diff --git a/export/index.html b/export/index.html index 0a255ff..2a9da1c 100644 --- a/export/index.html +++ b/export/index.html @@ -3,7 +3,7 @@ A PRACTICAL GUIDE TO FEMINIZING HRT - + @@ -351,7 +351,10 @@

You can use the table of contents to navigate to a particular section or question as needed, especially when re-visiting. I recommend saving this page / document so that you can refer back to it any time you have questions about your HRT. It is a lot to absorb up front, so it’s okay if it doesn’t! No rush on any of this.

-

This document can also be downloaded as a PDF. Please do so.

+

This document can also be downloaded as a PDF. Please do so.

+
+
+

Alternatively, you can read a 90s-00s style .txt version if you are inclined. It won’t stay up to date though.

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<1E154CFEE009BF39FBB3AD3ED28601E2>] >> startxref -1148237 +1148479 %%EOF diff --git a/export/pghrtgretchensversion.txt b/export/pghrtgretchensversion.txt new file mode 100644 index 0000000..663035e --- /dev/null +++ b/export/pghrtgretchensversion.txt @@ -0,0 +1,2795 @@ +============================================================================ +NOTE: If you're on mobile and the formatting is messed up, try rotating your +phone to ensure the optimum ASCII art experience. +============================================================================ + + XXXXXXXXXXXXX + XXXXX / |___ \ XXXXX + XXX _ _ | | __) | _ XXX + XX / / | | |/ __/ / | XX + X | | | |_|_____| | | X + XX | | | | | ____ XX + X_ ___ |_|_| |_| |___ \ X + X/ |/ _ \ __) | X + X | | | | | / __/ X + X | | |_| | |_____| X +X |_|\___/ _____ X +X / _ \ |___ / X +X| (_) | |_ \ X +X \__, | ___) |X +X /_/ |____/ X + X ___ _ _ X + X ( _ ) | || | X + X / _ \ | || |_ X + X| (_) | _____ ____ |__ _|X + X\___/ |___ | __ | ___| |_|XX + X / / / /_ |___ \ X + XX / / | '_ \ ___) | XX + XXX/_/ | (_) | |____/XXX + XXXXX \___/ XXXXX + XXXXXXXXXXXXX + + + ___ + / | + / /| | + / ___ | +/_/ _|_| __ _ __ ______ _ __ + / __ \_________ ______/ /_(_)________ _/ / / ____/_ __(_)___/ /__ + / /_/ / ___/ __ `/ ___/ __/ / ___/ __ `/ / / / __/ / / / / __ / _ \ + / ____/ / / /_/ / /__/ /_/ / /__/ /_/ / / / /_/ / /_/ / / /_/ / __/ +/_/___/_/ \__,_/\___/\__/_/\___/\__,_/_/ \____/\__,_/_/\__,_/\___/ + /_ __/___ + / / / __ \ + / / / /_/ / +/_/ _\____/ _ _ _ __ ______ ______ + / ____/__ ____ ___ (_)___ (_)___ (_)___ ____ _ / / / / __ \/_ __/ + / /_ / _ \/ __ `__ \/ / __ \/ /_ / / / __ \/ __ `/ / /_/ / /_/ / / / + / __/ / __/ / / / / / / / / / / / /_/ / / / / /_/ / / __ / _, _/ / / +/_/ \___/_/ /_/ /_/_/_/ /_/_/ /___/_/_/ /_/\__, / /_/ /_/_/ |_| /_/ + /____/ + + +============================================================================ +====================A Practical Guide To Feminizing HRT===================== +============================================================================ +============A comprehensive FAQ/Walkthrough for Feminizing HRT============== +============================================================================ +==="The Time Cube of HRT guides" - gretchen (@boxofmillipedes.bsky.social)== +============================================================================ +===================By: Katie Tightpussy (@katie.bzky.team)================== +===========================October 8, 2025================================== +=============================Version 1.21=================================== +============================================================================ + + +============================================================================ + ATTENTION! + + For easy navigation, press CTRL + F and type in your search string. + +This FAQ, and all of my posts/guides/clock drawings, are now dedicated to the +over 3,000 innocent people killed in the World Trade Center and Pentagon +terrorist attacks in New York City, New York, and Washington, D.C., on +September 11, 2001. To all of the innocent working people, and FDNY Firemen, +as well as other emergency workers, you will always be remembered. We won't +stop until we bring these criminals to justice, your deaths were NOT IN VAIN! +God Bless America, death to all terrorists of all races everywhere. +============================================================================ + + +A Practical Guide To Feminizing HRT +Katie Tightpussy + +Helpfully modified into a 90s-00s style .txt file by gretchen +(@boxofmillipedes.bsky.social) for Gen X and Millennial readers, mostly +because I thought it'd be funny. + +(October 8, 2025) + +============================================================================ +DISCLAIMER +============================================================================ + +I am not a doctor. I do not work in medicine. I am not a medical professional +in any capacity. I am a layperson offering lay opinions based on the extent of +my own education and experiences. All information and assertions below should +be treated accordingly as mere opinion rather than statement of fact or +medical advice. This guide prioritizes community moral truth where scientific +research falters. Basically, don’t get mad at me. + + +============================================================================ +0 - FOREWORD +============================================================================ + +The purpose of this living document is to catalogue my thoughts and opinions +regarding feminizing HRT because I believe that the various community wikis +are impractical. They are valuable resources, but in my view these wikis lack +utility for people who are more interested in clear actionable guidance than +they are in learning every semi-relevant biological progress and graph. I aim +to provide an exhaustive quick reference guide of simplified direct answers to +the most common questions on how to safely and effectively perform HRT that I +have received over the years with the goal of demystifying this life saving +medicine both for people considering HRT and for established transsexuals. As +such, I assume a baseline familiarity with the effects of HRT. In case you are +not familiar: HRT does a lot and probably more than you think. It’s great. +Changing your sex is really cool and fun. I recommend it. You deserve quality +transition healthcare and are capable of making the best decisions for +yourself. I hope that this document can be a useful tool in your +decision-making process and a starting point for further learning if that is +your interest. + +And stay off the trans subreddits, too. Just trust me on that one, okay? Or at +the very least /r/mtf since that one is particularly bad. Neither healthy +places nor sources of good wisdom. You’ll be pulling rotten brain worms out +for years. Best advice I can give. + +As for the fellas, sections of this are still highly relevant, but obviously +there are key differences in goals and outcomes. This guide for masculinizing +HRT [Warning: Google Docs link +(https://docs.google.com/document/d/ +1DXFxzN0XTudPZez_SO61fpqncRLPH_Be_QG_8Pcz9LU/edit?tab=t.0)] looks pretty +solid, but I haven’t examined it in full depth, so use your brain and your +judgement. Anyway they should make a tboy Katie Tightpussy. Oliver Longdick +or something. Maybe Xavier. + +If you would like to donate to support this project, +CashApp(https://cash.app/Katitties), Ko-Fi(https://ko-fi.com/katitties), and +Venmo(https://account.venmo.com/u/katitties) all work. I appreciate it! + + +How to Use This Document + +This document is structured linearly as a series of questions and answers such +that broadly-speaking each question and section flows into the next. I +encourage reading it top-to-bottom as that should hopefully answer any +questions (including ones you didn’t know that you had) in a conversational +narrative, but obviously this is lengthy. Take your time and read it in pieces +if you wish. + +You can use the table of contents to navigate to a particular section or +question as needed, especially when re-visiting. I recommend saving this +page/document so that you can refer back to it any time you have questions +about your HRT. It is a lot to absorb up front, so it’s okay if it doesn’t! No +rush on any of this. + + +============================================================================ +DEDICATION +============================================================================ + +This document is dedicated to all of our sisters who did not make it. May we +carry the light of their torch into another day. + + +============================================================================ +1 - INTRODUCTION +============================================================================ + +1.1 Is taking estrogen safe? + +With modern bioidentical hormones, HRT could not be much safer. You’re just +flipping the primary juice that your body runs on and shifting the balance of +hormones that are already in your body. Even where the details of optimization +get complex, the core principle of changing your biology is highly forgiving. +The body is malleable and you will be able to adjust to what feels right for +you. + + +1.2 What route of administration should I choose for estrogen? + +Injections. They are on the whole the most effective, easy, consistent, safe, +and inexpensive form of HRT. For some, injections become a ritual to look +forward to, and others they can become quite fun. + +But remember: any estrogen is better than no estrogen. + + +1.3 Why do you not recommend pills, patches, or gel? + +Chiefly, all three have major downsides that injections do not. It is not that +they do not work, it is that you deserve better than being forced to tolerate +major downsides. Let me reiterate: all forms of HRT can produce satisfactory +results, but that does not mean all forms of HRT are equal or good. + + +1.4 Is dosage of estrogen equivalent across administration routes or forms? + +No. This is important enough that I did not relegate it to Section 11 “MYTHS +AND MISCS”. Estrogen dosages cannot be directly compared across type or form. +1mg of one is not 1mg of another. Different types and forms have different +properties that affect how much estrogen is absorbed into the body +(“bioavailability”), at what rate, and the resulting half-life. + + +1.5 What is a “half-life”? + +In simple terms, the half-life of a substance is the time it takes until +half of that substance is eliminated. In the context of HRT, this is what +determines how long a dosage stays active in your system, and thus your +dosing frequency. This is referred to as your hormone cycle, and it forms a +curve. Levels go up, they peak, and then they fall. The properties of this +curve (how estrogen levels change over time) are important. + + +1.6 What’s wrong with pills? + +The largest issue with pills is that they carry increased long term blood +clotting and liver coagulation risks. The severity of these risks can be +mitigated in part by taking them sublingually or buccally (dissolving the pill +either underneath your tongue or between your gum and cheek, respectively) as +opposed to orally (swallowing the pill normally) to avoid first-pass +metabolism in the liver. Even with sublingual and buccal methods, however, +it’s common to ingest some amount of the pill, so it’s fair to assume that at +least some risk remains. Please understand that the absolute risk is still low +(e.g., acetaminophen has an order of magnitude more liver concerns than +estrogen), however this risk compounds even further with nicotine-related +estrogen risk. See Question 11.2 as well. + +Beyond this, numerous other issues with pills stem from two main +characteristics: 1) their short half-life and poor bioavailability, and +2) their common necessitation of antiandrogens. The former characteristic +makes pills largely unsuitable for monotherapy (discussed below) when compared +to injections. The latter often comes with an assortment of negative side +effects depending on the antiandrogens involved (see Section 10 +“ANTIANDROGENS”). Together, these characteristics add additional degrees of +variability that make poor regimens and their side effects (such as poor +energy/libido and slower results) more common than with other administration +routes. Pills are also more difficult to stockpile, and in some marketplaces +are more expensive than vials. Please also note that importing pills from +foreign distributors in large volumes may run afoul of customs which may lead +to seizure, financial loss, and/or possible legal trouble depending on your +country’s laws. If anyone asks, you don’t know who ordered those pills. + +If you are on pills for whatever reason, please take 4-8mg sublingually spaced +throughout the day. Under 4mg is almost never a sufficient dosage. + + +1.7 What’s wrong with patches? + + -Relatively expensive (typically even more than pills); + + -More difficult to procure DIY (only via grey market means); + + -Generally necessitate an antiandrogen (see Section 10 “ANTIANDROGENS”); + + -Can result in skin irritation; + + -Require being applied 24/7; + + -Are prone to falling off; + + -Aren’t always consistent in their absorption (such as with heat); + + -Are harder to stockpile (difficult to acquire in bulk); + + -Often fail to exceed menopause levels even with multiple on at once. + + +1.8 What’s wrong with gel? + + + -Difficult to dose accurately which leads to inconsistent levels; + + -Requires regular application of goop due to a relatively short half-life; + + -Can be messy (goopy); + + -Risk second-hand exposure via contact with others + + -Generally necessitates an antiandrogen (see Section 10 “ANTIANDROGENS”). + +It should be noted however that gel requires minimal supplies for +self-production which is a boon in some circumstances. + + +1.9 What about pellets? + + -Generally far more expensive than any other option; + + -Few providers who offer them; + + -Dosing adjustment periods are highly spread out; + + -Defective pellets can cause insufficient levels; + + -Crushed/broken pellets can cause unexpectedly high levels; + + -Generally not possible to DIY them. + +The last point in particular means that you can only go to those few +likely-expensive providers. It’s possible that this is the first time you have +even heard of pellets. See the issue? + + +1.10 What about sprays? + +These are still fairly experimental so there is little to say about them, but +they share pros and cons with gel. I mostly note this here so that you are +aware that they exist. + + +1.11 Is the difference that significant? + +Yes. To the point that I wrote all of this so that I could repeat myself less +by instead linking this. A properly dosed injection regimen is the best form +of estrogen that we have for achieving monotherapy target levels. + + +============================================================================ +2 - WHY INJECTIONS +============================================================================ + + +2.1 What makes injections so good? + +Consistency. Consistency is the name of the game when it comes to HRT. +Consistent hormones means stability, and stability is good. Even the “worst” +injection type (keep reading) can provide a more consistent hormonal cycle +than other routes of administration which provides many benefits. + + +2.2 Are antiandrogens necessary with injections? + +Generally, no. A properly dosed and spaced injection cycle that provides +consistently high enough estrogen levels can naturally stop testosterone +production which forgoes the need for an antiandrogen which is preferable in +most cases. This is referred to as “monotherapy”. + + +2.3 How does monotherapy work? + +In simple terms, the brain does not care which hormone it has, just as long as +it has enough. If there are consistently enough hormones in your body, it +stops producing more. The “consistent” part is what injections are capable of +that other administration routes struggle with. Trying to do sufficient +monotherapy on pills, for instance, is very likely impossible in most +situations. In more specific terms regarding the HPG axis, luteinizing hormone +(LH) and follicle-stimulating hormone (FSH) are suppressed by increased serum +estradiol levels, thus inhibiting GnRH production and by extension +testosterone production in the testes. + + +2.4 How are injections safer? + +By generally not necessitating antiandrogens (see Section 10 “ANTIANDROGENS”), +the long term risks associated with antiandrogens are obviated. Bioidentical +estrogen that bypasses the liver (see Question 11.1) is as close as we can +possibly get to natural estrogen production which removes additional risk. + + +2.5 But aren’t there risks with the physical act of injecting? + +Yes, but with minimal training required (see Section 5 “TECHNIQUE AND +SUPPLIES”), at worst one may experience a minor bruise. It is akin to riding +a bike in that once you know how to do it, you would have to try VERY hard to +do it significantly wrong. + + +2.6 How are injections easier? + +Once you are dialed in, you are good. Injections don’t require frequent +administration (e.g., a weekly injection vs multiple daily pills), are not at +major risk of inaccurate dosing, cannot fall off mid cycle, and don’t require +potentially significant travel to a provider. + + +2.7 How are injections cheap? + +In simple terms, far less estrogen is needed. A 5ml vial that is capable of +providing nearly a years’ worth of estrogen has only 200mg of estrogen in that +vial, whereas a minimum equivalent supply of pills for example +(4mg * 365 days = 1460 mg) is substantially more. This is not a rigorous +comparison, but it’s a useful demonstration of scale. Another fun comparison +is that you can fit 1-2 years of estrogen vials inside of a typical +three-month supply bottle of pills. + + +2.8 But I don’t have insurance / my insurance won’t cover it / pills are +cheaper than injections with my insurance / injections are not available in my +country / my doctor won’t prescribe injections? + +Please see Section 6 “SOURCING VIALS”. You will be amazed, and quite likely, +radicalized. + + +2.9 Is swapping to injections good even after years on HRT? + +Yes. Nothing is guaranteed, but many people experience substantial noticeable +differences after swapping to injections even after years on HRT. These range +from increased breast development, improved mental health, alleviated side +effects of antiandrogens or other forms of estrogen, generally feeling better, +etc. Switching is worth it. + + +2.10 But injections are scary? + +Yes, they are at first. Nobody likes needles because the body naturally does +not want to poke itself, but with proper technique and supplies, it won’t hurt +much at all. There are countless cases of people with debilitating +needlephobias who now find the experience of injecting to be boring. The fear +is normal and common, but it is wholly surmountable and worth overcoming. “Oh, +that wasn’t as bad as I thought,” is a very common sentence. As the mantra +goes: do it scared. You’ll be okay. + + +2.11 Are injections like a blood draw or a vaccine? + +No. Blood draws typically use much larger needles and go into a more sensitive +spot while also draining you of blood which is usually unpleasant. Vaccines +contain vaccines which cause painful immune reactions because they are +vaccines. HRT injections put a small amount of hormones in you which causes +you to feel good because you have hormones in you. You see the difference, I +trust. The act of injecting yourself can also be easier than someone else +injecting you, depending on your inclination. + + +2.12 Are there any accessibility tools for injections? + +Yes. Auto-injectors exist and can be quite useful if you have fine motor +control issues for instance. Please see Question 5.21, or just keep reading. + + +2.13 But I am special and can’t inject because I have glass bones and paper +skin and—? + +I understand the fear, but if you truly do not wish to do injections under any +circumstances and don’t have some sort of legitimate contraindication like +hemophilia, then don’t. You can just say that. It’s fine. When you change your +mind, this guide will still be here. And if you don’t, so be it + + + +============================================================================ +3 - TYPES AND DOSAGES +============================================================================ + + +Key Vocabulary + +3.1 What are the different types of injectable estrogen? + +The four main types used for HRT are estradiol valerate (EV), estradiol +cypionate (EC), estradiol enanthate (EEn), and estradiol undecylate (EUn). +Each of these is an “ester” of estradiol and will be converted to estradiol +in your body. + +Please note that in some regions pills are confusingly sold with the name +estradiol valerate, but this section only refers to the injectable form. + + +3.2 What are the differences between each type of injectable estrogen? + +The only relevant difference between esters is that each has a different +half-life and resultant hormone curve which in turn affects dosage and +frequency. + + +3.3 Does one type of injectable estrogen feminize better than another? + +No. The differences affect dosage and frequency which is a qualitative +difference in experience that can make one ester preferable to another, but +all four types work acceptably well and retain the benefits of injections. + + +3.4 What type of injectable estrogen should I choose if I have the choice? + +If you have the choice, estradiol enanthate is preferred for most people due +to the exceptionally stable levels it provides, with the caveat that in most +countries this choice only exists if you are doing DIY (see Section 6 +“SOURCING VIALS”). If you are going through a doctor, you may have the option +of estradiol cypionate, but usually in low concentrations which can make the +benefits moot depending on your tolerance for high volume injections. The most +commonly prescribed injectable estrogen (particularly in the US), estradiol +valerate, is still fully capable of producing good results, but it has some +minor annoyances that make it not preferred when there is the choice for +otherwise (i.e., when doing DIY). Keep reading. + + +3.5 What is “concentration”? + +Estrogen vials are made from estrogen held in an oil solution. The +concentration of a vial is the amount of estrogen held in that solution. This +is given as a ratio of mass to volume for the vial. In other words: for every +one milliliter of oil (volume measurement), there is that many milligrams of +estrogen (mass measurement). You will often see concentrations listed by the +vial’s total volume (e.g., 200mg / 5ml) but it is always preferred to simplify +this fraction (so 40 mg/ml in this case). Typical concentrations are 5 mg/ml, +10 mg/ml, 20 mg/ml, 40 mg/ml, and occasionally 50 mg/ml. + + +3.6 What is meant by “dosage and frequency”? + +Dosage and frequency are the two factors that determine your hormone cycle. +Dosage refers to how much estrogen you put in you (measured in mg), and +frequency refers to how often you put estrogen in you (measured in days or +weeks). You will often hear the word “regimen” as well, referring to +everything HRT-related that you are taking and at what frequencies. + + +3.7 How do I know what my dosage is? + +Your dosage is the concentration of your vial multiplied by the volume that +you are injecting. + + + Concentration(mg/ml)∗volume(ml)=dosage(mg) + + +Please understand that volume alone is not a dosage. An analogy would be with +baking: you cannot just say “bake for 45 minutes” because you have to know +what temperature to set the oven. + + +3.8 What are some example dosage calculations? + +The math is simple, I promise! Below is a small reference table comparing +concentrations and volume for a range of common dosages. Stick to only two +decimal places. You won’t be using syringes that have the accuracy for a +number like 0.153ml for instance. That’s within rounding error and isn’t a +relevant difference at our scale. + +Table 1: Example Dosages for Common Concentrations by Volume + +|-----------|---|---|----|---------| +| |Concentrations (mg/ml)| +| |5 |10 | 20 | 40 | +|----------------------------------| +|Dosage (mg)| Volume (mL) | +|----------------------------------| +|4 |0.8|0.4|0.2 | 0.1 | +|5 |1 |0.5|0.25| 0.13 | +|6 |1.2|0.6|0.3 | 0.15 | +|7 |1.4|0.7|0.35| 0.18 | +|8 |1.6|0.8|0.4 | 0.2 | +|9 |1.8|0.9|0.45| 0.23 | +|10 |2 |1 |0.5 | 0.25 | + +How to read this chart: Take your desired dosage on the left and find the +corresponding volume on the right for your given concentration in the column +at the top. You will notice that the volume requirements for 5 mg/ml vials to +have reasonable dosages is not good. That is because 5 mg/ml vials are not +good. + + +3.9 How do I convert dosages between esters? + +You don’t. Because they behave differently, there isn’t a “conversion” between +dosages in that sense. If you swap from one ester to another, you should just +do a typical dosage for the new ester and work from there. You can make +comparisons between them, but there is no method to convert one to another. + + +3.10 How can I compare different curves and dosages between esters? + +It should be noted that the dosages I list below should be sufficient on the +lower end of the range in most cases. Start with the lower number and move up +if you need. More is not inherently better, but we will discuss that in depth +later. These dosage ranges are unlikely to change regardless of where you +acquired your vial. + + +Meet Your Esters + +3.11 How do I dose estradiol valerate? + +Either twice a week at a lower dosage or once a week at a higher dosage is +necessary for good levels with estradiol valerate. It is a matter of comfort +and tolerance. The typical rule of thumb is about 1mg for every day in a cycle +with frequencies generally between 3-7 days. A weekly dosage between 6-8mg is +my typical recommendation, but 4-5mg per 5 days is also very common. The +frequency should never be less often than weekly (i.e., No more than seven +days between injections). Weekly is already pushing how long the ester can +last. Anything further is highly discouraged to avoid side effects related to +variance (See Question 7.3). + +Please note that in some regions pills are confusingly sold with the name +estradiol valerate, but this section only refers to the injectable form. + + +3.12 How is the hormone curve for estradiol valerate characterized? + +Estradiol valerate is the most finicky of esters. It rapidly spikes to a very +high peak a few days after injection and just as quickly crashes back down. +This relative instability can be unpleasant depending on your personal +sensitivities, but with adjustments to frequency and dosage this can be +mitigated to a degree. + +Figure 1: Serum Estradiol (pg / ml) of Estradiol Valerate vs Time (days) + + +++ +++ +++ + ++++ +++ +++++ +++ +++ + +++++ +++++ ++++++ +++++ ++++ + +++++++ +++++++ ++++++++ ++++++++ +++++++ + ++ +++++ +++ ++++ ++++ +++++ ++++++++++ ++++ ++++ + ++ +++++ +++ ++++++ +++ ++++++ +++ +++++ +++ ++++ + + +++++ ++ ++++++ +++ +++++ +++ ++++++ +++ ++++ + + ++++++++ +++++++++ +++++++++ ++++++++++ ++++ + + ++++++++ ++++++ ++++++ +++++++ +++ + +++++++ ++++++ ++++++ ++++ +++ + +++ +++ ++++ +++ ++ + +++ + + + +3.13 How do I dose estradiol cypionate? + +Estradiol cypionate can accommodate a weekly dosage without issue. A weekly +dosage between 5-7mg is typical. Extending the duration past weekly (e.g., +every 10 days) is not recommended because it is a less efficient use of +estrogen compared to weekly as it requires increasingly higher dosages to +reach acceptable levels. Any extension past weekly is much more prone to side +effects due to variance (See Question 7.3). + + +3.14 How is the hormone curve for estradiol cypionate characterized? + +Estradiol cypionate is more forgiving than estradiol valerate. The curve does +not progress as quickly with a much lower variation between high and low, but +there is still a noticeable rise and fall over a typical weekly duration. + +Figure 2: Serum Estradiol (pg / ml) of Estradiol Cypionate vs Time (days) + + + + +++++++ +++++++ ++++++++ +++++++ +++++ +++++ ++++++ +++ ++++ ++++ +++++++ +++ +++++++ +++ +++++ ++ ++++ ++++ +++ ++++ ++++ + + + +3.15 How do I dose estradiol enanthate? + +Estradiol enanthate can easily accommodate a weekly dosage without issue and +can possibly be extended up to 10 days if one is inclined. Beyond that is +technically possible but not recommended as levels will become increasingly +unstable. A weekly dosage of 4-6mg is typical, with 5-7mg recommended for up to +10 days. Weekly is still recommended regardless for consistency and ease of +scheduling as any extension up to 10 days does not offer much benefit in my +opinion. + + +3.16 How is the hormone curve for estradiol enanthate characterized? + +Estradiol enanthate is the gold standard for injectable estrogen. It has a +curve that is extremely flat (i.e., has little variance) over the duration of +a typical weekly duration. This allows for very consistent levels without any +negative side effects related to variance (See Question 7.3). + +Figure 3: Serum Estradiol (pg / ml) of Estradiol Enanthate vs Time (days) + + + + + ++++++++++ ++++++++ +++++++++ ++++++++ ++++++++ +++++++ +++++++++ +++++++ +++++++++ ++++++++++ ++++ + + + +3.17 How do I dose estradiol undecylate? + +Estradiol undecylate is capable of extending far beyond weekly into the range +of monthly or quarterly. The recommended dosing for this, however, is not +standardized or known. The factors that affect how the estrogen from an +injection is absorbed (“pharmacokinetics”) that are negligible for other +esters are significant for estradiol undecylate. As a result, this is still +highly experimental territory that is beyond the scope of this guide. Consider +consulting a witch’s almanac for the lunar calendar to inject once every full +moon. + + +3.18 How is the hormone curve for estradiol undecylate characterized? + +We don’t really know. The data is too sparse to paint an accurate picture of +it in full, and the variables are plentiful. It is something that you can +research and experiment with if you are interested, but it is new ground and +you need to understand the risks involved with being a human guinea pig, so I +don’t recommend it unless you know what you are doing. + + +Figure 4: The Moon + + + ++++++++++++++++++ + +++++ ++++++++++++++++++++ + +++++ +++++++++++ ++++++++++++++ + ++ + ++++++ + ++++ ++++++++ +++++ + + ++ +++ + + ++++ + ++ + ++++++++ + +++ + ++ ++ ++++ +++++ +++++++++++++++++++++++++++ + ++++ ++++++++++ + +++++ + ++ ++++++++++++++++ + ++ ++ + ++++ + +++ +++++++++ + +++++++++++ + ++ +++ + +++ + + + + + + ++++ ++ + + ++ +++++++++ + +++ +++ + + + ++++++ ++++ +++++ +++++++ ++++++++++ + ++++ +++ + +++++++++++++++++ +++++++ + +++ +++++++++ + ++++ + +++ +++++++ ++++++++++++ ++++ ++ +++ ++++++++++ + + + + + + +++ ++ +++ +++ ++++ +++ + + ++++ ++ +++++++++++ + +++ + + ++ ++ ++ + ++++ +++ ++++++ ++ + + +++ ++ +++++ ++ + +++++++ + ++ + + ++ + + ++++++ +++++ +++ +++++ + ++ + ++++++ + + + +++++ + +++ ++++ ++++++++++ ++++ + +++ + ++ + +++++++++ ++ + +++++++++++++++++++++++ + + ++ ++++++ ++ + ++ +++++++ ++++++++ + +++ +++++++++++++++++ ++ + ++ ++ ++++++ + +++++++++++ + + + ++ + ++++++++++++++++++++++ +++ +++ ++++++ + + ++++++++ + +++ + + ++ ++ ++++++++++++++++++++++++ + +++ + +++ ++++++++ +++ ++++++++++++++++++++++++++++++ ++ + ++++ + +++++++++ + ++++ ++ +++++++++++++++++++++ +++ ++ +++++ + ++++++++++++++ +++++++ ++++++++++++++++++++++ ++++ +++++ + + +++ ++ + + ++++++++++++++++++++++++++++++++++ ++++++ ++++ + +++++ ++++++ +++++++++++++++++++++++++++++++++++++ +++++ + +++++ +++++++++++++++++++++++++++++++++++++++++ ++ ++ + ++++ + +++++++++++++++++++++++++++++++++++++++++++++ + ++++++ +++++++++++++++++++++++++++++++++++++++++++ + ++++++++++++++++++++++++++++++++++++++++++++++ + ++++++++++++++++++++++++++++++++++++++++++ + +++++++++++++++++++++++++++++++ ++++++ + +++++++++++++++++++++++++++++++ + ++++++++++++++++++++++ + ++++++++++++ + + + +============================================================================ +4 - BLOOD TESTS AND LEVELS +============================================================================ + +Acquiring Results + +4.1 How often should I test my levels? + +While you are first dialing in your dosage, you will want to test relatively +frequently. Following any adjustment to your regimen, you should give your +levels 1-2 months to stabilize, and then test once they’ve reached their new +normal. + + +4.2 Do I have to test my levels before starting HRT? + +Arguably no, because testosterone will be too high and estrogen will be too +low so it’s not particularly useful data, but routine general blood tests +(i.e., a lipid panel and such) are recommended for your health nonetheless. +The exception is if you believe that you may have an intersex condition which +may affect your HRT regimen as sometimes this can be visible in the +preliminary blood test. + + +4.3 Do I have to test my levels if I haven’t changed my dosage in a long time? + +Arguably no, because if you have not changed anything then nothing should have +changed. It can be good for peace of mind if you have changed aspects of your +routine / supplier, and doctors/insurance often require it, but major +deviation shouldn’t be expected. A caveat is that if you are experimenting +with estradiol undecylate, you almost certainly should test quarterly at +minimum regardless. + + +4.4 I don’t have insurance or a doctor. Where can I get a blood test? + +Look into private blood testing options in your region depending on the +legality of it. In many locations, you are legally able to get private blood +tests, but they might not be cheap. There may be online options that allow you +to get those tests at a discount but it depends heavily on your region. + + +4.5 I can’t get / afford a blood test. Can I still do HRT? + +While having the information is obviously preferable to not, HRT is extremely +safe and at typical dosages should pose no issue. You will just have to rely +more on how you are feeling and what you observe. + + +4.6 What should I test for? + +Estradiol (E2) and total testosterone (T) at the least because these are the +main things to be concerned about. Sex hormone binding globulin (SHBG), +dihydrotestosterone (DHT), estrone (E1), and prolactin (PRL) can also be +useful to test if you are experiencing issues because these can be useful for +troubleshooting. Follicle-stimulating hormone (FSH) and luteinizing hormone +(LH) can tell you if your HPG axis is inactive which is the basis of +monotherapy (See Question 2.3). But again: Estradiol and Total Testosterone +are the primary concerns. + + +4.7 When should I take a blood test during my hormone cycle? + +At the end of your cycle (“trough”). You want as close to the bottom as +possible because this is the most useful piece of information. Arguably, it is +the only useful piece of information as consistent minimum levels are the +primary concern. Example: If you normally inject Thursday afternoon, get your +labs in the morning or early afternoon on the following Thursday before your +next injection. + + +4.8 My doctor said to take mid-point / peak level blood tests, should I? + +No. Measuring the peak estrogen level does not provide useful information and +is only a measure of what ester you are using. Charitably, it is incompetence +because of dated conservative standards of care. Uncharitably, it is malice to +ensure insufficient estrogen levels that will result in poor health, slow +results, or otherwise negative outcomes. I recommend measuring at trough +regardless. + + +Interpreting Results + +4.9 What estrogen levels do I want? + +This is probably the most controversial question with transition. The short +answer is that you want enough that you feel good and that you are suppressing +testosterone if you need to, but beyond that, higher levels are unnecessarily +wasteful at best and may be counterproductive at worst. This is a wide range +however, and with so many variables there is always personal deviation. In +other words: You want enough estrogen such that you feel good, and that’s it. + + +4.10 Do higher estrogen levels feminize better or faster? + +No. Higher estrogen levels than necessary might be preferred by someone for +their subjective experience, but they do not confer feminization benefits. In +fact, levels that are too high can feel bad by causing mood instability or +other undesirable side effects. Minimizing testosterone levels to a baseline +is far more important for feminization than maximizing estrogen levels. + + +4.11 Okay, but what number do I want to see from my estrogen lab result? + +With the understanding that the exact number does not matter, that the number +will always be slightly higher than whatever is in your body even on a trough +day because of latency, and that the number will be in a cloud of +possibilities based on any number of factors, I recommend a trough of about +200 pg/ml (730 pmol/L) minimum. This is a slightly conservative recommendation +to provide ample wiggle room as suppression of the HPG axis occurs below this. +Around here tends to work well for most, although some prefer higher or lower. +I don’t believe this is a number that should be overly fixated upon because it +is inherently variable and if you feel good that is what matters most, but +beyond 300pg/ml (1100 pmol/L) at trough is almost certainly higher than it +needs to be or should be. + + +4.12 What testosterone levels do I want? + +Testosterone suppression is the key requirement for adequate feminization, so +under 50 ng/dL (1.7 nmol/L) is generally sufficient. Notably, near-zero +testosterone is not desired. See Section 9 “TESTOSTERONE”. + + +4.13 I naturally have high/low T. Do I need to adjust my dosage? + +Probably not. The testosterone range that is typically found prior to HRT is +almost always higher than what is desired for feminization and will still be +suppressed regardless (See Question 2.3). The exception would be if you have +any variety of intersex conditions that may cause need for finer adjustment +than the recommendations listed in this guide which is beyond the scope of +what this guide can provide to you. You might not need to tweak, but maybe you +feel better if you do. Ultimately, do what feels right. See Question 9.2. + + +4.14 I have had bottom surgery. Do my estrogen levels need to be different? + +Since testosterone suppression is no longer a concern for you, you likely can +still feel great with lower estrogen levels than you currently have, but you +do still need estrogen. Because you no longer produce your own hormones, it is +crucial that you still maintain sufficient hormone levels for your health. +Having little to no hormones will lead to menopause symptoms which is the same +reason that older cis women might take HRT once they hit menopause. Adjust as +you see fit. + +For additional clarity: maintaining a minimum of about 100 pg/ml (350 pmol/L) +is essential to avoid bone mineral density concerns. If the bulk of your +feminization is already complete, then in many respects your hormonal profile +is comparable to a menopausal cis woman so lessons can be learned from them +(See Question 11.29). In some cases of fatigue or low energy, supplementing +low dosages of testosterone may be beneficial (See Question 9.2). + + +4.15 Is there anything that can cause a blood test to be inaccurate? + +Depending on how the blood is measured (“assay”), biotin supplements can cause +estradiol (E2) levels (among others, but estradiol is our concern) to be +unexpectedly high. It is not always possible to know the type of assay that +will be used, so pausing any biotin supplements a few days before testing is +recommended. It is also possible that there was an error with the equipment or +the sample, although this is not likely. + + +4.16 Do different estrogen esters or administration routes show up differently +on blood tests? + +No. There is no way to tell what type of estrogen someone is taking based +solely on a blood test result. The various injectable esters all convert to +estradiol like we want, and the same is true for pills, patches, gels, sprays, +or whatever else. It’s all estrogen at the end of the day. + + +============================================================================ +5 - TECHNIQUE AND SUPPLIES +============================================================================ + +Sites & Safety + +5.1 How do I safely perform an injection? + +I recommend the following two videos: + + 1. https://www.youtube.com/watch?v=cBabaGC2Dok + 2. https://www.youtube.com/watch?v=YfNlAZLxLyw + +Between these two videos, you should be fully equipped to properly inject with +minimal pain. I suggest studying them and revisiting as needed. One key thing +to emphasize is to inject with the bevel facing up to reduce pain. In other +words: the needle has a clearly defined point, and you want that to be what +touches your skin first. You want a nice straight line of travel. You can +think about how your hand/wrist rotates if that helps you visualize the +motion, but realistically it’ll be intuitive muscle memory that you’ll learn +naturally. + +Remember: injecting is a skill! You will get better with time, and it won’t +take long. You got this. + + +5.2 Do I have to inject exactly like this? + +No, variation is fine. Ultimately when the task is just poking yourself, +there’s a lot of ways to do that. Find the way that works best for you. Doing +a quick dart motion usually works best, but if you have to go slow that works +fine too if it’s something that is consistent that you can get better at doing. + + +5.3 How do I get past injection anxiety? + +I suggest making a ritual out of the process. By forming a routine, the +process becomes second nature. If you can distract your mind by listening to +music, having a conversation, watching a show, or doing something else that +works for you to let your muscle memory take over, that’s great! Find what +works for you. Having a friend or loved one do your first few injections can +help too. For most people, the first injection is the scariest. Usually people +say, “Oh, that was it?” because it’s never as bad as they expect. + + +5.4 Does it matter where I inject in my body? + +Yes and no. Staying within safe areas matters, but otherwise, where you inject +primarily depends on your mobility, the volume of fluid that you are +injecting, the needle/syringe combo that you are using, and your own comfort. +Either way, make sure to rotate injection sites. Alternate sides of your body +with every injection–for example, if you inject into your right leg one week, +use your left leg the next. This is to minimize any long term scarring risks. + + +5.5 What injection sites are safe? + +Opinions vary between medical authorities, but your body composition can also +play a role. I recommend injecting on the side of the leg as shown in the +video(s) because it is doable for most people and is capable of being very +consistent which means consistently painless injections once your technique is +practiced, but other people prefer their glute or their stomach. This video +(https://vertisis.com/articles/how-to-self-administer-a-subcutaneous-injection) +shows other injections sites that can be acceptable depending on the supplies +you use. Figure out what works best for you. + + +5.6 What do “intramuscular” (IM) and “subcutaneous” (SubQ/SC) mean? + +You will often hear these terms in the context of injections. Intramuscular +means injected into the muscle and subcutaneous means injected into the fatty +layer beneath your skin. + + +5.7 What is the difference between intramuscular injections (IM) and +subcutaneous injections (SubQ/SC)? + +In the context of HRT, there is little to no difference between intramuscular +and subcutaneous injections. Subcutaneous injections are absorbed more slowly +than intramuscular injections, however this is generally not significant +enough of a difference to impact dosing. It should also be noted that an +injection is rarely deposited fully in muscle or fully in the subcutaneous +layer which blurs any difference together even further on an injection-by- +injection basis. + + +5.8 Should I perform intramuscular injections (IM) or subcutaneous injections +(SubQ/SC)? + +This is the wrong question. An injection is an injection. Subcutaneous +injections are often recommended because people believe that they allow for +less painful injections by virtue of being subcutaneous, but there is not a +fundamental difference in how an injection is performed. The advantages that +people refer to are not inherent to the injection depot location; they are +inherent to the factors that affect injection pain. The better question would +be “How do I minimize pain during injection?”, but two other questions first. + + +5.9 Does my injection angle and/or preferred injection method matter? + +No. To reiterate, the most important part of performing an injection is that +you pierce a needle through your skin and deposit fluid into your body. If the +fluid doesn’t leak out (or at least, not much) and it doesn’t hurt (or at +least, not much), then you have done a fantastic job. I cannot stress enough +that the intramuscular vs subcutaneous “divide” is nonexistent and that the +question does not meaningfully impact the effectiveness of injectable +estrogen. Estradiol undecylate is the only case where depot location seems to +meaningfully affect absorption, but even then, we don’t fully understand the +details. Point being: please be concerned about the things that matter and not +the things that don’t matter. + + +5.10 Do I have to aspirate? + +No. “Aspiration” refers to pulling the plunger back after puncturing the skin +before injecting the fluid with the intent of ensuring a blood vessel is not +being injected into. Its necessity is controversial, but for hormone +injections following standard procedures, there are few benefits that outweigh +the negatives. The standard injection sites have low risk of striking a blood +vessel in the first place, lessened even further by shorter needle lengths, so +this practice is not recommended anymore by most medical organizations. + + +5.11 How do I minimize pain during injection? + +Aside from practicing your technique and improving your skill, the main factor +for injection discomfort is the needle and syringe combination that you are +using. To minimize discomfort, the highest needle gauge that your vial’s +carrier oil is capable of tolerating should be used along with an +appropriately sized syringe and needle length. You should ask “What needle +gauge and length should I inject with?” To answer that, let’s talk about how +needles work. + + +Knowing Your Needles + +5.12 What is “needle gauge”? + +Needle gauge is a measure of needle thickness. The bigger the number, the +thinner the needle. A 25G needle is thinner than a 20G needle, for instance. +Higher gauge needles also tend to be shorter because longer needles become +more prone to bending, so their length has a lower maximum. Unsurprisingly, +thinner needles generally hurt less. It should be noted that the gauge of +needle(s) used will not affect HRT in any way; it will only affect the ease +and comfort of the injection itself. + + +5.13 What are “Luer lock” and “insulin” syringe/needles? + +Luer lock syringes have separate syringes and needles so a separate needle can +be used for drawing and injecting. Insulin syringes have a needle fixed in +place which means that the same needle will be used for drawing and injecting. +Where possible, insulin syringes are preferred for comfort and for minimizing +dead space (See Question 5.26). + +Safety Warning: Recapping needles is generally not recommended out of concern +for sticking yourself, but if you do (such as when swapping out a drawing +needle), NEVER apply force with your hand towards the needle. + +It is possible that the cap may break and you may injure yourself if you place +the cap incorrectly. Gently “scooping” the cap onto the needle off of a +horizontal surface and pressing the loosely capped needle against a wall or +pulling the cap on the sides to fully seat the cap is preferred. There isn’t a +disease transfer risk when performing a self injection, so heed this warning +at your own discretion, but resticking is a VERY serious concern when +performing injections on others. For disposal, see Question 5.27. + + +5.14 What needle gauge should I draw with? + +If you are using Luer lock syringes, it is recommended to use a lower gauge +than what you inject with so that it takes less time to draw from the vial. +Too low can lead to coring (See Question 5.23), so at least 21-23G is +recommended. If you have patience and lower volumes to inject, then higher +gauges are recommended for the aforementioned coring risk reduction. Please +note that the needle does not meaningfully blunt on the stopper. This question +is irrelevant with insulin syringes because the needle is not removable. + + +5.15 What needle length should I draw with? + +If you are using Luer lock syringes, the length of the drawing needle does not +matter too much outside of the inconvenience of having too long of a needle +being unwieldy. In other words, no need to be picky. This question is +irrelevant with insulin syringes because the needle is not removable. + + +5.16 What needle gauge should I inject with? + +This is a tricky and highly subjective question, and your answer will depend +on 4 main factors: 1) the carrier oil for what you are injecting; 2) if the +vial contains a cosolvent; 3) your patience to have a needle in your leg for +longer; and 4) your willingness/ability to push harder on the syringe plunger. +It’s a question of comfort. Thicker oils mean more time and more effort when +using a higher gauge, but also higher gauges can be significantly less painful +going in. As a baseline, 25G is the minimum needle gauge that you should use +to manage discomfort. Most common carrier oils can generally do up to 27G +comfortably, whereas MCT oil in particular is notable for being able to easily +do 30G (See Question 6.16). + + +5.17 What needle length should I inject with? + +I recommend between 0.5” to 1” (12.5mm to 25mm) depending on your gauge. Below +0.5” (12.5mm) increases the likelihood of leakage. 0.25” (6.5mm) length +needles can be fine depending on your technique and the fluid you’re +injecting, but 0.5” (12.5mm) is a safe bet. Beyond 1” (25mm) is unnecessarily +daunting and painful without any added benefits. + + +5.18 Does syringe size matter? + +Yes, size matters. There are two reasons for this. 1) Higher volume syringes +tend to be less precise which leads to incorrect dosing, and 2) physics makes +higher volume syringes more difficult to inject. For dosing accuracy, you do +not want to use a syringe far larger than the volume that you are injecting +(i.e., for injections less than 0.1ml, get smaller than 1ml syringes). Avoid +3mL syringes entirely if you can. Obviously use them if it’s all you have, but +they’re really not meant for a task like this. Do not ask me why pharmacists +seem to near-exclusively hand them out. A cruel joke, maybe. + + +5.19 Where do I buy syringes and needles? + +It depends on your local jurisdiction as some localities ban the sale of +needles and syringes to individuals as a punitive measure against drug users. +Otherwise, medical and veterinary supply businesses or authorized manufacturer +retailers should be good places to look. Amazon is not recommended because the +quality is uncertain. + + +5.20 Is it okay if I reuse needles or syringes? + +No. Never reuse needles or syringes. Or share either. You probably already +know this but I’m just reminding you because it’s really not good or safe to +do! + + +5.21 What if I want to do injections but have difficulty performing it on +myself? + +You might like an auto-injector. As the name suggests, auto-injectors perform +the injection for you. Auto-injectors like the UnionMedico 45/90 Super Grip +can take 1ml syringes which can take the difficulty out of injecting (but you +still manually press the plunger), whereas auto-injectors like the Owen +Mumford Autoject 2 entirely hide the needle of an insulin syringe and +automatically push down the plunger. There are also a variety of 3D printable +designs available online. I have used none of these products and these are not +endorsements. + + +Basics of a Vial + + +5.22 What should I look for when inspecting vials? + +Aside from looking for signs of coring (see below), you should look for any +signs of discoloration, separation, contamination, crystallization, cracks in +the glass, fibers, hairs, etc. A properly made vial should not deviate too +much from usual. Always inspect your vials before use. Do not use a vial that +does not seem right. + + +5.23 What is “coring”? + +Coring is when a piece of the rubber stopper breaks away and falls into the +vial. This can occur with too large of drawing gauges, repeated punctures on +the exactly same spot, or too many punctures (i.e., a very small volume +injection with a very large volume vial). A cored vial should be immediately +discarded. The 45-90° technique (https://www.youtube.com/watch?v=w5F0SLoMjC8) +can also be used to help minimize coring. + +The concern with coring is that you do not want to inject bits of rubber into +you. If there are large bits of rubber, there might be smaller ones that you +can’t see. The purpose of the stopper is to protect the contents from the +elements, so a vial with a hole in the top is more prone to oxidation and/or +bacterial growth. As a side note: Please ensure that you remove the metal or +plastic cap off the top of a new vial. This may seem obvious, but some vial +designs can be confusing. + + +5.24 How long until a vial expires? + +A sealed vial could last for years without issue if it is stored at stable +temperatures away from the light. Concerns with age are primarily carrier oil +oxidation assuming that the vial was sterilized as it should be. A punctured +vial that has a preservative in it (See Question 6.17) should last at least a +year or whatever the life time of the vial is (i.e., how long until you use it +all). The “discard after 28 days” listing on vials is simply the minimum +requirement for how long manufacturers must guarantee sterility, not the +maximum shelf life. + + +5.25 How should I store a vial? + +Stable room temperature and away from light. High heat and UV can cause +degradation of the carrier oil, whereas low temperatures can cause +crystallization. Crystals can be dissolved and reincorporated, but it’s a +potential cause for irritation if they aren’t fully dissolved. This goes for +both sealed and unsealed vials. + + +5.26 What is “dead space”? + +Dead space refers to the amount of fluid that is wasted when performing an +injection. This is fluid that is trapped in the syringe or in the needle. With +a standard Luer lock needle/syringe this can be up to 0.1mL, whereas in an +insulin needle can be as low as 0.003mL. Reducing dead space is recommended +for economic reasons because it adds up to a lot of wasted estrogen. This +calculator (https://hrtcafe.net/Calc/) can be useful for estimating how much +estrogen is wasted depending on the supplies used. + +One thing to note if you are swapping needles for drawing and injecting, then +you should pull the plunger back slightly prior to taking off the drawing +needle so that the fluid inside the drawing needle is not wasted. It is very +minor, but it can make a difference. See Question 7.7 for another possible +strategy if concerned about high dead space. + + +5.27 What do I do with my used syringes and needles? + +Place all used injection supplies pointed down in a sharps container (either a +dedicated biohazard container or reusing hard plastic tubs such as from +protein powder or laundry detergent). When the container becomes +three-quarters full, seal it closed so that it cannot be accidentally opened. +Clearly label it “USED SHARPS” and then dispose of it according to your local +jurisdiction’s requirements. Note that sharps should NOT be placed into trash +or recycling containers. Your city/state/region likely has a website somewhere +describing how and where to dispose of household hazardous waste. For the US, +you can go here (https://safeneedledisposal.org/). + + +============================================================================ +6 - SOURCING VIALS +============================================================================ + +6.1 Where do I get estrogen vials to inject? + +Broadly speaking, you have two options: pharmaceutical sources and DIY +sources. Pharmaceutical sources typically require a doctor’s prescription +because HRT is not available over-the-counter (or if it is, vials are not +included) in most countries. DIY sources encompass everything else. + + +6.2 Should I use pharmaceutical sources or DIY sources? + +The choice is yours, but sometimes there is no choice at all. There are pros +and cons to each. Of course, there is nothing stopping you from procuring +estrogen from multiple sources to get the benefits of both. In many +situations, it may be recommended. + + +Pharmaceutical Sourcing + +6.3 What are the pros of pharmaceutical sources? + + -Can generally trust quality control processes and certifications; + + -Insurance may cover it in part or in full; + + -Can be more convenient depending on your luck with doctors; + + -The product most likely will be consistent; + + -At least appearing to be using pharmaceutical sources may be required if + you are seeking insurance approval for surgeries. + +6.4 What are the cons of pharmaceutical sources? + + -Reduced (or no) selection of esters; + + -Possible lengthy wait time (months or years); + + -May be required to have a prescription (depending on country); + + -Insurance may not cover costs in part or in full; + + -May not be prescribed at all in your country; + + -Your doctor may arbitrarily refuse to prescribe it to you; + + -Your doctor may arbitrarily withhold refilling a prescription; + + -Shortages may prevent filling a prescription at all; + + -Likely held to stringent WPATH requirements or worse; + + -Harder to stockpile; + + Access is subject to the whims of your country’s political situation which + also means that your transness will likely be included on your medical + record. + + +DIY Sourcing + +6.5 What are the pros of DIY sources? + + -Generally much cheaper in most places; + + -Available anywhere in the world; + + -Obtaining it can take months or even years less time than waitlists (the + only wait is shipping and production); + + -Easy to stockpile; + + -Full selection of esters; + + -No requirement of dealing with the medical system; + + -It’s probably made with love. + +6.6 What are the cons of DIY sources? + + -Almost certainly not made in a certified clean room; + + -Quality can vary depending on the source; + + -Can be inconvenient depending on the source; + + -Requires trusting the source; + + -Requires finding a source; + + -Sources are more likely to close than your local pharmacy; + + -Product delivery times can vary; + + -Most likely have to use cryptocurrency which is annoying; + + -Cannot use insurance if that was an option for you. + +Additionally as already stated, if you are seeking insurance approval for +surgeries, they likely require a minimum amount of time with an HRT +prescription. This may or may not be a concern for you. + + +6.7 What types of injectable estrogen are DIY only? + +Chiefly, estradiol enanthate. Pharmaceutical sources will almost always +prescribe you estradiol valerate, but not always at a 40 mg/ml concentration. +Estradiol cypionate may occasionally be prescribed, but rarely above 5 mg/ml +or 10 mg/ml concentrations, which are annoying to dose. The benefits provided +by estradiol enanthate alone are very good reasons to consider DIY, but you +can get any ester at 40 mg/ml from DIY sources. + + +6.8 What actually are DIY sources? + +DIY sources include commercial brewers, mutual aid projects, your friend, and +yourself if you have an entrepreneurial spirit! + + +6.9 Where can I get DIY vials? + +What are you, a cop? I’m not telling you that. That’s not the point of this +guide anyways. There are other resources that have that information. Stay +focused. + + +6.10 How can DIY sources be cheaper than pharmaceutical sources? + +The cost to produce a vial is roughly around $10, including labor and +amortized capex cost. This is likely a high estimate. The bulk of the cost for +commercial DIY sources are the layers of overhead and shipping involved in +anonymity. Non-commercial DIY sources likely have no such overhead. +Pharmaceutical sources generally do not have any incentive to be cheaper than +what they are. + + +6.11 Is DIY legal? + +In most locations including America, estrogen is not a scheduled substance, +whereas testosterone may or may not be criminalized. The US is an anomaly for +testosterone in this regard, as other countries don’t criminalize possession +of testosterone, but prosecution is rare anyway given the wide availability of +steroids. This guide is not legal advice. + + +6.12 Is DIY safe? + +“DIY” as a broad category of sources is neither safe nor unsafe, but not all +DIY sources are equal. When we are discussing the topic of safely injecting +something into your body, the real question is: do you trust that the person +who produced that vial properly followed aseptic techniques and procedures +such that the vial contains what you want and nothing else? For pharmaceutical +sources, that trust is innate on the assumption that laws and regulations +exist. For DIY sources, that trust must be earned through demonstration/ +explanation of process, independent third-party testing for concentration/ +purity, and community reputation. + + +6.13 What things should I look for to know if a DIY source is trustworthy? + +Use your gut and your brain. + + -Are they open to talking to you about their process / have it listed + somewhere? (e.g., do they filter for dust? The answer should be yes!!!) + + -Do they seem competent in their ability? + + -Have they had their product tested? + + -Are they a trusted member of the community? + + -Have they been vetted or vouched for by other members of the community + who you trust? (i.e., inspections, reviews, testimonials, etc) + + -Mistakes happen, but do they take accountability or do they try to + silence negativity? + + -For commercials, do they resolve any issues with customer orders? + + -For commercials, are they taking payment on product not yet produced + without indicating that it is a backorder? (You should never backorder!) + + -Do their vials contain preservatives? + + -How long have they been producing? (For good reason, they may not tell + you!) + + -How much do they produce? (For good reason, they may not tell you!) + + -Are the vibes just off? + +These are just some of the many questions that can be asked to know if you +trust that they care as much as you do about the quality of their product. + + +6.14 Should I hold different DIY sources to different standards? + +Likely, yes. Commercial brewers should also be held to a high standard if you +are giving them money in exchange for product because they can afford to do it +right. A mutual aid product on the other hand that is distributing vials for +free might not be something that you can afford to be picky about, although +that is not to say that the product is likely to be better or worse. As for a +friend or yourself, only you can decide that! + + +Anatomy of a Vial + +6.15 What should I look for in a vial? + +The ingredients inside of a vial can be categorized as “active” and +“excipient”. The active is the estrogen ester in our case, and the excipients +are everything else. There are generally three or four ingredients: 1) the +estrogen ester; 2) the carrier oil; 3) the preservative; and optionally, 4) +any cosolvent(s). We have already covered the estrogen esters in Section 3 +“TYPES AND DOSAGES”. Pharmaceutical vials almost always have all four +ingredients. + + +6.16 What carrier oil should I look for in a vial? + +This is a question of preference, personal tolerance, and possibly allergies. +The main variable relevant to you is viscosity because that affects injection +comfort and convenience. As discussed, thinner oils are able to more +conveniently use higher gauge needles without difficulty when drawing and +injecting. The most commonly used carrier oils for HRT are castor oil and MCT +oil. Castor oil is the thickest oils commonly used, but it also tends to +result in the least amount of irritation so pharmaceutical vials typically use +it. MCT oil is the thinnest oil commonly used, but some people find it more +irritating than other oils and it’s DIY only. Cottonseed oil and grapeseed oil +occasionally find use, but usually not by HRT manufacturers. Other oils like +sunflower or sesame or whatever else occasionally find use but aren’t +generally recommended. Depending on your circumstances, this question might +not matter to you, you might not have a choice, or it may be a strict +requirement. + + +6.17 What preservatives should I look for in a vial? + +The most common preservative used in injectable vials is benzyl alcohol (BA) +in low concentration. This is mandatory and not up to debate. You should never +use a vial without a preservative. For people with the rare allergy, +chlorobutanol is an alternate commonly used preservative, but almost never by +DIY sources which would necessitate hunting specific pharmaceutical formulas. + + +6.18 What cosolvents should I look for in a vial? + +The main cosolvent used is benzyl benzoate (BB) which reduces the viscosity of +the resulting solution. This is technically optional, but it is generally +recommended for batch consistency and in many cases is necessary depending on +the carrier oil and the desired concentration. Some people find it irritating, +but others don’t. + +============================================================================ +7 - TROUBLESHOOTING +============================================================================ + +Dosage Uncertainty + +7.1 My levels aren’t what I expected them to be. Why not? + +There are a number of possibilities. Recall first that model estimations +cannot take into account any plethora of factors which may cause some +deviation. Recall as well that it takes multiple injections until you reach +stability, so if you just changed your dosage that may be why. Quadruple +check with a friend that you are injecting as much as you think you are. That +is more commonly an issue than you might think, but for DIY sources it is also +possible that the concentration is lower than advertised due to inexperience +or less precise equipment. In that case, injecting you may just need to inject +a little more for that vial. But remember, the most important thing is how you +feel, not your levels. Please note that even professional compounding +pharmacies can produce dud vials not caught by quality control, as hopefully +rare as that may be! + + +7.2 Can I compare levels across different tests if I didn’t test at trough? + +No. Not accurately, anyway. This is part of why you should always test at +trough. Hours before your normal time for your next injection; that’s what you +want. Eliminating as many variables as possible makes the data far more useful +to you. If there is nothing else that you take from this guide, please just +test at trough. + + +7.3 I feel really bad on my trough days. What should I do? + +In most cases, either the dosage is too low or the frequency is too low. This +is most pressing for estradiol valerate and estradiol cypionate. Adjust your +dosage within the range listed or adjust the frequency. Find what works for +you. It is also possible with estradiol valerate in particular that your +dosage might actually be too *high* instead of too low as the high level +variability across your cycle may be the culprit for this crashing sensation. +In short: swap to estradiol enanthate if you can. + + +Injection Woes + +7.4 The injection is harder to do when it’s cold. What should I do? + +Warm up the vial before drawing, then warm the syringe before injecting. +Rolling the barrel of the syringe between your hands should be plenty to warm +up the fluid. Forming this as a habit all the time should improve your +injection consistency. + + +7.5 The injection hurts more when it’s cold. What should I do? + +Warm up your leg before injecting. Relaxing the muscles with a massage or a +hot shower (specifically: increasing the temperature with the water aimed at +your leg before you get out) before injecting can help. + + +7.6 I bled after my injection. Will I die? + +No. This means that you likely just hit a vein or a capillary which can happen +sometimes. You might experience some light bruising or increased soreness. +Using a cute bandage will make it heal faster. + + +7.7 There was some air in my syringe. Will I die? + +No. While you obviously do not want to inject just air and it can affect +dosage if there is too much in the syringe, a small amount of air under 0.1ml +is almost certainly not going to cause issue for you. It might actually be +recommended in some cases. For instance, the air lock technique (a standard +technique for injecting fluids that are irritating or can stain, not crucial +knowledge for HRT) generally involves injecting 0.1-0.3ml of air, so you have +nothing to be worried about. You aren’t doing intravenous injections. + + +7.8 Some of the fluid leaked out. Was my injection wasted and/or will I die? + +No. Leakage can happen for any number of reasons and is rarely enough to make +a difference, so you do not need to do another injection. For the future, make +sure to leave the needle in for 5-10 seconds before retracting and then apply +pressure afterwards. You might consider using the air lock technique mentioned +above if you are particularly concerned about leakage. + + +7.9 Sometimes I am really sore after an injection. Will I die? + +No. Assuming you have otherwise followed all of the suggestions within this +guide, sometimes the deposit of fluid hits an uncomfortable place for one +reason or another. Better luck next time. Make sure you alternate injection +spots! You do not want scar tissue to build up over the long term, and if a +spot is already sore, you do not want to make it more sore. + + +7.10 I am experiencing a lot of itchiness and irritation after injecting. Will +I die? + +Probably not. There are a number of possible causes. Infection is the most +concerning cause, but is unlikely in most cases. Immediately go to a doctor if +you are experiencing a fever, severe pain, muscle aches, pus, red streaks, or +other signs of infection. In most cases however, irritation like itchiness, +redness, light swelling, warmth, etc are the result of using a vial whose +estrogen and oil have separated (“crashed out of solution”). See below. It’s +possible that you may be having a reaction to the carrier oil, but if you are +suddenly experiencing issues after some injections without any issue, it is +most likely that the vial contents are out of solution. + + +7.11 My vial has crystals in it. Can I still use it? + +It most likely means your vial got too cold. Warm it up and gently shake to +reincorporate. If the crystals are not going away, then it’s possible the vial +contents have separated entirely. With a lot more heat and stirring the +crystals might reincorporate, but it is simplest and safest to replace the +vial if you can. + +============================================================================ +8 - PROGESTERONE +============================================================================ + +8.1 Do I want to take progesterone? + +Probably. This is a controversial question for some reason. Detractors +(namely, doctors) will argue that there’s no studies to show that it plays a +role in feminization therefore it should not be taken. Aside from +transfeminine subjects being woefully understudied, heuristically speaking, +progesterone is a key female sex hormone that plays an important role in the +brain and in many functions throughout the body. Regardless of physical +feminization, it is an important hormone for good health that should not be +lightly overlooked. + + +8.2 What is the difference between “progesterone” vs “progestin” / +”progestogen”? + +The class of hormones, both natural and synthetic, that activate the +progesterone receptor are “progestogens”. The natural, bioidentical, and most +important progestogen is “progesterone”. Synthetic progestogens are +“progestins”. These three terms are mistakenly used interchangeably in +scientific literature and in clinical settings, likely causing much of the +broader confusion regarding the role of progesterone in HRT, despite the fact +that they are not equivalent. + + +8.3 Do I want progesterone or a progestin? + +Progesterone. You want bioidentical progesterone. + + +8.4 What’s wrong with progestins? + +Progestins, most typically medroxyprogesterone, medroxyprogesterone acetate, +or levonorgestrel, are generally associated with the negative side effects and +long term risks (breast cancer, blood clots, depression, etc) that are falsely +attributed to progesterone. They are not bioidentical which means they do not +behave the same as progesterone and thus cannot be directly compared. + + +8.5 What does progesterone do for feminization? + +Progesterone is believed to play a role in breast development and libido in +particular, but as mentioned it’s a key hormone aside from its outward +appearance effects. It does also have some antigonadotropic (i.e., it +contributes to testosterone suppression) properties which can be sometimes +relevant. + + +8.6 Does it matter when I start progesterone? + +It is unknown. There is some belief that starting too early may harm breast +development long term, but this is purely theoretical and contrary anecdotal +evidence makes the answer unclear. The conservative estimate is waiting +roughly a year into HRT (until Tanner Stage 3 or 4) in the possible chance +that it does matter. + + +8.7 How is progesterone normally taken? + +Aside from topical applications, the main form is via a pill. It is prescribed +as an oral pill but is most effective when taken as a suppository. Topical +sprays and creams can also work very well. + + +8.8 Are you serious that progesterone should be taken as a suppository? + +Progesterone metabolizes entirely differently when taken orally vs rectally +due to passing through the liver when taken orally. Oral progesterone +primarily converts to allopregnanolone which can cause heavy drowsiness, +whereas rectal progesterone primarily converts to progesterone itself which is +what we want (although some still converts). Some people take additional oral +progesterone as a sleep aid, but please note that too much allopregnanolone +can sometimes lead to negative mental health side effects. + + +8.9 How do I take progesterone as a suppository? + +Just a bit of water on the pill should work, then dry off and wash your hands. +Obviously, don’t go to the bathroom for the next hour or so, so doing it +before bed is best. If you are having issues with it not dissolving then you +can try piercing the capsule but usually should be no issue. Be aware that if +you use large homebrew suppositories made using coconut oil, the large volume +of coconut oil will not want to stay in you. + + +8.10 How much progesterone should I take? + +For pills, Standard dosage is 100-200mg daily at night. It is a rather +arbitrary dosage; 200mg is the max that most doctors will prescribe. Some +people take more than 200mg on occasion, but be aware that spiking your levels +may lead to an unpleasant crash. See question below. + +For topical applications, nobody can tell you with certainty due to the high +variability of the delivery medium, nor is there any clear guidance on desired +levels, or even frequency (likely daily), as progesterone is simply +understudied. Because of this, I would advise titrating your dosage so that +you understand how progesterone affects you. + + +8.11 Is there any benefit to “cycling” progesterone? + +No. Some people do this to mimic a cis woman’s menstrual cycle, but there is +no reason to believe there is any benefit to this and it may cause negative +PMS symptoms. The only exception is if you have good reason to suspect that +you have an intersex condition involving a uterus that you are managing. I +discourage it otherwise. See Question 11.10. + + +8.12 How long should I take progesterone for? + +For as long as you plan to take estrogen and for as long as you want to. So, +probably forever. + +Sometimes people (or doctors) arbitrarily say to only take progesterone for X +years. There is zero theoretical or empirical reason to suggest that this is +sound advice. It’s about as coherent as if someone (or a doctor) asked how +long a trans person planned to take HRT for—oh wait never mind they do ask +that. + + +8.13 Can progesterone convert into dihydrotestosterone (DHT)? + +No. Well, strictly speaking yes, but also no. It is largely a myth, although +as outlined in detail by alix in this article +(https://whsah.co/posts/rethinking-progesterone-and-androgens/), for cases of +people with nonclassical congenital adrenal hyperplasia (ncCAH) progesterone +can cause some negative side effects of increased androgenic activity. In +those cases, discontinuing progesterone is recommended along with seeking out +a formal diagnosis/treatment for potential adrenal disorders. + + +8.14 Is there any benefit to topical progesterone applications in addition to +pills? + +Maybe. It’s a possible alternative to pills, especially in the case of someone +with a peanut allergy since the most common pill manufacturer uses peanut oil, +but again dosage is unclear. Some people find more progesterone fun, if +nothing else. Be safe and have fun. + +For clarity: Apply creams to your inner thigh region (elsewhere if directed), +or optionally on scrotal skin (it’s thin and highly vascular) in the case of +sprays. And no, applying progesterone to your breasts directly is unlikely to +make them grow bigger or faster compared to otherwise. + + +8.15 Can I snort progesterone powder? + +Please don’t. It’s hell on your sinuses. It isn’t hard to make your own +topical progesterone spray and there are guides out there. Do that instead. +It’s significantly more effective, consistent, and safer. + + +8.16 Where can I get progesterone? + +Progesterone tends to be more expensive through DIY sources due to the higher +mass of hormones required, so ideally get it through pharmaceutical sources +covered by insurance. There is also the option of grey market foreign +pharmacies, which are simply pharmacies in another country, although these +often require some hurdles to purchase from. Topical progesterone creams are +available OTC in some locations, although it is not always the most economical +depending on the concentration. + + +8.17 I would like to read more about progesterone in an HRT context. What +resources should I read? + +Originally I linked a document here but I opted to remove it due to a number +of faults that can be misleading. The problem with progesterone is that +literally nobody agrees about a single aspect of it. I don’t know a single +source or study that people agree is good. Hell, people don’t even agree if +the word starts with the letter “P”. The crucial thing to know is that +progesterone is not strictly required for full feminization or good breast +development, but assuming that it’s not contraindicated for you, it’s probably +worth taking. + +It should be noted that for the entire category of progestogens there are +countless myths and falsehoods invented whole cloth by both proponents and +detractors alike which does not make discerning truth from the already-sloppy +scholarship any easier. Fantastical claims of magical benefits and +fearmongering of alleged risks based on nothing are both equally unhelpful, +although the later is worse in my opinion when comes from a medical authority, +whether neglectful or malicious. + + +8.18 Does progesterone interact with any other drugs related to HRT? + +If you are taking 5α-Reductase Inhibitors like finasteride and dutasteride +(See Section 10 “ANTIANDROGENS”, or keep reading), these can affect how +progesterone naturally breaks down into allopregnanolone which can cause +adverse mood effects in some people, irrespective of how you are taking +progesterone. It is not fully clear how much the administration route for the +5α- Reductase Inhibitors (i.e., topical vs oral) makes a difference, but lower +systemic absorption via topical application may mitigate these side effects. +It is recommended to not take either of those if you are someone affected by +this interaction, but it is not in all cases anyway. Note that these +depressive effects may be felt for up to a month after stopping. + +============================================================================ +9 - TESTOSTERONE +============================================================================ + +9.1 Why don’t we want zero testosterone? + +Testosterone is an essential sex hormone which plays a key role in your health +and well-being. We want to suppress it for feminization, but near-zero +testosterone (less than 10 ng/dl, or 0.35 nmol/L) can cause issues such as +poor libido, low energy, low strength (fatigue beyond just the strength loss +of HRT), poor concentration, trouble sleeping, etc. Notably, issues very +similar to having too little estrogen. Cis women also have more than zero +testosterone, so that need not be the fear. Adequate hormone levels are +important! + + +9.2 Are there ever cases where I would want to supplement testosterone? + +Yes. If you are experiencing the issues of the above and your estrogen levels +are otherwise good, it’s possible that you might want to supplement with a +microdose of testosterone. If you wanted to improve your erectile function, +minimize any atrophy before bottom surgery, or otherwise wanted to experiment +with your hormones to see what feels best for you, then that might be a reason +to explore testosterone in a different context that you can hopefully +appreciate more compared to pre-HRT. + + +9.3 If I wanted to supplement testosterone, how would I do it? + +There’s a few possibilities. Testosterone comes in either injections or +topical gels/creams, similar to estrogen as already discussed. Topical is more +likely what you are going to be prescribed. Topical applications have the +downsides that we have discussed for estrogen, but those are less of a concern +here when precise levels are less important. + + +9.4 What are the topical forms of testosterone? + +There is gel and cream. Gel is typically what will be prescribed, but some +compounding pharmacies are able to make low-penetrating cream if someone +wanted just topical application on the genitals. The latter is harder to get +and generally more expensive, however. + + +9.5 Does it matter where I apply the testosterone? + +It depends on if you have gel or cream. If you have the kind of localized +cream as mentioned above, you would apply it as directly as mentioned. +Otherwise, shoulders and upper arms are where gel should go. Make sure not to +touch things until long after it dries! + + +9.6 How much and how often should I apply testosterone? + +Season to taste. This largely depends on how you are feeling. If you have too +much, you might start to experience side effects of testosterone (e.g., oily +skin and body hair), but only you can say what is preferred for you. A weekly +injection of 5-10mg of testosterone cypionate might work for you, but in the +case of 1% topical gels which are often disbursed in 25/50mg packets, there is +more variability. You almost never want even half a packet, and definitely not +daily. I would suggest starting with much less than you think to see how you +feel. + + +9.7 Where would I get testosterone? + +If you are an American, you would have to get a prescription or ask any juicer +at your closest Planet Fitness. Elsewhere, it depends on what gym chain is +closest to you. Disclaimer: This is a joke. See Question 6.11 “Is DIY legal?” + + +9.8 Are other steroids equivalent to testosterone in an HRT context? + +Anabolic-androgenic steroids, i.e., drugs that are structurally similar to +testosterone, are not all equivalent. Commonly used black market steroids like +trenbolone acetate have a laundry list of undesirable side effects, but +steroids like nandrolone decanoate are occasionally used for postmenopausal +cis women due to their relatively low androgenic properties which make them +very favorable for transfeminine individuals. Regardless, in America it is +unlikely you will be prescribed anything other than testosterone itself, if +you are able to get a prescription at all. + + +9.9 What is the relationship between testosterone and dihydrotestosterone +(DHT)? + +Dihydrotestosterone is primarily synthesized from testosterone via the +5α- Reductase enzyme with around 5% of testosterone in your body being +converted. Generally speaking, if testosterone levels are suppressed (or if +you have had bottom surgery) then there should not be much left to convert, +but systemic levels won’t be zero because it is still locally produced. +Depending on your body, this would be the main reason that you might want to +consider supplementing with a 5α-Reductase Inhibitor antiandrogen as discussed +in the following section. As a reminder, dihydrotestosterone is the hormone +that is responsible for body hair and hair loss. + +For any trans mascs reading this, I will make a brief detour to note that at +time of writing it is not clear what role the hormone plays with bottom growth +regarding speed or total size as it relates to 5α-Reductase inhibition. That +is to say: it is known that dihydrotestosterone plays a primary role in penile +development, but it’s not clear how directly the lack thereof affects a trans +masc person. Applying knowledge of micropenis treatment, we know that a +topical cream is more effective than exogenous injections particularly with +how dihydrotestosterone cream is useful when a patient doesn’t respond to +testosterone (particularly in the case of 5α-Reductase deficiencies). So, +food for thought. Someone get Oliver Longdick to handle the rest of this. + +============================================================================ +10 - ANTIANDROGENS +============================================================================ + +10.1 What are “antiandrogens”? + +Antiandrogens, commonly also referred to as “T blockers” or just “blockers”, +as the name(s) may suggest prevent androgens (that’s what testosterone is) +from acting on your body. There are many types of antiandrogens and they are +commonly prescribed as part of an HRT regimen. They are needed if someone +still produces testosterone and is not doing a form of HRT conducive to +monotherapy, such as injections, but they are usually not desirable. It also +should be noted that (most) antiandrogens do not reduce testosterone levels in +any way that matters but instead simply reduce/negate effects on the body. +This is relevant when interpreting lab results and such. + + +10.2 Why wouldn’t I want antiandrogens? + +The main issue with most antiandrogens is that they generally have very +undesirable side effects that are superfluous if testosterone is suppressed in +the first place by having enough estrogen, so those side effects are being +experienced despite—in most cases, at least—being rendered unnecessary by a +reasonably-dosed monotherapy regimen. Bottom surgery of any kind also makes +antiandrogens unnecessary in most cases. + + +10.3 When might I want antiandrogens? + +If you are not most cases, if you desire peace of mind, or if your insurance +requires a prescription on file before they will cover a procedure, then you +may want antiandrogens. The medications used as antiandrogens might have other +effects that may be desirable outside of their antiandrogen properties +depending on your health situation. Additionally, if you are supplementing +androgens, you may want a dihydrotestosterone (DHT) blocker to minimize side +effects related to body hair and hair loss, but be aware that this may not be +the case if you are not using bioidentical testosterone (e.g. nandrolone +decanoate) because not all androgens behave the same. + +It should be noted that temporarily using antiandrogens at the start of HRT +when planning to perform monotherapy is unlikely to be necesssary nor is it +recommended. There is an adjustment period that you will experience regardless +while your body adapts to the change in your primary hormones, so there is no +need to overcomplicate what you are doing. Don’t worry about it. + + +10.4 What kinds of antiandrogens are there? + +The main medications taken as general testosterone blockers in an HRT context +are spironolactone, bicalutamide, and cyproterone acetate. The main +medications taken to block the conversion of testosterone into +dihydrotestosterone (DHT) called “5α-Reductase Inhibitors” (5-ARI) are +finasteride and dutasteride. There are also GnRH agonists like leuprolide and +triptorelin, but both of those are more often used as puberty blockers in +minors, although in parts of Europe they are used for adults as well. + + +10.5 When might I want to take spironolactone? + +Due to the heroic dosages and significant negative side effects required for +it to function as an antiandrogen in most cases, the only time I would ever +recommend taking spironolactone would be if you would benefit from its other +effects such as its antimineralocorticoid (i.e., blocking aldosterone) +properties as it relates to blood pressure management or edema. If you insist +on taking spironolactone, please do not take more than 100mg daily. It has a +bad reputation for a reason. “The Devil”, as it were. + +In case you are unfamiliar, some of the many side effects include: brain fog, +lethargy, poor memory, increased urination frequency, low blood pressure, low +sodium / electrolyte imbalance, etc. In other words, spironolactone is a blood +pressure lowering dieurtic that is a mediocre antiandrogen which is typically +prescribed at high dosages in an otherwise-healthy population for questionably- +effective off-label use. In any other healthcare context this would (or +SHOULD!) be highly unadvisable given the undesirable side effect profile and +the widely-available preferable alternatives that already exist, but that’s +the state of trans healthcare for you. + + +10.6 When might I want to take bicalutamide? + +If you are going to take an antiandrogen, bicalutamide is likely the one to +take. It is generally well tolerated, barring 1% cases of abnormal liver +function test results and symptoms of liver dysfunction, but otherwise +performs the job with relatively minimal side effects. If you take +bicalutamide, ensure regular liver function tests to make sure that your +results are in range. The liver risks are dependent on your body rather than +cumulative so any problem would likely present itself within the first year. +Otherwise, there should be no issues. + + +10.7 When might I want to take cyproterone acetate? + +Likely never. Take bicalutamide instead. + +The long term risk profile is poor and there is no situation that I can think +of in which I would recommend this over an alternative solution. You can do +everything cyproterone acetate can by just taking more estrogen and adding +progesterone to your regimen. + + +10.8 When might I want to take dutasteride? + +If you are extremely concerned about possible hair loss and/or want to +maximize your chances for hair regrowth, you may want to take dutasteride. If +your testosterone is otherwise suppressed then it theoretically shouldn’t have +much benefit as your dihydrotestosterone levels should be relatively low, but +bodies can be complicated, so it may be something of interest to you. Also, +see Question 11.14. + +It should be noted that dutasteride can cause adverse mood effects in some +people, in which case stopping is strongly recommended. Note as well that +these depressive effects may be felt for up to a month after stopping. + + +10.9 When might I want to take finasteride? + +If dutasteride is not something prescribed to you or if your insurance +mandates finasteride specifically to cover a hair treatment. Otherwise, +dutasteride is preferred as it is more effective and better tolerated. + +It should be noted that finasteride can cause adverse mood effects in some +people, in which case stopping is strongly recommended. Note as well that +these depressive effects may be felt for up to a month after stopping. + + +10.10 Where can I get antiandrogens? + +Aside from being prescribed them by your doctor or perhaps available over-the- +counter, there is also the option of grey market foreign pharmacies. These are +simply pharmacies in another country, although these often take some hurdles +to purchase from. Dutasteride and finasteride are generally the easiest to get +over-the-counter because of their commonality as hair loss medication. + +============================================================================ +11 - MYTHS AND MISCS +============================================================================ + +Common Questions + +11.1 Should I be worried about blood clots? + +Yes and no. It is true that there is a correlation between estrogen dosages/ +levels and blood clot risk, but this is primarily related to the route of +administration and the type of estrogen. Synthetic estrogens are the rightful +cause of scorn and do lead to significantly increased blood clot risk, but +bioidentical estrogens are not as concerning. In particular, the route of +administration makes a major difference. Oral bioidentical estrogen passes +through the liver which is what causes the increased blood clot risk. +Injections bypass the liver, and there’s no evidence to suggest nor reason to +believe that injections of bioidentical estrogen provide any significant risk +increase beyond the innate differences between testosterone and estrogen. The +pervasive fearmongering towards all estrogen has persisted for decades despite +these differences. + +If you are undergoing surgery, please know that pausing hormones out of +concern for blood clots is no longer recommended by WPATH. Many surgeons +still include it in their pre-surgery guidelines out of concern for blood +clots, but this is torture that has been disproven and even WPATH doesn’t +recommend it anymore. Remarkable, I know. + +Per WPATH SOC 8 Statement 12.19: + + "After careful examination, investigators have found no perioperative + increase in the rate of VTE [KT: venous thromboembolism, i.e. a blood + clot] among transgender individuals undergoing surgery, while being + maintained on sex steroid treatment throughout when compared with that + among patients whose sex steroid treatment was discontinued + preoperatively" (Gaither et al., 2018; Hembree et al., 2009; Kozato et + al., 2021; Prince & Safer, 2020). + +I should put this in another question entirely, but to not break links, it +would have to be at the bottom of a section and I think this is too important +for that, so I note it here. A very important clarification that I should have +had sooner. + + +11.2 Is it okay to use nicotine while on HRT? + +This is related to the above question. Nicotine usage on HRT, especially if +you’re on pills, compounds your risk of a blood clot on top of all the other +reasons that nicotine is not good. This extends to all forms of nicotine +usage, but obviously smoking is by far the worst. You really do not want a +blood clot. Even if you are not on pills, nicotine disrupts the way estrogen +is metabolized and can lead to significantly reduced feminization effects. +This aspect is understudied but community anecdotal reports are common. It’s +not easy to quit, but I believe in you. There are good resources out there and +strategies like tapering down by using patches really does work. You got this. + +However, to be abundantly clear, this does not mean that you cannot or should +not take estrogen. The downsides of not taking estrogen at all far exceed the +downsides of using nicotine. This section is simply seeking to make you aware +of any increased risks and potentially slower transition as a very strong +recommendation and encouragement to quit. One step at a time. + + +11.3 Is there benefit to starting at a low dosage vs a high dosage? + +To the best of knowledge, no. Sex hormones are not like other drugs that need +to be titrated to manage side effects as we know the dosages that work for the +majority of people, so personally I view “starter dosages” and “antiandrogen +first” regimens as medical abuse. Some people believe that mimicking the slow +timeline of puberty might be best (even though there are far more things +happening than just estrogen levels), but there’s no evidence to support this. +An orchiectomy day one might be best for all we know, but who is going to do +that the moment they decide they are trans and/or want to start HRT? + +Reframing this in another way: there is no reason to believe that “starting +slowly” on a dosage below the typical range is advantageous or preferable for +feminization outcomes. There isn’t a concern of going “too fast” or anything +like that. Both doctors and other trans women seemingly invent new myths by +the day. + + +11.4 Does body weight affect dosage? + +No. Because there is no “optimal” blood level for estrogen and because the +therapeutic range of acceptable levels is so wide, body weight does not +meaningfully affect dosage for HRT. It is for the same reason that slight +deviations in dosage are unlikely to affect how you feel. There is no such +thing as being “too light” or “too heavy” for HRT in any capacity. + +Adjusting your dosage in increments of 0.1mg is a difference that should not +be expected to be perceived simply because our bodies are not sensitive enough +to such exact measurements, let alone the high possibility of imprecision when +performing an injection that makes that certainty of this measurement unlikely. +In other words, the accuracy of your dosage is more important than the +precision. + + +11.5 Is there such a thing as starting estrogen too late? + +No. No matter when you start, estrogen is able to do a LOT and a proper +regimen will be able to have powerful results. Sex hormones are some of the +strongest hormones in our body in terms of our appearance. Everybody always +wishes that they could’ve started sooner, but that’s no reason not to start +now. Even if you’ve been on estrogen for years, there is still a benefit to be +had in improving the quality of your regimen. + + +11.6 Does feminization / breast development stop after X years? + +No. There is not an arbitrary time where estrogen suddenly stops working. +Various numbers are given and usually it’s either 1) entirely made up or 2) +pointing to a study that only went for X years. Doctors in particular love to +tell trans women not to expect more than B cup breasts (which isn’t even how +breast sizing works, but I digress) or for any growth after 2 years, but this +is simply not true. There are cases of people who restarted estrogen after +stopping for many years and still experiencing new growth. + + +11.7 I haven’t seen any changes in years on injections. Would swapping back to +pills make a difference? + +Maybe, but maybe not. There are some anecdotes of people swapping back from +injections to pills (or adding pills on top of injections) and experiencing +more breast growth after “stalling out”, but the mechanism is not clear. There +is speculation that the E1:E2 ratio (estrone : estradiol) heavily weighted +towards E1 with oral pills compared to E2 for injections might make a +difference for some people, although estrone is not typically associated with +feminization. There likely are other factors at play, but you are free to +experiment if you wish. Data is limited. + + +11.8 Is low energy and low libido normal on HRT? + +Generally, no. How libido is expressed changes in the beginning, but the vast +majority of the time that someone experiences abnormally low libido it’s +because they haven’t gotten their hormones sorted. The same goes for low +energy. Get your hormones squared away, and barring that, check your +diet/vitamins next. Make sure you don’t randomly have critically low vitamin +D levels or something like that. It happens more often than you think. + + +11.9 I hear about [random drug / strategy] that my friend said helps +feminization. Does it actually? + +Maybe, but probably not. There is a lot of wild speculation about ways to +achieve feminization goals, but many of them are akin to snake oil or have +potentially serious risks far beyond HRT itself. You have the right to bodily +autonomy and I cannot stop you, but I can encourage you to be smart about what +you are doing. The more you get into the weeds of biology as it relates to +transition, the shakier the ground becomes as quality data becomes less and +less available. Desperation can lead to a lot of unwise and dangerous +decisions. So be smart, and be safe. + + +11.10 Do we want to mimic the estrogen cycle of cis women? + +Arguably no. This is controversial, but I am of the belief that because we +(well, most of us) do not have a uterus and corresponding menstrual cycle +synced to our hormone levels, then there is no reason we should strive to +copy that behavior. This is an is-ought problem, in my view. The primary +hormonal concern for most trans women is testosterone suppression which +necessitates consistently high enough levels (barring post bottom surgery, +where there is no testosterone to suppress), so high fluctuation and/or +relatively low levels are likely to cause undue distress. You’re welcome to +experiment, of course. Especially if testosterone suppression is no longer a +concern for you. See Question 8.11, and see below. + + +11.11 Do trans women experience periods? + +Similar to the last question, it’s important to understand what is happening. +The unique hormone curve produced by your particular ester, your dosage, and +your frequency can cause changes in your mood as your estrogen levels +oscillate between injections. Some trans women liken this phenomenon to a +period, but the underlying cause for these physiological changes is +different and is usually a sign that your regimen needs tweaking so that you +feel the best that you can. The exception here are the intersex trans women +who have a uterus and literally are having a period, in which case: yeah duh. +See Question 11.35. + + +11.12 Can too much estrogen convert to testosterone? + +No. Aromatase is the enzyme responsible for converting testosterone into +estrogen, but there is no mechanism to convert estrogen into testosterone. +This cannot happen. This is a completely false myth and you should be +immediately wary of the knowledge level of anyone who says it to you. +Unfortunately, it is doctors who repeat this myth the most. + + +11.13 Does bottom surgery cause an increase in testosterone? + +No. This is not a thing. There is not a magic mechanism that suddenly causes +testosterone to increase the moment that testicles are removed. Even if magic +was stored in the balls, this simply isn’t how hormone production works. +“Well, your adrenals…” They don’t work like that either. The only possible +rare exception would be undiagnosed adrenal hyperandrogenism conditions that +were suppressed by an antiandrogen like spironolactone prior to surgery which +might show itself after antiandrogens are ceased. Please stop repeating this +myth. + + +11.14 How do I prevent/revert hair loss? + +Mechanically, it is pretty simple. A standard HRT regimen alone is borderline +magic (don’t ask where the magic is stored) in this regard already, but the +inclusion of 5α-Reductase Inhibitors (5-ARI) as discussed in Section 10 +“ANTIANDROGENS” is recommended in more extreme cases to completely halt any +loss. Topical minoxodil 5% is the only thing that works to firm up your +hairline beyond hormones alone, but keep in mind that aside from miracle +cases, you’re only saving dying/dormant follicles. Dead follicles don’t come +back. + +If this alone is insufficient for you, hair transplant technology has improved +significantly. The Follicular Unit Extraction (FUE) procedure is what you want +to look into. Here is where in the future I will link a guide written by an +expert on getting insurance to cover that, once she writes it. This is peer +pressure. Watch this space. + + +11.15 Does exercise affect feminization? + +Probably. HRT causes gradual body recomposition, so you can help encourage +your body to shift through exercise. Keep in mind that this process is VERY +SLOW, so it is crucial that you eat enough to fuel how patient you have to +be. The growth hormones from muscle stimulation via strength training also +play a role in breast development, so it’s probably a good thing even aside +from the rest of the obvious health benefits of exercise. + +This is NOT just the writer’s barely-disguised fetish; strength training is +important for your health! I mention this because a lot of trans women believe +that touching a dumbbell will make them look like the hulk. I get it, but if +you have no testosterone in you and you aren’t on steroids, then you aren’t +going to look like that. Let alone the constant time, effort, and diligence +required to even get close. + + +11.16 What should I exercise then? + +Cardio is useful for living which is important. Lower body exercises will fill +out your hips and glutes to accentuate your figure. Upper body exercises will +improve your posture and support your breasts which will make them look +bigger. In other words, everything. You’re on estrogen. Have you seen cis +women athletes? Exercise will feminize you. + +This guide was shared with me [Warning: Google Docs link +(https://docs.google.com/document/d/ +1-NyE5EY5TTaRRMhk7HlTbKJ7HifjEsA4jlDO1qKQVl0/edit?tab=t.0)] and looks to be +a good starting place. I will note that there aren’t particular exercises that +feminize vs masculinize as bodies don’t work like that, but you may wish to +focus more on lower body exerices and flexibility more than the typical lifter. + + +11.17 Can estrogen really cause height shrinkage? + +Yes. It is possible that it’s related to water content changes within tendons +and ligaments, but it is not something that has been studied so the cause is +fully speculation. Scientists: free study idea! + + +11.18 Can estrogen really cause foot shrinkage? + +Yes. See above. + + +11.19 Can estrogen really cause any other kinds of shrinkage? + +Well, “use it or lose it” like they always say. + + +Sexual Health + +11.20 How do I improve erectile function on HRT? + +Aside from using it regularly, ways to improve erectile function include: +1) Improving your fitness and physical health, particularly your +cardiovascular ability; 2) consider medication like tadalafil or sildenafil; +and 3) consider testosterone supplementation (see Section 9 “TESTOSTERONE”). + + +11.21 How do I increase cum/pre-cum volume on HRT? + +Don’t be embarrassed, it’s a common question. Sunflower lecithin and pygeum +increase both of those. It seems to also make a difference for vaginal +wetness and arousal for those who have had bottom surgery, but data and +anecdotes are limited so it’s hard to say. Otherwise just be sure you drink +enough water and have your nutrition in check. + + +11.22 Can I lactate on HRT? + +Yes. Domperidone, fenugreek, sunflower lecithin, ample estrogen, and ample +progesterone. Get a pump. Knock yourself out. + +It should be noted that domperidone has side effects and risks associated +with it, and that ability to lactate does not affect breast development. +Newman-Goldfarb protocols would be what you want to look into. + + +11.23 Can HRT change your senses and your perceptions, i.e. smell? + +You very likely were dissociated and depressed for years prior to starting +HRT. The world is more vibrant now because you are no longer dissociating +24/7. The wonders of modern medicine! + +It can, however, directly change your eye prescription. That can definitely +happen. + + +11.24 Can HRT change your sexuality? + +Similar to being dissociated as with above, HRT often incurs a lot more +openness and acceptance with yourself which can cause a shift in how your +sexuality presents itself. It is largely a semantics argument as to whether +that is chemical or behavioral. A matter of perspective. + + +11.25 Should I be on PrEP? + +Yes. + + +Medical Malpractice + +11.26 I heard that injections are actually less stable because you do them +less frequently. Is that true? + +Only if you follow the dipshit WPATH SOC 8 guidelines that list a recommended +regimen of estradiol valerate or estradiol cypionate in the range of 5-30mg +every two weeks which, to be abundantly clear, you absolutely should never do +in a million years. “Do no harm”, my ass. + + +11.27 But my doctor said-? + +The average doctor has essentially no training in anything related to trans +healthcare, and 4/5 endocrinologists have never had any formal training in +trans healthcare +(https://www.endocrine.org/news-and-advocacy/news-room/2017/ +endocrinologists-want-training-in-transgender-care). It is most likely that +you are their first trans patient and that they are inexperienced in the +practical elements of managing a trans patient. Even among doctors who care a +lot, they are often limited by conservative standards of care that they are +forced to follow which do not always align with the care best for you. See +above. + +Please also be aware of “trans broken arm syndrome”, aka the tendency of +doctors to blame everything on HRT. If your arm is broken, it’s probably not +“because of those hormones”! + +And I should put this as a separate question but I don’t want to break the +formatting: in line with medical malpractice, there is no situation in which +it is reasonable for a doctor to request to see or feel your breasts to +“monitor growth” or for any other reason. It is far less common these days, +thankfully, but it is sexual assault and completely unacceptable. + + +11.28 My doctor won’t prescribe me injections. What do I do? + +Attempt to convince them, replace them, or seek DIY sources. Do not let a +gatekeeping medical establishment prevent you from receiving the appropriate +care that you deserve. The most crucial aspect of interfacing with the +medical system while trans is that you have to advocate for yourself. This is +compounded with disability, ethnicity, and other afflictions that scare +doctors like womanhood. + + +11.29 How does HRT for menopausal cis women relate to HRT for trans women? + +While we generally have different goals and crucially have very different +dosage requirements, there is an immense amount of overlap in experience for +trans women and menopausal cis women. Medical misogyny in the form of +incompetence, dismissiveness, antagonism, and/or misinformation is something +that we unfortunately both experience. It is for this reason that it is +paramount to build solidarity on this front. To give an example of what I +mean, the first 30-40 minutes of this interview +(https://www.youtube.com/watch?v=W0XW6av2wLQ) will likely sound extremely +familiar to you if you would like to raise your blood pressure. The +interviewee herself notes the connection too! The WHI ruined the lives of +countless women. + + +Intersexuality and Comorbidities + +11.30 What’s up with Ehlers-Danlos Syndrome? + +This connective tissue disorder doesn’t actually relate to HRT but a lot of +trans people have it so congrats in case this is how you learned that you do +too. Aside from general cardiovascular long term concerns to maybe look into, +keep up with strength training so that your joints work. Look into that +elsewhere though. See Question 11.16. + + +11.31 What kind of intersex things should I keep in mind? + +Throughout this guide, I have mentioned intersex conditions vaguely. Below is +a short list of things that might be useful for you to know in your travels +for yourself or for a friend. + + +11.32 What’s up with Klinefelter Syndrome? + +This is a relatively (considering chromosomal mutations) common +intersex-related condition that some trans women might not realize that they +have as the two can overlap. It generally presents as low testosterone at the +start of puberty. Good for you to know the name, just in case. + + +11.33 What’s up with Persistent Müllerian Duct Syndrome (PMDS)? + +Another “I’m putting this here because this might be the first time you’ve +even heard of the term” intersex-related condition that can affect some trans +women, however few that may be since we don’t have numbers. The possible +presence of an underdeveloped uterus leads to some possible complications and +oddities. You probably extra want to have progesterone to avoid uterine +cancer risks. + + +11.34 What’s up with ovotesticular syndrome? + +This intersex condition in particular can cause early level fluctuations which +made lead to confusing test results due to the presence of both ovarian and +testicular tissues, either separate or combined in an ovotestis. This presents +in many different ways which HRT can interact with as you begin suppressing +luteinizing hormone (LH). A uterus may or may not be present, multiple sets of +gonads could be present, and/or it could look outwardly typical. + + +11.35 What’s the difference between intestinal cramps and uterine cramps? + +These are commonly misattributed in early transition as a symptom of intersex +conditions. Intestinal cramps are widespread and diffuse across your abdomen, +whereas uterine cramps are highly concentrated in a location somewhere below +your belly button and tend to be sharp stabs/contractions in rapid succession. +Like the inside of your body is used as a stress ball. Very different! + + +11.36 What about other intersex conditions? + +I have listed a few notable ones, but there are far more expressions and ways +of testing them that go far beyond the scope of this guide. Anecdotally, +prevalence is higher than average among trans people so basic familiarity +with this is useful. + + +Oddball Questions + +11.37 Many DIY sources only take crypto. Is that required? How does that work? + +There are other guides that cover this in better depth than I can on how to +use crypto safely, including some vendors who have their own guides. But yes, +crypto is often required for a lot of reasons. “Crypto” means a lot of things, +but using it as a currency was the original point after all. It’s mostly just +a pain in the ass. Monero (XMR) is good. + + +11.38 What about Selective Estrogen Receptor Modulator (SERM) drugs for +nonbinary regimens? + +Some people use SERMs as a part of a transition that is not looking to +feminize as much for a more androgynous look, but it’s pretty much entirely +uncharted waters thus why their mention is otherwise absent from this guide. +You’re on your own if that’s something you want to explore, so please be safe. +I don’t personally rate them very highly as I have not seen much to suggest +that they work well for how people usually think or want them to work, at +least not without a lot more caveats, but obviously there are people who like + them. It’s just not something I feel comfortable giving recommendations for. + +The various proposed nonbinary regimens are often highly individualized +because they are specific to what a persons’ particular goals are. All HRT +should be individualized to a degree, but there is often more variation in +desired outcomes when people ask about androgyny. Hormonally, it is +nontrivial. Everything stated in this guide should be treated solely as a +starting place if you are wanting to experiment with something more +complicated, but do remember that there is much more to achieving transition +goals than just hormones alone. + + +11.39 Are things like “herbal HRT” or “phytoestrogens” legitimate? + +No. If someone is telling you they have “herbal HRT”, they are telling you +they have snake oil. The only thing that is going to feminize you is estrogen, + not plant estrogens. No amount of “natural” products are a replacement for + estrogen itself. This isn’t a common scam and you probably already know, but + just in case you run into it, now you know for sure. If it smells like + bullshit, it’s probably bullshit. Unless we’re talking about bug steroids in + which case yeah those are actually cool. Won’t feminize you though. + + +11.40 Is the Reddit Doctor that people constantly talk about good? + +No. + + +11.41 I hear DIY estrogen is made in a bathtub. Is that true? + +No. I honestly have no idea where or why this joke started that people now +take seriously, but there’s no step in any process where a bathtub would even +be considered. Don’t believe everything you read online. I don’t even know +what you could even theoretically do with a bathtub, unless you think estrogen +vials are full of the bathwater of trans women. I don’t know why you would +think that though. It’s obviously cum. + +============================================================================ +12 - CREATINE [gretchen's note: oh for fuck's sake] +============================================================================ + +12.1 What is creatine? + +Creatine is an organic compound in your muscles and in your brain. It recycles +ADP into ATP which is important for energy production in your body, especially +initial high burst applications before other energy systems take over. + + +12.2 Isn’t it like a steroid or something that bodybuilders use? + +No. Bodybuilders and athletes like it because having more energy means more +activity before getting tired. They aren’t the only ones who use it since it +is basically the #1 supplement in terms of things that are actually useful and +are actually researched. + + +12.3 How is creatine related to HRT? + +It isn’t! But it’s something I yell about because I think it’s good and I am +tired of repeating myself because people keep asking and you’re reading this +anyway, aren’t you? I love a captive audience. My standup routine is at the +bottom. + + +12.4 Okay well why should I take creatine then? + +What a great question! It’s good for your brain and your muscles. Creatine is +often found in relatively low concentrations for many people depending on +their diet, especially people who don’t eat meat. There is compelling research +about various chronic fatigue and post-viral conditions (long COVID in +particular) being related to depleted creatine reserves in the brain, so some +people find cognitive benefits from supplementing it. It isn’t magic but it is +dirt cheap so it is worth trying in my opinion. + + +12.5 What are the forms? + +Just creatine monohydrate powder is what you want. The pills tend to be low +dosage and are up charging you anyway, while gummies often destroy the +creatine in the creation of the gummy. A lot of brands include creatine in +some sort of mix but the pure stuff is usually cheaper. + + +12.6 How do I take it then? + +The general recommendation is 5-10g daily dissolved in some sort of liquid. +It dissolves best in things that aren’t just water. It’s mostly flavorless, +so just throw a scoop or two in your coffee or a smoothie and call it a day. +It can be a little chalky or gritty depending on the quantity and the fluid. + + +12.7 Does it matter when I take it? + +Not really. It doesn’t have an immediate effect like that which is why it’s +silly that it’s microdosed in pre-workout mixes. Take it whenever it’s +convenient for you. + + +12.8 How does it work then? + +It builds up in your body to a maximum level of saturation over a week or +two. Then you just maintain that and reap the rewards (of maybe feeling +better). + + +12.9 Do I have to do a “loading” phase of taking more at first? + +Probably not. Unless you’re on some sort of intense training time crunch or +something, this probably doesn’t matter at all. Just take whatever is +convenient with some regularity. + + +12.10 What are the side effects? + +Slight weight gain may be possible because of increased water weight in your +muscles (which to be clear is Good, so don’t be alarmed). If you don’t take it +with water, or if you take too much at once, you might get a tummy ache. +Ouchie. + + +12.11 Who shouldn’t take it? + +People with kidney issues. Not because it causes them, but because creatinine +(Different spelling! Creatine becomes creatinine) is used as a marker in lab +tests for a number of kidney issues and supplementing might give a false +positive. Just keep it in mind. + + +12.12 Do you have any brand recommendations? + +No. It shouldn’t really matter. Just get whatever seems reputable and is a +reasonable price. I’d give a recommendation for the one I like but when I +asked the brand for affiliate link they turned me down, so their loss! No +free clout. + + +12.13 You seriously put creatine into this document, huh? + +Yeah it’s pretty funny. It’s not my fault that I joked about it and people +told me it legitimately helped them because now I feel obligated to keep +talking about it!!! + + +============================================================================ +13 - CLOSING REMARKS +============================================================================ + +If any of the following are true: + + -you are still mad at me despite the disclaimer; + + -you spotted an issue or typo; + + -you have a clarifying question that should be put into the text; + + -you have an objection that hopefully isn’t an Uhm Ackshually; + + -you wish to sing my praises; + + -you wish to pledge fealty; + + -you wish to send tithes my way; + +Then please feel free to contact me and I’ll see what we can do. Bluesky is +the easiest contact point, and you can DM me for my Signal. Otherwise, thank +you for reading and I hope it helps. + +If you would like to donate to support this project, +CashApp(https://cash.app/Katitties), Ko-Fi(https://ko-fi.com/katitties), and +Venmo(https://account.venmo.com/u/katitties) all work. I appreciate it! + +And lastly: The most important thing that you can do as a trans person is to +live. For as much as this document is a manual, it is in equal measure a +message to you as a trans person that your existence is a gift upon the world, +your presence is a blessing on those around you, and that you deserve to be +treated with respect. Even if you do nothing else, your life is a feat worth +praising. Thank you. + +============================================================================ +ABOUT THE AUTHOR +============================================================================ + +Katie Tightpussy is an award-winning author and professional trans woman with +nearly a decade of experience in the field of transgender. Her accomplishments +include transiferating her sex through the novel technique of cross-sex hormone +injections, being physically unable to shut up, and utilizing a very fortunate +set of hyperfixations as they relate to transbobulation of the humors. She +spends her days in the idyllic rural countryside of Los Angeles scheming of +new ways to achieve world domination and enjoys riding her bicycle. Media +inquiries can reach her agent at katietightpussy.com. + +============================================================================ +DISCLOSURES +============================================================================ + +No robot girls were harmed in the making of this document, including any +usage of generative large language models. The author does not endorse any +reproduction without attribution nor scraping of this work. Leave those poor +robot girls alone. + +The author declares an attraction towards women and acknowledges a potential +conflict of interest for the existence of more beautiful trans women in the +world. + +============================================================================ +ACKNOWLEDGEMENTS +============================================================================ + +Though the text is primarily my voice, this document would not be even half +as good without the contributions, feedback, and suggestions from others +involved at every step along the way. A good reminder as ever that transition +is not something best done alone. + +Many thanks to Q, R, RM, and S in alphabetical order for close review and +generally being fun nerds to talk to; love y’all. Special thanks to CB and J +for close review that also inspired some very good bits. Thanks to KG for +additional intersex information. Thanks to w [sic] for additional injection +resources. Thanks to BIR collectively for a plethora of crucial nerd nitpicks. +Appreciation for general review from C, JTP, K, S, and V. Thanks to everyone +on Bluesky who encouraged me to write this up in the first place, and everyone +over the years sharing knowledge. And of course: much appreciation to all HRT +nerds, even when we disagree, since we’re all trying to do the best for our +community where we’ve otherwise been let down. Keep up the good work everyone. + +Shout out to my IB Chemistry HL teacher many years ago who quite reasonably +doubted my studiousness even though I’m now putting much of that knowledge +to use for the art of transsexuality; go figure. + +============================================================================ +CHANGELOG +============================================================================ + +Full Compilation Datetime: \DTMnow + +(There aren’t LaTeXML bindings for datetime2 so this is only for versioning +the PDF. For the webpage, look at the bottom of your screen silly. There +aren’t bindings for hanging or hyphenat either, so the formatting is slightly +ugly. My life is so hard.) + +2025-08-20: Initial release. 15.9k words. + +2025-08-20: A lot of typos and minor verbiage tweaks. Added Question 8.18. + +2025-08-21: Typos grow on trees. Added Question 5.27. + +2025-08-21: More tweaks. Opted to remove “WHY PROG” from Question 8.17. 17.0k +words. + +2025-08-22: Nitpicks, clarifications, and typos. 17.2k words. + +2025-08-24: A few more twinks sorry tweaks. 17.3k words. + +2025-08-27: How long until remaining typos are embarrasing? 17.3k words. + +2025-08-28: Reduced ambiguity in a few areas. 17.4k words. + +2025-08-29: Additional clarity for frequencies in Section 3. 17.5k words. + +2025-09-01: Sisyphus boulder meme captioned fixing typos dot png. 17.5k words. + +2025-09-07: Added donation links per request. That’s very kind. 17.5k words. + +2025-09-07: Few more tweaks. Clarified an additional common progestin. 17.6k +words. + +2025-09-19: Added Question 4.16 plus tweaks. 17.7k words. + +2025-09-23: A wide variety of clarifications up and down the line. 18.1k words. + +2025-09-24: Added an important note about surgery to Question 11.1. 18.3k words. + +2025-09-24: “Katie my doctor told me-” It never ends. 18.5k words. + +2025-09-26: Another pass of clarification edits. Yes I should have a git diff. +Sorry that I don’t. I thought I’d be done by now anyway! 18.7k words. + +2025-09-30: Added some cross references for clarity. 18.7k words. + +2025-10-02: More cross references. Likely will do another pass. 18.8k words. + +2025-10-02: Added a big bold warning about recapping to Question 5.13 because +SOMEONE didn’t watch the video smh. 18.9k words. + +2025-10-08: .txt version done. Deal with it. 19.4k words. diff --git a/output_prebuild.html b/output_prebuild.html index 2a15b78..9f19db0 100644 --- a/output_prebuild.html +++ b/output_prebuild.html @@ -2,7 +2,7 @@ A PRACTICAL GUIDE TO FEMINIZING HRT - + @@ -346,7 +346,10 @@

You can use the table of contents to navigate to a particular section or question as needed, especially when re-visiting. I recommend saving this page / document so that you can refer back to it any time you have questions about your HRT. It is a lot to absorb up front, so it’s okay if it doesn’t! No rush on any of this.

+ @@ -3006,7 +3009,7 @@
-
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[36] [37] -Overfull \hbox (5.6764pt too wide) in paragraph at lines 761--761 +Overfull \hbox (5.6764pt too wide) in paragraph at lines 763--763 []\OT1/cmr/bx/n/12 What is the dif-fer-ence be-tween \pro-ges-terone" vs \pro- [] @@ -435,7 +435,7 @@ Overfull \hbox (5.6764pt too wide) in paragraph at lines 761--761 [41] [42] -Overfull \hbox (15.16298pt too wide) in paragraph at lines 874--875 +Overfull \hbox (15.16298pt too wide) in paragraph at lines 876--877 \OT1/cmr/m/it/10 Dihydrotestosterone \OT1/cmr/m/n/10 is pri-mar-ily syn-the-sized from testos-terone via the 5$\OML/cmm/m/it/10 $\OT1/cmr/m/n/10 -Reductase [] @@ -452,7 +452,7 @@ Overfull \hbox (15.16298pt too wide) in paragraph at lines 874--875 [47] [48] -Overfull \hbox (8.90694pt too wide) in paragraph at lines 983--983 +Overfull \hbox (8.90694pt too wide) in paragraph at lines 985--985 []\OT1/cmr/bx/n/12 Do we want to mimic the es-tro-gen cy-cle of cis women? 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<1E154CFEE009BF39FBB3AD3ED28601E2>] >> startxref -1148237 +1148479 %%EOF diff --git a/pghrt.synctex.gz b/pghrt.synctex.gz index 2fa4c01..ac5c706 100644 Binary files a/pghrt.synctex.gz and b/pghrt.synctex.gz differ diff --git a/pghrt.tex b/pghrt.tex index 1098eee..2b7fe29 100644 --- a/pghrt.tex +++ b/pghrt.tex @@ -54,7 +54,9 @@ This document is structured linearly as a series of questions and answers such t You can use the table of contents to navigate to a particular section or question as needed, especially when re-visiting. I recommend saving this page / document so that you can refer back to it any time you have questions about your HRT. It is a lot to absorb up front, so it’s okay if it doesn’t! No rush on any of this. -\noindent\underline{\textbf{\href{pghrt.pdf}{This document can also be downloaded as a PDF. Please do so.}}} +\noindent\textbf{\href{pghrt.pdf}{This document can also be downloaded as a PDF. Please do so.}} + +\noindent\href{pghrtgretchensversion.txt}{Alternatively, you can read a 90s-00s style .txt version if you are inclined.} It won't stay up to date though.