Feminising hormone therapy is the term we use to describe gender-affirming hormone treatments that we offer to transgender and gender-diverse people who would like to change their bodily appearance and/or appear more traditionally “feminine”.
Feminising hormone therapy is just one of the options available that allow people assigned male at birth (AMAB) to feel more comfortable in their bodies, relieve gender dysphoria, and/or change the way they look and sound to better match their gender identity.
Who is feminising hormone therapy for?
Feminising hormone therapy is for anyone assigned male at birth (AMAB) who wants to appear more feminine, no matter their gender or presentation. Whether you’re a transgender woman, non-binary, genderqueer, agender, gender expansive, or gender non-conforming in numerous other ways.
That said, it’s important to emphasise that trans people do NOT need to medically or surgically transition in order to be trans. If you’re trans and can’t (or don’t want to) medically transition (no matter the reason), you are 100% valid.
How does feminising hormone therapy work?
Feminising hormone therapy consists of taking a medication called oestrogen (or E). Oestrogen is the “female” sex hormone that is responsible for developing traditionally “feminine” secondary sex characteristics like having breasts, softer skin and more fat around the hips and thighs.
When a person assigned male at birth (AMAB) takes oestrogen, it increases the oestrogen levels in their blood, which also then suppresses their testosterone (or “male”) hormone levels. These hormone changes can then trigger physical changes that can help better align the body with a person’s gender identity.
Depending on the type of oestrogen used and whether it’s having the desired effect, we can add on testosterone blockers to help keep the oestrogen level up and the testosterone level down. Sometimes, we add progesterone into the mix.
What are the requirements for starting feminising hormone therapy?
Gender affirming healthcare is (and should be) based on an informed consent model. This means that the healthcare provider and client share in the decision making process after discussing all of the risks and benefits of hormone therapy.
The informed consent model recognises that the client is the expert of their own needs and experience, while respecting that the healthcare provider needs to utilise their expertise to enable safe and effective treatment.
Feminising hormone therapy does not need to be prescribed or monitored by an endocrinologist. Prescribing hormone therapy is well within the realm of a suitably skilled general practitioner (GP).
That said, the requirements for starting feminising hormone therapy include:
- A desire to use feminising hormone therapy.
- Persistent gender incongruence between one’s experienced and assigned gender.
- Capacity to make a fully informed decision and consent to treatment.
- The decision is made of your own free will.
You do NOT need to have a referral letter from a mental health professional. Seeing a psychologist is not a requirement for initiating feminising hormone therapy. While previously, some healthcare providers required a letter of diagnosis or referral, this is no longer necessary under international best practice.
What effects can you expect from feminising hormone therapy?
The changes you will experience while on feminising hormone therapy often take some time to fully develop. Some of these changes are reversible and will disappear if you stop taking the hormones, while other changes are irreversible and will persist even if you stop taking your hormones.
The timeline for these changes to begin is variable, but most effects will only reach their maximum degree after 3–5 years on hormone therapy.
Reversible changes include:
- Loss of muscle mass and decreased strength.
- Changes in body fat distribution, possibly associated with weight gain (increased fat deposition in breasts, bum, hips and thighs).
- Softer and thinner skin.
- Reduced acne.
- Lighter and thinner body and facial hair.
- Cessation of male-pattern balding, possible scalp hair regrowth.
- Changes in libido (usually a decrease initially, followed by an increase together with a change in sexual response cycle, i.e. the way you think about sex, become interested in sex, become sexually aroused, experience orgasms, and how long your recovery phase lasts).
- Changes in the strength and frequency of erections, as well as changes in the amount and consistency of ejaculate.
- Changes in mood and emotional response.
Irreversible changes include:
- Breast development: Whilst the size of breast tissue may fluctuate, hormone therapy will cause permanent development of breast structures, which will remain even if hormone therapy is withdrawn.
- Testicular atrophy: This is a permanent reduction in size of the testes.
- Infertility: Infertility is not guaranteed and hormone therapy cannot be used as contraception. If you have sex with someone with a uterus, they could potentially get pregnant, so you need to ensure you’re using effective contraception.
- Changes in bone density.
The extent to which changes can be reversible depends on how long you take the hormones for, the dosage you used, and how responsive your body was to the hormones.
The table below shows the different effects of feminising hormone therapy and the estimated time it takes to see the changes:
| Effects | Time from initiation to onset | Time from initiation to maximum effect | Reversible? |
| Body fat redistribution | 3–6 months | 2–3 years | Yes |
| Decreased muscle mass and strength | 3–6 months | 1–2 years | Yes |
| Skin softening | 3–6 months | Unknown/variable | Yes |
| Changes in sexual desire and arousal | 1–3 months | 3–6 months | Yes |
| Decreased erections | 1–3 months | 3–6 months | Yes |
| Breast growth | 3–6 months | 4 years | No |
| Decreased sperm production | Unknown/variable | >3 years | Possibly |
| Decreased body hair growth | 6–12 months | >3 years | Yes |
| Scalp hair growth | Variable | Unknown/variable | Yes |
| Voice change | None | N/A | N/A |
Please note: When taking feminising hormone therapy, it’s important to have realistic expectations regarding the effects that hormones can have on your body. Everyone is different and will react differently to hormones for a variety of reasons.
Is there anything feminising hormone therapy can’t change?
There are certain features that hormone therapy cannot change. Among others, these include:
- Presence of facial hair: Although hormone therapy may make the hair thinner, or cause it to grow more slowly, hormone therapy will not eliminate facial hair. You can consider laser hair removal or electrolysis for permanent hair removal if this is desired.
- Pitch of the voice: This can be altered with speech therapy and/or vocal cord surgery, if desired.
- Bone structure of the face: The appearance of the face can be altered with botox, fillers or reconstructive facial surgery.
- Presence of prominent thyroid cartilage (Adam’s apple): This can be reduced with a surgical procedure called a tracheal shave.
What are the different types of oestrogen preparations available in South Africa?
| Type | Examples | Advantages | Disadvantages |
| Tablet, taken orally. | Estrofem Premarin | Easy to use. Accessible at most pharmacies. | Higher risk of blood clots. Often need to add a testosterone blocker. |
| Tablet, dissolved sublingually (under the tongue). | Estrofem | Accessible at most pharmacies. | Time consuming (takes 30min to absorb) Often need to add a testosterone blocker. |
| Injectable | Estradiol valerate | Safer. Affordable. Once-a-week dosing. Testosterone blockers usually unnecessary. | Available only from compounding pharmacies. Requires knowledge of injection technique. Requires disposables (syringes, needles and alcohol swabs) |
| Patch | Estradot | Safer. Available at most pharmacies. Twice-a-week dosing. Testosterone blockers usually unnecessary. | Patches need to be applied and cared for correctly. May cause skin reactions/irritation because of adhesive. May need to use multiple patches at a time which may become impractical. |
What are the different types of testosterone blockers available in South Africa?
| Blocker | Type | Advantages | Disadvantages |
| Spironolactone | Tablet, taken orally. | Affordable. Available at most pharmacies. Can start with a very low dose. | Requires frequent blood tests to monitor potassium levels. Can reduce strength and frequency of erections (if this is not a desired effect). |
| Cyproterone acetate | Tablet, taken orally. | Affordable. Very potent blocker. Low doses are sufficient. | Cannot be used if you have a history of liver disease or blood clots. Not recommended for those with unstable psychiatric conditions. |
| Bicalutamide | Tablet, taken orally | Very potent blocker. May enhance breast development.* | Expensive. Not recommended for those with liver disease, cardiovascular disease, autoimmune disease, diabetes, anaemia, those over the age of 35, or those who engage in heavy alcohol use. |
| Micronised progesterone (Utrogestan) | Tablet, taken orally. | May improve mood, sleep, energy and libido.* May enhance breast development and fat redistribution.* May allow for reduction in oestrogen dose.* | Testosterone blocking effects are less strong. Can only start using it after breast development has already started and oestrogen levels are high (± 6-12 months). Higher risk of blood clots. |
During your consultation, you can discuss the various options for feminising hormone therapy with your doctor, and decide which form of treatment is best for you.
How much does feminising hormone therapy cost?
It’s important to remember that not only do different people have different needs when it comes to hormone therapy, but also that prices for medication may vary and fluctuate over time.
The majority of people can expect to spend R300–R600 per month on feminising hormone therapy, depending on the form and dose of oestrogen and the addition of blockers or progesterone. This doesn’t include the cost of blood tests or doctor’s visits.
What are the risks and side effects of feminising hormone therapy?
As with any medication, feminising hormone therapy carries with it certain risks and side effects. Some of these risks can be mitigated or reduced by lifestyle factors, while others are independent risks that cannot be altered.
According to the latest research, the biggest concern with oestrogen therapy is the risk of clot formation, which can lead to deep venous thrombosis (DVT), life-threatening pulmonary emboli (blood clots in the lung), heart attacks and strokes.
It’s this risk that limits the amount of oestrogen that we can safely prescribe. Oral oestrogens (e.g. Estrofem or Premarin) carry a higher risk of these adverse events than parenteral (i.e. administered outside the digestive tract) oestrogens, like injections or patches.
Side effects and risks include:
- Blood clot formation, including DVT, pulmonary embolism, heart attacks and strokes.
- Cardiovascular disease.
- Loss of fertility.
- Erectile difficulties.
- Nausea or vomiting.
- Migraines or other headaches.
- Gallstones and other diseases of the gallbladder.
- Elevated levels of prolactin: This is a rare occurrence in clients on feminising hormone therapy, and it’s due to the development of a prolactinoma, a benign (non-cancerous) tumour of the pituitary gland.
- Changes in sleep.
- Changes in appetite and/or weight gain.
- Taste changes.
- Body odour changes.
- Mood changes.
Will I really lose my fertility if I start taking hormones?
Yes, feminising hormone therapy can cause you to become infertile. Some people might regain fertility if they stop hormone therapy, while others may become irreversibly infertile. Unfortunately we cannot predict how each individual will react.
If there’s any possibility that you may want to have biological children at some point in the future, then the safest thing to do is to use a cryobank to preserve genetic material for future use.
What do I need to do to prepare for feminising hormone therapy?
Before starting feminising hormone therapy, you and your doctor need to have a good understanding of your current health status.
Your doctor will need to know your medical history, including:
- Medical conditions: Current and previous medical conditions, including admissions.
- Medications: This includes prescriptions, contraceptives, over-the-counter medications, herbal medications and supplements.
- Allergies: This includes allergies to medications, iodine and food.
- Surgeries: Any procedures done for any reason, not only gender affirming surgeries.
- Family history: Especially a history of blood clots, heart disease or cancer.
- Psychiatric history: Current and previous diagnoses, symptoms, treatments and admissions.
- Sexual history: To assess of your risk regarding HIV and other STIs.
- Lifestyle history: Substance use, including alcohol, tobacco or other drugs.
Your doctor may then perform a physical examination to assist them with determining your current health status.
Please note: Intimate examinations are NOT required before starting hormone therapy. Intimate examinations are only done when medically indicated, with your explicit consent.
Before you start hormone therapy, you will also need to do certain baseline blood tests. These tests are important because your doctor needs to know how well your organs are functioning (e.g. liver and kidneys), so that they know whether it is safe for you to start hormone therapy.
While you’re on hormone therapy, you’ll need to be monitored regularly to ensure the safety and efficacy of your hormone regimen. Usually, this will involve regular check-ups and blood tests.
Do I need to see a doctor to get hormones?
Yes. I strongly advise against obtaining your oestrogen, progesterone or blockers through any other means other than from a doctor’s prescription from a registered pharmacy. Please do NOT use hormones or medication you’ve found on the internet or “black market”. These products can be extremely dangerous and cause irreversible harm.
In summary
Feminising hormone therapy is a wonderful option to consider for those assigned male at birth (AMAB) who want to feminise to feel more comfortable in their bodies. When making your decision to start hormones, always keep in mind the benefits, risks, changes you can expect, and other important considerations, so that you can make an informed decision regarding your healthcare.
If you’re ready to start feminising hormone therapy or want to know more about it, please feel free to book a consultation. I’d love to support you on your exciting gender affirmation journey (South African residents only).
Helpful links and resources
- Information on self-injection technique.
- Information on safe tucking.
- Where to buy tucking underwear.
- How to make your own gaff at home.
- Where you can purchase breast prosthetics:
- Laser hair removal and electrolysis in Johannesburg: Electrolysis by Claire
- Information on safer sex for transgender and gender diverse people.
- Information on legal gender marker changes.
References:
- Tomson A, McLachlan C, Wattrus C, Adams K, Addinall R, Bothma R, Jankelowitz L, Kotze E, Luvuno Z, Madlala N, Matyila S, Padavatan A, Pillay M, Rakumakoe MD, Tomson-Myburgh M, Venter WDF, de Vries E. Southern African HIV Clinicians’ Society gender-affirming healthcare guideline for South Africa. South Afr J HIV Med. 2021 Sep 28;22(1):1299. doi: 10.4102/sajhivmed.v22i1.1299. PMID: 34691772; PMCID: PMC8517808.
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