Mental effects of HRT

[Elizabeth G]

If my decision to transition were to affect only myself I would be on that path now but but among other complications I have a wife who didn't sign up for this so to speak. That being said I am considering a short trial period of HRT (about three months) as a means to evaluate the mental effects but short enough so the physical effects aren't irreversible.

Currently I find that gender related thoughts occupy an enormous amount of mental real estate and it is only increasing as time matches on. Concentration can be difficult and it is affecting my work and other aspects of my life as well.

So my question to the group is, during your initial period of HRT how did it effect you from a mental standpoint?

Thank you,
Elizabeth

[Nikki.]

It definitely reduced the constant thoughts about being a woman, and reduced the negative thoughts and feelings about not being a woman, aka dysphoria. it took about two weeks. whether or not this was a placebo effect, or actual physical/chemical effect in the hormone/neurotransmitter soup of my brain, I’ll never know. I do know that after 3.5 years, how i think and perceive, and how i experience emotions has definitely changed.

[Aunt Kelly]

Estrogen is not a psychoactive substance. Period.

Yes, there is some documentation that long-term use can produce changes in the brain, but to my knowledge there have no studies on how that might affect the psyche of a trans person.

All that said, do not underestimate the effect that the very act of embarking on a course of HRT will have. While not exactly the placebo effect, there are many here who have related significant relief of their GD very early on. Nikki has confirmed the effect (if not the chemistry) and I can say the same.

[IamWren]

I found a study from 2019 that suggests otherwise. It can be found here:

Effects of Estradiol Therapy on Resting-State Functional Connectivity of Transgender Women After Gender-Affirming Related Gonadectomy
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6692765/

In the conclusion statement of the study it does acknowledge that mental health turning positive could be (as Kelly states) because of simply starting cross sex hormone therapy however it also says:
“ Although these improvements can be partially assumed to be a consequence of the reduction of the body incongruence once CSHT has started, they might also owe to changes in functional connectivity of areas involved in emotions and cognition.”

And I can tell you from personal experience, that after having been on cross sex hormone therapy for more than a year and then stopping for a month… it took about three weeks for me to turn back into a raging jerk and I KNEW it was going to be a temporary stop. I knew I would be going back on the Femme n M’s. There was something DEFINITELY going on in the chemical and electrical firing in the lump of meat inside my noggin.

I still contend I had very little if any dysphoria. I didn’t desperately want to physically change my body toward being female. I didn’t hate my male body… I was simply indifferent.

I sat on my prescription for estrogen for a month and a half. And when I finally started, I continued to question whether it was the right thing to do. So for me, it was NOT placebo or psychosomatic.

There is something in that little pill that is scrambling my brain up in such a way that I am now no longer indifferent about my body but really like what I see. I cry… at crazy, silly dumb things that I normally wouldn’t have given a second thought toward. And I’m nicer. I’m a nicer person than when I had a testosterone based body.

There may not be conclusive studies that say it is a psychoactive substance but for me…

it’s done something to my brain for the better.

[Nikki.]

hrt has definitely affected my consciousness and how i perceive the world. my sense of humor has changed, there is a subjective softness to my perceptions that wasn’t present before, my emotions are more labile and i feel different. this was apparent before i came out as well. i had to stop hrt before ffs and perceived a change as well.

[HelpMe,Rhonda]

I definitely felt a mental relief within days of starting HRT, and since I had read mostly medical site explainers about what HRT can do, had no idea that it was possible to feel such a thing so fast, so not sure if that's a placebo effect. Was only expecting mental relief would come after enough physical changes had happened, so was thinking months or years and not days.

I described the change at the time that there was a relaxation of a tension that I must have felt so long that it didn't even register until it disappeared.

Went online looking to see if what was happening was even possible, and gradually found other anecdotes of people feeling something like that.

Months, now years, in, and who knows if it's the HRT or just being halfway out of the closet, but I'm told I'm happier by people who know or don't yet know, I can laugh out loud for real instead of just muttering, 'that's funny' when amused, and I'm way more social than I used to be.

[Aunt Kelly]

Correlation and causation are two very different things. Nevertheless, they are commonly conflated, and from this springs the belief (in this case) that the medication is the cause for this or that emotional change. It is not, and there is, again, no clinical study that supports the notion that it is, especially in the short term. HRT, like many other measures, is prescribed to treat gender dysphoria by producing physical changes in the patient. Those changes typically take many months, or even years to fully manifest.

So how do we explain the rather common accounts of emotional changes in the short term? Correlation. Concurrent with the beginning of the first "real" steps being taken to align one's body with one's gender identity is a change in emotion. Emotion is a complex and powerful thing. It is influenced by so many things, so why is it so hard to accept that these other things are the actual cause?

[HelpMe,Rhonda]

Hadn't realized there was enough clinical studies to say that there is no causation. The Journal of the Endocrine Society wrote about it last year, saying more research was needed, but...

Despite the limitations of the available evidence, however, our review indicates that gender-affirming hormone therapy is likely associated with improvements in QOL, depression, and anxiety. No studies showed that hormone therapy harms mental health or quality of life among transgender people. These benefits make hormone therapy an essential component of care that promotes the health and well-being of transgender people.

[Katya@]

Hi Elizabeth,
I have been on this journey 5+ years. What I can say is that thoughts themselves about gender, still occupy a larger portion of my mental real estate as you put it. I think it what makes me a trans person. I would never be a cis-gender person who doesn't thinks about their gender. The key difference for me from before and after are the kind of thoughts. I do not feel helplessness, despair, anger, etc. I feel happier, calmer, and can concentrate on my work. With time, my brain shifted a bit a became very sensitive to how others see me. Whether they dead name me or not, use the right pronouns or not, and whether socially accept me as a woman or not. It just I'm more sensitive to this and the self consciousness remains. This results in some emotional setbacks but also full of small moments of gender euphoria.
But again, I am still on this journey and it is just something I am getting used to. However, I would never want to return to where I was before the transition, as dysphoria was really crippling at times.
Good luck!

[Charla]

I’ve been less angry and more agreeable, according to my wife. I feel more at ease and less anxious.

[Lana Mae]

I don't know about the research, but I am the happiest I have ever been! My mind is more clear! Placebo effect or not I don't care! I am happy where I am! Hugs Lana Mae

[April Rose]

Wren! "Femme n M's"You're killing me!

[Dorit]

"Estrogen acts everywhere in the body, including the parts of the brain that control emotion. Some of estrogen's effects include: Increasing serotonin, and the number of serotonin receptors in the brain. Modifying the production and the effects of endorphins, the "feel-good" chemicals in the brain."

I brief quote from one of the many online articles about the effects of hormones on emotions.

[Nadine Spirit]

Over those first three months I generally just felt better than I ever had. No physical changes happened. I could have easily stopped and I would have had no long term effects. My three month experiment showed me that I didn't ever want to stop having E be my main hormone.

Being as this is not a scientific journal or outlet, and people are asking for anecdotal experiences, my story is that I felt that change in my hormones on day one. I didn't suddenly feel more feminine nor did I suddenly grow boobs, but I felt something. It wasn't huge, and overwhelming, but subtle and under the surface. Something was different. That is really the best I can describe it, I could feel a difference. I didn't even feel the very first tingle of possible breast buds until about three months in, but I for sure felt something on that first day. It was such an undeniable feeling that I knew by the end of that first week that I would never go back.

Good luck to you Elizabeth, I wish you my best in your journey of self discovery.

[Devi SM]

I think that's no needed to go for research and complicated mental studies or estrogen effects on the brain.

Many trans report great emotional changes. In fact, HRT help to stop suicides.

In my case, I had a problem waking up in the middle of the night, always around 3 am, with big fears for whatever in turn could be, religious, financial, social, work, etc. Since the very first day of the HRT I sleep like a baby.

You can say placebo, I thought it too but i feel great.

At week eight, after seeing the evident boobs were growing, I quit of hormones, just one week and i had to go back again on them.

Those night wake ups keep from time to time, now .the fear of the future as a woman were the disrupters but that's dissapeared, fully whole nights sleeping well.

I do t need toention the happiness from the satisfaction on living as my real me because that's a n effect of the changes and no and effect of the hormones..

Good luck...

[Katya@]

A friend recently explained, when I recounted that I cry more easily (pain, emotional movie scenes, you name it), "You do that because you've given yourself permission to feel that way, the way women have always been allowed to feel." That explanation borders on the glib when considered against the complex web of changes that come with embracing our true gender identity, but I believe that it's a far more plausible explanation than some imagined effect of a well-studied drug.

Not only I gave myself permission to cry before hormones, I wanted but I couldn't. Not even on funerals of my close family members I loved. I felt something is wrong with me, that I some kind of heartless person. My emotions were mute, to even offer a hug to comfort. ALL of that has changed. I was crying a lot when our friend's child died in an accident. I am getting emotional watching movies and have tears. My first thought is to offer a hug to someone who I think may want one. It comes naturally too now. Call it a long term effect of hormones (noticed some time into it, not right away of course) or whatever you want, but this just is for me (and I love it).

[HelpMe,Rhonda]

Oh I was always a crier, if not a laugh out loud-er, so crying has just upped its game since I started.

Lucky to grow up in a family where being 'sensitive' was OK, even if no one ever guessed what was going on deeper inside-even if it took me decades to figure out wanting to wake up the next day a girl (and later on a woman) just might possibly mean you're trans and not just a crossdresser.

[sarahcsc]

If my decision to transition were to affect only myself I would be on that path now but but among other complications I have a wife who didn't sign up for this so to speak. That being said I am considering a short trial period of HRT (about three months) as a means to evaluate the mental effects but short enough so the physical effects aren't irreversible.

Currently I find that gender related thoughts occupy an enormous amount of mental real estate and it is only increasing as time matches on. Concentration can be difficult and it is affecting my work and other aspects of my life as well.

So my question to the group is, during your initial period of HRT how did it effect you from a mental standpoint?

Thank you,
Elizabeth

Hi Elizabeth,

I've got patients like you who would like to 'experiment' with HRT as a way to move forward because they feel very stuck for whatever reason. Generally speaking, I'd encourage them to go ahead because any tiny experimental step is a tiny step towards knowing oneself.

In your case, the only thing I'd point out is this: Taking HRT for 3 months will probably affect very little (if any) physical changes. Therefore, any changes in the way you feel are likely due to a placebo (or nocebo) effect. In other words, regardless of how you feel, it is most likely due to a psychological rather than a biological change.

The pros of taking HRT for just 3 months is that you can always stop it, return to your baseline, and nothing would have changed. The cons? Well, NOTHING would have changed.

You don't have to experiment with HRT to find out if it will affect how you feel because you are already guaranteed to feel something by virtue of the placebo/nocebo effect. Why conduct an experiment to find out something you already know?

Most people want to experiment with HRT because they want to know what biological changes will ensue and how they might feel about those changes, not the other way around.

Taking it for 3 months, in my opinion, is not harmful or beneficial, except it is kinda pointless. If you really want to know if HRT is right for you, try taking it for 12 months. Most of the changes brought on by HRT within 12 months are reversible, except for breast growth. Therefore, you can stop your experiment before 12 months is up depending on how comfortable you feel with your breast development.

Again, I'm not stopping you with your experimentation, I'm just recommending a better way to go about it. You should of course discuss this with your wife and endocrinologist before proceeding.

Yours,
S

[Aunt Kelly]

Thank you, Sarah, for sharing your learned point of view. In your opinion, is the risk of adverse effects low enough to be an inconsequential consideration in "experimenting" in this way?

[HelpMe,Rhonda]

I asked a friendly endocrinologist about how dangerous HRT is and the answer, paraphrased, "NO. NO. It's not significantly dangerous when done correctly by a appropriate clinician, it's not dangerous. It's just making a person have the hormones they should have always had. No more dangerous than any other medicine. Oxygen has side effects. Water has side effects. Everything has side effects. We weigh the benefits and the risks and HRT is not significantly more dangerous than any other medication."

[Dutchess]

I don't know about that at all.. I tend to agree with Aunt Kelly about the side effects as the result of so many years of hrt was a contributing factor to my fiances death. Though not the primary , it would've led to his death in the near future without medical intervention( this was part of the medical examiners notes ) but he was so convinced he needed it that he never would've checked anything like that.

A few years before total meno, I had HAD to be on progesterone I had such severe problems so this was mandatory to avoid hysterectomy, I was just way too low. Yet my ob/gyn was adamant I stay on no longer than 5 years due to side effects.

[Aunt Kelly]

The question was about relative risk, as in "Is the risk worth it if I'm just 'experimenting'". As you have observed, no drug is without side effects and adverse events. Adverse events include stroke, heart attack and deep vein thrombosis. While rare, these are potentially lethal complications. Yes, they are relatively rare, but what reasonable person would take on such risk without being fully committed to achieving the desired effects? There is an alarming trend here, which is not only attributing magical properties to HRT, but is also treating it as no more impactful than a course of antibiotics.
No, I am absolutely not trying to be a gatekeeper here. I believe firmly in the "informed consent" model. Being informed means acknowledging the potential benefits, risks, and limitations of the course of therapy in question. Not seeing a lot of that in these threads, and as a former health care provider, I find the trend concerning, at best, and dangerous, at worst.

[sarahcsc]

The question was about relative risk, as in "Is the risk worth it if I'm just 'experimenting'". As you have observed, no drug is without side effects and adverse events. Adverse events include stroke, heart attack and deep vein thrombosis. While rare, these are potentially lethal complications. Yes, they are relatively rare, but what reasonable person would take on such risk without being fully committed to achieving the desired effects? There is an alarming trend here, which is not only attributing magical properties to HRT, but is also treating it as no more impactful than a course of antibiotics.
No, I am absolutely not trying to be a gatekeeper here. I believe firmly in the "informed consent" model. Being informed means acknowledging the potential benefits, risks, and limitations of the course of therapy in question. Not seeing a lot of that in these threads, and as a former health care provider, I find the trend concerning, at best, and dangerous, at worst.

You are right that the informed consent model of care is gaining favor but there will always be reservations about it for the reasons you mentioned. This is not to say there isn't a role for gatekeeping because I will still advise against prescribing 10x the recommended dose of estrogen just because my patient is wanting it. However, the risk of someone developing severe adverse effects when taking the recommended dose is still exceeding small. I compare this to the risk of getting into a major car accident when driving to work. Yes, the risk is present and potentially fatal, but one still has to work to put food on table.

If you want to start a conversation about informed consent, then just start it on another thread. I have delivered tutorials nationwide about 'informed consent' to educate people on this topic. It is very nuanced and most people misunderstand what it means on a practical level.

S

[Nikki.]

I wasnt “fully committed”. I was miserable though, and decided to “experiment” with a low dose and see what happened and see how i felt about it. and while i had some anxiety about the changes, and stopped for a week or two, I decided to press on.

[sarahcsc]

Thank you, Sarah, for sharing your learned point of view. In your opinion, is the risk of adverse effects low enough to be and inconsequential consideration in "experimenting" in this way?

Hi Kelly,

I wouldn't say anything is 'inconsequential' to avoid the risk of invalidating a patient's experience. Every change, no matter how big or small is consequential depending on the patient's perspective.

The research (https://core.ac.uk/reader/153399329?utm_source=linkout) published by the endocrine society states that most bodily changes of feminizing hormones takes a least 3 - 6 months to trigger the onset of change, and up to 2 - 3 years for maximum change to occur. Therefore, I recommend 12 months because it allows for at least some meaningful change in one's body before considering their next treatment options.

Risks and adverse effects are a part of life when taking any medication. Yes, one might theoretically develop a DVT 2 weeks into HRT but that doesn't mean the trial shouldn't have proceeded since we cannot predict the future. It is fine as long as the patient is informed of the risks before proceeding.

I'm not someone who is very overly eager in prescribing hormones because I understand this is a heavy and consequential decision. But when I do, I want to make sure my patients are making meaningful decisions that will ultimately lead to some kind of closure. To me, taking HRT for 3 months on its own not only accomplishes very little, but it could be a reflection of severe resistance or ambivalence which is usually a red flag. Having said that, I never say never to my patients so I always hear their stories out before deciding a way forward.

For example, I have a group of non-binary patients who really don't want the full effects of HRT and therefore only take a small dose of it for x number of months then stopping it. That's fine too.

Having said all this, I'd like to point out that HRT may have a very different effect on biological women because they have more estrogen receptors. I've treated a number of patients with PMDD who had a variable response to HRT despite only taking it for a week or two. I bring this up so to avoid the risk of misleading everyone into believing that HRT does NOT affect mood in the short term, because it does. The immediate mood effects HRT has on transgender women, however, is not well documented.

I hope this helps.

S