Hormone replacement therapy (HRT) is often a life-changing treatment for those experiencing symptoms of menopause or looking to feminize their body. For transgender women and others taking feminizing hormones, having access to estrogen long-term can be incredibly validating and improve quality of life. However, some question if staying on hormones indefinitely could have health risks. Below we’ll go over the safety, risks, and alternatives for lifelong hormone replacement therapy.
Is it safe to stay on HRT long-term?
For most people, staying on feminizing hormone therapy long-term is safe. Guidelines generally recommend transgender women and others taking estrogen stay on hormones at least until the typical age of menopause (around ages 45-55).
There are a few key factors to consider regarding the safety of long-term HRT:
- Dosage – Taking feminizing hormones at higher doses does increase health risks. However, taking estrogen and anti-androgens at typical replacement doses is generally safe long-term.
- Age – There may be more risks associated with HRT if you start later in life. Those who begin hormones around or after menopause may consider lower doses.
- Lifestyle – Maintaining a healthy weight, not smoking, limiting alcohol, and staying active can help minimize any risks.
- Monitoring – Getting periodic bloodwork and checkups to monitor for potential side effects allows prompt adjustment if any issues arise.
Overall, current evidence suggests transfeminine people and postmenopausal women taking standard replacement doses of hormones have no increased mortality or cardiovascular risk compared to the general population. However, more research is still needed on the long-term safety of feminizing HRT extending beyond the menopausal years.
What are the potential risks of lifelong HRT?
Some potential risks can occur with long-term hormone replacement therapy, though the likelihood of serious complications is generally low:
- Cardiovascular effects – Estrogen may raise the risk of blood clots, stroke, and heart disease. However, this mainly applies to oral estrogen at higher doses taken by older individuals.
- Breast cancer – There is a small increased risk of breast cancer associated with taking estrogen long-term.
- Prolactinoma – Estrogen can rarely cause this benign pituitary tumor that elevates prolactin levels.
However, the cardiovascular and breast cancer risks associated with hormone therapy are quite small at typical feminizing replacement doses started earlier in life. For context, the increased risk of blood clots is comparable to risks during pregnancy and birth control pill use.
Regular medical checkups can help detect any potential issues early on. Your doctor may also recommend medications like aspirin or selective estrogen receptor modulators (SERMs) to help minimize risks if you decide to continue HRT long-term.
What are the effects of stopping feminizing HRT?
If you decide to stop hormone therapy after taking it for an extended time, you may experience a number of effects:
- Menopausal symptoms – Hot flashes, mood changes, vaginal atrophy
- Fat redistribution – Weight gain, more “masculine” fat patterns
- Breast development – Breasts may decrease in size over time without estrogen
- Facial changes – Facial hair regrowth, more masculine features
- Emotional changes – Potential worsening of anxiety, depression
The physical changes from stopping HRT are generally gradual, but many find the emotional effects most challenging. Some also report “menopause brain” symptoms like memory or concentration problems after discontinuing estrogen.
If you do choose to stop hormones, doing so gradually rather than abruptly can help ease the transition. You may also consider switching to a lower dose instead of quitting entirely. Discuss any concerns thoroughly with your doctor to determine the best approach for you.
Are there alternatives to lifelong HRT?
For those concerned about indefinite hormone use, there are some alternatives to consider:
Take a “hormone holiday”
This involves temporarily stopping HRT for a short period of time, such as a few months annually. This gives your body a break from exogenous hormones while minimizing long-term risks and side effects if you restart treatment.
Lower dose HRT
Reducing your estrogen and anti-androgen dosages over time may help mitigate risks while still providing feminizing effects. However, emotional effects may be more likely at lower doses.
Non-systemic estrogen
Localized treatments like vaginal estrogen, transverse penile blockers, or topical estrogen creams provide feminizing effects without raising systemic hormone levels.
SERMs
Selective estrogen receptor modulators like raloxifene or tamoxifen can help selectively activate estrogen receptors in some tissues without raising risks associated with systemic estrogen.
Regular screening
Getting regular health monitoring, like mammograms for those with breast development, may provide some reassurance if continuing HRT long-term against potential risks.
Should I plan to stay on HRT indefinitely?
There is no definitive answer, as it depends on your individual goals, health status, and risk tolerance. However, for many, lifelong hormone replacement therapy is safe and often the best option.
Here are some key questions to consider when deciding:
- How long have I been on HRT? Health risks are lower if you started hormones at a younger age.
- What effects am I hoping to maintain? Keeping feminizing effects may take higher/continued doses.
- What is my family health history? Increased cancer/clotting risks may warrant more caution.
- How are my current health markers? Concerning lipid profiles, bone density, etc. may warrant adjustments.
- What is my mental health status? For gender dysphoria, emotional benefits often outweigh risks.
Have an open discussion with your doctor weighing your goals against any personal risk factors. Many individuals find staying on feminizing HRT safely improves their mental health and quality of life long-term. But periodic evaluation ensures you and your doctor can adjust your care over time for optimal health.
Conclusion
Taking feminizing hormones long-term is generally safe for transgender women and others at typical replacement doses. While some increased health risks exist, regular monitoring and preventive care can help mitigate these risks in most cases. For those struggling with gender dysphoria, the benefits of indefinite hormone therapy often outweigh the small potential risks.
Discuss your particular situation thoroughly with a trans-competent doctor. They can help you determine if lifelong HRT is a good option based on your individual needs, risks, and values. With appropriate care and screening, hormone therapy can allow many transgender individuals to thrive indefinitely.