How to Begin HRT
This article is a rough draft!
This means that although usable, the article may be missing citations, contain grammar errors, and likely still needs to be expanded upon.
So you're looking to start HRT by yourself with no doctor intervention, whether that's because of gate-keeping, long waiting lists, or doctors requiring letters of approval for starting HRT. However, you don't know where to begin, where to acquire your hormones, what to buy, or how much to take. This guide can help point you in the right direction so you can begin HRT as soon as possible.
Please note that this guide will never be perfect and will not guarantee a perfect or even favorable transition. A lot of it relies on genetics, the age at which you begin HRT, keeping your hormone levels in balance, your general health/well-being among many other factors (e.g. mutations, intersex conditions, etc.), any of which can alter the outcome. Please do your own research before considering following any methods presented in this guide and always get your hormone levels checked before and after to ensure you receive the proper care. Although this guide is meant to help you bypass gate-keeping from doctors in order to begin HRT, it is always recommended that you consult a doctor before and after following this guide, as they may be able to predict any negative interactions you may have with the medications due to your medical history. Continue to do your own research beyond what you read here. This guide is designed with MtFs in mind. A more in-depth guide for those requiring FtM and non-binary HRT methods is in the works.
It's been suggested the slower you incorporate your medications and ramp their dosages up in your regimen, the more likely you are to have a more favorable transition, notably with breast growth. It's recommended that you take a blood test before increasing your medication dosages in order to determine whether or not you actually need to increase them. Ideally, you want to take just enough medications to maintain stable levels of estradiol and testosterone. Don't take too much estrogen right away or else you run the risk of over-sensitizing your estrogen receptors and seeing less results. If your goal is to maintain erectile function, you may also consider skipping anti-androgens and opting for estradiol monotherapy. This can be hit-or-miss for some folks, however, so do this at your own/your doctor's discretion.
This guide currently only discusses the standard WPATH method. If you are looking to follow the Dr. Powers method, please refer to his powerpoint presentation on his website as well as his (outdated) YouTube video.
The subreddit r/TransDIY and r/DrWillPowers may help you make sense of your blood tests and advise you on your next steps if posted there, but please do not place all of your faith in their help and do plenty of research on your own. After all, they are not all doctors and even if they were, they are not obligated to help every single person that comes their way.
That being said, let's begin...
If you are experiencing symptoms of gender identity dysphoria and have decided to transition, you may want to or are already considering Hormone Replacement Therapy (HRT). In an ideal situation, this would be prescribed by an experienced doctor via your country's health care system. However, it is often the case that a trans girl cannot immediately access HRT for a variety of reasons and may want to self medicate. This guide has been written in an attempt to provide some basic information on how to do it as safely and efficiently as possible.
The most common way to start is by taking an antiandrogen (AA) with estrogen. The AA is used to reduce and block the effects of testosterone while the estrogen is used to replace the testosterone and induce feminizing changes to your appearance. This works because there are hormone receptors within every cell of the human body. The hormones that these receptors are exposed to dictates whether the cell functions in a male or female manner. The same process of physical masculinization or feminization via hormone exposure also occurs naturally during puberty.
The combination of an antiandrogen with estrogen can have powerful feminizing effects. The most noticeable of these are skin softening, breast development, reduced body hair, stopping/reversing of male pattern baldness, muscle atrophy, and the redistribution of fat into a more feminine shape.
These changes take place over 1-10 years and can vary in both their effectiveness and intensity between individuals. This can depend on a variety of factors such as health, age, and genetics. Thus, the goal of HRT is to optimize your doses and regimen to fit your bodies individual biology. It's absolutely critical that one receives regular blood tests during this process to ensure the most effective medical transition possible.
Step 0.5 - Take a baseline blood test!
This step is not required, but can be extremely beneficial when starting HRT. You absolutely want to know what your baselines are before considering your options. You may not need as much of a certain medication as you think you do. You may have 5α-Reductase or Testosterone deficiency and won't need much in the way of antiandrogens, if at all. Maybe your body has been aromatizing testosterone into estradiol lately. It helps tremendously to have this information at your disposal to better understand your body's endocrine system.
Consult a doctor to acquire hormone tests before beginning, or click here to find out where to order blood tests online.
You will want to test estrogen (total, free, serum), testosterone (total, free, serum), luteinizing hormone (LH), dihydrotestosterone (DHT), complete blood count (CBC), lipid profile, and acquire a Comprehensive Metabolic Profile (CMP). Although not as important, you can also test for sex-hormone binding globulin (SHBG) and follicle-stimulating hormone (FSH). It's recommended you get as many as you can, as any preliminary information you have could benefit you later.
Step 1 - Pick an Antiandrogen
Bicalutamide (Bical/Bica) is an androgen receptor antagonist. It does not lower testosterone but rather blocks it from exerting its effects by occupying the androgen receptors so testosterone can not bind to them. Bicalutamide is considered by some to be the golden standard of antiandrogens as it has less common and/or intense side effects compared to cyproterone acetate or spironolactone. Bical also allows users to maintain their sex drive and erectile function.
- Start by taking 50 mg per day. Depending on your pre-HRT blood levels, you may only need half as much. Bica does not lower testosterone and may initially raise it due to your body's attempt to maintain homeostasis. Because of this, your blood tests will not reflect how much testosterone is effecting your androgen receptors and it may be hard to tell whether you need more or less. Most people only need 50 mg per day and will slowly taper the amount down over the course of a year until they can achieve estradiol monotherapy.
Be patient, as it can take up to a month for Bicalutamide to build up and exert it's full effects on your endocrine system on a daily basis. If one desires to switch from another AA to bical, continue taking your current AA until about 15 days or so into taking bicalutamide and slowly wean off of the other medication. Try to avoid cold-stopping your current regimen as people tend to notice testosterone rebound effects from doing this. Instances of hair shedding and/or remasculinization have been reported with bicalutamide use despite the users taking adequate dosages. In these cases, one might consider an alternative antiandrogen, like spironolactone.
Although very uncommon, some people may require more than 50 mg of bicalutamide. In this case, people may use up to 100 mg per day. One reason why one might consider this is because they are "DHT mutant", meaning their body produces additional DHT through a backdoor method about which little is known. Use caution before considering adding extra bicalutamide to your regimen.
Spironolactone (Spiro) is a weaker but effective antiandrogen. It works by blocking the production of testosterone and as a very mild antagonist of androgen receptors. Spiro is a potassium sparring diuretic and the most common complaint is that it will increase frequency of urination. It's very affordable and easy to acquire but may require higher doses depending on your blood levels.
- Start by taking 50 mg per day.
- After about 1.5 to 2 months, raise the dosage up to 100 mg per day.
Take frequent blood tests and assess whether or not you need to raise your dosage further after about the 4th or 5th month. There is a rumor that high levels of spironolactone upon beginning HRT can hinder future breast growth, but this has not been proven. Dosages of 200 mg a day are common and it's recommended that you do not exceed 400 mg per day. For now, start slowly and add small amounts of spironolactone in over a longer period of time only when necessary.
Cyproterone Acetate (CPA) is a strong antiandrogen and progestogen. CPA works by suppressing testosterone levels via its progestogenic activity at low doses and blocking androgen receptors at high doses. Make sure to watch your Vitamin B12 levels while on CPA, as it has been linked to a B12 deficiency. The progestogenic effects of CPA may not be beneficial during early transition for future breast growth, however more research needs to be done on this topic. Regardless, higher dosages can potentially result in adverse side effects, including but not limited to: weight gain, high prolactin levels, depression and blood clots.
- Start by taking 5 mg per day. Take frequent blood tests to ensure you are taking the proper dosage of the drug required to bring your testosterone into female range (15-50 ng/dL). Should your testosterone still be high, slowly increase your dosage until you reach the proper range. Be patient and go slow when administering CPA in order to avoid the adverse side effects.
- Should you require more for adequate testosterone inhibition, start taking 10 mg per day and check your blood levels again after a month.
- Dosages of CPA vary among transgender women, with very common doses being 25 to 50 mg per day, with some reaching as high as 100 mg per day.
Please do plenty of research before considering high dose CPA HRT.
Step 2 - Pick an Estrogen
We currently don't have anything else written for this section, as most people generally opt to take estradiol valerate. There are other forms of estradiol available, but EV tends to be the most common medication prescribed or taken upon beginning HRT.
Estradiol Valerate (EV) is the most common form of estradiol prescribed for the purpose of MtF hormone replacement therapy and comes in the form of oral/sublingual tablets and intramuscular injections. When beginning HRT, most people opt for EV pills because they're easier to administer, are relatively easy to obtain and affordable.
- Start by taking 1 mg per day sublingually. Sublingual means you place it under your tongue and let it dissolve completely without swallowing anything. Try to avoid swallowing, as this will result in first-pass metabolism and convert your estradiol (E2) into estrone (E1). You may need a pill cutter to split your pills up. Do not take all of your pills at once. Instead, split them throughout the day in order to maintain elevated estradiol levels, avoiding gaps where the half-life of the medication ends and you are left without estrogen in your system for long periods of time.
- After 1 to 2 months, increase your dosage from 1 mg to 2 mg per day.
- After 4 to 6 months, increase your dosage from 2 mg to 4 mg per day.
Try to stay on a lower dosage as long as you can. It's speculated that the longer you maintain low dose estrogen HRT, the better your final breast growth outcome will be. Too high of a dose administered too soon may hinder breast growth, however this has not been proven and more research needs to be done. One may desire to increase their estradiol dosage faster than this to achieve quicker overall body feminization, but it's recommended that you remain patient if you desire better breast growth. 6 mg per day is a common late-term dose and most people do not exceed 8 mg per day sublingually.
Make sure to take regular blood tests to ensure that your levels are within adequate feminization ranges, around 100 pg/mL to 300 pg/mL. Again, be patient and let your hormones do the work! You can always increase dosages slowly, but it can be slightly more difficult to work backwards.
Step 3 - Order your pills online
Please refer to our Megalist of Online HRT Sources for more information on where to acquire medications. This list comes from a popular 9channel spreadsheet that has recently moved to HRT.Cafe. After discovering that 9channel had gone offline and the original spreadsheet had moved, we took it upon ourselves to backup the information to this website. Although unlikely, if the new spreadsheet ever goes offline, the information will still be available on this website for users to utilize. Please go give the HRT.Cafe a visit and consider donating to them for all of their hard work in putting this together.
Step 4 - Blood tests!
This absolutely cannot be stressed enough, but it is imperative that you acquire blood tests in any way possible to ensure you are administering the proper dosages. You must ensure that your hormone levels are within female range in order to achieve optimal effects from HRT and avoid as many negative side effects as possible from your medications of choice.
It's important to receive a blood test from a doctor every 3 months, but recommended that you try and acquire a test 1 month after changing any dosages.
Acquiring a blood test is usually as simple as telling your doctor that you are self medicating, that you are not going to stop, and that you need a blood test to ensure your safety. However, blood tests can also be ordered online without a physician.
Although estrogen (total, serum, and free) and testosterone (total, serum, and free) are the most crucial things to test for, it is also important to test for Complete Blood Count (CBC), kidney profile/electrolytes, TSH (thyroid), prolactin, potassium (if on spiro), and AST/ALT or LFT (liver function).
Other recommended tests you can acquire are dihydrotestosterone (DHT), sex-hormone binding globulin (SHBG), Dehydroepiandrosterone (DHEA), Dehydroepiandrosterone sulfate (DHEA-S), Follicle-stimulating Hormone (FSH), Luteinizing Hormone (LH), Insulin-Like Growth Factor 1 (IGF-1), Vitamin D, 25-Hydroxy, Pregnenolone, Cortisol, and Progesterone.
|Target estrogen level||Target testosterone level|
|200 to 300 pg/mL||15 to 50 ng/dL|
|734 to 1101 pmol/L||0.5 to 1.73 nmol/L|
Note from PrivateMDLabs for best blood test results: Patient should fast for 12 hours preceding collection of specimen. No radioisotopes administered 24 hours prior to venipuncture. This test may exhibit interference when sample is collected from a person who is consuming a supplement with a high dose of biotin (also termed as vitamin B7 or B8, vitamin H or coenzyme R). It is recommended to stop biotin consumption at least 72 hours prior to the collection of specimen. If using a testosterone cream please be sure you have not rubbed any into the antecubital area of your arm for the last 24 hours as it can give elevated results.
- Wikipedia.com | Side effects of cyproterone acetate - High progestogenic exposure | https://en.wikipedia.org/wiki/Side_effects_of_cyproterone_acetate#High_progestogenic_exposure