Hormone therapy for trans women has the following objectives:

• Feminization of secondary sexual characteristics, e.g., breast development, softer skin, and fat redistribution.
• Reduction of male characteristics, such as facial hair, muscle mass, and testosterone levels.
• Improvement in psychological well-being through physical alignment with the experienced gender identity.

Procedure and Administration of Hormone Therapy

1. Before Starting Therapy

Several steps are required before initiating hormone therapy:

• Psychological Evaluation: Diagnosis of gender incongruence according to ICD-11 or DSM-5.
• Medical Counseling regarding the effects, risks, and side effects of therapy.
• Physical and Medical Examinations:
  • Hormone levels (LH, FSH, testosterone, estradiol)
  • Blood count, liver function, kidney function, lipid profile, blood glucose
  • Cardiovascular evaluation (blood pressure, ECG)
  • Screening for comorbidities (e.g., diabetes, thrombotic risks)
• Fertility Counseling: Sperm cryopreservation prior to therapy if fertility is desired.

2. Administration of Hormones

The therapy consists of two main components:

1. Estrogens
   Goal: Suppression of testosterone levels and promotion of female characteristics.
   • Oral Estrogens: Estradiol tablets (e.g., Estrofem®), 2–6 mg daily.
   • Transdermal Estrogens: Estradiol gels (e.g., Estreva®) or patches (e.g., Climara®), 50–100 µg daily.
   • Injectable Estrogens: Depot injections of estradiol valerate or estradiol enanthate, every 1–2 weeks.
2. Antiandrogens
   Goal: Inhibition of testosterone activity.
   • Cyproterone Acetate: An antiandrogen that blocks testosterone effects (dosage: 25–50 mg daily).
   • Spironolactone: A potassium-sparing diuretic with antiandrogenic effects (100–300 mg daily).
   • GnRH Analogs: Suppress testosterone production in the testes. These drugs are more expensive and used selectively.

3. Effects of Hormone Therapy

Physical changes occur gradually over several months to years:

Early Effects (1–6 months):

• Softer skin due to reduced oil production.
• Fat redistribution toward a typically female pattern (hips, thighs).
• Reduced libido and sexual function.

Mid-Term Effects (6–12 months):

• Breast development (irreversible), usually complete in 2–3 years.
• Reduction in muscle mass and strength.
• Reduction of facial and body hair, although additional hair removal may be needed.

Long-Term Effects (1–5 years):

• Feminine body shape due to fat redistribution.
• Shrinking of the testes and decreased sperm production (irreversible).
• Halt of male-pattern hair loss (androgenetic alopecia).

4. Side Effects and Risks of Hormone Therapy

Hormone therapy requires close medical monitoring due to potential side effects:

• Increased risk of thrombosis (blood clots), particularly with oral estrogen use.
• Weight gain due to fat redistribution.
• Enlargement of breast tissue (gynecomastia).
• Increased risk of cardiovascular disease.
• Mood swings and emotional sensitivity.
• Liver strain with high doses of oral estrogens.
• Long-Term Monitoring

Regular medical check-ups are essential to detect side effects early and adjust therapy:

• Hormone levels (testosterone, estradiol) every 3–6 months.
• Blood count, liver function, and lipid profile annually.
• Blood pressure and blood glucose to monitor cardiovascular risks.
• Bone density: Estrogens protect against osteoporosis, but regular monitoring remains essential.

6. Complementary Measures

• Hair Removal: Laser or electrolysis to eliminate unwanted facial and body hair.
• Surgical Procedures: Breast augmentation (mammoplasty), orchiectomy (removal of testes), and vaginal reconstruction (neovagina).
• Psychological Support: Assistance with social, emotional, and psychological challenges during the transition.

Conclusion

Hormone therapy for male-to-female (trans women) individuals is a central aspect of gender-affirming treatment. It leads to feminization of the body and reduces male characteristics, but requires regular medical supervision to minimize risks and achieve optimal results.