Endocrine Care of Transpeople Part II

A Review of Cross-sex Hormonal Treatments, Outcomes and Adverse Effects in Transwomen

Maria Cristina Meriggiola; Giulia Gava


Clin Endocrinol. 2015;83(5):607-615. 

In This Article

Feminizing Effects

Hormonal treatment achieves two fundamental objectives: suppression of endogenous testosterone production with subsequent attenuation of male characteristics and feminization of the phenotype. Initial changes include a decrease in libido, facial and body hair, some initial growth of breast tissue, a decrease in oiliness of the skin, redistribution of fat mass with an increase in subcutaneous fat and body weight, and a decrease in lean body mass and muscle strength.[9]

Breast development begins within the first 3–6 months after initiation of oestrogens administration and is typically at its maximum after 2 years, after which no further development should be expected.[23] Between 50 and 60% of transwomen will consider their breast growth insufficient subsequently opting for surgical breast augmentation.[17] Adult male pattern body hair (lip, chin, chest, upper back, sacroiliac region, abdomen, arm and thigh) becomes thinner and lighter with hormonal therapy and may eventually diminish. Initial results in the reduction of body hair may occur as early as 4 months after start of treatment, but hair density on cheeks and upper abdomen reduces slowly and progressively.[31] Adult male beard growth is resistant to inhibition by hormones, and many transwomen also undergo hair removal treatment for additional cosmetic benefits.[31] With androgen suppression, sebaceous gland activity is reduced which can lead to a drier skin and less acne.[31] Complete elimination of previous androgen effects on the skeleton is not possible. The greater height of natal men in comparison with women, the size and shape of hands, feet, jaws, pelvis and development of laryngeal prominence cannot be pharmacologically altered.[32]

After SRS, anti-androgens have been suggested only in transwomen who continue to experience male pattern hair growth.[33] Obviously, oestrogen intake should be continued to maintain female phenotypic characteristics and to avoid symptoms of sex hormone deficiency. Because of the potential increased risks with age, the continuation of CHT may require dose adjustment and a change in administration method from oral to transdermal. As ageing is a predictor of cardiovascular risk, it is important to closely monitor elderly transwomen who commence or continue oestrogens and to adapt the hormonal therapy in cases of modification of personal risk factors.[34] If oestrogens are contraindicated in elderly transwomen, they can be treated with anti-androgenic compounds[35] devoid of oestrogen receptor agonist activity.