Six Things They Don’t Tell You About Long-Term HRT

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As adolescents continue to adopt transgender identities at record numbers, a spotlight has been placed on hormone replacement therapy (HRT), with many touting it as a potential cure-all for children struggling with gender dysphoria. This treatment, once reserved for menopausal women and rare medical conditions, is now increasingly being used on people not old enough to legally vote, despite the lack of long-term studies on this cohort. As a result, a growing movement of detransitioners is now pushing back and speaking up about the hardships they’ve faced after years of these experimental treatments.

Because the very existence of detransitioners does not fit the popular rosy narrative that depicts transitioning as a ubiquitously positive experience, the personal stories of detransitioners are almost universally ignored or mischaracterized as rare exceptions to the rule. Or they’re politicized, leaving their voices buried in the rubble of the culture war. But the growing number of in-depth writings about the damage puberty blockers and HRT can inflict on the developing adolescent body are becoming impossible to ignore. Despite these clear warning signs, the number of children being diagnosed and medically “affirmed” as transgender continues to rise unabated.

Since nobody can seem to muster the time or energy to listen to the negative experiences of detransitioners who took cross-sex hormones, perhaps some will listen to my own negative experiences taking supplemental same-sex hormones to treat my damaged endocrine system. After all, if it’s not all sunshine and rainbows taking hormones your body has naturally evolved to handle in large doses, why should we assume uniformly positive experiences for those who supplement with hormones their bodies were not naturally evolved to handle?

I hope that my simple and honest breakdown will outline exactly what is at stake when an adolescent is given puberty blockers or other experimental treatments that interfere with their endocrine systems. 

My understanding of this topic does not come from an elective medical procedure hastily and mistakenly made in my youth. Instead I became reliant on HRT because of a rare medical diagnosis at the age of 29. After experiencing amenorrhoea (not having a period) for six months, and other menopausal symptoms for over a year, I was diagnosed with premature ovarian failure (POF) just a few months before my 30th birthday.

Once diagnosed, I was instructed to begin HRT to help alleviate the discomfort of hot flashes, night sweats, depression, acne, and a low libido, as well as to lower the long-term risk factors of osteoporosis, heart disease, and an increased risk of dementia. Before my physician would prescribe me these drugs, I was required to sign a consent waiver, similar to the one seen here, which outlined the risks I would face by taking oral estrogen and progesterone. While the risks of taking HRT were frightening, I felt I had no choice but to gamble with these drugs because the inevitable deterioration of my mental and physical health without estrogen and progesterone would have been far worse.

Which brings me to my first point:

1) HRT Is Accompanied By Very Real Health Risks

After reading the consent waiver, I became filled with fear. I wasn’t even 30 years old, and the form clearly stated “it is recommended that you use that medication at the lowest possible dosage and for the shortest duration possible to minimize the associated risks,”—i.e. cancer, blood clots, heart attacks, and stroke. Yet I needed to take this medication for 25-30 years at a dose higher than is given to your average granny just to mimic what my body should have been naturally producing. My stomach churned at the thought of needing to pop pills for the rest of my life, and that night I cried after taking my first dose.

Though I’ve developed a deep sense of gratitude for modern medicine over the years, that gratitude doesn’t take away the burden of daily medications, frequent trips to the pharmacy, regular blood tests, and continued care from multiple specialized physicians. And the need to continuously tweak my dosage or medication brand in response to my ever-changing physiology is exhausting. 

Consenting to a lifetime of hormone therapy is not a decision that I took lightly, but my options were limited. This is why it is so hard for me to imagine children half my age with healthy bodies and sound minds gambling with their health before they’re even old enough to fully comprehend their own mortality. I picked the lesser of two evils and tried to believe these pills would allow me to return to normal with little variation in treatment moving forward, but reality quickly dashed these hopes. 

2) Infertility Can Be Treated But Never Cured

As a teenager I never desired to be a parent. When I told my parents that I wanted to have my tubes tied and be done with it, they warned me that I’d meet the right person one day and change my mind. Six years later, shortly after I met my husband, they were proven right. But my feelings, and subsequent change of heart, is anything but unique.

There is a reason why Planned Parenthood doesn't recommend teenagers receive tubal ligations, and Medicaid requires a consent form to be signed 30 to 180 days before a sterilization procedure. In fact, some states have age restrictions for Medicaid recipients seeking sterilization, including Massachusetts, Tennessee, California, South Dakota, and many more. The Code of Federal Regulations clearly states that sterilization of a person in the Federally Assisted Family Planning Projects can only be performed or arranged for people at least 21 years old who are not deemed mentally incompetent at the time consent is obtained.

Yet, in an attempt to provide “gender-affirming” care, medical institutions now participate in the compulsory sterilization of adolescents incapable of giving informed consent. The inability to conceive children will undoubtedly seem abstract to a child or a person who has never experienced infertility, but take it from me, the journey to parenthood can be heartbreaking and extremely painful.

After my initial diagnosis at the age of 29, my first prescription was a combination of Premarin and Prometrium, which I took for three years until I underwent IVF using an egg donor. During the year I underwent IVF, my medications were changed frequently with only the intention of sustaining a pregnancy. This included daily progesterone in oil shots using a 1.5-inch needle. I took 168 shots in total that left me with welts and temporary nerve damage in my glute muscles. It was a torture that I wouldn’t wish upon my worst enemy. In the end I was rewarded with my one and only daughter, but not all IVF stories end with a live birth, nor are all adoptions successful.

Even after a baby is born to a woman experiencing infertility, the child isn’t a cure for the underlying medical condition. I tried to play the hand I’d been dealt with grace and remain grateful for modern medicine, but I was still in for an uphill battle

3) Even The Best Doctors May Not Be Able To Help

After having my daughter, I went off all HRT in order to breastfeed without passing artificial hormones to my daughter through my breast milk. This caused my menopause symptoms to return with a vengeance, and during the initial lockdown stage of the COVID pandemic, the symptoms had become unbearable. Not only was I experiencing hot flashes and night sweats, but my mood swings and anxiety were enhanced tenfold by the lack of natural female hormones necessary to maintain my mental health. Nevertheless, I powered through these symptoms for 10 months until my daughter stopped breastfeeding.

The most embarrassing symptom to surface during this time was severe vaginal atrophy. When I made the decision to wean my baby and go back on my medication, I immediately scheduled an appointment with my OB/Gyn to discuss treatment options, but since her specialty was caring for women during pregnancy, she knew nothing of my medical condition and offered no solutions. She simply renewed my old prescription from two years earlier. Though my symptoms did get slightly better, they were never fully relieved, so I toughened my mental fortitude and accepted my lot in life while trying to remain grateful for what little relief I had.

It wasn’t until listening to an episode of the Dr. Drew Podcast that I realized there were more treatment options, and I began researching doctors who could help me. Most gynecologists specialized in menopause but not pre-mature ovarian failure; therefore, they continued to prescribe the same medications to me and advised me to use lubrication during sex. A few doctors assumed I just had the “baby blues,” and promised that taking antidepressants would allow me to enjoy sex again! Discouraged yet determined, I continued my search until I found an MD in my city who specialized in vulvovaginal disorders. The waitlist was long, but after only one appointment an entire world of treatments opened up to me, and I was able to find what works best for me.

Once the endocrine system is damaged a person can no longer just go to their primary care physician as a one-stop shop for all their medical needs. Since women on HRT have a heightened risk for many other conditions, including those likely to cause infertility, they will need to see an endocrinologist and other gynecologic specialists for the rest of their life.

Endocrine damage can limit a person’s future in more ways than can often be imagined. Once a person relies on access to specialized doctors, they must not only remain fully insured at all times, but they must also remain cognizant of where they live or travel. Not every city has a specialist who can address the complex symptoms that arise from HRT, and even if there is a good doctor nearby, there is no guarantee they will be covered by insurance. Before finding a doctor in my city who could help me, I was considering flying to Washington DC and paying out of pocket just for a chance to feel better.

This is not a burden we should be asking young people to bear before they’ve fully matured. 

4) One Size Does Not Fit All

Once I found the vulvovaginal disorder specialist, I began to try new forms of HRT coupled with physical therapy and, much to my relief, they worked! Instead of just taking daily pills before bed, I had a new elaborate routine to keep up with:

• Daily AM: Thyroid pill 

• Daily PM: Progesterone pill

• Twice weekly: Estrogen patch 

• Twice weekly: Estrogen vaginal suppository

• Once weekly: Visit a physical therapist for vaginal dilator therapy 

• Thrice weekly: Vaginal dilator therapy at home 

After about six weeks of this routine my libido came back, the hot flashes disappeared, and my anxiety and mood swings subsided. I could finally sleep through the night, and I was able to have intercourse without pain. Though high maintenance, this is a routine I’m willing to do for the rest of my life because the benefits outweigh the inconvenience. But at times I feel resentful, and I long to just be a “normal” 37-year old woman.

After scouring my city for medical professionals who could help me, I was left with three separate doctors managing my hormones and health. This requires that, should I change one prescription with one doctor, I must follow up with the other two to ensure their prescriptions don’t need to be modified in response. The latest update is changing the progesterone pill to a Mirena IUD that will administer progesterone continuously. This is a necessary change because of prolonged menstrual bleeding I’ve been experiencing since receiving the Moderna COVID vaccine. If this doesn’t fix the bleeding, my gynecologist has recommended a total hysterectomy with bilateral salpingo-oophorectomy. She has never seen such heavy and prolonged bleeding with HRT, but she assured me that every patient is unique and their bodies respond to therapy differently. 

There is unfortunately no way to know how a person will be impacted by HRT before they begin the regimen. This is an accepted reality outlined in this waiver, which states: “Each person’s body responds to estrogen differently, and it is hard to promise or predict with certainty how each person may respond to treatment.” Similarly, this consent form from Cornell Health says that “Each individual person responds to testosterone differently, and it is difficult to predict how each person will respond.”

After seven years on a hormonal roller-coaster a part of me welcomes the hysterectomy if it means I will no longer have to experience the psychological symptoms of changing medication. For me, this is in every way a last resort procedure to give my life a semblance of normalcy and stability, and not something I can ever imagine a healthy adolescent girl with gender dysphoria to be able to meaningfully consent to.

5) HRT Exacerbates Mental Health Issues 

Low estrogen levels in women can lead to mood swings, anxiety, and increase the risk of dementia, so HRT may be necessary for some. However, if a person is suffering from a mental illness that is not caused by hormonal imbalances, proactively creating the hormone imbalance, such as by jumping into gender-affirming HRT, will only further destabilize them.

Another publicly available consent form from the University of Wisconsin, Madison, reads: “Changes in mood or pre-existing mood disorders such as depression, suicidal feelings, anxiety, and psychosis (disorganization and loss of touch with reality) may occur.”

As a naturally anxious person, changing my HRT routine only adds fuel to the fire, and it is coupled with extreme changes in my energy levels, patience, and perception. It’s a wonder that I’m still married. Thankfully I’m also extremely self-aware, so before every medication switch up I speak honestly with my husband so he knows to batten down the hatches for the rough seas ahead. The mood swings are one of the worst side effects and have led to feelings of doubt and caused me to mistrust of my own intuition. Fortunately my husband takes the time to talk through things with me so I can feel better—he has the patience of a saint.

With growing evidence of the two-way relationship between a diagnosis of autism and gender dysphoria, it’s reasonable to question if HRT could jeopardize the patient’s mental health by exacerbating existing mental health issues. Perhaps it would be prudent to administer less invasive forms of therapy that will address the underlying issue and not just the symptoms.

If the long-term impacts of damaging one’s endocrine system aren’t scary enough, then the short term instability of a mental health crisis should make anyone weary of electing to begin HRT. 

6) Sexual Spontaneity Is a Thing of The Past

Though I’m fortunate to have found an HRT routine that flipped my switch back on and rejuvenated my romantic life, that doesn’t mean I will ever again be carried away in a fit of passion where I am convinced to engage in the kind of exhibitionist love making detailed in a romantic novel (or a Cancun spring break party). I have come to peace with this, in large part because I had youthful fun with my husband 12 years ago. We had the chance to fall in love and share romantic trips around the world, but now we are in a different stage of our lives. 

If these symptoms had afflicted me in my early 20s, I doubt that I would have felt comfortable dating, let alone getting married. Low estrogen has not only led to a decrease in my libido, vaginal atrophy, and painful intercourse, but without HRT I lack an interest in romance of any kind. I become effectively asexual and incapable of seeing anyone through a romantic lens. Turning again to gratitude to help me face hardships, I feel incredibly lucky to have found my husband before my ovaries failed. It was the knowledge that I was married to a good man, a handsome man, a smart man, a man I loved and liked, that motivated me to seek out a specialist who would help me. There is no reason to risk this opportunity for happiness before a child is old enough to personally experience this. 

If damage is done to their endocrine system through puberty blockers and HRT, they may be robbed of one of life’s greatest joys. 

The reality of being a lifelong patient is fraught with complex trade-offs where the costs and benefits can only be approximated. My motivation for sharing my experience is not fostered by an ill-will against the medical community or people suffering from gender dysphoria. It is done with the hopes that it will serve as a cautionary tale. If gender-affirming care is really motivated by a sense of duty to the patient, then it’s time to rethink invasive medical intervention for gender dysphoric adolescents, as this path is in direct conflict with the oath many doctors take to “first do no harm.”

For parents, I would argue that structure and safety are the primary duties we owe our children. We can provide firm boundaries while simultaneously validating a child's feelings and showing them compassionate love when they struggle. Remember that sometimes the right thing to do is not popular, but we don’t need to turn a temporary phase into a lifelong medical condition.

I know most parents just want better for their children than they had for themselves, but can anyone honestly say that after reading my story they believe a life like mine is the best they can give their child? 

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Organizations to Support

• Sex Matters

• Parents Defending Education

• Transgender Trend

• LGB Alliance

• Fair Play for Women

• Society for Evidence-Based Gender Medicine

• Counterweight

• The Free Speech Union

• Heterodox Academy