This article was updated by the FOLX Editorial Team on 9/21/23.
"Androgens" are hormones that regulate the development of sex characteristics. People born with XY chromosomes and/or assigned male at birth (AMAB) often have high levels of androgens. Folks born with XX chromosomes and/or assigned female at birth (AFAB) often have low levels of androgens (and high levels of estrogen). So anti-androgens work to block the effects of androgens such as testosterone. Because estradiol decreases the amount of testosterone produced by your body over time, some people are able to eventually stop using anti-androgens.
Fewer folks choose to take progesterone in addition to estrogen and anti-androgens, and most people who decide to try progesterone wait until about a year after starting estrogen HRT. Unfortunately, there is not a lot known about progesterones and how they affect overall changes in people undergoing estrogen HRT because it has not been studied well. What is known is inconclusive: some studies suggest that progesterone does not help with breast development or body fat redistribution, and it may increase the risks of estrogen. Some clinicians have found that progesterone may be helpful in improving breast or areolar development only if you don’t achieve full breast development with estrogen. There may be some testosterone-blocking effect of progesterone. Some people also report improvement in mood and libido, while others report a worsening. Overall, the response to progesterone is often very individualized, with some noticing benefits and others not noticing any benefits or noticing only negative effects. If unclear about which progesterone to take, we recommend Prometrium since it may be safer than other forms of progesterone.
Use of testosterone blockers (in addition to estradiol) increases the likelihood that someone may experience decreased libido and/or erectile dysfunction.
FOLX offers two main categories of anti-androgens, and two types of progesterone, each of which can be taken at different dosage levels, based on personal preference.
Prometrium (micronized progesterone) or Provera (medroxyprogesterone) are the two options for progesterone, and both are pills taken daily.
Progesterone dosage levels
- Starting dose: 100mg daily.
- Average dose: 100mg daily.
- Maximum dose: 200mg daily.
Spironolactone is a daily pill that lowers testosterone levels and blocks testosterone from working. Spiron is the most common type of anti-androgen used for HRT. It is important to have regular lab work when taking this medication.
Common pros and cons of spironolactone
- Very effective at decreasing testosterone levels.
- Relatively inexpensive.
- A diuretic, so it can make you have to pee more frequently.
- Diuretics can lead to lower blood pressure, fatigue, and dehydration.
- Can increase potassium levels in the blood, especially with kidney issues--very rarely this can lead to dangerous changes in heart rhythm.
Because spironolactone is a diuretic, we recommend starting low and titrating slowly so your body can get used to this side effect slowly. Some folks jump right on a high dose and can get turned off by the side effects at that dosage!
Spironolactone dosage levels
- Low dose: 25mg daily.
- Average starting dose: 50mg daily.
- Maximum dose: 400mg daily.
Finasteride and dutasteride (anti-androgen)
Finasteride and dutasteride belong to a different class of androgen blockers. They block the conversion of testosterone into a stronger androgen, called DHT (dihydrotestosterone) but testosterone levels still go up a little bit with these medications. These medications may also help with balding and help soften body hair. Between the two, dutasteride may have a slightly stronger effect, but it can also be more expensive.
Common pros and cons of finasteride and dutasteride
- These are the only medications that can protect against genetic hair loss or balding.
- Can be used in addition to spironolactone if already at a high dose and need additional testosterone-blocking.
- Can be a good option as a single medication for people who are looking to achieve only partial changes.
- Not a full testosterone blocker, so the effects may not be as strong as with spironolactone.
- Often not covered by insurance.
Finasteride and dutasteride dosage levels
- Low Dose: 1mg daily.
- Average starting dose: 2.5mg daily.
- Maximum dose: 5mg daily.
- 0.5mg daily.
With the different routes and dosages of estrogen in combination with anti-androgens or progesterone, there are a lot of ways to find the one that fits your body best. If you're ready to get started with FOLX for estrogen, sign up for a membership to schedule a time with one of our LGBTQIA-expert clinicians. For existing FOLX members with questions about dosage, don't hesitate to schedule time with a clinician. And for those who’ve just got some more questions, learn more about gender-affirming estrogen HRT in the FOLX Library.
FOLX Health is the first digital healthcare company designed by and for the LGBTQIA+ community. Our services include virtual primary care, gender-affirming hormone therapy including estrogen and testosterone (HRT), mental health care, sexual and reproductive health care, preventive care, and fertility consultations. FOLX memberships give you access to LGBTQIA+ expert clinicians, peer support, thousands of LGBTQIA+ resources, and more. Whether you’re lesbian, gay, bisexual, transgender, queer, gender non-conforming, or nonbinary, you can find LGBTQIA+-specialized health care that helps you meet your wellness goals. FOLX Health is health care that's queer all year. Get all the benefits of becoming a FOLX member and sign up today!