Gender-Affirming Hormone Therapy

When exploring where you are on the gender spectrum, you may be considering the role of hormones or surgeries as part of your journey. Our providers can talk with you about your treatment options for affirming your gender as part of a wide range of gender-affirming care available at UPMC.

Some people may turn to medical or surgical techniques to help them feel more comfortable in their bodies.

Gender-affirming hormone therapy (GAHT) is the use of medications to help you achieve body changes that better align with your gender. Gender-affirming hormone therapy can also be referred to as transgender hormone therapy or gender-affirming hormone replacement therapy (HRT).

If you're thinking about gender-affirming hormone therapy, our endocrinologists are here to help.

What Is Gender-Affirming Hormone Therapy (GAHT)?

GAHT, sometimes called transgender or gender-affirming hormone replacement therapy, may include hormones or hormone blockers.

These drugs help transgender, gender noncongruent, and nonbinary people change physical traits to align better with their gender identity. You can affirm your gender without any medical intervention or with medication and/or surgery. Your journey is unique, and we are happy to help you explore your options.

UPMC follows the World Professional Association for Transgender Health standards of care.

Our doctors ask about your life and goals to best meet your needs. These may include questions about:

• Your gender journey.
• Your physical goals.
• Your sexual practices.
• Your fertility goals.
• Family planning.

What does hormone replacement therapy (HRT) help with?

HRT changes physical traits in your body to better match your gender identity. The specific traits that change depend on the hormone used.

Who can benefit from hormone therapy?

People who may benefit from discussing, starting, or continuing GAHT include:

• Those with gender dysphoria.
• Those experiencing gender noncongruence.
• Transgender men.
• Transgender women.
• Nonbinary people.
• Transfeminine and transmasculine people.
• Those with a fluid gender.
• Others under the LGBTQIA+ umbrella.

You don't have to be sure you want to start GAHT to talk to our doctors.

To help you decide if hormone therapy is right for you, our doctors can explain:

• The risks and benefits of hormone therapy.
• The types of GAHT treatments and the effects of each type.
• How hormone therapy can change the gendered physical traits.
• Any tests you need before starting treatment.

They'll also note how temporary or permanent the changes are. Some effects only last until you stop taking the hormones, while others last longer or may be irreversible. Rarely, patients may decide to discontinue hormones for a variety of reasons. UPMC endocrinologists are happy to help you wherever you are in your journey.

People seeking hormone therapy should have an active primary care provider (PCP). Your PCP can be at UPMC or somewhere else. UPMC endocrinologists focus on the hormones and don't provide primary or mental health care, so you should continue seeing your PCP or other specialists for your other medical issues.

Gender-Affirming Hormone Therapy Options

What happens when you start testosterone hormone therapy?

Taking testosterone leads to a wide range of physical, emotional, and sexual changes. Some of these changes will happen faster than others. Some may begin within a few weeks, while others may take months to years.

Here are some changes to expect:

• Your skin will thicken, and your pores will become larger and produce more oil. You'll sweat more often and may get acne.
• Your urine and sweat may smell different.
• Your periods may slow down, become irregular, or go away completely. You may still be able to become pregnant and should use contraception during sex if your partner makes sperm and if you don't want a pregnancy.
• You'll grow more, thicker, and darker "terminal" facial and body hair, especially on your arms, back, and chest. Some people can grow a beard relatively soon after starting testosterone, but it takes longer for others.
• The hair on your scalp may thin, especially around the temples. Some people will get male pattern baldness if it runs in their family, and some people experience total hair loss.
• You'll get more muscle mass and become physically stronger for the same amount of exercise.
• Your body's fat distribution will shift. You'll likely lose fat in your hips and butt but may gain fat in your abdomen.
• Your vocal cords will thicken, eventually deepening your voice. It may take one to two years for your voice to become as deep as it will get. Some patients also see our speech-language therapist for further guidance in getting comfortable with their new voice.
• Your clitoris will increase in size and may gain greater sensitivity. This change is irreversible. Your vagina will become dryer, and the lining will become thinner; if bothersome, this can be managed with topical treatments.
• Your sex drive may increase or change in quality.
• You may experience emotional changes or mood swings until your hormone levels stabilize and your body adapts to them.
• Your face will become more angular and masculine appearing.

Is testosterone hormone therapy permanent?

Many changes that occur with testosterone will stop or reverse if you stop taking it. How much these changes reverse depends on how long you have been taking testosterone. For instance, most people who stop testosterone will notice fat redistribution and less muscle mass.

Other changes from testosterone will become permanent even if you stop testosterone in the future. These include:

• Deeper voice.
• Facial and terminal body hair.
• Larger clitoris.
• Male baldness.
• Possible impact on fertility.

Testosterone treatment can stop ovulation and menstrual periods, but these usually resume if you stop taking testosterone. However, testosterone doesn't count as a reliable contraception. We still recommend contraception if relevant to one's sexuality. It's unclear what the long-term effects on fertility might be.

Trans men can stop testosterone therapy and become pregnant, with limited data showing similar healthy outcomes as cis women. Unintended pregnancies have occurred in trans men on testosterone but not on contraception.

Of note, trans men shouldn't take testosterone during conception and pregnancy because it may harm the developing baby. If having biological children is important to you, we recommend meeting with our expert reproductive endocrinologists to discuss fertility preservation, including egg freezing.

What happens when you start estrogen hormone therapy?

Estrogen has physical and emotional effects that make a person feel and appear more traditionally feminine. As with testosterone, these changes occur at different rates. Some may begin within a few weeks, while others may take months to years.

Here are some changes to expect:

• Your skin will become drier, and the pores will become smaller and produce less oil, so your skin will feel less oily.
• Your urine and sweat may smell different.
• You'll have slower and thinner hair growth on your face and body, especially your chest, arms, and back.
• You'll have fewer erections, especially spontaneous ones, and may find it tougher to get an erection. You'll also have less ejaculation.
• Your testicles will become smaller, as much as half the size they were before.
• Your body may stop creating sperm permanently, but it varies for each person. You should continue to use contraception if you have sex with someone who could become pregnant.
• Your sex drive may decrease and change in quality.
• You'll slowly begin growing breasts. These will start as buds that gradually get larger. The speed of breast growth and the final size of breasts will vary by person. It may take up to five years to reach final growth, and some patients may choose surgery to attain changes sooner.
• If you were losing hair on your scalp, this hair loss will slow down or may stop entirely.
• Your muscle mass will decrease, and you won't be as physically strong at the same level of activity/exercise.
• As the muscle mass decreases, body fat percentage tends to increase, and it will distribute more in other places in your body, such as your hips and thighs and possibly your buttocks. Your arms and legs may also appear smoother and softer as fat collects under the skin on them.
• You may experience emotional changes or mood swings until your hormone levels stabilize and your body adapts to them.
• The fat on your face will shift, and your face will usually get more rounded with more full cheeks and less angular.
• You may be at a slightly higher risk for blood clots, heart attack, stroke, diabetes, or certain cancers, depending on your personal history. Talk to your doctor about whether these risks will increase for you and how much. Smoking will increase the risk of blood clots. We recommend you stop smoking.

Is estrogen hormone therapy reversible?

Many changes that occur with estrogen will end or reverse if you stop taking it. How much these changes reverse depends on how long the person has been taking estrogen. For instance, changes to the skin, fat distribution, and muscle mass tend to be reversible.

Irreversible changes from estrogen therapy include:

• Breast growth.
• Smaller testicles.
• Loss of fertility (in some people).

The effect of estrogen treatment on fertility and sperm production is unclear. Studies have found that sperm production can continue during estrogen therapy but usually stops.

For some people who lose sperm count with estrogen therapy, sperm returns three to six months after stopping it. Others permanently lose the ability to produce sperm after they start estrogen therapy.

The longer you take estrogen, the less likely it may be for your sperm count to return.

Gender-Affirming Tests, Procedures, and Treatments

UPMC doctors will ask your PCP for prior medical records, including lab results. This will help your care team assess your current health, confirm your gender dysphoria diagnosis, and prescribe GAHT.

For testosterone therapy, the labs need to show the percentage of red blood cells in your blood. Your doctor will look for unusual results and ask about your health issues.

You will take many of your medications at home after receiving education from your care team.

Hormone treatments may include:

• Estrogen pills, skin patches, or shots (in the muscle or skin).
• Testosterone gels or shots (in the muscle or skin).
• Testosterone blockers such as spironolactone, finasteride, and dutasteride.
• Hormone blockers like leuprolide.

UPMC doesn't offer estrogen pellets or compounded estrogen because they aren't FDA-regulated.

We can also refer you to experts in:

• Reproductive endocrinology.
• Urology.
• Plastic surgery.
• Speech-language therapy.
• Hair removal.

How to Get Gender-Affirming Hormone Therapy

UPMC removes as many barriers as possible for gender-affirming care.

Adults with a PCP and controlled health issues may be able to start GAHT as early as their first visit. If you've had a recent physical exam with your PCP, this visit can be in person or virtual.

PCPs can prescribe GAHT, but some may not feel comfortable without expert guidance. In that case, they can refer you to UPMC endocrinology.

Some people may see an endocrinologist once or twice, rather than for long-term care, if they want to:

• Get a hormone expert's opinion.
• Learn about their GAHT options more thoroughly.

Others may stay in endocrine care in parallel with their PCP, with fewer appointments over time.

UPMC's experts can talk about your options and answer all of your questions.

Why Choose UPMC for Gender-Affirming Hormone Treatments?

UPMC offers comprehensive care and counseling for those seeking gender-affirming care.

If you already receive care from other UPMC providers, the UPMC GAHT team will work with them.

Janet Leung, MD, is UPMC's transgender medicine lead. She provides extra counseling for complicated cases. The people we treat often comment on the quality of counseling for those exploring gender-affirming care.

We want you to feel happy and healthy when it comes to your gender.

Plan a Gender-Affirming Hormone Therapy Visit at UPMC

You can see UPMC's GAHT experts in person or by video. Plan a visit online.

Contact us to learn more about our full range of gender-affirming care.

Call 412-586-9700 or find an endocrinology location near you.