hrt-internet.md 23 KB
% Self-medicating with HRT purchased on the Internet
We are NOT medical doctors. You are responsible for your own health, and we take ZERO responsibility if you don't do your research properly before self-medicating. We try to provide accurate information on this page, but we cannot guarantee it. You should seek proper medical advice. Self-medication is a last resort (e.g. gatekeeping doctors, or long waiting times to receive hormones from your doctor).
If you're a child in the UK, you should at least self-medicate on puberty blockers if possible, ideally full cross-hormones. Ask your parents to take you to see GenderGP, a private gender clinic, which is listed on our list of private trans clinics - they have been known to provide full HRT to children in the past. Their waiting times are low (NHS's waiting times are literally years, and you will go through your natal puberty if you're left waiting for NHS treatment only).
Otherwise, and especially if you're an adult, we recommend private treatment if you can afford it, instead of self-medicating. Your waiting times will be considerably reduced. You should also get yourself immediately on the waiting list to see someone at a gender clinic, on the NHS, if your country has publicly funded healthcare. Note that in some states in USA, medicaid covers trans care; check if it's available for this purpose, to you, in your state, if you can't get decent health insurance.
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
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.
NOTE: we looked into this, and most stores in Portugal sell ethinylestradiol which is not bioidentical, and has some very nasty side effects including heightened risk of DVT. Avoid ethinylestradiol like the plague. Make sure that you only buy estradiol valerate or estradiol hemihydrate.
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 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.
Recommended pills (trans women):
- Spiractin 100 (spironolactone)
- progynova 2mg (estradiol valerate)
- prometrium 200mg (micronized progesterone)
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:
Also look up side effects of micronized progesterone.
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.
QUIT SMOKING before you start HRT (e-cigarettes / vapour is fine). Smoking tobacco (or smoking anything, for that matter, including weed) increases clotting risk, which is even riskier with estradiol.
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.
Only use bioidentical estradiol. This is either estradiol valerate (progynova 2mg), or estradiol hemihydrate (estrofem 2mg).
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, after all).
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.
In our opinion, GnRH antiandrogen injections are the best T blockers. If you can get this with your doctor, that's great. Otherwise, use spiro or cypro.
Once you get to a decent estradiol/testosterone level in blood tests (T below 1 nmol/l, E 500 pmol/l), you could consider taking micronized progesterone (make sure it's bioidentical, and doesn't contain ethinylestradiol. some pills do) at 100mg daily for first 14 days of the month at half your usual estradiol dose, then stop taking progesterone until the end of the month and take estradiol at full dose. Repeat this every month. This may increase breast growth and simulate mental effects of periods that cis women get.
Oral estradiol may raise IGF-1, according to some people we've spoken to, which could also assist breast growth. Oral estradiol valerate/hemihydrate is therefore interesting to consider, instead of sublingual.
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.
Common/Blood tests:
Get blood tests before you start HRT! Go to your GP and ask for these tests:
- urea and electrolytes
- bone profile
- thyroid function
- C reactive protein
- ferritin
- full blood count
- baseline full blood tests
- random glucose
- FSH
- liver function
- estradiol
- testosterone
- rheumatoid factor
- SHBG
- HDL cholesterol
- TFT1: suspected thyroid disease
- uric acid
- lipids
- LH
- prolactin
- cortisol
- dihydrotestosterone (DHT)
book an appointment with your GP, and ask for the authorisation form, then find the hospital in your area that holds the blood samples taken, and go there to get your blood taken. It\'ll be on the list of blood clinics that your GP will probably give you. Go there, and then they\'ll send the results to your GP usually a week later, and you can go to collect them. If your GP refuses to authorise a blood test, try another GP. Some GPs are assholes.
Every 3 months afterwards, get these tested:
- liver function
- testosterone
- estradiol
- potassium (if taking spironolactone)
- B12 (if taking cyproterone acetate)
- Iron (if taking cyproterone acetate)
If you're taking progesterone, then also get progesterone tested, during your 14 day cycle. Your level should be no more than 40nmol/l
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.