FOLX uses an informed consent model to provide our members with gender-affirming hormone therapy (GAHT, sometimes known as HRT). We know that many people starting HRT have been thinking about this decision for awhile. Many have done their own research and discussed this with other folks on HRT.
Our responsibility is to provide as much clear information on the benefits, risks, alternatives, and explanations as possible before someone makes a decision. With an informed consent model, there is no requirement that a mental health provider assess whether or not a patient is a candidate for hormone therapy.
When signing up for estrogen at FOLX, we need our members to understand and acknowledge the information below to get started. But don’t worry: no one needs to make these decisions on their own if they don’t want to. Your first visit is a chance to speak with a FOLX clinician about the information below, and more.
When starting estrogen with FOLX, members agree that they understand the following:
Overview:
Gender affirmative care is tailored to each individual and their unique gender development and identity. Gender affirmative hormone therapy (GAHT), or hormone replacement therapy (HRT), is one aspect of many options used to affirm a person’s internal gender identity and gender expression in the world. Over the almost 100 years that HRT hormone replacement therapy has been around, there is a growing body of medical evidence that consistently, persistently, and insistently demonstrates their usefulness, effectiveness, and safety.
The 17-B estradiol used in GAHT is the same estrogen that ovaries make. You can choose the route by which you “deliver” this estrogen to the bloodstream, where it begins to circulate throughout the body to find tissues and cells with estrogen receptors. When the hormone estradiol connects with an estrogen receptor, it starts a whole series of changes that begin the cell, tissue, physical and neurologic changes that are a part of hormone therapies.
The following consent materials are based on current medical evidence that we use when patients elect to start estrogen based GAHT at FOLX. Medical evidence changes over time, and the medical care we provide at FOLX will stay aligned with these evidence based updates. Individuals who want to receive a prescription for estrogen, anti-androgens, and/or progesterone from FOLX agree that they have read, understand, and consent to the following:
- Some changes caused by estrogen based GAHT are permanent, while others are reversible.
- The effects of estrogen based GAHT vary from person to person and depend on many factors.
- There may be some common side effects and rare adverse events when using estrogen based GAHT, but for most people the benefits outweigh the risks when taking these medications with medical supervision.
Our clinicians are happy to answer any questions you have related to GAHT during your video visits.
Benefits
Permanent changes
Most permanent changes take some time to occur. If any of the following changes occur for you, they are permanent and would not go away even if you stop taking hormones.
- Breast growth and breast tissue
- Potential for decreased testicular volume and decreased fertility
Reversible changes
Many changes go away or lessen if you stop taking hormones. Most of these changes are desired and well tolerated. If you have questions or concerns about any changes, you can discuss directly with your clinician in your video visit.
- Changes in body fat and fat redistribution (more fat in the buttocks, hips and thighs)
- Decreased muscle mass, strength, and muscle definition
- Softer and less noticeable body and facial hair (hair can only be eliminated/removed with interventions such as electrolysis or laser hair removal)
- Softer, less oily skin
- Changes in libido (sex drive)
- Changes in erectile function (more difficult to get, stay hard; orgasm and ejaculate is different; sometimes pain with ejaculation)
- Changes in moods or emotions (contact our clinicians if these are disruptive to your daily life)
- Subtle changes in cholesterol panel (LDL, HDL improvements; increased TG); lower risk for problems with blood pressure and cardiovascular disease
Length of time it takes hormones to work
The effects and outcomes for estradiol and other affirming medications take time and vary from person to person. Changes start in the first three months but may continue for 2-3 years. Different changes take different amounts of time to start and to reach maximum effect. Both the rate and degree of changes depends on many factors such as: how you take your hormones (do you take them regularly and as instructed, dosage); age you start hormones; general health and genetics. Estradiol will not change vocal pitch; but voice therapy and vocal coaching can help with that. Estradiol will not change bone/skeletal structures, so does not change height, shoulder width, hands or feet size.
Risks
Most people take these medications because they need them. We find that for most people the benefits far outweigh the theoretical and actual risks or bad outcomes. All medications might have some risks. Below are the more serious but much less common risks seen when taking these medications.
- Gender hormones are metabolized and broken down by the liver. Severe liver failure might cause problems with hormone metabolism.
- Cause small, treatable and NOT cancerous cell growth in the pituitary gland in the brain, called prolactinoma
- Increase a person’s risk for blood clots in the veins that travel to the lungs or brain, causing pulmonary embolism or stroke. Your personal risk depends on your genetics and family history as well as lifestyle issues such as age, cardiovascular risks, tobacco/nicotine use, general health including weight and exercise.
- Create a small, but statistically significant increase in breast cancer risk, that does not seem to translate into many more cases of actual breast cancer.
Estrogen and fertility
Taking estradiol over time could lead to smaller testes and infertility. If you want to use your sperm to have genetic children, we recommend saving sperm while you are young and before using estradiol. Taking estradiol does not work like birth control. If you do not want a pregnancy, you should use birth control when needed to prevent pregnancy.
Migraine with aura
A different type of estrogen used in birth control pills seems to increase risk of stroke in cis women with classic migraines (preceding aura, scotoma, and neurologic changes). The estradiol hormone in gender care has less risk for blood clots and stroke. If you have these types of headaches, make sure your clinician knows, but yes, you can use estradiol for gender care. We also recommend that you monitor your migraines and let us know if they worsen while taking estradiol.
Thyroid hormone levels
Estrogen impacts the thyroid gland and visa versa. If you have an underactive (hypothyroidism) or overactive (hyperthyroidism) thyroid, we recommend that you have extra monitoring for changes in your thyroid hormone levels and medication doses.
Additional Medications & Considerations
Estradiol is the single most important feminizing hormone, changing your body inside and out. There are other medications that we use to help support or maximize your goals.
Spironolactone
Spironolactone is a medicine that blocks androgens or male hormone receptors on hair and skin. It helps lessen face, body hair, skin oil and acne. It is a diuretic, working through the kidney, causing you to urinate more, retain potassium, and lower your blood pressure. We check potassium and creatinine labs during your care to make sure using spironolactone does not impact your kidneys and electrolytes. We do not recommend using this medication if you have chronic kidney dysfunction or very low blood pressure. Some people discontinue spiro because they notice they do not like the side effects of urinating too much or feeling "foggy" headed with spiro.
Finasteride and Dutasteride
Finasteride and dutasteride block the conversion of testosterone into an even more potent male hormone. We use this medication to prevent head hair balding and potentially decrease face and body hair. These medicines are safer to use than spiro in people with kidney problems or low blood pressure. We do not need to follow blood work. They are associated with erectile dysfunction and possible depression and suicidality in cis gender men.
Progesterones
Progesterones, another ovarian hormone, are used to potentially improve: breast size and shape, lower body fat distribution, skin and hair, mood and libido. There is no hard science as to how well these medicines work; but they appear to be safe and beneficial to many patients. Progesterone has some sedative-like effects that might be useful for people with anxiety or difficulty falling asleep. Medroxyprogesterone injections have been found to increase appetite or cause some changes in moods; the oral version may have less of these side effects.
Mood changes
All of the medications can actually impact how you think and feel. Taking GAHT usually leads people to feeling "relief," "happier,'' more confident, and more congruent with who they know themselves to be. Estradiol can lead to more expansive moods, bigger ups and downs, more tearfulness, a different sex drive and sexuality. Spiro can lead to some foggy headedness and finasteride/dutasteride has been associated with erectile dysfunction, depression and suicidality in cis men. Know that you can discuss these changes any time with your clinical team if you have questions or concerns.
Allergic reactions
People do not have allergic reactions to estrogens or testosterones. They exist in all bodies. But, people can have allergic reactions to the substances in the vehicle which delivers the medication. Minor foreign body or local allergic reactions can happen because of the sesame or cottonseed oil bases. These present as small, red, irritated bumps at the site of injection. They can be managed with ice, benadryl, or ibuprofen. People with allergies or anaphylactic reactions to the preservative benzoate in injections or peanut products in progesterone (prometrium) should not use these medications. Please contact us if you notice a rash or skin swelling. If you experience lip or tongue swelling, trouble breathing, or feel like your throat is closing up, this is a medical emergency and you should contact 911. Stop taking any new medications that could be the source of the allergic reaction.
Alternatives
For some people, gender is a fluid and changing aspect of their identity. There are many ways to affirm your individual gender identity. There are alternative methods not currently provided by FOLX Health that you may want to explore. Alternatively, there may be a time when you choose not to continue taking estrogen. We respect that you know your body, your identity and your needs better than anyone. Please feel free to talk with a member of the FOLX team if you have any questions or concerns.
And that’s that.
With the different routes and dosages of estrogen, there are a lot of ways to find the one that fits best for each individual body. For those ready to get started with FOLX for estrogen, the process begins here. And for those who’ve got some more questions about our informed consent approach or getting started, reach out to support.folxhealth.com.
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FOLX Health is the first digital healthcare company designed by and for the LGBTQIA+ community. Our services include virtual primary care, gender-affirming hormone therapy including estrogen and testosterone (HRT), mental health care, sexual and reproductive health care, preventive care, and fertility consultations. FOLX memberships give you access to LGBTQIA+ expert clinicians, peer support, thousands of LGBTQIA+ resources, and more. Whether you’re lesbian, gay, bisexual, transgender, queer, gender non-conforming, or nonbinary, you can find LGBTQIA+-specialized health care that helps you meet your wellness goals. FOLX Health is health care that's queer all year. Get all the benefits of becoming a FOLX member and sign up today!
