Citations

Risk Reduction for DIY Gender-Affirming Hormone Therapy

(last updated 5/21/2025)

The citations on this page are mostly from academic sources. We have provided links to these, but many of the articles we cite may be pay-walled. Your academic or public library may have direct access to these articles, or may be able to obtain them through Inter Library Loan. Finally, the corresponding authors of academic papers are often willing to respond favorably to a polite email request for a copy of their published article.


Citation topics

1. Finding the right dose, and problems with high doses

2. Blood clot risks from smoking tobacco and vaping nicotine

3. Blood clots and combining smoking tobacco or vaping nicotine with gender-affirming estrogen

4. Blood clots and gender-affirming estrogen

5. Signs of blood clotting and stroke

6. 17β-estradiol (especially as a patch) and lowest risk for blood clots

7. Ethinyl estradiol (oral contraceptives) and higher risk for blood clots

8. Injectable estradiol higher in blood levels shortly after injection

9. Estrogen function

10. Spironolactone effects

11. Eplerenone effects

12. Finasteride effects

13. Bicalutamide effects

14. Progesterone effects

15. Micronized progesterone

16. ‘Progesterone’ in birth control pills is not actually progesterone, and comes with higher risk of blood clots

17. Feminizing hormones and fertility & pregnancy prevention

18. Testosterone effects

19. Blood thickening and gender-affirming testosterone

20. Cholesterol and gender-affirming testosterone

21. Masculinizing hormones and fertility & pregnancy prevention


1. Finding the right dose, and problems with high doses

Canonico, M., et al. (2008). Hormone replacement therapy and risk of venous thromboembolism in postmenopausal women: systematic review and meta-analysis. British Medical Journal, 336(7655), 1227–1231.

de Bastos, M., et al. (2014). Combined oral contraceptives: venous thrombosis. Cochrane Database of Systematic Reviews.

Misakian, A. L., at al. (2025), Injectable Estradiol Use in Transgender and Gender-Diverse Individuals throughout the United States. The Journal of Clinical Endocrinology & Metabolism, Online first.

Testosterone Side Effects: Common, Severe, Long Term. (2020). Drugs.com. Accessed: April 11, 2021.


2. Blood clot risks from smoking tobacco and vaping nicotine

Ageno, W., et al. (2008). Cardiovascular Risk Factors and Venous Thromboembolism. Circulation, 117(1), 93–102.

Burns, D. M. (2003). Epidemiology of smoking-induced cardiovascular disease. Progress in Cardiovascular Diseases, 46(1), 11–29.

Cheng, Y.-J., et al. (2013). Current and former smoking and risk for venous thromboembolism: A systematic review and meta-analysis. PLoS Medicine, 10(9).

Holst, A. G., Jensen, G., & Prescott, E. (2010). Risk Factors for Venous Thromboembolism. Circulation, 121(17), 1896–1903.

Hom, S., et al. (2016). Platelet activation, adhesion, inflammation, and aggregation potential are altered in the presence of electronic cigarette extracts of variable nicotine concentrations. Platelets, 27(7), 694–702.

Kannel, W. B. (2005). Overview of hemostatic factors involved in atherosclerotic cardiovascular disease. Lipids, 40(12), 1215–1220.

Qasim, H., et al. (2017). Impact of Electronic Cigarettes on the Cardiovascular System. Journal of the American Heart Association, 6(9), 1–14.

Ramirez, J. E., et al. (2020). The JUUL E-Cigarette Elevates the Risk of Thrombosis and Potentiates Platelet Activation. Journal of Cardiovascular Pharmacology and Therapeutics, 25(6), 578–586.


3. Blood clots and combining smoking tobacco or vaping nicotine with gender-affirming estrogen

Coleman, E., et al. (2012). Standards of Care for the Health of Transsexual, Transgender, and Gender-Nonconforming People, Version 7. International Journal of Transgenderism, 13(4), 165–232.

Iwamoto, S. J., et al. (2019). Health considerations for transgender women and remaining unknowns: a narrative review. Therapeutic Advances in Endocrinology and Metabolism, 10, 1–27.


4. Blood clots and gender-affirming estrogen

Canonico, M., et al. (2008). Hormone replacement therapy and risk of venous thromboembolism in postmenopausal women: systematic review and meta-analysis. British Medical Journal, 336(7655), 1227–1231.

Irwig, M. S. (2018). Cardiovascular health in transgender people. Reviews in Endocrine and Metabolic Disorders, 19(3), 243–251.

Iwamoto, S. J., et al. (2019). Health considerations for transgender women and remaining unknowns: a narrative review. Therapeutic Advances in Endocrinology and Metabolism, 10, 1–27.

Tangpricha, V., & Safer, J. D. (2019). Transgender women: Evaluation and management. (Requires subscription). uptodate.com. Accessed: March 8, 2021.

Van Kesteren, P. J., et al. (1997). Mortality and morbidity in transsexual subjects treated with cross-sex hormones. Clinical Endocrinology, 47(3), 337–343.

Weinand, J. D., & Safer, J. D. (2015). Hormone therapy in transgender adults is safe with provider supervision; A review of hormone therapy sequelae for transgender individuals. Journal of Clinical & Translational Endocrinology, 2(2), 55–60.


5. Signs of blood clotting and stroke

American Heart Association. (2017). Symptoms and Diagnosis of Venous Thromboembolism (VTE). heart.org. Accessed: April 12, 2021.

American Stroke Association. (2021). Stroke Symptoms. stroke.org. Accessed: April 12, 2021

National Blood Clot Alliance. (2020). Signs and Symptoms of Blood Clots. stoptheclot.org. Accessed: April 12, 2021


6. 17β-estradiol (especially as a patch) and lowest risk for blood clots

Asscheman, H., et al. (2013). Venous thrombo-embolism as a complication of cross-sex hormone treatment of male-to-female transsexual subjects: a review. Andrologia, 46(7), 791–795.

Canonico, M., et al. (2008). Hormone replacement therapy and risk of venous thromboembolism in postmenopausal women: systematic review and meta-analysis. British Medical Journal, 336(7655), 1227–1231.

Goldstein, Z., et al. (2019). Managing the risk of venous thromboembolism in transgender adults undergoing hormone therapy. Journal of Blood Medicine, 10, 209–216.

Irwig, M. S. (2018). Cardiovascular health in transgender people. Reviews in Endocrine and Metabolic Disorders, 19(3), 243–251.

Ott, J., et al. (2010). Incidence of thrombophilia and venous thrombosis in transsexuals under cross-sex hormone therapy. Fertility and Sterility, 93(4), 1267–1272.

Renoux, C., et al. (2010). Transdermal and oral hormone replacement therapy and the risk of stroke: a nested case-control study. British Medical Journal, 340(jun03 4), c2519–c2519.

Samsioe, G. (2004). Transdermal hormone therapy: gels and patches. Climacteric, 7(4), 347–356.

Wilson, R., et al. (2009). Effects of high dose oestrogen therapy on circulating inflammatory markers. Maturitas, 62(3), 281–286.


7. Ethinyl estradiol (oral contraceptives) and higher risk for blood clots

Asscheman, H., et al. (2011). A long-term follow-up study of mortality in transsexuals receiving treatment with cross-sex hormones. European Journal of Endocrinology, 164(4), 635–642.

Asscheman, H., et al. (2013). Venous thrombo-embolism as a complication of cross-sex hormone treatment of male-to-female transsexual subjects: a review. Andrologia, 46(7), 791–795.

de Bastos, M., et al. (2014). Combined oral contraceptives: venous thrombosis. Cochrane Database of Systematic Reviews, (3).

Goldstein, Z., et al. (2019). Managing the risk of venous thromboembolism in transgender adults undergoing hormone therapy. Journal of Blood Medicine, 10, 209–216.

Hembree, W. C., et al. (2017). Endocrine Treatment of Gender-Dysphoric/Gender-Incongruent Persons: An Endocrine Society* Clinical Practice Guideline. The Journal of Clinical Endocrinology & Metabolism, 102(11), 3869–3903.

Hugon-Rodin, J., Gompel, A., & Plu-Bureau, G. (2014). Epidemiology of hormonal contraceptives-related venous thromboembolism. European Journal of Endocrinology, 171(6), R221–R230.

Toorians, A. W., et al. (2003). Venous Thrombosis and Changes of Hemostatic Variables during Cross-Sex Hormone Treatment in Transsexual People. The Journal of Clinical Endocrinology & Metabolism, 88(12), 5723–5729.

Unger, C. A. (2016). Hormone therapy for transgender patients. Translational Andrology and Urology, 5(6), 877–884.

Weiss, G. (1999). Risk of venous thromboembolism with third-generation oral contraceptives: A review. American Journal of Obstetrics and Gynecology, 180(2), S295–S301.


8. Injectable estradiol higher in blood levels shortly after injection

Deutsch, M. (2020, July). Information on Estrogen Hormone Therapy. UCSF Transgender Care & Treatments and Guidelines. Accessed: April 12, 2021.

Irwig, M. S. (2018). Cardiovascular health in transgender people. Reviews in Endocrine and Metabolic Disorders, 19(3), 243–251.


9. Estrogen function

Deutsch, M. (2020, July). Information on Estrogen Hormone Therapy. UCSF Transgender Care & Treatments and Guidelines. Accessed: April 12, 2021


10. Spironolactone effects

American Society of Health-System Pharmacists. (2018). Spironolactone: Drug Information. MedlinePlus. Accessed: April 23, 2021.

Deutsch, M. B. (Ed.). (2016, June 17). Guidelines for the Primary and Gender-Affirming Care of Transgender and Gender Nonbinary People. UCSF Transgender Care & Treatments and Guidelines. Accessed: April 12, 2021

Deutsch, M. (2020, July). Information on Estrogen Hormone Therapy. UCSF Transgender Care & Treatments and Guidelines. Accessed: April 12, 2021

Prior, J. C., Vigna, Y. M., & Watson, D. (1989). Spironolactone with physiological female steroids for presurgical therapy of male-to-female transsexualism. Archives of Sexual Behavior, 18(1), 49–57.


11. Eplerenone effects

American Society of Health-System Pharmacists. (2016). Eplerenone. MedlinePlus. Accessed: April 23, 2021.

Craft, J. (2004). Eplerenone (Inspra), a New Aldosterone Antagonist for the Treatment of Systemic Hypertension and Heart Failure. Baylor University Medical Center Proceedings, 17(2), 217–220.


12. Finasteride effects

American Society of Health-System Pharmacists. (2018). Finasteride. MedlinePlus. Accessed: April 23, 2021.

Levine, D., & Terhune, C. (2021, February 3). Exclusive: Merck anti-baldness drug Propecia has long trail of suicide reports, records show. Reuters.


13. Bicalutamide effects

American Society of Health-System Pharmacists. (2018). Bicalutamide. MedlinePlus. Accessed: April 23, 2021.

Deutsch, M. (2020, July). Information on Estrogen Hormone Therapy. UCSF Transgender Care & Treatments and Guidelines. Accessed: April 12, 2021

Kolvenbag, G. J. C. M., & Blackledge, G. R. P. (1996). Worldwide activity and safety of bicalutamide: a summary review. Urology, 47(1), 70–79.


14. Progesterone effects

Deutsch, M. B. (Ed.). (2016, June 17). Guidelines for the Primary and Gender-Affirming Care of Transgender and Gender Nonbinary People. UCSF Transgender Care & Treatments and Guidelines. Accessed: April 12, 2021

Deutsch, M. (2020, July). Information on Estrogen Hormone Therapy. UCSF Transgender Care & Treatments and Guidelines. Accessed: April 12, 2021

Prior, J. C. (2019). Progesterone is important for transgender women’s therapy—applying evidence for the benefits of progesterone in ciswomen. The Journal of Clinical Endocrinology & Metabolism, 104(4), 1181–1186.


15. Micronized progesterone

Practice Committee of the American Society for Reproductive Medicine. (2017). Combined hormonal contraception and the risk of venous thromboembolism: a guideline. Fertility and Sterility, 107(1), 43–51.

de Bastos, M., et al. (2014). Combined oral contraceptives: venous thrombosis. Cochrane Database of Systematic Reviews, (3).


16. ‘Progesterone’ in birth control pills is not actually progesterone, and comes with higher risk of blood clots

Practice Committee of the American Society for Reproductive Medicine. (2017). Combined hormonal contraception and the risk of venous thromboembolism: a guideline. Fertility and Sterility, 107(1), 43–51.

de Bastos, M., et al. (2014). Combined oral contraceptives: venous thrombosis. Cochrane Database of Systematic Reviews, (3).


17. Feminizing hormones and fertility & pregnancy prevention

Amato, P. (2016, June 17). Fertility options for transgender persons. UCSF Transgender Care & Treatments and Guidelines. Accessed: April 12, 2021

Hembree, W. C., et al. (2017). Endocrine Treatment of Gender-Dysphoric/Gender-Incongruent Persons: An Endocrine Society* Clinical Practice Guideline. The Journal of Clinical Endocrinology & Metabolism, 102(11), 3869–3903.

Iwamoto, S. J., et al. (2019). Health considerations for transgender women and remaining unknowns: a narrative review. Therapeutic Advances in Endocrinology and Metabolism, 10, 1–27;.


18. Testosterone effects

Deutsch, M. B. (Ed.). (2016, June 17). Guidelines for the Primary and Gender-Affirming Care of Transgender and Gender Nonbinary People. UCSF Transgender Care & Treatments and Guidelines. Accessed: April 12, 2021

Deutsch, M. (2016, June 17). Overview of masculinizing hormone therapy. UCSF Transgender Care & Treatments and Guidelines. Accessed: April 12, 2021

Unger, C. A. (2016). Hormone therapy for transgender patients. Translational Andrology and Urology, 5(6), 877–884.


19. Blood thickening and gender-affirming testosterone

Irwig, M. S. (2018). Cardiovascular health in transgender people. Reviews in Endocrine and Metabolic Disorders, 19(3), 243–251.


20. Cholesterol and gender-affirming testosterone

Bhasin, S., et al. (2018). Testosterone Therapy in Men With Hypogonadism: An Endocrine Society* Clinical Practice Guideline. The Journal of Clinical Endocrinology & Metabolism, 103(5), 1715–1744.

Irwig, M. S. (2018). Cardiovascular health in transgender people. Reviews in Endocrine and Metabolic Disorders, 19(3), 243–251.


21. Masculinizing hormones and fertility & pregnancy prevention

Amato, P. (2016, June 17). Fertility options for transgender persons. UCSF Transgender Care & Treatments and Guidelines. Accessed: April 12, 2021

Hembree, W. C., et al. (2017). Endocrine Treatment of Gender-Dysphoric/Gender-Incongruent Persons: An Endocrine Society* Clinical Practice Guideline. The Journal of Clinical Endocrinology & Metabolism, 102(11), 3869–3903.