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============================================================================
====================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)
+++ +++ +++
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++ +++++ +++ ++++ ++++ +++++ ++++++++++ ++++ ++++
++ +++++ +++ ++++++ +++ ++++++ +++ +++++ +++ ++++
+ +++++ ++ ++++++ +++ +++++ +++ ++++++ +++ ++++
+ ++++++++ +++++++++ +++++++++ ++++++++++ ++++
+ ++++++++ ++++++ ++++++ +++++++ +++
+++++++ ++++++ ++++++ ++++ +++
+++ +++ ++++ +++ ++
+++ +
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
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+ ++++++++ + +++ + + ++ ++ ++++++++++++++++++++++++ + +++
+++ ++++++++ +++ ++++++++++++++++++++++++++++++ ++ + ++++
+++++++++ + ++++ ++ +++++++++++++++++++++ +++ ++ +++++
++++++++++++++ +++++++ ++++++++++++++++++++++ ++++ +++++ +
+++ ++ + + ++++++++++++++++++++++++++++++++++ ++++++ ++++
+++++ ++++++ +++++++++++++++++++++++++++++++++++++ +++++
+++++ +++++++++++++++++++++++++++++++++++++++++ ++ ++
++++ + +++++++++++++++++++++++++++++++++++++++++++++
++++++ +++++++++++++++++++++++++++++++++++++++++++
++++++++++++++++++++++++++++++++++++++++++++++
++++++++++++++++++++++++++++++++++++++++++
+++++++++++++++++++++++++++++++ ++++++
+++++++++++++++++++++++++++++++
++++++++++++++++++++++
++++++++++++
============================================================================
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.
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