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.
The research here is thinner than it should be. 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 rather than pretend.
I am not a doctor, and this is information, not advice. The point of this page is to help you 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.
Some prescribers arrange a bone density scan (often called a DEXA scan) for people with risk factors, such as long gaps without hormones or after gonad removal. 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
This is the area with the most research and the most mixed picture.
On estrogen, the best-known risk is blood clots, especially with estrogen tablets and in people who smoke, are older or have other risk factors. Transdermal estrogen, patches and gel, is generally considered to carry less clot risk than tablets, which is one reason many prescribers prefer it for older people. Some studies have also suggested higher rates of stroke and heart attack in trans women on estrogen than in the general population, though how much of that is the hormones and how much is other factors such as smoking and older medicines is not settled.
On testosterone, the main concerns are a rising hematocrit, changes in cholesterol similar to those seen in cisgender men, and blood pressure. Whether that translates into more heart disease over decades is not clear from current evidence.
For both, the things that make the biggest difference are the ordinary ones: not smoking, blood pressure, cholesterol, weight and exercise. Those are also the things a GP can check at any routine appointment.
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, which means trans people are often invited for tests they do not need and missed for ones they do.
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.
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.
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.
Health systems that are not used to older trans patients can be a practical problem in hospitals and care homes, where medication records may not match what you actually take. Keep your own list of what you are on and why.
What is still not known
It is worth being plain about the gaps. Research has not yet answered well:
- 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 be wary of anyone, for or against, who talks about the long term with more certainty than the evidence supports.
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. See bones.
Does estrogen increase the risk of blood clots?
It can, especially as tablets and alongside smoking, age or other risk factors. Patches and gel are generally considered lower risk. See heart and circulation.
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.