Hormone Replacement Therapy for Transgender Women

Core Treatment Components

The American College of Physicians recommends transdermal 17β-estradiol patches (50-100 μg/24 hours) as first-line therapy due to lower cardiovascular and thrombotic risk compared to oral preparations 1, 2
Transdermal administration avoids hepatic first-pass metabolism, minimizing impact on hemostatic factor synthesis and providing superior safety profiles regarding blood pressure, lipid metabolism, and inflammatory markers 1
The standard anti-androgen in the United States is spironolactone, typically dosed 100-300 mg daily in divided doses, with a target testosterone suppression to <50 ng/dL (female reference range) 1, 2

Initial monitoring should include checking testosterone and estradiol levels after 1-3 months of therapy initiation, and every 3-6 months during the first year 1
Annual monitoring after stabilization is recommended, including regular assessment of liver function, lipid profile, and hemoglobin/hematocrit 1

Breast development typically begins within 3-6 months, and body composition changes with increased fat mass and decreased muscle mass 2, 3
Skin softening, decreased body and facial hair, decreased libido, and reduced erectile function are also expected physical changes 2, 3

Transgender women have consistently elevated risk of venous thromboembolism compared to both cisgender men and women, even with modern estradiol preparations 2, 4
Transdermal estradiol significantly reduces thrombotic risk compared to oral formulations 1

Testosterone suppression therapy (spironolactone) should generally be continued perioperatively 2, 4
Estradiol therapy continuation versus cessation requires individualized risk-benefit discussion, as routine discontinuation lacks supporting evidence and may cause psychological harm 2, 4