Estrogen HRT and Sexual Function
Sexual pleasure looks different for everyone. For transgender women, trans femmes, non-binary and intersex people exploring or taking estrogen gender-affirming hormone therapy (GAHT), there are important things to know about how estrogen HRT can affect sexual health.
Illustrations by Leo Mateus.
Erectile function is driven by testosterone. When testosterone levels decrease in the body with estrogen use, especially when used together with a testosterone blocker, such as a progesterone medication such as spironolactone, dutasteride, or finasteride, some people can experience symptoms of erectile dysfunction (ED). ED specifically happens when someone stops being able to maintain erections when they’d like to.
Obviously, sex looks different for everyone, therefore, maintaining an erection may not be important for you and your sex life; this change may even help alleviate feelings of gender dysphoria. However, if having or maintaining an erection matters to you personally, keep reading for related health information for what options are available to help manage these changes.
Medication is available to be prescribed.
First off, we know that some people might be frustrated with this change in their sexual function. While this isn’t always an easy change to navigate, you should know that ED medications are an option for improving sexual function. The most common ED medications are Sildenafil (Viagra) and Tadalafil (Cialis), which both work by increasing the blood flow to the penis and creating an erection. Although ED medications are usually marketed for cisgender men, people of all gender identities—including trans women—can absolutely use them. Beyond those two medications, there are other options available including Verdenafil and Avafil which a FOLX clinician may be able to prescribe through a local pharmacy at an additional cost.
ED medications can help you get and maintain an erection, but don’t affect sex drive.
Some medications work on-demand, meaning that taking a pill will lead to an erection at that moment. Others can help with spontaneous erection, meaning that you won’t get an erection right away, but it will be easier to get and maintain an erection when you are aroused. Unfortunately, these medications cannot help increase someone’s libido or sex drive nor change their ability to ejaculate.
ED medications can come with side effects.
Some people taking estradiol can experience side effects including flushing (reddening of the skin), headache, stomach upset, and/or nasal congestion. Some may notice a slight change in vision like blurriness or a slight blue tinge to their vision. Less common side effects are dizziness or lightheadedness related to a decrease in blood pressure. Much more rarely, people can experience effects that require immediate medical attention such as a loss of vision or hearing, or an erection that does not go away on its own after four hours. Alcohol intake should be limited, as increased drinking can worsen the side effects.
Additionally, those taking ED medication should avoid drinking grapefruit juice as it can affect the levels of the medication in your body. (Who knew?!) You and your healthcare provider should also discuss any previous health conditions before taking ED meds.
There are also other options if ED medication doesn’t work or isn’t desirable.
If someone’s ED is related to estrogen HRT, there are options to alter one’s estrogen/anti-androgen levels to increase testosterone levels that can help regain some erectile function while not compromising the overall effects of estrogen HRT. The dosage of your estradiol and/or testosterone blocker can be decreased to increase your testosterone levels. This may help to improve your sexual function. Your personal goals will be taken into consideration, and you can work with a FOLX clinician to determine the plan and dosage that works best for you.
Vacuum/pump devices can also be used to help increase blood flow to cause an erection, followed by the use of a ring to prevent the blood from flowing back out of an erection. The vacuum should not be applied for more than 30 minutes; while an orgasm can be achieved, there may not be any release of fluid as the path of the fluid on its way out may be blocked by the ring. Vacuum and ring devices can be easily and readily obtained in stores and online without a prescription! There are also additional injection and surgical options that can be discussed with a urologist if the medications and the pump either cannot be used or have not worked.
Above all, it’s important to remember there are other causes for erectile dysfunction beyond HRT effects, such as overall physical health, pre-existing medical conditions, and mental health. Remember to always discuss your full experience with your health care provider to figure out what is right for you.
For those ready to get started with FOLX for erectile medication, the process begins here. For existing FOLX members with questions about ED, don't hesitate to schedule time with a clinician. For those who have additional questions or concerns, please reach out to firstname.lastname@example.org.