https://diyhrt.wiki/What is HRT?
HRT stands for hormone replacement therapy.
For transfeminine people, this usually means trying to replicate the hormones found in cisgender women. People who are assigned male at birth (AMAB) will have higher testosterone levels and lower estradiol (estrogen) levels compared to those assigned female at birth (AFAB).
The purpose of HRT is to decrease testosterone levels and raise estradiol levels to levels comparable to that of healthy cis females. This is usually accomplished using antiandrogens (blocks testosterone and prevents masculinization) and estradiol (causes feminization).
In this guide, you will see the terms estradiol and estrogen used interchangeably. Estradiol is the main human female sex hormone, and is a type of estrogen. Traditionally, you don't directly administer types of estrogens other than estradiol (E2), so the rest are not relevant for this guide to discuss. Estradiol is later metabolized by your body into esterone (E1) and estriol (E3), and these are optional blood tests that you can get, but aren't necessary.
What does it do?
HRT will give a myriad of changes. Here is a chart showing all of the changes you can expect, along with typical onset times and when effects reach their maximum.
Keep in mind that all forms of HRT will likely make you infertile, possibly irreversibly. Consider sperm banking if this is a concern.
Accessing Prescribed HRT vs DIY:
Prescribed HRT:
If you are in the US: you can try informed consent (Planned Parenthood locations offer this service), or any endocrinologist that allows it. Informed consent is essentially an easier method of obtaining HRT without having to go through multiple psychologist/psychiatrist assessments (essentially having to 'prove' your transness), or be actually diagnosed with gender dysphoria. You just sign a consent form and that's it.
You have to be 18+ to access informed consent services in the USA. Here is a community-compiled worldwide map that shows clinics offering informed consent: Erin's Informed Consent Map with particular focus on clinics in the USA. Many new mobile apps and telehealth services in the USA also offer informed consent access to HRT, see this short document for a full list for all current app/telehealth HRT services in the USA:
diyhrt.wiki/apps.
To save on prescribed HRT in the USA, try goodrx.com for free coupons to use at participating pharmacies. There are no strings attached to this service! Cost Plus Drugs is also a good source for affordable medications delivered to you by mail if you have a doctor's prescription.
You have to be 18+ to access informed consent services in Australia. Dr Johnathan Hayes (click here) is an Endocrinologist in St. Leonards that offers Informed consent.
If you are in the UK: GenderGP (if you can afford it) is a private healthcare service aiding transgender people in getting on HRT. It uses a model similar to informed consent and asks about your plan for transition. Unfortunately, they have a bit of a reputation for giving rather undesirable dosing regimens and not following clinical guidelines, and can be quite expensive.
Beyond this point, this guide will focus exclusively on how to safely dose, source, and administer DIY HRT.
DIY:
DIY HRT refers to any HRT that is obtained without a prescription.
Ideally, you would be on prescribed HRT through legit means. However, you may not have the privilege or means to access prescribed HRT, so this guide may be of use for you.
If you are willing to attempt DIY, it is a preferable option to not being on HRT for many.
If you do not want to be on waitlists, have to prove your transness while allowing your body to masculinize, or are unable to get HRT legally, DIY may be preferable.
Depending on where you order from, you may need to find out how to buy Bitcoin/other cryptocurrencies or find a way to send an international bank transfer, Moneygram, etc.
In some countries, HRT medications are sold over the counter without the need for a prescription.
For the majority of individuals, DIY HRT commonly entails buying legitimate pharmaceutical-grade medications from foreign companies located in countries that permit the sale of medications internationally.
Homebrewed vs Pharmaceutical Grade?
Homebrewed - Refers to HRT produced by individuals, by sourcing raw estradiol ester/bicalutamide/etc powder and compounding the medication themselves. They do not synthesize (create from scratch) hormones. While the concept sounds scary, there are a couple well respected members of the community that produce high quality and safe HRT medications. However, homebrew will always carry more inherent risk, so keep this in mind.
Pharmaceutical grade - Refers to HRT produced by legitimate pharmaceutical companies that are licensed and subject to regulation. They are the same quality as those found in your local pharmacy. They can be ordered without a prescription from companies that are based in countries that allow for the legal exportation of such medications. These will almost always carry less inherent risk versus homebrewed hormones.
If you want to acquire DIY injections that aren't prohibitively expensive/difficult to source, homebrewed injections are the only options available.
It is highly recommended to always try to order from non-homebrew sources unless cost or logistical concerns make it unfeasible to order from pharmaceutical grade sources. Pharmaceutical grade HRT is always safer, and we highly recommend you choose to buy from these sources. 90%+ of trans feminine people who are on DIY HRT order from pharmaceutical grade sources.
What forms of estradiol are there?
There are many forms of estradiol, each with their drawbacks, pros, and levels of ease in terms of obtaining them.
This section does not cover dosing (see the Dosing section for more information). Given prices are rough estimates for DIY sourced HRT.
Prices below are in $USD. Shipping usually goes between $10-35 USD depending on the source. It's best to order at least several months worth at once to offset the shipping costs.
Pills - $20-$40 per month ($240-480 per year)
By far the most popular and well known, pills are the easiest to come by if you choose to DIY. Unfortunately, they tend to be somewhat expensive. Choose bioidentical estrogens (bioidentical means the pills contain the exact same estrogen produced by human bodies).
Bioidentical estradiol pills usually come in three forms:
Estradiol hemihydrate (e.g. Estrofem, Estrace) is equivalent to estradiol (mostly sold by homebrewers). Estradiol valerate may also be found in pills. (ex: Progynova) Estradiol valerate has about 75% of the potency of estradiol or estradiol hemihydrate.
Avoid non-bioidentical estrogens such as Premarin or Ethinylestradiol (EE). These carry elevated thromboembolism (blood clot) risks compared to bioidentical estrogens.
Pills also tend to be quite convenient to take. Also very easy to acquire if you choose to DIY.
Oral pills:
Oral intake is simply swallowing your pills. Usually twice per day in ~12 hour intervals. Results in more stable levels versus sublingual/buccal administration.
Sublingual/Buccal pills:
Sublingual intake refers to placing a tablet under the tongue and letting it dissolve, and buccal intake refers to placing a tablet between your gum and the inside of your cheek to dissolve. These two administration methods are interchangeable and have essentially the same results.
Sublingual/Buccal administration causes higher peak levels of estradiol in the blood that quickly dissipate. Because of this, it is recommended that sublingual administration be three (or more) times a day, in 8 hour intervals.
Transdermal - $30-$45 per month ($360-540 per year)(patches)
Transdermal (estradiol applied to the skin) comes in forms like gels, patches, solutions, etc.
Patches are typically switched out once to twice a week and are designed to give out a set dose of estradiol every day. Usually applied to the lower stomach or upper buttocks.
Prescribed gels typically come in packets or in a pump that dispenses a set amount each time. Estradiol gels are compounded in an alcohol base to increase absorption. Usually applied to the skin once per day. Squeeze tube style gels that aren't properly dosed are not recommended due to difficulty of accurate dosing. Unfortunately most gels available from DIY sources are in this category.
Solutions are usually sold from homebrewers, containing estradiol in an alcohol-based solution that is applied to the skin, usually in an eyedropper style bottle.
Estrogen Creams are not very relevant to transfeminine people because of the low absorption rate into the bloodstream and the difficulty of accurate dosing.
Injections - $100-$200 per year
There are certain esters estradiol is commonly compounded in. Estradiol is esterified in order to last longer in your body.
Raw estradiol injected into your tissues will very quickly dissipate, which is why estradiol injections all come in ester form. It's still just estradiol, your body just slowly converts it into estradiol from its esterified form.
Estradiol valerate, estradiol cypionate and estradiol enanthate are the most commonly prescribed and used estradiol esters. They all have different half lives (time it lasts inside the body before half the medication is metabolized).
Assuming you inject the same amount of estradiol, esters with shorter half lives mean the levels of estradiol in your blood and tissues will be higher, but for a shorter period of time.
An ester with a longer half life means you will have to inject a bit more to get to those same peak levels, but also means you can inject less frequently.
Estradiol Valerate's (EV) half life is about 3.0 days. EV should be injected every 5 days.
Estradiol Cypionate's (EC) half life is about 6.7 days. EC should be injected every 7 days.
Estradiol Enanthate's (EEn) half life is about 4.6 days. Although research suggests that the peak of EEn comes later than EC. Essentially, treat EEn as similar to EC, with EEn possibly lasting longer. EEn should be injected every 7-10 days.
Detailed information on estradiol injection dosing will be found later in this guide in the Estradiol injection dosing section.
Valerate is typically prescribed by doctors, with cypionate being occasionally prescribed. Cypionate and Enanthate are most commonly found sold by homebrew estrogen sellers.
Pellets - N/A
Estradiol pellets are implanted into the body (usually the butt) and slowly release estrogen into your body over the course of many months.
This cannot be found from DIY sources (obviously).
These are more experimental in terms of dosages compared to the other more common methods. You can get them implanted if your insurance covers it (or if you're very wealthy). Because they slowly dissolve and release estrogen over time, you don't have to worry about missing a dose.
They last about 3-6 months. Most doctors that offer pellets compound them to give a patient quite a high dosage of estradiol.
What are the different types of antiandrogens?
⚠️ Note:
All of these should be swallowed unless stated otherwise.
Spironolactone (AKA Spiro) - $10-20 per month
Spironolactone is a weak antiandrogen, albeit quite safe.
Common side effects include increased thirst, salt cravings and frequent urination.
Can be taken alongside a regular HRT regimen as an experimental erection-prevention drug if getting erections is bothersome due to its blood pressure lowering effects (recommend 100-400mg/day¹ for this (start low)).
Not recommended as a first choice of antiandrogen due to its weak anti antiandrogenic effects.
❗ If you are currently taking spironolactone, and your total testosterone (T) levels are under ~30ng/dL, you can almost certainly stop taking spiro at that point. The estradiol is doing most of the work of suppressing your T.
Cyproterone acetate (AKA Cyproterone, Cypro) - $5-20 per month
Cyproterone is a very effective antiandrogen when combined with estrogen.
High doses should be avoided due to a harsher risk profile.
Keeping under a certain dosage is important, especially considering that cyproterone is usually sold in dosages 4-8 times that of recommended dosages for transfeminine individuals (get a pill cutter!).
Bicalutamide (AKA Bica) - $15-40 per month
Bicalutamide is a very effective antiandrogen, moreso when paired with estrogen. It works in a unique way by preventing testosterone from having an effect on your body, but it does not actually prevent your body from producing testosterone. Ironically, this will increase your blood testosterone levels (your body thinks that you have zero testosterone inside you and tells your testes to produce even more), but don't worry, all that extra testosterone can't do anything.
People tend to report bica being better at preserving penile function, libido and semen volume better versus other antiandrogens.
In cis male prostate cancer patients, bicalutamide has about a 1/4000 chance of causing either severe liver or severe lung toxicity. All published case reports of either severe liver or lung toxicity have been in cis men over 59 years of age. Despite this, it's likely that trans women still face a much lower but still present risk.
It's strongly recommended to get liver function tests every 3 months if you take bicalutamide.
GNRH Agonists - $270 per year (For Busrelin)
Extremely safe and effective antiandrogens that prevent your testes from producing testosterone. Commonly referred to as puberty blockers, they work just as well at blocking T for people who have gone through a full AMAB/testosterone puberty.
Unfortunately the most powerful forms are not available from DIY sources due to being prohibitively expensive.
An GNRH agonist called buserelin can be found DIY, but its administration method can be quite annoying (sprayed into the nostrils 3 times a day).
Estradiol Monotherapy - $100-$200 per year
Monotherapy means to only use one type of medication. As such, estradiol monotherapy means using only high doses of estradiol to suppress your body's testosterone production, as estradiol itself functions as an antiandrogen.
High enough levels of estradiol in the body is enough to cause your body's testosterone production to lower significantly. This is usually only easily achievable with estradiol injections, which allow a person to more easily achieve high estradiol levels versus other methods of administration.
Some people are able to maintain an estradiol monotherapy regimen using transdermal estrogens, but this is less consistent and more difficult to achieve. Transdermal estradiol monotherapy is not recommended due to these reasons.
Attempting estradiol monotherapy using non-injectable or transdermal forms of estradiol such as pills carry an elevated risk of blood clotting, and we recommend you do not try this.
The vast majority of people on a decent estradiol injection monotherapy regimen (only taking estrogen, no antiandrogen) are able to suppress testosterone levels adequately without needing to take antiandrogens.
Side Effects/risks:
⚠️ Important Note:
When you google a medication talked about here, you will probably see a massive list of side effects, in the context of antiandrogens, most of these effects (like hot flashes, fatigue, bone density loss, etc.) are actually just side effects of sex hormone deprivation seen in cis men who take antiandrogens without an estrogen for the treatment of prostate cancer. You will not see the effects of sex hormone deprivation if you take estrogen with your antiandrogens.
All forms of HRT will likely make you infertile, possibly irreversibly.
All recommended tests mentioned in this section can be tested from blood samples taken during a regular blood test. You don't have to get fancy expensive tests.
Estradiol
All forms of estrogen will increase your risk of blood clots (thromboembolism), including serious blood clots (e.g. deep vein thrombosis, pulmonary embolism). The likelihood of this is still very low in absolute risk but it is present. The risk of getting blood clots on HRT is essentially comparable to that of cis women if you take a modest HRT regimen.
Higher levels of estradiol means higher blood clot risk.
Assuming the exact same blood levels of estradiol, taking oral estradiol will carry a higher risk of causing blood clots versus other forms of administration (due to oral estradiol being metabolized through the liver).
However, because of the higher levels of estradiol in your blood that other methods usually result in (transdermal, injections, etc.), the unique risks of oral estradiol aren't particularly relevant in practice.
Spironolactone:
The main reason I recommend against spironolactone is because spiro is a very weak antiandrogen. There are just better options out there.
However, it's very safe, but common side effects include increased thirst, salt cravings and frequent urination due to it being a diuretic (makes your body get rid of water faster).
Spiro is also known to reduce blood pressure, which can make it hard for some people to attain erections.
Ideally you should get U&E (urea and electrolytes) tested for (see if you're dehydrated, basically) if you are on spiro.
If you are predisposed to developing hyperkalemia (elevated potassium levels), you should also get your potassium levels tested regularly if you take spironolactone, as spiro can cause your body to retain more potassium.
For the vast majority of people though, this is not a relevant concern.
Cyproterone acetate:
Extremely high doses of cyproterone, mostly found above 50mg/day and 100mg/day can cause a myriad of different harsh side effects and risks, mainly prolactinomas and meningiomas (small benign brain tumors).
At dosages relevant to transfeminine people (6.25-12.5mg/day) the risk profile is much different. The same risks are still present but much lower at smaller doses.
Cyproterone is also known to slightly increase blood clot risk, although the increase in risk is quite low at dosages used in trans people.
Cypro may increase the risk of B12 deficiency and slightly increase depression risk. Despite the relative safety at these doses, ideally you should still get prolactin (PRL) and B12 tested to make sure it's within a healthy range. These risks are cumulative (risks gradually get higher the longer you stay on cyproterone).
Bicalutamide:
Due to dysphoria, some transfeminine people do not want to experience a higher libido and an easier time getting erections. These are things that bica tends to preserve better than other antiandrogens. Some may see this as a beneficial effect, however.
