transit-website/hrt-internet.md

% Hrt Internet

We are NOT medical doctors. The information on this page is based on typical advice usually given by doctors, but we cannot guarantee its safety. We try our best to offer safe advice, however. If you can, its better to get HRT through your doctor, but we also recognise that for some people, self-medication is the only way to go about the process. If you're being delayed or gatekept by your healthcare provider for starting HRT and not having HRT makes you suicidal, then we *highly recommend* self-medicating.

You are responsible for your own health. We are not responsible for any harm you may bring upon yourself. In most cases, though, if done properly with adequate research, self-medicating can be safe. You should especially read about the potential side effects of medications that you may take (we link to them on this page) and monitor yourself to the best of your ability. You're taking your health into your own hands. Unless you have a serious medical issue, HRT is safe. It's also worth noting that some doctors will prescribe HRT without an endocrinology exam.

If you're in the UK and trying to self-medicate because of NHS waiting lists, you might be able to get private health insurance and use it to pay for private treatment, which is usually faster. We have a list of private gender clinics on our private care providers list (GenderGP is very good and prescribes HRT quickly, including to children). We also have lists of other trans care providers in other countries on that page. If you live in USA, you can usually get HRT prescribed within a month, if you go to an informed consent clinic. We strongly recommend going private if you can. You'll get faster and better treatment. If the waiting list is short enough and you can manage waiting, we also recommend waiting for HRT prescription from them instead of self-medicating. We only recommend self-medicating if you are a child (NHS in the UK is too slow for most children, in prescribing puberty blockers) or if you are an adult trans person who is suicidal without HRT to the point where waiting more than a few weeks is too much.

Table of contents

• New Zealand
• Portugal
• United States
• Suppliers
• Check whether you're intersex
• Trans women (MtF)
• Trans men (FtM)
• Non-binary trans
• External links

Children

If you're of puberty age, start puberty blockers IMMEDIATELY. Take antiandrogens (E.g. spironolactone) if you're assigned male at birth, and antiestrogens (E.g. clomiphene or tamoxifem - tamoxifen is less safe and more problematic) if you're assigned female at birth. As a child, you have no choice but to self-medicate in most countries, either because they don't allow children to have HRT, or because they do but the services have too high waiting times to be treated (e.g. UK).

**There is a private clinic in the UK which prescribes HRT quickly, including to children. You can request blockers or full HRT, even at age

1. They have prescribed full HRT to children in the past! Go to the GenderGP clinic. You do not have to go to them physically, you can do everything over the internet, and they are licensed doctors.**

You should take a lower dose than adults. So for instance, a typical daily dose for adult trans women is 100mg per day. As a child, you might start on 25mg and see how you go (blood tests can check hormone levels). Same thing for trans men. Non-binary people we're not sure about, since there are all kinds of NB people.

We also believe that it is the right of a child to start on estrogen/testosterone if they want to, even at age 13. Again, your dose will be lower than for adults (the rest of this page talks about doses for adults).

New Zealand, Germany and others {#nz}

Importing HRT in New Zealand for personal use is restricted. You will be unable to self-medicate while living in NZ. You *can* order HRT, but you need to prove that you have a prescription for it.

See: http://www.customs.govt.nz/features/prohibited/imports/Pages/default.aspx (see: Medicines Act 1981). Click on the section that says Prescription medicines.

It might still be possible to self-medicate in New Zealand. TODO: research ways of doing this

Citizens of NZ should campaign for a change in the law, so that importing HRT without a prescription becomes allowed, and so that GPs prescribe HRT on an informed consent basis, without gatekeeping.

The same is true in Germany and many other countries.

It might still be possible to import, even with restrictions. Customs is less efficient, depending on your location, and might not even check your package. Order smaller quantities e.g. 1.5 month supply, and make sure to always order the next 1.5 month supply a few weeks before your current supply will run out. You can ask your supplier to package it as discretely as possible, and use a generic description on the package contents when shipping (i.e. not HRT or pharmaceuticals). QHI is good at that, but inhouse might be too (make sure they are discrete about packaging).

Portugal {#pt}

In Portugal, it is possible to purchase estradiol over the counter at some pharmacies. Look around. We're not sure exactly what brand or type, or whether it can be taken sublingually or buccal method, etc, but this can be a legitimate way to get estradiol without a prescription in Portugal.

Spironolactone is not available OTC in Portugal. You have to get it prescribed or buy it on the internet.

United States {#usa}

In the US, depending on your city/state, you might be able to get HRT prescribed quickly (within a month) by a doctor, instead of having to self-medicate. Look for an informed consent clinic in your area.

If you can get HRT quickly via informed consent, we recommend doing that instead of self-medicating. Your insurance will cover any expenses, and if not, HRT is usually cheap enough without insurance, depending on income (it's certainly cheaper than self-medicating, in a lot of cases).

We have a list of informed consent clinics here - if you know of any that are not listed there, let us know!

Suppliers

These companies are overseas (none of them are in the UK), and you can import HRT into the UK. It's legal to import HRT for your own personal use. Order no more than a 6 month supply per order. A 3 month supply would be safer.

InhousePharmacy.vu

InhousePharmacy is well-known and commonly used by trans people when self-medicating. It has existed for a number of years, and the meds that they provide are the real thing.

The box that arrives will say "pharmaceuticals" on it. If you need to receive them secretly, without someone (e.g. parents) knowing, then you should use a PO box or a friends house, or anywhere where you can receive them safely.

Quality Health Inc

This supplier ships to Portugal (Inhouse does not, last time we checked). For other people who can't order from Inhouse, this company might also be usable.

The box that arrives will be blank, with no information on it from the outside. This is good if you need to receive it discretely (e.g. at parents house).

TODO: add more suppliers

Check whether you're intersex {#intersex}

Ignore the doses on this page and do not self-medicate at all, if you are intersex. You will require special treatment, under close medical supervision from a doctor.

This page has information about what intersex means: https://nonbinary.miraheze.org/wiki/Intersex

The endocrine system is the collection of glands that produce hormones that regulate metabolism, growth and development, tissue function, sexual function, reproduction, sleep, and mood, among other things.

You can go to an endocrinologist. This is recommended anyway, because an endo can tell whether HRT is safe for you to take, along with blood tests. An endocrinologist can check whether you're intersex; this means having sexual characteristics of both male and female. Being intersex can have an effect on what type of hormone therapy is suitable for you. For instance, your doctor might put you on a lower dose of hormones than if you were not intersex.

In the UK, you can get a referral from a GP. If you're already receiving treatment from a GIC, they can also refer you to an endocrinologist.

In the UK, Dr. Leighton J Seal is one of the most well known endocrinologists specializing in endocrinology for transgender people, including intersex. However, you might also have luck with another endo if you don't live near London (where Seal operates). If you can, we recommend seeing Dr. Seal.

Trans women (MtF) {#women}

You should also make sure to book an appointment with an endocrinologist, if you can (in the UK, you need a GP referral).

UK residents: you might be able to get help from CliniQ on things like blood tests and so on, to make sure that you're safely taking HRT. They can offer advice. It's a private clinic, but also part of NHS.

You should also test your blood pressure. If you suffer from low blood pressure, you should not take spironolactone for instance (use cyproterone acetate instead, or if you can't get that, take finasteride and a higher estradiol dose). Similarly, if you have high blood pressure, you should get that sorted before starting HRT.

You'll see information online about having to lose weight before starting HRT. It's not actually true. It's good to not be overweight, but you can still be and start HRT. Just watch for side effects. This is the same for anyone, regardless of their weight.

Side effects of various medication:

• cyproterone acetate
• estradiol valerate/hemihydrate
• Spironolactone
• Finasteride

Not all of these are serious. Watch out for the serious ones e.g. blood clots, etc. If you get any of the serious side effects, stop taking HRT immediately and seek medical help. This paragraph is not meant to scare you away from taking HRT. You should take it, if you want to. But you are also taking your own health into your own hands, so you need to be more aware of risks.

Note about progesterone: progesterone is sometimes prescribed to trans women. The UK NHS has information about it on their website. In some cases, it can cause further breast growth, so it's worth looking into. You can usually get it as medroxyprogesterone (inhouse sells it, QHI probably does too). It's normally used in cis women for birth control, but also exists naturally. Ask your doctor for advice on dosages. Do read that NHS page, since it contains useful information about other side effects which you should be aware of.

Estrogen (estradiol valerate/hemihydrate) can come in pill, gel, patch (estradot brand) or injectable form. We generally recommend NOT injecting, because... needles, also injecting has a high risk of blood clots and you can damage the outer appearance of your skin (you might get needle marks).

For pills, we recommend 2mg Estrofem pills because they can easily be taken sublingually or via buccal method. 2mg Progynova pills might be possible to take sublingually or via buccal method but some people report difficulty. We do not recommend oral, for reasons documented on this page. Sublingual is when you leave it under your tongue, in the middle, at the back, where it will absorb directly into the bloodstream. We don't recommend swallowing the pill (oral usage), but some people do that too. It takes about 20 minutes to absorb, and you should try not to talk much while absorbing; you should also try not to cough or swallow, and not let any saliva drool from your mouth. Oral is also possible, but when swallowing estrogen, some of it is destroyed in the liver, which means that you have to take a higher dose, and oral increases risk of side effects e.g. DVT, blood clots, liver damage, etc. If you smoke or use nicotine in any way, then you SHOULD NOT take estradiol orally, because of the clotting risk, but also because nicotine interferes with oral estrogen by making more of it be lost/destroyed when metabolised, making it basically pointless to take (sublingual, buccal or transdermal while smoking is OK). How to quit smoking

An antiandrogen blocks testosterone. The most popular one is spironolactone, but cyproterone acetate is also popular in Europe. Both are toxic long-term and have different side effects. You should research which one. We recommend using spironolactone, unless you can't use it for some reason, in which case cyproterone acetate would also work. Inhouse and QHI both sell 100mg spironolactone pills and 50mg cyproterone acetate pills.

Spironolactine reduces the amount of salt in your body, so you should take in more salt in your diet while using it. It also increases the amount of potassium in your body, so you should lower your potassium consumption in your diet. Some spironolactone pills contain lactose, so if you are lactose intolerent you might have to take your lactase pills. We're not sure if the amount is high enough to warrant this.

Cyproterone acetate reduces iron and B12, so you should take supplements for those while using it. Cypro is an alternative to spiro, which some doctors in Europe prescribe (in USA, cypro is a controlled substance and not currently prescribed by doctors). Avoid alcohol like the plague, while taking cypro, because you can get massive hangovers with much smaller amounts.

If you've already had vaginoplasty or orchiectomy (genital surgery), then you do not need to take spironolactone, cyproterone acetate or indeed any antiandrogen, because your body no longer produces high amounts of testosterone (your testicles have been removed, afterall).

Fun fact: after surgery, some trans women actually have too low testosterone. Cis women have testosterone, just in small amounts. Some women have to actually take testosterone (the same kind that trans men take), but in very very very small doses, to get their testosterone up to female ranges. This page documents some symptoms of low testosterone in women (applies to cis women and post-surgery trans women). Blood tests will show whether your levels are too low (most women are between 0.5 to 1.5 nmol/l testosterone levels).

DHT is what causes hair loss in men, or trans women who waited too long. Hair loss can be reversed, by taking Finasteride which blocks DHT. You can get the 5mg finasteride tablets on inhouse or qhi (use a pill cutter to split them into 2.5mg pills, to be taken every 12 hours). Doctors usually prescribe between 1-6mg of finasteride. If you already have a full head of hair without hair loss, then you don't need finasteride. Finasteride can prevent hair loss, and in some cases can cause lost hair to grow back.

NOTE: patches often contain ethinyl estradiol, which is not ideal. This is not bioidentical to real estradiol, but a synthesized version that is more potent. The clotting risk is higher with this when taking orally. It replaces diethylstilbestrol, which is known to be cancinogenic. We recommend using the Estradot brand of patches (whether 25, 50 or 100mcg variant) because it uses the superior estradiol hemihydrate.

Most good doctors start you off on 100mg spironolactone and 2mg or 4mg oral estradiol (or 1mg/2mg gels or 50mcg/100mcg patches) daily. Start on that first (low dose recommended) - take the estradiol sublingually or via buccal method. If you have trouble with sublingual method, try the buccal method instead. The buccal mucosa is the inner wall on your cheeks, between teeth and gums. Here are some pics on Google image search You might need a pill cutter, depending on what dose you take and how you spread it out into the day. Spread your spiro dose into 2 daily doses (every 12 hours), so for instance with 100mg daily spiro you'd split it into 50mg every 12 hours. Split the estradiol dose into 2 doses daily (gels) or 2-3 doses daily (pills, whether oral, sublingual or buccal). For patches, you don't need to split anything because the patch stays applied constantly, until you have to put a new one on.

You should use spironolactone and estradiol, usually. If you can't take spiro (e.g. don't respond well to it, side effects, low blood pressure, etc) then you could try cypro instead (50mg daily - some trans women go up to 100 or 150mg). Most doctors would start you off on 50mg if using cyproterone acetate.

Take spiro or cypro orally, NOT sublingually or buccal. Only take the estradiol sublingually (or buccal method)!

If you can't or don't want to take an antiandrogen (spiro, cypro, GnRH), you can take estradiol alone, which on its own can block testosterone, but it means that you have to take it at a higher dose than usual. Finasteride is a weak antiandrogen.

Our opinion about patches (estrogen): Patches often fall off, and they can cause skin irritation. They're generally uncomfortable to wear, and have a lot of reliability issues, especially if your skin doesn't absorb it well. Some people like it because it guarantees more stable levels throughout the day, but the problem is that you have to wear each patch for 3 days, and it can get dirty. Washing is not very practical with patches, nor is swimming.

Our opinion gels (estrogen): Gels are easier to use than patches, because it doesn't fall off during the day and it's less intrusive, but also has the same problem that it doesn't always work with some people depending on their skin type. You also have to wash your hands after using it, etc. Gel containers are also large and heavy, so they are impractical to carry around, and they are not easy to take privately or discretely.

Whatever daily (24h) dose you take, you should split that into 2 doses every 12 hours, or 3 doses to be taken every 8 hours. 3 is better, but 2 is more convenient for most people. With sublingual or buccal, the estrogen wears off quicker so you get more peaks/lows. This is one reason why oral is better (more even levels throughout the day). If you can, taking sublingually (or buccal method) every 8 hours is good, otherwise every 12 is also ok.

Estrogen alone, in high enough doses, can also block testosterone. In the old days, trans women were given only estrogen, because antiandrogens didn't exist in most trans healthcare.

2 months after you start HRT, get estradiol and testosterone levels checked in a new blood test. Female range is about 0.4 to 1.5nmol/l testosterone, and 400-500 pmol/l estradiol (some trans women go between 500-600). You will start developing breasts and your face will transform, as will the rest of your body. If your T is too high, *and* your estradiol is too low, try increasing your estradiol dose a bit - e.g. from 4mg to 6mg, and check levels again in 2 months. Note that the extra estradiol will also lower T a bit more. If T is still a bit high on the next blood test, try increasing your spiro dose - e.g. 100mg to 150mg. Then try again. If you're taking HRT while getting blood tests, then before each blood test MAKE SURE that you take your dose 1 hours before, assuming that this is 12 hours after your last dose, so that you know roughly what your peak levels are.

We are not responsible for any harm that you may bring upon yourself. Self-medication is usually safe for most people (and most trans women do it, or consider it, in their early transition). If you have some abnormality in your blood results (doctor will tell you) pre-HRT then get checked up with an endrocrinologist if you can (several private ones exist, if you can't use NHS) and ask their approval. They are there to help you. Certain benign brain tumours (prolactinoma) can be susceptible to estradiol too; blood test results can tell you signs (your prolactin will be too high, e.g. 3x higher than normal - there are other reasons that this could occur, not just prolactinoma), and an MRI scan can be used to detect it. You can take a dopamine antagonist which doctors will prescribe, to treat the prolactinoma. If it works, your prolactin levels may drop to normal levels after a month. The antagonists suppress the prolactinoma, making estradiol safe to take in a lot of cases. Your doctor will start you off on a very low dose of estradiol while the antagonists take effect, and then check you later on. If the prolactinoma is suppressed enough, they'll increase your dose. DO NOT SELF MEDICATE *AT ALL* IF YOU HAVE A PROLACTINOMA. USE AN ENDOCRINOLOGIST, GET FREQUENT BLOOD TESTS AND ONLY TAKE HRT PRESCRIBED BY A DOCTOR, UNDER CLOSE MEDICAL SUPERVISION.

Self-medication is always risky, but we also understand that dysphoria is also risky and that delaying HRT can be deadly for some people. We strongly recommend NOT taking estrogen orally. Take it sublingually, via buccal method or transdermally (the blood clotting risk is much less than oral, with less risk to liver, etc. People with serious heart conditions shouldn't take estrogen orally either)

This website (not run by Transit) also has some useful information about HRT for trans women.

Trans men (FtM) {#men}

Trans men take testosterone (steroids). This is a controlled substance in the UK, and not legal to purchase without a prescription, unlike male-to-female HRT. You can still get it though, just not in inhouse or qhi. *hint hint*

TODO: put dosages on this section, as a general guide.

This website (not run by Transit) has some information about HRT for trans men.

Non-binary {#nonbinary}

This page has info: https://madgenderscience.miraheze.org/wiki/Non-binary_hormone_therapy_guide

• We don't have much info about it on Transit. We do not run the madgenderscience wiki.

It's difficult to recommend anything to non-binary people, because they are not binary. There is a lot more variation in non-binary people, and a lot of cross over between trans men/women.

Assigned male at birth: whatever dose you take, HRT (if you want HRT) will still cause breasts to develop. If you're dysphoric about breasts (you might not know you are until you start) or you start being so, stop all HRT immediately. We've had experiences before with people who thought they were trans women, but then decided that they were non-binary, because although they wanted feminization, breast growth increased their dysphoria, so they had to stop taking HRT. Feminization without breasts is possible, if you later get top surgery (breast removal) after a few years on HRT when breast growth has settled. You can wear a binder. On the other hand, some non-binary people like having breasts.

Assigned female at birth: taking testosterone will masculinize you also. If you want to masculinize a bit (low dose testosterone), but don't want hair growth, you might be out of luck, so you'd have to later get laser hair removal. If you want an androgynous voice, and testosterone masculinizes your voice too much, note that you can still use the same kind of voice training that trans women use, to get back to a voice that you're more comfortable with. Taking testosterone means that your voice will deepen over time, but this can be overcome.

Intersex: TODO, write about intersex people. (this has nothing to do with non-binary identity necessarily, but intersex people need different HRT treatment, if they take HRT).

Some non-binary assigned male at birth take spironolactone without estrogen, or with low estrogen dose (e.g. 0.5mg) because they want to not have too much of either hormone. or they take full HRT but there are certain things they don't want; e.g. they don't want hair removal (hormones will not reduce facial hair, but will reduce body hair a bit), etc. If they're assigned female at birth, they might just just an antiestrogen (e.g. tamoxifem).

These are just some notes with a few bits of advice. We don't assume how a person is, and we recognize that non-binary people have more variation between them than binary people. You will just have to make your own mind up. Transition is more difficult for non-binary people than for binary people.

External links

https://madgenderscience.miraheze.org/wiki/Main_Page also has information about self-medication.