Start Here: Your Guide to Gender-Affirming Hormones
Thinking about starting hormones, just started, or several years in and wanting to understand what your prescriber is doing? This page is the map for the whole site. It covers what hormones change and how fast, what they leave alone, how people get a prescription, what the blood tests are for, and what it all costs.
I have spent over a decade coordinating trans patients through hospitals in Bangkok, and hormones come up in almost every one of those conversations, usually as a question somebody should have answered years earlier. I am not a doctor and I have not taken hormones myself, and this site is not medical advice. It is what that vantage point teaches you, written down plainly so you can ask better questions of the person who prescribes for you.
On this page
What hormones actually do
Gender-affirming hormone therapy, usually shortened to HRT, replaces the hormone your body makes most of with the other one. Feminizing HRT is estrogen, usually as estradiol, often with an anti-androgen to lower testosterone. Masculinizing HRT is testosterone on its own.
What follows is a second puberty, and it runs on puberty's timescale. Some changes start within weeks, most take one to three years to settle, and they arrive in roughly the same order for most people, though at very different speeds.
Two things surprise people. The first is how much of the change is invisible for the first few months: skin, mood, how you feel in your body, how your sex drive works. The second is that the end result is shaped heavily by genetics, age and what your first puberty already did, far more than by dose. A higher dose does not make changes come faster, and it can make some side effects worse.
What they cannot do
It is worth knowing the limits before you start, because waiting for a change that is never coming is one of the most disheartening parts of the first year.
Estrogen does not raise a voice that has already dropped, shrink bones, reduce height or remove an established beard. Voice training, voice surgery and hair removal exist for exactly those reasons. Testosterone does not shrink breast tissue, narrow hips that have already widened or add height after your growth plates have closed. Chest surgery exists for that reason.
The changes timelines for each direction set out what moves, what does not, and roughly when. The masculinizing timeline does the same the other way.
Before you start
Take a few photos in ordinary light and write down how you feel in your body, and keep them somewhere private. Change is slow enough that you will not see it day to day, and a clear before is the easiest way to know it is happening.
Getting a prescription
How you get hormones depends almost entirely on where you live and how you pay.
Under the informed consent model, common in US community clinics and telehealth services, a prescriber explains the effects and risks, checks your health and your bloods, and you decide. It can take one or two appointments. Under the assessment model used by many gender clinics, including NHS gender services in the UK, you are assessed over several appointments first, and waiting lists can run to years.
Plenty of people end up using both, starting privately while they wait for public care. If you are in that position, bridging prescriptions and GP shared care are the terms to know. If your goals are not at either end, non-binary and low-dose HRT covers how to talk to a prescriber about them.
Staying on them safely
For most people, staying healthy on hormones is routine: blood tests every few months in the first year, then once or twice a year, and a prescriber who adjusts the dose to the results.
The tests check two things. One is whether your hormone levels sit roughly where guidelines aim. The other is whether the medicine is causing a problem you would not feel yet: potassium with spironolactone, prolactin with some anti-androgens, and hematocrit, the thickness of your blood, with testosterone. Blood tests and monitoring explains each one, and the blog post on reading your results goes through the units and ranges on a lab sheet.
The main serious risk on the feminizing side is a blood clot, a DVT, which smoking raises a lot. On the masculinizing side it is blood becoming too thick. Both are why the monitoring matters. The risks pages for feminizing and masculinizing hormones cover the rest, including what to report straight away.
-
1
First appointment
1–2 appointments
A prescriber goes through what the medicine does and its risks, takes a health history and orders baseline blood tests.
-
2
Starting
Day one
You start at the dose your prescriber sets. Nothing much happens at first; that is normal.
-
3
Early checks
Every 3 months or so in year one
Blood tests and a review. The dose is adjusted to your levels and how you are feeling.
-
4
Changes settle
1–3 years
Most visible changes happen over this stretch, in roughly the same order for most people.
-
5
Long-term care
Once or twice a year
Routine bloods, a review, and the ordinary screening for the organs you have.
At your first appointment
Ask when your blood tests will be, what time relative to your dose they should be taken, and who looks at the results. The timing question in particular changes what the numbers mean, and it is easy to get wrong.
Things to plan early
Two decisions are much easier before you start than after.
Fertility. Both directions of HRT can reduce fertility, and nobody can promise it will come back if you stop. Freezing sperm or eggs is simplest before hormones begin. Fertility covers the options and the costs.
Surgery, if it is on your list. Surgeons have views on hormones before and after an operation, and they are not all the same. Some ask people on estrogen to pause, many no longer do, and after some operations your dose will need to change. Hormones and surgery is the page I most wish people read before they book.
What it costs
The medicines themselves are mostly old, off-patent and cheap. Generic estradiol pills and spironolactone typically cost a few pounds or dollars a month, while patches, gels and some injections cost more. Where most of the money goes is appointments and blood tests, particularly if you pay privately.
In the US, costs range from very little on good insurance to somewhere around a few hundred dollars a year self-pay for medicine and labs, more with private appointments. In the UK, NHS care is free apart from standard prescription charges in England, and private clinics charge for consultations, bloods and a markup on some prescriptions. Cost and insurance has the detail by country.
How to use this site
Feminizing hormones and masculinizing hormones cover the medicines, the changes and the risks. Getting hormones covers the routes in and the costs. Staying healthy covers monitoring, fertility, surgery and the long term. The glossary explains the words prescribers use as if everyone knows them.
The about page explains who is writing and why, including the commercial interest I have and how I handle it, and the contact page is where questions and corrections go. Nothing here is medical advice. Your prescriber knows your history and your blood results; I do not. Use this to ask them better questions, and never start, stop or change a dose because of something you read here.
Frequently asked questions
How long does HRT take to work?
The first changes usually show within a few months and most take one to three years to settle. See what hormones actually do.
Will hormones change my voice?
Testosterone lowers most voices over the first year. Estrogen does not raise a voice that has already dropped. See what they cannot do.
Do I need a diagnosis to get hormones?
Not everywhere. Informed-consent clinics prescribe after explaining the effects and risks; gender clinics assess you first. See getting a prescription.
Is HRT expensive?
The medicines are mostly cheap. Appointments and blood tests are where the cost is, especially privately. See what it costs.