Transgender Health Program: Hormone Therapy

Photo of a person smiling at the camera.

If you are transitioning, hormone therapy may be your first medical step, regardless of whether you plan to have other gender-affirming treatments. At OHSU, providers will tailor your therapy to your goals.

OHSU’s Transgender Gynecology clinic and many OHSU primary care clinics offer:

  • Providers who prescribe and monitor hormone therapy in consultation with the Transgender Health Program.
  • Primary care services tailored to the unique needs of gender-expansive patients.

This page is about hormone therapy for adults, who can be treated by a primary care provider.

  • Learn about our care for children and teens.
  • If you are an adult who needs specialty care because of conditions such as hard-to-control diabetes, your primary care provider also may refer you to an OHSU endocrinologist.

Treatment overview

Hormone therapy basics

Dr. Christina Milano.
Dr. Christina Milano is an OHSU family medicine doctor and a leader in transgender health care. She won the OHSU Women in Academic Medicine Clinical Excellence Award in 2018, and OHSU’s Faculty Excellence in Education Award in 2019. She trained at UCSF and OHSU.

What is hormone therapy? Hormone therapy is medication to increase or suppress hormones. It causes physical, emotional and other changes so you more closely match your gender identity. How much you take and for how long depend on your goals and other factors. Many people transition only through hormone therapy. Others use it in addition to gender-affirming surgery.

Mental health therapy: You do not need a mental health letter of support to begin hormone treatment. We do recommend that you see a mental health professional to support you in your transition.

Your changes: Hormone therapy affects people at different times and to different degrees. Genetics may play a role, such as whether your family has male pattern baldness.

Doses: You can achieve your goals with small doses. Your doses may increase over time, but taking high amounts may be unhealthy and won’t necessarily speed changes.

Timeline: You can often begin hormone therapy within a few weeks of your first visit with your provider. You will probably see some changes within months. Others can take years. You may decide to take hormone therapy for most of your life to maintain the effects. Hormones can also help your health after gender-affirming surgery, such as preventing bone loss if you’ve had ovaries or testicles removed.

Risks: Hormone therapy is likely to affect your sexual function and fertility, perhaps permanently. There may be long-term health risks. Make sure your health care provider knows your health history, any medications you’re taking and whether you smoke. Smoking can cause complications.

Hormone therapy effects

Physical: Your body will change over time. Your hair, skin, muscle mass and fat distribution will become different to varying degrees.

Emotional: Hormone therapy can have some of the same effects on your emotions as puberty does. For example, you may swing from highs to lows often. You may have new feelings, and your interests may change.

Sexual: You probably will experience erotic pleasure differently. You may get aroused by different body parts. Your orgasms will probably change.

Reproductive: Testosterone will gradually stop menstruation. It’s still possible for someone with ovaries and a uterus to become pregnant, though, so using birth control is recommended. Estradiol, a form of estrogen, may decrease sperm counts for those with testicles. This may be reversible if hormone therapy stops for several weeks, but it’s not for some people. OHSU fertility specialists can help you plan ahead.

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Getting treatment

The Transgender Health Program can help you start on hormone therapy with a primary care provider in any part of Oregon.

Getting started

  • Visit our Primary Care site. Look for a provider who can meet your overall needs and who is accepting new patients.
  • Call the number listed and ask for a “new patient” appointment with that provider. If you are OK with seeing one of several  providers, you may be able to get in sooner. Some first appointments have a monthslong wait.
  • Learn more about finding a primary care provider.

Contact the Transgender Health Program for more information:

  • Let the provider know you would like to start or continue hormone therapy.
  • Some providers may refer you to consult with the OHSU Transgender Health Program for hormone therapy.
  • The THP will contact you to schedule and provide instructions for a virtual visit over a secure video link.
  • A specialist in hormones and gender care will meet with you in our virtual clinic. The provider will go over your goals and needs, and send prescription recommendations to your primary care provider.
  • Another option is to have your primary care provider schedule their own consultation with our specialist. Your doctor will receive guidance from our specialist and go over your goals, needs and prescription recommendations.

Hormone therapy with an OHSU provider

Our providers are trained to assess how to safely and optimally begin your hormone therapy. We will consider all the aspects of your health that hormones might affect. We will also evaluate and treat your overall health as part of your care.

We’ll discuss:

  • Your transition goals, so we can get you started on what may be a long process.
  • Your overall health needs and how they may be treated.
  • Your medical history and gathering your records.
  • Any mental health therapy you’ve had or plan to have, and help finding a therapist if needed.
  • A recommended health care routine and screenings.
  • The benefits, risks and expected changes of hormone therapy.

At your first in-person visit (if your first was with our virtual clinic):

  • You might have a physical exam. We’ll ask your permission; we will not do any exam that requires you to undress unless we identify an urgent need.
  • You might have tests, such as a blood test, to get baselines and to make sure there’s no medical issue before you start hormones.

We will regularly check your physical and mental health, and your hormone levels. We’ll also check for signs of potential effects such as changes in your blood counts or cholesterol:

  • One to two months after you start therapy
  • Four to six months after you start
  • Nine to 12 months after you start, and that often thereafter

  • We will confirm or adjust your dose with your pharmacy. You may need more tests if results aren’t available from previous providers.
  • We’ll explore whether your previous provider went over benefits and risks, and revisit topics as needed.
  • If you have been off hormones for a time, we may review test results before restarting your prescription. This may take a few days.
Two people close to each other.

Estrogen therapy

Regular doses of the hormone estrogen, also called estradiol, develop traits and reduce others. Estradiol is sometimes combined with a testosterone blocker. You typically take an estradiol pill twice a day to start.

Your changes may include:

Physical:

  • Small, sometimes slightly painful breast growth
  • Less muscle mass and strength, and less muscle tension that leads to stress
  • More fat in thighs and hips
  • More fat under skin, smoothing your appearance
  • Thinner, slower-growing hair on arms, chest and back
  • Less facial hair, but rarely disappears

Reproductive:

  • Smaller testicles
  • Decreased or absent sperm count
  • Diminished erections

Permanent changes: Some changes may be reversible if you stop therapy, but breast growth and fertility changes are often permanent.

Bone structure and voice: Hormone therapy will not change your bone structure and may not alter your voice. Voice therapy, vocal surgery and facial surgery are options.

Your doctor may recommend against estrogen therapy if you:

  • Have had problems with blood clots
  • Have had hormone-influenced cancer such as prostate or breast cancer
  • Have other medical conditions that significantly increase your risk of a heart attack or stroke if you take estrogen

Risks: Serious health risks are uncommon, but your doctor may monitor you for:

  • High blood pressure
  • Increased cholesterol levels
  • High potassium levels
  • Type 2 diabetes
  • Blood clots in your deep veins or lungs
  • Liver inflammation or damage
  • Gallstones

Possible side effects:

  • Weight gain
  • Milk leaking from nipples
  • Diminished sex drive
  • Infertility
  • Erectile dysfunction
  • Temporary hot flashes, mood swings and headaches

Testosterone blockers

For someone with testicles, the doctor may recommend a testosterone blocker, also called an antiandrogen, to enhance estrogen therapy. Antiandrogens, usually taken as pills, block the effects of testosterone in the body.

Antiandrogens will decrease the effects of testosterone but won’t produce most of the changes of estrogen. You may experience:

  • Diminished sex drive
  • Smaller testicles
  • Erectile dysfunction
  • Lighter, thinner body hair
  • Less tension
A person standing outside in a winter coat.

Testosterone therapy

Regular doses of the hormone testosterone increase some traits and reduce others. Testosterone is almost always injected, usually once a week or every other week. We will teach you how to inject into your muscles or just under your skin.

Changes may include:

Physical:

  • Thicker, more oily skin that may cause acne
  • Increased perspiration
  • Change in perspiration and urine odor
  • More muscle mass and strength
  • Less fat in thighs and hips, and possibly more in your belly
  • Sharper facial features
  • Thicker, darker, faster-growing hair on your chest, arms, legs and back
  • Thinning or receding of your head hair
  • More facial hair, although beard development varies widely

Reproductive:

  • Menstrual cycles lighten, then disappear
  • Larger clitoris

Permanent changes: Some changes are reversible if you stop therapy, but voice changes and an enlarged clitoris aren’t. Hair growth may remain. Fertility may or may not return for patients who still have ovaries.

Your doctor may recommend against testosterone therapy if you:

  • Have had problems with producing too many red blood cells
  • Have very high blood pressure that might first benefit from medication
  • Have other medical conditions that significantly increase your risk of a heart attack or stroke if you take testosterone

Risks: Serious health risks are uncommon, but your doctor may monitor you for:

  • High blood pressure
  • Increased cholesterol levels
  • High red blood cell counts
  • Type 2 diabetes
  • Liver inflammation or damage
  • Increases in blood pressure

Possible side effects:

  • Loss of scalp hair (also known as male pattern baldness)
  • Acne (your provider can offer treatments to help)
  • Increased libido
  • Infertility