Starting Doses

Before You Start

Get a baseline blood test first

Before taking any hormones, get a baseline blood test including:

• E2 (estradiol)
• Total T (testosterone)
• LH, FSH
• SHBG
• CBC (complete blood count)
• Comprehensive metabolic panel (liver, kidney function)
• Lipid panel

This gives you a reference point to measure changes against.

Doses below are for adults (18+).

Adolescent-specific guidance is provided in the section below.

Adolescent Dosing (Under 18)

Adolescent hormone therapy follows a start low, go slow approach to mimic the gradual pace of endogenous puberty. These guidelines are based on WPATH SOC8 and Endocrine Society (2017) recommendations.

Important

This guide does not recommend DIY HRT for minors without medical supervision. Hormone therapy in adolescents ideally involves a multidisciplinary team including a qualified provider. The information below is provided for educational purposes and to help adolescents and families understand standard protocols.

General Principles for Adolescents

• Pre-pubertal children: Hormone therapy is not recommended — social transition and supportive care are the standard of care .
• Tanner stage 2+: Puberty blockers (GnRH agonists) are the first-line intervention if suppression of natal puberty is desired .
• Gender-affirming hormones are typically added around age 14–16, after a multidisciplinary team confirms persistence of gender incongruence and the adolescent has sufficient capacity for informed consent .
• The goal is to mimic pubertal hormone levels, gradually increasing over 2–3 years until adult doses are reached .

Estrogen — Pubertal Induction (Early to Mid Puberty)

For adolescents in early puberty (Tanner stage 2–3), estrogen is introduced at very low doses and increased every 6 months:

Phase	Oral Estradiol	Transdermal Estradiol	Duration
Starting dose	0.25–0.5 mg/day (or 5 µg/kg/day)	6.25–12.5 µg/24h (¼–½ of a 25 µg patch)	6 months
Step 2	0.5–1 mg/day (or 10 µg/kg/day)	25 µg/24h	6 months
Step 3	1–2 mg/day (or 15 µg/kg/day)	37.5 µg/24h	6 months
Step 4	2–4 mg/day (or 20 µg/kg/day)	50 µg/24h	6 months
Adult maintenance	2–6 mg/day	50–200 µg/24h	Ongoing

Doses per Endocrine Society (2017) pubertal induction protocol and Hopkins Adolescent Dosing Guide .

Estrogen — Post-Pubertal Adolescents (Tanner Stage 5)

Adolescents who have completed natal puberty can increase doses more rapidly:

Timeline	Oral Estradiol	Transdermal Estradiol
Months 0–6	1 mg/day	25–50 µg/24h
Month 6+	2 mg/day	50–100 µg/24h
Adult maintenance	2–6 mg/day	50–200 µg/24h

Anti-Androgens in Adolescents

Medication	Adolescent Dosing	Notes
Spironolactone	Start 25 mg/day; titrate up slowly to max 100–200 mg/day	Monitor potassium and blood pressure. Lower starting doses than adults.
GnRH agonist	Per protocol (e.g., leuprolide 11.25 mg IM q3m or 22.5 mg SC q3m)	First-line for adolescents. Fully reversible. Prescription only.
CPA	Generally not recommended in adolescents due to meningioma risk with long-term use	Risk-benefit should be carefully evaluated

Age-Based Summary

Age Range	Typical Approach
Under 13	Social transition + supportive care. Puberty blockers at Tanner stage 2, if indicated.
13–15	Puberty blockers if not already started. Low-dose estrogen (pubertal induction protocol). Increase slowly every 6 months.
16–17	May follow post-pubertal protocol (more rapid increase). Full adult doses may be appropriate by age 17–18, guided by levels and response.
18+	Adult dosing as below.

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Note on HRT Dosing

Any regimen: There's no strong evidence that starting with a low estradiol dose and slowly increasing it is better than starting at a moderate dose. Some anecdotes suggest it may improve breast development or feminisation, but these claims lack clinical support. While generally not harmful, lower starting doses may make testosterone suppression more difficult. You can experiment if you choose.

For regimens with antiandrogens: There is usually no reason to start HRT on a lower than standard dose of antiandrogen — you should go directly onto a typical dose of antiandrogen and adjust accordingly if needed.

For regimens with oral or sublingual/buccal estradiol: To dose pills accurately, you may need a pill cutter, which you can find on Amazon or at most pharmacies. Check your HRT pill type to see how it should be split to match your dose. For example, if you take 2 mg of estradiol three times a day but only have 4 mg pills, you'll need to cut each pill in half.

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Antiandrogen + Estradiol Dosing

The following example regimens use typical doses of estradiol on the higher end of what would be considered a moderate dose. Adjust accordingly if you have access to blood testing (see Blood Testing below).

Cyproterone Acetate

If you take cyproterone, you will need a pill cutter! (Pill cutters are sold at any pharmacy over the counter or online.) Cyproterone tablets are almost always 25–50 mg tablets (way over a recommended dose). It is not recommended to go above 12.5 mg of cyproterone daily. Increase your estrogen dosage if testosterone is not adequately suppressed instead. Cyproterone acetate is taken orally.

Method	Cyproterone Acetate Dosage	Estradiol Form	Total Daily Estradiol
Oral	6.25–12.5 mg once a day	3 mg oral tablets twice daily	6 mg
Sublingual	6.25–12.5 mg once a day	1 mg sublingual/buccal tablets three times daily	3 mg
Transdermal	6.25–12.5 mg once a day	200 µg patches changed twice weekly*	~200 µg daily equivalent
Topical	6.25–12.5 mg once a day	4 mg gel once daily	4 mg

Cyproterone acetate may be effective for many people when taken at a dosage of 12.5 mg every other day. Blood tests would be useful to check if this adjustment may work for you.

*Estradiol patches usually come in a form intended to be changed every 3–4 days, although some may allow for weekly use. Check the packaging to be sure how often you are meant to change your patch.

Bicalutamide

Reminder! Bicalutamide may cause blood testosterone levels to increase slightly, so even though your T may be adequately blocked, your testosterone levels on a blood test will likely show quite high levels. Bicalutamide also has a long half-life, which means it doesn't really matter what time you take it every day, as long as you take it every day. 50 mg daily is almost always enough to ensure adequate testosterone suppression when combined with estradiol. Bicalutamide is taken orally.

Method	Bicalutamide Dosage	Estradiol Form	Total Daily Estradiol
Oral	50 mg once daily	3 mg oral tablets twice daily	6 mg
Sublingual	50 mg once daily	1 mg sublingual/buccal tablets three times daily	3 mg
Transdermal	50 mg once daily	200 µg patches changed twice weekly*	~200 µg daily equivalent
Topical	50 mg once daily	4 mg gel once daily	4 mg

*Estradiol patches usually come in a form intended to be changed every 3–4 days, although some may allow for weekly use. Check the packaging to be sure how often you are meant to change your patch.

Relugolix

Relugolix is taken orally once a day, usually in 40 mg pills. From DIY sources, it usually comes in a capsule form. Relugolix does not have the testosterone flare side effect that GnRH agonists have, so you do not have to increase your dose at the start.

Method	Relugolix Dosage	Estradiol Form	Total Daily Estradiol
Oral	40 mg once daily	3 mg oral tablets twice daily	6 mg
Sublingual	40 mg once daily	1 mg sublingual/buccal tablets three times daily	3 mg
Transdermal	40 mg once daily	200 µg patches changed twice weekly*	~200 µg daily equivalent
Topical	40 mg once daily	4 mg gel once daily	4 mg

*Estradiol patches usually come in a form intended to be changed every 3–4 days, although some may allow for weekly use. Check the packaging to be sure how often you are meant to change your patch.

Buserelin

Buserelin (sometimes sold as the brand name Suprefact) has a short half-life, so it should be administered three times a day to be effective. You can double the recommended dose of buserelin during the first week to counteract the testosterone flare effect that GnRH agonists have. Alternatively, you can take cyproterone or bicalutamide for the first three weeks on buserelin.

Buserelin comes in a bottle that dispenses a set amount of medicine with each spray (300 µg per spray in these examples).

Method	Buserelin Dosage	Estradiol Form	Total Daily Estradiol
Oral	300 µg sprayed three times per day (900 µg/day)	3 mg oral tablets twice daily	6 mg
Sublingual	300 µg sprayed three times per day (900 µg/day)	1 mg sublingual/buccal tablets three times daily	3 mg
Transdermal	300 µg sprayed three times per day (900 µg/day)	200 µg patches changed twice weekly*	~200 µg daily equivalent
Topical	300 µg sprayed three times per day (900 µg/day)	4 mg gel once daily	4 mg

*Estradiol patches usually come in a form intended to be changed every 3–4 days, although some may allow for weekly use. Check the packaging to be sure how often you are meant to change your patch.

Spironolactone

For some individuals, spironolactone may not be able to adequately suppress testosterone levels. It's recommended to get a blood test to monitor your levels to see if this is an effective antiandrogen for you.

Method	Spironolactone Dosage	Estradiol Form	Total Daily Estradiol
Oral	200 mg once daily	3 mg oral tablets twice daily	6 mg
Sublingual	200 mg once daily	1 mg sublingual/buccal tablets three times daily	3 mg
Transdermal	200 mg once daily	200 µg patches changed twice weekly*	~200 µg daily equivalent
Topical	200 mg once daily	4 mg gel once daily	4 mg

*Estradiol patches usually come in a form intended to be changed every 3–4 days, although some may allow for weekly use. Check the packaging to be sure how often you are meant to change your patch.

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Injection Monotherapy Dosing

Here are some reasonable dosages for estradiol injections used in transfeminine hormone therapy:

Estradiol Formulation	Recommended Dose	Injection Volume	Frequency
Estradiol Valerate (EV)	4 mg	0.1 mL (assuming 40 mg/mL vial)	Every 5 days
Estradiol Cypionate (EC)	4 mg	0.1 mL (assuming 40 mg/mL vial)	Every 7 days
Estradiol Enanthate (EEn)	4 mg	0.1 mL (assuming 40 mg/mL vial)	Every 7 days
Estradiol Enanthate (EEn) — Alternative	7 mg	~0.18 mL (assuming 40 mg/mL vial)	Every 10 days
Estradiol Undecylate (EUn)	24 mg	0.3 mL (assuming 80 mg/mL vial)	Every 21 days
Estradiol Undecylate (EUn) — Alternative	32 mg	0.4 mL (assuming 80 mg/mL vial)	Every month (28–31 days)

Because estradiol undecylate takes longer to accumulate in the body, you may choose, for the first dose only, to take up to 2.5× the standard dose to reach stable levels more quickly. For example, if your intended dose is 32 mg every month, your initial loading dose may be 80 mg (32 × 2.5).

Estradiol Undecylate (EUn)

It is highly recommended to inject estradiol undecylate intramuscularly, as subcutaneous injections may produce unpredictable levels.

Notes on Injection Dosing

• Usually, homebrew estradiol injections are compounded at a concentration of 40 mg/mL, with the exception of estradiol undecylate (EUn), which is usually compounded at 80 mg/mL.
• EEn has two common dosing schedules.
• EUn has two common dosing schedules.
• These are general guidelines for dosing.
• These dosages should give the vast majority of people high enough estradiol levels to suppress testosterone on its own.

Adjust accordingly if you have access to blood testing (see Blood Testing below). Ideally you should be aiming for the lowest possible estradiol levels (that are still above 100 pg/mL at trough) that still adequately suppress testosterone < 50 ng/dL at trough. Though people usually require trough estradiol levels of 200–250 pg/mL to adequately suppress testosterone. ("Trough" refers to your blood levels at the lowest point of your dosage regimen, which is right before you take your next dose.)

Calculating Injection Dosages

Vials of estradiol are usually compounded at 40 mg/mL.

This means that for a 40 mg/mL vial, every 1 mL of liquid will contain 40 mg of estradiol. A 40 mg/mL 10 mL vial will then contain a total of 400 mg of estradiol.

We will unfortunately be doing some math here.

The formula to calculate how much liquid to inject is:

(amount you want to inject) ÷ (concentration of the vial) = amount to inject per dose in mL

Dosing Examples

Desired Dose	Vial Concentration	Calculation	Injection Volume
4 mg	40 mg/mL	4 ÷ 40 = 0.1	0.1 mL
5 mg	40 mg/mL	5 ÷ 40 ≈ 0.13	0.13 mL
8 mg	40 mg/mL	8 ÷ 40 = 0.2	0.2 mL
10 mg	10 mg/mL	10 ÷ 10 = 1	1 mL
10 mg	20 mg/mL	10 ÷ 20 = 0.5	0.5 mL
10 mg	40 mg/mL	10 ÷ 40 = 0.25	0.25 mL
10 mg	80 mg/mL	10 ÷ 80 ≈ 0.13	0.13 mL

Not too complicated, hopefully! If you still need help with calculating dosages, this is a useful tool.

How to Perform an E Injection

Needles can be bought from any pharmacy over the counter in most countries without a prescription (you may have to ask the pharmacist directly). Most countries also have online sites that sell appropriate injection needles. Amazon is a popular source for those in America.

Injection Supplies

Make sure to buy 1 mL syringes, as the small amounts of fluid we are using for each injection are only easily measured with 1 mL syringes. The more common 3 mL syringes are not ideal due to the difficulty in accurately measuring dosage. It is fine to use 3 mL syringes if you are using estradiol undecylate due to the high injection volumes.

Subcutaneous vs Intramuscular

There are two methods for an E injection:

• Subcutaneous (subq/SQ/SC) — injection into the layer of fat under the skin
• Intramuscular (IM) — injection deep into the muscle underneath the skin and fat

Both methods result in identical absorption rates and levels of the drug (unless you're using estradiol undecylate). Whether you prefer subq or IM is mostly personal preference.

Homebrewed injections typically contain benzyl benzoate (a safe solvent also commonly used in prescription-grade medications), which can cause some minor irritation if injected subcutaneously. Usually there will be less post-injection pain if injected intramuscularly.

Needle Sizes

Injection Type	Gauge (Thickness)	Needle Length
Subcutaneous (subq)	25–30G	½"–⅝"
Intramuscular (IM)	23–25G	1"–1½" (1" for thinner people, 1½" for larger people)

Subq needles are thinner than IM needles, which some people find less intimidating.

Video Guide

There are many online videos and guides for how to administer an intramuscular or subcutaneous injection. Here is a decent one:

Guide by Plume: https://support.getplume.co/support/solutions/articles/72000544742-all-about-injections

Very detailed video guides on both IM and subq injections, with the downside that they are split into multiple long videos.

Note that around 0.1 mL of fluid will be lost with each injection due to needle dead space.

Injections With Antiandrogens

Generally, injections will not need antiandrogens, though if you prefer to take a lower injection dosage, you may need an antiandrogen (also note that lower injection dosages may require the use of fixed needle, insulin-type syringes of 0.3 mL or 0.5 mL to accurately measure dosage).

Here are some recommended injection dosages if you are taking antiandrogens along with it (refer to the antiandrogen dosing tables above for recommended antiandrogen dosing):

Estradiol Formulation	Recommended Dose	Injection Volume	Frequency
Estradiol Valerate (EV)	2 mg	0.05 mL (assuming 40 mg/mL vial)	Every 5 days
Estradiol Cypionate (EC)	2 mg	0.05 mL (assuming 40 mg/mL vial)	Every 7 days
Estradiol Enanthate (EEn)	2 mg	0.05 mL (assuming 40 mg/mL vial)	Every 7 days
Estradiol Enanthate (EEn) — Alternative	3 mg	~0.075 mL (assuming 40 mg/mL vial)	Every 10 days
Estradiol Undecylate (EUn)	12 mg	0.15 mL (assuming 80 mg/mL vial)	Every 21 days
Estradiol Undecylate (EUn) — Alternative	16 mg	0.2 mL (assuming 80 mg/mL vial)	Every month

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Blood Testing

Cost

$50–$150 per test, depending on source.

Blood testing is highly recommended, but not absolutely mandatory — especially if not particularly affordable or feasible.

It is recommended to do your first blood test within the first 3 months, and then adjust your dosage if necessary. If you change your dosage, try to retest again within 3 months. If your levels look good, blood testing frequency can be reduced to just once a year.

Here are some sources of private blood testing if you cannot access blood testing through the medical system: Blood Testing Sources.

When to Test

Get your estradiol (E2) and total testosterone (T) tested every time. Get your blood taken as close as possible to your next scheduled injection/dose (test your blood as far away as possible from a previous dose, right before your next scheduled dose — preferably the day of your shot, or the day before). Your blood levels of estradiol and testosterone when taken at this time are called trough levels, because they are the levels of E2 and T that are present in your body at the lowest point in your HRT dosing regimen.

Trough levels are most useful for injection monotherapy — for determining if your testosterone is adequately suppressed at the lowest point of your injection cycle.

Target Levels

The most essential component of transfeminine HRT is to get:

• Total testosterone (T) below 50 ng/dL (< 1.73 nmol/L)
• Estradiol (E2) above 100 pg/mL (367 pmol/L)

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Footnotes

1. However, I strongly recommend regular blood tests (every 3 months) to get liver function tests (ALT/AST) if you are taking bicalutamide, due to the extremely low but still present risk of severe liver toxicity. You can stop these tests after about a year or so if your liver enzymes are normal on bica after a year — you're fine.

2. Most private blood testing lets you print off a requisition form, which you can bring to a local blood lab to get your blood drawn. You don't have to mail anything in or take your blood at home. In some places like the UK, you will get sent a blood testing kit, which you can take to a local clinic to get your blood drawn.

3. Different abbreviations of subcutaneous in common usage include: subq/subQ, SQ and SC.

References

1. Hembree WC, et al. (2017). Endocrine Treatment of Gender-Dysphoric/Gender-Incongruent Persons: An Endocrine Society Clinical Practice Guideline. JCEM, 102(11):3869–3903. https://academic.oup.com/jcem/article/102/11/3869/4157558

2. Deutsch MB, ed. (2016). Guidelines for the Primary and Gender-Affirming Care of Transgender and Gender Nonbinary People. UCSF Transgender Care. https://transcare.ucsf.edu/guidelines

3. Coleman E, et al. (2022). Standards of Care for the Health of Transgender and Gender Diverse People, Version 8. International Journal of Transgender Health, 23(S1). https://www.tandfonline.com/doi/full/10.1080/26895269.2022.2100644

4. Coleman E, et al. (2022). SOC8 — Chapter 6: Adolescents. WPATH. https://www.tandfonline.com/doi/full/10.1080/26895269.2022.2100644

5. Hembree WC, et al. (2017). Section 1.4: Prepubertal children. JCEM, 102(11):3869–3903. https://academic.oup.com/jcem/article/102/11/3869/4157558

6. Hembree WC, et al. (2017). Section 2.1–2.3: Pubertal suppression. JCEM, 102(11):3869–3903. https://academic.oup.com/jcem/article/102/11/3869/4157558

7. Coleman E, et al. (2022). SOC8 — Statement 6.5: Sex hormone therapy in adolescents. International Journal of Transgender Health, 23(S1). https://www.tandfonline.com/doi/full/10.1080/26895269.2022.2100644

8. Hembree WC, et al. (2017). Table 8: Protocol for induction of puberty. JCEM, 102(11):3869–3903. https://academic.oup.com/jcem/article/102/11/3869/4157558

9. Coleman E, et al. (2022). SOC8 — Statement 6.2: GnRH agonists in adolescents. International Journal of Transgender Health, 23(S1). https://www.tandfonline.com/doi/full/10.1080/26895269.2022.2100644

10. Coleman E, et al. (2022). SOC8 — Chapter 12: Hormone Therapy (safety considerations). International Journal of Transgender Health, 23(S1). https://www.tandfonline.com/doi/full/10.1080/26895269.2022.2100644

11. Hembree WC, et al. (2017). Table 8: Induction of puberty with oral/transdermal 17β-estradiol. JCEM, 102(11):3869–3903. https://academic.oup.com/jcem/article/102/11/3869/4157558

12. Hedian HF, et al. (2024). Dosing Guide: Gender Affirming Hormone Therapy for Transgender and Gender Diverse Adolescents. Johns Hopkins Medicine. https://www.hopkinsmedicine.org/-/media/center-for-transgender-health/documents/adolescentdosingguide41224.pdf