Starting hormonal treatment (also known as hormonal replacement therapy), is a significant step towards transformation of a transgender from M to F. It has a dramatic positive impact over physical as well as psychological quality of life. Hormonal therapy leads to changes in body structure making it more feminine; incongruent to psychological feelings and expectations, hence this leads to tremendous boost in self esteem. Positive response and increase in self esteem level inspires a transgender for further positive decision making for a better life. Unique positive effect of hormones is important to serve the essential purpose of bringing one’s mind and body closer together.

The extent and speed in physiological and psychological changes vary from person to person; depending on the individual response, age of start and dosage of hormones. Individualization of treatment becomes necessary to get maximum benefit with minimal potential risks and side effects involved.

Physiological effects of hormones

Hormonal therapy is one of the integral part of overall feminization during the process of transformation of a transgender from Male to Female.

Hormones not only lead to certain changes in physical appearance but also they changes the way you feel about yourself.

Effects of feminizing hormones on your body are:

  1. Skin Texture: Skin becomes softer and more feminine with glow.
  2. Skin Colour: Female hormones specially estrogen make the skin colour lighter.
  3. Fat: Hormones lead to deposition of an extra layer of fat below the skin. The fat deposition helps in smoothening the hard bony / masculine edges making a feminine appearance.
  4. Cheeks: Hormones change hollow masculine cheeks to fuller and rounder malar prominences.
  5. Lips: lips tend to become fuller with a little feminine pout.
  6. Jaws: Hormones don’t have effects on jaw bones but they do reduce muscle mass. This reducing effect on masseter muscles (chewing muscles), leads to narrowing of lower face.
  7. Beard Reduction: Though not significantly but few people report that hairs become softer and less thicker.
  8. Neck: Neck contour tends to become more feminine owing to skin texture and mild fat deposits. Fat layer indirectly tend to cover the Adam’s apple making it less prominent.
  9. Breasts: Everybody (male as well as females) has milk ducts in chest area. When female hormonal therapy is started (estrogen), the breast tissues start growing making the breasts larger. This has been termed as secondary puberty.On clinical ground breast development has been defined in five stages (Tanner Stages):

    • Stage 1: This is underdeveloped pre hormonal breast; there is small nipple only without significant underlying palpable breast.
    • Stage 2: Nipples becomes sensitive and clinically nodules can be felt under the areola at 6 weeks after start of hormonal therapy. At 3 months breast buds becomes visible owing to growth of milk ducts. Breast mound becomes visible and areolar diameter begins to enlarge.
    • Stage 3: At 6 months of Hormonal Therapy, breasts get enlarged with elevation of breast and areola (with no separation of breast and areola contour). Areola becomes darker and underlying milk glands start growing.
    • Stage 4: After 1 – 2 years, this is characterised by differentiation of nipple areola.
    • Stage 5: This is the stage of mature filled out breasts. Nipple is still projected but areola is recessed and becomes in plane with surrounding breast contour. It means secondary mound disc of raised nipple disappears. Very few, who are taking hormonal therapy for feminization, reach this stage.

    In summary once the feminizing hormonal therapy is started, breasts gradually evolve, often with periods of increase in size and periods of static size. Initial period is commonly associated with nodules which may be painful.

    After hormonal therapy, breast growth is irreversible; this means breast growth will persist even after you stop taking hormones.

    Final size and shape of breasts after hormonal therapy vary from individual to individual. There may be asymmetry in size of both breasts. Younger you start, better development you notice.

  10. Effect on Body Hair distribution:Facial hairs (beard and moustaches) are minimally affected, by the anti-androgen therapy. There is slight effect leading to some reduction in intensity with slower growth. Those who are in teens, will have significant difference, and anti–androgens prevent new facial hair growth.Body hairs tend to disappear / became lighter with anti-androgen therapy.
  11. Fat distribution over body parts:
    With hormonal therapy fat distribution slowly changes over months. Body develops a tendency to accumulate fats in more feminine pattern. The areas like hips, thighs, arms, breasts tend to develop fat deposits; waist becomes smaller as compared to shoulder and hip area. Fat over face also increases; overall fat deposits conceal the muscular and boney prominences giving more curvaceous and rounded off feminine appearance.
  12. Effects on external genitalia:Transgender on anti-androgens may report reduction in libido with decrease in frequencies of penile erections. Testicular volume decreases (by about 25 to 50 %) depending on the dosages of anti-testosterone medicines. Testicular spermatic cells undergo atrophy gradually leading to halt in spermatogenesis.The prostate and urinary bladder also shrink in size. The raphae running down under the penis over scrotum in midline tends to darken
  13. Body shape / Body Composition:During hormonal therapy, under the influence of rising levels of female hormones, (specially Oestradiol), lower pelvis and hips tend to increase, especially if hormonal therapy is started in early age before or around puberty. In later stages when bones have developed fully, these may not lead to significant changes in bony structures.

Frequently Asked Questions

  • Is hormone replacement therapy required for a year before Sex Reassignment Surgery?
Sex Reassignment Surgery procedure can also be done after 3 to 6 months of Hormonal therapy. In MTF cases prolonged HRT before operation is not required because hormones lead to shrinkage of Penis and Scrotal skin which is extremely useful for genital reconstruction during Sex change operation.In MTF transgenders best outcome is achieved even after 3 to 6 months of HRT.

In FTM cases prolonged HRT before operation is said to be useful specially for those who want metoidioplasty. prolonged HRT leads to enlargement of clitoris and labia majora and makes the tissue available for metoidioplasty and scrotoplasty. Those who want free flap phalloplasty (Radial artery forearm flap, ALT flap, MLD flap etc. ) instead of metoidioplasty can undergo procedure even after 6 months of HRT.