Transitioning
Acceptance
Transitioning can be one of the most challenging things a person will ever do, mentally. The pressure of coming out to everyone, not knowing whether their reactions will be positive or negative. Starting a life-long medication plan just to be yourself. Not even talking about the whole “accepting the truth” at the beginning.
I, myself, have battled with this fact for quite some time. Growing up in a catholic family, the idea of not being cisgender and/or heteresexual sounded very distant. And yet, when I met my first queer friends during a sport shooting club, I realised - these people are just like me. And thus the floodgates of thoughts have opened and the phase of questioning has begun.
During COVID and the associated lockdowns, I have - as have many other people during that time - came to the conclusion that I am trans. After about a year and many visits to various doctors (czech bureaucracy is wonderful, if anyone would like to ask…), I finally got access to HRT. But something was wrong. I still wasn’t ready. Even after a whole year of “accepting” myself, I just couldn’t do it. Mind you, I was still attending high school at that time, and I had no idea how my peers and/or teachers would react. To say that I was scared would be a fair assumption. And so, after 2 months, I stopped taking the hormones I was prescribed at such an early age and went back to living as a male.
The feeling of “finally being free” was addicting. Not having to worry about everyone’s reactions, the potential side effects of HRT, etc. It seemed like quitting hormones was actually the right thing to do. I was happy, I even got a girlfriend. But just like the final episodes of Mr. Robot, the joyous life ridden of all problems is only an illusion. It can only be an illusion, because you’re ignoring all of the monsters that you have locked in your closet. They may stay there for a while, but no lock is strong enough to withstand all of time.
Times changed. Some of my friends left. My girlfriend broke up with me. I was still trying to hold on to the fleeting moments of happiness I have felt back then when I went back into the closet. Slowly, but surely, I was beginning to understand that the only way to defeat the monsters is to actually fight them, not pretend like they do not exist.
I wish that you could just come to a conclusion like that. To have such a big realisation without a fight would be amazing. Sadly, in my case, it took a year of slow, yet ever present, mental breakdown. I remember, the last two months before I got a prescription for HRT again, were probably the most painful months of my life. There were days where all I managed to do was just lay in bed and stare at the ceiling.
Hormones
Before you go scouring the web for dosages and what not, remember that each and every person will need to do HRT slightly differently. For some, pills just don’t work (like for me!). Some need to take 8 mg / day, others only 4 mg. What every website and person will tell you is that what really matters are the resulting levels. The dosages that you will find are supposed to start you off on something and your job is to go and get a bloodtest(s) and adjust your dosage accordingly!
Levels
Now what are the ideals levels a transfemminine person should have? Great question! There isn’t a concrete answer. Many websites will probably tell you the same thing - that the main thing that matters is getting estradiol above 100 pg/mL and testosterone below 50 ng/dL. However, that doesn’t apply for all regiments and/or all people. Yes, you should generally aim for those testosterone levels. The estrogen levels can vary greatly, though. Someone can have great feminisation on those 100 pg/mL. Someone might need more. If you’re doing monotherapy, it is said that your levels should be somewhat above 200-250 pg/mL. What matters in the end, is if you are happy and feel great, mentally.
“But isn’t that hugely a personal thing,” I hear you ask. And you’re not wrong. That’s why this thing is so damn hard. Listen to your body and adjust accordingly. But be sure to not overstress it. Once you find something that you are happy and feel comfortable with, it is likely that you can use that thing until the end of time.
Regiments
Having talked about hormone levels, I would like to throw in my two cents about the different HRT regiments that are out there. (Please don’t take my word as gospel and do your own research.)
Having been on HRT for two years now (and counting!), I tested quite a lot of different methods of delivering estrogen to my body and limiting its access to the testosterone it so stupidly makes. While some of them worked great, others failed horribly, and I would like to share these experiences with you so that you can come to your own conclusion about which one you would like to take.
Estradiol
Firstly, estradiol. The first method of delivery which you may come across are pills. While I would recommend them to people starting HRT, I would also recommend switching to a stronger method of delivery sometime around the 8 - 12 month mark. Pills can be effective to some degree, but reaching high levels with them can be quite ineffective and sometimes even dangerous! They can be stronger when taken sublingually (under the tongue), but why bother when there are other, stronger methods available? Like transdermal estrogen! There is gel, patches, and these days even sprays. The last method is obviously injectable estradiol esters.
Anti-androgens
Now for anti-androgens. Unfortunatelly, there aren’t any options that don’t come with at least some negative. Depending on where you’re from, the most popular anti-androgen prescribed by endocrinologists is either spironolactone (“spiro” for short) or cyproterone acetate (“cypro” or “CPA” for short). Both of these are awful. Spiro is a diuretic, meaning it will most likely make you go to the toilet every hour. While I haven’t taken it and can’t confirm these accounts, people report other major side effects, like brain fog, depression, etc. It’s also quite ineffective.
Cypro on the other hand is like a hammer. It will lower your testosterone to female ranges, just, not in the way you would expect it to. With the levels that prostate cancer patients take it, cypro really does lower testosterone levels. However, transfeminnine people tend to take it at such low levels to prevent other major side effects that come with it (more on that later…), that the main way it blocks testosterone is via its progestine properties. Being a synthetic progestine, it doesn’t act as progesterone itself, however, it induces comparable effects (like lower testosterone levels!). Unfortunately, CPA is also quite dangerous. While the exact mechanics alude me at the moment of writing this, it is reported to cause a plethera of brain tumors. While benign, these tumors can grow to quite a large size, which means they can push on various important nerves and cause blindess, hearing loss, issues with motor control, etc. Not meantioning the fact that in a lot of cases, these tumors are reactive to prolactins, meaning once you have them, you will probably have to be taken of HRT indefinitely.
So, you may be wondering, are there any better options? Firstly, there’s bicalutamide (or “bica” for short). While still quite new, it is regarded as a safer option to both spiro and CPA. There are some reported cases of liver toxicity, however, so if you plan on taking it, make sure to get your liver tested at least once per year (mainly the liver function indicators - AST, ALT, ALP - and also bilirubin). Its mechanics differ from other AAs. Traditional AAs block testosterone production, meaning you can test their effectivenes via a blood test. Bicalutamide blocks testosterone at the receptor level, meaning that the body will actually produce more testosterone than by default. The only way to judge its effectivenes is whether you personally think it’s working. (This is not entirely true. Due to how the body regulates hormone production, if your estradiol levels are raised at the same time as taking bica, the body might make less testosterone than if you weren’t on HRT. I recommend reading a more medical focused paper on this, though :D).
At last, there are GnRH agonists. They work by hijacking the bodies sex hormone production pipeline, telling it that it doesn’t need to produce as much hormones as it thinks it needs to. Many different variants exists, amongst the most common are triptorelin, goserelin and leuprorelin. These are the safest, most effective way to block testosterone. So what’s the downside? Firstly, they tend to be quite expensive, even with a doctor’s prescription (hello from EU). Even then, they come in injectable form which needs to be injected deep into the muscle by a nurse, so probably not the most effective route to DIY.
Rankings
“So, wise witch, what regiment would you recommend?” Here is my tierlist, in order in which I would recommend it.
- Estradiol injections monotherapy
- Estradiol injections + any blocker (not really needed on injections, but in some cases it might be needed).
- Transdermal estradiol + GnRH agonists
- Transdermal estradiol + bicalutamide
- Transdermal estradiol + any other AA (personally would avoid)
- Oral estradiol + any AA (first couple a months, then avoid)
Other resources
Here are links to some of the resources which I have found useful during my transition so far. Be careful though, some of the information on some of these sites can be quite outdated (such as the infamous “table of changes”).
General information
- The DIY HRT Directory 2.0 - Don’t let the name fool you! Apart from hosting DIY related information, it provides information surrounding available forms of estradiol/testosterone and their respective dosages.
- Transfeminine Science - Site dedicated to providing studies surrounding transfeminine people, including the original injectable simulator.
- estrannai.se - A better, more advanced injectables simulator with presets for monotherapies and corrections for missed doses.
- 4mg and pghrt.diy - Read and be radicalized!
DIY resources
- HRT Cafe - Great repository of vendors selling both pharmaceutical grade and homebrewed HRT.
- DIYHRT.market - Another great repository of vendors.
Forums
- r/trans - A subreddit for general discussion about trans related topics.
- r/asktransgender - A subreddit dedicated for asking questions about transitioning, for trans folk and their relatives, partners and/or friends.