Hormone replacement therapy (often known by its acronym, HRT) is a medical treatment where the levels of sex hormones (testosterone, estrogen, and progesterone) are changed by using sex hormones and/or hormone blockers. HRTHormone replacement therapy is used for a variety of medical applications, ranging from relief of menopause symptoms, relief of andropause symptoms (andropause is kind of like the male version of menopause- cis mens’ testosterone levels decline with age, which can cause symptoms similar to menopause in cis women), and treating hormone sensitive cancers such as breast cancer and prostate cancer. However, this literature will focus on the use of hormone replacement therapy to treat gender dysphoria in transgender and non binary people.
Be sure to check the GLOSSARY at the end of the post if there are any words that are new to you!.
DISCLAIMER: THIS IS NOT MEDICAL ADVICE, AND THIS INFO IS NOT A SUBSTITUTE FOR A MEDICALLY SUPERVISED HRT REGIMEN.
This literature is based on information compiled from the lived experiences of trans people who are unable to access health care for hormonal transition, and decide to self-medicate HRT. Although the risks of HRT are very low when medically supervised, they are significantly higher when one is undergoing a DIY regimen. The information in this literature is only intended to provide a level of information that is slightly better than wild guessing for DIY HRT. The risks of DIY HRT cannot be eliminated or ruled out by following any of the info in this literature, and this is not intended to be information on how to administer DIY hormones safely. This is intended for the sake of getting information out there. Unfortunately, some online trans spaces ban discussion of things like recommended doses of hormones, which leaves people completely in the dark. Even though the risks of DIY HRT are alwaysstill present, it’s still better at the very least to know what dose ranges and what drugs are prescribed by doctors, rather than completely guessing what drugs and what doses to take.
Harm reduction for grey market hormones:
Disclaimer: this does not constitute medical advice. This information is not a substitute for taking hormones with medical supervision. This information is provided so that those who are unable to access hormones from the medical establishment have at least some information rather than none at all.
If the reason why you are taking DIY hormones is due to being denied by a gatekeeper, one thing you can try to get them to get you on a medically supervised regimen is to try to get to have another appointment with them after being on a DIY hormone regimen for a while. That way, they may feel more compelled to refer you to an endocrinologist, since you are already taking hormones anyway and they may give in and put you on medically supervised HRT for the sake of reducing liability if you are gonna take hormones anyway.
Hormones may be difficult to access for some trans people, whether due to cost, medical gatekeeping, or both. This leads some trans people to acquire hormones from the grey market without medical supervision. This can have various risks, some of which can be mitigated, although not to the extent that they can be with medical supervision.
Drugs used for HRT regimens:
Estradiol (aka estrogen): Estradiol is commonly called “estrogen”, even though estrogen is actually an umbrella term for a variety of hormones that all exhibit similar effects as estradiol. Estradiol is the hormone that is primarily responsible for physical feminization, and it is by far the most prominent estrogen in the human body, and the one that is prescribed for HRT.
Progesterone: Progesterone is kind of like an “androgynous” hormone. Although it plays roles in the menstrual cycle and pregnancy, it doesn’t induce the same extent of physical changes that estrogen or testosterone does. Progesterone is sometimes used to augment breast development for male to female transitioners, or to stop the menstrual cycle for people who have dysphoria due to menstruation but do not desire masculinization.
Testosterone: Testosterone is a hormone that causes physical masculinization, and it is used to alleviate gender dysphoria for people who want to have more masculinized physical features. Testosterone usually does not require an estrogen blocker, as estrogen levels tend to become suppressed with testosterone treatment.
Premarin: Premarin is a form of estrogen that is derived from the urine of pregnant horses. The reason why it exists is because the estradiol in the human body cannot be patented, so drug companies took the estrogens out of horse pee so they could make money off it. It does not contain estradiol, the estrogen that is present in the human body, and rather contains different types of estrogens that are present in horses. Premarin has a high rate of adverse side effects and is less effective than estradiol, and it has fallen out of favour now-a-days.
Spironolactone: Spironolactone is a drug that blocks the androgen receptors, meaning that it prevents testosterone from having an effect on the body. Spironolactone is usually used in conjunction with estrogen, because unlike testosterone, estrogen on its own usually does not suppress testosterone production, unless it is taken in very high, dangerously blood clot inducing doses. Only if one has had an orchiectomy (removal of the testes) or vaginoplasty, is when spironolactone is no longer needed. It is unsafe to be on spironolactone without estrogen for people who are transitioning from male to female for longer than a couple years, because the lack of sex hormones can cause osteoporosis over time.
The main risks to look out for with spironolactone is that it is a potassium sparing diuretic, meaning it causes your kidneys to flush out more water and retain more potassium than usual, so it’s important to drink enough water and get one’s potassium levels checked to make sure they don’t become too high, which can be a medical emergency. Spironolactone lowers blood pressure so one may feel a bit of wooziness when standing up after sitting for a while, but this effect tends to fade after a few weeks. It’s important to drink lots of water since spironolactone diuretic effects cause frequent urination.
Cyproterone Acetate: This is another testosterone blocker, and it also acts as a progestin (meaning it has effects similar to progesterone). It is more often prescribed outside of North America.
Finasteride: Finasteride blocks a hormone called dihydrotestosterone, or DHT, which is a byproduct of testosterone. It is generally used to prevent male-pattern baldness among trans women, and occasionally among trans men, cis men, and cis women who want to prevent male pattern baldness from testosterone treatment (or endogenous testosterone in the case of cis men or women). One thing to be aware of with this drug is that it can cause depression in some people, and it should be discontinued if one is experiencing any mental illness.
Lupron: Lupron is a drug that stops the body from producing sex hormones. It is generally only used for transgender youth to prevent the onset of the “wrong” puberty, with spironolactone being preferable for people beyond puberty age for suppressing testosterone. Testosterone by itself generally suppresses estrogen production for female to male transitioners beyond puberty age.
Lupron only blocks hormones that are produced by the body, and does not block externally administered hormones. This makes Lupron specifically useful for transgender preteens who may be near the onset of the “wrong” puberty but are still too young for cross hormone treatment.
Harm Reduction Tips
Use bioidentical hormones, and try to avoid synthetic hormones.
Bioidentical hormones refer to the hormones that are naturally produced by the human body. Synthetic hormones are hormones that are have similar effects as human hormones, but are often far more potent and have much higher health risks. Synthetic hormones are usually found in birth control pills or anabolic steroids used by bodybuilders. Keep in mind that this doesn’t mean bioidentical hormones are “safe”- they still carry similar risks as synthetic hormones when they are taken without medical supervision.
For those seeking estrogen, one should seek estradiol or its injectable esterified versions (such as estradiol valerate). Ethinylestradiol, which commonly encountered in birth control pills, is 80 times more potent than estradiol, cannot be detected on a blood test, and has a high risk of causing blood clots. A particularly dangerous synthetic hormone pill is Diane 35, which is a combination of ethinylestradiol and cyproterone acetate. The combination of these two drugs in particular has a very high level of risk for blood clots, strokes, and pulmonary embolisms, and a number of deaths have been implicated due to Diane 35. Avoid ethinylestradiol and Diane 35.
For those seeking testosterone, esterified forms of testosterone like testosterone cypionate are bioidentical. Testosterone is not available on its own in oral form like estradiol is, because it has a very low oral bioavailability. For those who have a fear of needles, testosterone is also available in a transdermal gel form. Synthetic versions of testosterone such as trenbolone that are used by bodybuilders are very risky and should be avoided at all costs. Avoid bodybuilder synthetics such as trenbolone.
Eat a low potassium diet on spironolactone:
Since spironolactone causes the kidneys to retain more potassium than usual, it is recommended to eat a diet that is low in potassium to prevent the risk of dangerously high potassium levels, which can cause cardiac issues in extreme cases. If you like eating bananas and avocados, get a blood test to ensure your potassium levels are at a safe level. One food that spironolactone is known to cause cravings for, pickles, are ideal to eat since they are relatively low in potassium but contain other electrolytes.
Always use sterile injection equipment.
- Never share injection equipment, as that can spread diseases like HIV and Hepatitis C.
- In Toronto, you can access sterile injection equipment at South Riverdale Community Health Centre, Queen West Community Health Centre, Parkdale Community Health Centre, and the Works. You may also be able to pick up sterile injection equipment at some pharmacies.
- Make sure you ask for intramuscular (IM) injection equipment, not intravenous (IV). For most IM injections, you need a 21 to 23 gauge needle that is 1-1.5 inches long.
- Never use the same equipment for your hormones and for drugs! If you inject both hormones and drugs, try to switch up injection times/spots as much as possible to prevent one area from being overused. If you are injecting drugs IM (ie. ketamine), try to plan it so that the injections don’t happen on the same day, and use alternate thighs, or use your upper arms for shooting IM drugs.
Where to inject hormones:
Hormones are injected IM, as they would be flushed right out of your system if they were injected IV. The best spot to inject hormones is on your front thigh, right in the middle between the hips and the knee, as this area contains large muscles. Another area one can inject (this can only be logistically done if someone else is injecting you) is the SIDE of the butt- NEVER on your actual butt itself, as there is the risk of poking and causing damage to your sciatic nerve. An advantage of the side of the butt is that you don’t get as much soreness during walking as from a thigh shot, but thigh shots are easiest to do alone. Alternate sides in between each injection to give each muscle a bit of a break from being poked.
How to inject hormones:
This may seem like a lot of steps at first, but it will become easier once you’ve done it a few times.
1. Wash your hands and find the most sterile environment available to you.
2. Unwrap your sterile needle from its packaging, and put the tip into the vial of hormones.
3. Slowly draw the required mL amount into the syringe. (We will discuss dosage late on).
4. To get rid of any air bubbles, turn the vial and syringe upside down, and push the plunger of the needle forward slightly, until a drop of oil comes out of the end of the needle and drips back into the hormone vial. Don’t worry too much about every single tiny air bubble- with IM injections, you don’t need to worry about air bubbles causing strokes.
5.Turn it right side up again, and remove the syringe from the vial.
6. Put the needle into the injection site at a 90* angle, straight down– not at an angle like with IV injections.
7. Try to avoid veins as best as you can. To make sure you didn’t hit a vein, pull up on the plunger of the syringe a VERY GENTLY (if you pull too hard you will get air in the syringe) to make sure no blood goes in. If you see blood, pull it out and try another injection site.
8. If there is no blood, push down very slowly on the plunger. When pushing down on the plunger, push slowly enough that it takes about a minute for all the oil to go in. If you push down too fast, there will be too much pressure and the oil will squirt out of the injection site and it will be a waste.
9. After you pull out the needle, immediately push the skin aside with your thumb and apply pressure for about a minute- this prevents the oil from leaking out. Do not move your legs at all, as muscle movement will cause the oil to squirt out.
10. After about a minute passes, take your thumb off the injection site, and put a band-aid on. Don’t move your legs for another few minutes to make sure no oil squirts out the injection site.
It’s normal to have muscle soreness for 2-3 days after injecting, so if possible, time your shots when you don’t need to exert yourself as much.
Start with a low dose, and wait a while before working your way up.
When one is self-medding, the dosage is kind of a shot in the dark, since one does not know what the resulting hormone levels from a specific dose will be. Therefore, it is recommended to start with a low dose, and wait a while to determine whether or not a higher dose is needed to produce the desired effects. Remember that once the dose level required to produce physical changes is reached, a higher dose will not increase the physical changes. The ideal dosage is the lowest dose that is needed to induce physical changes.
Note that these dose ranges are very tentative!
With spironolactone, it is recommended to start with 50mg a day.
If 50mg is not having any effect after 6 months, then go up to 50mg twice a day.
If 50mg twice a day is not having any effect after ANOTHER 6 months (one year total), then go up to 100mg twice a day.
It is not recommended to exceed 200mg per day.
For estrogen, if one is taking it in pill form, it is recommended to start with 1mg a day. If no noticeable changes occur in 6 months, one can increase to 1mg twice a day, and then to 2mg twice a day after another 6 months if there are still no noticeable changes.
It is not recommended to exceed 4mg per day.
Injectable Estradiol Valerate
With injectable estradiol valerate, it is recommended to start with a dosage of 10mg every two weeks, or 5mg once a week. If one does not notice any results after 6 months, one can move up to 20mg every two weeks or 10mg every week.
It is not recommended to exceed this dosage.
Injectable Testosterone Cypionate
With injectable testosterone cypionate, it is recommended to start with 50mg every two weeks, or 25mg per week. If one has no noticeable results after 6 months, one can move up to 100mg every two weeks or 50mg once a week.
It is not recommended to exceed 100 mg every two weeks.
For testosterone gel, it is recommended to start with 1 pump of gel. The packaging will often contain dose instructions, as it’s designed so that each pump of gel contains a specific dose. The same applies for estradiol gel. If you use gel, beware that you don’t accidentally expose others to your hormones– it’s best to use the gel on a part of skin where other people will not come into contact with.
For progesterone, it is recommended to go with 100mg per day.
Cyproterone acetate is recommended to be taken in a 50mg dose.
For finasteride, it is recommended to go with a dose below 1mg, which is lower than the 5mg dose that it is usually available in.
If possible, get bloodwork done.
The main risk with self medicating is not knowing what your hormone levels are. Most of the risks occur when hormone levels are too high or fluctuate too much, and there are also risks that are associated with various anti-androgen drugs. Getting blood work done shines some light on all these unknowns that can increase the risks.
You can get blood work done by asking a general practitioner for a requisition. Ideally, blood work should be done every 6 months.
Hormones and recreational drugs:
If one is using cyproterone acetate as an anti-androgen, it is not recommended to drink alcohol in amounts that are enough to get drunk, as cyproterone acetate is hard on the liver, and in combination with alcohol it can cause significant damage to the liver.
If one is taking estrogen and spironolactone, alcohol tolerance can be reduced and the diuretic effects of spironolactone can cause alcohol to be even more dehydrating than it already is. Estrogen decreases the amount of alcohol dehydrogenase in the stomach, an enzyme which breaks down alcohol, so more alcohol is absorbed in the stomach. The effect of estrogen of increasing body fat over time can also reduce alcohol tolerance, as more fat tissue leads to less water in the body, increasing alcohol concentrations in the blood. The extent to which this occurs varies widely, with some people becoming extreme lightweights, and others noticing no change- nonetheless, one should keep the possibility of lower alcohol tolerance in mind.
Alcohol tolerance can increase on testosterone, but that is not guaranteed and it’s still quite possible that it will have no effect on alcohol tolerance. One should keep in mind that their limit for alcohol may still remain the same. Even if alcohol tolerance does go up, one should still beware of their limits and not try to drink more to compensate.
If one is taking estrogen and spironolactone, some of the risks of MDMA regarding overheating, electrolyte imbalance, and dehydration are increased. Estrogen levels influence body temperature, and higher estrogen levels increase the risk of overheating from MDMA. This also applies to cis women, and MDMA’s effects can vary in strength among the same dose through the menstrual cycle.
With spironolactone being a diuretic and affecting electrolyte levels, IT IS VERY IMPORTANT to drink electrolyte water, and be mindful of the level of potassium in the electrolyte water- it’s generally ideal to dilute your electrolyte water by half. It is very pertinent to be careful with hydration and electrolytes if one is using MDMA with spironolactone.
GHB increases the amount of human growth hormone in the body, which is responsible for growth during the puberty age and into the early to mid 20s, especially muscle growth and breast growth if started younger than age 25, as discussed earlier. However, this is not a reason to use GHB frequently, as frequent GHB use can cause very dangerous and debilitating drug dependence. GHB withdrawal can be fatal! If one wants to use GHB for its bodybuilding effect, it should only be used occasionally (no more than once a week or so), when going to sleep after a workout session. It is also not known whether an occasional increase of human growth hormone from occasional GHB use has any appreciable effect on HRT results for people starting at an age where human growth hormones have declined, so overall it’s really not worth it to use GHB for the purpose of augmenting HRT results, as it is implausible that 3 hours a week of increased human growth hormone have any appreciable effect on growth.
Cigarettes increase the risk of blood clots if one is on estrogen, especially if one is on an excessive dosage of estrogen without medical supervision. As long as one’s estrogen levels are measured with blood work and are within average cis female levels, the blood clot risk is still increased but still comparable to the risk in cis women who smoke cigarettes. The highest risk is when one is self medicating estrogen and does not know their levels.
For those taking testosterone, the risk for cardiac disease from cigarettes is increased, especially if hormone levels are not being checked- they should be within cis male norms for the risk to remain comparable to that of cis men.
It is not well known how hormone replacement therapy changes the effects of other drugs, and some people report that drugs hit them stronger or weaker while on HRT. For most people, there is no change with how one reacts to drugs other than the ones listed while on HRT. However, one should still be aware of the possibility that drugs might affect one differently on HRT in ways that may not be predictable, so it’s ideal to take it easy with any drug use when starting HRT.
Transgender: The prefix “trans” means “across”. Thus, transgender refers to people whose gender does not correspond with the gender that was assigned to them at birth.
Cisgender: Cisgender is more or less the “opposite” of transgender, and refers to people who identify as the gender they were assigned at birth. The prefix “cis” means “on the same side of”, meaning that a person’s gender is on the “same side” of the one they were designated at birth.
Transition: Transitioning refers to the process that transgender people undertake to take on the traits of the gender that they identify with. This can include the medical regimens discussed in this literature, but may also includes non-medical things, such as name/pronoun change, change in aesthetic/style, etc. There is no “right” way to transition. People may transition at different rates, or choose not to undertake certain aspects that others do. All of these are valid.
Non-binary: Non-binary refers to people whose gender does not correspond to the male-female binary. Some people who are non-binary may have an identity that is both male and female, neither, or a gender or genders that have no relation to maleness or femaleness. Usually, non-binary people go by they/them pronouns or other gender neutral pronouns like ze/zir or xe/xir, although some non-binary people may also be okay with he/him and/or she/her pronouns. Never assume- if you aren’t sure, it doesn’t hurt to ask what pronouns a person goes by.
Despite what one might expect, not all non-binary people necessarily have an androgynous style or appearance- for example, some non-binary people may look masculine or feminine enough that they might “look like” a man or a woman to you, but regardless of appearance, they are still non-binary. Conversely, someone who appears very androgynous is not necessarily non-binary.
Some non-binary people undergo medical transition, and others do not, and medical transition for non-binary people may either be similar or different compared to medical transition for binary trans people- although non-binary people all have in common that their gender identity does not fully correspond to the male-female gender binary, the identities of individual non-binary people can be different.
Gender dysphoria: Gender dysphoria refers to feelings of despair that occur when one’s assigned gender does not correspond to who they are as a person. There are three main kinds of gender dysphoria- social gender dysphoria refers to a sense of dissonance related to the social gender roles that one fits into. Ego gender dysphoria refers to a sense of dissonance from their assigned gender related to who one is as a person. Physical gender dysphoria refers to a sense of dissonance of one’s body type not matching the body type that the person feels that would suit them.
These three kinds of gender dysphoria often overlap, but sometimes may occur on their own- for example, someone with only social gender dysphoria only feels dissonance with the gender role they are assigned to, but do not feel dysphoric about their body or the gendered aspects of their identity. Hormones are usually sought to alleviate physical gender dysphoria, although some people with only ego gender dysphoria may also take hormones so that they can more easily “pass” as a member of their identified gender if unwanted secondary sex characteristics cause style-related changes to be insufficient for someone to express their gender identity.