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| Bend over. |
Month 2: Given continued health, add anti-androgens: 100mg/day spironolactone plus fractional tablet (0.05-0.5mg)/day finasteride. If spironolactone is not available but cyproterone acetate is, employ 10mg/day cyproterone acetate. (Actually, a GnRH agonist is much more effective to reduce androgens and their effects, but it is also prohibitively expensive.)
Month 3: Given continued health, add progesterone or progestin: 200mg/day oral progesterone, or monthly injections of 125mg hydroxyprogesterone caproate, or 10mg/day sl-oral dydrogesterone.
Month 4: If breasts are not yet developing (budding), given continued health, increase estrogen dosage to the following: twice-monthly injections of 40mg estradiol valerate, or 4mg estradiol cypionate. Also, take 1-3mg/day sl-oral estradiol or 2-4mg/day sl-oral estradiol valerate or a single 0.075-0.1mg transdermal estradiol film changed weekly. If these injectables are not available, employ 2 0.1mg transdermal estradiol films changed twice weekly, offset (e.g., change the first film Monday morning and Thursday evening; change the second film Wednesday morning and Saturday evening), or 6mg/day sl-oral estradiol, or 9mg/day sl-oral estradiol valerate. Note that injectables or films are much preferable to administration of the entire estrogen therapy orally. Do not increase estrogen at this time if there is currently progress in breast development.
Month 5: If androgens are still a problem (continued scalp hair recession, frequent spontaneous erections, etc.), given continued health, increase antiandrogens to the following: 200mg/day spironolactone plus larger fractional tablet (0.1-1mg)/day finasteride. If spironolactone is not available but cyproterone acetate is, employ 25mg/day cyproterone acetate.
Month 6: If breasts are not yet developing, given continued health, increase progesterone/progestin dosage to the following: 300-400mg/day oral progesterone, or twice-monthly injections of 125mg hydroxyprogesterone caproate, or 20mg/day sl-oral dydrogesterone.
Month 7: If breasts are not yet developing, given continued health, increase estrogen dosage to the following: twice-monthly injections of 60mg estradiol valerate, or 6mg of estradiol cypionate. Also, take 2-4mg/day sl-oral estradiol or 3-6mg/day sl-oral estradiol valerate or a single 0.1mg transdermal estradiol film changed every 4-7 days. If these injectables are not available, employ 3-4 0.1mg transdermal estradiol films each changed twice weekly, offset, or 8mg/day sl-oral estradiol, or 12mg/day sl-oral estradiol valerate (do not attempt to run up the oral doses in the same ramp as other deliveries; if this dose of orals is not doing the job, it is quite unlikely that adding more will help). Do not increase estrogen at this time if there is currently progress in breast development.
Month 8: If androgens are still a problem, given continued health, increase antiandrogens to the following: 300-400mg/day spironolactone plus larger fractional tablet (~0.25-2.5mg)/day finasteride. If spironolactone is not available but cyproterone acetate is, employ 50mg/day cyproterone acetate.
Given continued health, keep on with this regimen, or adjust as appropriate (titrating downwards, preferrably) for up to 3 years. After that, if one cannot--or does not wish to--obtain orchidectomy or full srs, it is still best to reduce oral estrogen, progestins, and cyproterone acetate after 3 years. Estradiol via injection and film is relatively safe, as is progesterone.
Srs minus 1 month: Stop progestins and sl-oral estrogen.
At orchidectomy or srs: Stop all estrogens, antiandrogens and progesterone. Beginning 1-2 weeks after, employ a single 0.075mg transdermal estradiol film changed weekly, or 2mg/day sl-oral estradiol, or 3mg/day sl-oral estradiol valerate, or an injection of 15mg estradiol valerate or 1.5mg estradiol cypionate once per 3 weeks. Keep this simple regimen for 3 months to allow time for adjusting to the abrupt reduction of endogenous androgens (unless one was on an effective GnRH agonist course, in which case gonadal androgen production was already shut down).
3 months after testes are removed: If menopausal symptoms are noted just before the injection, either increase the frequency of the shots to twice monthly (reducing the dose of each shot, respectively, to 10mg ev or 1mg ec), or add 1mg/day sl-oral estradiol or 2mg/day sl-oral estradiol valerate. If menopausal symptoms are continual, increase the dosage ~50% each month until the symptoms disappear, or at least are tolerable. An alternative, and perhaps safer way to deal with menopausal symptoms and/or low energy, is to add progesterone or a progestin: 100mg/day progesterone or 5mg/day sl-oral dydrogesterone.
If one has not attained significant feminization (still using breast growth as the most obvious measuring device, but keeping in mind the modest expectations which are required in this matter), and no progress whatsoever is noted after the testes have been removed for 6 months, try aggressive cycling for 3 months timed as outlined in the philosophy section, with peaks of 30mg injectable estradiol valerate or 3mg injectable estradiol cypionate, plus peaks of 125mg hydroxyprogesterone caproate or 200-300mg/day progesterone or 10mg/day dydrogesterone. If some development is achieved by month 3, then continue for a total of 6 months. If no development is achieved by month 3, then revert to a very conservative regimen for 3 months, then try again with double the peak dosages. If menopausal symptoms are unbearable in the several days before each estrogen shot, add a constant 1-3mg/day sl-oral estradiol or 2-4mg/day sl-oral estradiol or a single 0.5mg estradiol transdermal film changed weekly. The usual pattern is for there to be some development, then it trails off after some months. Repeat for up to 6 months at a time with 3 or more months rest (reverting to a very conservative regimen) between. Aggressive cycling is meant to facilitate several bursts in development, and is not appropriate for lifetime maintenance or pre-ops.
If scalp hair continues to recess, try a fractional tablet (0.05-0.5mg)/day finasteride for several months. If it stalls the recession, continue taking it for a year, then stop for a few months to see what happens. If recession resumes, then restart the finasteride and consider yourself a lifetime customer.
For lifetime maintenance, use the lowest dosages consistent with skeletal and mental health. Lifetime cycling feels right for some people, and is safe as long as it is done with conservative dosages, for example, with timing as described in the philosophy section, and the following peak dosages: 0.075mg-0.1 transdermal estradiol film, or 2-4mg/day sl-oral estradiol, or 3-6mg/day sl-oral estradiol valerate, or 10-20mg injectable estradiol valerate or 1-2mg injectible estradiol cypionate. If progesterone or a progestin is included, peak at 200-400mg/day oral progesterone, or 125mg injectable hydroxyprogesterone caproate, or 10mg/day sl-oral dydrogesterone. Only exceed these peaks on a long-term basis if absolutely necessary. Be especially wary of oral estrogens and progestins. Between peaks, if using orals or films, run the troughs down to as close to zero as you can without causing significant emotional or physical discomfort. The effects at post-op levels are subtle; observe yourself closely to determine what is the most healthy for your individual case.
If you are post-op more than a couple of years, and find yourself devoid of energy, stamina, motivation, and libido, even when you are on what seems to be the best possible lifetime estrogen/progesterone regimen, consider this: after ruling out purely psychological issues, you might need a subtle boost of testosterone. As perverse as that might sound after spending years fighting the evil T, some post-ops find that residual endogenous androgen production (mainly from the adrenal glands) is just not quite enough to sustain a high level of activity. Some genetic women have the same problem. If this bothers you enough to do something about it, take a tiny daily dose of testosterone. Unfortunately, it can be difficult to find low-dosage preparations, especially to be funded by your national or commercial health plan. 0.25-1.0mg/day of oral fluoxytestosterone or 0.5-2mg/day oral methyltestosterone can do the trick, but tablets are especially difficult to obtain because of laws meant to prevent the abuse of anabolic steroids. Some people cover at least 3/4 of the active surface of a testosterone transdermal film before wearing it (rotating the barrier as needed), or else open the film and apply a small amount of the gel each day. It is also possible to have a compounding pharmacy add 5-10mg of micronized testosterone to a custom estrogen and/or progesterone capsule or pessary. If you prefer to cycle, take into account that endogenous androgens in genetic women generally peak just before ovulation and again just before menstruation--that is, on roughly days 13 and 27 of the cycle described in the philosophy section of this document. Testosterone is powerful and tricky stuff--consult your doctor and pharmacy about it.
