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 Family Medicine, Internal Medicine and Transgender Gynecology clinics offer:

  • Providers trained in transgender hormone therapy.
  • Gender-affirming services in convenient locations.
  • Expertise in coordinating your hormone therapy with your overall health.

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 is an OHSU family medicine doctor and a leader in transgender health care
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 feminine or masculine 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 your 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.

Getting treatment

OHSU offers hormone therapy in welcoming environments at:

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.

Find information on getting hormone treatment through your own primary care provider or a provider closer to your home.

Here’s what to expect at OHSU:

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.

Physical exam: We’ll ask your permission before any exam. We will not do any exams that require you to undress unless we identify an urgent need.  

Tests: You may have tests, such as a blood test, to get baselines and to make sure there’s no medical issue to address before you start hormones.

Consent: We will review the benefits, risks and expected changes of hormone therapy before we write the prescriptions. We will ask you to sign a consent form to document your understanding of this information.

Your provider may decide at this visit that all the information to begin therapy is in hand. For example, you may have all needed lab results in your medical record. Most often, though, a second visit will allow time for results to come back and for your records to be reviewed.

This usually happens a few weeks after your first visit.  Your provider usually will:

  • Review test results and medical history.
  • Review benefits and risks.
  • Answer questions.
  • Collect and document your consent to take the medication.
  • Teach you how to take your medication.
  • Discuss what to expect when you visit the pharmacy to pick up your medication.
  • Schedule follow-up visits.

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.
A transmasculine gender-nonconforming person and transfeminine non-binary person cuddling

Feminizing therapy

Estrogen therapy

Regular doses of the hormone estrogen, also called estradiol, develop feminine traits and reduce masculine ones. 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 feminization surgeries are options.

Feminizing Hormone Therapy: Timelines

Effect Expected onset Expected maximum effect
Body fat redistribution 3-6 months 2-5 years
Muscle mass and strength decrease 3-6 months 1-2 years
Libido decreases 1-3 months 1-2 years
Breast growth 3-6 months 2-3 years
Skin softens and becomes less oily 3-6 months Unknown
Thinning and slowed growth of body and facial hair 6-12 months Less than 3 years (full removal requires treatment)
Diminished erections 1-3 months 3-6 months

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

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

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

  • Diminished sex drive
  • Smaller testicles
  • Erectile dysfunction
  • Lighter, thinner body hair
  • Less tension
A transmasculine person in a winter coat on the sidewalk

Masculinizing therapy

Testosterone therapy

Regular doses of the hormone testosterone increase masculine traits and reduce feminine ones. 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.

Masculinizing Hormone Therapy: Timelines

Effect Expected onset Expected maximum effect
Body fat redistributes 3-6 months 2-5 years
Muscle mass and strength increase 6-12 months 2-5 years
Skin thickens and grows oilier 1-6 months 1-2 years
Periods stop 2-6 months n/a
Voice deepens 3-12 months 1-2 years
Hair loss on scalp About a year Varies
Clitoris grows 3-6 months 1-2 years

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

Contact us

Location

Dillehunt Hall, Room 1007
3235 S.W. Pavilion Loop
Portland, OR 97239

Dillehunt Hall can be reached through Sam Jackson Hall.

Refer a patient

Please download our referral form and fax with relevant medical records to 503-346-1501. Learn more on our For Health Care Professionals page.