What is the best form of estradiol therapy for Feminizing hormone therapy?

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Feminizing hormone therapy with Estrogen is a treatment that can be utilized to help alleviate the symptoms of gender dysphoria. Often it's combined with progesterone and testosterone blockers, which can help transition more smoothly 

For some people, feminizing hormone therapy is an important part of their journey to authenticity. The goal for this type of treatment would typically be inducing physical changes that match gender identity and expression- like developing breasts or less facial hair. 

For example: 

Reduction in facial hair, most individuals will notice a decreased need to shave. For best results, we recommend laser hair removal or electrolysis. Laser hair removal may be the perfect solution for some individuals to reduce their need or desire in shaving. Laser treatments work by targeting and destroying hairs with high-energy light, while electrolysis uses an electric current that causes pores on your skin to strip away cells creating space between follicles causing them to die off over time. 

The process of redistribution, or storing fat into different areas can cause a woman's figure to develop. Estrogen is what causes this change in shape because it increases the storage and development of body fats throughout your entire system - including breasts as well as hips. Here is a detailed article to address the development of breasts with hormone therapy  

  • Changes in voice pitch 
  • Prevention of male pattern baldness 
  • Decrease in the size of testis 
  • Skin becomes much softer 

Before treatment can be started we require:  

  • Basic lab work. This includes CBC, comprehensive metabolic panel, hemoglobin A1c to exclude diabetes, TSH to test for thyroid problems 
  • Baseline hormone levels of estrogen, progesterone, and testosterone 
  • Established diagnosis of gender dysphoria. 
  • Informed consent 

Dose versus duration: 

Some providers are using much higher doses of estradiol therapy in an attempt to accelerate feminization. There is no data supporting this practice, however. The duration of hormones is an important factor to consider when it comes to physical changes. Hormone therapy can take up to 2 years before you start seeing maximal results, and those who use them for a long enough period will notice that their voice may change over time. We discourage the use of high doses and supraphysiological levels of estrogen as this can lead to significant side effects such as a risk increase in blood clots, cancers, anxiety/depression, and heart disease. 

  

Potential side effects of feminization therapy  

  • Increased risk of blood clots such as DVT and pulmonary emboli 
  • Increase risk of elevated liver enzymes is thought to be secondary to fat deposits in the liver 
  • Increase risk of gallstones 
  • Hyperlipidemia 
  • Weight gain through increased fat storage deposits 
  • Symptoms of hypothyroidism such as cold feeling, constipation, fatigue. Estrogen tends to block the effect of thyroid hormone at the tissue level. TSH and thyroid hormone typically are normal 

Estrogen: 

This is the mainstay of Feminizing hormone therapy. Estradiol is a steroid sex hormone that is produced by the ovaries and adrenal glands in biological females. Individuals who are overweight also tend to have a conversion of testosterone to estrogen in body fat by an enzyme called aromatase. Estrogen therapy also helps suppress the production of androgen such as testosterone. 

Types of estrogen therapy  

  • Ethinyl estradiol: This is a synthetic version of estrogen, and is extremely potent. This estrogen is derived from horse urine and is found in commonly prescribed oral contraceptives. This type of Ethinyl estradiol is not recommended for feminization therapy as it has a very high rate of blood clots. 
  • Estradiol 2-4 mg in divided doses is most commonly prescribed due to affordability and predictable blood levels. Current smokers should be on a much lower dose to reduce the likelihood of developing blood clots. 
  • Transdermal patch of estradiol: This is a much safer version of estradiol, however, tends to be expensive and absorption from the skin is variable leading to inadequate levels. We do not use this type of estradiol in our practice 
  • Estradiol valerate: Typical dose is 5 to 30 mg IM every two weeks. We often do not use this therapy as it has been shown to accumulate in the body and can cause toxicity. There is also a concern of receptor desensitization from consistently elevated levels of estrogen 
  • Estradiol pellets: These are the size of a rice grain, are inserted in the fat layer in a quick 10-minute outpatient procedure, and slowly dissolve over several months. This is our preferred approach due to the use of bioidentical estradiol which tends to be much milder than synthetic versions of estrogen. This also eliminates the need to take tablets and injections. Since the pellets are slowly dissolved, this avoids the negative effects associated with estradiol injections. You can watch a video of the procedure here 

Other useful tips  

  • Avoid cruciferous vegetables as they are naturally occurring estrogen blockers. Individuals with a very high intake of these vegetables such as broccoli, Kale, may require higher doses of estradiol therapy. 
  • Estrogen therapy should always be combined with progesterone. This may help reduce many side effects of estrogen therapy such as feelings of bloating, anxiety. Progesterone also binds to GABA receptors in the brain which may help with insomnia and anxiety. 
  • Avoid smoking as this can increase the risk of complications associated with estrogen therapy 
  • Do not take higher doses of estradiol as this can increase the risk of complications however does not help with the feminization process 

Have more questions? Schedule a consultation with one of our licensed providers to get started. 

 

* All information subject to change. Images may contain models. Individual results are not guaranteed and may vary.