Hot Tips: Risk Reduction for DIY Gender-Affirming Hormone Therapy

(last updated 5/23/2025)

Some transgender folks choose to use gender-affirming hormone therapy. There are many reasons why some people choose a Do It Yourself (DIY) route without seeing a doctor (or other provider, such as a nurse practitioner). If you are taking DIY hormones and are done with puberty, here are tips for minimizing some of their health risks along the way. These tips are based on our current best understanding.

Emotional or physical changes from hormones depend on how long you’ve been on them. Taking higher than ‘typical’ doses may actually create undesired outcomes. A low-risk strategy is to aim for the lowest dose that brings the changes you welcome and want to maintain.

As with any other part of your health, you decide when to involve a doctor. Hormone therapy is no different—you may choose to share your DIY hormone experiences with a provider, and ask a provider for help with labs (see UCSF Transgender Care’s shareable provider resource for labs) or transgender-specific care (WPATH maintains a trans-specific provider listing).

Throughout this resource we use the phrase “feminizing hormones” as a label for use of estrogens, progesterone or progesterone analogs, or androgen-blockers, and the phrase “masculinizing hormones” as a label for use of testosterone. This is just a convenient shorthand, and we recognize that gender is not binary, that sex is not binary, and that gender is not sex.

Feminizing hormones

1) Know your estrogens

Estrogens are strong feminizing hormones. There are many kinds of estrogens. Estrogens may raise the risk of blood clots, and blood clots can result in stroke and death. 17β-estradiol in the form of a patch has the lowest risk of blood clots. 17β-estradiol patches are generally more expensive than other forms of estrogen. Estradiol taken in the form of pills under the tongue gives lower risk for clots than swallowing the same estradiol pills. Estrogen in the form of a birth control pill (ethinyl estradiol) is more likely to cause blood clots. Injectable 17β-estradiol is also an option. At higher doses blood clots may be more likely to form in the first few days after the injection because the estrogen levels in the blood may be very high.

2) Know the signs of a blood clot

Some important signs of a blood clot include: deep pain in one calf or thigh not from injury; difficulty breathing; sudden weakness in a part of your body that isn’t from exerting yourself (see signs of a stroke); chest pain; blood when you cough (see signs of a blood clot). Seek emergency medical attention for any of these signs.

3) Know about blood clots and tobacco and nicotine use

Smoking tobacco and vaping nicotine will raise your risk of getting blood clots. Taking estrogen also raises risk of blood clots. Combining the two is extra risky for blood clots. Quitting or decreasing smoking/vaping will lower that risk (see quitting resources or call 1-800 QUIT NOW in the USA).

4) Know your anti-androgens (testosterone blockers)

Estrogen is the main hormone that lowers your body’s production of testosterone for people with healthy testicles. For some folks, that is the only feminizing medicine they wish to take. Other folks might choose to take some kind of anti-androgen, which lowers the masculinizing effects of testosterone in the body. Some anti-androgens are:

mineralocorticoid receptor antagonists (i.e. spironolactone, eplerenone)
5-alpha reductase inhibitors (i.e. finasteride)
nonsteroidal anti-androgens (i.e. bicalutamide)

At high doses (200–400mg/day) spironolactone can cause dehydration and impairs cognitive function. It may also lower your blood pressure to the point of dizziness. Generally, drinking more water will counter these effects. Spironolactone can also raise your levels of potassium, which can interfere with your regular heart beat. Visiting a clinic every year or so while taking spironolactone to check electrolytes and how the kidneys are working will allow you to address changes if they happen. Eplerenone has similar side effects to spironolactone, and is less likely to increase breast tissue than other anti-androgens. Finasteride is a weaker anti-androgen and has been tied with increased risk for depressive and suicidal thoughts. Bicalutamide can be harmful to your liver, and laboratory tests will help monitor this risk.

5) Progesterone: Yes or No

Some people add progesterone to their routine, as it may help with breast growth, skin texture, and the emotional dimension. Similar to the medicines above, it also has anti-androgen effects. Oral medroxyprogesterone or micronized progesterone are most commonly used. Birth control pills containing ‘progesterone’ actually contain progesterone lookalikes, which may increase the risk of blood clots compared to actual progesterone medications.

6) Fertility preservation / pregnancy prevention

As testosterone levels go down, so will sperm levels. Fertility is likely to decline the longer one is on feminizing hormones or anti-androgens. In order to keep fertility options open in the future, one ought to consider sperm-banking before or soon after starting hormones. While taking hormones, it may still be possible to conceive.

Masculinizing hormones

1) Testosterone: The main way to achieve masculinizing effects is with testosterone (T). T is used in injectable, gel, cream, patch and pellet forms. Using overly high doses of T to speed up masculinizing effects can cause high blood pressure, fast heart rates, bleeding from the uterus to start again (as excess T gets converted back into estrogen), dryness and irritation in your canal, and more rapid loss of hair on your head (aka male-pattern baldness). For folks who have a uterus, aiming for the lowest dose that suppresses the monthly cycle has less risk compared to higher doses.
2) Blood thickening: T causes your bone marrow to make lots of red blood cells. This can make your iron stores (ferritin) go down to unsafe levels because of all the red blood cells being made. When there are too many red blood cells moving around the body, they don’t do their job as well. This can increase your risk of heart attacks and strokes, especially if you also smoke or vape tobacco. You can lower this risk by donating blood every 4–6 months, and quitting or decreasing smoking and vaping (see quitting resources or call 1-800 QUIT NOW in the USA).
3) Cholesterol: T may lower the “good” cholesterol in your body (called HDL), and may increase the triglycerides, which are the storage molecules for fat. This combination, over the long run, can increase your risk of heart attack and stroke, and also increase your risk of developing type 2 diabetes. Monitoring cholesterol levels once a year while you are on T, will allow you to address changes if they arise.
4) Fertility preservation / pregnancy prevention: T may lower your present and future fertility. In order to keep fertility options open in the future, you may want to consider freezing eggs before or soon after starting T. It is still possible to conceive while taking and after stopping T if you have a uterus and ovaries. Any form of birth control is safe for a trans person to use with T. A progesterone-releasing intrauterine device (IUD) is the most effective in stopping menstrual bleeding, while not adding extra estrogen to the body.

DIY hormones & seeking clinical support

You should not be forced to choose between medical care or DIY gender-affirming hormone therapy. Every human being deserves the highest possible quality of medical care. We believe those using DIY hormones deserve competent and compassionate clinical care, including gender-affirming care if and when they seek it. However, not all providers are competent in transgender-specific care and may benefit from your experience and assistance. Some providers may be uncomfortable with providing supportive care for those using DIY hormones. Some providers may be limited to provide care by anti-transgender laws. These providers should be encouraged to reach out to more transgender-competent providers for support (WPATH maintains a trans-specific provider listing).

Who we are

Cassandra Majewski is a risk reduction specialist, who organized the ethical and communication frameworks of this resource.

Christina Milano is a family physician and the medical director of OHSU’s Transgender Health Program.

Alexis Dinno is an epidemiologist who is transgender and transsexual, and is a professor at the OHSU-PSU School of Public Health. Her scholarship and community includes transgender health advocacy and advocates.

This project came together out of conversations around clotting risk among transgender folks using hormones while smoking in the context of COVID-19 which also poses risk for blood clots.