Why anti-androgens?
"Androgens" are hormones that regulate the development of sex characteristics. Those born with XY chromosomes and/or assigned male at birth often have high levels of androgens, while those born with XX chromosomes and/or assigned female at birth often have low levels of androgens (and high levels of estrogens). So anti-androgens work to block the effects of androgens such as testosterone. Because estradiol decreases the amount of testosterone produced by a body over time, some people are able to eventually stop using anti-androgens.
Why progesterone?
Fewer people choose to take Progesterone in addition to estrogen and anti-androgens, and most people who decide to try progesterone wait to start until about a year after they start estrogen. 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 to improve 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.
The use of testosterone blockers (in addition to estradiol) increases the likelihood that someone may experience decreased libido and/or erectile dysfunction, more on that here.
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.
Spironolactone (Anti-Androgen)
This is a daily pill that lowers testosterone levels and blocks testosterone from working. Spironolactone 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 & cons of spironolactone:
| PROS | CONS |
| Very effective at decreasing testosterone levels | As a diuretic, it can make someone have to pee frequently. This can lead to lower blood pressure, fatigue, and dehydration* |
| Relatively inexpensive | Can increase potassium levels in the blood, especially in those with kidney issues -- very rarely this can lead to dangerous changes in heartbeat. |
*Because Spironolactone is a diuretic, we recommend to start low and titrate slowly so that the body can get desensitized to this side effect as strongly. Some people jump right on a high dose and can get turned off by the side effects at that dosage!
Spironolactone dosage levels:
| Spironolactone | |
| Low Dose | 25mg daily |
| Average Start | 50mg daily |
| Maximum Dose | 400mg daily |
Finasteride & Dutasteride (Anti-Androgen)
These medications belong in a different class of androgen blockers. They block the conversion of testosterone into a stronger androgen, called DHT, 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 & cons of Finasteride & Dutasteride
| PROS | CONS |
| These are the only medications that can protect against genetic hair loss or balding | Not a full testosterone blocker, so the effects may not be as strong as with Spironolactone |
| Can be used in addition to Spironolactone if already at a high dose and need additional testosterone blocking | Often not covered by insurance |
| Can be a good option as a single medication for people who are looking to achieve only partial changes |
Finasteride & Dutasteride dosage levels:
| Finasteride | Dutasteride | |
| Low Dose | 1mg daily | 0.5mg daily |
| Average Start | 2.5mg daily | |
| Maximum Dose | 5mg daily |
Progesterone
FOLX offers Prometrium (micronized progesterone) for progesterone, a pill taken daily.
Progesterone dosage levels:
| Prometrium | |
| Starting Dose | 100mg daily |
| Average Dose | |
| Maximum Dose | 200mg 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 best for each individual body. For those ready to get started with FOLX for Estrogen, the process begins here. 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, read up on estrogen HRT here, and feel free to reach out to us at support@folxhealth.com.
