Information About Hormone Regimes for Transwomen / Non-Binary
- Karen Impey
- Oct 21
- 5 min read
Updated: Oct 27
Prescribing for Transfeminine
/ Non-binary
Oestrogen Options
Transdermal Estradiol Patch (25/50/75/100 micrograms/24h)
Androgen Blocker Options
Monitoring Requirements for Transwomen
Prescribing for Transwomen / Non-Binary
Transdermal Estradiol Patch (25/50/75/100 micrograms/24h)
Brand names: Estradot, Evorel, Estraderm, Femseven, Progynova
Starting dose: 25-50 micrograms twice weekly
Directions: Stick the patch onto clean dry healthy skin below your waist (lower abdomen, upper thigh, or buttock). Press them down for the first minute to activate the adhesive. Change the patch twice per week. You can swim/shower/bathe with them on as normal.
Dose range: Usually up to 200mcg twice weekly patch, exceptionally up to 300 micrograms twice weekly. Usually increased in 25-100 micrograms increments every 3-4 months
Suitability: Should be first line option for patients: a) Over 40, b) With risk factors for blood clots (VTE) (including BMI >35), c) With risk factors for Cardiovascular Disease (including cigarette smoking), d) With Type 2 Diabetes. Consider lower starting doses in older patients or those with CV risk factors. Current smokers or those with BMI > 40 kg/m² should not exceed 100 mcg patch or 1.5mg gel.
Transdermal Estradiol Gel
Brand names: Oestrogel pump pack 0.06%; one pumped dose = 0.75mg. Sandrena sachets 0.1%; 0.5 mg and 1 mg sachets
Starting dose: 0.75-1.5 mg daily
Directions: Rub in to clean, dry, healthy skin of inner thigh. If you are using more than two pumps per day you can divide the dose. Once your skin is dry, usually after 20-30 minutes, you can wear clothes and exercise as normal. Wait 30 minutes before applying other creams or sun screen.
Dose range: Usually up to 6 mg daily, exceptionally up to 8 mg daily. Usually increased in 0.5 mg increments for Sandrena and 0.75 mg for Oestrogel every 3-4 months
Suitability: [Same as transdermal patch]
Transdermal Spray (new!) - Lenzetto
Brand names: Lenzetto
Starting dose: 1 spray daily
Directions: Apply to clean, dry, healthy skin of inner forearm, in areas that do not overlap. Let the spray dry for 2 minutes before getting dressed and at least 60 minutes before bathing/washing/applying other creams e.g. sunscreen.
Dose range: Up to 6 sprays. Usually increased in increments every 3-4 months
Suitability: [Same as transdermal patch]
Oral Estradiol
Brand names: Elleste Solo, Progynova, Zumenon, Bedol
Starting dose: 1 or 2mg daily
Directions: Swallow the tablet(s) once per day. Sublingual administration (dissolving under the tongue) is an alternative to swallowing the tablets and potentially avoids the first-pass liver effect so may be safer; however, this is not something that we routinely advise.
Dose range: Up to 8 mg od. Usually increased in 0.5-2 mg increments every 3-4 months
Suitability: Use oral Estradiol with caution if: a) Over 40, b) With risk factors for blood clots (VTE) (including BMI >30), c) With risk factors for Cardiovascular Disease (including cigarette smoking), d) With Type 2 Diabetes. Transdermal Estradiol should be first line in these patients. Consider lower starting doses in older patients or those with CV risk factors. Current smokers should not exceed maximum conventional HRT doses (up to 3 mg OD)
Androgen Blocker
GnRH Agonist - Leuprorelin (Prostap)
Brand names: Prostap
Starting dose: 11.25mg every 10-12 weeks
Directions: IM injection
Dose range: Initiated at 12 week frequency
Additional Notes: Can cause an initial 'flare' of testosterone, before it suppresses testosterone, in the first 3-4 weeks after initiation. Other GnRH agonists are available but are infrequently used by our service including: Nafarelin, Buserelin (both nasal sprays), Goserelin and other doses of Leuprorelin and Triptorelin
GnRH Agonist - Triptorelin (Decapeptyl SR)
Brand names: Decapeptyl SR
Starting dose: 11.25mg IM every 10-12 weeks
Directions: IM injection
Dose range: Initiated at 12 week frequency
Additional Notes: [See Leuprorelin notes]
Oral Antiandrogen - Spironolactone
Brand names: Spironolactone
Starting dose: 50-100mg twice daily
Directions: One or two tablets daily or sometimes in divided doses
Dose range: 50-200mg daily
Additional Notes: GnRH agonists are the treatment of choice, but other oral agents may be used if preferred by the individual. Spironolactone is a weak diuretic/BP lowering medication and can often result in side effects. Will need blood pressure monitoring.
Oral Antiandrogen - Finasteride
Brand names: Finasteride
Starting dose: 5mg alternate days
Additional Notes: Where scalp hair loss is an ongoing concern, consider adding finasteride 1mg daily or 5mg alternate days.
Oral Antiandrogen - Cyproterone Acetate
Brand names: Cyproterone acetate
Starting dose: 12.5 alternate days or two 12.5 twice weekly
Additional Notes: This is an effective testosterone blocker but side-effects do include low mood and a long-term increase miningiomas. I can be used short-term as an alternative to Spironolactone or long-term but at low dose.
Monitoring Requirements for Transwomen
Estradiol (E2)
Action: Target - 350-750 pmol/l if aged <40, - 300-600 pmol/l if aged 40-50, - 200-400 pmol/l if aged >50 or younger and significant CV risk factors. Use transdermal route E2 administration for this group. Discuss with specialist if target range not achieved within these parameters. Monitoring blood tests are taken ideally on day 2 of patch wear (24-36 hours after new patches applied), 4-6 hours after applying gel/spray and around 4 hours after dosing with oral Estradiol. The dose is gradually increased to achieve the desired degree of feminisation, within agreed target ranges. High levels of Estradiol are associated with an increased risk of adverse effects. Doses are increased every 3-4 months and slower gradual titration is thought to be important for optimising breast development.
Testosterone
Action: Monitoring levels of Testosterone is important to assess response to antiandrogen therapy or to those who are doing monotherapy with estrodial alone. Please note: following gender reassignment surgery, Testosterone is not routinely monitored unless there are clinical signs of viralisation.
Prolactin
Action: If persistent hyperprolactinaemia (>1000 mU/l or lower levels with symptoms/signs of hyperprolactinaemia) refer to local endocrinologist for further evaluation provided other reasons for raised prolactin levels are absent.
Blood Pressure
Action: May increase. Treat as appropriate. Anything over 140/85 should be followed up in primary care and a diagnosis of hypertension made or management of established hypertension adjusted. It is not safe to start or change HRT with uncontrolled high blood pressure but it is safe to use in well managed people with controlled blood pressure and a diagnosis of hypertension.
LFTs
Action: Refer back to the specialist if three times greater than upper limit of normal reference range.
Lipids
Action: Full lipid screen including fasting triglycerides. Treat raised triglycerides as per local guidance.
HbA1c
Action: If diabetes or pre-diabetes.
Breast Cancer Screening
Action: Performed according to usual screening protocols: Any one with breasts from the ages of 50 to 70. If there is continued use of Estradiol then breast cancer screening should continue past 70 until Estradiol is ceased. If you are registered female with your GP you will be automatically invited to breast cancer screening.
