Getting the correct dosage is important to get the results you want! Getting regular blood tests is important but this is not always viable for everyone, this page’s dosages are some general dosage recommendations on getting an appropriate E level.
Pill dosage
Doctors tend to prescribed sub-optimal dosages for feminising HRT, especially for pills. It is crucial to remain informed ane enure that you advocate for what a dosage which attains the levels you require. See Underdosing for more information on underdosing.
Commonly for pills a 6mg daily dose is a good target, I’ve done 2mg pill 3 times a day (morning, lunch and dinner), others do 3mg twice a day.
Some sources recommend a lower dose if you start taking the pills via sublingual administration at 3mg a day, 1mg pills 3 times a day.
I personally took 6mg a day sublingual, if you have access to blood tests then please keep aiming for your preferred target range (See MTF Target Ranges) and adjust as needed.
There are two formulations of estrogen in pill form, estradiol valerate (Progynova) and estradiol hemihydrate (Zumenon), in practical terms however they are entirely interchangeable. Feel free to try out both formulations and compare your results with blood tests to see if as an individual you have a better result with one over the other, but this process isn’t necessary by any means.
Gel dosage
Gel-based Estradiol comes in 3 main modalities: (1) in a pump bottle, where each pump delivers a single dose, (2) individually dosed sachets or (3) a tube you manually dose with. Of the three, manual dosing is the hardest to accurately dose, and should be avoied where possible. Pump based estradiol gel is generally the most economical, and also the most commonly prescribed.
The recommended dosing for transdermal Estradiol gel is 4-6mg daily, which raises E2 levels above target for most individuals. While it is theoretically possible to perform monotherapy with gels, it is highly recommended to NOT do that as it is much easier to miss your application window and allow T levels to start rising again as the half life of gels is quite short. Additionally, serum E2 levels through transdermal Estradiol are highly variable among individuals based off multiple factors affecting transdermal absorption, namely site of administration, thickness of applied gel, other skin pathology.
Addition considerations for individuals considering gel-based HRT include (1) ability to cope with sensation (2) applying 1-2 doses daily etc…
Notes:
Underdosing
In many standards of care that doctors follow it states to start at a much lower dose of estrogen to “ease into” the process such as:
- WPATH SoC8 has the recommendation of 2.0-6.0 mg/day for oral estrogen
- AutsPATH has the recommendation of 2-8mg daily
- New Zealand’s PATHA recommends starting at 1-2mg daily and only changing up the dosage incrementally every 3 months to 4-6mg maintenance
The big issue with the recommended low end of the dosages is when prescribed with T blockers you are likely to have neither sex hormone at a healthy level. When both hormones are low you can be risking accelerated bone loss, fatigue, low mood, hot flushes, low libido, joint aches, brain fog, and poor sleep. Not even mentioning the lower than desired feminizing effects.
PATHA is exceptionally egregious here with the 1mg recommendation which is lower than WPATH, AusPATH and the Endocrine Society’s recommendations for a minimal dose. 1mg single oral dose provides a peak at only ~35 pg/mL of serum estradiol1 which compared to MTF Target Ranges is far bellow a desired level.
Footnotes
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According to “Pharmacokinetics of Sublingual Versus Oral Estradiol in Transgender Women” - https://doi.org/10.1016/j.eprac.2021.11.081 ↩