HRT: levels and a community standard of care
So we are writing this based on a combination of personal and community experience, the AusPATH standards of care and AusPATH standards of care V2 (which expand and improve on the WPATH standards of care and in our opinion are the current best on the planet) and the standard cis ranges (which we believe should always be prioritised over any levels stated in a standard of care). It is a sad and well known fact that medical professionals are under trained in treating TGD beings and medical transphobia is rife within the medical community, leading to a significant mistreatment and chronic under dosing of estrogen (or worse overdosing of blockers) severely hampering trans folks transition and putting them at significant health risk. It is our hope this document is comprehensive enough to help those starting or already under going treatment in identifying if their HRT is being handled correctly or if their doctor, intentionally or otherwise, is mistreating them. This piece will cover the standard ranges, common HRT (GAHT) doses, monitoring and what to expect.
One thing to keep in mind is that many studies (and both above standards of care although the AusPATH ones are much better at using both groups) generally discuss risk of TGD beings developing a given medical condition to that of a cisgender member of their sex at birth. We firmly believe this is falsely representing risks and relative risks should be compared to that of a cisgender beings aligned with TGD being's HRT.
Disclaimer: We are not medical professionals, and do not claim to be. This is instead based of our study of the literature, the experiences gathered from the trans and gender diverse community based on what has been found to work best, the feedback of the community on the standards and common issues the community has had with medical professionals. All parts of this document are subject to community feedback and criticism, and if you have something you think should be added, changed or corrected please tell us so we can discuss and update this document and keep it a useful and up to date source of knowledge and experience.
Feminising HRT
Female hormone levels are the more variable of the two, the following table will include the standard cis female ranges at different ages and points in the menstrual cycle. One very important thing to keep in mind is that cis female levels are extremely variable, and during pregnancy the body will happily tolerate levels up to 10x the normal levels for extended lengths of time. As a result any claims if high levels being dangerous can be flat out proven to be false by this simple fact alone, and can be argued that higher levels are in fact normal and preferred.
| Cis Female | Range (SI units) | Range (non-SI units) |
|---|---|---|
| Fillicular | 77-921 (pmol/L) | 21-251 (pg/mL) |
| Mid-cycle | 140-2380 (pmol/L) | 38-648 (pg/mL) |
| Luteal | 77-1145 (pmol/L) | 21-312 (pg/mL) |
| Menopausal | <100 (pmol/L) | <27 (pg/mL) |
| Testosterone | 0.5-2.0 (nmol/L) | 14-57 (ng/dL) |
You should never be in the menopausal range or below the mid-cycle range. Ideally you should be aiming in the middle half of the mid-cycle range. Many doctors will try to quote 150-300 pmol/L (41-82 pg/mL) as the target range, do not let them convince you in this or that going above 300 is dangerous, 300 should be considered the absolute minimum target value and feminisation will only start at about this level. The Fenway Health follow the Endocrine Society has confirmed levels up to 1468 pmol/L (400 pg/mL) are safe. Low levels can cause menopausal symptoms and lead to poor bone health over time.
WPATH recommends the range of 367–734 pmol/L (100–200 pg/mL) which more reasonable but still very conservative. AusPATH standards of care on the other hand recommend 250–1000 pmol/L (68-272 pg/mL). A realistic and healthy target range in practice to achieve good results is 500-1000 pmol/L (136-272 pg/mL).
Testosterone should be aimed to be maintained in the the cis range, however when on blockers it is extremely common to end up below the minimum. Many transfems have an attitude of less is best and try to hit 0, this is extremely unhealthy and dangerous long term and should be avoided at all costs. If your testosterone is below or near the minimum consider it a good sign to reduce blocker dose or to switch to monotherapy (more in a moment). It is also worth noting that some blockers (Bicalutamide and to a much lesser degree Spironolactone) do not prevent testosterone production but just block its action which can result in observed higher testosterone levels then expected, if levels fall into cis female range on these it is good sign that testosterone production is suppressed and blocker can be discontinued or cut back.
Feminising HRT is broken into three components; estrogen, testosterone blockers and progesterone.
Estrogen is the most important component of feminising HRT and is responsible for basically all of the effects. There are many different for es if estrogen we will cover below. Generally a transdermal or oral ruite is preferred early in transition and once levels are stable then moving to injections or implants.
Testosterone blockers are used to suppress testosterone early in transition. Testosterone is significantly more potent then estrogen and needs to be blocked until stable long term estrogen levels are reached high enough to trigger the body to stop producing testosterone. Ideally the end goal should be to move to "monotherapy" where blockers are completely phased out and testosterone is purely suppressed by estrogen. Blockers have nasty side effects, especially long term, and you should be always trying to minimise the dose as much as possible. A small selection if blockers are available with different side effects and benefits which we will discuss.
The final component is Progesterone (or Prog). Progesterone is a secondary hormone responsible for maintaining a lot of female body functions and is also responsible a variety of secondary feminisation. Progesterone increase breast grown, increases sex drive, stabilises and improves mood and helps with regulating sleep. It can also slightly help suppress testosterone on monotherapy. Progesterone is also known to cause massive spikes in sex drive that can be difficult to manage, and may cause drowsiness and intoxication like effect immediately after taking in some users. There is a lot of debate when to start progesterone with some saying it start as soon as possible while others say you get the best effects of breast development by waiting till the 12-18 month mark. Recent studies do confirm there is a significant improvement to breast growth but don't confirm if those benefits are transient, have an optimal timing or if they will occur at any point. What is known is that you should make sure your estrogen levels are stable and at a good level before starting and otherwise the timing is really up to you.
Estrogen options:
Tablets (Estradiol hemihydrate/Zumenon or Estradiol Valerate/progynova):
Minimum dose: 2mg/day
Maximum dose: 8mg/day
Recommended starting dose: 4mg/day
Available in: 1mg and 2mg tablets.
When to test levels: Immediately before you would normally take a dose (trough).
Tablets are by far the most common and easiest form of estrogen to use. They can either be swallowed or taken sublingually (let dissolve under the tongue). Most Drs will recommend swallowing but based on results from transfems sublingually appears to produce better results. Sublingual doses produce higher spikes and fall off quicker but avoids processing by liver and provides better overall absorption and effectiveness of the estrogen. Progynova tablets are sugar coated and much better for sublingual. Tablets in general have the greatest potential side effects with a rare case of of liver issues, blood clots and stroke, although these are small increases and minimised by taking the tablets sublingually. However, for those with medical conditions that increase risk or a medical history of these, oral estrogen is best avoided. Trans/sub-dermal forms of estrogen (gel, patches, injection or implant) bypass the liver entirely which eliminate this risk entirely. It's recommended to split dose into two doses a day when taking more then 4mg. The exact way you split the dose is up to you and what works best for you.
Gel (Sandrena or Estrogel):
Minimum dose: Sandrena: 1 sachet/day, Estrogel: 1 pumps per day.
Maximum dose: 3 sachet/day (standards say 2, but have seen 3 routinely prescribed), Estrogel: 4 pumps per day.
Recommended starting dose: Sandrena: 1 sachet/day, Estrogel: 1 pumps per day.
Available in: Sandrena: 1g (1mg estradiol) sachet. Estrogel: 80g pump, 1.25g (0.75mg estradiol)/pump.
When to test levels: Immediately before you would normally take a dose (trough).
Gel like all transdermal forms of estrogen completely bypasses the liver and enters direct into the bloodstream. This makes it ideal for when pre-existing medical conditions exist and patches are either not available or cause reactions. Gel is less reliable for dosage as it can rub off before completely dry and can potentially transfer onto others and/or pets. Dosage can be split to keep levels more stable across the day.
Patches (Estraderm, Estradot and Estramon):
Minimum dose: 50mcg/24hr, 2 per week
Maximum dose: 200mcg/24hr, 2 pee week
Recommended starting dose: 50-100mcg/24, twice per week
Available in: 25, 32.5, 50 and I 100mcg/24hr patches
When to test levels: Immediately before you would normally apply a patch (trough).
Patches are the most stable of the transdermal options. Like with gel they bypass the liver and are suitable for those with medical conditions that prevent oral estrogen. Patches are significantly harder to get due to demand and lack of production and can cause allergic reactions to the adhesive for some users. If a reaction is observed, your prescribing Dr should be informed immediately so another option can be considered.
Injections (Cypionate, Valerate and others):
Minimum dose: 2mg/week (equivilent)
Maximum dose: 15mg/week (equivilent)
Recommended starting dose: 2-5mg/week (equivilent)
Available in: Compounded
When to test levels: Immediately before you would normally take a dose (trough) and a little after a dose (post spike) to make sure maximum and minimum levels are within target range.
Injections are the most common sub-dermal estrogen source and one of the most reliable overall. They are very low risk and high effectiveness, with relatively long times between doses. The main down side of injections is the cost to compound and the need to self inject (which many beings find difficult). Currently two main forms of injection are available: Cypionate and Valerate although other forms exist and are increasing in availability. All forms of injectable estrogen are effectively equivalent with only time between doses varying due to the time it takes to breakdown in the body.
Implants:
Minimum dose: 50mg/12+ months
Maximum dose: 200mg/6 months
Recommended starting dose: 100mg/6-12 months
Available in: Compounded as 50 and 100mg pellets.
When to test levels: every 3 months after first implant for 12 months till long term stable level confirmed then once every 6-12 months.
Implants are a rarer sub-dermal estrogen source and the longest lasting overall source of estrogen. Implants have extremely long stability, often lasting between 6 and 12 months at a constant level. Implants require minor surgical procedure often with a port being installed to make future implants easier. The main drawback of implants are the high initial cost and the lack of pharmacies/Drs who can compound and perform the implant.
Testosterone blocker options:
Spironolactone (Aldactone or Spiractin):
Minimum dose: 50mg/every second day
Maximum dose: 200mg/day
Recommended starting dose: 4mg/day
Available in: 25 and 100mg tablets.
When to test levels: Immediately before you would normally take a dose (spike). Note that spironolactone may not actually lower observed testosterone levels significantly.
Side effects: Hyperkalemia, diuresis, polydipsia, hypotension, GI upset and rash.
Spironolactone (Spiro) is the preferred blocker in the US and is a well proven blocker with a relatively stable tong term side effect profile. Spironolactone acts as a potassium-sparing diuretic which will result in a significant increase in the need to pee as well as cravings for salt. It can also cause long term issues with potassium levels which may need monitoring. Do
Cyproterone (Androcur):
Minimum dose: 12.5mg/week
Maximum dose: 25mg/day (doses above 12.5mg every second day should be avoided at all costs)
Recommended starting dose: 12.5mg/day (reduced quickly)
Available in: 50mg and 100mg tablets.
When to test levels: Immediately before you would normally take a dose (spike).
Side effects: Depression, hepatitis, hyperprolactinaemia, meningioma (a form of minor brain tumour associated with long-term use at high doses well above the maximum HRT dose).
Cyproterone (Cypro) is an extremely potent blocker preferred in many countries outside the US. Cyproterone is able to reduce testosterone to almost zero from extremely low doses (as little as 12.5mg a week may still produce levels below the minimum target range) and will do so extremely quickly. This often makes it the best choice for those who want a fast acting blocker. Cyproterone has significant long term drawbacks and should be reduced to the lowest possible dose or stopped as soon as possible. While tumours are rare, depression is extremely common at the 12-18 month mark even on very low doses and both first and second hand experiences all agree that it will produce significant mental health impacts often described as a feeling of "emptiness" and "despair" even in individuals with minimal previous mental health issues.
Bicalutamide:
Minimum dose: 25mg/day
Maximum dose: 50mg/day
Recommended starting dose: 25mg/day
Available in: 50mg tablets.
When to test levels: Immediately before you would normally take a dose (spike). Note that bicalutamide will not actually lower observed testosterone levels significantly. Liver function should be closely monitored.
Side effects: liver toxicity, liver transaminitis, liver failure and lung toxicity.
Bicalutamide (Bica) is a much rarer blocker that has very few studies done on it and a much more severe side effect profile. It is generally recommended only to consider bicalutamide if the other options are unavailable due to medical reasons as it has fairly common and severe liver side effects.
5 alpha-reductase inhibitors (Finasteride or Dutasteride):
Minimum dose: finasteride: 1mg/day, dutasteride: N/A
Maximum dose: finasteride: 5mg/day, dutasteride: 0.5mg/day
Recommended starting dose finasteride: 1.25mg/day, dutasteride: 0.5mg/day
Available in: finasteride: 5mg tablets, dutasteride: 0.5mg tablets.
When to test levels: Immediately before you would normally take a dose (spike). Note that these are not true blockers and will likely not have observable effects.
Side effects: incompatible with a wide number of other medications or blockers.
5 alpha-reductase inhibitors are not true blockers but rather prevent the conversion of testosterone into secondary forms of testosterone such as DHT (responsible for male pattern baldness). They should not be used in place of blockers are are best suited as a way to control some effects of testosterone without total blocking in non-binary individuals or to prevent things like male pattern baldness early in transition before testosterone is suppressed by estrogen or a true blocker can be obtained. Since 5 alpha-reductase inhibitors are easily available for hair loss treatment they can be easily obtained before beginning transition proper or doing informed consent for HRT and are safe to use without taking estrogen to replace testosterone.
Progesterone:
Progesterone (Prometrium, Progesterone ASVZ):
Minimum dose: 100mg/day
Maximum dose: 400mg/day
Recommended starting dose: 100mg/day
Available in: 100mg soft captule.
When to test levels: Testing optional but immensity before taking a dose (trough) is recommended if you are testing.
Progesterone (Prog) is a secondary hormone responsible for breast growth, increased sex drive, stabilising and improving mood and helping regulate sleep. It can be taken orally or rectally (although common, this is not officially supported by Drs) where different effects will be prioritised. Oral doses produce better sleep and mood regulation (aka secondary effects) due to first being processed by the liver. Rectal dosed produce greater breast growth and increased sex drive (primary effects) as the liver is bypassed. Both methods will produce some level of both and choice of method is dependant on personal goals. Both methods can also be used in conjunction to balance out effects. Progesterone is known to produce a temporary intoxicating and sedative like effect on some users and is recommended only to take at night before bed
Effects:
The main effects of feminising HRT are breast development, skin softening, change in body odour, reduced face and body hair growth and fat redistribution. Muscle mass will also begin to reduce unless effort is taken to maintain muscles, this will lead to situations where you significantly overestimate your ability to do something ans struggle. There will also be significant increase in emotional range, the highs of emotion will feel significantly better, but likewise the lows will feel much worse, be ready to cry at even slightly emotional things.
When beginning feminising HRT it is common to go through a multiple week period of heavy fatigue as your body gets used to the new hormones and your levels stabilise. This is especially common on blockers (and especially cyproterone) as they block and reduce testosterone levels much faster then estrogen levels are able to reach long term stable levels. Some doctors and TGD beings will choose to delay the start of blockers by a few weeks to help with this and make sure the body always has some level of hormone to run on. If there is any benefit to this is unknown and should be entirely up to personal choice.
Feminising HRT has a few unexpected or potentially unwanted effects. Often spoken about is the effect on sex drive, which is often significantly lowered in the first 12 months (although progesterone can help recover this) and the way feeling horny changes. On feminising arousal is less spontaneous but significantly more intense and full body. Atrophy of the penis is very common if not being used (the saying goes use it or loose it for a reason). This may be desirable for some, but if not achieving regular erection can prevent this. Feminising HRT weakens the pelvic muscles, this leads to an often annoying dribble when finishing peeing that can be mildly annoying but easily dealt with, no this is not your imagination.
Feminising HRT may cause infertility but should not be relied on as a contraceptive. Proper birth control should still be used even if infertility is suspected.
Masculinising HRT
So a quick disclaimer before this section, she is far less experienced with masculinising HRT then with feminising HRT. As a result this section will hold very close to the AusPATH guidelines except where she has been explicitly informed otherwise. Likewise there will be much less on the pros, cons and what to expects as she simply doesn't have the experience first or second hand to write about it. If you have that experience, see a mistake or wish to add a comment she encourages you to talk to her so she can add to this document and improve it.
Male hormone levels are generally relatively stable in comparison to female levels. However, there is still normally some variation is cis male levels over time both with age and as part of a cycle. However since the levels vary much less dramatically the target range is much easier to define.
| Cis Male | Range (SI units) | Range (non-SI units) |
|---|---|---|
| Testosterone | 11.1-34.7 (nmol/L) | 320-1000 (ng/dL) |
| Estrogen | 36.7-183.5 (pmol/L) | 10-50 (pg/mL) |
The AusPATH standards of care guidelines recommend aiming in the lower part of the testosterone range in the trough. This is because testosterone levels in the higher end of the range or above can cause estrogen spikes which result in unintentional and unwanted feminisation. This effect is also observed and confirmed in cis male body builders who take testosterone as well as in transmascs on too high of a dose. The recommended target range is: 10-20 nmol/L (288.4-576.8 ng/dL). Haematocrit values should also be closely monitored and kept below 0.5L/L for the same reasons.
Estrogen should also be aimed to be maintained in the lower part of the cis male range. However, as long as a significant spike is avoided the levels are generally ok simply being suppressed by testosterone.
Masculinising HRT consists of a single component, testosterone treatment. Testosterone is generally available is two categories: topical (cream or gel) or intramuscular (injections). Both options appear to be equally as viable and choice comes down to personal preference, goals and risk profile. Generally, most beings start in topical formulations and move to injections later on in transition once levels are stable.
Testosterone options:
Testosterone 1% gel (Testogel):
Minimum dose: 1 pump (12.5mg)/day or 1 sachets (50mg)/day
Maximum dose: 8 pump (100mg)/day or 2 sachets (100mg)/day
Recommended starting dose: 4 pump (50mg)/day or 1 sachets (50mg)/day
Available in: 12.5 mg/pump and 50mg/5g sachets
When to test levels: Immediately before you would normally take a dose (trough).
1% gel is recommended for non-binary folks or those otherwise wishing partial masculinisation due to the fine control over dosing. It is recommended to apply to the shoulders or upper arms for best absorption and effect. Care should be taken as gel can rub off before completely dry and can potentially transfer onto others and/or pets.
Testosterone 2% gel (Testavan):
Minimum dose: 1 pump (23mg)/day
Maximum dose: 3 pumps (69mg)/day
Recommended starting dose: 1 pump (23mg)/day
Available in: 23 mg/pump
When to test levels: 2–4 hours after application (as per product information) and adjust based on recommendations.
It is recommended to apply to the shoulders or upper arms for best absorption and effect. Care should be taken as gel rub can off before completely dry and can potentially transfer onto others and/or pets.
Testosterone 5% cream (Antroforte):
Minimum dose:1mL (50mg)/day
Maximum dose:4mL (200mg)/day
Recommended starting dose:1–4 mL (50–200 mg)/day
Available in: 50mg/mL cream
When to test levels: Immediately before you would normally take a dose (trough).
It is recommended to apply to the shoulders or upper arms for best absorption and effect. Care should be taken as cream can rub off before completely dry and can potentially transfer onto others and/or pets.
Testosterone undecanoate (Reandron):
Minimum dose:250mg/10-14wk (range can be as wide as 7-20 weeks for some individuals)
Maximum dose:1000mg/10-14wk (range can be as wide as 7-20 weeks for some individuals)
Recommended starting dose:1000mg/10-14wk (first two doses six weeks apart)
Available in: 1000mg/4mL
When to test levels: Immediately before you would normally take a dose (trough). Do not test till after the third injection.
Testosterone injections (and especially Reandron) are generally administered by a nurse or GP not self administered like others forms of testosterone. This is due to the thick oil base being more difficult to administer and requiring a more substantial needle. Oil based injections are generally slow and may take minutes to fully administer a larger dose. Generally they are no more painful then any other injection unless administered too fast. Testosterone undecanoate is the most common form of injection testosterone due to its long stability meaning less frequent dose and a lower risk of testosterone spikes. Injection may cause pulmonary oil microembolisms which are very rare (~0.1% on a given injection) short lived respiratory problems caused by an oil based injection. They are normally harmless and pass quickly but may cause some discomfort and should be monitored. Reandron injections are normally Castor oil based and allergies should be considered and other brands considered if allergy occurs.
Testosterone enanthate (Primoteston):
Minimum dose: 0.5mL (125mg)/2–4wk
Maximum dose: 1mL (250mg)/2–4wk
Recommended starting dose: 1mL (250mg)/2–4wk
Available in: 250mg/mL
When to test levels: Immediately before you would normally take a dose (trough) and a little after a dose (post spike) to make sure maximum and minimum levels are within target range. Alternatively mid way between doses.
Testosterone injections are generally administered by a nurse or GP not self administered like others forms of testosterone. This is due to the thick oil base being more difficult to administer and requiring a more substantial needle. Oil based injections are generally slow and may take minutes to fully administer a larger dose. Injection may cause pulmonary oil microembolisms which are very rare (~0.1% on a given injection) short lived respiratory problems caused by an oil based injection. They are normally harmless and pass quickly but may cause some discomfort and should be monitored. Primoteston injections are normally Castor oil based and allergies should be considered and other brands considered if allergy occurs.
Testosterone esters (Sustanon, Cypionate):
Minimum dose: Sustanon: 0.5mL (125mg)/2–4wk , Cypionate: 50mg/week
Maximum dose: Sustanon: 1mL (250mg)/2–4wk, Cypionate: 200mg/week
Recommended starting dose: Sustanon: 1mL (250mg)/2–4wk, Cypionate: 100mg/week
Available in: Sustanon: 250mg/1mL, Cypionate: 100mg/1mL and 200mg/1mL
When to test levels: Immediately before you would normally take a dose (trough) and a little after a dose (post spike) to make sure maximum and minimum levels are within target range. Alternatively mid way between doses.
Testosterone injections are generally administered by a nurse or GP not self administered like others forms of testosterone. This is due to the thick oil base being more difficult to administer and requiring a more substantial needle. Oil based injections are generally slow and may take minutes to fully administer a larger dose. Injection may cause pulmonary oil microembolisms which are very rare (~0.1% on a given injection) short lived respiratory problems caused by an oil based injection. They are normally harmless and pass quickly but may cause some discomfort and should be monitored. Sustanon injections are normally Peanut oil based and allergies should be considered and other brands considered if allergy occurs. Other esters may be suitable for self injection and preferable as a result. Cypionate is the preferred injectable in the US but may be hard to obtain elsewhere.
Testosterone patch (Androderm):
Minimum dose: 2mg/24hr patch
Maximum dose: 8mg/24hr patch
Recommended starting dose: 4mg/24hr patch (Note the AusPATH standards give no guidelines for patches and the source for these values states max doses equivalent to the AusPATH minimum for other forms of testosterone)
Available in: 2, 4 and 5(?)mg/24hr patch
When to test levels: Immediately before you would normally take a dose (trough).
Is listed on the AusPATH informed consent guidelines but not standard of care so values are not readily available. Patches can cause allergic reactions to the adhesive for some users. If a reaction is observed, your prescribing Dr should be informed immediately so another option can be considered.
Effects:
Masculinising HRT effects include facial and body hair growth, deepening of voice, muscle growth, fat redistribution, increased appetite, changes in body odour and changes to skin. Clitoris/phallus growth is expected alongside an increased sex drive. Periods will at first slow then in most cases stop all together within the first 12 months. However, it is not uncommon for them to stop then restart again over time. This is normal and not something to be concerned about.
Intense sweating is a common side effect of testosterone especially at night. It is recommended to get cheap easy to replace bed sheets if you experience intense sweating. Vaginal dryness and intense cramps during or after sex due to vaginal atrophy are not uncommon on testosterone. These are usually treated with a topical estrogen gel and your doctor should be able to advice what is what here. This should not effect testosterone levels or interfere with transition as long as your doctor is managing it properly.
Testosterone is not an effective birth control on its own and should not be assumed to be a contraceptive. Standard birth control methods are perfectly safe to use once testosterone levels are stable with no interference on levels or your transition.
Non-binary HRT
Non-binary HRT is significantly more complex then binary HRT. At least one hormone must be kept within the cis range for the the body to function properly. Very little research has been done as to exactly how high both can get along side each other without their being risk. A common approach to non-binary HRT is to take small doses of HRT below the normal clinical dose required for full HRT. The exact formulation of non-binary HRT should be dependant on your goals and body and should be discussed in detail and a plan agreed upon on your terms. Do not let a doctor convince you that your goals should be something else or you should either do all or nothing. However, do remember it is not possible to be selective of certain effects and any amount of HRT may result in any or all of the effects of that particular form of HRT to some degree (for example it is not possible to select for voice changes but not facial hair growth on testosterone or breast growth without general fat redistribution on estrogen).
Intersex and HRT
The effectiveness of HRT in intersex beings is poorly understood and relatively unresearched. Being intersex can raise or lower ones sensitivity to either or both hormones and lead to unexpected effects. Dosages may need to be heavily experimented with to find what works best for you and that dosage may fall outside the normally used dosage You and your doctor should regularly be monitoring until your exact situation is well understood. Likewise unexpected or unusual effects should be discussed with your doctor and monitored.
Contributors:
Special thanks to the following beings who have either provided feedback, criticism, editing, direct input, answered questions or shared their experiences. Without them this document would have been far less complete.
Kanas Bird
Sorrel
Tiarna
The Coven
The Dimitrov System
And every other member of the TBD community who has ever shared it discussed their lived experience. ard of care so values are not readily available. Patches can cause allergic reactions to the adhesive for some users. If a reaction is observed, your prescribing Dr should be informed immediately so another option can be considered.
Effects:
Masculinising HRT effects include facial and body hair growth, deepening of voice, muscle growth, fat redistribution, increased appetite, changes in body odour and changes to skin. Clitoris/phallus growth is expected alongside an increased sex drive. Periods will at first slow then in most cases stop all together within the first 12 months. However, it is not uncommon for them to stop then restart again over time. This is normal and not something to be concerned about.
Intense sweating is a common side effect of testosterone especially at night. It is recommended to get cheap easy to replace bed sheets if you experience intense sweating. Vaginal dryness and intense cramps during or after sex due to vaginal atrophy are not uncommon on testosterone. These are usually treated with a topical estrogen gel and your doctor should be able to advice what is what here. This should not effect testosterone levels or interfere with transition as long as your doctor is managing it properly.
Testosterone is not an effective birth control on its own and should not be assumed to be a contraceptive. Standard birth control methods are perfectly safe to use once testosterone levels are stable with no interference on levels or your transition.
Non-binary HRT
Non-binary HRT is significantly more complex then binary HRT. At least one hormone must be kept within the cis range for the the body to function properly. Very little research has been done as to exactly how high both can get along side each other without their being risk. A common approach to non-binary HRT is to take small doses of HRT below the normal clinical dose required for full HRT. The exact formulation of non-binary HRT should be dependant on your goals and body and should be discussed in detail and a plan agreed upon on your terms. Do not let a doctor convince you that your goals should be something else or you should either do all or nothing. However, do remember it is not possible to be selective of certain effects and any amount of HRT may result in any or all of the effects of that particular form of HRT to some degree (for example it is not possible to select for voice changes but not facial hair growth on testosterone or breast growth without general fat redistribution on estrogen).
Intersex and HRT
The effectiveness of HRT in intersex beings is poorly understood and relatively unresearched. Being intersex can raise or lower ones sensitivity to either or both hormones and lead to unexpected effects. Dosages may need to be heavily experimented with to find what works best for you and that dosage may fall outside the normally used dosage You and your doctor should regularly be monitoring until your exact situation is well understood. Likewise unexpected or unusual effects should be discussed with your doctor and monitored.
Contributors:
Special thanks to the following beings who have either provided feedback, criticism, editing, direct input, answered questions or shared their experiences. Without them this document would have been far less complete.
Kanas Bird
Sorrel
Tiarna
The Coven
The Dimitrov System
And every other member of the TBD community who has ever shared it discussed their lived experience.