Risk Mitigation Strategies

This page outlines practical steps to minimise the risks associated with feminising HRT. Not all risks can be eliminated, but most can be significantly reduced.

1. Choose the Safest Route of Estrogen

Route	VTE Risk	Recommendation
Transdermal (patches/gel)	Lowest	✅ Preferred by guidelines
Injectable	Low	✅ Good alternative
Sublingual	Moderate	⚠️ Acceptable with monitoring
Oral (swallowed)	Highest	❌ Avoid if risk factors present

If you must use oral estrogen

• Take it sublingually (under the tongue) when possible — this reduces first-pass metabolism
• Keep the dose as low as effective
• Do not smoke
• Monitor blood pressure and lipids regularly

2. Use the Lowest Effective Anti-Androgen Dose

Anti-Androgen	Maximum Safe Dose	Notes
Spironolactone	200 mg/day	Monitor potassium
CPA	10–12.5 mg/day	Higher doses increase meningioma risk
Bicalutamide	50 mg/day	Monitor liver function

3. Lifestyle Modifications

Smoking

Smoking + estrogen = significantly increased VTE risk

If you smoke and take oral estrogen, your VTE risk is multiplicative — much higher than either risk alone. Quitting smoking is the single most impactful thing you can do to reduce HRT risks.

Weight Management

• Obesity (BMI > 30) independently increases VTE risk
• Maintain a healthy weight through diet and exercise
• Even modest weight loss (5–10%) reduces risk

Exercise

• 150 minutes moderate cardio per week
• Strength training 2×/week
• Walking, swimming, cycling are all excellent options
• Reduces cardiovascular risk and improves mental health

Hydration and Electrolytes (Spiro Users)

• Drink plenty of water
• Increase salt intake (spiro causes sodium loss)
• Avoid potassium supplements and high-potassium salt substitutes

4. Regular Monitoring

Test	Frequency	Why
Blood pressure	Every 1–3 months	Estrogen can raise BP
E2 + T	Every 3 months (first year)	Confirm levels in target range
CBC (complete blood count)	Every 3–6 months	Check for anaemia, etc.
Comprehensive metabolic panel	Every 6–12 months	Liver/kidney function, electrolytes
Lipid panel	Annually	Cholesterol, triglycerides
Prolactin (if on CPA)	Annually	Monitor for prolactin elevation
Potassium (if on spiro)	Every 3 months (year 1), then annually	Monitor for hyperkalemia

5. Know Your Family History

Ask your family about:

• Blood clots (DVT, PE)
• Clotting disorders (Factor V Leiden, etc.)
• Breast cancer
• Heart disease (early onset)
• Meningioma

If you have a family history of any of these, discuss with a provider before starting HRT.

6. Emergency Preparedness

• Keep a list of your medications and doses
• Know the emergency signs (see "When to Stop / Seek Help" page)
• Have a backup supply of medication
• If DIY, have a plan to access medical care if needed
• Share your HRT status with a trusted friend who can advocate for you

7. Birth Control (If Needed)

HRT is NOT contraception

If you have a partner who can get you pregnant, use reliable contraception. Estrogen and anti-androgens do not reliably prevent pregnancy.

8. Mental Health Monitoring

• HRT improves mental health for most trans people, but can worsen mood temporarily
• Monitor your mental health weekly (simple 1–10 scale)
• Have a therapist or support system
• If you have a history of depression, CPA may not be the best anti-androgen choice

Summary Checklist

✅	Action
☐	Choose transdermal or injectable E2 if possible
☐	Use lowest effective AA dose
☐	Do not smoke
☐	Exercise regularly
☐	Monitor blood pressure monthly
☐	Get blood tests every 3 months (first year)
☐	Know emergency signs
☐	Have a support system

References

1. Connelly PJ, et al. (2021). Managing the risk of venous thromboembolism in transgender adults undergoing hormone therapy. PMC. https://pmc.ncbi.nlm.nih.gov/articles/PMC6628137/

2. UCSF Transgender Care. Guidelines for the Primary and Gender-Affirming Care of Transgender and Gender Nonbinary People. https://transcare.ucsf.edu/guidelines

3. WPATH (2022). Standards of Care, Version 8. https://www.tandfonline.com/doi/full/10.1080/26895269.2022.2100644