate post about them and will amend this paragraph accordingly to link to it when I upload it.
Medications
Antiandrogen
My antiandrogen is bicalutamide, which comes as a 50mg oral tablet. I take 25mg, i.e. one half tablet, once per day.
I specifically requested bicalutamide. The PBS-approved medications for gender transition at the time were spironolactone and cyproterone acetate, per Endocrine Society guidance (Hembree et al., 2017). As bicalutamide is not PBS approved, it costs significantly more.
Estrogen
My estrogen is in tablet form which I take sublingually. From about July—August 2020, I was on estradiol valerate 2mg/day. In about August, it was stepped up to 4mg/day, my current dosage level. In about April 2021, due to supply issues (Australasian Menopause Society, 2021), I had to switch over to estradiol hemihydrate, at the same dosage level.
For estradiol valerate, I took Bayer Progynova 2mg. For estradiol hemihydrate, I took Novo Nordisk Estrafem 2mg, then Mylan Zumenon 2mg. As of mid-2021, according to my pharmacist, Zumenon has PBS approval for transition HRT; Estrafem does not and is approximately 10 times the price.
Progestogen
I am intending to start progesterone 100mg/day, at a dosage of 100mg every two days, taken rectally (by “boofing”), as is increasingly usual for progesterone (W, 2018/2021), which has low oral bioavailability (Fotherby, 1996). The progesterone I have is Besins Healthcare Prometrium 100mg (capsule).
Effects
Breast development
As above, prior to starting HRT, I had some breast development, up to maybe a Tanner II. At date I think I have developed to approximately Tanner III. For a variety of reasons, I haven’t bothered actually measuring.
Thinning/slowed growth of facial/body hair
To my eye, my facial and body hair have not appreciably thinned. Growth has indeed significantly slowed; I would say facial hair grows at <20% of its previous rate of growth. Body hair might be growing slightly faster but I haven’t been keeping track.
Cessation/reversal of male-pattern scalp hair loss
Yes indeed. Prior to starting HRT I had lost a significant amount of hair. I don’t know how much hair I had lost off my crown because I couldn’t bear to look, but could see the front edge of my bald spot through dry hair if I tilted my head forward more than a little. I had significant recession in my hairline on both sides; over the left temple my hairline had receded most of the way toward the crown. I also had diffuse hair thinning to the point that if I walked through rain I could easily see my scalp.
After 12 months HRT, I can no longer see my bald spot through my hair at any angle. My hairline has filled in considerably and there is no longer more pronounced recession over my temples. The general mass of my hair also seems to have thickened considerably; there’s enough to run my fingers through.
Softening of skin/decreased oiliness and acne
Prior to HRT I was told I had unusually soft skin. The softest part of my skin was the inside of my forearm. Most skin on my body now feels like that to the touch.
I became much less oily and sweaty from pretty much the moment I started HRT, like turning off a switch. My hair developed more apparent volume as a result and I smelled a lot better (although my actual body odour is not significantly different in quality, there is less of it).
I didn’t have much acne prior to starting HRT but have had none since that I can think of.
Redistribution of body fat in a feminine pattern
Prior to HRT, I had most of my fat on my upper body, in a pseudo-hourglass shape that stopped at my hips, leaving basically no fat on my legs (a body shape I described as “two toothpicks in a meatball”).
At 1 year on HRT, my thoracic and abdominal fat seems to have migrated downward a couple of inches, clearing off the bottom of my ribcage and accumulating around and slightly over the iliac crest of my pelvis. I have a belly, but it now seems to rise relatively less far above the rest of my abdomen. In addition, I have more fat on the back of my thighs.
Decreased muscle mass/strength
As far as actually moving my arms or legs went, I didn’t notice that I had more difficulty picking up a given load or that it felt subjectively heavier; I did notice that I burned energy faster carrying it.
I noticed more changes in structural muscles. There were two changes that were particularly important to me. The first is that, although I have always had trouble maintaining a straight, upright posture, that difficulty seems to have somewhat worsened. However, I don’t believe this is an effect of HRT; rather, I believe this is a congenital condition for which testosterone compensated and which estrogen is decompensating (see Unverifiable, below).
The second is that prior to HRT I had some overdevelopment of the muscles of the neck, shoulders and (for some reason) jaw; this was persistent even accounting for changes in fat mass. I had assumed this was due to supporting my (disproportionately large) head, but never medically verified that. On HRT, all of those have slimmed down considerably, although I have no subjective change in the feeling of moving my head.
Widening and rounding of the pelvis
As I started HRT at 25, the expected degree of widening and rounding is zero. I have no reason to doubt that, but have noticed what seems like a slight outward movement of the greater trochanter of each femur. I have no way of verifying that this has in fact happened and no explanation for why it might have happened if it did.
Decreased sex drive
Prior to HRT, my sex drive was pretty much just there as a kind of background noise. I didn’t want it to be there; I felt that it distracted me, took up my valuable time, and subtly impaired my judgement. I tried to ignore it as much as I could, and was aggressively uninterested in sex to the point of being (for lack of a better word) frigid.
On HRT, the level of ambient sexual neediness which I found so unpleasant has basically cratered. I no longer feel that my time is being wasted, that my judgement is impaired, or that I have to put effort into ignoring my sex drive. For a couple of days every several weeks I do wake up feeling annoyingly horny but that’s about it. I also feel much more comfortable with the idea of actually having sex.
Decreased fertility
No idea. I’m honestly not sure I was fertile to begin with.
Voice changes
Feminising HRT is not expected to prevent, reverse or induce any major voice changes. However, as a former professional voice user (baritone singer and public speaker), I have noticed minor changes. In general,
- my natural vibrato seems to be a tad steadier and healthy vocal production seems to be easier
- I feel I have better fine pitch control over the upper half of my singing range
- I need somewhat less preparation to produce high notes and somewhat more preparation to produce low notes; it is no longer assured that I can produce a low note without warming up
- it is physically less strain to use head voice and somewhat harder to use chest voice than it previously was
Psychological changes
Prior to HRT, I had near-constant suicidal ideation with frequent peaks in intensity. Especially during peaks, I was completely incapable of self-soothing, tended to angrily defend myself against people trying to calm me down, and tried to kill myself multiple times. On HRT, I have much less frequent suicidal ideation, much less frequent peaks in intensity, much less intensity of suicidal ideation, a somewhat improved ability to self-soothe, an ability to listen to those around me, and have not tried to kill myself.
Prior to HRT, I had a great deal of difficulty expressing emotional warmth. On HRT, I feel much more able to express happiness, love, and appreciation.
Prior to HRT, I felt my negative emotions much more in my body; anything that made me angry or distressed would evoke a somatic sensation like severe heartburn. I felt professional and romantic insecurity and jealousy very deeply and painfully. In addition, it wasn’t unusual for any prolonged period of negative emotion to lead to an uncontrollable, seemingly unprovoked spiral into a significantly worse headspace of self-hatred. On HRT, my negative emotions are much less visceral; I still feel some professional jealousy, but little to no romantic or sexual envy of any kind; and spiralling is much less frequent.
Prior to HRT, I was never completely calm, to the point that “clearing my mind” and “slowing down” were nonsense concepts to me. On HRT, while my mind is still fairly frenetic and frazzled, I have the capacity to clear it and slow down without having it rocket out of my control.
Prior to HRT, in retrospect, I felt that I had an extremely atomised, bitsy way of looking at problems in front of me, unable to connect one thing to the next or develop a cohesive picture of the entirety of a situation. On HRT, I feel that I have significantly better cognitive functioning as regards strategic planning, motivation and execution.
Prior to HRT, I was effectively incapable of editing my own written work; I couldn’t tell whether my arguments were well-structured, whether I had chosen the right words to effectively express a particular sentiment, or at what point I should stop writing. On HRT, I became much better at assessing structure and word choice, and at ceasing to write when I was done.
Prior to HRT, I found it very difficult to take in anything I was reading without actively taking notes on it. On HRT, this is still the case to some degree, but nowhere near as much so.
Prior to HRT, I felt like my lips and tongue were thick and difficult to manage. On HRT, I no longer feel that.
Changes not known to be from HRT
These are things I have observed changes in since starting HRT, and which I think are conceivably linked to starting HRT, but which are not noted as being HRT-related by any resource of which I am aware.
Changes in ADHD
I was diagnosed with attention deficit/hyperactivity disorder predominantly inattentive type (ADHD-PI) in late 2017, a couple of years prior to starting HRT. I was prescribed stimulant medication to treat it; for the first couple of months of my transition, I was on a medication regimen which (seemingly unintentionally) forced me to cyclically detox (2 weeks on, 2 weeks off). This was stressful, mostly due to the functional impairment, but did allow me to observe differences in my cognitive functioning with and without medication but with HRT.
I felt that, at baseline, relative to my previous symptom severity, I had moderately better concentration, moderately better executive functioning, and moderately better memory; still certainly poor enough to qualify for clinical diagnosis, but noticeably less severely impaired than without either HRT or medication.
Changes in ADHD medication response and withdrawal symptoms
Since 2017, I have taken dexamphetamine sulfate 5mg instant-release oral tablets to handle my ADHD. Prior to HRT, the amount of medication I needed in order to function increased extremely rapidly, going from my starting dose (10mg/day) to the maximum legally allowable dose (30mg/day) in 18 months de facto. I still don’t completely understand why this happened. My medication response was also poor, with a constantly shortening period of peak effectiveness; prior to HRT, I would certainly have no more than 2 hours of peak effectiveness, but sometimes as little as 30 minutes.
On HRT, my dosage requirement has stopped escalating and may have diminished slightly (I can occasionally get through the day accidentally taking 20mg/day without realising I have done so, which would never have happened before). The period of peak effectiveness has also increased markedly; it is not now usually less than 2 hours, but can be up to 5 or 6 (I don’t know what is influencing this variation).
In addition, when I had to detox from medication prior to HRT, it was an absolutely brutal experience involving major depression, suicidality and deep dissociation, to the point that the most recent time I detoxed prior to HRT, I had to go to my GP after two days and explain how bad it was. This has been almost completely relieved on HRT; the only really noticeable effect is simply having to deal with the annoyance of unmedicated ADHD. In some ways I actually find it preferable to be unmedicated for ADHD now (but I need to function at a normal level so unfortunately the pills stay).
Changes in anxiety and motor skills
I am a pianist, which prior to COVID-19 was my primary occupation. Prior to HRT, I had a bachelor’s degree level of qualification and skill, but also had to work exceptionally hard to keep it up. I experienced fairly considerable stage fright and had to practice hard enough to avoid any mistakes, because one or two mistakes would often cause me to irrecoverably lose my nerve, which also made it effectively impossible for me to solo, improvise or ad lib. I also had relatively poor “luck,” meaning that no matter how hard I practiced a piece and my degree of competency and fluency prior to the performance, I would usually end up making an unanticipated audible slip-up on the day.
On HRT, I found that my “luck” sharply and immediately improved; I developed fluency faster and was much less prone to unanticipated slip-ups, as well as experiencing a noticeable immediate improvement in my sight reading skills. I no longer lost my nerve after mistakes and developed greater confidence with improvisation and ad lib.
Factors that I think may have influenced this include: that areas of the brain known to be generally female-shifted in trans women are known to be involved in motor execution, learning, planning and preparation, and movement selection, sequencing and amplitude; the previously described increase in “strategic” thinking; the previously described relief of anxiety and increase in emotional resilience.
Ehlers—Danlos syndrome
I have always had subclinical symptoms of a hypermobility spectrum disorder or Ehlers—Danlos syndrome hypermobile type (hEDS). These have gotten somewhat worse over the past year, in particular my joint hypermobility, my back pain, and my existing difficulty staying upright for long periods of time. This is consistent with estradiol’s known role in hEDS symptoms (Bird, 2017).
Migraine
This was a late addition to this post. On 18 July I experienced a transient visual disturbance. It was mostly on my right side and consisted of an “oil slick” or “shimmering” effect making it impossible to read text with my right eye. I was ordered to go to the ER but they turned nothing up. I’ve since been advised it was a migraine aura. Unfortunately, “priming” with high levels of estrogen, followed by a drop in estrogen concentration, appears to be a trigger for migraine (Reddy et al., 2021), as does use of oral estradiol (Women’s Health Concern, 2020).
Reversible cognitive dysfunction
I was experiencing increasing issues with primarily word-finding, and secondarily alertness, concentration, memory, quickness and efficiency of thought. In a previous draft of this post, I had this down under “fibromyalgia?” — this is a similar presentation to cognitive dysfunction in fibromyalgia (“fibro fog”).
However, I now have an alternative hypothesis which I think is more compelling. Someone suggested to me that I might be experiencing iron deficiency, which is linked with cognitive impairment (Jáuregui-Lobera, 2014). As it turns out, in people not experiencing menstrual bleeding, higher serum estradiol acts on the body’s homeostatic mechanisms in a way which actually decreases iron levels (Miller, 2016). When I started taking vitamin C, which enhances iron absorption (Lynch & Cook, 1980), the brain fog episodes decreased. When I started taking a dietary supplement including 5mg iron, the brain fog episodes decreased dramatically further. I am therefore operating on the hypothesis that it was to do with iron.
Sense of smell
My experience in this area was fairly consistent with anecdotes by other trans women regarding having a blunted sense of smell prior to HRT and a much stronger sense of smell once on it, which may be linked to estradiol’s known role in olfactory performance (Kanageswaran et al., 2016).
Sleep
Prior to both ADHD diagnosis and HRT, I could not sleep earlier than 2am. ADHD medication pulled that forward to about midnight. After I started HRT, it seemed to pull back further to about 10 or 11 PM, which may be linked to estrogen’s known role in regulating circadian rhythm (Morin et al., 1977).
Temperature regulation
Prior to HRT, I was virtually always uncomfortably warm. On HRT, I feel much cooler.
Visual impairment
I was fairly astigmatic and had worn glasses for several years before starting HRT. After HRT, I noticed a small but perceptible drop in visual acuity. The reason I think it is linked to HRT is entirely anecdotal — an AFAB friend who was also taking exogenous estrogen also reported a drop in visual acuity.
Future plans
Hair removal
My plans to remove hair from my face and body are currently at a standstill. I have no spare money and no means of transport to get either laser or electrolysis, a situation which is likely to continue for some time specifically because my body and facial hair will be a component in determining my “professional presentation” and therefore employability, meaning the fact that I have them will prevent me from getting rid of them.
Legal updates
My plans to change my name are currently at a standstill for the same reasons as removing my facial and body hair — changing my name costs more money than I have at any one time.
Wardrobe
My plans to regender my wardrobe are at a standstill, etc. While op shopping is an option in theory, I have a fairly large build and a lot of weight, meaning op shopping is not an option for me in fact. I also have no bras, which is becoming increasingly problematic but equally unsolvable. In addition, due to increasing decompensation of my EDS-like symptoms, etc., I would benefit from acquiring corsets (for lower back support) and combat boots (for ankle support), but have little to no capacity to do either.
Conclusion
I came into this transition not sure that I was going to enjoy it. Some things about my life have changed; I have had to take more care of a body that I used never to be invested in; I had a few spills and scares along the way.
However, altogether, this is one of the better decisions I have ever made and I intend to keep it going until the end.
Special thanks
There are certain people without whose help and influence (intentional or otherwise) I could not have transitioned. For the sake of brevity I am omitting people I personally knew or was working alongside at the time they originally inspired me. Some of these people I do know now, and have the honour of being their friend; some of them are or were public figures who will never know me. I owe them my thanks nonetheless.
In alphabetical order by surname, I wish to thank Helen Barton, Arthur Chu, Bridget Clinch, Émilia Decaudin, Madeline Deutsch, Laura Jane Grace, Heron Greenesmith, Éilis Harney, Zinnia Jones, Amanda Jetté Knox, Anne Ogborn, Penelope Pilbeam, Will Powers, Jerilynn Prior, Jordan Raskopoulos, Julia Serano, SOPHIE, Chase Strangio, Susan Stryker, Linda Tirado, Dr Clara Tuck Meng Soo, Robert Pirsig, Kristin Tynski, M Veselak, Aly W., and Asher Wolf.
References
Australasian Menopause Society (2021, June 23). Menopausal hormone therapy and non-hormonal options shortages in Australia — update 23 June 2021. Menopause.org.au.
Bird, H. (2017, August). Hormones and hypermobility (version 3). Hypermobility Syndromes Association.
Fotherby, K. (1996, August 1). Bioavailability of orally administered sex steroids used in oral contraception and hormone replacement therapy. Contraception, 54(2), 59-69. doi:10.1016/0010-7824(96)00136-9.
Hembree, W.C., Cohen-Kettenis, P.T., Gooren, L., Hannema, S.E., Meyer, W.J., … & T’Sjoen, G.G. (2017, September 13). Endocrine treatment of gender-dysphoric/gender-incongruent persons: An Endocrine Society clinical practice guideline. Journal of Clinical Endocrinology & Metabolism, 102(11), 3869-3903. doi:10.1210/jc.2017-01658.
Jáuregui-Lobera, I. (2014, November 10). Iron deficiency and cognitive functions. Neuropsychiatric Disease and Treatment, 10, 2087-2095. doi:10.2147/NDT.S72491.
Kanageswaran, N., Nagel, M. Scholz, P., Mohrardt, J., Gisselmann, G., & Hatt, H. (2016, August 5). Modulatory effects of sex steroids progesterone and estradiol on odorant evoked responses in olfactory receptor neurons. PLoS ONE 11(8), e0159640. doi:10.1371/journal.pone.0159640.
Lynch, S.R., & Cook, J.D. (1980). Interaction of vitamin C and iron. Annals of the New York Academy of Sciences, 355, 32-44. doi:10.1111/j.1749-6632.1980.tb21325.x.
Miller, E.M. (2016, March 15). Hormone replacement therapy affects iron status more than endometrial bleeding in older US women: A role for estrogen in iron homeostasis?. Maturitas, 88, 46-51. doi:10.1016/j.maturitas.2016.03.014.
Morin, L.P., Fitzgerald, K.M., & Zucker, I. (1977, April 15). Estradiol shortens the period of hamster circadian rhythms. Science, 196(4287), 305-307. doi:10.1126/science.557840.
Reddy, N., Desai, M.N., Schoenbrunner, A., Schneeberger, S., & Janis, J.E. (2021, March 10). The complex relationship between estrogen and migraines: A scoping review. Systematic Reviews, 10, 72. doi:10.1186/s13643-021-01618-4.
W, A. (2021, March 10). Administration of oral progesterone capsules rectally instead of orally for greatly improved efficacy in transfeminine people. Transfeminine Science. (Original work published 29 December 2018.)
Women’s Health Concern (2020, October). Migraine and HRT. British Menopause Society.