This page covers the different options for hormone replacement therapy (HRT) and related medications.
The main medication used is bioidentical estradiol. Also referred to as 17β-Estradiol, Oestradiol, 17β-Oestradiol, or E2. It is the main estrogen that causes feminisation.
It is common that an anti-androgen (also called a blocker) is used, generally one of Spironolactone, Cyproterone Acetate or Bicalutamide.
Sometimes Progesterone is also used.
Bioidentical Estradiol can be taken via many routes (Pills, Patches, Gel, Injection, Implants) as well as different forms (Micronised, Hemihydrate, Valerate and many other ester forms). The different routes and forms have different absorptions and half-life properties.
Generally, doctors will start you on a low dose and increase it over time. Starting this way should involve checking your serum levels frequently and adjusting the dose up each time until you don't have menopause symptoms (if on a blocker), generally feel emotionally stable, and have reasonable serum levels (see guideline ranges). Different options take different times to stabilise into a steady state where your levels are consistent with each dose. Doctors also take into account the frequency of appointments, frequency of blood tests, time to observe symptom changes, as well as level stabilisation in reviewing changes. Around six (6) weeks between tests is a good time to review a dose based on the above, however guildlines often suggest three (3) months.
Ensuring a short time between dosage changes is most important when a blocker as you are very likely to experience menopause symptoms at low doses which will likely impact your life, work, and mental health.
Micronised estradiol, estradiol hemihydrate, and estradiol valerate are all used as part of estrogen therapy. They can either be swallowed as normal for most medications or dissolved in the mouth sublingually (placing the tablet under the tongue) or buccally (placing the tablet between the cheek and gum). Some pills may specifically be labeled for sublingual/buccal administration, generally all pills can be taken this way.
This is the most common way that doctors prescribe pills. The exact timing of when you take the pills isn't as important here as it takes 12 hours for levels to reach a peak, according to at least one study that monitored levels. It might be useful to plan ahead and take your pills at a time when you can also get blood tests, such as in the morning with breakfast. This will make it easier to ensure you are getting an accurate reading from blood tests. However, taking them at a time when you will remember is better than a good schedule for tests where you often forget to take your medication.
There are two types of transdermal application, gel - a thick liquid that is spread over the skin, or patch - a plastic backed adhesive rectangle that is applied to the skin.
Gel either comes in individual sachets or in a pump bottle where each dose is spread over a small area of skin. Often suggested is forearm or abdomen, however thigh and buttock are also options.
Small patch that sticks onto the skin. Gets changed every 3.5 or 7 days depending on the patch type. Often placed on the abdomen, but can also be placed on the buttocks.
Injections come in a vial where you draw the liquid into a syringes and then inject either intramuscularly or subcutaneous. These come in various ester forms of estradiol to increase the time between injections.
It is also possible to get a solid pellet of estradiol implanted under the skin. The pellet then dissolves slowly over time leading to very stable levels that increase over a month and then slowly decrease over months. Generally, the first inserted pellet or pellets implanted only lasts 3 to 6 months, after that each pellet or pellets should last closer to 12 months. This makes it a very low maintenance option, but each implant does leave a small scar.
These are common in Australia, they are also available in the United States. However, they are either uncommon or unavailable in most of the rest of the world.
The following is a description of the procedure. This contains a description of surgery.
The procedure for getting them inserted involves preparing and cleaning the implant site, either the stomach, or the top of the buttock. Giving an injection of a local anesthetic, and waiting for that to take effect. Making a small incision (cut) in the upper layers of the skin to expose the layer of fat underneath, the subcutainious fat. Then they use a trocar which allows them to push the pellet into the incision. Afterward, they then sew up the incision, often with a single suture (often called a stitch). The suture is often dissolved, so you don't need to return to get it removed or cut it and remove it yourself. They will tell you which they used and if you need to come back. The whole process can be done in under 15 minutes, but an appointment can be up to 30 minutes depending on what else is covered.
It leaves a small scar, but it's not really noticeable.
With pellets, you normally have a peak after a few weeks to a month after which there is a slow decrease over months. It provides one of the most stable forms for dosing. Generally, you get a blood test every 3 months until you get close to the expected replacement level, where you might have extra tests.
Your doctor might aim for a specific level, in Australia 600 pmol/L seems to be a common target for adding a new pellet. This will seem high compared to other methods, but you don't have the peak and trough pattern under You wont be able to get 100mg pellets in the US, it will be like 50mg max per pellet or something.
Let me know what you have questions on.