Hormone replacement therapy for trans women is safe and well-studied, but good monitoring matters. Most doctors focus on hormone levels and miss the wider picture: cardiovascular risk, bone density, and haematocrit all need watching too. Knowing what to ask for puts you in control of your own care.
Why the conversation about monitoring is so often incomplete
People tell me the same thing, over and over. They have started oestrogen, they are making progress, they feel more like themselves, and then at their next appointment the doctor checks their oestradiol level, says it looks fine, and sends them on their way. That is it. No lipids, no blood pressure discussion, no mention of bone density, no conversation about what the coming years of monitoring should look like.
This is not malice. It is a gap in training. General doctors were not taught trans-specific care at medical school, and many still have not filled that gap. The international guidelines, particularly the WPATH Standards of Care 8 and the Endocrine Society guidelines, are detailed and evidence-based, but they do not automatically translate into what happens in a ten-minute appointment. So the job of knowing what good care looks like often falls to you, the person taking the hormones. That is not how it should be. It is, however, how it is for a lot of people right now, and I would rather you were prepared for it.
What HRT for trans women actually involves
The standard approach combines oestrogen with an anti-androgen, at least in the early stages, to suppress testosterone and allow feminising changes to develop. Oestrogen is typically given as a patch, gel, or injection, since oral oestradiol is processed through the liver in a way that raises certain cardiovascular risks slightly. Anti-androgens vary by country: cyproterone acetate is widely used in Europe, spironolactone is common in North America, and bicalutamide is increasingly used as an alternative. Some people also use a progestogen as part of their regimen.
None of these are exotic medications. Oestrogen and progesterone are bio-identical hormones. Spironolactone is a well-established blood pressure medication. Cyproterone has been used for decades. The pharmacology here is familiar; what is less familiar to many clinicians is its application in trans care, which is why the monitoring conversation needs to be explicit.
Hormone levels: what you are aiming for and how to read your results
Oestradiol and testosterone are the headline figures, and they do matter. The Endocrine Society guidelines suggest aiming for oestradiol levels in the mid-follicular range typical for cisgender women, roughly 100 to 200 pmol/L, though individual targets vary and the right level for you is something to discuss with your prescriber. Testosterone should ideally fall into the female reference range.
What the headline figures do not tell you is whether your method of delivery is working consistently. Injections, for example, produce peaks and troughs: a level drawn on the wrong day can look wildly different from one drawn at the optimal point. Patches and gels give more stable levels but absorb differently depending on skin type, placement, and sweating. Knowing when in your cycle to test, relative to your dose or application, is genuinely important for interpreting your results, and many people are never told this.
The tests most doctors do not mention
This is the part I want to spend time on, because it is where monitoring most often falls short.
Haematocrit and full blood count
Haematocrit measures the proportion of your blood made up of red blood cells. Testosterone tends to raise it, which is why it is monitored carefully in trans men on testosterone. In trans women it is less commonly discussed, but it remains a baseline worth tracking, particularly in the early months when your anti-androgen is still establishing suppression. A full blood count also picks up early signs of things entirely unrelated to your hormones, which is a reason to do it routinely rather than only when something feels wrong.
Liver function
Some anti-androgens, particularly cyproterone acetate at higher doses, can affect liver enzymes over time. This is not a reason to avoid them, but it is a reason to check liver function at baseline and at intervals. If you are on oral oestradiol rather than transdermal, the first-pass metabolism through the liver is an additional reason to monitor. Most people on patches or gels do not have concerns here, but it is still worth including in your annual check-up.
Lipid panel
Oestrogen tends to have a favourable effect on lipid profiles: it generally raises HDL (the protective cholesterol) and can lower LDL. But the overall picture depends on your baseline, your weight, your family history, and whether you are on any medications that interact with lipid metabolism. A lipid panel at baseline and then every couple of years is reasonable, and if you have cardiovascular risk factors, more frequently. This is basic preventive medicine that many trans women are not having.
Blood pressure
Spironolactone lowers blood pressure, which is part of why it works as an anti-androgen and part of why it needs watching. Cyproterone can also have cardiovascular effects at higher doses. Checking blood pressure at every appointment is straightforward and costs nothing; it is surprising how often it does not happen.
Prolactin
Oestrogen can raise prolactin levels, and cyproterone does so particularly strongly. Elevated prolactin over a long period is associated with benign pituitary changes. This is not common and it is not a reason to avoid these medications, but prolactin should be checked at baseline and at least annually if you are on cyproterone. If levels are elevated and rising, your prescriber may want to adjust your regimen or refer you for further investigation. Most people are never told to ask about this.
Bone density
Oestrogen protects bone density in the same way it does in cisgender women. If your levels have been well-maintained and consistent, your bones should be fine. The concern arises when there have been prolonged gaps in treatment, inconsistent levels, or a period of low oestrogen without adequate replacement, which can happen if testosterone suppression is incomplete or treatment is interrupted. A DEXA scan (a low-dose X-ray that measures bone density) is worth discussing if any of those apply to you, or after several years on HRT as a baseline check.
Timing and frequency: a rough framework
There is no single universal schedule, and your individual circumstances matter more than any generic timetable. That said, the general shape of monitoring that most guidelines support looks something like this: hormone levels and blood pressure checked at every significant dose change and at three to six month intervals in the first year, then annually once you are stable. Liver function, full blood count, and lipids at baseline and at least annually. Prolactin at baseline and annually if you are on cyproterone. Bone density discussed at your five-year review or earlier if there have been treatment gaps.
The word "annually" is doing a lot of work in that paragraph, and I want to name that clearly: annual monitoring only works if you actually have an annual appointment, and for a lot of trans women, consistent access to a knowledgeable prescriber is the harder problem. If you are between providers, or managing a gap in care, keeping a note of what was last checked and when gives you something concrete to hand to whoever sees you next.
What to do if your doctor is not offering this
Ask for it by name. "Can we also check my liver function and prolactin today?" is a reasonable, specific request that most doctors can act on without needing specialist knowledge. If you are met with uncertainty about why you are asking, pointing to the Endocrine Society guidelines or WPATH Standards of Care 8 is entirely appropriate. These are internationally recognised clinical guidelines, not fringe documents.
If your doctor is consistently unable to support your monitoring needs, a specialist provider is the better option. GenderGP can help with the medical side of trans care, including prescribing, monitoring, blood tests, and the ongoing clinical oversight that makes HRT genuinely safe over the long term. Access to a doctor who knows this area well is not a luxury; it is the standard of care you deserve.
The bigger picture: this is long-term care
Many people approach HRT as something that happens in the first year and then settles into the background. In some ways that is right: once your levels are stable and you feel well, the day-to-day management is not heavy. But the monitoring that protects your long-term health requires a little sustained attention, and the trans women I hear from who feel most confident about their care are the ones who understand what is being checked and why.
You do not need to become a clinician to navigate this well. You need to know enough to ask the right questions and to notice when something is not being offered. The checklist above is a starting point for that conversation, not a substitute for a prescriber who knows what they are doing. The two things together, your informed engagement and a clinician who takes trans care seriously, are what make this work properly.
If there is a topic that you would like me to cover, just let Sammy know.
Dr Helen Webberley is a Gender Specialist and advocate for trans healthcare, and the founder of GenderGP. She works in advocacy, education and public engagement, promoting understanding of gender diversity.
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