Be advised that this entry includes biological terms.

Estrogen treatment is intended for people on the trans spectrum who are interested in feminizing hormone replacement therapy (HRT). The treatment is given by taking the hormone estrogen, sometimes together with testosterone blockers.

Estrogens are a group of hormones that are responsible for the development of the reproductive system and of female sex characteristics in people who were assigned female at birth, but they are found and necessary in every human body. This article will detail the physical, emotional and sexual effects of estrogen hormonal treatment, as well as the side effects and risks that come with this treatment which are important to consider.
Keep in mind that there’s no way to predict the body’s reaction to HRT. The reaction varies from person to person and is greatly affected by differences in genetics, age, medical condition and more. So we recommend that you manage your expectations with yourself and with your doctor.

Physical changes

There are several changes which you can expect at different times over the course of estrogen treatment. Not all of the changes happen for every person, and each change can happen at various points in the process and for varying amounts of time, וחלק מהשינויים מושפעים ממינון האסטרוגן הנצרך.

Usually you can expect the following changes to start:

• First 1-3 months of treatment – the stopping or slowing of any balding process (soft “peach fuzz” hair can get stronger; there’s not necessarily renewed growth of hair); the skin becomes softer and less dry but also more vulnerable; a decrease in libido and in the number of erections.
• 3-6 months into the treatment – decrease in strength or muscle mass; redistribution of body fat; breast growth; decrease in size of testicles.
• 6-12 months into the treatment – body hair starts to get sparser and grow more slowly.

The full effect of the changes usually only arrives after about 2-3 years of treatment, and the changes continue throughout your lifetime alongside natural growth processes. A treatment that includes testosterone blockers can enhance some of these expected changes. Sometimes there’s a change in shoe size or height, but this it not due to any changes in bone structure, but rather changes in the muscles and ligaments of the legs and spine. Feminizing HRT doesn’t affect your voice; those who are interested in voice feminization should seek out voice training (a treatment which is covered by your Kupat Holim (HMO) as part of the healthcare basket (Sal Habriut סל הבריאות) and available through voice therapists).

Sexuality and fertility

In the first few months after starting feminizing HRT there’s a decrease in the number, length and quality of erections. That said, there will still be erotic feelings and you can still achieve an orgasm. For those who are concerned about the decrease in erections, medications like sildenafil (viagra) may help (you should consult with a doctor). You can also talk with your doctor about the types of hormones available, and what you feel is important for you to retain throughout the process. The erotic experience itself may also change. There are accounts of orgasms starting to feel more like a “whole body” experience (as opposed to centered in one organ) and lasting longer. Beyond that there might be changes in ejaculation, which may produce a small amount of clear or white liquid or no liquid at all. Over time the testicles will shrink to less than half their previous size, but the amount of skin in the scrotum, which can be used in a future bottom surgery, won’t change.

The effect of estrogen treatment on fertility is still not fully known, but it’s assumed that within a few months of starting treatment the damage to fertility can be irreversible, although some people have returned to satisfactory fertility after stopping the treatment. The fact that there’s not a lot of information is one of the reasons that people are encouraged to take care of fertility preservation before beginning HRT, but this is still a personal choice without any clear “right or wrong” answer. Also, you should know that taking estrogen is not a replacement for contraceptives.

Emotional effects

HRT affects not only the body, but also your psychological and emotional condition. The effect varies from person to person. The beginning of HRT is similar to puberty, and can be accompanied by sharp mood swings and turbulent emotions.
The hormonal treatment may lead to a wider range of emotions, or a change in interests and preferences. Some of the most common emotional changes caused by estrogen treatment are higher sensitivity, an increase in moments of crying, and sometimes a deeper feeling of empathy. These changes can be intense or gentle, depending on the individual physical and psychological effects of the treatment, your psychological state, and your environment. Usually the changes balance out after a period on HRT. But, by their nature, hormones continue to affect the body, mind and connection between the two, and part of the process is learning the individual ways hormones affect you and the personal needs that arise for you. Therapy may be a good idea as a part of the process so you can get support, skills and a supportive space, and similarly, social or family support, music, pets, diet, sports and so on can be a part of your support system.

Risks

The decision to take hormones is personal, and influenced by many factors. That said, it’s important that you use all of the knowledge that exists at present about this treatment to make your decision. As mentioned, one of the effects of estrogen is damaging fertility, and we do not yet know if this is irreversible. So for anyone who wants to have genetic material available for reproduction, it’s best to get fertility preservation before starting hormones.
In addition, there’s a small risk that you’ll have an increased likelihood of blood clots, heart attacks, strokes, diabetes, and cancer, usually for people with preexisting medical conditions or who start HRT after the age of 50. The risk of blood clots is high for those who smoke and take estrogen at the same time, and so the medical recommendation is to stop smoking before starting the treatment.
In addition, from age 50 you should start having regular mammographs to avoid breast cancer.