estrogen.fyi - User contributions [en]

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2023-11-28T21:27:45Z

Plants:

"the transfeminine encyclopedia"

Injections and Vial Care

2023-11-27T23:27:06Z

Plants:

[[Category:Medical]]
If you have to self-administer injections for your HRT, it's essential to know how to do it safely, make it as painless as possible, and take care of your vial to prevent coring or other issues.

=== Supplies ===
There are many different types of needles and syringes. Firstly, you should use something other than a non-detachable syringe that comes with the needle and syringe in one device. With these, you will be forced to draw from your vial and inject with the same needle. Drawing medication dulls the hand and will make injecting needlessly painful.

You will need to buy syringes, a larger gauge needle for drawing, and a smaller gauge needle for injecting, along with medical alcohol prep pads or wipes for sterilizing yourself and your vial. You should look for two types of syringes: luer lock or luer slip. Both will do the job. The main difference is that with luer lock syringes, the needle is twisted on, and luer slip syringes are pushed on. Regardless, you must buy matching needles, or you won't be able to connect them.

The higher the gauge a needle is, the thinner and less painful it will be, but it will also be slower to inject or draw. You should have a 21-23 gauge for drawing. The length doesn't matter. You should use a 1-1.5<nowiki>''</nowiki> 21-27G needle for injecting intramuscularly and a 0.5<nowiki>''</nowiki> 25-31G needle for subcutaneous injections.

=== How to Draw Medication ===
Your vial contains a solution comprised of a carrier oil, typically MCT or castor oil for estradiol, preservatives such as benzyl benzoate and benzyl alchohol, and your estradiol dissolved in it. Your vial should state its concentration, for example, 40 milligrams per milliliter. You will figure out how much liquid you need to draw for your desired dosage by dividing your dosage by the concentration.
[[File:Original.00000539-201504000-00038.F1-38.jpg|thumb]]
Firstly, take off the cap of your vial. This does not stay with your vial and should be thrown away. The rubber stopper is air-tight and will protect the medication. Next, take one of your alcohol wipes and clean the top of the vial; then, we will prepare your syringe. Unpackage one single-use syringe and drawing needle and attach them, avoiding touching the ends. Uncap the needle and draw up your dosage in air; this maintains pressure in the vial and makes drawing much easier. Stick your needle into the vial at a 45-degree angle, like in picture B. This significantly reduces the risk of coring (puncturing a hole in the vial).<ref>Gragasin, Ferrante S. MD, PhD, FRCPC; van den Heever, Z. A. Neethling MB, ChB, DA (SA). The Incidence of Propofol Vial Coring with Blunt Needle Use Is Reduced with Angled Puncture Compared with Perpendicular Puncture. Anesthesia & Analgesia 120(4):p 954-955, April 2015. | DOI: 10.1213/ANE.0000000000000599 </ref>

Inject the air into the vial and flip it upside down with the needle still in it. Now, slowly pull the plunger back to your desired dose; it should fill with liquid. If it doesn't, you may need to be patient, or you haven't put enough air into the vial and have created a vacuum. Tap the syringe to push any air bubbles to the top, and gently push them out of the syringe, though they are not usually dangerous. Once you have drawn up your medication, it's time to remove the syringe from your vial and inject.

=== Injecting Medication ===
When you have your medication in your syringe, you will face the needle up and swap the drawing needle for a higher gauge injection needle, carefully twist it off, put it into a sharps container, and attach the new needle.

Subcutaneous and intramuscular injections are relatively equally effective, and it is entirely up to personal preference which to do.<ref>Herndon, A. et al. (2023). Comparison of the Subcutaneous and Intramuscular Estradiol Regimens as Part of Gender-Affirming Hormone Therapy. ''Endocrine Practice, Volume 29, Issue 5'' <nowiki>https://www.endocrinepractice.org/article/S1530-891X(23)00050-2/fulltext</nowiki></ref>

==== Subcutaneous Injections ====
[[File:SQ01 locator retina.png|thumb|Subq injection locations<ref>https://www.healthline.com/health/subcutaneous-injection</ref>]]
Subcutaneous injections are when you use a shorter needle to inject medication between the skin and the muscle. This can be less painful but also more tedious. Subq injection sites can be seen in this section's attachment.

Prepare the site by wiping it with an alcohol prep pad and letting the alcohol dry before continuing. Pinch the skin between your thumb and index finger and hold it. Insert the needle into your skin at a 45-degree angle in a smooth motion, and push the plunger down. Wait a few seconds and pull the needle straight back out. Pat, do not wipe the area with an alcohol prep pad and put your favorite Band-Aid on it. Cap the needle and put it into your sharps container.

==== Intramuscular Injections ====
[[File:IM injection site.jpg|thumb|IM injection locations<ref>https://psychonautwiki.org/wiki/File:IM_injection_site.jpg</ref>]]
Intramuscular injections are when you inject directly into the muscle. They can be much faster than subq injections but also may leave bruising and hurt more. IM injections follow most of the same steps subq does. Im injection sites are listed in the attachment.
Prep the site with an alcohol wipe and let it dry. Uncap and insert the needle at a 90-degree angle. Push the plunger down fully, wait a few seconds, and remove the needle. Now pat the area with an alcohol wipe and apply a Band-Aid. Some bleeding is normal and should be expected occasionally.<ref>Brand, Heather (Accessed November 11, 2023). "SUBCUTANEOUS (SUBQ) SELF-INJECTION VIDEO TRANSCRIPT" (PDF). ''Planned Parenthood''. https://www.plannedparenthood.org/uploads/filer_public/a7/e7/a7e715f5-af56-4a54-adb8-8f2435fdf715/subq_self-injection_video_transcript.pdf</ref>

=== Vial Shelf Life ===
A good rule of thumb with vials is that they last about two years; depending on exposure to light and heat exposure, they can sometimes be used for up to five years. It's best to store your vial away from sunlight in a room-temperature place like a drawer. Don't refrigerate and expose a vial to moisture.

==== Vial Coring ====
Another massive factor in vial shelf life is coring. The rubber stopper should be self-healing and close after every use, but if you draw too many times in the same place, at the wrong angle, or with too large of a needle, it can puncture a hole in the rubber. This is called coring. If your vial leaks has a visible hole or particles floating around it, do not inject from it. You can prevent coring by drawing correctly, like from the drawing section of this page, with a 21-23 gauge needle.

Intro to HRT

2023-11-17T06:36:19Z

Plants: Protected "Intro to HRT" ([Edit=Allow only autoconfirmed users] (indefinite))

[[Category:Medical]]

'''Hormone replacement therapy''', or HRT, is a relatively common medical treatment used in many contexts. Despite what many may think, this is not a new or experimental practice, nor is it exclusive to transgender individuals. Hormone replacement therapy has been used for over half a century, starting its use in the 1960s and is widely popular in treating menopause in AFAB (assigned female at birth) patients.

In this page, we will cover how HRT can be used in AMAB (assigned male at birth) patients for gender affirmation, a type of HRT known as feminizing HRT. Feminizing HRT can have profound effects even on patients who are post-puberty, and has the potential to significantly improve quality of life for transfeminine individuals.

== What can HRT do for me? ==
Feminizing HRT seeks to lower a patient's testosterone level and raise their estradiol (AKA E2, the most biologically active estrogen) level, targeting levels similar to those of an average cisgender woman. Feminizing HRT can also involve many other medications, such as antiandrogens or progestogens. The end result is overall feminization of the body and its secondary sex characteristics. Changes may include healthier skin, female fat redistribution throughout the body, and breast growth.
{| class="wikitable sortable"
|+Below is a chart outlining most of the common changes from HRT:<ref>Mayo clinic: Feminizing hormone therapy

https://www.mayoclinic.org/tests-procedures/feminizing-hormone-therapy/about/pac-20385096</ref>
!Effect
!Permanence
!Expected Onset
!Maximum effect
|-
|Body fat redistribution
|Reversible
|1-2 months
|2-5 years
|-
|Decreased muscle mass
|Reversible
|1-2 months
|1-1.5 years
|-
|Decreased skin oiliness
|Reversible
|1-2 months
|1-1.5 years
|-
|Skin softening
|Reversible
|1-2 months
|1-2 years
|-
|Decreased libido
|Reversible
|days-weeks
|weeks-months
|-
|Less or no random erections
|Reversible
|days-weeks
|weeks-months
|-
|Erectile dysfunction*
|Reversible
|days-weeks
|weeks-months
|-
|Breast development
|Irreversible
|2-6 weeks
|2-6 years
|-
|Decreased testicular volume
|Variable
|1-3 months
|2-3 years
|-
|Decreased sperm production
|Variable
|2-6 weeks
|1-3 years
|-
|Decreased semen volume
|Veriable
|2-6 weeks
|1-3 years
|-
|Slowing of body & facial hair growth**
|Reversible
|1-3 months
|6 months-1 year
|-
|Voice changes***
|N/A
|none
|none
|-
|Reversal of male pattern hair loss****
|Reversible
|1-3 months
|1-2 years
|}
<nowiki>*:</nowiki> Most individuals do not experience erectile dysfunction.

**: HRT will slow down body and facial hair growth, but only laser or electrolysis can stop it entirely.

***: Feminizing HRT does not cause an effect on an individual's vocal folds.

****: Male pattern hair loss can be prevented with HRT, but reversal of hair loss is rare.

== So, what should I take, and how much? ==
Again, the goal of feminizing HRT is to bring your hormone levels (estradiol and testosterone in particular) from your current male range to that of a healthy cisgender woman. On top of this, there are some medications and other hormones we will cover, such as antiandrogens, progestogens, and other niche or specific medications, including hair loss treatments and more experimental methods for feminization.

Before we talk about specific medications, you need to have a basic understanding of the target hormone levels. For feminization to be effective, you should be within the levels of a premenopausal female:

'''100-200 pg/ml estradiol & <50 ng/dl testosterone.'''<ref>Wylie C Hembree, Peggy T Cohen-Kettenis, Louis Gooren, Sabine E Hannema, Walter J Meyer, M Hassan Murad, Stephen M Rosenthal, Joshua D Safer, Vin Tangpricha, Guy G T’Sjoen, Endocrine Treatment of Gender-Dysphoric/Gender-Incongruent Persons: An Endocrine Society Clinical Practice Guideline, ''The Journal of Clinical Endocrinology & Metabolism'', Volume 102, Issue 11, 1 November 2017, Pages 3869–3903, https://doi.org/10.1210/jc.2017-01658</ref>

Blood tests are the only effective way to measure these levels and are extremely important in minimizing the risks of HRT and maximizing its effectiveness. We will talk about how to manage being in a situation where you cannot access bloodwork. This is not impossible, but we highly recommend against it.

Now, onto the fun stuff: what to take, and how to dose it.

=== Injection monotherapy ===
The big one. Estradiol is the most biologically active estrogen and heavily contributes to feminization. On top of this, it contributes to the suppression of testosterone.

In estradiol-only HRT, also known as monotherapy, estradiol alone provides both feminization and suppression of testosterone into female ranges. This is possible because of estradiol's suppressing effect on testosterone by itself at high enough levels. Monotherapy removes or reduces certain potential risks and side effects that may be caused by antiandrogens used to help with testosterone suppression, but usually requires more estradiol and is much harder to achieve with specific routes of administration such as oral or transdermal.

Injections are an excellent example of an ROA suitable for monotherapy. It is rare for someone to be unable to achieve proper levels through injections. There are several common esters (chemical variations) used for injectable estradiol. These include valerate, cypionate, enanthate, and less commonly, undecylate.

Effective dosages vary wildly from person to person, though there is a reasonable range of starting dosage. If you have access to bloodwork, finding your dosage should be simple. Start with a sane dosage that works for most people, which we are about to cover now, and get a blood test just before the next injection at the "trough", or lowest level in your cycle, after a few weeks.

The most significant difference between the esters is their stability, or biological half-life. Estradiol valerate has a half-life of 4-5 days<ref>Düsterberg, B., & Nishino, Y. (1982). Pharmacokinetic and pharmacological features of oestradiol valerate. ''Maturitas'', ''4''(4), 315–324. <nowiki>https://doi.org/10.1016/0378-5122(82)90064-0</nowiki></ref>, cypionate 8-10 days<ref>Thurman, A., Kimble, T., Hall, P., Schwartz, J. L., & Archer, D. F. (2013). Medroxyprogesterone acetate and estradiol cypionate injectable suspension (Cyclofem) monthly contraceptive injection: steady-state pharmacokinetics. ''Contraception'', ''87''(6), 738–743. <nowiki>https://doi.org/10.1016/j.contraception.2012.11.010</nowiki></ref>, and enanthate 5-7 days<ref>Wiemeyer, J. C., Fernandez, M., Moguilevsky, J. A., & Sagasta, C. L. (1986). Pharmacokinetic studies of estradiol enantate in menopausic women. ''Arzneimittel-Forschung'', ''36''(11), 1674–1677.</ref>. However, research suggests that enanthate's peak comes later than cypionate, so it is generally best to treat them the same. Valerate is the most common pharma-grade ester in the US due to the cypionate shortage. Enanthate is the most common ester found in homebrew due to its incredible stability, and is prescribed in some countries.
{| class="wikitable"
|+This graph shows reasonable starting monotherapy injection dosages. It is possible that you may not need to adjust your regimen past this.
!Ester
!Elimination Half life
!Starting dosage
!Maximum time in between injections
|-
|Valerate
|4-5 days
|3.5mg/5 days
|7 days
|-
|Cypionate
|8-10 days
|4mg/7 days
|14 days
|-
|Enanthate
|5-7 days*
|4mg/7 days
|14 days
|}
These dosages must be adjusted based on bloodwork. It is possible to extend the time between your dosages from every 5 days with valerate up to every 7 or even every 2 weeks with cypionate or enanthate (however 10 days is a much safer bet).

[https://transfemscience.org/misc/injectable-e2-simulator/ This] lovely simulator can be helpful if you are trying to approximate your dosage. It averages the estradiol level of many people on injections into a graph based on several studies, but it is important to remember that it can be highly inaccurate on an individual basis and should not be used as a replacement for bloodwork. I was on a prescription dosage of 8mg estradiol valerate, with my trough (right before the next injection) over 650 pg/ml; the simulator's estimate is just below 200 pg/ml.

==== No access to bloodwork ====
'''Dosing your HRT without bloodwork may be unsafe and could lead to complications; it is highly recommended that you get bloodwork if at all possible.''' We cover how to get blood tests even without a doctor or prescription HRT [[HRT Bloodwork|here]], but if you ''absolutely cannot'' get bloodwork, all you can do is take a reasonable dosage and hope it works. Some things to look out for to guess if your dosage is working are breast growth, nipple sensitivity (sensitivity is rarely constant and can go away for long periods), and general changes HRT is supposed to have on a person.

==== How to do an injection ====
Injecting medication is a relatively straightforward process but easy to screw up. Learn how to do a proper injection [[Injections and Vial Care|here]].

=== Antiandrogens AKA testosterone blockers ===
Antiandrogens are medications that counteract the effects of androgens—male sex hormones such as testosterone or DHT. High-dose estradiol is an effective antiandrogen, but for some patients it may be very hard or impossible to get proper levels without an antiandrogen. Common antiandrogens for feminizing HRT are cyproterone acetate, spironolactone, and bicalutamide. These medications all work in different ways to suppress androgens.

Bicalutamide is an antiandrogen also used to treat prostate cancer by blocking the effects of testosterone, which in turn slows or stops the growth of cancerous cells.<ref>Mayo Clinic. (Nov. 01, 2023). Bicalutamide (Oral Route) - Side Effects. Retrieved from <nowiki>https://www.mayoclinic.org/drugs-supplements/bicalutamide-oral-route/side-effects/drg-20072486?p=1</nowiki></ref> This testosterone blocking effect is desirable in feminizing HRT, and as such, bicalutamide is a common choice of antiandrogen. It is commonly dosed at 25-50mg/day. Keep in mind when taking bicalutamide that it does not block testosterone production; testosterone blood levels may significantly increase.<ref>Cockshott I. D. (2004). Bicalutamide: clinical pharmacokinetics and metabolism. ''Clinical pharmacokinetics'', ''43''(13), 855–878. <nowiki>https://doi.org/10.2165/00003088-200443130-00003</nowiki></ref> Instead, it prevents testosterone from attaching to its receptors. Although you still have it in your blood, on a proper dosage you will not experience any androgenic effects.

Cyproterone acetate is a progestin with androgenic and progestogenic effects. Like bicalutamide, it is used in treating prostate cancer. It is not approved for use in the US but is a standard option in many other countries. Even without estrogens, cyproterone acetate reduces testosterone levels very efficiently.<ref>de Voogt H. J. (1992). The position of cyproterone acetate (CPA), a steroidal anti-androgen, in the treatment of prostate cancer. ''The Prostate. Supplement'', ''4'', 91–95. <nowiki>https://doi.org/10.1002/pros.2990210514</nowiki></ref> Cyproterone acetate is most effective in daily doses of 10mg, though most patients take 12.5mg because they split one 50mg pill into 4 pieces.

Spironolactone is one of the most common antiandrogens used in feminizing HRT. It is also a diuretic, and as a result may cause you to urinate more often. Spironolactone helps your body retain potassium, so you should be mindful when consuming potassium-rich foods while taking it.<ref>National Health Service. (6 July 2022). About Spironolactone. Retrieved from <nowiki>https://www.nhs.uk/medicines/spironolactone/about-spironolactone/</nowiki></ref> Spironolactone is a weaker antiandrogen compared to the two above, but is relatively safe and commonly prescribed in the US. It is typically dosed at 100-200mg daily.<ref name=":0">UCSF Transgender Care. (June 17, 2016). Feminizing hormone therapy. Retrieved from <nowiki>https://transcare.ucsf.edu/guidelines/feminizing-hormone-therapy</nowiki></ref>

Finasteride is an antiandrogen used in treating prostate inflammation and male pattern hair loss. It inhibits the conversion of testosterone into its more potent form, DHT (dihydrotestosterone).<ref>Zito, P. M., Bistas, K. G., & Syed, K. (2022). Finasteride. In ''StatPearls''. StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK513329/#:~:text=2%5D%5B3%5D-,Finasteride</ref> Finasteride does not lower testosterone significantly and should not be used as a replacement for the antiandrogens above, although it is an effective treatment for hair loss.<ref>Roehrborn, C. G., Lee, M., Meehan, A., Waldstreicher, J., & PLESS Study Group (2003). Effects of finasteride on serum testosterone and body mass index in men with benign prostatic hyperplasia. ''Urology'', ''62''(5), 894–899. <nowiki>https://doi.org/10.1016/s0090-4295(03)00661-7</nowiki></ref>

Before taking any antiandrogen, it is important to understand the safety profile and possible side effects. Be sure to monitor yourself for side effects when starting a new medication, and consult your doctor if you experience any serious issues.

=== Oral or sublingual estradiol ===
If you cannot handle performing injections, or are unable to source injectable estradiol, oral or sublingual estradiol tablets are another option. Usually taken with an antiandrogen, estradiol tablets are commonly composed of one of two common forms of estradiol: ethinyl estradiol or estradiol valerate. They are both very similar<ref>Haverinen, A., Kangasniemi, M., Luiro, K., Piltonen, T., Heikinheimo, O., & Tapanainen, J. S. (2021). Ethinyl estradiol vs estradiol valerate in combined oral contraceptives - Effect on glucose tolerance: A randomized, controlled clinical trial. ''Contraception'', ''103''(1), 53–59. <nowiki>https://doi.org/10.1016/j.contraception.2020.10.014</nowiki></ref>, with only minor differences in their half-lives. Ethinyl estradiol has a slightly longer half-life, and 1mg of estradiol valerate orally equals 0.76mg of ethinyl estradiol.<ref>"General information: Oestradiol valerate is equal to oestradiol 0.76 mg." ''ScienceDirect''. Retrieved from <nowiki>https://www.sciencedirect.com/topics/neuroscience/estradiol-valerate#:~:text=General%20information%3A%20Oestradiol%20valerate%20is,equal%20to%20oestradiol%200.76%20mg</nowiki></ref> Overall, you don't have to be super picky, and either one is likely to be just as effective.

While oral estradiol is administered simply by swallowing the tablet, sublingual ROA for estradiol is administered by placing the tablet under the tongue, where it is absorbed through the dense blood vessels found in the connective tissue. Relatively new but very promising, sublingual dosing achieves much higher levels when compared to oral dosing, and avoids passing through the liver, which is safer and reduces the risk of blood clots. However, it generally requires more frequent dosing, as it has a much shorter half-life.<ref>Doll, Elizabeth E et al. “SUN-LB9 Pharmacokinetics of Sublingual Versus Oral Estradiol in Transgender Women.” ''Journal of the Endocrine Society'' vol. 4,Suppl 1 SUN-LB9. 8 May. 2020, doi:10.1210/jendso/bvaa046.2237</ref>
{| class="wikitable"
|+This graph shows the dosage and frequency of oral estradiol.<ref>Boston University School of Medicine. (2013). ''Practical Guidelines for Transgender Hormone Treatment''. Retrieved from <nowiki>https://www.bumc.bu.edu/endo/clinics/transgender-medicine/guidelines/</nowiki></ref><ref name=":0" />
!Route of Administration
!Low/Initial Dosage
!Maximum Dosage
!Frequency
|-
|Oral
|2-4mg/day
|6-8mg/day
|1-2x daily
|-
|Sublingual
|1-2mg/day
|4-6mg/day
|2-3x daily
|}
'''The dosages above should be divided throughout the day according to the frequency, not multiplied.'''

=== Transdermal estradiol ===
Transdermal estradiol is another ROA for feminizing HRT. It is one of the safest methods, prescribed especially in older patients or those with risk factors such as tobacco use. Typically, a patch or gel is applied to the skin, but less commonly, a spray form of estradiol can be used. A common downside of transdermal estradiol is that many find it hard or infeasible to achieve cisgender hormone levels; antiandrogens are often used in conjunction if testosterone cannot be suppressed by the estradiol alone.

Patches can come in dosages up to 100mcg released per day; often, it takes wearing multiple 100mcg patches at a time to remain within target ranges or effectively block testosterone, with a typical dosage being 100-400mcg per day. Patches must be changed weekly or twice weekly.<ref name=":0" />

=== Dihydrotestosterone ===
Dihydrotestosterone, or DHT, is an androgen that affects the growth of the prostate, along with being the primary cause of male pattern hair loss. Depending on your regimen, you may want to take a DHT blocker to prevent hair loss. Read more on hair loss [[Hair Care|here]].

=== Progesterone ===
The effects of progesterone in transgender women is very controversial. Some say, that there are no effects at all, while others believe that there are improvements in permanent fat distribution. There are many articles & studies about this topic, and we will not teach one specifically. You can go check the [[progesterone]] page for more information on individual theories.

The TLDR is: it is known that progesterone has anti-depressant effects, and allows water weight to move to more feminine areas. Due to a lack of studies, we cannot definitively say any more information.

=== Experimental HRT ===
There are a few somewhat common medications—pioglitazone or estrone, for example—that some people claim help with feminization. This section will probably take a while to write and research. For now, it is empty.

Injections and Vial Care

2023-11-17T06:35:19Z

Plants: Protected "Injections and Vial Care" ([Edit=Allow only autoconfirmed users] (indefinite))

[[Category:Medical]]
If you have to self-administer injections for your HRT, it's essential to know how to do it safely, make it as painless as possible, and take care of your vial to prevent coring or other issues.

=== Supplies ===
There are many different types of needles and syringes. Firstly, you should use something other than a non-detachable syringe that comes with the needle and syringe in one device. With these, you will be forced to draw from your vial and inject with the same needle. Drawing medication dulls the hand and will make injecting needlessly painful.

You will need to buy syringes, a larger gauge needle for drawing, and a smaller gauge needle for injecting, along with medical alcohol prep pads or wipes for sterilizing yourself and your vial. You should look for two types of syringes: luer lock or luer slip. Both will do the job. The main difference is that with luer lock syringes, the needle is twisted on, and luer slip syringes are pushed on. Regardless, you must buy matching needles, or you won't be able to connect them.

The higher the gauge a needle is, the thinner and less painful it will be, but it will also be slower to inject or draw. You should have a 21-23 gauge for injecting. The length doesn't matter. You should use a 1-1.5<nowiki>''</nowiki> 21-27G needle for injecting intramuscularly and a 0.5<nowiki>''</nowiki> 25-31G needle for subcutaneous injections.

=== How to Draw Medication ===
Your vial contains a solution comprised of a carrier oil, typically MCT or castor oil for estradiol, preservatives such as benzyl benzoate and benzyl alchohol, and your estradiol dissolved in it. Your vial should state its concentration, for example, 40 milligrams per milliliter. You will figure out how much liquid you need to draw for your desired dosage by dividing your dosage by the concentration.
[[File:Original.00000539-201504000-00038.F1-38.jpg|thumb]]
Firstly, take off the cap of your vial. This does not stay with your vial and should be thrown away. The rubber stopper is air-tight and will protect the medication. Next, take one of your alcohol wipes and clean the top of the vial; then, we will prepare your syringe. Unpackage one single-use syringe and drawing needle and attach them, avoiding touching the ends. Uncap the needle and draw up your dosage in air; this maintains pressure in the vial and makes drawing much easier. Stick your needle into the vial at a 45-degree angle, like in picture B. This significantly reduces the risk of coring (puncturing a hole in the vial).<ref>Gragasin, Ferrante S. MD, PhD, FRCPC; van den Heever, Z. A. Neethling MB, ChB, DA (SA). The Incidence of Propofol Vial Coring with Blunt Needle Use Is Reduced with Angled Puncture Compared with Perpendicular Puncture. Anesthesia & Analgesia 120(4):p 954-955, April 2015. | DOI: 10.1213/ANE.0000000000000599 </ref>

Inject the air into the vial and flip it upside down with the needle still in it. Now, slowly pull the plunger back to your desired dose; it should fill with liquid. If it doesn't, you may need to be patient, or you haven't put enough air into the vial and have created a vacuum. Tap the syringe to push any air bubbles to the top, and gently push them out of the syringe, though they are not usually dangerous. Once you have drawn up your medication, it's time to remove the syringe from your vial and inject.

=== Injecting Medication ===
When you have your medication in your syringe, you will face the needle up and swap the drawing needle for a higher gauge injection needle, carefully twist it off, put it into a sharps container, and attach the new needle.

Subcutaneous and intramuscular injections are relatively equally effective, and it is entirely up to personal preference which to do.<ref>Herndon, A. et al. (2023). Comparison of the Subcutaneous and Intramuscular Estradiol Regimens as Part of Gender-Affirming Hormone Therapy. ''Endocrine Practice, Volume 29, Issue 5'' <nowiki>https://www.endocrinepractice.org/article/S1530-891X(23)00050-2/fulltext</nowiki></ref>

==== Subcutaneous Injections ====
[[File:SQ01 locator retina.png|thumb|Subq injection locations<ref>https://www.healthline.com/health/subcutaneous-injection</ref>]]
Subcutaneous injections are when you use a shorter needle to inject medication between the skin and the muscle. This can be less painful but also more tedious. Subq injection sites can be seen in this section's attachment.

Prepare the site by wiping it with an alcohol prep pad and letting the alcohol dry before continuing. Pinch the skin between your thumb and index finger and hold it. Insert the needle into your skin at a 45-degree angle in a smooth motion, and push the plunger down. Wait a few seconds and pull the needle straight back out. Pat, do not wipe the area with an alcohol prep pad and put your favorite Band-Aid on it. Cap the needle and put it into your sharps container.

==== Intramuscular Injections ====
[[File:IM injection site.jpg|thumb|IM injection locations<ref>https://psychonautwiki.org/wiki/File:IM_injection_site.jpg</ref>]]
Intramuscular injections are when you inject directly into the muscle. They can be much faster than subq injections but also may leave bruising and hurt more. IM injections follow most of the same steps subq does. Im injection sites are listed in the attachment.
Prep the site with an alcohol wipe and let it dry. Uncap and insert the needle at a 90-degree angle. Push the plunger down fully, wait a few seconds, and remove the needle. Now pat the area with an alcohol wipe and apply a Band-Aid. Some bleeding is normal and should be expected occasionally.<ref>Brand, Heather (Accessed November 11, 2023). "SUBCUTANEOUS (SUBQ) SELF-INJECTION VIDEO TRANSCRIPT" (PDF). ''Planned Parenthood''. https://www.plannedparenthood.org/uploads/filer_public/a7/e7/a7e715f5-af56-4a54-adb8-8f2435fdf715/subq_self-injection_video_transcript.pdf</ref>

=== Vial Shelf Life ===
A good rule of thumb with vials is that they last about two years; depending on exposure to light and heat exposure, they can sometimes be used for up to five years. It's best to store your vial away from sunlight in a room-temperature place like a drawer. Don't refrigerate and expose a vial to moisture.

==== Vial Coring ====
Another massive factor in vial shelf life is coring. The rubber stopper should be self-healing and close after every use, but if you draw too many times in the same place, at the wrong angle, or with too large of a needle, it can puncture a hole in the rubber. This is called coring. If your vial leaks has a visible hole or particles floating around it, do not inject from it. You can prevent coring by drawing correctly, like from the drawing section of this page, with a 21-23 gauge needle.

Blood Tests

2023-11-17T06:34:56Z

Plants: Protected "Blood Tests" ([Edit=Allow only autoconfirmed users] (indefinite) [Move=Allow only autoconfirmed users] (indefinite))

[[category:medical]]
Bloodwork is the only way to be sure HRT is feminizing and effective. In many countries, it is possible to order blood tests for personal use without a doctor's permission.

E2/estradiol and T/testosterone should be tested every time, though other tests should be run depending on what you take.

Antiandrogens can impact organ functions. You should run specific tests depending on your antiandrogen. Cyproterone acetate and bicalutamide both may rarely cause liver toxicity. This can be monitored via a liver function test (LFT). Spironolactone can cause kidney problems and kidney function and potassium should be tested. Your lab will provide reference ranges. If your levels are abnormal, stop taking the antiandrogen immediately.

Liver toxicity onset with cyproterone ranges from months to a year but is typically within the first six months. You should test for liver function after several months and continue annually.<ref>LiverTox: Clinical and Research Information on Drug-Induced Liver Injury [Internet]. Bethesda (MD): National Institute of Diabetes and Digestive and Kidney Diseases; 2012-. Cyproterone. [Updated 2017 Jul 5]. Available from: <nowiki>https://www.ncbi.nlm.nih.gov/books/NBK548024/</nowiki></ref>

Liver toxicity from bicalutamide is less common compared to cyproterone, and its onset is typically two to three months, in rare cases taking up to six. You should test liver function after three months and continue annually.<ref>LiverTox: Clinical and Research Information on Drug-Induced Liver Injury [Internet]. Bethesda (MD): National Institute of Diabetes and Digestive and Kidney Diseases; 2012-. Bicalutamide. [Updated 2023 Mar 15]. Available from: <nowiki>https://www.ncbi.nlm.nih.gov/books/NBK547970/</nowiki></ref>

Spironolactone can impact kidney function. Renal (kidney) function and potassium should be tested after three and six months and then annually.<ref>UCSF Transgender Care. (June 17, 2016). Feminizing hormone therapy. Retrieved from <nowiki>https://transcare.ucsf.edu/guidelines/feminizing-hormone-therapy</nowiki></ref>

Some individuals may still experience androgenic side effects despite suppressed testosterone; DHT may be the culprit. DHT (dihydrotestosterone) is one of the primary causes of male pattern baldness, and DHT blockers such as dutasteride can be used if levels don't go down.

Category:Medical

2023-11-17T06:34:43Z

Plants: Protected "Category:Medical" ([Edit=Allow only autoconfirmed users] (indefinite) [Move=Allow only administrators] (indefinite))

= Medical Transition Pages =
This category contains all medical transition topics, including hormones, operations, and more. This will not cover topics like skin care, exercise, makeup, fashion, and more. You can find those in the nonmedical section of the website.

Blood Tests

2023-11-17T05:10:54Z

Plants:

Blood Tests

2023-11-17T05:10:45Z

Plants:

[[category:medical]]

== THIS PAGE IS A WIP ==
Bloodwork is the only way to be sure HRT is feminizing and effective. In many countries, it is possible to order blood tests for personal use without a doctor's permission.

E2/estradiol and T/testosterone should be tested every time, though other tests should be run depending on what you take.

Antiandrogens can impact organ functions. You should run specific tests depending on your antiandrogen. Cyproterone acetate and bicalutamide both may rarely cause liver toxicity. This can be monitored via a liver function test (LFT). Spironolactone can cause kidney problems and kidney function and potassium should be tested. Your lab will provide reference ranges. If your levels are abnormal, stop taking the antiandrogen immediately.

Liver toxicity onset with cyproterone ranges from months to a year but is typically within the first six months. You should test for liver function after several months and continue annually.<ref>LiverTox: Clinical and Research Information on Drug-Induced Liver Injury [Internet]. Bethesda (MD): National Institute of Diabetes and Digestive and Kidney Diseases; 2012-. Cyproterone. [Updated 2017 Jul 5]. Available from: <nowiki>https://www.ncbi.nlm.nih.gov/books/NBK548024/</nowiki></ref>

Liver toxicity from bicalutamide is less common compared to cyproterone, and its onset is typically two to three months, in rare cases taking up to six. You should test liver function after three months and continue annually.<ref>LiverTox: Clinical and Research Information on Drug-Induced Liver Injury [Internet]. Bethesda (MD): National Institute of Diabetes and Digestive and Kidney Diseases; 2012-. Bicalutamide. [Updated 2023 Mar 15]. Available from: <nowiki>https://www.ncbi.nlm.nih.gov/books/NBK547970/</nowiki></ref>

Spironolactone can impact kidney function. Renal (kidney) function and potassium should be tested after three and six months and then annually.<ref>UCSF Transgender Care. (June 17, 2016). Feminizing hormone therapy. Retrieved from <nowiki>https://transcare.ucsf.edu/guidelines/feminizing-hormone-therapy</nowiki></ref>

Some individuals may still experience androgenic side effects despite suppressed testosterone; DHT may be the culprit. DHT (dihydrotestosterone) is one of the primary causes of male pattern baldness, and DHT blockers such as dutasteride can be used if levels don't go down.

Blood Tests

2023-11-17T04:31:58Z

Plants:

[[category:medical]]

== THIS PAGE IS A WIP ==
Bloodwork is the only way to be sure HRT is feminizing and effective. In many countries, it is possible to order blood tests for personal use without a doctor's permission.

E2/estradiol and T/testosterone should be tested every time, though other tests should be run depending on what you take.

Antiandrogens can impact organ functions. You should run specific tests depending on your antiandrogen. Cyproterone acetate and bicalutamide both may rarely cause liver toxicity. This can be monitored via a liver function test (LFT). Spironolactone can cause kidney problems, and kidney function and potassium should be tested.

Liver toxicity onset with cyproterone ranges from months to a year but is typically within the first six months. You should test for liver function after several months and continue annually.<ref>LiverTox: Clinical and Research Information on Drug-Induced Liver Injury [Internet]. Bethesda (MD): National Institute of Diabetes and Digestive and Kidney Diseases; 2012-. Cyproterone. [Updated 2017 Jul 5]. Available from: <nowiki>https://www.ncbi.nlm.nih.gov/books/NBK548024/</nowiki></ref>

Liver toxicity from bicalutamide is less common compared to cyproterone, and its onset is typically two to three months, in rare cases taking up to six. You should test liver function after three months and continue annually.<ref>LiverTox: Clinical and Research Information on Drug-Induced Liver Injury [Internet]. Bethesda (MD): National Institute of Diabetes and Digestive and Kidney Diseases; 2012-. Bicalutamide. [Updated 2023 Mar 15]. Available from: <nowiki>https://www.ncbi.nlm.nih.gov/books/NBK547970/</nowiki></ref>

Spironolactone can impact kidney function. Renal (kidney) function and potassium should be tested after three and six months and then annually.<ref>UCSF Transgender Care. (June 17, 2016). Feminizing hormone therapy. Retrieved from <nowiki>https://transcare.ucsf.edu/guidelines/feminizing-hormone-therapy</nowiki></ref>

Blood Tests

2023-11-17T04:31:34Z

Plants: more

[[category:medical]]
Bloodwork is the only way to be sure HRT is feminizing and effective. In many countries, it is possible to order blood tests for personal use without a doctor's permission.

E2/estradiol and T/testosterone should be tested every time, though other tests should be run depending on what you take.

Antiandrogens can impact organ functions. You should run specific tests depending on your antiandrogen. Cyproterone acetate and bicalutamide both may rarely cause liver toxicity. This can be monitored via a liver function test (LFT). Spironolactone can cause kidney problems, and kidney function and potassium should be tested.

Liver toxicity onset with cyproterone ranges from months to a year but is typically within the first six months. You should test for liver function after several months and continue annually.<ref>LiverTox: Clinical and Research Information on Drug-Induced Liver Injury [Internet]. Bethesda (MD): National Institute of Diabetes and Digestive and Kidney Diseases; 2012-. Cyproterone. [Updated 2017 Jul 5]. Available from: <nowiki>https://www.ncbi.nlm.nih.gov/books/NBK548024/</nowiki></ref>

Liver toxicity from bicalutamide is less common compared to cyproterone, and its onset is typically two to three months, in rare cases taking up to six. You should test liver function after three months and continue annually.<ref>LiverTox: Clinical and Research Information on Drug-Induced Liver Injury [Internet]. Bethesda (MD): National Institute of Diabetes and Digestive and Kidney Diseases; 2012-. Bicalutamide. [Updated 2023 Mar 15]. Available from: <nowiki>https://www.ncbi.nlm.nih.gov/books/NBK547970/</nowiki></ref>

Spironolactone can impact kidney function. Renal (kidney) function and potassium should be tested after three and six months and then annually.<ref>UCSF Transgender Care. (June 17, 2016). Feminizing hormone therapy. Retrieved from <nowiki>https://transcare.ucsf.edu/guidelines/feminizing-hormone-therapy</nowiki></ref>

2023-11-12T03:43:28Z

Plants: me :P

I'm plants! One of the ppl writing on this site from the start, reach me at screamingplants on discord <3

Intro to HRT

2023-11-12T03:41:59Z

Plants: dht section linking to hair care

Intro to HRT

2023-11-12T03:36:44Z

Plants:

[[Category:Medical]]

'''Hormone replacement therapy''', or HRT, is a relatively common medical treatment used in many contexts. Despite what many may think, this is not a new or experimental practice, nor is it exclusive to transgender individuals. Hormone replacement therapy has been used for over half a century, starting its use in the 1960s and is widely popular in treating menopause in AFAB (assigned female at birth) patients.

In this page, we will cover how HRT can be used in AMAB (assigned male at birth) patients for gender affirmation, a type of HRT known as feminizing HRT. Feminizing HRT can have profound effects even on patients who are post-puberty, and has the potential to significantly improve quality of life for transfeminine individuals.

== What can HRT do for me? ==
Feminizing HRT seeks to lower a patient's testosterone level and raise their estradiol (AKA E2, the most biologically active estrogen) level, targeting levels similar to those of an average cisgender woman. Feminizing HRT can also involve many other medications, such as antiandrogens or progestogens. The end result is overall feminization of the body and its secondary sex characteristics. Changes may include healthier skin, female fat redistribution throughout the body, and breast growth.
{| class="wikitable sortable"
|+Below is a chart outlining most of the common changes from HRT:<ref>Mayo clinic: Feminizing hormone therapy

https://www.mayoclinic.org/tests-procedures/feminizing-hormone-therapy/about/pac-20385096</ref>
!Effect
!Permanence
!Expected Onset
!Maximum effect
|-
|Body fat redistribution
|Reversible
|1-2 months
|2-5 years
|-
|Decreased muscle mass
|Reversible
|1-2 months
|1-1.5 years
|-
|Decreased skin oiliness
|Reversible
|1-2 months
|1-1.5 years
|-
|Skin softening
|Reversible
|1-2 months
|1-2 years
|-
|Decreased libido
|Reversible
|days-weeks
|weeks-months
|-
|Less or no random erections
|Reversible
|days-weeks
|weeks-months
|-
|Erectile dysfunction*
|Reversible
|days-weeks
|weeks-months
|-
|Breast development
|Irreversible
|2-6 weeks
|2-6 years
|-
|Decreased testicular volume
|Variable
|1-3 months
|2-3 years
|-
|Decreased sperm production
|Variable
|2-6 weeks
|1-3 years
|-
|Decreased semen volume
|Veriable
|2-6 weeks
|1-3 years
|-
|Slowing of body & facial hair growth**
|Reversible
|1-3 months
|6 months-1 year
|-
|Voice changes***
|N/A
|none
|none
|-
|Reversal of male pattern hair loss****
|Reversible
|1-3 months
|1-2 years
|}
<nowiki>*:</nowiki> Most individuals do not experience erectile dysfunction.

**: HRT will slow down body and facial hair growth, but only laser or electrolysis can stop it entirely.

***: Feminizing HRT does not cause an effect on an individual's vocal folds.

****: Male pattern hair loss can be prevented with HRT, but reversal of hair loss is rare.

== So, what should I take, and how much? ==
Again, the goal of feminizing HRT is to bring your hormone levels (estradiol and testosterone in particular) from your current male range to that of a healthy cisgender woman. On top of this, there are some medications and other hormones we will cover, such as antiandrogens, progestogens, and other niche or specific medications, including hair loss treatments and more experimental methods for feminization.

Before we talk about specific medications, you need to have a basic understanding of the target hormone levels. For feminization to be effective, you should be within the levels of a premenopausal female:

'''100-200 pg/ml estradiol & <50 ng/dl testosterone.'''<ref>Wylie C Hembree, Peggy T Cohen-Kettenis, Louis Gooren, Sabine E Hannema, Walter J Meyer, M Hassan Murad, Stephen M Rosenthal, Joshua D Safer, Vin Tangpricha, Guy G T’Sjoen, Endocrine Treatment of Gender-Dysphoric/Gender-Incongruent Persons: An Endocrine Society Clinical Practice Guideline, ''The Journal of Clinical Endocrinology & Metabolism'', Volume 102, Issue 11, 1 November 2017, Pages 3869–3903, https://doi.org/10.1210/jc.2017-01658</ref>

Blood tests are the only effective way to measure these levels and are extremely important in minimizing the risks of HRT and maximizing its effectiveness. We will talk about how to manage being in a situation where you cannot access bloodwork. This is not impossible, but we highly recommend against it.

Now, onto the fun stuff: what to take, and how to dose it.

=== Injection monotherapy ===
The big one. Estradiol is the most biologically active estrogen and heavily contributes to feminization. On top of this, it contributes to the suppression of testosterone.

In estradiol-only HRT, also known as monotherapy, estradiol alone provides both feminization and suppression of testosterone into female ranges. This is possible because of estradiol's suppressing effect on testosterone by itself at high enough levels. Monotherapy removes or reduces certain potential risks and side effects that may be caused by antiandrogens used to help with testosterone suppression, but usually requires more estradiol and is much harder to achieve with specific routes of administration such as oral or transdermal.

Injections are an excellent example of an ROA suitable for monotherapy. It is rare for someone to be unable to achieve proper levels through injections. There are several common esters (chemical variations) used for injectable estradiol. These include valerate, cypionate, enanthate, and less commonly, undecylate.

Effective dosages vary wildly from person to person, though there is a reasonable range of starting dosage. If you have access to bloodwork, finding your dosage should be simple. Start with a sane dosage that works for most people, which we are about to cover now, and get a blood test just before the next injection at the "trough", or lowest level in your cycle, after a few weeks.

The most significant difference between the esters is their stability, or biological half-life. Estradiol valerate has a half-life of 4-5 days<ref>Düsterberg, B., & Nishino, Y. (1982). Pharmacokinetic and pharmacological features of oestradiol valerate. ''Maturitas'', ''4''(4), 315–324. <nowiki>https://doi.org/10.1016/0378-5122(82)90064-0</nowiki></ref>, cypionate 8-10 days<ref>Thurman, A., Kimble, T., Hall, P., Schwartz, J. L., & Archer, D. F. (2013). Medroxyprogesterone acetate and estradiol cypionate injectable suspension (Cyclofem) monthly contraceptive injection: steady-state pharmacokinetics. ''Contraception'', ''87''(6), 738–743. <nowiki>https://doi.org/10.1016/j.contraception.2012.11.010</nowiki></ref>, and enanthate 5-7 days<ref>Wiemeyer, J. C., Fernandez, M., Moguilevsky, J. A., & Sagasta, C. L. (1986). Pharmacokinetic studies of estradiol enantate in menopausic women. ''Arzneimittel-Forschung'', ''36''(11), 1674–1677.</ref>. However, research suggests that enanthate's peak comes later than cypionate, so it is generally best to treat them the same. Valerate is the most common pharma-grade ester in the US due to the cypionate shortage. Enanthate is the most common ester found in homebrew due to its incredible stability, and is prescribed in some countries.
{| class="wikitable"
|+This graph shows reasonable starting monotherapy injection dosages. It is possible that you may not need to adjust your regimen past this.
!Ester
!Elimination Half life
!Starting dosage
!Maximum time in between injections
|-
|Valerate
|4-5 days
|3.5mg/5 days
|7 days
|-
|Cypionate
|8-10 days
|4mg/7 days
|14 days
|-
|Enanthate
|5-7 days*
|4mg/7 days
|14 days
|}
These dosages must be adjusted based on bloodwork. It is possible to extend the time between your dosages from every 5 days with valerate up to every 7 or even every 2 weeks with cypionate or enanthate (however 10 days is a much safer bet).

[https://transfemscience.org/misc/injectable-e2-simulator/ This] lovely simulator can be helpful if you are trying to approximate your dosage. It averages the estradiol level of many people on injections into a graph based on several studies, but it is important to remember that it can be highly inaccurate on an individual basis and should not be used as a replacement for bloodwork. I was on a prescription dosage of 8mg estradiol valerate, with my trough (right before the next injection) over 650 pg/ml; the simulator's estimate is just below 200 pg/ml.

==== No access to bloodwork ====
'''Dosing your HRT without bloodwork may be unsafe and could lead to complications; it is highly recommended that you get bloodwork if at all possible.''' We cover how to get blood tests even without a doctor or prescription HRT [[HRT Bloodwork|here]], but if you ''absolutely cannot'' get bloodwork, all you can do is take a reasonable dosage and hope it works. Some things to look out for to guess if your dosage is working are breast growth, nipple sensitivity (sensitivity is rarely constant and can go away for long periods), and general changes HRT is supposed to have on a person.

==== How to do an injection ====
Injecting medication is a relatively straightforward process but easy to screw up. Learn how to do a proper injection [[Injections and Vial Care|here]].

=== Antiandrogens AKA testosterone blockers ===
Antiandrogens are medications that counteract the effects of androgens—male sex hormones such as testosterone or DHT. High-dose estradiol is an effective antiandrogen, but for some patients it may be very hard or impossible to get proper levels without an antiandrogen. Common antiandrogens for feminizing HRT are cyproterone acetate, spironolactone, and bicalutamide. These medications all work in different ways to suppress androgens.

Bicalutamide is an antiandrogen also used to treat prostate cancer by blocking the effects of testosterone, which in turn slows or stops the growth of cancerous cells.<ref>Mayo Clinic. (Nov. 01, 2023). Bicalutamide (Oral Route) - Side Effects. Retrieved from <nowiki>https://www.mayoclinic.org/drugs-supplements/bicalutamide-oral-route/side-effects/drg-20072486?p=1</nowiki></ref> This testosterone blocking effect is desirable in feminizing HRT, and as such, bicalutamide is a common choice of antiandrogen. It is commonly dosed at 25-50mg/day. Keep in mind when taking bicalutamide that it does not block testosterone production; testosterone blood levels may significantly increase.<ref>Cockshott I. D. (2004). Bicalutamide: clinical pharmacokinetics and metabolism. ''Clinical pharmacokinetics'', ''43''(13), 855–878. <nowiki>https://doi.org/10.2165/00003088-200443130-00003</nowiki></ref> Instead, it prevents testosterone from attaching to its receptors. Although you still have it in your blood, on a proper dosage you will not experience any androgenic effects.

Cyproterone acetate is a progestin with androgenic and progestogenic effects. Like bicalutamide, it is used in treating prostate cancer. It is not approved for use in the US but is a standard option in many other countries. Even without estrogens, cyproterone acetate reduces testosterone levels very efficiently.<ref>de Voogt H. J. (1992). The position of cyproterone acetate (CPA), a steroidal anti-androgen, in the treatment of prostate cancer. ''The Prostate. Supplement'', ''4'', 91–95. <nowiki>https://doi.org/10.1002/pros.2990210514</nowiki></ref> Cyproterone acetate is most effective in daily doses of 10mg, though most patients take 12.5mg because they split one 50mg pill into 4 pieces.

Spironolactone is one of the most common antiandrogens used in feminizing HRT. It is also a diuretic, and as a result may cause you to urinate more often. Spironolactone helps your body retain potassium, so you should be mindful when consuming potassium-rich foods while taking it.<ref>National Health Service. (6 July 2022). About Spironolactone. Retrieved from <nowiki>https://www.nhs.uk/medicines/spironolactone/about-spironolactone/</nowiki></ref> Spironolactone is a weaker antiandrogen compared to the two above, but is relatively safe and commonly prescribed in the US. It is typically dosed at 100-200mg daily.<ref name=":0">UCSF Transgender Care. (June 17, 2016). Feminizing hormone therapy. Retrieved from <nowiki>https://transcare.ucsf.edu/guidelines/feminizing-hormone-therapy</nowiki></ref>

Finasteride is an antiandrogen used in treating prostate inflammation and male pattern hair loss. It inhibits the conversion of testosterone into its more potent form, DHT (dihydrotestosterone).<ref>Zito, P. M., Bistas, K. G., & Syed, K. (2022). Finasteride. In ''StatPearls''. StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK513329/#:~:text=2%5D%5B3%5D-,Finasteride</ref> Finasteride does not lower testosterone significantly and should not be used as a replacement for the antiandrogens above, although it is an effective treatment for hair loss.<ref>Roehrborn, C. G., Lee, M., Meehan, A., Waldstreicher, J., & PLESS Study Group (2003). Effects of finasteride on serum testosterone and body mass index in men with benign prostatic hyperplasia. ''Urology'', ''62''(5), 894–899. <nowiki>https://doi.org/10.1016/s0090-4295(03)00661-7</nowiki></ref>

Before taking any antiandrogen, it is important to understand the safety profile and possible side effects. Be sure to monitor yourself for side effects when starting a new medication, and consult your doctor if you experience any serious issues.

=== Oral or sublingual estradiol ===
If you cannot handle performing injections, or are unable to source injectable estradiol, oral or sublingual estradiol tablets are another option. Usually taken with an antiandrogen, estradiol tablets are commonly composed of one of two common forms of estradiol: ethinyl estradiol or estradiol valerate. They are both very similar<ref>Haverinen, A., Kangasniemi, M., Luiro, K., Piltonen, T., Heikinheimo, O., & Tapanainen, J. S. (2021). Ethinyl estradiol vs estradiol valerate in combined oral contraceptives - Effect on glucose tolerance: A randomized, controlled clinical trial. ''Contraception'', ''103''(1), 53–59. <nowiki>https://doi.org/10.1016/j.contraception.2020.10.014</nowiki></ref>, with only minor differences in their half-lives. Ethinyl estradiol has a slightly longer half-life, and 1mg of estradiol valerate orally equals 0.76mg of ethinyl estradiol.<ref>"General information: Oestradiol valerate is equal to oestradiol 0.76 mg." ''ScienceDirect''. Retrieved from <nowiki>https://www.sciencedirect.com/topics/neuroscience/estradiol-valerate#:~:text=General%20information%3A%20Oestradiol%20valerate%20is,equal%20to%20oestradiol%200.76%20mg</nowiki></ref> Overall, you don't have to be super picky, and either one is likely to be just as effective.

While oral estradiol is administered simply by swallowing the tablet, sublingual ROA for estradiol is administered by placing the tablet under the tongue, where it is absorbed through the dense blood vessels found in the connective tissue. Relatively new but very promising, sublingual dosing achieves much higher levels when compared to oral dosing, and avoids passing through the liver, which is safer and reduces the risk of blood clots. However, it generally requires more frequent dosing, as it has a much shorter half-life.<ref>Doll, Elizabeth E et al. “SUN-LB9 Pharmacokinetics of Sublingual Versus Oral Estradiol in Transgender Women.” ''Journal of the Endocrine Society'' vol. 4,Suppl 1 SUN-LB9. 8 May. 2020, doi:10.1210/jendso/bvaa046.2237</ref>
{| class="wikitable"
|+This graph shows the dosage and frequency of oral estradiol.<ref>Boston University School of Medicine. (2013). ''Practical Guidelines for Transgender Hormone Treatment''. Retrieved from <nowiki>https://www.bumc.bu.edu/endo/clinics/transgender-medicine/guidelines/</nowiki></ref><ref name=":0" />
!Route of Administration
!Low/Initial Dosage
!Maximum Dosage
!Frequency
|-
|Oral
|2-4mg/day
|6-8mg/day
|1-2x daily
|-
|Sublingual
|1-2mg/day
|4-6mg/day
|2-3x daily
|}
'''The dosages above should be divided throughout the day according to the frequency, not multiplied.'''

=== Transdermal estradiol ===
Transdermal estradiol is another ROA for feminizing HRT. It is one of the safest methods, prescribed especially in older patients or those with risk factors such as tobacco use. Typically, a patch or gel is applied to the skin, but less commonly, a spray form of estradiol can be used. A common downside of transdermal estradiol is that many find it hard or infeasible to achieve cisgender hormone levels; antiandrogens are often used in conjunction if testosterone cannot be suppressed by the estradiol alone.

Patches can come in dosages up to 100mcg released per day; often, it takes wearing multiple 100mcg patches at a time to remain within target ranges or effectively block testosterone, with a typical dosage being 100-400mcg per day. Patches must be changed weekly or twice weekly.<ref name=":0" />

=== Dihydrotestosterone ===

=== Progesterone ===
The effects of progesterone in transgender women is very controversial. Some say, that there are no effects at all, while others believe that there are improvements in permanent fat distribution. There are many articles & studies about this topic, and we will not teach one specifically. You can go check the [[progesterone]] page for more information on individual theories.

The TLDR is: it is known that progesterone has anti-depressant effects, and allows water weight to move to more feminine areas. Due to a lack of studies, we cannot definitively say any more information.

=== Experimental HRT ===
There are a few somewhat common medications—pioglitazone or estrone, for example—that some people claim help with feminization. This section will probably take a while to write and research. For now, it is empty.

Intro to HRT

2023-11-12T03:33:58Z

Plants: ujpdaate links

[[Category:Medical]]

'''Hormone replacement therapy''', or HRT, is a relatively common medical treatment used in many contexts. Despite what many may think, this is not a new or experimental practice, nor is it exclusive to transgender individuals. Hormone replacement therapy has been used for over half a century, starting its use in the 1960s and is widely popular in treating menopause in AFAB (assigned female at birth) patients.

In this page, we will cover how HRT can be used in AMAB (assigned male at birth) patients for gender affirmation, a type of HRT known as feminizing HRT. Feminizing HRT can have profound effects even on patients who are post-puberty, and has the potential to significantly improve quality of life for transfeminine individuals.

== What can HRT do for me? ==
Feminizing HRT seeks to lower a patient's testosterone level and raise their estradiol (AKA E2, the most biologically active estrogen) level, targeting levels similar to those of an average cisgender woman. Feminizing HRT can also involve many other medications, such as antiandrogens or progestogens. The end result is overall feminization of the body and its secondary sex characteristics. Changes may include healthier skin, female fat redistribution throughout the body, and breast growth.
{| class="wikitable sortable"
|+Below is a chart outlining most of the common changes from HRT:<ref>Mayo clinic: Feminizing hormone therapy

https://www.mayoclinic.org/tests-procedures/feminizing-hormone-therapy/about/pac-20385096</ref>
!Effect
!Permanence
!Expected Onset
!Maximum effect
|-
|Body fat redistribution
|Reversible
|1-2 months
|2-5 years
|-
|Decreased muscle mass
|Reversible
|1-2 months
|1-1.5 years
|-
|Decreased skin oiliness
|Reversible
|1-2 months
|1-1.5 years
|-
|Skin softening
|Reversible
|1-2 months
|1-2 years
|-
|Decreased libido
|Reversible
|days-weeks
|weeks-months
|-
|Less or no random erections
|Reversible
|days-weeks
|weeks-months
|-
|Erectile dysfunction*
|Reversible
|days-weeks
|weeks-months
|-
|Breast development
|Irreversible
|2-6 weeks
|2-6 years
|-
|Decreased testicular volume
|Variable
|1-3 months
|2-3 years
|-
|Decreased sperm production
|Variable
|2-6 weeks
|1-3 years
|-
|Decreased semen volume
|Veriable
|2-6 weeks
|1-3 years
|-
|Slowing of body & facial hair growth**
|Reversible
|1-3 months
|6 months-1 year
|-
|Voice changes***
|N/A
|none
|none
|-
|Reversal of male pattern hair loss****
|Reversible
|1-3 months
|1-2 years
|}
<nowiki>*:</nowiki> Most individuals do not experience erectile dysfunction.

**: HRT will slow down body and facial hair growth, but only laser or electrolysis can stop it entirely.

***: Feminizing HRT does not cause an effect on an individual's vocal folds.

****: Male pattern hair loss can be prevented with HRT, but reversal of hair loss is rare.

== So, what should I take, and how much? ==
Again, the goal of feminizing HRT is to bring your hormone levels (estradiol and testosterone in particular) from your current male range to that of a healthy cisgender woman. On top of this, there are some medications and other hormones we will cover, such as antiandrogens, progestogens, and other niche or specific medications, including hair loss treatments and more experimental methods for feminization.

Before we talk about specific medications, you need to have a basic understanding of the target hormone levels. For feminization to be effective, you should be within the levels of a premenopausal female:

'''100-200 pg/ml estradiol & <50 ng/dl testosterone.'''<ref>Wylie C Hembree, Peggy T Cohen-Kettenis, Louis Gooren, Sabine E Hannema, Walter J Meyer, M Hassan Murad, Stephen M Rosenthal, Joshua D Safer, Vin Tangpricha, Guy G T’Sjoen, Endocrine Treatment of Gender-Dysphoric/Gender-Incongruent Persons: An Endocrine Society Clinical Practice Guideline, ''The Journal of Clinical Endocrinology & Metabolism'', Volume 102, Issue 11, 1 November 2017, Pages 3869–3903, https://doi.org/10.1210/jc.2017-01658</ref>

Blood tests are the only effective way to measure these levels and are extremely important in minimizing the risks of HRT and maximizing its effectiveness. We will talk about how to manage being in a situation where you cannot access bloodwork. This is not impossible, but we highly recommend against it.

Now, onto the fun stuff: what to take, and how to dose it.

=== Injection monotherapy ===
The big one. Estradiol is the most biologically active estrogen and heavily contributes to feminization. On top of this, it contributes to the suppression of testosterone.

In estradiol-only HRT, also known as monotherapy, estradiol alone provides both feminization and suppression of testosterone into female ranges. This is possible because of estradiol's suppressing effect on testosterone by itself at high enough levels. Monotherapy removes or reduces certain potential risks and side effects that may be caused by antiandrogens used to help with testosterone suppression, but usually requires more estradiol and is much harder to achieve with specific routes of administration such as oral or transdermal.

Injections are an excellent example of an ROA suitable for monotherapy. It is rare for someone to be unable to achieve proper levels through injections. There are several common esters (chemical variations) used for injectable estradiol. These include valerate, cypionate, enanthate, and less commonly, undecylate.

Effective dosages vary wildly from person to person, though there is a reasonable range of starting dosage. If you have access to bloodwork, finding your dosage should be simple. Start with a sane dosage that works for most people, which we are about to cover now, and get a blood test just before the next injection at the "trough", or lowest level in your cycle, after a few weeks.

The most significant difference between the esters is their stability, or biological half-life. Estradiol valerate has a half-life of 4-5 days<ref>Düsterberg, B., & Nishino, Y. (1982). Pharmacokinetic and pharmacological features of oestradiol valerate. ''Maturitas'', ''4''(4), 315–324. <nowiki>https://doi.org/10.1016/0378-5122(82)90064-0</nowiki></ref>, cypionate 8-10 days<ref>Thurman, A., Kimble, T., Hall, P., Schwartz, J. L., & Archer, D. F. (2013). Medroxyprogesterone acetate and estradiol cypionate injectable suspension (Cyclofem) monthly contraceptive injection: steady-state pharmacokinetics. ''Contraception'', ''87''(6), 738–743. <nowiki>https://doi.org/10.1016/j.contraception.2012.11.010</nowiki></ref>, and enanthate 5-7 days<ref>Wiemeyer, J. C., Fernandez, M., Moguilevsky, J. A., & Sagasta, C. L. (1986). Pharmacokinetic studies of estradiol enantate in menopausic women. ''Arzneimittel-Forschung'', ''36''(11), 1674–1677.</ref>. However, research suggests that enanthate's peak comes later than cypionate, so it is generally best to treat them the same. Valerate is the most common pharma-grade ester in the US due to the cypionate shortage. Enanthate is the most common ester found in homebrew due to its incredible stability, and is prescribed in some countries.
{| class="wikitable"
|+This graph shows reasonable starting monotherapy injection dosages. It is possible that you may not need to adjust your regimen past this.
!Ester
!Elimination Half life
!Starting dosage
!Maximum time in between injections
|-
|Valerate
|4-5 days
|3.5mg/5 days
|7 days
|-
|Cypionate
|8-10 days
|4mg/7 days
|14 days
|-
|Enanthate
|5-7 days*
|4mg/7 days
|14 days
|}
These dosages must be adjusted based on bloodwork. It is possible to extend the time between your dosages from every 5 days with valerate up to every 7 or even every 2 weeks with cypionate or enanthate (however 10 days is a much safer bet).

[https://transfemscience.org/misc/injectable-e2-simulator/ This] lovely simulator can be helpful if you are trying to approximate your dosage. It averages the estradiol level of many people on injections into a graph based on several studies, but it is important to remember that it can be highly inaccurate on an individual basis and should not be used as a replacement for bloodwork. I was on a prescription dosage of 8mg estradiol valerate, with my trough (right before the next injection) over 650 pg/ml; the simulator's estimate is just below 200 pg/ml.

==== No access to bloodwork ====
'''Dosing your HRT without bloodwork may be unsafe and could lead to complications; it is highly recommended that you get bloodwork if at all possible.''' We cover how to get blood tests even without a doctor or prescription HRT [[HRT Bloodwork|here]], but if you ''absolutely cannot'' get bloodwork, all you can do is take a reasonable dosage and hope it works. Some things to look out for to guess if your dosage is working are breast growth, nipple sensitivity (sensitivity is rarely constant and can go away for long periods), and general changes HRT is supposed to have on a person.

==== How to do an injection ====
Injecting medication is a relatively straightforward process but easy to screw up. Learn how to do a proper injection [[Injections and Vial Care|here]].

=== Antiandrogens AKA testosterone blockers ===
Antiandrogens are medications that counteract the effects of androgens—male sex hormones such as testosterone or DHT. High-dose estradiol is an effective antiandrogen, but for some patients it may be very hard or impossible to get proper levels without an antiandrogen. Common antiandrogens for feminizing HRT are cyproterone acetate, spironolactone, and bicalutamide. These medications all work in different ways to suppress androgens.

Bicalutamide is an antiandrogen also used to treat prostate cancer by blocking the effects of testosterone, which in turn slows or stops the growth of cancerous cells.<ref>Mayo Clinic. (Nov. 01, 2023). Bicalutamide (Oral Route) - Side Effects. Retrieved from <nowiki>https://www.mayoclinic.org/drugs-supplements/bicalutamide-oral-route/side-effects/drg-20072486?p=1</nowiki></ref> This testosterone blocking effect is desirable in feminizing HRT, and as such, bicalutamide is a common choice of antiandrogen. It is commonly dosed at 25-50mg/day. Keep in mind when taking bicalutamide that it does not block testosterone production; testosterone blood levels may significantly increase.<ref>Cockshott I. D. (2004). Bicalutamide: clinical pharmacokinetics and metabolism. ''Clinical pharmacokinetics'', ''43''(13), 855–878. <nowiki>https://doi.org/10.2165/00003088-200443130-00003</nowiki></ref> Instead, it prevents testosterone from attaching to its receptors. Although you still have it in your blood, on a proper dosage you will not experience any androgenic effects.

Cyproterone acetate is a progestin with androgenic and progestogenic effects. Like bicalutamide, it is used in treating prostate cancer. It is not approved for use in the US but is a standard option in many other countries. Even without estrogens, cyproterone acetate reduces testosterone levels very efficiently.<ref>de Voogt H. J. (1992). The position of cyproterone acetate (CPA), a steroidal anti-androgen, in the treatment of prostate cancer. ''The Prostate. Supplement'', ''4'', 91–95. <nowiki>https://doi.org/10.1002/pros.2990210514</nowiki></ref> Cyproterone acetate is most effective in daily doses of 10mg, though most patients take 12.5mg because they split one 50mg pill into 4 pieces.

Spironolactone is one of the most common antiandrogens used in feminizing HRT. It is also a diuretic, and as a result may cause you to urinate more often. Spironolactone helps your body retain potassium, so you should be mindful when consuming potassium-rich foods while taking it.<ref>National Health Service. (6 July 2022). About Spironolactone. Retrieved from <nowiki>https://www.nhs.uk/medicines/spironolactone/about-spironolactone/</nowiki></ref> Spironolactone is a weaker antiandrogen compared to the two above, but is relatively safe and commonly prescribed in the US. It is typically dosed at 100-200mg daily.<ref name=":0">UCSF Transgender Care. (June 17, 2016). Feminizing hormone therapy. Retrieved from <nowiki>https://transcare.ucsf.edu/guidelines/feminizing-hormone-therapy</nowiki></ref>

Finasteride is an antiandrogen used in treating prostate inflammation and male pattern hair loss. It inhibits the conversion of testosterone into its more potent form, DHT (dihydrotestosterone).<ref>Zito, P. M., Bistas, K. G., & Syed, K. (2022). Finasteride. In ''StatPearls''. StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK513329/#:~:text=2%5D%5B3%5D-,Finasteride</ref> Finasteride does not lower testosterone significantly and should not be used as a replacement for the antiandrogens above, although it is an effective treatment for hair loss.<ref>Roehrborn, C. G., Lee, M., Meehan, A., Waldstreicher, J., & PLESS Study Group (2003). Effects of finasteride on serum testosterone and body mass index in men with benign prostatic hyperplasia. ''Urology'', ''62''(5), 894–899. <nowiki>https://doi.org/10.1016/s0090-4295(03)00661-7</nowiki></ref>

Before taking any antiandrogen, it is important to understand the safety profile and possible side effects. Be sure to monitor yourself for side effects when starting a new medication, and consult your doctor if you experience any serious issues.

=== Oral or sublingual estradiol ===
If you cannot handle performing injections, or are unable to source injectable estradiol, oral or sublingual estradiol tablets are another option. Usually taken with an antiandrogen, estradiol tablets are commonly composed of one of two common forms of estradiol: ethinyl estradiol or estradiol valerate. They are both very similar<ref>Haverinen, A., Kangasniemi, M., Luiro, K., Piltonen, T., Heikinheimo, O., & Tapanainen, J. S. (2021). Ethinyl estradiol vs estradiol valerate in combined oral contraceptives - Effect on glucose tolerance: A randomized, controlled clinical trial. ''Contraception'', ''103''(1), 53–59. <nowiki>https://doi.org/10.1016/j.contraception.2020.10.014</nowiki></ref>, with only minor differences in their half-lives. Ethinyl estradiol has a slightly longer half-life, and 1mg of estradiol valerate orally equals 0.76mg of ethinyl estradiol.<ref>"General information: Oestradiol valerate is equal to oestradiol 0.76 mg." ''ScienceDirect''. Retrieved from <nowiki>https://www.sciencedirect.com/topics/neuroscience/estradiol-valerate#:~:text=General%20information%3A%20Oestradiol%20valerate%20is,equal%20to%20oestradiol%200.76%20mg</nowiki></ref> Overall, you don't have to be super picky, and either one is likely to be just as effective.

While oral estradiol is administered simply by swallowing the tablet, sublingual ROA for estradiol is administered by placing the tablet under the tongue, where it is absorbed through the dense blood vessels found in the connective tissue. Relatively new but very promising, sublingual dosing achieves much higher levels when compared to oral dosing, and avoids passing through the liver, which is safer and reduces the risk of blood clots. However, it generally requires more frequent dosing, as it has a much shorter half-life.<ref>Doll, Elizabeth E et al. “SUN-LB9 Pharmacokinetics of Sublingual Versus Oral Estradiol in Transgender Women.” ''Journal of the Endocrine Society'' vol. 4,Suppl 1 SUN-LB9. 8 May. 2020, doi:10.1210/jendso/bvaa046.2237</ref>
{| class="wikitable"
|+This graph shows the dosage and frequency of oral estradiol.<ref>Boston University School of Medicine. (2013). ''Practical Guidelines for Transgender Hormone Treatment''. Retrieved from <nowiki>https://www.bumc.bu.edu/endo/clinics/transgender-medicine/guidelines/</nowiki></ref><ref name=":0" />
!Route of Administration
!Low/Initial Dosage
!Maximum Dosage
!Frequency
|-
|Oral
|2-4mg/day
|6-8mg/day
|1-2x daily
|-
|Sublingual
|1-2mg/day
|4-6mg/day
|2-3x daily
|}
'''The dosages above should be divided throughout the day according to the frequency, not multiplied.'''

=== Transdermal estradiol ===
Transdermal estradiol is another ROA for feminizing HRT. It is one of the safest methods, prescribed especially in older patients or those with risk factors such as tobacco use. Typically, a patch or gel is applied to the skin, but less commonly, a spray form of estradiol can be used. A common downside of transdermal estradiol is that many find it hard or infeasible to achieve cisgender hormone levels; antiandrogens are often used in conjunction if testosterone cannot be suppressed by the estradiol alone.

Patches can come in dosages up to 100mcg released per day; often, it takes wearing multiple 100mcg patches at a time to remain within target ranges or effectively block testosterone, with a typical dosage being 100-400mcg per day. Patches must be changed weekly or twice weekly.<ref name=":0" />

=== Hair loss and DHT ===

=== Progesterone ===
The effects of progesterone in transgender women is very controversial. Some say, that there are no effects at all, while others believe that there are improvements in permanent fat distribution. There are many articles & studies about this topic, and we will not teach one specifically. You can go check the [[progesterone]] page for more information on individual theories.

The TLDR is: it is known that progesterone has anti-depressant effects, and allows water weight to move to more feminine areas. Due to a lack of studies, we cannot definitively say any more information.

=== Experimental HRT ===
There are a few somewhat common medications—pioglitazone or estrone, for example—that some people claim help with feminization. This section will probably take a while to write and research. For now, it is empty.

2023-11-08T06:28:19Z

Plants: finished antiandrogen section

Intro to HRT

2023-11-06T21:09:06Z

Plants:

HRT Bloodwork

2023-11-06T18:15:50Z

Plants: Created page with "<nowiki>Category:Medical</nowiki>"

<nowiki>[[Category:Medical]]</nowiki>

Intro to HRT

2023-11-06T18:13:58Z

Plants:

Intro to HRT

2023-11-06T18:10:31Z

Plants:

Intro to HRT

2023-11-06T17:52:10Z

Plants: changed one word

Category:Medical

2023-11-06T01:33:58Z

Plants: making medical transition page

= Medical Transition Pages =
Pages pertaining to medical transition resources.

If you are entirely new to medical transition, check out the [[Intro to Medical Transition]] page. If you need something specific, check out the links below.

Category:Medical

2023-11-06T01:24:38Z

Plants: testing

= Medical Transition Pages =
Pages pertaining to medical transition resources.

If you are entirely new to medical transition, [[Intro to HRT]] is a good place to start.

Main Page

2023-11-06T01:22:15Z

Plants: /* Before you read: */

= estrogen.fyi =
'''Trooning out since 2023.'''

This site serves to provide an open source of knowledge, guides, and resources on transition and self-care for transfeminine individuals.

{{Infobox}}
<div class='infobox'>
<table class="wikitable">
<tr><th><h3>Categories</h3></th></tr>
<tr><td><categorytree mode="pages">Medical</categorytree></td></tr>
<tr><td><categorytree mode="pages">Nonmedical</categorytree></td></tr>
</table>
</div>

== Before you read: ==

* Be sure to read the [[estrogen.fyi:General_disclaimer|disclaimer]].
* Remember that the wiki is a living document - nothing is final.
* To contribute, [[Special:CreateAccount|register for an account]].
* On some pages, changes must be approved by an editor before they are displayed by default.
* If you see a mistake, or want to improve a page, please submit an edit.
* Remember to cite your sources!

Main Page

2023-11-06T01:21:45Z

Plants: /* Before you read: */

= estrogen.fyi =
'''Trooning out since 2023.'''

This site serves to provide an open source of knowledge, guides, and resources on transition and self-care for transfeminine individuals.

{{Infobox}}
<div class='infobox'>
<table>
<tr><th><h3>Categories</h3></th></tr>
<tr><td><categorytree mode="pages">Medical</categorytree></td></tr>
<tr><td><categorytree mode="pages">Nonmedical</categorytree></td></tr>
</table>
</div>

== Before you read: ==

* Be sure to read the [[estrogen.fyi:General_disclaimer|disclaimer]].
* Remember that the wiki is a living document - nothing is final.
* To contribute, [[Special:CreateAccount|register for an account]].
* On some pages, changes must be approved by an editor before they are displayed by default.
* If you see a mistake, or want to improve a page, please submit an edit.
* Remember to cite your sources!

Main Page

2023-11-06T01:21:23Z

Plants: /* Before you read: */

Intro to HRT

2023-11-06T00:53:30Z

Plants:

Intro to HRT

2023-11-06T00:51:24Z

Plants: more headings

Intro to HRT

2023-11-06T00:48:16Z

Plants: monotherapy without bloodwork