A guide to HRT self-management.
i wish i didn't have to write this
N.B. Before we begin, I want to emphasize the title of this post. This is a guide to HRT self-management. It is not the guide to HRT self-management. There are many other resources floating around on the internet on this topic. These guides are indeed quite accessible. No single guide will have “all the right answers,” so consult as many as you need if you choose to self-manage.
Rather, I hope that this post is part of a conversation about how we collectively maintain our health moving forward. Self-management of HRT is nothing new to queer and trans communities.We can push forward together and learn from each other. I hope you’ll join the conversation too.
If you are a trans adult on HRT in the United States, then you probably are concerned that the Trump regime will move to ban your transition-related medical care, just as they have already sought to do for trans youth. Last week, journalist Erin Reed raised alarms that the administration could move to do so very soon, pending the release of a junk science “review” of trans care.
A ban on adult care will leave many without continued access to life-saving medications. Reed recommends taking steps now to prevent gaps in HRT access. There are many options available to source HRT, including getting a multi-month supply now from a medical provider (which will be easier for those in Washington state starting next January), decreasing your dose to stockpile supply, or purchasing from “gray market” sources.1
The sourcing option you choose is entirely up to you. I am not here to recommend any particular approach because, as I see it, each option shares an important feature which I do want to address: HRT management will be moved outside of a medical setting. By taking HRT management outside of the hands of medical professionals, the risks to trans people on HRT will rise by removing the people who are supposed to monitor our health. I hope that this piece can provide resources and information to reduce these potential harms.
Don’t mishear me, however. The medical system has unfairly gatekept HRT and pathologized trans people for even longer than HRT has been used to facilitate medical transitions. In fact, this could be an opportunity to fully embrace the autonomy of trans people to self-determine their sex/gender - if it weren’t for the increasingly genocidal ambitions of the Trump regime and the impending increase in out-of-pocket costs.
dosing
If you are already taking HRT prescribed by a medical professional and are looking to start self-management, then I recommend keeping your dosing and route of administration the same! You can always adjust your dosage up or down later, once you feel confident about self-monitoring.
There is also a lot of “anecdata” out there (i.e. tips from the community on how to achieve the best outcomes). Most medical professionals strictly adhering to the published research will generally tell you to ignore these insights because there is no or little data to support them.
I would argue there is no data because health professionals haven’t invested in research on HRT to test these anecdata (even before the Trump-Vance administration). Absence of evidence is not evidence of absence. So, if there’s a tip out there that sounds interesting to you, feel free to give it a chance. If it doesn’t work or you don’t like it, then you can always go back to what you have done previously. As always, don’t do anything you aren’t comfortable with.
If you are new to HRT, welcome!! Below are some dosing considerations broken down by gender identity.
transfemmes
Transfemmes have the most *options* available (which can be good or bad depending on how your bodymind operates). First, estradiol comes in a few forms. The most common are injectables and pills (both pills you can swallow and tablets that dissolve under the tongue). Estradiol is also available as a gel or patch applied to the skin. Generally, injectable estradiol is the cheapest option.
I recommend starting a moderate dose and seeing how your body responds. You can always increase your dosage in a few months if your body is being stubborn. (This is exactly what I did with my medical provider when I started HRT!) If you are taking injectable estradiol, consider starting around 5mg per week, with some slight variation depending on the precise form of injectable intramuscular estradiol you are using. Oral estradiol regimens can start at 2-4mg per day, and transdermal (skin-applied) estradiol can start around 0.2-0.4mg per week. The differences in dosage between the routes of administration is due to different ways the body processes each type of medicine.
Transfemmes can also decide whether they want to take an anti-androgen (T-blocker) like cyproterone acetate or spironolactone. You definitely don’t need a T-blocker if you no longer have testes. If you are taking injectable estradiol, then you may not need to take a T-blocker. Perhaps start without a T-blocker, and consider adding one later if your testosterone levels aren’t dropping as fast as you’d like. If you are taking oral or transdermal estradiol, then a T-blocker will likely be helpful. Start with 6.25mg per day of cypro or 50mg per day of spiro to help suppress your testosterone levels. These can also be adjusted, but try not to take more 12.5mg per day of cypro. Instead, adjust your estradiol dosage upwards.
Some transfemmes are using progesterone to complement therapeutic estradiol. This is a popular example of “anecdata.” I have heard from friends that it helps suppress testosterone while boosting your libido. If you want to take progesterone, start dosing around 100mg per day.
transmascs
The options for transmascs are much more constrained. Testosterone is best administered as an intramuscular or subcutaneous injectable. However, transdermal gels also exist. If you are injecting testosterone, consider starting a dose around 50mg per week. You can then increase the dose depending on how your body is responding. The maximum recommended dose is 100mg per week.
Transdermal dosing will depend on how concentrated the gel or patch is. If your gel is 1% T, then your initial dose should be 50mg per day. The maximum recommended dose is 100 mg per day. Apply the gel in the morning to your arms or shoulders.
the thorny issue of blood testing
Everything in life comes with risks, including HRT. I’m going to focus here on the ones that could raise serious health issues if not under control. (There are less threatening side effects like decreased libido for transfemmes on T-blockers and acne for transmascs on testosterone.)
Estradiol raises the risk blood clots if your levels climb too high. T-blockers also have risks: spironolactone is a diuretic (and can thus lower blood pressure) and low doses of cyproterone can raise the risk of blood clots and decrease vitamin B12 levels. For those on testosterone, the biggest risk is increased red blood cell counts (known as polycythemia) where the blood thickens and impedes normal flow.
Overall, these risks are relatively low, but given the potential issues, it is good practice to monitor both your hormone levels and a few other measures (depending on your HRT regimen) through blood tests. Ideally, you would use the results of regular blood testing to guide any changes in dosage.
However, blood testing is not required to self-manage your HRT. They can be expensive which makes them financially unfeasible for many. Price will likely vary by area, but I did a quick search for labs near me (in Los Angeles), and it came out to just over $100 for one round of testing for me as a transfemme on estradiol and spiro.
If you have the financial resources to do so, consider testing periodically. For those on testosterone, testing every 3-6 months is ideal, and those on feminizing therapy can have slightly longer intervals between tests (6-12 months). It is certainly not a requirement to self-manage HRT, but it will help you track whether your hormone composition is moving in the right direction as well as whether rare, adverse side effects should be a concern to you.
Again, this is not required. If you cannot afford regular testing but are feeling good in your body, then you likely are healthy and well! If you hit a rough patch of unexplained symptoms, consider a basic blood test just to rule out HRT-related complications. (Perhaps at that point, a doctor ally could order the blood test so that insurance pays for the bulk of the cost.)
If you are able to do regular testing, which tests should you get? Always check your hormone levels, estrogen and testosterone. Transmascs should consider getting a compete blood count (CBC) once in a while to determine whether their red blood cells are elevated. Instead of a CBC, you can also test your hematocrit and/or hemoglobin to gauge your red blood cells (which contain hemoglobin). Transfemmes on T-bockers should consider checking additional measures depending on the exact medication you are taking (prolactin if you are on cypro, urea and electrolytes if you are on spiro).
What are the target ranges for estradiol and testosterone? These are totally up to you! Some people go into HRT wanting to target their hormone levels within the normal bounds as cis people of the same gender identity. Others want their hormone levels in the middle between cis men and cis women. There are no right answers.
Below, I am including the normal hormone ranges for cis men and cis women. If you want the maximum effects of HRT, then you probably want to target these ranges. But, you can set your goal wherever you’d like. Don’t go over the set limits of cis women’s estradiol (400 pg/mL) or cis man’s testosterone (1000 ng/dL) as doing so will raise your risk for side effects discussed above.
cis women’s hormone ranges (pre-menopause)
estradiol: 30-400 pg/mL
testosterone: 15-70 ng/dL
cis men’s hormone ranges
estradiol: 10-40 pg/mL
testosterone: 300-1000 ng/dL
Note the difference in units between estradiol and testosterone levels. Friendly reminder that everyone (regardless of gender identity) has higher testosterone levels than estradiol levels.
Use the results of your blood test to guide changes in dosage. To get the most accurate results, schedule the test for the day before your next dose (if you take injectable hormones) or 6 hours after your last dose (if you take oral hormones).
a few practical considerations
There are MANY reasons to be alarmed by the possibility of a ban on affirming care for trans adults. (Otherwise, I would be writing about something else!!) But, I also want to raise some practicalities because the way in which a hypothetical ban is implemented will also be important. There may be loopholes.
Take, for example, Trump’s executive order purporting to ban affirming care for trans adolescents. If you set aside the junk science, the order set forth the enforcement methods that the federal government would take to implement the ban. This includes withdrawing from WPATH guidelines, banning federal funding to institutes that provide affirming care to youth, removing coverage of adolescent affirming care from government insurance plans (including Medicare, Medicaid, plans offered to federal employees and veterans, and anti-discrimination protections for Affordable Care Act plans), and misconstruing existing law to include affirming care for trans youth.
Notice what isn’t in this executive order: an outright ban on the prescription of affirming care to trans adolescents. Yes, there the threat of prosecution which would be harrowing for those involved. But, it’s unclear if the novel legal argument (that adolescent affirming care is tantamount to “female genital mutilation”) would result in a unanimous jury in favor of conviction.
Frankly, the executive order lacks real teeth with respect to individual doctors and patients. Despite the administration’s lawlessness (like racially profiling people and sending them to foreign prisons), only Congress can outright ban affirming care in the way state legislatures around the nation have.
Instead, the executive order targets the money that executive branch disburses to the medical system. Large hospitals (especially those affiliated with universities) are most susceptible and likely to comply in order to preserve access to those funds. An adult care ban modeled after the youth care ban will have a huge impact by closing off avenues to care for the many people (myself included) who receive HRT from these venues. But, it wouldn’t be a total ban. Many small or specialized clinics may be able to weather the financial disruption and keep providing affirming care (albeit with higher caseloads).
Another big impact of an adult care ban à la the youth care ban is the loss of insurance coverage for those on government insurance plans. Such moves will, unfortunately, increase the cost of accessing care for trans people on these plans. If folx want to continue accessing affirming care, they will pay 100% of the costs out-of-pocket since their insurer will not pick up part of the tab. This is real economic harm.
Yet, we as a community could help mitigate these harms if we started crowdsourcing funds to cover these increased costs. (Would this be of interest? Personally, I’m intrigued by this idea and would love any suggestions y’all may have on how to implement it.)
A final lesson from the youth care ban is that the government was blocked from implementing it just 16 days after Trump issued the executive order.2 It’s likely that a court injunction would similarly follow an attempted ban on adult care. As long as hospitals aren’t complying with the ban during the injunction (and the administration follows the court orders), this will add an extra cushion for anyone scrambling to stockpile HRT.
Keep in mind that the Supreme Court is also deciding US v. Skrmetti which will determine whether youth care bans are constitutional. We can expect a ruling around the end of June, and the decision in this case (good or bad) may be applicable to an adult care ban as well.
So far in this section, I have tried to frame a hypothetical ban as not-quite-a-ban, or at least one with workarounds. However, there is a critical downside consideration for transmascs that I want to highlight.
Testosterone (unlike estradiol) is a scheduled substance, meaning that there are already federal restrictions on possession. This gives the Trump regime the option to prosecute transmascs with illegal possession of a controlled substance (i.e. affirming testosterone). Again, this threat is not associated with estradiol possession unless the Drug Enforcement Administration (DEA, housed within the Department of Justice) reclassifies estradiol as a scheduled substance.
As I have written before, testosterone’s drug scheduling means that all testosterone prescriptions are housed in state-level databases called prescription drug monitoring programs. Twenty-four states share this data with law enforcement on demand. The other twenty-six states require law enforcement to first get a warrant or a subpoena to access these records.
Under a hypothetical adult care ban, the government could easily identify, surveil, and target any person (cis, trans, or otherwise) with a testosterone prescription as well as the doctor who prescribed it and the pharmacy that fulfilled it. Again, it will be critical to see the text of the associated executive order banning adult care to see whether the regime is eager to go down this route of enforcement.
But even if you choose to go with non-prescription testosterone, possession without a prescription is criminalized. Having a stock at home would not be an issue unless someone snitches on you. But receiving packages addressed to you through the mail could be, if a customs agent seizes the package and gets the DEA involved. I honestly don’t know the likelihood of this happening, but it is something to consider if you are sourcing testosterone internationally.
Truthfully, these are thorny issues, and there is no single, “right” approach to maintaining your health moving forward. These decisions are about which risks you are comfortable taking for the continuation of your health care. Only you can answer that question for yourself.
Let’s keep this conversation going. If you have tips for those considering HRT self-management, please share them! Likewise, if you have remaining questions/concerns about what’s needed to self-manage HRT, please ask! We will get through this together. 💜
from the archive
In this instance, gray market refers to online sellers unaffiliated with the traditional pharmaceutical industry. There are lots of online resources that can help you select a safe gray market vendor if this is the path you are interested in.
It remains partially blocked in court as of this writing.
FYI: Sometime in the last three - four months, the VA became no longer able to provide prosthetics for trans veterans.
Fantastic post! I have two things to add.
1) Even if you can’t get a single prescription to be filled for a year, check the rules of how often you can fill a prescription in your state. Some states allow 90 day supplies to be filled monthly, which can be a slower but still effective way to build a backlog.
2) For progesterone, my provider has prescribed it many times and believes that best results for breast growth are starting it 6-12 months after starting estrogen.