Long-Term Health on HRT
Most of what gets written about hormones covers the first year or two: what changes and when. This page is about the decades after that. For most people, long-term health on HRT looks a lot like long-term health for anyone else, with a few adjustments for the hormones you take and the organs you have.
Research here is still building. Most long-term studies of trans people on hormones are relatively small, many followed people on older medicines and doses, and very few have followed large numbers of people into their seventies and eighties. Where that is the state of the evidence, I say so. Use this page to know which questions to raise with a GP and a prescriber who can look at your actual history.
On this page
Bones
Sex hormones protect bone. Estrogen does most of that work in everyone, including in cisgender men, where some testosterone is turned into estrogen in the body. What harms bones is having too little of any sex hormone for a long time.
That is why the risk is not really about HRT itself. People on a stable dose of estrogen or testosterone generally keep their bone density. The risk comes from long gaps: stopping hormones for months or years, a dose that is too low for a long time, or having the testes or ovaries removed and then not taking hormones afterwards. Time on puberty blockers without hormones also affects bone, which is one reason that period is closely monitored.
After the testes or ovaries are removed, your prescribed hormone is your only significant source of sex hormone. A lapsed prescription is no longer cushioned by what your own gonads made, which is why prescribers keep people on estrogen or testosterone long term after gonadectomy. Hormones and surgery covers the dose changes around the operation itself.
Some prescribers arrange a bone density scan (often called a DEXA scan) for people with risk factors, such as long gaps without hormones, gonad removal, a long time on blockers, a low body weight or a family history of osteoporosis. One thing to ask about the result: bone density is reported against a reference group, and which group the scanner compares you with, male or female, changes the score. Ask which was used, and make sure later scans use the same one. Weight-bearing exercise, enough calcium and vitamin D, and not smoking help everyone.
If you have had a long gap without hormones
Tell your prescriber how long and when, and ask whether a bone density scan is worth doing. It is a quick, low-dose scan, and a baseline makes later ones meaningful.
Heart and circulation
The medication risks are covered in feminizing hormone risks and masculinizing hormone risks. In short, estrogen tablets raise clot risk more than patches or gel, and testosterone tends to raise hematocrit and shift cholesterol in a less favourable direction. Whether either adds up to more heart attacks and strokes over decades is not settled, partly because much of the older research involved smoking and older medicines.
Over the long run, what makes the biggest difference is the ordinary list: not smoking, blood pressure, cholesterol, blood sugar, weight and exercise. Hormones can nudge several of these, and all of them also drift with age, so a check that was fine at 25 is worth repeating at 45.
What to ask for over time. A blood pressure reading at each hormone review is common. Cholesterol and blood sugar (often as an HbA1c, a measure of average blood sugar over a few months) are usually part of the baseline and then repeated every few years, or more often if you have risk factors. Many countries also run a routine heart-health check from middle age, such as the NHS Health Check in England from 40; you are entitled to it like anyone else, and it is worth telling whoever does it which hormones you take.
Cancer screening for the organs you have
The simplest rule is that screening follows your anatomy, not the gender on your record. Most national screening programmes invite people based on the sex on their record, so it is worth checking you are on the right lists for the organs you have.
Breasts. Trans women on estrogen develop breast tissue, and breast cancer risk rises above that of cisgender men, though it appears to stay well below that of cisgender women. Many guidelines suggest screening along similar lines to cisgender women after some years on estrogen. Trans men who have had chest surgery usually keep a small amount of breast tissue, so some screening may still be relevant depending on what was removed.
Cervix. Trans men and non-binary people who still have a cervix need cervical screening like anyone else. Testosterone can make the sample harder to take and more likely to be unclear; asking for a smaller speculum, or self-sampling where available, can help.
Prostate. Trans women keep their prostate even after vaginoplasty. Prostate cancer appears to be less common on estrogen, but it is not impossible, and the usual PSA blood test reads lower on estrogen, so some doctors interpret it differently.
Ovaries and uterus. If they are still in place, they still need the same attention to symptoms as anyone else's. Bleeding that returns after periods have stopped on testosterone is worth reporting rather than waiting on.
Bowel. Bowel screening applies at the usual age whatever your hormones; check you are still on the list after a record change.
At your next GP appointment
Ask what screening you are due for based on the organs you have, and whether the practice can make sure you are invited. In some systems you have to ask to be added manually.
Getting older on HRT
There is no set age at which people stop taking hormones. Many prescribers adjust doses as people get older, and some move older patients towards lower doses or transdermal estrogen because of clot risk. On testosterone, doses are sometimes adjusted in line with what would be typical for a cisgender man of the same age.
Other medicines become common from middle age, such as blood pressure tablets, blood thinners and diabetes medicines, and some interact with hormones or with spironolactone, which already lowers blood pressure and raises potassium. Make sure every doctor who prescribes for you knows about your hormones, and your hormone prescriber knows about everything else.
Stopping hormones entirely in older age, for anyone who has had their gonads removed, is similar to going through menopause with nothing to replace it: hot flushes, mood changes and bone loss. That is sometimes the right choice, and it is a decision to make with a prescriber, not one to drift into because a repeat prescription lapsed.
Hospitals and care homes not used to older trans patients may hold medication records that do not match what you take. Keep your own list of what you are on and why.
Keeping your records when things change
Over decades, most people change prescriber at least once, and many move country. The new prescriber starts with whatever you hand them; arrive with nothing and you may be restarted on cautious doses and a fresh round of baseline tests.
What is worth keeping, in one place you control:
- Every blood result, with the units, the reference range and when you last dosed before the draw
- What you have taken, in what form and dose, and roughly when each change happened
- Any operation that changed your hormones, such as orchiectomy, vaginoplasty or hysterectomy with the ovaries removed, with the date and the hospital's discharge summary
- Bone density scans and screening results, with the reference group or programme used
Moving country adds snags. Units change, and how to read your hormone blood results has the conversions. Your patch or injection may not exist under the same name, or at all. And prescribing rules differ, so find out how the new system works before your supply runs low. Getting hormones covers the main access routes, and travel, moving and keeping your supply covers the move itself.
Before you change prescriber or move
Ask for a printed or PDF copy of your results and a short letter setting out what you take and since when. It takes your current prescriber a few minutes and can save you months with the next one.
Questions research is still answering
Research is still working on:
- How the risks of today's medicines and doses compare with the older ones many long-term studies were based on
- What happens to heart and cancer risk over thirty or forty years on HRT, especially for people who started young
- How ageing interacts with hormones in people in their seventies and beyond
- The long-term effects of lower-dose and non-binary regimes, including microdosing
None of this is a reason to avoid hormones. The benefits for people who need them are well documented, and most of the risks are manageable with monitoring. It is a reason to keep going to routine appointments, and to lean on sources that are clear about what is and isn't yet known.
Frequently asked questions
Does HRT cause osteoporosis?
Not usually. A stable dose of estrogen or testosterone protects bone; long gaps with too little of either are the risk, especially after the testes or ovaries are removed. See bones.
Does estrogen increase the risk of blood clots?
It can, especially as tablets and alongside smoking, age or other risk factors. Feminizing hormone risks covers it in detail.
Do trans women need prostate checks?
The prostate stays even after vaginoplasty, so it is worth asking your doctor. PSA results read differently on estrogen. See cancer screening for the organs you have.
Do trans men still need cervical screening?
Yes, if you still have a cervix. See cancer screening for the organs you have.
What should I take with me when I change prescriber?
Your blood results with units and dose timing, a list of what you have taken and when it changed, and details of any surgery that affected your hormones. See keeping your records.