For regimens with antiandrogens: There is usually no reason to start HRT on a lower than normal dose of antiandrogen, you should go directly onto a standard dose of antiandrogen and adjust accordingly if needed.
For regimens with oral or sublingual/buccal estradiol: To accurately dose pills you may need to buy a pill cutter (Amazon or any local pharmacy sells them). Check your HRT pill type to see if your pills need to be split a certain way for your preferred dosages (e.g. if you’re taking 2mg of estradiol three times a day, and you only have 4mg pills, you will need to cut your pills into 2mg doses).
Any regimen: There’s no strong evidence to suggest that starting on a low dose of estradiol and slowly raising your dose is necessarily better than starting on a moderate dose. There are anecdotes and theories floating around that suggest that you may get better breast development or feminization if you start low and slowly ramp up your dose. Despite the lack of clinical data and evidence, there’s no real harm in doing this. Feel free to experiment if you wish.
The following example regimens use typical doses of estradiol on the higher end of what would be considered a moderate dose. Adjust accordingly if you have access to blood testing (see blood testing section above).
If you take cyproterone, you will need a pill cutter! (Pill cutters are sold at any pharmacy over the counter or online from sites like Amazon). Cyproterone tablets are almost always 25mg-50mg tablets (way over a recommended dose). It is not recommended to go above 12.5mg of cyproterone daily. Increase your estrogen dosage if testosterone is not adequately suppressed instead. Cyproterone acetate is taken orally.
| Method | Cyproterone Acetate Dosage | Estradiol Form | Total Daily Estradiol |
|---|---|---|---|
| Oral | 6.25-12.5mg once a day | 3mg Oral tablets twice daily | 6mg |
| Sublingual | 6.25-12.5mg once a day | 1mg Sublingual/Buccal tablets three times daily | 3mg |
| Transdermal | 6.25-12.5mg once a day | 200μg Patches changed twice weekly* | ~200μg daily equivalent |
| Topical | 6.25-12.5mg once a day | 4mg Gel once daily | 4mg |
*Estradiol patches usually come in a form that is intended to be changed out every 3-4 days, although some may allow for weekly use. Check the packaging to be sure how often you are meant to change your patch.
Reminder! Bicalutamide may cause blood testosterone levels to increase slightly, so even though your T may be adequately blocked, your testosterone levels on a blood test will likely show quite high levels. Bicalutamide also has a long half life, which means it doesn’t really matter what time you take it every day, as long as you take it every day. 50mg daily is almost always enough to ensure adequate testosterone suppression when combined with estradiol. Bicalutamide is taken orally.
| Method | Bicalutamide Dosage | Estradiol Form | Total Daily Estradiol |
|---|---|---|---|
| Oral | 50mg once daily | 3mg Oral tablets twice daily | 6mg |
| Sublingual | 50mg once daily | 1mg Sublingual/Buccal tablets three times daily | 3mg |
| Transdermal | 50mg once daily | 200μg Patches changed twice weekly* | ~200μg daily equivalent |
| Topical | 50mg once daily | 4mg Gel once daily | 4mg |
*Estradiol patches usually come in a form that is intended to be changed out every 3-4 days, although some may allow for weekly use. Check the packaging to be sure how often you are meant to change your patch.
Relugolix is taken orally once a day, usually in 40mg pills. From DIY sources, it usually comes in a capsule form. Relugolix does not have the testosterone flare side effect that GNRH agonists have, so you do not have to increase your dose at the start.
| Method | Relugolix Dosage | Estradiol Form | Total Daily Estradiol |
|---|---|---|---|
| Oral | 40mg once daily | 3mg Oral tablets twice daily | 6mg |
| Sublingual | 40mg once daily | 1mg Sublingual/Buccal tablets three times daily | 3mg |
| Transdermal | 40mg once daily | 200μg Patches changed twice weekly* | ~200μg daily equivalent |
| Topical | 40mg once daily | 4mg Gel once daily | 4mg |
*Estradiol patches usually come in a form that is intended to be changed out every 3-4 days, although some may allow for weekly use. Check the packaging to be sure how often you are meant to change your patch.
Buserelin (sometimes sold as the brand name ‘Suprefact’) has a short half life, so it should be administered three times a day to be effective. You can double the recommended dose of buserelin during the first week to counteract the testosterone flare effect that GNRH Agonists have. Alternatively, you can take cyproterone or bicalutamide for the first three weeks on buserelin.
Buserelin comes in a bottle that dispenses a set amount of medicine with each spray (300μg per spray in these examples).
| Method | Buserelin Dosage | Estradiol Form | Total Daily Estradiol |
|---|---|---|---|
| Oral | 300μg sprayed three times per day (900 μg/day) | 3mg Oral tablets twice daily | 6mg |
| Sublingual | 300μg sprayed three times per day (900 μg/day) | 1mg Sublingual/Buccal tablets three times daily | 3mg |
| Transdermal | 300μg sprayed three times per day (900 μg/day) | 200μg Patches changed twice weekly* | ~200μg daily equivalent |
| Topical | 300μg sprayed three times per day (900 μg/day) | 4mg Gel once daily | 4mg |
*Estradiol patches usually come in a form that is intended to be changed out every 3-4 days, although some may allow for weekly use. Check the packaging to be sure how often you are meant to change your patch.
For some individuals, spironolactone may not be able to adequately surpress testosterone levels. It’s recommended to get a blood test to monitor your levels to see if this is an effective antiandrogen for you.
| Method | Spironolactone Dosage | Estradiol Form | Total Daily Estradiol |
|---|---|---|---|
| Oral | 200mg once daily | 3mg Oral tablets twice daily | 6mg |
| Sublingual | 200mg once daily | 1mg Sublingual/Buccal tablets three times daily | 3mg |
| Transdermal | 200mg once daily | 200μg Patches changed twice weekly* | ~200μg daily equivalent |
| Topical | 200mg once daily | 4mg Gel once daily | 4mg |
*Estradiol patches usually come in a form that is intended to be changed out every 3-4 days, although some may allow for weekly use. Check the packaging to be sure how often you are meant to change your patch.
Here are some reasonable dosages for estradiol injections used in transfeminine hormone therapy:
| Estradiol Formulation | Recommended Dose | Injection Volume | Frequency |
|---|---|---|---|
| Estradiol Valerate (EV) | 4mg | 0.1mL (assuming 40/mg/mL vial) | Every 5 days |
| Estradiol Cypionate (EC) | 4mg | 0.1mL (assuming 40/mg/mL vial) | Every 7 days |
| Estradiol Enanthate (EEn) | 4mg | 0.1mL (assuming 40/mg/mL vial) | Every 7 days |
| Estradiol Enanthate (EEn) - Alternative | 7mg | ~0.18mL (assuming 40/mg/mL vial) | Every 10 days |
| Estradiol Undecylate* (EUn) | 16mg | 0.2mL (assuming 80/mg/mL vial) | Every 20 days |
| Estradiol Undecylate* (EUn) - Alternative | 32mg | 0.4mL (assuming 80/mg/mL vial) | Every 30 days |
* It is highly recommended to inject estradiol undecylate intramuscularly, as subcutaneous injections may produce unpredictable levels and a shorter half life.
Notes:
These dosages should give the vast majority of people high enough estradiol levels to suppress testosterone on its own.
Adjust accordingly if you have access to blood testing (see Blood Testing section below). Ideally you should be aiming for the lowest possible estradiol levels (that are still above 100pg/mL at trough) that still adequately suppress testosterone < 50ng/dL at trough. Though people usually require trough estradiol levels of 200-250pg/mL to adequately suppress testosterone. (‘Trough’ refers to your blood levels at the lowest point of your dosage regimen, which is right before you take your next dose. This will be explained in more detail in the Blood Testing section below)
Vials of estradiol are usually compounded at 40mg/mL.
This means that for a 40mg/mL vial, every 1mL of liquid will contain 40mg of estradiol. A 40mg/mL 10mL vial will then contain a total of 400mg of estradiol.
We will unfortunately be doing some math here.
The formula to calculate how much liquid to inject is:
(amount you want to inject) ÷ (concentration of the vial) = amount to inject per dose in mL
| Desired Dose | Vial Concentration | Calculation | Injection Volume |
|---|---|---|---|
| 4mg | 40mg/mL | 4 ÷ 40 = 0.1 | 0.1mL |
| 5mg | 40mg/mL | 5 ÷ 40 ≈ 0.13 | 0.13mL |
| 8mg | 40mg/mL | 8 ÷ 40 = 0.2 | 0.2mL |
| 10mg | 10mg/mL | 10 ÷ 10 = 1 | 1mL |
| 10mg | 20mg/mL | 10 ÷ 20 = 0.5 | 0.5mL |
| 10mg | 40mg/mL | 10 ÷ 40 = 0.25 | 0.25mL |
| 10mg | 80mg/mL | 10 ÷ 80 ≈ 0.13 | 0.13mL |
Not too complicated now, hopefully!
Needles can be bought from any pharmacy over the counter in most countries without a prescription (you may have to ask the pharmacist directly). Most countries also have online sites that sell appropriate injection needles. Amazon is a popular source for those in America.
Injection Supplies
Make sure to buy 1mL syringes, as the small amounts of fluid we are using for each injection are only easily measured with 1mL syringes. The more common 3mL syringes will still work if you cannot find 1mL syringes, but are not ideal. It is fine to use 3mL syringes if you are using estradiol undecylate due to the high injection volumes.
There are two methods for an E injection, subcutaneous/subq³ (injection into the layer of fat under the skin), and intramuscular/IM (injection deep into the muscle underneath the skin and fat). Both methods result in identical absorption rates and levels of the drug, whether you prefer subq or IM is mostly personal preference.
Homebrewed injections typically contain benzyl benzoate (a safe solvent that is also commonly used in prescription grade medications), which can cause some minor irritation if injected subcuaneously. Usually there will be less post-injection pain if injected intramuscularly.
Appropriate gauges (needle thickness) for a subcutaneous injection are 25-30g, for intramuscular, 23-25g. Subq needles are thinner than IM needles, which some people will find less intimidating.
Recommended needle lengths are as follows: 1”-1 ½” (IM, 1 inch is better for thinner people and 1 ½” for thicker people) ½”-⅝” (Subq, up to personal preference)
There are many online videos and guides for how to administer an intramuscular or subcutaneous injection, here is a decent one:
Note that around 0.1mL of fluid will be lost with each injection due to needle dead space.
Generally, injections will not need antiandrogens, though if you prefer to take a lower injection dosage, you may need an antiandrogen (also note that lower injection dosages may require the use of fixed needle, insulin type syringes of 0.3mL or 0.5mL to accurately measure dosage).
Here are some recommended injection dosages if you are taking antiandrogens along with it, refer to the tables in the antiandrogen dosing section above for recommended antiandrogen dosing:
| Estradiol Formulation | Recommended Dose | Injection Volume | Frequency |
|---|---|---|---|
| Estradiol Valerate (EV) | 2mg | 0.05mL (assuming 40/mg/mL vial) | Every 5 days |
| Estradiol Cypionate (EC) | 2mg | 0.05mL (assuming 40/mg/mL vial) | Every 7 days |
| Estradiol Enanthate (EEn)³ | 2mg | 0.05mL (assuming 40/mg/mL vial) | Every 7 days |
| Estradiol Enanthate (EEn)³ - Alternative | 3mg | ~0.075mL (assuming 40/mg/mL vial) | Every 10 days |
| Estradiol Undecylate (EUn) | 8mg | 0.1mL (assuming 80/mg/mL vial) | Every 20 days |
| Estradiol Undecylate (EUn) - Alternative | 16mg | 0.2mL (assuming 80/mg/mL vial) | Every 30 days |
$50-$150 per test, depending on source
Regular blood testing every ~3 months or so is useful, but not absolutely mandatory¹, especially if not particularly affordable or feasible. Here are some sources of private blood testing² if you cannot access blood testing through the medical system:
Blood Test Sources
Get your estradiol (E2) and total testosterone (T) tested every time. Get your blood taken as close as possible to your next scheduled injection/dose (Test your blood as far away as possible from a previous dose, right before your next scheduled dose. Preferably the day of your shot, or the day before). Your blood levels of estradiol and testosterone when taken at this time are called ‘trough levels’, because they are the levels of E2 and T that are present in your body at the lowest point in your HRT dosing regimen.
Trough levels most useful for injection monotherapy; for determining if your testosterone is adequately suppressed at the lowest point of your injection cycle.
The most essential component of transfeminine HRT is to get total testosterone (T) below 50ng/dL and estradiol (E2) above 100pg/mL.
1
However, I strongly recommend regular blood tests (every 3 months) to get liver function tests (ALT/AST) if you are taking bicalutamide, due to the extremely low but still present risk of severe liver toxicity. You can stop these tests after about a year or so (if your liver enzymes are normal on bica after a year you’re fine).
2
Most private blood testing lets you print off a requisition form, which you can bring to a local blood lab to get your blood drawn. You don’t have to mail anything in or take your blood at home.
3
Different abbreviations of subcutaneous in common usage include: subq/subQ, SQ and SC.