things you can add to your (feminising) hrt regiment

here is a few additional things you might want to consider adding to any hrt ur taking as a trans fem person! i've split it into sections based on what they target :3 ive not added links to where u can get any of this stuff but if u email me (bottom of the page) i can send it to u directly :3

also, if you do decided you are interested in any of these please look into side effects and contraindications as i have not gone over these on this page. if you are struggling to find or understand the information, pls feel free to email me!

some of the language I use might be dysphoric for some people as I'll be referring to genitals (for example) but I try and use as scientific language as possible!

blockers

if you are taking an injectable form of estradiol, there is a good chance you won't need a blocker as the e should be able to suppress your testosterone production by itself. but in some cases, even with high (but safe) e levels, testosterone production is not adequately suppressed and you may need to use a blocker. I have only gone into detail about two types of blockers which are available, as these are the two I would most strongly recommend depending on your preference, but I will add a list of other blockers you can look into at the end of this section which I haven't gone into detail about.

gnrh analogues

gnrh analogues, also known as gonadotrophin-releasing hormone analogues, come in a few different forms and two methods of delivery. most commonly gnrh analogues are done as injections, commonly at intervals of every 4 weeks, 12 weeks or 6 months. the other form of gnrh analogue you may be able to find is as a nasal spray administered twice daily, however, this can be more difficult to get a hold of.

the injectable form comes in 3 varieties typically: goserelin (zoladex), triptorelin (decaptepyl), and leuprorelin (prostap).

decapeptyl is usually a 11.25mg intramuscular injection every 12 weeks, but can be taken as a 3mg injection monthly or a 22.5mg injection every 6 months
goserelin is a 10.8mg subcutaneous injection every 12 weeks, or as a 3.75mg subq injection monthly
leuprorelin can be taken as an 11.25mg intramuscular injection every 3 months, or as a 3.75mg im injection monthly

the nasal spray form comes in two forms: buserelin and nafarelin, both are taken twice a day at the same time.

gnrh analogues have very minimal side effects, but if your e levels are inadequate, you are just taking the gnrh analogue, or you have a significant increase in bone pain, you should try and get a DEXA scan as it is associated with osteoporosis in some cases. they are also much more likely to cause erectile issues than the other blocker I am going to talk about.

one thing to note about gnrh analogues is that they are very expensive off prescription and it can be hard to find the exact dose you are looking for. one goserelin 10.8mg injection is about £185 + shipping and the price tends to go up from there.

nb! when you first start taking a gnrh analogue it can temporarily increase your testosterone production for the first two weeks. a second blocker taken for these two weeks can help alleviate this.

bicalutamide

bicalutamide is taken as a tablet once daily, at a dose of dose 25-50mg. it is not prescribed at all in the uk (shocker, as if the gic does anything helpful) but is in other places. bicalutamide is slightly estrogenic (it can cause some feminising changes on its own) and is less associated with erectile function issues. it is also considerably cheaper. 28 tablets is about ~£25 + shipping on the grey market.

bicalutamide is a bit complicated in one aspect. while other blockers halt the production of testosterone, bicalutamide instead prevents your body from using any of the testosterone that you are producing. the effect is the same, but you may notice in blood tests that your t levels remain the same or even go up. this is because the blood test can only measure how much t is in your blood, not how much of it actually being used, so if you decide to take bicalutamide that is something to remember. a good way of seeing if your testosterone is adequately suppressed is by checking the colour and consistency of your semen. when your t is adequately suppressed, your semen should be close to clear and quite thin and runny, so you can use this as a metric to check that your t levels are low enough for yourself.

nb! bicalutamde should NOT be taken if you have significant liver function issues! in very rare cases it can cause severe liver toxicity (primarily in men with prostate cancer over the age of 65, but no studies have been done on trans fem's use of bicalutamide).

other blockers you might want to consider

spironolactone
cyproterone acetate

nb! if you have been told that finasteride can be used as a t blocker you have been misinformed, finasteride is a DHT blocker and not a testosterone blocker and will not block the production of testosterone.

hair loss & hair growth

there may be two aspects about your hair you are concerned about: "male pattern hair loss" and body hair growth. this section will talk about both of these things.

nb! there is a lot you can do if you are unhappy about your hairline or thinning of your hair, but there is only so much. these methods can help you if you have hair loss but the follicle has not died yet. once the follicle is dead, there is nothing you can do to regrow the hair that was once there. this does take a few years to happen to a significant degree, but is something that should be considered!

finasteride

if you are looking for a tablet you can take once daily which will prevent "male pattern hair loss" or progression as well as reducing the amount of body hair you have the best option is probably finasteride 5mg. finasteride is a DHT blocker (rather than a full testosterone blocker), meaning it slows down and reduces "male pattern hair loss" from occurring as well as reducing the amount of body hair that you grow, and often will lighten the colour of any body hair that you do have.

finasteride is available over the counter without prescription in many countries, but if it isn't available where you are, it is readily available through grey market means. a box of finasteride on the grey market usually comes to around $23 + shipping for 30 tablets. it may also be possible to get a prescription from a doctor if you request it by saying you are concerned about hair loss, but whether or not you get that will vary from practitioner to practitioner.

minoxidil/regaine

minoxidil is the active ingredient in regaine, a foam which you apply to your head to encourage hair regrowth with a lot of success. regaine is commonly available over the counter, but it is quite expensive (in the UK, it is about £50 for a months worth). the upside of taking regaine rather than minoxidil tablets is that as it is applied to your hair directly, the hair growth is concentrated where the foam is applied, whereas with minoxidil tablets, hair growth is not concentrated in a specific area and you may end up developing more body hair as a side effect.

eflornithine

eflornithine is a cream applied to the face (ONLY!) to reduce the amount of hair, especially around the chin and upper lip. it is typically (when used for hair growth prevention) prescribed to cis women who are unhappy with the amount of facial hair that they have. in studies, 81% of cis woman who used elfornithine reported clinical improvement after 12 months, and positive results are seen within 8 weeks. however, if the cream is discontinued, hair growth will return to its baseline level within about 8 weeks as well. eflornithine is taken twice daily, usually about 8 hours a part and costs ~£20 + shipping on the grey market

libido & erectile issues

a decreased libido and issues developing and maintaining erections are associated with estrogen hormone replacement therapy and blockers (though blockers more so, and some more than others). there is no way of knowing before you start e (or blockers) whether this is something you will experience as it varies from person to person a lot, but it is common.

to begin with, i will go over ways you can help yourself develop or maintain erections if this is an issue and something you would want to be able to do. the reason that e (and blockers) are associated with difficulty developing and maintaining erections is due to the atrophy of the erectile tissues. people with penises who are not taking HRT or blockers avoid this atrophy (even when not actively utilising their penises) by having nocturnal erections. however, this often stops happening when you take e.

here are some options for helping with developing and maintaining erections:

use it

a commonly talked about method of maintaining erectile function is simply to “use it” regularly. generally the advice is to maintain an erection at least 3 times a week for a minimum of 10 minutes each session as this should greatly decrease the amount of atrophy of the erectile tissues.

viagra/sildenfafil

viagra (generic: sildenafil) is commonly used by many people who have erectile issues to, in the moment, develop and maintain an erection if they should otherwise struggle with this. viagra is only taken when needed, but also is associated with decreased functionality of the penis’s ability to develop and maintain erections naturally over time and can affect the heart

cialis/tadalafil

this is a tablet taken daily which restores spontaneous erectile function in response to stimuli and closely mimics natal erectile functions. it may even restore nocturnal erections in some people. the trans fem community tends to prefer this over viagra.

low dose topical testosterone

testosterone gel can also be used to help with erectile function. the gel is applied to the scrotum, and the dose is akin to what menopausal cis women take as part of their hrt regiments (one pump 2x a week/1 satchet a week split into two doses per week depending on what form of t-gel you get) and should not raise your general testosterone levels outside the range you want them in.

if you are interested in reading more in depth about this specifically relating to people on feminising hrt, then this substack article goes into a lot of depth and is very informative!!

in terms of low libido, one option you have is bremelanotide or PT141. it is usually prescribed to cis women experiencing low sexual desire before menopause that is not due to medical, psychiatric or social problems. it should be taken at least 45 minutes before any anticipated sexual activity and no more than one dose per 24 hours should be taken, further no more than eight doses is recommended per month. nausea is fairly commonly associated with PT141 (in around 40% of people), but can be managed with anti-nausea medications prior to taking your dose. bremelanotide is a 1.75mg injection done subcutaneously and retails at around £20 for 10mg + shipping. it is easily available if you google it.

progesterone

nb! progesterone is not generally recommended to start until at least a year on estrogen or when you have reached tanner stage 3 breast growth.

i'll mostly be talking about the options you have for taking prog, rather than how it works and can help you with your transition as well as other benefits, but you can read a paper here about the benefits of taking progesterone in conjunction with estrogen (though it is obviously not complete and doesn't account for anecdotal evidence from trans fems particularly)!

to summarise, progesterone is linked with:

more rapid feminisation
decreased endogenous testosterone production
optimal breast maturation to tanner stage 4/5
increased bone formation
improved sleep and vasomotor symptom control
cardiovascular health benefits

in terms of prog, you have essentially two options:

micronised progesterone tablets (starting at 100mg and going up to 200mg max if so desired, taken either orally or as a suppository)
medroxyprogesterone acetate (a 1ml depot injection every 13 weeks)

micronised progesterone is generally preferred by the diy community as there is some evidence to suggest it is less associated with venous thromboembolism, but this is a very slight difference and neither poses an especially high risk on its own (though you should be conscious of any other increased risk factors, and if you are at a particularly high risk of VTE I would potentially recommend micronised prog over medroxyprogesterone). micronised prog tablets are also usually taken, in diy circles, as suppositories to help increase absorption. depending on where you live, you may be able to get them over the counter at a pharmacy or by filling out an online form for an online pharmacy (and claiming to be a menopausal cis woman), otherwise it is available from grey market pharmacies. prices for micronised prog on the grey market are usually about £25 + shipping for 50x100g and £50 + shipping for 50x200mg.

medroxyprogesterone acetate, usually under the brand depo-provera (though you may be able to find sayanna press which is the same thing but as a subcutaneous injection), is an injection every 13 weeks. it is typically used as a form of birth control for people who can't take combination birth control, and in people who can get periods, is often associated with the cessation of periods. there is some evidence it may increase the risk of VTE ever so slightly, but this is more associated with the pill forms of medroxyprogesterone acetate rather than the injection. the two main benefits of the medroxyprogesterone are not having to take a tablet every day in the case of people who may struggle to remember this, and secondly, one injection usually retails at ~£30 per injection at grey market pharmacies so it is considerably cheaper than the micronised progesterone. it is possible to get depo-provera from online pharmacies by filling out an online consultation form (I would recommend saying something along the lines of that you are a cis woman looking for birth control and period cessation if you try this), but this is usually a bit more expensive than getting it grey market and obviously has the risk of being catalogued somewhere which you might not want.

if you are interested in any of these and want more information, or have questions about other additions to your hrt regiment that you are considering, please email me!

email me if u need more help!!