What are Health Concerns for Transwomen?
Sometimes, transwomen (or MAAB transgender-identified students) with male genitalia feel disconnected from their bodies, and in particular may dissociate from their genitals. This can cause physical or emotional discomfort. Additionally, you may find it is difficult to find a medical provider who is sensitive to your needs. Because of these barriers, transwomen may be less likely to receive regular medical exams, which are important to maintain a healthy body and detect cancers, STIs, or other illnesses. During all phases of your transition process, regular medical exams remain an important piece of your total health care.
Some transwomen take estrogen in order to give their bodies more conventionally female characteristics. For some, this choice is made easily, while others struggle with the idea and may go on and off estrogen at different points in their lives. If you are considering estrogen therapy it is important to visit a medical provider for a physical exam and regular updates on blood work and health status. Everybody reacts differently to estrogen therapy, and various personal and family health factors will influence how your body reacts to it.
Many transwomen take two types of hormone replacement therapy: anti-androgen therapy (which nullifies the effects of testosterone) and estrogen (which introduces estrogen into the system). Sometimes, progesterone is also introduced into the system, in order to help further feminize the body. Similar to transmen, non-oral administration of medications into the body is preferred, in order to prevent liver damage. The preferable administration of hormones is sublingual (dissolved under the tongue), transdermal (through a patch), or injections (through a needle directly into the muscle). Oftentimes, the younger a transwoman is, the more effective hormones will be on her body.
Anti-androgens prevent further masculinization of the body (stops male pattern baldness, decreases libido, etc). Oftentimes transwomen take anti-androgens for a period of time before beginning estrogen therapy. The most typically prescribed anti-androgens are spironolactone and finasteride. Cyproterone has also been used, but carries risks of depression and liver problems. The most commonly prescribed anti-androgen is spironolactone (dose can range from 50 to 300 mg daily, depending on the individual). Anti-androgens do not serve as the hormone that physically feminizes one’s body - rather, they bring the body to a more androgynous state (towards the middle of the gender spectrum) and as a result decrease the amount of estrogen necessary during HRT. (Some MAAB genderqueer individuals choose to only take anti-androgens to give their bodies a more androgynous look. See the “What about hormone replacement therapy for genderqueer individuals?” section for more details.) Anti-androgens are pills taken daily.
Estrogen is the drug that does the most feminization to the body. For transwomen over 40, who are smokers, or are at risk for blood clots, transdermal application of estrogen is recommended due to the decreased risk for blood clots. Transwomen with high blood pressure are also recommended to use a transdermal means of hormone replacement therapy. A transwoman without these problems can take estrogen sublingually or through an injection. Sublingual methods are used daily, while injections are either weekly or biweekly. Again, discuss with your doctor about the possible advantages or disadvantages of each method, as well as your comfort level. For example, some individuals don’t feel comfortable around needles, and prefer taking a pill instead. Other individuals would much rather take their hormones weekly instead of daily, and prefer injections instead. It depends on the individual.
The effects of progesterone are still unclear. Some providers have stated that progesterone has helped with breast development and further feminization of the body. Other providers have stated that progesterone has also served as a mood stabilizer. Some individuals have felt a negative effect on mood due to taking progesterone. It is considered an optional medication to take during hormone replacement therapy. Some individuals have tried it and have experience positive effects, others have felt negative effects. It all depends on the individual. Progesterone is introduced to the body through daily pills.
The effects of hormones differ from individual to individual. Be sure to talk to your doctor about how you are doing on HRT, especially during the first several months.
It is important to only use estrogen obtained through a prescription. Using estrogen that is bought off the “black market” is illegal and unsafe. It may limit your access to clean needles (some states require a prescription to buy and carry needles), and it can be impure (cut with other substances). It is also critical to use the appropriate dosage as determined by a medical provider. Taking more estrogen than prescribed will not speed up the changes desired and may increase the risk of serious side effects.
Effects of Hormones
The amount of time it takes for hormones to take effect depends on dosage, body type, and other medical characteristics. Between one to three months of beginning anti-androgens, individuals experience a decreased sex drive, loss of the ability to have an erection, and a decrease in sperm count and penis size. Within two days of anti-androgen therapy, facial/body hair growth slows down and male pattern hair loss stops.
Within one to three months of beginning estrogen therapy, skin becomes softer, muscle mass decreases, and body fat redistributes to the hips and waist. Within one to two years breast development begins. Also, the long term effects of estrogen include further slowing of facial/body hair and balding, and eventually a decrease in testicular size. On long term estrogen therapy, some transwomen have less firm erections, and some are not able to achieve erection at all. Other common side effects include mood swings, altered perceptions, changing hunger patterns, and slower metabolism. Weight gain may be seen during the initial months of therapy.
Since transwomen are essentially experiencing a second puberty, expect a physical experience similar to when ciswomen go through puberty, such as increased sensitivity around the nipple area during breast growth. In terms of breast development, transwomen usually grow to a size that is about a cup smaller than ciswomen in their family. Some transwomen decide to get breast implants later on. Regular breast self exams (BSE) should be performed once breast tissue growth occurs.
Unlike the effects of testosterone on transmen, estrogen therapy does not affect one’s voice, nor will it make one’s Adam’s apple smaller. Also, facial hair will not disappear - transwomen can get electrolysis along with hormone therapy in order to get rid of facial hair.
Smoking while using estrogen therapy increases the risk for blood clots, which can lead to heart attacks, strokes, or other permanent damage.
Although there may be a reduction in sperm count when taking estrogen, it is still possible to cause a pregnancy, especially during the first year of estrogen use. Some transwomen choose to have their sperm frozen prior to starting hormone therapy, in order to have it available for later use.
If you decide to start hormones during the school year, take a lighter workload that quarter in order to adjust to the possible emotional side effects of hormones. Some transgender individuals have decided to take a quarter, several quarters, or even a year off in order to fully focus on transitioning.
Silicone and Oil Injections
It is dangerous to inject silicone or oils in order to add to your cheekbones, lips, thighs, breasts, hips, buttocks, etc. Silicone is toxic to the body and can lead to serious health risks, such as pain, swelling, blistering of the skin, and disfigurement. The FDA has never approved silicone injections for sale for human use. For more information, check out “Silicone Use: Illicit, Disfiguring, Dangerous.”
Some transwomen decide to have reconstructive surgery, and/or electrolysis for hair removal.
If you decide to have surgery as part of transitioning from male to female, some surgical options are breast augmentation, tracheal shave (reducing the size of Adam’s apple), orchiectomy (removal of testicles), and vaginoplasty (creation of a vagina). It is recommended that you are on hormones for an extended period of time before you get surgery.
If, as part of a vaginoplasty, tissue from the penis is used to create a neo-cervix, you should ask your provider about beginning to get regular gynecology screenings, including Pap smears. Also, after a vaginoplasty, frequent dilation (inserting a dildo inside the neo-vagina) is necessary in order to keep the neo-vagina from closing up.
If you have an orchiectomy (removal of the testicles), bone density screeningsare recommended. Your MD can follow guidelines for ciswomen when conducting the screenings.
As with any surgery, there can be minor or major complications during and after these procedures. It's important to follow the guidelines given by the surgeon and medical provider at all times. These surgeries are expensive, and are likely to require time off from school or work. Not everyone will be a candidate due to other medical conditions. Most respected surgeons in the US will also require a clearance letter from a psychologist or psychiatrist, in compliance with the World Professional Association for Transgender Health (WPATH) Standards of Care.
You can find more detailed information and useful links on Trans Health at Transgender Care for Students.