Informed Consent Considerations for Estrogen HRT

Everything to know to make an empowered decision with estrogen HRT.

Estrogen tablets packaging.

FOLX uses an informed consent model to provide our members with hormone replacement therapy (HRT). We know that folx starting HRT have been thinking about this decision for awhile. Many have done their own research and discussed this with other folx on HRT.

Our responsibility is to provide as much clear information on the benefits, risks, alternatives, and explanations as possible before someone makes a decision. With an informed consent model, there is no requirement that a mental health provider assess whether or not a patient is a candidate for hormone therapy.

When signing up for a FOLX estrogen HRT membership, we need our members to understand and acknowledge the information below to get started. But don’t worry: no one needs to make these decisions on their own if they don’t want to. Your membership includes the option to speak with a FOLX clinician about the information below, and more.

When starting estrogen with FOLX, members agree that they understand the following:

Permanent changes

If any of the following changes occur for you, they are changes that are permanent and will likely not go away even if you stop taking estrogen:

  • Breast growth
  • Decreased testicular volume / decreased fertility

Reversible changes

If any of the following changes occur for you, they are changes that usually go away or lessen if you stop taking estrogen:

  • Body fat redistribution (more fat in the buttocks and thighs)
  • Decrease in strength and muscle definition
  • Softer and less noticeable body hair (the body hair you have never goes away with hormones)
  • Softer skin
  • Decrease in libido
  • Less or no erectile function
  • New or different moods (contact our clinicians if these are disruptive to your daily life)

Health risks

The biggest concerns with estrogen are blood clots, heart attacks, and strokes. Blood clots happen in the veins in the legs (DVT) or lungs (PE) can be deadly. Adding progesterone may increase those risks. Estrogen may also:

  • Increase the amount of fat and/or cholesterol in the blood
  • Increase blood pressure
  • Increase the chance of diabetes
  • Harm the liver
  • Increase the chance of gallbladder problems
  • Cause or worsen migraine headaches
  • Cause pituitary tumors (small gland in the brain)
  • There isn’t a lot of research on the long-term risks of Estrogen for HRT, so there may be other risks that we don’t know about yet.

Your personal risk depends on your genetics (health problems that are inherited). You may be at higher risk for blood clots, heart attacks, strokes, or cancer if the family you are biologically/genetically related to has a history of:

  • Blood clots: DVTs (deep vein thrombosis) or PE (Pulmonary embolism)
  • Heart attacks or strokes
  • Breast cancer

Progesterone

Progesterone may increase the risks that come with taking estrogen, particularly blood clots, strokes, and heart attacks. Progesterone may also cause increased appetite and weight gain*.

*FOLX believes in Health at Every Size (HAES) and never believes weight gain to be a bad thing!

Spironolactone

Spironolactone also works as a diuretic (water pill), so it may lower your blood pressure and make you urinate more. If you take too much of it, it may cause kidney damage. 

This medication can increase the amount of potassium in your blood. In normal amounts, potassium is not harmful to you. However, when it becomes too high, it can cause changes in your heartbeat that can be life-threatening. We will be monitoring this potassium level regularly for you to make sure it stays in a safe range. 

Spironolactone often decreases libido/sex drive. Spironolactone will also decrease your fertility. There is controversy on whether or not starting spironolactone early in transition may limit breast development.

Finasteride and Dutasteride

For folx who have a prostate organ, these medications can slow the growth of prostate cells. These blockers may also decrease libido/sex drive or affect sexual function. 

Length of time it takes hormones to work

This depends on your starting dose. If you start with a low or average dose, it can take about three months to notice a change. Each change takes varied amounts of time to start and to reach maximum effect. Some changes take years to reach maximum effect. This is dependent on many factors--your dosage, the age you started hormones, your genetics. For instance, if you start hormones later in life, you may not see the same kind of changes as a younger person since sex hormones affect tissues of older folx in more subtle ways. 

How long do I need to take hormones?

This is your decision. To keep the non-permanent changes to your body, you will need to take your hormones for life.

The longer you're on hormones, the lower a dose you might need. For folx who have their testes removed, you may want to or be able to take a lower dose of estrogen and/or stop taking a testosterone-blocker.

Estrogen and fertility

Taking estrogen and androgen-blockers will most likely decrease your fertility, while on and even after discontinuing use. If you have your testes, pregnancy is possible while you are on estrogen and androgen-blockers.

We recommend birth control for you and/or your partner if you are having the type of sex that can lead to pregnancy and do not want to cause one. If it is important for you to use your own sperm to make a pregnancy, please talk to your clinician.

And that’s that.

With the different routes and dosages of estrogen, there are a lot of ways to find the one that fits best for each individual body. For those ready to get started with FOLX for estrogen, the process begins here. And for those who’ve got some more questions about our informed consent approach or getting started, reach out to support@folxhealth.com.