I am not a medical professional. The knowledge here stems from other transgender people, my own experiences, and personal research.
There is the option to pay a private healthcare provider to handle your transition. They will charge fees for services, but often have significantly shorter waiting times than NHS services. They should conduct assessments, organise relevant blood tests, issue prescriptions, and oversee the medical process. This may be attractive for those who don't wish to self-medicate.
There is a good comparison of private providers on the /r/transgenderUK subreddit here
Shared care refers to the collaboration between a private provider and a local GP to provide gender affirming services. This typically involves the private provider requesting blood tests and prescriptions, and the GP fulfilling them. It's ideal to have a shared care agreement, but GPs can refuse.
It's a sad reality that most (citation needed) transgender people in the UK have to DIY. NHS waiting times are criminally long, up to 7 years in some cases, with no sign it's going to get better. Furthermore, not everyone can afford the couple-hundred pounds a month required for private care. HRT can be considered life saving medication, due to the dysphoria caused by going through the wrong puberty. Thankfully, information and resources on self-medication are plentiful, with thanks to the supportive and active transgender community. It's a common misconception that self-medication is inherently harmful - you are likely taking the same medication as would be prescribed by a doctor; however you are shouldering the burden of your medical transition. Self medication should be considered as a last-resort option. But for most, it is the only option.
Transfeminine HRT consists of an estrogen, and often an anti-androgen. Estrogens are a group of hormones that are responsible for feminisation. You'll also it being spelled Oestrogen. Anti-Androgens suppress the production or function of androgens, such as Testosterone.
Estrogen causes feminisation, with effects including
Estrogen itself somewhat suppresses testosterone, but it's unlikely to suppress T alone to female levels with any method other than injectables. Estrogen Monotherapy refers to only taking estradiol for feminisation, without an anti-androgen. This is most viable with injections, and sometimes patches.
Pills are arguably the most popular form of DIY MtF HRT. They are relatively cheap, widely available, and very effective. You'll usually find them in 2mg/pill form. 4-8mg is a standard daily dose. You can either take them orally (swallowing) or sublingually - holding under the tongue. It's best to space out doses throughout the day. Pills are quite convenient as long as you remember to take them :) You should choose estradiol valerate or estradiol hemihydrate. A box of 84 pills is around £25-40.
Injectable estrogen are becoming increasingly popular in transfeminine people as they have a number of advantages over other estrogen routes. For example, they are usually cheaper than other methods and often provide higher estradiol levels, often enough for sufficient testosterone suppression, negating the need for an anti-androgen. They are administered via intramuscular or subcutaneous injection. Estradiol Valerate, Estradiol Cypionate, and Estradiol Enanthate are common injectable estradiol esters.
Injections are a very economical route - vials of injectable estradiol are typically 400mg, with a standard dose being 4mg. With 100 doses, and a frequency of one dose every 5-7 days, a single vial can last over a year.
More information on injections here
It's not recommended to DIY transdermal, as there are few sources, and they tend to be expensive. Transdermal estrogen is usually prescribed. There is frequently a shortage of transdermal forms in the UK. Transdermal (applied to the skin) comes in the form of gels, patches. Patches are usually switched out once to twice a week and give a set dose of estradiol every day. Gels come in packets or a pump that dispense a set amount of estrogen at a time. These are usually applied to the lower stomach, inner thighs, or buttocks.
Anti-Androgens refer to drugs that suppress the production or effects of androgens. Testosterone is an example of an androgen. The effects of anti-androgens include reduction of body hair, decrease in penile function, and decreased sperm volume.
https://transfemscience.org/articles/buserelin-inexpensive/ Buserelin is a GnRH-analogue type anti-androgen, these are very effective medications that suppress gonadal testosterone production and have almost no side effects. It can be found as a nasal spray, which is administered 2-3 times a day. GnRH antagonists are often used by the NHS and other large medical bodies in transfeminine care due to their effectiveness and lack of negative side effects, however are typically prohibitively expensive to self-medicate. Buserelin can be obtained relatively cheaply from online pharmacies and may be the preferred choice for transfeminine self-medication. It may be preferred to increase or double the dose for the first few weeks of starting Buserelin, as GnRH antagonists cause a flare in testosterone levels soon after starting. This takes about 2-4 weeks to return to normal.
https://transfemscience.org/articles/bica-adoption/ Bicalutamide is a very effective anti-androgen, even moreso when paired with estrogen. It doesn't suppress testosterone production, just the effect it can have on your body. People tend to report bica being better at preserving sexual function than other anti-androgens. It's strongly recommended to get regular liver function tests, every 3 months, if you take bicalutamide. A typical dose is 50-100mg a day
https://transfemscience.org/articles/cpa-dosage/ rYou'll usually find it in 50mg pills, but should only take at maximum 12.5mg (1/4 pill) daily. Ideally, you should start at a quarter pill a week, and increase the dose based off necessity of testosterone suppression. get a pill cutter - you can usually get one from any local pharmacy. This is to reduce the risks of long-term, high-dose side effects that have been observed. Low doses of CPA are maximally effective for testosterone suppression.
Progesterone is one of the other sex hormones produced for the menstrual cycle and is important in cis women's bodies. Progesterone can be considered as it may have some desirable feminisation effects in transitioning. Progesterone is not necessary for transfeminine medical transitioning, however it figures to reason that it is desirable for trans women if cis women also have progesterone.
There is little 'official' research into the effects of progesterone in transfeminine people, however common anecdotes include helping to 'round out' breast growth after the third tanner stage. It's also reported to increase libido, improve fat redistribution, and have inherent anti-androgenic effects.
There is a very informative document as to the effects of progesterone in transfeminine people here
Progesterone is most efficient when taken rectally. You gotta boof it. You'll find it in 100mg and 200mg gel capsules. Oral progesterone loses the majority of its efficacy.
All forms of estrogen will increase your risk of blood clots. Cis women carry this risk too. Higher the estradiol level, higher the risk. Oral estrogen carries a higher risk due to it being metabolised by the liver.
There are essentially no common side effects of bicalutamide. The main risk of bicalutamide is severe liver toxicity and lung toxicity. The chances of either happening are about 1/4000 in cis male prostate cancer patients. All published case reports of either severe liver or lung toxicity have been in cis men over 59 years of age. Risk of liver toxicity can be monitored if you get regular liver function tests every 3 months or so. After a year of normal liver function tests, you can stop taking them. The risks of bicalutamide after a period of time with no side effects are known to not be cumulative (you can confidently assume that your risk of lung/liver toxicity will not increase over time if it's already been a period of time without symptoms).
Cyproterone may cause side effects including increased prolactin levels and depression. Cyproterone Acetate has been observed to have a heightened risk of complications including meningioma (small benign brain tumours). These risks have primarily been observed in extremely high doses of 50-100mg/day, for extended periods of time. These risks are still present, but much lower in doses relevant to transfeminine people. Due to only small doses being necessary for testosterone suppression, it's generally considered safe for HRT purposes. https://transfemscience.org/articles/cpa-meningioma/
When on HRT, it is necessary to get blood tests to measure hormone (and other relevant tests) levels. Without them, you may not know if the dose you are on is right for you. It's useful to make a spreadsheet to keep track of blood test results. Data is cute.
It's beneficial, but not necessary, to get a blood test done before you start HRT. You should ideally get blood tests done at following marks:
Depending on HRT regimen, you should get different tests, but critically you need Estradiol (E2) and Testosterone measured every time.
Required every time: Estradiol, Testosterone
Useful to have: SHBG, Albumin, Prolactin, FBC, DHT
Required every time: Estradiol, Testosterone, Prolactin
Useful to have: B12, Liver Function Test, SHBG, Albumin, FBC, DHT
Required every time: Estradiol, Testosterone, Liver Function Test
Useful to have: SHBG, Albumin, Prolactin, FBC, DHT
Some doctors in the UK are known to be particularly unhelpful with trans healthcare, with anecdotes including outright refusal to help. Other doctors can be extremely helpful, receptive, and communicative. It really is a postcode lottery. There's an incomplete list of trans-friendly GPs put together by the community here: https://actionfortranshealth.org.uk/resources/for-trans-people/list-of-trans-friendly-gps/
If you are DIYing, it's important for your doctor or GP to be aware. You should tell them what medication you are taking and at what doses.
You can request blood tests from your GP or registered doctors surgery. Be sure to specifically request the required tests, and triple check they are being tested on the day. You'll need to mention:
A doctor may issue a prescription for HRT whilst you are waiting for an NHS GIC or private care. This is referred to as a 'bridging prescription'. This is ideal, but quite rare. You may try your luck with requesting this. I've had success by insisting the following:
For more information, including other guides and community resources, check out: