Reasons FOLX Might Not Be Able to Prescribe Estrogen

There aren’t a lot of hard stops on trans, nonbinary, or intersex folx taking estrogen, but there are a few.

February 4, 2021

While there aren’t many, there are some conditions and factors which means that FOLX is unable to safely recommend someone start estrogen and/or anti-androgens such as spironolactone.

For the most part, you will know if one of these conditions applies to you! If you’re not sure, or think they may, you can reach out to our member advocate team at to better understand.

FOLX is currently unable to prescribe estrogen if someone:

1. Has end stage liver disease

Most often, chronic liver failure is the result of cirrhosis, a condition in which scar tissue replaces healthy liver tissue until the liver cannot function adequately. The body processes estrogen through the liver, so if a person has severe liver disease, taking estrogen could put an additional, life-threatening burden on the liver.  

2. Has had an estrogen-sensitive cancer

Estrogen-sensitive cancers include breast/chest, pituitary, and prostate cancer. Estrogen can cause these types of tumors to grow or spread. Because of this effect, estrogen is not recommended for folx with these types of cancers.

3. Is cisgender

Currently, FOLX is only prescribing estrogen for gender affirming therapy, and are currently unable to prescribe estrogen to cisgender women (assigned female at birth with estrogen-producing parts,i.e. ovaries).

4. Is under 18

We honor transgender youth and fully support  their right to all gender affirming care. However, at this time, due to complicated regulatory and legal reasons, we are not able to offer care to anyone under the age of 18 years old.

There are additional considerations for those taking spironolactone.

Spironolactone (aka Spiro) decreases testosterone levels, which is why we use it as a feminizing treatment. It is also a diuretic (sometimes called “water pill” or “fluid pill”) that takes water and salt out of the body while keeping potassium inside. It also lowers blood pressure.

FOLX is currently unable to prescribe spironolactone if the individual:

1. Has hyperkalemia

This is a fancy word for high potassium levels in the blood. Since spiro can increase potassium levels, it could cause dangerously high amounts in folks who already have elevated potassium. Potassium is an electrolyte that regulates the heartbeat, so too much could cause serious abnormal heart beats (arrhythmia), and in severe causes, death. High potassium can also cause muscle weakness. This is also why we closely monitor labs for those on spiro.

2. Has Addison’s Disease

Addison’s Disease is a relatively rare condition where the adrenal glands do not make enough of the hormones cortisol and aldosterone. The adrenal glands make these hormones during times of stress, such as an injury, infection, or illness. When folx with Addison’s Disease experience stress, their adrenal glands are unable to produce these hormones. This can lead to a life threatening condition called  Addisonian Crisis. Folx may experience dangerously low blood pressure,  high levels of potassium, and low levels of sodium in the body.  Since spiro can also elevate potassium, decrease sodium, and lower blood pressure, it would make an Addisonian crisis even more dangerous.  

3. Has a kidney dysfunction

When kidneys are damaged due to a kidney dysfunction, they have a hard time getting rid of potassium. We check a test called creatinine for every member taking spiro. Creatinine gives us an idea of how well your kidneys work and whether there are signs of kidney damage due to spiro. For folx with kidney disease, the GFR test estimates how badly their kidneys are damaged.  If GFR is less than 30, the risk for deadly heart beats (arrhythmias) with spiro is too high, and that person would not be able to safely use spiro.  

Gratefully, this list is relatively short! Some people are able to safely receive treatment closer to home while having one of these conditions, but at present, FOLX is unable to (which isn’t to say we don’t want to!). Learn more about estrogen routes available here, spironolactone and other anti-androgen routes here, and get started here. And don't hesitate to reach out at

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