Estrogen-Based Gender-Affirming Hormone Therapy: Medications and What to Expect

Most people have probably heard of the hormone estrogen. Estrogen is a hormone we all naturally make, but different bodies make different amounts. It is one of the sex steroid hormones involved in the development of the various physical changes classically associated with puberty (think hair growth and changes in voice and body parts). 

If you’re transgender, a broad term generally describing someone whose gender identity is different from their sex assigned at birth, estrogen might be a part of your gender-affirming hormone therapy (GAHT). This is also true for gender-nonconforming, nonbinary, and intersex people. 

What is gender-affirming care?

Gender-affirming care, a model discussed in-depth by the trans telehealth company Plume, is, at its core, exactly what it sounds like: healthcare that affirms you to live authentically in your gender. Previously, care for transgender people often followed an outdated one-size-fits-all framework, which meant that providers recommended the same set of hormones and surgery for every trans person seeking medical care. Instead, gender-affirming care allows individuals to seek only those interventions they desire to affirm their gender identity.

What is gender-affirming hormone therapy?

GAHT is part of gender-affirming care. It’s prescribed to encourage physical changes in the body to help people live their authentic selves with respect to their gender identity.

Research has shown that the gender-affirming care model improves health outcomes for trans people. In fact, it is considered the standard of care and is considered medically necessary by nearly every major medical association in the U.S., including the American Medical Association, the American Academy of Family Physicians, and the American Psychiatric Association. 

GAHT vs. hormone replacement therapy

Since GAHT and hormone replacement therapy (HRT) are often confused or used interchangeably, let’s take a moment to differentiate them. 

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HRT classically describes the process of prescribing hormones to cisgender people, often to relieve symptoms of hormone imbalance. For example, estrogen may be prescribed to postmenopausal cisgender women to help with hot flashes.  

The term HRT has often been used by the trans community to describe the process of GAHT. However, GAHT is a more accurate description of the use of hormones by trans people because nothing is technically being “replaced.” Medical professionals who treat transgender people are moving away from saying “HRT” as not to conflate the terms.

Who typically uses estrogen-based (feminizing) GAHT?

The use of estrogen-based GAHT (also known as feminizing hormone therapy) is not limited to people with specific gender identities. But generally speaking, it’s commonly prescribed to trans women, and transfeminine, nonbinary, and intersex people. 

Therapies used in estrogen-based GAHT

Estrogen, testosterone blockers or androgen blockers, and progesterone are the large groups of therapies that are typically used in estrogen-based GAHT. Each group of medications can be administered in a variety of dosages and routes. 

The Endocrine Society, the University of California, San Francisco, and the World Professional Association for Transgender Health (WPATH) have published clinical guidelines around how to prescribe medications for GAHT. In the sections below, we’ll review the different options that are available and what to expect from each therapy. 

Estrogen therapy

Estrogen is a cornerstone of estrogen-based GAHT. In estrogen-based GAHT, bioidentical estrogen (also known as 17-beta estradiol) is used. The term “bioidentical” describes hormone therapies that are chemically similar to the hormones produced by our own bodies. 

Below, we’ll briefly compare the three main uptake methods of estrogen — tablet, injection, and patch — and their related dosages. Please note that all doses listed below are examples of starting ranges. Your specific dose would be determined based on a personalized conversation with your provider. 

1. Tablet

Estradiol tablets are typically made to be taken orally. But, with GAHT, it’s generally recommended to take them sublingually (dissolved under the tongue). The sublingual route is thought to be potentially safer than swallowing the tablet. 

Your pharmacist may be unfamiliar with the sublingual method, and that’s okay! If your provider recommends this method, just let your pharmacist know that you’ve discussed it with them.

The starting dose of estradiol tablets is typically 2 mg to 4 mg per day. With a GoodRx coupon, this therapy can cost as little as $7.05 per month.

2. Estrogen injections

Most commonly, estradiol injections are given in the upper, outer thigh (intramuscularly). But an injection under the skin (subcutaneously) in the lower belly or thigh area is also an option if there’s enough skin or fat there. 

There are two common types of injectable bioidentical estrogen: estradiol valerate (Delestrogen) and estradiol cypionate (Depo-Estradiol). 

Not all pharmacies keep injectable estradiol in stock, so it is best to call ahead to make sure that a location has it available. If you are unable to find it, you always have the option to switch to the tablet or patch.

A common dosage for estradiol valerate, for example, is 6 mg to 8 mg (0.3 mL to 0.4 mL) once weekly, and it can be adjusted based on individual goals. With a GoodRx coupon, a vial of 20 mg/mL estradiol valerate will generally cost as little as $52.07 for the generic version. 

A common dosage of Depo-Estradiol is 1.5 mg to 2 mg (0.3 mL to 0.4 mL) once weekly. It is currently only available as a brand; there is no lower-cost generic version. With a GoodRx coupon, a vial can cost as little as $203.14 . 

3. Patch

Estradiol is also available as a patch that comes in once- and twice-weekly options. According to UCSF guidelines, the patch seems to be the safest and preferred form of estradiol in terms of blood clotting risk and for active smokers. 

It’s worth noting that some people find the patch difficult to keep on. And it can sometimes cause skin irritation.

The maximum-dose patch contains 0.1 mg of estradiol, and most people use one or two at a time. Depending on the dose, a one-month supply may cost as little as $26.89 based on current GoodRx prices.

What to expect from estrogen therapy

The first changes people taking estrogen typically notice are chest development and nipple tenderness, at around 3 to 6 months after starting therapy (regardless of method). Mental health issues, especially anxiety and depression, can also improve soon after a person starts taking estrogen. 

Some of the other body changes that occur more gradually can include:

• Redistribution of fat to the outside of the body (including the hips, thighs, and glutes)

• Softer and less oily skin

• Thinning and slowed growth of coarse body and facial hair

• Decreased libido (sex drive) and sexual function

• Decrease in size of some parts of the genitals

Most people will max out on physical changes after taking estradiol for 2 to 5 years. But people often continue taking it beyond that point to maintain the changes that have occurred and for bone health.

Testosterone blocker or androgen blocker therapy

Testosterone is a type of androgen, another sex hormone produced in all bodies in different amounts. Medications for testosterone blocker therapy are often referred to as testosterone (“T”) blockers or androgen blockers. While T-blockers are one type of therapy that can be used in combination with estrogen in GAHT, the decision of whether or not to use them is very personal. Some people don’t take T-blockers and others take one or multiple. 

T-blockers block the effects of testosterone in different ways, but they do not typically lower testosterone levels alone. It is important to know that estrogen (not testosterone blockers) is primarily what lowers testosterone in the body. One way that T-blockers work is by directly blocking testosterone receptors, proteins that testosterone normally interacts with to activate certain biological processes. Or they can block the conversion of testosterone to dihydrotestosterone (DHT), a stronger form of testosterone. 

The most common T-blockers used in GAHT include spironolactone, or “spiro” for short, and DHT-blockers like finasteride and dutasteride. We’ll briefly compare these two types of medications and some sample doses below.

1. Spironolactone

Spironolactone (Aldactone) is a direct androgen receptor blocker that can be used off-label as a supplement to estrogen. It is also a diuretic, meaning that it can make you pee more often, and it can raise your potassium levels. So you’ll need to have blood work done while you’re taking it to make sure your potassiums levels don’t get too high. 

Other potential side effects of spironolactone include lowering blood pressure and reportedly causing depression and brain fog.

The typical starting daily dose of spironolactone is one 50 mg tablet taken orally, and it can be increased as needed. Currently, the lowest price for 30 tablets of spironolactone 50 mg is $9.00 with a GoodRx coupon.

2. Finasteride and dutasteride 

Finasteride (Proscar) and dutasteride (Avodart) block the conversion of testosterone to DHT, which is short for dihydrotestosterone, the stronger form of testosterone in the body. Dutasteride may be more effective at blocking testosterone’s effects than finasteride. 

Since DHT plays a big role in scalp hair loss, finasteride is also prescribed outside of gender-affirming care to treat hair loss. For those who are worried about scalp hair loss or are concerned about the side effects of spironolactone, finasteride can be a good option. 

The typical starting daily dose of finasteride is one 5 mg tablet. It also comes in a 1 mg tablet for people who prefer a lower dose. With a GoodRx coupon, the lowest prices for 30 tablets of the 1 mg and 5 mg doses are $7.20 and $8.77. The typical dosage of dutasteride is one 0.5 mg capsule per day. With a GoodRx coupon, the lowest price for 30 tablets of 0.5mg dutasteride is $12.00.

What to expect from testosterone or androgen blocker therapy

Using T-blocker therapy to inhibit the effects of testosterone can allow estrogen to work more quickly. The effects of these therapies in conjunction with estrogen can vary significantly. Generally speaking, the changes you should expect are similar to the ones outlined above in the section on estrogen therapy; though, the effects may occur a bit faster. 

Progesterone therapy

Progesterone is another hormone that can be used as part of estrogen-based GAHT. Bioidentical progesterone, called micronized progesterone (Prometrium), is generally used in this scenario. 

What to expect from progesterone therapy

We unfortunately don’t have any evidence to show that progesterone causes significant changes within the context of gender-affirming care, mostly because the studies have not been done. 

While the research is lacking, there are a fair amount of people who feel that progesterone helps with things like breast development, including rounding out the breasts and areolar development, adding fullness to the hip area, and possibly improving mood and increasing libido. And this therapy does appear to be safe based on current evidence. 

Side effects and risks of estrogen-based (feminizing) GAHT

Before you begin GAHT, there are a few side effects and risks to keep in mind.

Blood clots

Certain forms of estrogen, like Premarin (conjugated estrogens) and ethinyl estradiol (like in birth control pills), are known to cause blood clots. But the link between bioidentical 17-beta estradiol and blood clots isn’t as clear. The studies that have identified a possible link between estrogen and blood clots, heart attack, and stroke don't look at the specific forms of estrogen being used.

Since there may be a small, increased risk of blood clots, stroke, or heart attack, it’s recommended that estrogen levels stay at less than 200 pg/mL during estrogen therapy. Your healthcare provider will monitor your levels to make sure you stay in a range that’s safe for you.

Fertility problems

Another risk of estrogen therapy is infertility. Over time, estrogen causes the levels of testosterone in the body to drop. This causes changes to other body parts that are important in allowing pregnancy to occur.

If preserving fertility — having children with your own genetic material in some way — is important to you, talk to a reproductive specialist. They can help you freeze genetic material that can be used for a pregnancy later.

Other side effects

Some risks and side effects of progesterone therapy specifically are drowsiness, nausea, and occasional weight gain. There’s also a risk of androgenic effects, or changes similar to those caused by testosterone, such as coarse or dark hair growth on the face and acne. This is because some synthetic forms of progesterone are made from hormones in the same family as testosterone. Micronized progesterone is less likely than other forms of synthetic progesterone to cause these effects.

How to save on estrogen-based gender-affirming hormone therapy

Most medications used for estrogen-based GAHT are available in lower-cost generic versions. As detailed above, a free GoodRx coupon can help make your prescription more affordable.

Double-check the medication, dose, and quantity on your prescription to ensure you’ve pulled up the correct GoodRx coupon. If you’re not sure, your pharmacist should be able to help.

How to learn more about estrogen-based GAHT

If you want to learn more about estrogen-based GAHT, the best place to start is by talking to your healthcare provider. If you don’t already have one, you can find a local provider who practices gender-affirming care by visiting the WPATH provider directory. You can also check to see if you live in a state covered by Plume, a telehealth company that provides gender-affirming care, made by and for trans people. 

Plume offers a mobile app that allows you to consult with a provider, develop an individualized treatment plan, and have your prescriptions delivered to your door, all for a flat monthly fee of $99 (no insurance required). You can learn more about Plume’s GAHT services on their website.

Why trust our experts?

Written by:

Jerrica Kirkley, MD

Jerrica Kirkley, MD, is chief medical officer and co-founder of Plume, the first digital health company dedicated to the transgender community that provides gender-affirming hormone therapy at the convenience of a smartphone.

Edited by:

Alyssa Billingsley, PharmD

Alyssa Billingsley, PharmD, is the director of pharmacy content for GoodRx. She has over a decade of experience as a pharmacist and has worked in clinical, academic, and administrative roles.

Reviewed by:

Christina Aungst, PharmD

Christina Aungst, PharmD, is a pharmacy editor for GoodRx. She began writing for GoodRx Health in 2019, transitioning from freelance writer to editor in 2021.

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Co-contributor: Rachel Percelay