Do I need a psychiatrist's letter to get hormone therapy in Australia?

No — for adults (18 and over), Australia follows an informed-consent model under the AusPATH 2022 guidelines. This means a GP or other prescriber who is knowledgeable about gender-affirming care can assess, counsel, and prescribe hormone therapy without requiring a prior mental health clearance. A thorough informed-consent discussion covering expected changes, timeline, fertility, and risks is required before prescribing, but it does not require a psychiatry letter. Some GPs still refer to an endocrinologist or gender clinic for a shared-care arrangement, particularly for complex presentations.

What changes can I expect from feminising hormone therapy, and how long do they take?

Feminising hormone therapy using oestradiol and an anti-androgen produces changes over months to years. Within the first 1–3 months you may notice breast tenderness and early breast development, skin softening, and reduced libido. Over 3–12 months body fat redistribution (hips, thighs, buttocks), reduced body hair growth rate, and continued breast development typically occur. Muscle mass reduction happens gradually over 1–2 years. Breast development continues for 2–5 years but the final cup size is partly genetic. Fertility — sperm production — is significantly reduced by oestradiol and anti-androgens; banking before starting is strongly recommended if future biological parenthood is desired.

Is testosterone for gender-affirming care available on the PBS?

Yes. Testosterone for gender-affirming masculinising therapy is explicitly listed on the PBS under the testosterone class, which includes gender dysphoria as an indication — Authority Required Streamlined (ARS). This means your GP or specialist can prescribe PBS testosterone with an online authority approval, making it significantly cheaper than a private script. The most commonly used formulations are Reandron 1000 mg intramuscular injection (given every 10–14 weeks) and Testogel 25–50 mg daily transdermal gel. In contrast, most feminising medications — oestradiol and cyproterone acetate — are currently prescribed as private scripts, costing approximately $30–80 per month.

What blood tests do I need while on gender-affirming hormone therapy?

Your GP will check a set of blood tests before starting and then every 3 months for the first year, then every 6 months once your levels are stable. For feminising therapy, key tests include oestradiol (target 250–600 pmol/L), testosterone (target <2 nmol/L), full blood count, liver function, lipids, and prolactin (cyproterone increases prolactin). For masculinising therapy, total testosterone (target 10–30 nmol/L), haematocrit (polycythaemia risk — if haematocrit exceeds 0.54, testosterone dose is reduced or venesection considered), lipids, and blood pressure are monitored. Bone density (DEXA) is recommended if hormone levels are inadequate for more than 12 months.

Do transgender and gender-diverse people still need cancer screening?

Yes — cancer screening in Australia is based on the organs you have, not your gender identity or the gender marker on your Medicare card. Trans women (assigned male at birth) retain a prostate that still responds to PSA testing, though oestradiol can lower PSA levels, so discuss the interpretation with your doctor. Trans men (assigned female at birth) who retain a cervix should continue HPV self-collection or cervical screening per the standard schedule (every 5 years from age 25). Trans men who have not had a hysterectomy may still need endometrial monitoring. BreastScreen eligibility should be clarified with the programme based on breast tissue presence, regardless of gender marker.

Gender-Affirming Hormone Therapy

Gender-Affirming Hormone Therapy: What to Expect in Australia

Q: Do transgender and gender-diverse people still need cancer screening?

Yes — cancer screening in Australia is based on the organs you have, not your gender identity or the gender marker on your Medicare card. Trans women (assigned male at birth) retain a prostate that still responds to PSA testing, though oestradiol can lower PSA levels, so discuss the interpretation with your doctor. Trans men (assigned female at birth) who retain a cervix should continue HPV self-collection or cervical screening per the standard schedule (every 5 years from age 25). Trans men who have not had a hysterectomy may still need endometrial monitoring. BreastScreen eligibility should be clarified with the programme based on breast tissue presence, regardless of gender marker.

By Dr HB Lo, FACRRM Reviewed 7 August 2026 9 min read

Gender-affirming hormone therapy (GAHT) uses oestradiol and anti-androgens to produce feminising effects, or testosterone for masculinising effects. Australia's AusPATH 2022 guidelines support an informed-consent model: eligible adults can access GAHT via a GP without requiring psychiatry letters.

Feminising therapy is oral or transdermal oestradiol combined with an anti-androgen; masculinising therapy is injectable or topical testosterone. Both require 3-monthly monitoring in year one. Most feminising medications are private scripts; testosterone is PBS-listed. Cancer screening follows the organs you have, not your gender identity.

Gender-affirming hormone therapy (GAHT) produces physical changes that align the body with a person’s gender identity. Australia has moved progressively toward an informed-consent prescribing model for adults, meaning knowledgeable GPs can provide GAHT without requiring prior specialist letters in most cases. This article outlines the feminising and masculinising regimens used in Australian practice, what changes to expect, monitoring requirements, and how to navigate PBS access and anatomy-based health screening.

A. Core clinical — the AU general-practice framework

Informed-consent model

The AusPATH 2022 Australian Informed Consent Standards of Care establish that adult patients (18 years and over) do not require a psychiatry assessment or mental health letter before commencing GAHT. A GP who has adequate knowledge of gender-affirming care can:

Conduct a comprehensive informed-consent discussion covering expected changes, timeline, reversibility, fertility implications, and risks
Document that the patient understands and accepts those risks
Prescribe GAHT directly

The WPATH Standards of Care Version 8 (2022) and the Endocrine Society 2017 guideline (Hembree et al.) provide the international clinical framework underpinning AusPATH recommendations.

Many GPs opt for a shared-care arrangement with an endocrinologist or gender health specialist, particularly for complex cases. This is not a requirement but can be helpful when a GP is gaining experience or when the patient has significant comorbidities.

Adolescents

Stage 1 treatment (puberty blockers — GnRH agonists) and Stage 2 treatment (sex hormone therapy) in adolescents follows a different pathway. Re Kelvin [2017] established that Family Court authorisation is no longer required for Stage 2 in adolescents whose parents (or guardians) and treating clinicians agree it is in the young person’s best interests. Assessment by a multidisciplinary team including a psychologist or psychiatrist remains best practice for adolescents. Refer to the Royal Children’s Hospital Melbourne Gender Service for paediatric and adolescent protocols.

B. Feminising hormone therapy

Oestradiol

The cornerstone of feminising therapy is 17β-oestradiol, not synthetic oestrogens. Ethinyl oestradiol (found in the oral contraceptive pill) should be avoided — it carries substantially higher venous thromboembolism (VTE) risk and is not routinely used in GAHT.

Available formulations in Australia:

Oral oestradiol valerate (Progynova) — 2–6 mg/day; convenient but first-pass hepatic metabolism means higher VTE risk than transdermal
Transdermal oestradiol patch (Estradot, Climara) — changed twice weekly; bypasses hepatic metabolism, lower VTE risk
Transdermal oestradiol gel (Sandrena, Estrogel) — daily application; similar VTE advantages to patches

The Vinogradova BMJ 2019 study confirmed that transdermal oestradiol confers materially lower VTE risk than oral oestradiol. Transdermal formulations are preferred in smokers, adults over 40, those with BMI >30, or anyone with a prior VTE or known thrombophilia.

Target oestradiol level: 250–600 pmol/L (measured as trough before next dose or midpoint for transdermal).

Anti-androgens

Oestradiol alone does not fully suppress testosterone in adults with testes. An anti-androgen is usually added unless surgical orchidectomy has occurred:

Cyproterone acetate (Androcur) — 12.5–25 mg/day; most commonly used in Australia. The TGA has issued a safety advisory regarding meningioma risk at high cumulative doses — use the lowest effective dose (12.5 mg is often sufficient) and consider annual dose review
Spironolactone — 100–200 mg/day; an aldosterone antagonist with anti-androgenic properties; increases urinary frequency and potassium — monitor electrolytes; less potent than cyproterone
GnRH agonists (leuprorelin, triptorelin) — most effective testosterone suppression; expensive and not PBS-funded for GAHT in adults

Target testosterone: <2 nmol/L.

Expected feminising changes and timeline

Change	Onset	Maximum effect
Breast development	1–3 months	2–5 years
Body fat redistribution (hips, thighs)	3–6 months	2–5 years
Skin softening, reduced sebum	3–6 months	Unknown
Reduced body hair growth rate	6–12 months	3+ years (electrolysis/laser usually still needed)
Reduced erections and libido	1–3 months	Variable
Muscle mass reduction	1–2 years	2–3 years
Permanent changes: breast development, testicular atrophy	—	—
Not changed by hormones: skeletal structure, height, voice pitch	—	—

Progesterone

The role of progesterone in feminising therapy remains controversial. Some patients report subjective benefits (mood, breast development, libido), but robust evidence is lacking. Vaginal progesterone (Utrogestan) is not PBS-listed for this indication and is a private script. Oral synthetic progestogens (medroxyprogesterone) are not recommended due to adverse metabolic and mood profiles.

C. Masculinising hormone therapy

Testosterone

Testosterone is the single agent required for masculinising therapy. Available formulations in Australia:

Reandron 1000 mg/4 mL IM injection — given at weeks 0 and 6 (loading), then every 10–14 weeks; very convenient for people who dislike daily application; available on PBS
Testogel 25–50 mg/day transdermal gel — applied daily to shoulders, upper arms, or abdomen; avoids injection; PBS-listed
Primoteston Depot 250 mg/mL IM — given every 2–3 weeks; older formulation, greater peak-trough fluctuation; less commonly used as a first choice

All testosterone formulations for gender-affirming care are PBS Authority Required Streamlined (ARS) — the prescriber obtains approval online through the PBS system before issuing the script. This makes testosterone substantially more affordable than private-script feminising medications.

Target testosterone: 10–30 nmol/L (within the cisgender male reference range).

Expected masculinising changes and timeline

Change	Onset	Maximum effect
Clitoral growth	1–3 months	1–2 years
Voice deepening	3–6 months	1–2 years (permanent)
Increased body/facial hair	6–12 months	4–5 years
Scalp hair loss (androgenic alopecia)	Variable	Variable
Cessation of menses	1–6 months (usually)	—
Body fat redistribution (more central)	3–6 months	2–5 years
Increased muscle mass	3–6 months	2–5 years
Permanent: clitoral growth, voice, facial hair, scalp changes	—	—
Not changed: height, bone structure if post-pubertal	—	—

Polycythaemia

Testosterone stimulates erythropoiesis. If haematocrit (HCT) rises above 0.54, the dose should be reduced or the injection interval extended. If HCT remains persistently elevated despite dose reduction, therapeutic venesection (phlebotomy) may be required. Monitor HCT at every monitoring visit during the first year.

D. Australian operations

PBS access summary

Medication	PBS status
Testosterone (Reandron, Testogel)	PBS ARS — gender dysphoria listed indication
Cyproterone acetate (Androcur)	Private script (~$15–25/month)
Oestradiol patches/gel (Estradot, Sandrena, Estrogel)	Private script (~$30–60/month feminising total)
Oral oestradiol valerate (Progynova)	Private script
GnRH agonists (leuprorelin)	Not PBS-funded for adult GAHT
Vaginal progesterone (Utrogestan)	Not PBS for GAHT

The cost gap means that feminising therapy requires out-of-pocket expenditure; this is a known equity barrier that advocacy groups and AusPATH continue to raise with the Pharmaceutical Benefits Advisory Committee (PBAC).

Monitoring schedule

For the first year, check blood tests every 3 months. Once stable, 6-monthly reviews are standard. At each visit:

Feminising therapy monitoring:

Oestradiol level (trough or midpoint)
Testosterone (target <2 nmol/L)
Full blood count, liver function tests
Lipids
Prolactin (cyproterone elevates prolactin; check at baseline and 3 months; reduce dose if elevated)
Blood pressure

Masculinising therapy monitoring:

Total testosterone (10–30 nmol/L)
Haematocrit (hold or reduce dose if ≥0.54)
Lipids (testosterone worsens LDL/HDL ratio)
Blood pressure
Liver function tests

Bone density (DEXA) is recommended if hormone levels have been subtherapeutic for more than 12 months, or at baseline in anyone with pre-existing osteoporosis risk factors.

Anatomy-based cancer screening

Health screening follows the organs present, not gender identity or gender marker:

Organ	Person	Screening recommendation
Cervix	Trans men or non-binary with intact cervix	HPV self-collection or clinician-collected sample every 5 years from age 25 (National Cervical Screening Programme)
Breast tissue	Trans women on oestradiol ≥5 years, or trans men with retained breast tissue	BreastScreen Australia eligibility — discuss with BreastScreen service directly
Prostate	Trans women assigned male at birth	PSA testing — note oestradiol suppresses PSA, so levels may be lower than in cisgender men; discuss interpretation with your GP
Uterus/ovaries	Trans men with intact uterus	No routine screening programme exists; pelvic USS if symptoms develop

Conversion practices

Attempting to change or suppress a person’s gender identity or sexual orientation through prayer, counselling, or other means constitutes conversion practices, which are unlawful in Victoria, Queensland, the ACT, and New South Wales, with legislation under review or pending in other states. AHPRA has also issued conduct guidance. GPs must not engage in or refer to conversion practices.

E. Special populations

Fertility and parenthood

Oestradiol combined with anti-androgens significantly suppresses spermatogenesis; testosterone suppresses ovulation and may cause uterine and ovarian atrophy. Fertility effects are not always fully reversible on cessation. Individuals wishing to preserve fertility before commencing GAHT should be referred to a fertility specialist before initiating treatment:

Trans women: sperm banking (cryopreservation) before starting oestradiol/anti-androgens
Trans men: oocyte or embryo cryopreservation; ovarian tissue cryopreservation (experimental)
Note: fertility preservation funding varies by state; discuss out-of-pocket costs upfront

Pregnancy is possible in trans men who retain a uterus and stop testosterone. Testosterone must be ceased before conception (teratogenic) — refer to obstetric services experienced in gender-diverse care if pregnancy is desired.

Older adults commencing GAHT

Adults over 40 commencing feminising therapy have increased cardiovascular and VTE risk baseline. Transdermal oestradiol is strongly preferred over oral in this age group. A baseline cardiovascular risk assessment (lipids, blood pressure, smoking history, HbA1c) and shared decision-making about risk-benefit are important. Older adults commencing testosterone should have a baseline prostate assessment (PSA, DRE) documented, and haematocrit monitored carefully.

Mental health and wellbeing

Research consistently shows that GAHT substantially improves psychological wellbeing, anxiety, depression, and quality of life measures in gender-diverse people when they receive affirming care. GPs should screen for depression and anxiety at initiation and at regular intervals — not as a gatekeeping exercise but as part of holistic care, given the elevated mental health burden from stigma, discrimination, and social minority stress in this population.

Crisis and peer support

QLife 1800 184 527 — LGBTIQ+ peer support and referral, 3 pm–midnight daily
Beyond Blue 1300 22 4636 — mental health support
13YARN 13 92 76 — crisis support for Aboriginal and Torres Strait Islander peoples
Lifeline 13 11 14 — 24/7 crisis line

When to escalate

Refer or seek urgent advice in the following situations:

Suspected or confirmed VTE (pulmonary embolism or deep vein thrombosis) in someone on oestradiol — cease oestradiol and manage VTE; restart as transdermal after anticoagulation established with specialist input
Haematocrit ≥0.54 on testosterone not responding to dose reduction — venesection and haematology review
Prolactin significantly elevated (>2000 mIU/L) on cyproterone — MRI brain to exclude prolactinoma or meningioma
Persistent pelvic pain or abnormal uterine bleeding in a trans man — gynaecology referral
Adolescent presenting for GAHT — multidisciplinary gender service referral
Patient requesting genital surgery, orchiectomy, or mastectomy — surgical team referral via gender clinic or specialist

What this article is and is not

This article provides patient-education information about gender-affirming hormone therapy in Australia based on AusPATH 2022 guidelines, WPATH Standards of Care Version 8, and current Australian prescribing practice as of 2026. It is not a substitute for a consultation with a GP or specialist who can assess your individual health history, discuss all risks in detail, and tailor a treatment plan for you. Individual responses to GAHT vary considerably.

If you are considering starting or adjusting GAHT, book an appointment with a GP experienced in gender-affirming care. AusPATH maintains a directory of affirming practitioners on its website.

Sources cited

Frequently asked questions

Do I need a psychiatrist's letter to get hormone therapy in Australia?

No — for adults (18 and over), Australia follows an informed-consent model under the AusPATH 2022 guidelines. This means a GP or other prescriber who is knowledgeable about gender-affirming care can assess, counsel, and prescribe hormone therapy without requiring a prior mental health clearance. A thorough informed-consent discussion covering expected changes, timeline, fertility, and risks is required before prescribing, but it does not require a psychiatry letter. Some GPs still refer to an endocrinologist or gender clinic for a shared-care arrangement, particularly for complex presentations.
What changes can I expect from feminising hormone therapy, and how long do they take?

Feminising hormone therapy using oestradiol and an anti-androgen produces changes over months to years. Within the first 1–3 months you may notice breast tenderness and early breast development, skin softening, and reduced libido. Over 3–12 months body fat redistribution (hips, thighs, buttocks), reduced body hair growth rate, and continued breast development typically occur. Muscle mass reduction happens gradually over 1–2 years. Breast development continues for 2–5 years but the final cup size is partly genetic. Fertility — sperm production — is significantly reduced by oestradiol and anti-androgens; banking before starting is strongly recommended if future biological parenthood is desired.
Is testosterone for gender-affirming care available on the PBS?

Yes. Testosterone for gender-affirming masculinising therapy is explicitly listed on the PBS under the testosterone class, which includes gender dysphoria as an indication — Authority Required Streamlined (ARS). This means your GP or specialist can prescribe PBS testosterone with an online authority approval, making it significantly cheaper than a private script. The most commonly used formulations are Reandron 1000 mg intramuscular injection (given every 10–14 weeks) and Testogel 25–50 mg daily transdermal gel. In contrast, most feminising medications — oestradiol and cyproterone acetate — are currently prescribed as private scripts, costing approximately $30–80 per month.
What blood tests do I need while on gender-affirming hormone therapy?

Your GP will check a set of blood tests before starting and then every 3 months for the first year, then every 6 months once your levels are stable. For feminising therapy, key tests include oestradiol (target 250–600 pmol/L), testosterone (target <2 nmol/L), full blood count, liver function, lipids, and prolactin (cyproterone increases prolactin). For masculinising therapy, total testosterone (target 10–30 nmol/L), haematocrit (polycythaemia risk — if haematocrit exceeds 0.54, testosterone dose is reduced or venesection considered), lipids, and blood pressure are monitored. Bone density (DEXA) is recommended if hormone levels are inadequate for more than 12 months.
Do transgender and gender-diverse people still need cancer screening?

Yes — cancer screening in Australia is based on the organs you have, not your gender identity or the gender marker on your Medicare card. Trans women (assigned male at birth) retain a prostate that still responds to PSA testing, though oestradiol can lower PSA levels, so discuss the interpretation with your doctor. Trans men (assigned female at birth) who retain a cervix should continue HPV self-collection or cervical screening per the standard schedule (every 5 years from age 25). Trans men who have not had a hysterectomy may still need endometrial monitoring. BreastScreen eligibility should be clarified with the programme based on breast tissue presence, regardless of gender marker.

Source quality

Sources grouped by evidence tier. AU primary tier first; international where AU is silent or lagging; named-author reconstruction where guidelines have not yet caught up. How tiers work.