site/hrt-internet.md

@@ -187,6 +187,8 @@ you know of any that are not listed there, let us know!
 Suppliers
 ---------
 
+See also: https://hrtcafe.net/
+
 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
@@ -235,8 +237,6 @@ 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}
 ------------------------------
 
@@ -273,6 +273,38 @@ operates). If you can, we recommend seeing Dr. Seal.
 Trans women (MtF) {#women}
 -----------------
 
+The goal of MtF HRT is to adjust your blood testosterone
+and blood estrogen levels into female ranges, which is about 0.4 to 1.5 nmol/L 
+testosterone (T), and 400-500 pmol/L estradiol (E2), though some trans women go between 500-600.
+This is achieved by taking an anti-androgen and estrogen. Try to create a
+regime that aims for these levels. Then, 2 months after you start HRT, 
+get estradiol and testosterone levels checked in a new blood test. 
+
+An anti-androgen (AA) 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. Less popular options are bicalutamide or GNRH agonists/antagonists. 
+We recommend using spironolactone, unless you can't use it
+for some reason, in which case cyproterone acetate would also work.
+
+Around this time, you should 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 anti-androgen (e.g. spiro) dose - e.g. 
+100mg to 150mg, or switching an anti-androgen. Keep trying until
+in target ranges. If encountering difficulties, feel free to reach out
+for help.
+
+***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.***
+
+***Pull Request note: I think trough levels are more useful than peak levels in general***
+
+
 You should also make sure to book an appointment with an
 endocrinologist, if you can (in the UK, you need a GP referral).
 
@@ -287,22 +319,19 @@ 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.
 
-**WARNING: cypro causes depression symptoms. Use with care.**
-
 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:
+You should always research the side effects of the medications you are taking yourself. 
+Here is some links for your convenience.
 
 -   [cyproterone acetate](http://www.cancerresearchuk.org/about-cancer/cancers-in-general/treatment/cancer-drugs/cyproterone-acetate)
 -   [estradiol valerate/hemihydrate](https://www.drugs.com/estradiol.html)
 -   [Spironolactone](https://www.drugs.com/spironolactone.html)
 -   [Finasteride](https://www.drugs.com/sfx/finasteride-side-effects.html)
 
-**WARNING: cypro causes depression symptoms. Use with care.**
-
 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
@@ -310,24 +339,7 @@ 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.
 
-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.***
-
-**WARNING: cypro causes depression symptoms. Use with care.**
-
-Another alternative to spiro/cypro is flutamide or bicalutamide.
-bicalutamide is usually taken at 50mg daily, though we're not sure about
-flutamide. NOTE: the pills are plastic and harder to cut/split.
-Both affect certain liver enzymes which could be a problem; in extreme cases,
-jaundice and liver failure. They don't suppress testosterone, but they block
-its effects, so free flowing testosterone in your body will not actually work.
-You should be careful when taking this, and get constant blood tests to check
-for this.
+### Spironolactone
 
 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
@@ -336,25 +348,130 @@ 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
+
+### Cyproterone acetate
+
+Cyproterone acetate is a synthetic progestin, which decreases your testosterone production
+significantly. When combined with estrogen it easily surpresses testosterone it into female ranges.
+Cypro is thus 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,
+not currently prescribed by doctors). 
+
+Cyproterone acetate reduces iron and B12, so you should take supplements
+for those while using it. ***Avoid alcohol like the plague,
 while taking cypro, because you can get massive hangovers with much
 smaller amounts.***
 
-**WARNING: cypro causes depression symptoms. Use with care.**
+**WARNING: Never exceed 12.5 mg daily. Long term, cypro causes depression symptoms. Cypro increases your lifetime risk of benign brain tumors, this risk increases cumulatively over the years. Cypro might be toxic
+to your liver. There might be other side effects not mentioned here. Use with care.**
 
-NOTE: cyproterone acetate on long term usage, depending on dosage, has been
-known to cause some depression symptoms.
+### Bicalutamide
 
-**Only** use bioidentical estradiol. This is either estradiol valerate (progynova 2mg),
-or estradiol hemihydrate (estrofem 2mg).
+Another alternative to spiro/cypro is bicalutamide (or possibly flutamide).
+Bicalutamide is usually taken at 50mg daily. Bicalutamide has a long half life in the body, 
+and might take a few weeks to build up or completely leave the system. 
+NOTE: the pills are plastic and harder to cut/split, if you have 150 mg pills and want to take 50 mg daily,
+it can be okay to take one pill every 3 days, as long as you don't forget.
+
+Both affect certain liver enzymes which could be a problem; in extreme cases,
+jaundice and liver failure. They can also affect the kidneys.
+**You should do a liver function test (LFT; commonly including
+tests such as AST, ALT) at months 1, 3 and 6, 12, and then at least yearly**
+and discontinue usage if they are elevated (it becomes elevated in 1-4% of people,
+most commonly manifesting in the first 6 months of usage). Avoiding alcohol
+while taking bicalutamide is advised, and you should probably measure your
+liver function before taking it too. **There are very rare documented cases of sudden onset complete liver
+failure associated with hospitalization and sometimes death with bicalutamide.**
+
+Bicalutamide is an androgen receptor antagonist, which means it doesn't reduce testosterone production, 
+but it blocks its effects, so free flowing testosterone in your body will not actually work.
+This unfortunately means that you will be unable to monitor if your T is surpressed,
+which is I think one of the reasons why endocrinologists aren't too keen on using it.
+
+### GnRH agonists/antagonists
+
+In our opinion, GnRH antiandrogen injections are the best T blockers.
+Generally they are known to have little side effects.
+They are also called colloquially as puberty blockers, but they
+work equally well for adults.
+
+If you can get this with your doctor, that's great. They are usually prohibitively expensive to DIY.
+The best affordable ways to get them I know of were buserelin nasal sprays from
+Russia, though this might be difficult since the war, or to get raw relugolix powder
+from China, and to make 40 mg capsules from it yourself (in a controlled environment).
+Neither is ideal.
+
+When taking GNRH agonists, the first 2-3 weeks there is a testosterone flare-up
+that can be blocked with taking bicalutamide alongside for a few weeks. This is not
+an issue with GNRH antagonists, such as relugolix.
+
+### Estradiol monotherapy
+
+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. In the old days, trans women were given only estrogen, because
+antiandrogens didn't exist in most trans healthcare.
+
+When going for monotherapy, having consistently high enough levels is key.
+Having a hormonal profile that is "spiky" (varies a lot) is undesirable.
+Monotherapy is often synonymous with estrogen injections in DIY circles,
+though it is also possible to achieve, with diligence through other
+means, such as patches or sublingual (with very careful timing). 
+With oral it might be more difficult to achieve high enough levels due
+to low bio availability. With gel (and possibly patches), skin absorbtion
+of estrogen might vary because of your lifestyle, or the season 
+(temperature, how much you sweat). Since monotherapy is sensitive to variations
+in levels, you should get them tested more often when on gel (or possibly patches).
+
+That being said, let's talk about injections. In contrast to pills, injectables
+produced by pharmaceutical companies are often expensive. Most DIY injectables
+will be homebrew, that is made by a trans woman at home, using similar procedures
+as the body building community manufactures injectable steroids. They sell multi use
+vials of oil solutions (MCT oil or castor oil) of estradiol esters (estradiol valerate,
+cypionate, enanthate or undecylate). Because of the homebrew nature,
+these vials last long (more than a year) and are one of the cheapest methods to do DIY MtF HRT.
+**However, these vials will not be subject to the same testing as pharmaceutical products.**
+
+Estrogen injections are not as scary as they sound in the first place, as they are usually done
+subcutaneously (or rarely intramuscularly), which means you are only injecting into the fat (or muscle) under
+the skin. You are not injecting estrogen into veins. This means that for example you don't need to panic 
+about small bubbles. You do need to research which parts of the body are safe to inject (to avoid hitting
+nerves), you do need to sterilize your vial before every use (with alcohol wipes), and you do
+need to use a sterile unused needle every time, and dispose of needles safely (collect used syringes/needles
+in a hard plastic sealable container marked biohazard). For subcutaneous injections insulin needles can be
+a practical option, as they are designed for comfortable self-injection subcutaneously.
+
+You can actually simulate your estradiol levels on injections using tools such as
+https://www.estrannai.se/. These are based on averages from pharmacology studies of estradiol esters,
+so your levels might be significantly different - **simulators are not a substitute for blood testing**.
+The different esters have different half lives, therefore they require different dosing. The simulator
+contains some quite sane starting points for dosing monotherapy.
+- 4 mg of estradiol enanthate (EEn) every 7 days
+- 5 mg of estradil cypionate (EC) every 7 days
+- 3 mg of estradiol valerate (EV) every 4 days
+- 40 mg of estradiol undecylate (EUn) every month - note: the data on EUn is sparse, do more blood tests and do extra research, but yes, monotherapy can be possible at a single injection a month.
+
+### Finasteride
+
+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 2.5 mg pills, to be taken every 12 hours). Doctors
+usually prescribe between 1-6 mg 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.
 
-***If you've already had vaginoplasty or orchiectomy (genital surgery),
+Note: finasteride is not a suitable testosterone blocker. It only
+prevents the conversion of testosterone into DHT.
+
+### Surgical removal of testes
+
+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).***
+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
@@ -366,14 +483,12 @@ in women](http://www.everydayhealth.com/low-testosterone/guide/women/)
 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.
+### Estrogen
+
+**Only** use bioidentical estradiol. This is either estradiol valerate (progynova 2mg),
+other estradiol esters such as estradiol enanthate or undecylate, or estradiol 
+hemihydrate (estrofem 2mg). You should not be taking ethinyl estradiol
+or conjugated estrogens (colloquially known as horse piss estrogen).
 
 **NOTE: patches often contain ethinyl estradiol, which is not ideal.
 This is not bioidentical to real estradiol, but a synthesized version
@@ -385,7 +500,10 @@ cancinogenic. We recommend using the *Estradot* brand of patches
 
 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 is recommended, when you first start HRT).
+that first (low dose is recommended, when you first start HRT). 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 (12.5 mg daily). Monotherapy is always a good
+option too, to avoid the side effects of anti androgens.
 
 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
@@ -396,22 +514,6 @@ daily (gels) or 2-3 doses daily.
 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.
-
-**WARNING: cypro causes depression symptoms. Use with care.**
-
-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.
-
 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. NOTE: there is not a
@@ -432,27 +534,16 @@ Wear it on your lower abdomen, around your hips on either side, left or right.
 Gels: we do not currently have information about estradiol applied via gels.
 We recommend oral or patch method.
 
+**Do not apply estrogen gel near the breast area, as it might significantly increase
+your breast cancer risk**
+
+Injections: see monotherapy.
+
 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.
 
-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.***
+### Disclaimer
 
 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
@@ -482,6 +573,9 @@ dysphoria is also risky and that delaying HRT can be deadly for some people.***
 (not run by TransChat) also has some useful information about HRT for
 trans women. NOTE: some of the information there is highly experimental.
 
+[Transfeminine science](https://transfemscience.org/articles/transfem-intro/)
+provides an in depth introduction to feminizing HRT.
+
 Blood tests
 ------------------
 
@@ -611,3 +705,6 @@ External links
   transition.
 * <https://madgenderscience.miraheze.org/wiki/Main_Page> also has
   information about self-medication.
+* [Transfeminine science](https://transfemscience.org/) is a collection of 
+  in-depth articles written by volunteers about feminizing HRT
+