How to Get on HRT: Steps, Costs, and What to Expect

Getting on hormone replacement therapy typically involves a conversation with a doctor, some bloodwork, and a prescription — a process that can take anywhere from a single appointment to a few months depending on where you live, what type of HRT you need, and whether additional specialist referrals are involved. The term “HRT” covers two distinct medical contexts that share medications but differ in their goals and access pathways: menopausal hormone therapy for people experiencing menopause symptoms, and gender-affirming hormone therapy for transgender and gender-diverse individuals. Both are well-established medical treatments, but the steps to access them, the medications prescribed, and what your body goes through afterward look quite different.

Two Distinct Pathways, One Abbreviation

When someone searches “how to get on HRT,” they could mean either menopausal hormone therapy or gender-affirming hormone therapy. The clinical infrastructure treats these as separate tracks, and understanding which one applies to you determines your next steps. Menopausal HRT is prescribed to relieve symptoms like hot flashes, night sweats, vaginal dryness, and sleep disruption caused by declining estrogen during perimenopause and menopause. Four major medical societies recommend it for symptomatic menopausal women, and it is typically initiated by a gynecologist, endocrinologist, or primary care physician after a risk assessment.

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Gender-affirming hormone therapy (GAHT) uses estrogen or testosterone to align a person’s physical characteristics with their gender identity. Access varies significantly by region and clinic model. Some clinics use an informed consent model, where a primary care physician can assess your readiness and prescribe hormones without requiring a prior mental health evaluation, while others follow a referral-based model that routes you through a mental health professional first. In a large Australian study of informed consent clinics, the median time from first consultation to starting hormones was under one month when a GP handled the assessment directly, compared to about three months when a mental health referral was involved.

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The First Appointment and Medical Evaluation

Regardless of which type of HRT you are pursuing, the first appointment involves a medical history review, a discussion of your goals and symptoms, and usually blood tests. For menopausal HRT, your doctor will want to know your age, the timing of your symptoms relative to menopause, your personal and family history of blood clots, breast cancer, stroke, and heart disease. The decision to prescribe HRT requires individual assessment that weighs your age, the timing of when you start, and any existing health conditions against the expected benefits.

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For gender-affirming HRT, the evaluation covers similar ground but also includes a discussion of fertility, your understanding of the expected changes (some reversible, some not), and baseline hormone levels. At an informed consent clinic, this can happen in one or two visits. At a referral-based clinic, you may need a letter from a mental health provider before a prescription is written, which adds time. Interestingly, in the Australian study mentioned earlier, 80% of people who went through the faster GP-assessed pathway still chose to seek mental health support on their own, suggesting that informed consent doesn’t discourage people from getting psychological care — it just doesn’t force it as a gate.

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Baseline blood tests typically include a complete blood count, liver function, lipid panel, and hormone levels (estradiol, testosterone, and sometimes thyroid hormones). If you are starting menopausal HRT, your doctor may also look at clotting markers. One large study found that an elevated baseline D-dimer level was associated with a roughly six-fold increase in odds of developing a blood clot while on HRT, compared to people with normal levels at baseline.

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Menopausal HRT Medications

If you still have a uterus, you will almost certainly be prescribed both estrogen and a progestogen. Estrogen alone drives relief of hot flashes, night sweats, and vaginal dryness, but taking estrogen without a progestogen increases the risk of endometrial hyperplasia and cancer. The progestogen component is there to protect the uterine lining.

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If you have had a hysterectomy, estrogen alone is typically sufficient. The specific progestogen matters. Micronized progesterone (sometimes called “body-identical” progesterone) has been shown to prevent endometrial hyperplasia from estrogen while also helping with vasomotor symptoms and quality of life.

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Estrogen comes in several forms: oral tablets, transdermal patches, gels, sprays, and vaginal preparations. The choice of delivery method isn’t just about convenience — it affects your risk profile in meaningful ways, particularly around blood clots. This is covered in detail further on.

Feminizing Hormone Therapy

For transgender women and transfeminine people, the standard regimen is estradiol (a natural estrogen) plus an anti-androgen to suppress testosterone. Estradiol alone often isn’t enough to bring testosterone levels into the typical female range, so an additional blocker is usually needed.

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The most commonly used anti-androgens vary by country. Spironolactone is widely prescribed in the United States at doses up to 400 mg daily. Cyproterone acetate, used heavily in Europe and Australia, can be effective at doses up to 100 mg daily. A systematic review found that cyproterone acetate and GnRH agonists like leuprolide may be more effective than spironolactone at driving down total testosterone.

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Breast development is often the change people are most eager to see. In a multicenter study that tracked transwomen over their first year of hormone therapy, most breast growth happened in the first six months. Over the first three months, breast-chest difference increased by about 1.8 cm, followed by another 1.3 cm from months three to six. After that, growth slowed considerably, adding only about half a centimeter over the remaining six months. After a full year, the average increase was 3.7 cm from baseline.

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Other feminizing changes — softened skin, redistribution of body fat, reduced body hair growth, and decreased erectile function — develop more gradually over months to years. Some of these changes are reversible if you stop treatment; breast tissue growth generally is not.

Masculinizing Hormone Therapy

For transgender men and transmasculine people, the primary medication is testosterone, delivered via intramuscular injection, subcutaneous injection, transdermal patch, or topical gel. Expected changes include voice deepening, facial hair growth, increased muscle mass, fat redistribution, cessation of menstruation, and clitoral growth. Voice changes and facial hair growth are among the first things people notice, usually within the first few months, though full effects can take years.

One important side effect to watch for is erythrocytosis, an increase in red blood cell concentration. This is a well-recognized consequence of testosterone therapy and can raise the risk of blood clots if it goes unchecked. Monitoring hemoglobin and hematocrit levels before starting testosterone and periodically afterward is standard practice.

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Mood and Emotional Changes

Hormone therapy affects your emotions, and the nature of those changes depends on which hormones you are taking. For menopausal HRT, the progestogen component can cause cyclical mood shifts. In one study, women on combined estrogen-progestogen therapy experienced negative mood and physical symptoms peaking during the late progestogen phase, with positive mood during the estrogen-only phase.

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The type of progestogen also matters. A comparison of two common regimens found that women on one combination reported more depression, irritability, and tension than women on another. Both groups developed side effects during the first week, including breast tenderness, swelling, and depression, but the severity differed between regimens.

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For people on gender-affirming hormones, a recent study tracked day-to-day mood variability before and after starting GAHT. People who started masculinizing hormones (testosterone) showed decreased variability in tense and restless feelings over the first year, moving toward a pattern that more closely resembled cisgender men. People who started feminizing hormones showed increased variability in low mood and restlessness, moving toward patterns typical of cisgender women. This doesn’t mean feminizing hormones make you unhappier — it means the emotional texture of your daily experience shifts to align more with the hormonal profile you’re moving toward.

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Why the Route of Estrogen Matters

This is one of the most underappreciated practical decisions in HRT. Whether estrogen enters your body through a pill or through the skin makes a real difference to your blood-clot risk. Oral estrogen passes through the liver before reaching the rest of the body (the “first-pass effect”), and this liver processing activates clotting factors. Transdermal estrogen — patches and gels — bypasses the liver and enters the bloodstream directly.

A randomized trial in postmenopausal women found that oral estradiol caused measurable decreases in several procoagulant variables and a significant increase in fibrinolysis, while transdermal estradiol had almost no detectable effect on hemostasis.

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The practical takeaway: if you have risk factors for blood clots — obesity, a history of clotting, known genetic clotting disorders like Factor V Leiden — transdermal estrogen is the safer choice. Overall, HRT roughly doubles the risk of venous blood clots compared to not using it, but transdermal delivery appears to sidestep much of that added risk.

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Costs, Insurance, and Access Barriers

What you pay for HRT depends enormously on where you live, what kind of insurance you have, and which medications your doctor prescribes. Generic estradiol pills and patches are relatively inexpensive, often under $30 per month without insurance and sometimes less with a coupon or through a generic pharmacy program. Testosterone (injections or gel) is similarly affordable in generic form. Branded formulations, compounded hormones, or GnRH agonists like leuprolide can be far more expensive — GnRH agonists in particular can run into hundreds or thousands of dollars monthly without coverage.

Insurance coverage for gender-affirming HRT has expanded considerably in recent years, but it remains inconsistent. Some insurers cover hormones and lab work with no special hurdles; others require prior authorization or documentation of a gender dysphoria diagnosis. State-by-state laws vary, and employer-sponsored plans can differ even within the same state. For menopausal HRT, insurance coverage is more straightforward since it’s treating a recognized medical condition, but you may still face formulary restrictions or step-therapy requirements.

Access also depends on the supply chain. Injectable estrogen experienced significant shortages in the United States in 2016 and 2017, forcing some transgender patients to go without or switch formulations abruptly. Advocacy efforts eventually restored all injectable estrogen formulations to market, but the episode exposed the fragility of supply for a medication that many people depend on daily.

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In some countries, the situation is worse. Even basic formulations of oral estrogen or injectable testosterone can have severe supply shortages, limiting options for people who need them.

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Telehealth has emerged as one real bright spot for access. Scoping reviews of barriers and facilitators to gender-affirming care have identified telemedicine as a meaningful way to connect patients with knowledgeable clinicians, particularly in areas with few local providers.

¹⁹ One federally qualified health center found that its rapid pivot to telehealth during the pandemic allowed it to continue providing gender-affirming care without interruption and reach patients who would otherwise have had to travel significant distances.²⁰

Fertility Preservation

This is a conversation your doctor should bring up before you start, though in practice it often doesn’t happen. Gender-affirming hormone therapy can impair fertility, and some surgical interventions eliminate reproductive potential entirely. If having biological children matters to you — now or in the future — the time to act is before your first dose.

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For transwomen, sperm banking is the most straightforward option and is widely available at fertility centers. Ideally, you would bank sperm before starting estrogen, since estrogen and anti-androgens suppress sperm production. The number of samples to freeze depends on whether you envision using them for intrauterine insemination or in vitro fertilization, so a consultation with a fertility specialist is worth the time.

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For transmen, egg or embryo freezing is the best current option for fertility preservation. Transmen who have already started testosterone can still pursue these techniques — the process requires temporarily halting testosterone and undergoing ovarian stimulation, which some people find distressing. All patients should be counseled on their options before starting medical or surgical transition, yet this appears to seldom occur in practice.

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Long-Term Monitoring

Starting HRT is not a one-and-done event. You will need regular follow-up appointments and bloodwork, especially in the first year as your doctor adjusts your dose. For gender-affirming HRT, hormone levels are typically checked every three months initially, then every six to twelve months once levels are stable. For menopausal HRT, follow-up schedules vary but usually involve an annual review of symptoms, side effects, and whether continuing therapy is still appropriate.

For people on testosterone, monitoring hematocrit (the proportion of red blood cells in your blood) is especially important because of the erythrocytosis risk discussed earlier. If your hematocrit climbs too high, your doctor may reduce your dose, switch your delivery method, or recommend blood donation to bring it down.

For menopausal HRT, bone health is worth tracking. Estrogen plays a significant role in maintaining bone density, and HRT can slow or reverse bone loss. Bone turnover markers measured in blood or urine can be used to monitor the bone density response to HRT at the individual level, offering a way to gauge effectiveness without waiting for a full bone density scan.

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Drug Interactions Worth Knowing About

If you take other medications, it’s worth flagging them for your prescribing doctor. A review of pharmacological interactions with menopausal hormone therapy identified 23 drug groups that interact with HRT to varying degrees. Some were categorized as safe to use together without concern, while others required monitoring, dose adjustment, or were flagged as potentially problematic. Vaginal HRT, because it delivers very little estrogen systemically, was broadly compatible with nearly all other drug categories examined.

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The most commonly relevant interactions involve drugs that affect liver enzymes responsible for metabolizing estrogen. Certain anticonvulsants, some antibiotics, and the herbal supplement St. John’s wort can speed up estrogen metabolism, potentially reducing its effectiveness. Going the other direction, some antifungals and grapefruit juice can slow estrogen breakdown, increasing levels in your body. If you are on any chronic medications, your doctor or pharmacist should review potential interactions before you start.

Hair Changes on HRT

Hair is one of those topics people care about intensely but doctors sometimes brush past. For menopausal women, HRT is not prescribed for hair loss alone, but the choice of hormone formulation can affect hair outcomes. A review aimed at trichologists found that transdermal or topical estrogen combined with oral medroxyprogesterone did not appear to worsen hair loss. Systemic testosterone is contraindicated in women, but transdermal or topical testosterone formulations at low doses, under gynecological supervision, usually do not adversely affect hair either.

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For people on masculinizing hormone therapy, testosterone can trigger male-pattern hair loss if you are genetically predisposed, just as it does in cisgender men going through puberty. The same treatments that cisgender men use — finasteride, minoxidil — are options for transmen, though finasteride can partially interfere with some of testosterone’s masculinizing effects, so it’s a tradeoff to discuss with your provider. For those on feminizing hormones, the reduction in testosterone typically slows or stops male-pattern hair loss, and some people see modest regrowth, though results vary widely.

The WHI Shadow Over Menopausal HRT

If you are a menopausal woman considering HRT, you will almost certainly encounter anxiety — your own or a doctor’s — rooted in results from a large trial published in 2002. The Women’s Health Initiative announced findings suggesting that HRT had more harmful than beneficial effects, and the resulting publicity caused widespread panic among users and a dramatic drop in prescriptions. The history of HRT’s popularity, from its rise in the 1960s to its peak in the 1990s, was upended practically overnight.

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In the years since, medical consensus has shifted considerably. The WHI study participants were, on average, well past menopause onset — many were in their 60s and 70s. The risks of HRT look quite different for women who start within ten years of menopause compared to those who start much later. For younger, recently menopausal women with bothersome symptoms, the benefit-risk balance is generally favorable. But the aftershocks of 2002 are still felt: some doctors remain reluctant to prescribe, and some women who would benefit go untreated because the old headlines loom larger than the updated evidence. If your doctor dismisses HRT out of hand without discussing your individual risk profile, it may be worth seeking a second opinion from a menopause specialist.