Gender affirming hormone treatment
This booklet is a simple guide to help you get started on gender affirming hormones in the simplest way possible.
It aims to give patients a solid foundation of knowledge, to help you make the best decisions for yourself, and to help you advocate for yourself with your healthcare provider. This guide is read over 10,000 times each year.
Whatever the process in your region, and whatever your age, the first step is usually your GP or sexual health clinic.
Guidelines
At 2023 there are no official national guidelines, however the commonly used guidelines are called the Guidelines for Gender Affirming Healthcare for Gender Diverse and Transgender Children, Young People, and Adults in Aotearoa New Zealand (2018).
There is a checklist at the end of this booklet, developed by Gender Minorities Aotearoa, based on international best practice and the best medical frameworks globally.
You can find comprehensive information at genderminorities.com, including clinical guidelines, consent forms, and more.
In New Zealand, gender affirming hormone treatment is usually carried out in alignment with the World Professional Association for Transgender Health (WPATH).
WPATH is a slow moving and somewhat conservative body, which admits that international best practice is often ahead by the time new standards of care are published.
The current WPATH standards of care (v8, published 2022) require the following to initiate hormone treatment.
WPATH standards of care v8 (SoC8)
These are the WPATH SoC8 recommendations for adults, unless ‘suggestion’ is stated.
If your GP is confident
If your GP is confident, they can give you information at your first visit, assess whether you’ve understood the info and are able to make your own healthcare decisions, and accept your informed consent
They may need to ask some standard health questions and run some blood tests, but should be able to proceed with a prescription at this point.
Medically speaking, they do not typically need to wait for your blood test results as complications are extremely rare. and individual patients can be contacted if they need to discontinue the medication.
Technically they can carry out the checklist at the back of this booklet and prescribe for you at the first visit.
This is international best practice, as provided by Planned Parenthood Great Northwest (USA).
There are consent forms on our website, though these are not technically required..
In reality, many GPs haven’t done this before and don’t feel confident.
They may ask you to see a psychologist to assess whether you can give informed consent, and/or an endocrinologist for blood tests. However, unless there is a reason to believe you are not capable of making your own healthcare decisions, or you have other known health complications, you shouldn’t need to see one of these specialists. Your primary provider (such as your GP) should provide this care.
Working with your healthcare provider
Gender affirming hormone therapy can be a long-term process, so it’s important to build a healthy relationship with your healthcare provider. Whether you end up working with an experienced provider, or with one who has never met a transgender person before, having rapport with your provider can help you get the best care that is available to you.
Don’t be afraid to ask them to explain things to you, or justify their reasoning, or to ask to try a different medication.
Not all healthcare providers have the knowledge or experience to optimally provide you with hormones, nor are the most common pathways and treatments the best for everyone. Your provider may not know about the availability of certain medications, they may not be aware of publicly funded treatments, or they may not know about the common side effects of the medicines they prescribe.
This may mean that your own personal knowledge of the process and treatments available could be the difference between optimal and non-optimal care.
It is important that both you and your provider work to build a relationship that facilitates open two-way communication. This helps to facilitate addressing any problems that may arise with treatment,.
It is also important that your provider is committed to providing you with the safest and most effective treatment, tailored to your needs.
If your healthcare provider is not open to tailoring your treatment to best benefit you, you may need to provide them with the most up to date Guidelines for Gender Affirming Healthcare in Aotearoa New Zealand, or to seek a different provider.
Youth
After age 16, patients have the right to make healthcare decisions for themselves, and the same right as adults to use informed consent..
People aged under 16 can also give informed consent to the extent that they are able to understand and make healthcare decisions. The Gillick Competency framework is sometimes used to determine their capacity to understand and consent.
“Consent requires the cognitive capacity to understand the risks and benefits of a treatment and the potential negative and positive outcomes. It also requires the ability to retain that information for the purposes of making the decision (using aids as necessary) as well as the cognitive ability to use that understanding to make an informed decision” – WPATH SoC8
However, people aged 16 or 17 will usually go through whichever process is available to adults in their region, or the one available to people aged under 16 years.
For people aged under 16 years, the process is different depending on their age, regional pathways, individual providers, and parental support.
Gender Minorities Aotearoa advocates for a ‘harm reduction’ model that removes barriers to care, but currently it can be challenging.
The current recommendation is to use the Guidelines for Gender Affirming Healthcare. (2018).
Initial discussion with your healthcare provider
First, establish how they can show basic respect for your gender. Be clear with your provider about the sex/gender you were assigned at birth, whether you are intersex (if you know this), and what your actual gender (or ‘gender identity’) is. Tell them how you like to be referred to (she, he, ko ia, they, etc).
Next, it may help if they know it’s not a passing idea – if you’ve felt this way for a long time, tell them.
They may ask about your support system, such as whether you have supportive family or friends, whether you currently present to the world as your gender (or if you are ‘out’), whether you have any history of substance use, or whether you have any mental health issues such as depression or anxiety.
These are all standard lines of questioning. While you can probably guess the ideal answers, none of the less ideal answers should prevent you from being prescribed hormones.
The only “hard nos” are hormone-sensitive cancers (such as testicular cancer).
Your provider is likely to ask for a blood test, check your blood pressure, carry out cardiovascular and respiratory exams, and ask some other physical health questions.
Some providers may recommend weight loss prior to starting treatment. However, no amount of dieting is generally effective long term, with over 90% of diets failing to produce long term weight loss.
Managing other risk factors is a much more attainable goal – consider reducing or stopping smoking, alcohol and other drug use, supporting your health by drinking lots of water every day, getting enough sleep, getting enough food, and managing vitamin and salt intake to support your liver, heart, bone health, and circulation.
It’s all about weighing risks vs. benefits, so lower your risk factors and be sure to tell your healthcare provider how positively hormone treatment will impact your life!
Let your provider know that you understand all the possible effects of hormone treatment.
Include your mental health – such as relief of anxiety, feeling more comfortable, reduction in stress – and the physical effects too, discussed later in this booklet.
Include both the positive and possible negative effects.
Show them that you have a holistic and realistic understanding.
Discuss with them your intended journey and where you want to be. For example you may want to take hormones and have voice coaching but not have surgeries, or you may only want hormones in order to be allowed Genital Reconstruction Surgery (though this is not technically required).
Fertility preservation should also be discussed.
There is no one right or wrong way to transition, and accessing medical treatments is becoming simpler as more people transition in a variety of ways.
Categories of medicine
There are two main categories of medicine involved in treatment:.
The first category is “blockers”, which pause puberty, suppress testosterone in adults, or stop certain hormones from affecting your body. Blockers are fully reversible – if a patient stops taking blockers, their natural hormones will begin to affect their body again. These can be prescribed from the start of puberty.
The second category of medicines are often referred to as “gender affirming hormone treatment” or “hormone replacement therapy” (HRT), and consist of various sex hormones which add effects to your body.
Some of these can also do the job of blockers, eliminating the need to take blockers completely.
Sex hormones are usually prescribed from age 14-16, though there is emerging medical evidence which suggests it may be best to begin earlier, as would naturally occur at the onset of puberty.
Forms of administration
Some hormone treatments are available in multiple forms, or can be taken in multiple ways. These different preparations and delivery methods can have an effect on how well the medicine works, its side effects, and its risks. It’s good to be aware of what options are available to you and how one medicine, its preparation, or delivery method might be better for you than another.
Some forms of administration are:
| Injection | into either muscle or fat |
| Pellet implant | usually injected into fat |
| Patch | stuck to and absorbed through the skin |
| Pill | swallowed orally, dissolved under the tongue sublingually, or absorbed rectally via suppository |
| Topical | applied to the skin as a gel or cream |
Availability and cost
It may be useful to be aware of which medicines for HRT are available in Aotearoa, and whether or not they’re funded for NZ citizens and permanent residents. Medicines are not usually funded for people visiting NZ on a temporary visa.
Ask your healthcare provider, or check whether a medicine is available using the Medsafe website (medsafe.govt.nz).
You can see whether a medicine is funded using the pharmaceutical schedule website (pharmac.govt.nz/tools-resources/pharmaceutical-schedule).
If you request a particular form of the medicine (for example, you prefer injections rather than pills), these may not be funded. However, your doctor can still prescribe them so long as you are willing to pay for them yourself, and they are available in New Zealand, or you can import them using an international pharmacy which ships to New Zealand.
If a medicine you’ve been prescribed is no longer funded by the government, the funded brand of the medicine may have changed, so your doctor will need to update your prescription accordingly.
If you cannot afford the medicine that has been prescribed to you, you may be able to have it funded through Work and Income NZ (WINZ) on a disability allowance.
You do not have to be unemployed or disabled to do this. It is also possible to get other transition-related treatments such as laser hair removal or electrolysis funded through this pathway (see the health section on our website for more information).
Blockers
Puberty blockers
Gonadotropin Releasing Hormone Agonists (GnRH agonists) – or ‘puberty blockers’, suppress or pause puberty changes.
Puberty blockers are safe and fully reversible, and do not affect long term fertility. They have been used for decades to treat Precocious Puberty (early puberty at 6 or 7 years old) in cisgender children.
These are generally Leuprolide (Leucrin, Lucrin, or Lupron) by intramuscular injection (usually every 3 months), or Goserelin (Zoladex) chip implant (usually every 10-12 weeks).
These are prescribed to people who are starting puberty, and are funded up to the age of 16.
“this treatment is fully reversible, it is regarded as an extended time for adolescents to explore their gender identity by means of an early social transition” – WPATH SoC8
Blocking Testosterone in adults
The sex hormone testosterone can be ‘blocked’ or ‘suppressed’ using puberty blockers as above, or by using anti-androgens – sometimes referred to as “T blockers”.
T-blockers should not be taken long term without a replacement sex hormone, as sex hormones are vital for bone health (among other things), and the risk of osteoporosis increases the longer an adult patient is without sex hormones.
T-blockers
Cyproterone Acetate (brand names Androcur, Procur, or Siterone), is a commonly prescribed anti-androgen pill, usually taken orally on a daily basis. Note that while much higher doses are often prescribed, 25mg is usually a sufficient dose and generally shouldn’t be exceeded unless testosterone suppression is insufficient.
Micronised Progesterone (brand names Utrogestan or Prometrium), a pill taken regularly, usually orally, sublingually, or rectally. It can have testosterone suppressing effects but is not commonly prescribed for this sole purpose.
Spironolactone (brand name Spiractin), is a pill taken orally daily. Much like Cyproterone, Spiro is also commonly prescribed. Some studies have linked taking Spironolactone with a higher likelihood of seeking breast augmentation surgery.
Bicalutamide (brand names Binarex, Bicalox, or Cosudex), is a pill taken daily orally. Bicalutamide has fewer side effects compared to other anti-androgens.
The Monotherapy Method (oestrogen-only therapy) is another option for blocking testosterone. With a pmol/L of 367.09 (the minimum level recommended by The Endocrine Society), many trans women do not need blockers. With a pmol/L level of 734.19 (the high end of the range recommended by The Endocrine Society) most trans women do not need blockers.
To gain these levels of oestrogen through oral administration, a patient would need to take a dose that would likely present risks for their liver function. However, other methods (such as injections) bypass the liver.
Many healthcare providers in NZ are unaware that injectable oestrogen can be obtained by prescription from compounding pharmacies, and that bioidentical oestrogens do not pose the same health risks as synthetic oestrogens. Therefore they are often unwilling to prescribe for the recommended pmol/L levels, or use the monotherapy method.
5alpha-reductase inhibitors – or ‘DHT blockers’, prevent testosterone from being converted into the more powerful androgen dihydrotestosterone. DHT causes scalp hair loss, and preventing its production can help regrow a receding hairline. These include:
Finasteride (brand names Propecia, Ricit, or Finpro), is a pill taken daily orally. Some people have reported strong negative side effects on mental health.
Progesterone (brand names Utrogestan or Prometrium), is a pill taken daily, usually orally, sublingually, or rectally. Progesterone is also available in a cream which can be bought from compounding pharmacies, and administered to the hairline.
Blocking Oestrogen and menstruation in adults
The sex hormone oestrogen can be ‘blocked’ or ‘suppressed’ using puberty blockers, as discussed. For adults, sex hormones are necessary, so continued use of blockers long term without taking testosterone is not advised.
If a patient is taking testosterone (discussed overleaf), they no longer need to take (GnRH) agonists as the testosterone will suppress their natural oestrogen.
However, birth control is still necessary. Progesterone based Long Acting Reversible Contraceptives (LARCs) such as Depo provera, Jadelle, or an IUD or IUCD are suitable forms of contraception.
Sex hormones
Taking Oestrogen & Progesterone
The sex hormone oestrogen (also known as estrogen or “E”) is a primary sex hormone. Progesterone is sometimes taken in addition to oestrogen, to enhance breast development and assist in regrowing hair.
These hormones are available in the following forms:
Oestradiol Valerate (brand name Progynova), is available as a pill, usually taken orally or sublingually, and can be taken rectally. This is usually taken daily. It is also available as an injection taken every 3-7 days in either gluteus muscle or subcutaneous tummy fat, that can be ordered from a compounding pharmacy with a prescription.
Micronised Oestradiol Hemihydrate (brand name Estrofem), is available as a pill taken daily, usually orally or sublingually. Because it is micronised, Estrofem is especially good for sublingual delivery.
17beta-oestradiol (brand name Estradot), is available as a patch, usually re-applied twice a week.
Progesterone is a secondary sex hormone which some people take in addition to oestrogen. Progesterone enhances breast development in cisgender women and causes “gynocomastia” (breast development) in cisgender men. However, due to a lack of trans-specific research, there is currently no medical indication for progesterone in treating trans women. As a result, most healthcare providers in NZ will not prescribe progesterone.
Progesterone is available in NZ as micronised Progesterone (brand names Utrogestan or Prometrium), a capsule pill which can be taken orally, sublingually, or rectally. Progesterone is also available in a cream which can be bought from compounding pharmacies. Oral delivery is not recommended as it can have a greater chance of causing side effects such as drowsiness, and sublingual delivery can be hard due to the bad taste of the oil in the capsule.
Progesterone is sometimes taken cyclically (referred to as “cycling”) i.e. for a set duration of days every month, in combination with lowering the dose of oestrogen during this period, in order to mimic the ovarian secretion of the hormone as seen in menstruating people. Some endocrinologists have indicated that this method is very effective, however some people find that cycling can cause side effects such as mood swings.
Due to the current difficulty of obtaining a prescription for progesterone, some patients import it without a prescription and self-medicate, however this is not recommended. If a patient does do this, they are still entitled to have their hormone levels monitored by a healthcare provider, and it is recommended to have regular blood tests.
“Previously used conjugated estrogens have been abandoned in favor of bioidentical estrogens.” – WPATH SoC8
Tests for people taking estrogen or progesterone
Annual blood tests: Electrolytes – monitor more frequently if on spironolactone, LFT HbA1c – if risk factors suggest indicated, Lipids – if risk factors suggest indicated, Oestradiol – aim for normal female range (The Endocrine Society recommends target 367.09 pmol/L to 734.19 pmol/L), Testosterone (aim for level < 2 nmol/L).
Taking testosterone
The sex hormone testosterone (also known as “T”) is a primary sex hormone. Adequate levels of testosterone also usually suppress oestrogen and prevent monthly bleeding, however there is still a possibility of becoming pregnant while on this treatment.
Testosterone is available in the following forms:
Testosterone (brand name Androderm), is available as a patch re-applied daily. It’s common for the skin around the patch to feel irritated.
Testosterone is also available as a non-branded injection into muscle or subcutaneous fat (SubQ) from compounding pharmacies such as Optimus Health and CompoundLabs. The advantage of this option is higher concentrations can be ordered than those that are fully funded, meaning that the volume of liquid injected is much smaller.
Testosterone esters (brand name Sustanon), are available in combination as an injection into muscle or subcutaneous fat, usually administered every 2-3 weeks.
Testosterone cipionate (brand name Depo-Testosterone), is available as an injection into muscle or subcutaneous fat, usually every two weeks. Subcutaneous injections are often easier and less risky to administer than intramuscular.
Testosterone undecylate (brand name Reandron), is available as an injection into muscle every 10-12 weeks. This is usually administered by a healthcare provider, and patients are not permitted to self-administer.
Dihydrotestosterone – or ‘DHT’, is a more powerful androgen than testosterone. It can be topically applied directly to the genitals to increase growth. However, the cream is not available in Aotearoa and should not be used without the supervision of a qualified professional.
Tests for people taking testosterone
FBC – every 3 months in first year, then 1-2 times yearly, LFT HbA1c – if risk factors are indicated, Lipids, Testosterone (aim for normal male range).
Physical and physiological changes
Overleaf are the main physical and physiological changes which you need to be aware of before discussing with your provider. The lists are not exhaustive.
There are also psychological, emotional, spiritual, and social changes to consider.
The charts of changes and times which you may have read online are always somewhat inaccurate, as the effects of hormone treatment are very different from person to person, and the time at which different changes may occur or complete are even more so.
For example, many charts will say breast growth on oestrogen will stop after 2 years, but many transfeminine people report breast growth happening up to 10 years after starting, sometimes with changes in medications or doses..
Because of the variability from person to person, we have not included expected time frames.
Managing your expectations is important. Transition looks different for every patient, and it’s important to remember that puberty takes time – usually around 7 years to completely finish. However, if you’re getting notably unsatisfactory results from your treatment, making changes to your lifestyle, medication, delivery method, or dosage amount may improve your results.
Estrogen based treatment
| Change in body scent and sweat smell | More fat in lips |
| Decreased production of sperm and ejaculatory fluid | Slower growing and finer face and body hair |
| Decreased libido and ability to have erections, though erectile function can usually be maintained if desired | Decrease in muscle and redistribution of body fat to hips, thighs, buttocks, and breasts |
| Breast growth | Slowed or stopped scalp hair loss |
| Softer skin | Change in genitals – erections may become less firm, decrease in testes size, penis may become smaller and change shape, becoming more like a clitoris |
Testosterone based treatment
| Change in body scent and sweat smell | Deeper sleep and increased snoring (heightened risk of sleep aponea) |
| Increased libido | Facial and body hair growth – thicker, darker, and more |
| Increase skin oil and acne | Scalp hair loss |
| Increased ejaculatory fluid | Increase in muscle, and redistribution of fat from buttocks, hips, and thighs to tummy |
| Lighter or absent menstruation | Decreased vaginal lubrication, thinning of vaginal tissues, vaginal canal may shorten |
| Voice cracking and dropping | Genitals change – clitoris may become larger and change shape becoming more like a penis |
Getting the right support
Most providers will want to be supportive, even if they’re not sure how to support you. In these cases, providing information to them can help.
Gender Minorities Aotearoa has a web page of comprehensive healthcare resources, research reports, and information at genderminorities.com. There is also a database of trans-friendly healthcare providers by region.
Remember that even if it’s frustrating, unfair, discriminatory, or takes a long time, you will have an easier time in the long run if you keep your cool. If something needs to change, making a complaint is better done in writing than in the heat of the moment.
You are also entitled to a second opinion. This isn’t always easy to get, you may live rurally, have limited time or other resources, and yes, you shouldn’t have to. However, if you’re not getting anywhere, a well written formal complaint can be effective, and if your complaint is not addressed, it can be used to make a complaint to an external body such as the Health and Disability Commissioner.
For a faster solution in some cases, a change of provider may be the simplest course of action. A supportive healthcare provider is everything.
Appropriate health care is a human right, and you are legally entitled to get the right health care. Don’t give up! It may take time but you will get there.
For more in depth information, ideal doses, friendly doctors in your area, or to talk with us, please see our website genderminorities.com or get in touch.
Checklist for initiating gender-affirming hormone treatment
This checklist is for your GP, and is based on international best practice.
These are the questions you should expect.
References
Checklist for initiating gender affirming hormone treatment (2022)., Gender Minorities Aotearoa.
Code of Health and Disability Services Consumers’ Rights – Health and Disability Commissioner.
Australian Informed Consent Standards of Care for Gender Affirming Hormone Therapy (2022)., Australian Professional Association for Transgender Health.
A Primary Care Toolkit (2023)., Trans Care BC Provincial Health Services Authority.
Guidelines for Gender Affirming Healthcare (2018)., Jeannie Oliphant, Jaimie Veale, Joe Macdonald, Richard Carroll, Rachel Johnson, Mo Harte, Cathy Stephenson, Jemima Bullock, David Cole, Patrick Manning.
Endocrine Treatment of Gender-Dysphoric/Gender-Incongruent Persons: An Endocrine Society Clinical Practice Guideline (2017)., Wylie C Hembree, Peggy T Cohen-Kettenis, Louis Gooren, Sabine E Hannema,Walter J Meyer, M Hassan Murad, Stephen M Rosenthal, Joshua D Safer,Vin Tangpricha, Guy G T’Sjoen.
Standards of Care for the Health of Transgender and Gender Diverse People, Version 8, (2022) International Journal of Transgender Health, 23:sup1, S1-S259, DOI: 10.1080/26895269.2022.2100644 E. Coleman, A. E. Radix, W. P. Bouman, G. R. Brown, A. L. C. de Vries, M. B. Deutsch, R. Ettner, L. Fraser, M. Goodman, J. Green, A. B. Hancock, T. W. Johnson, D. H. Karasic, G. A. Knudson, S. F. Leibowitz, H. F. L. Meyer-Bahlburg, S. J. Monstrey, J. Motmans, L. Nahata, T. O. Nieder, S. L. Reisner, C. Richards, L. S. Schechter, V. Tangpricha, A. C. Tishelman, M. A. A. Van Trotsenburg, S. Winter, K. Ducheny, N. J. Adams, T. M. Adrián, L. R. Allen, D. Azul, H. Bagga, K. Başar, D. S. Bathory, J. J. Belinky, D. R. Berg, J. U. Berli, R. O. Bluebond-Langner, M.-B. Bouman, M. L. Bowers, P. J. Brassard, J. Byrne, L. Capitán, C. J. Cargill, J. M. Carswell, S. C. Chang, G. Chelvakumar, T. Corneil, K. B. Dalke, G. De Cuypere, E. de Vries, M. Den Heijer, A. H. Devor, C. Dhejne, A. D’Marco, E. K. Edmiston, L. Edwards-Leeper, R. Ehrbar, D. Ehrensaft, J. Eisfeld, E. Elaut, L. Erickson-Schroth, J. L. Feldman, A. D. Fisher, M. M. Garcia, L. Gijs, S. E. Green, B. P. Hall, T. L. D. Hardy, M. S. Irwig, L. A. Jacobs, A. C. Janssen, K. Johnson, D. T. Klink, B. P. C. Kreukels, L. E. Kuper, E. J. Kvach, M. A. Malouf, R. Massey, T. Mazur, C. McLachlan, S. D. Morrison, S. W. Mosser, P. M. Neira, U. Nygren, J. M. Oates, J. Obedin-Maliver, G. Pagkalos, J. Patton, N. Phanuphak, K. Rachlin, T. Reed, G. N. Rider, J. Ristori, S. Robbins-Cherry, S. A. Roberts, K. A. Rodriguez-Wallberg, S. M. Rosenthal, K. Sabir, J. D. Safer, A. I. Scheim, L. J. Seal, T. J. Sehoole, K. Spencer, C. St. Amand, T. D. Steensma, J. F. Strang, G. B. Taylor, K. Tilleman, G. G. T’Sjoen, L. N. Vala, N. M. Van Mello, J. F. Veale, J. A. Vencill, B. Vincent, L. M. Wesp, M. A. West & J. Arcelus.
Links
pg/mL to pmol/L converter
CompoundLabs compounding pharmacy
Optimus Health Compounding Pharmacy
Comprehensive Healthcare Information