Estrogen Routes Offered by FOLX

Whether someone is just starting estrogen hormone replacement therapy (HRT), or has been on it and is looking for a different route, FOLX has three options to choose from: oral/sublingual (pill), injections, or transdermal (patches). With each of those routes, there are different dosage levels that can result in slower or quicker physical changes, depending on personal preference. Of course, there are pros and cons to each method, and it’s really up to what feels best for someone’s body and mind. And don’t worry, routes can be changed.

Oral / Sublingual

A daily dose of estrogen in pill form, taken once or multiple times a day, usually dissolved under the tongue. It can take up to 30 minutes to dissolve.

Common pros & cons of oral / sublingual

PROS	CONS
Simple to take	Need to remember daily (or multiple times a day) dosage
Steady daily dose of estrogen (fewer highs and lows than injectable)	Passes into digestive system and into liver, with some minimal risks of liver toxicity
No needles!	Some people feel like changes they experience with oral route is not as fast as injectable route

Oral / sublingual estrogen dosage levels:

	Oral / Sublingual Estrogen
Low Dose	2mg daily
Average Start	4mg daily
Maximum Dose	8mg daily

Injections

A weekly, or every other week, self-administered injection of estrogen. There are two injection methods: Intramuscular (into the muscle) and subcutaneous (into the fatty tissue under the skin).

There are two different types of injectable estrogen: estradiol valerate and estradiol cypionate. The most common injectable estrogen used in the US is estradiol valerate, so that is the one we usually initiate for people wanting an injectable route. Both valerate and cypionate are prodrugs of estradiol and have similar affinity for estrogen receptors in the body, which essentially means they're equally effective.

There are a few key differences between estradiol valerate and estradiol cypionate to note: Valerate is suspended in castor oil, whereas cypionate is suspended in cottonseed oil. Valerate has a more predictable pattern of movement throughout the body (aka pharmacokinetics!), and cypionate has a longer active life (meaning it can be dosed every two weeks).

The dosing is not the same for each, so if switching from one to the other, dosage would also shift substantially. Lastly, cypionate is often only prescribed if valerate is unavailable, so just something to note!

Common pros & cons of injectable estrogen:

PROS	CONS
Being weekly or biweekly medication, it’s not something to remember every day	Not everyone feels comfortable giving themselves a shot!
Good option for people who have skin sensitivity to patches or don’t want to take a daily pill	Injections can be a bit uncomfortable or painful for some
Some people feel they notice faster changes using injectable estrogen than other methods	Some people don’t like the peaks and lows that they feel on a weekly or biweekly medication--they may start to feel lower energy/lack of estrogen as they get to the end of their week
	Some people worry about storing their injection supplies and keeping them safe from kids or other people who they don’t want to have access to needles.

Injectable estrogen dosage levels:

	Estradiol valerate	Estradiol cypionate
Low Dose	0.25mL (5mg of 20mg/mL vial) weekly or 0.15mL (6mg of 40mg/mL vial) weekly	0.25mL (1.25mg of 5mg/mL vial) weekly
Average Start	0.5mL (10mg of 20mg/mL vial) weekly or 0.25mL (10mg of 40mg/mL vial) weekly	0.5mL (2.5mg of 5mg/mL vial) weekly
Maximum Dose	1mL (20mg of 20mg/mL vial) weekly or 0.5mL (20mg of 40mg/mL vial) weekly	1mL (5mg of 5mg/mL vial) weekly

Transdermal Patch

A patch applied to skin every 3-4 days, allowing estrogen to be absorbed through the skin, and into the bloodstream.

Common pros & cons of transdermal patch estrogen

PROS	CONS
Easy to apply	Some people get skin reactions (rash and itching) to the patch adhesives
Less fluctuation in hormone levels (than injectable) since the patch evenly releases the medicine through the skin little by little throughout the week	The patch can fall off with excessive sweating
No needles!	Patch should be covered with plastic while swimming or taking a shower/bath to avoid it falling off
Considered “safest” route for people who may have increased risk for blood clots

Transdermal patch estrogen dosage levels:

	Transdermal patch
Low Dose	100mcg every 3-4 days
Average Start	200mcg every 3-4 days
Maximum Dose	400mcg every 3-4 days

Lastly, for some, estrogen HRT can include taking anti-androgens and/or progesterone in addition to one of the above routes. More on those methods here.

With the different routes and dosages of estrogen, 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 here, and feel free to reach out to us at thelibrary@folxhealth.com.