This page covers the basics of common hormone replacement therapy (HRT) medication. This tries to cover some starting doses and very basics only. See the full section on medications for more details.
The regular options are pills, patches, and gel. In some countries, injections are common and are a starting option. In some countries, implants are available, but they aren't a starting option.
Note that it is really common for doctors to start doses very low for trans fems. If combined with anti-androgens, also called blockers, this can lead to menopause symptoms.
Pills are common because they are generally fairly cheap and easy to take, they do have a higher chance of blood clots when swallowed. It can be hard to get estradiol levels high enough to suppress testosterone with pills by themselves, so using blockers is common. If taken sublingually (dissolved slowly under the tongue) or buccally (placed in between the gums and cheek to dissolve) it should be more likely to suppress testosterone.
Pills should be of the type Estradiol, Estradiol Hemihydrate, or Estradiol Valerate. Never take Ethinylestradiol, Conjugated Estrogens, or Conjugated Equine Estrogens.
| Pill Size | Multiple | Frequency | Type |
|---|---|---|---|
| 1 mg | 1x | Every 8 hours | Sublingual |
| 2 mg | 1x | Every 8 hours | Sublingual |
| 2 mg | 2x | Every day | Oral |
| 2 mg | 5x | Every day | Oral |
Generally 2mg, every 8 hours, sublingually or buccally will be enough for the majority of people to achieve good levels.
Gel is a common starting option in some countries. It is more variable with levels because of differences between people in how well the skin absorbs estradiol. You also don't want to spread gel over too large an area as this will also decrease the amount absorbed. A palm-sized area is optimal. Some people find gel can be slow to dry and some people don't get good levels with gel.
The common gel formats are in sachets at 1mg per sachet or a measured dose tube at 0.75mg per pump. Like with pills, you can spread the dose out over time, this can help with more stable levels overall. The suggested areas are forearm, stomach, or thighs but never the breasts or upper torso. For some people, application to the scrotum can help to achieve reasonable levels, or others it will lead to levels that are too high.
| Dose | Multiple | Frequency |
|---|---|---|
| 0.75 mg | 1x | Every 12 hours |
| 0.75 mg | 2x | Every day |
| 0.75 mg | 2x | Every 12 hours |
| 1 mg | 1x | Every 12 hours |
| 1 mg | 2x | Every day |
| 1 mg | 3x | Every 12 hours |
For some people, gel just won't get levels high enough, and it might need to be mixed with other types formats. Blood tests are important for getting the dose right.
Patches are also common in some countries. However, because they are also used by cis women for menopause, trans people can be prescribed doses that are too low. Cis women are topping up their estrogen that already exists, trans people are replacing all their sex hormones and so need higher doses. Patches can be more variable with levels because of differences between people in how well the skin absorbs estradiol.
Patches come in different types of different sizes. For trans healthcare the largest dose patch should be used, 100 μg (also written 100 mcg) per day. Smaller patches might be added based on blood tests to get the level right but not used on their own. The different brands are different sizes for the same dose, and some are not as good at sticking to the skin as others. Different brands also last different lengths of time, either 3.5 days or 7 days per patch.
They should be placed on the stomach, in line with the belly button or lower, and the application site should be rotated over time. The butt or thigh might also be reasonable candidates.
| Dose | Multiple | Frequency |
|---|---|---|
| 100 μg | 1x | Every 3.5 days |
| 100 μg | 2x | Every 3.5 days |
| 100 μg | 1x | Every 7 days |
| 100 μg | 2x | Every 7 days |
For some people patches just won't get levels high enough, and it might need to be mixed with other methods. Blood tests are important for getting the dose right.
Injections have more options, both in the concentration of the liquid and the types of estradiol esters. Generally, the amounts prescribed give more reasonable and more consistent levels, but there are still some individual differences in a dose to serum level.
Injections come in different concentrations and esters (molecular formulations) that impact how much and how often you need to take a dose. Generally there is a 'sweet spot' where the peak isn't too high, and you aren't dosing too frequently, for each of the available esters.
If the peaks get too high, your body will produce more SHBG, which decreases the available estradiol for use in your body. If you don't dose frequently enough, you will likely get tired and moody in the last days before the next dose.
Estradiol Valerate (EV) is the most common ester, and together with Estradiol Cypionate (EC) make up the main ones available from pharmacies. Estradiol Enanthate (EEn) and Estradiol Undecylate (EU) both used to be available from pharmacies but have been generally phased out because the main use of them has switched to other products, they are now only available from DIY providers.
| Ester | Dose | Frequency |
|---|---|---|
| Valerate | 4 mg | 5 days |
| Cypionate | 5 mg | 7 days |
| Enanthate | 7 mg | 10 days |
| Undecylate | 32 mg | 31 days(*) |
(*) Undecylate has only recently become available again, and dosing should rely more on serum testing to work out the correct dose.
Pellets are only available in a few countries. They are a compounded medicine where estradiol hemihydrate powder is compressed into a pellet. These are then implanted under the skin in the stomach area beside the belly button or the upper buttocks, in a simple surgical procedure done in a doctor's office.
Based on anecdotal experience, a starting dose of two 100mg pellets is implanted, and levels monitored every three months until levels drop under 600 pmol/L (163 pg/mL). At which point a single 100mg pellet can be added, and blood tests monitoring every 3 months starting 6 months after implanting. The first dose is expected to last six months, and the following doses around a year.
| Dose | Multiple | Frequency |
|---|---|---|
| 100 mg | 2 | Starting dose - Should last 6 months |
| 100 mg | 1 | Maintenance dose - should last 12 months |
Starting dose might need to be adjusted up or down based on how other methods have gone. People who have issues with getting reasonable serum levels might need to start with three pellets, and people who get high levels with lower doses might need to start on one pellet.
Generally, the dose and multiple stays the same and the time between implants is adjusted to ensure the correct levels are maintained.
Pellets take some time to increase to their maximum level before slowly dropping down. Generally, they should reach their maximum level after 1 month and before 3 months. For the follow-up pellets, the previous one will still be keeping the levels reasonable, but for the first you need to continue using your previous method and slowly decrease that dose over the first month.
For example, if you were on 3x 2mg pills, keep that does for the first week. Take 2x 2mg for the second week, and 1x 2mg for the third week. Otherwise, you may find you drop back to low levels and have testosterone levels increase or if you are on blockers, you will experience menopause.
If you experience symptoms of menopause or increasing testosterone, supplement for longer. You will need to stop supplementing to do a blood test, stop for roughly a week prior to the blood test.
Anti-Androgens are used to block the effects of testosterone or to block the production of testosterone.
Cyproterone Acetate, often just called cyproterone or cypro, is a progestin as well as at higher doses an androgen receptor antagonist. Its main effect as a progestin is to block the production of testosterone by signaling to the hypothalamus that there are enough sex hormones.
Cyproterone is the most common anti-androgen outside the USA.
Doses high enough to block receptors are generally not proscribed anymore, and shouldn't be, because of the risk of Meningioma. Meningiomas are a slow-growing tumor that forms from the meninges, the other membranes that cover your brain. This risk increases with the total life-time dose of cyproterone. Higher doses increase your risk faster, and the longer you are on it the higher your risk gets. As such, we try and reduce the dose as much as possible and switch to other ways of blocking testosterone for longer treatment.
| Dose | Frequency | Comment |
|---|---|---|
| 12.5 mg | Once a day | Starting dose where 50mg tables are the only available |
| 12.5 mg | Once every other day | Once testosterone is confirmed under 1nmol/L decrease the dose |
| 12.5 mg | Once every three day | Continue decreasing the dose if testosterone stays low |
| 12.5 mg | Once a week | Test stopping after this point |
| 10 mg | Once a day | Starting dose where 10mg tables are the only available |
| 5 mg | Once a day | Again decreasing the dose if testosterone is low |
| 5 mg | Once every other day | |
| 5 mg | Twice a week |
Cyproterone acetate has a long half-life, this allows you to take it less frequently while it still has a therapeutic effect.
While taking cyproterone you should have your liver function tested on a regular basis for the first year as it can have an impact on it.
Spironolactone, often just called spiro, is a blood pressure medication that also blocks androgen receptors as its main effect for HRT. The general understanding is that spironolactone can block the action of testosterone serum levels for up to 6 nmol/L and decrease the effect of levels above this, while on the maximum dose. Lower doses will not give the full effect but will give some effect. This increases the levels of testosterone you can have while still having maximum feminisation.
Spironolactone is the most common medication for androgen blocking in the USA as cyproterone isn't available there.
Twice a day dosing is preferred but not necessary required.
| Dose | Frequency | Comment |
|---|---|---|
| 25 mg | Once a day | Low dose |
| 25 mg | Twice a day | Medium dose (preferred) |
| 50 mg | Once a day | Medium dose |
| 50 mg | Twice a day | High dose (preferred) |
| 100 mg | Once a day | High dose |
| 100 mg | Twice a day | Maximum dose |
Spironolactone has more side effects which may be off-putting than other blockers but is safer overall. Licorice may decrease many of the side effects by negating its blood pressure lowering effects while maintaining its androgen blocking effects. However, the exact dosages of licorice to take are not currently known.
Kidney function tests should be done before starting spironolactone, and people with low blood pressure should be careful with symptom management.
Bicalutamide, often called bica, is an anti-androgen mainly used for prostate cancer. It is a receptor blocker like spironolactone. The general understanding is that spironolactone can block the action of testosterone serum levels for up to 6 nmol/L and decrease the effect of levels above this.
It is not as common as cyproterone or spironolactone and somewhat newer in the use in HRT.
| Dose | Multiple | Frequency |
|---|---|---|
| 50 mg | 1 | Once a day |
While taking bicalutamide you should have your liver function tested on a regular basis for the first year as it can cause sudden liver failure without symptoms. After the first year, a test once a year should be done. There have been no cases of liver failure in clinical trials. These tries had liver function tests as part of the protocol, suggesting that stopping bicalutamide when abnormal liver levels are detected makes this medication safe to take.
The regular options are gel and injections, but patches can also be available. The most common injection is a long injection administered by a doctor or nurse every 12 weeks. Pellets are available in some countries.
This option is basically the only one if you don't want to do injections. It is more variable with levels because of differences between people in how well the skin absorbs testosterone. You also don't want to spread gel over too large an area as this will also decrease the amount absorbed. A palm-sized area is optimal. Some people don't get good levels with gel.
The common gel formats are in sachets or a measured dose pump tube. It might take multiple doses per day to get desired levels, and you can spread out the doses over the day to help get more stable levels in that case.
Injections have more options, both in the concentration of the liquid and the types of testosterone ester. Generally, the long acting ester is given in a doctor's office, and the shorter acting one can be done at home.
| Ester | Dose | Frequency |
|---|---|---|
| Enanthate | 250 mg | 14 days |
| Undecylate | 1000 mg | 31 days |
These are treated similar in half-life while they most likely act similar to the Estradiol versions. It is commonly dosed every 7 days to give a smoother levels curve, but can be dosed longer to reduce the number of injections you have to do. Generally between 25 and 250 mg is injected weekly.
Generally given in a doctor's office as a fixed dose size with variable dosing schedule. Each injection is 1000 mg and starting at 12 weeks per injection, adjusting a shorter schedule if the level is under 13.8 nmol/L (400 ng/dl) a longer schedule if the level is significantly over that.
These are even less common than Estradiol pellets and small pellets which shorter dosing schedules are used. While they would give smoother levels than even testosterone undecylate injections, the frequency of implanting, and associated scaring might not be preferred to injections.