Progesterone (Oral)

EV + Bicalutamide Pathway

Estradiol valerate with bicalutamide non-steroidal anti-androgen. Bicalutamide blocks androgen receptors without affecting LH/FSH or testosterone production — testosterone remains high but its effects are blocked. Liver monitoring required. Growing in popularity as a spironolactone and CPA alternative.

Progesterone oral after 3 months.

EV + CPA (European Pathway)

Estradiol valerate injections with low-dose cyproterone acetate (CPA) anti-androgen. Standard in Germany, Netherlands, and much of Europe. CPA at low dose (6.25–12.5mg/day alternate days) provides potent androgen suppression with significantly lower meningioma risk than legacy high doses.

Progesterone oral after 3 months.

EV Injection Monotherapy — DIY Community

Estradiol Valerate injection monotherapy per community consensus: 4–7mg every 5 days (IM) targeting trough E2 >200 pg/mL to suppress testosterone without an anti-androgen. The community-driven approach to transfeminine HRT — higher estradiol targets than clinical guidelines. Every-5-day schedule is community standard; clinical biweekly schedule causes unacceptable level swings.

Add progesterone at Tanner stage 3–4 per Dr Powers recommendation.

EV Monotherapy (High-Dose Clinical)

High-dose estradiol valerate monotherapy targeting oestradiol levels high enough to suppress testosterone without any anti-androgen. Clinical version — biweekly schedule as prescribed. See community regimen C4 for DIY every-5-day variant.

Progesterone oral after 3 months.

Menopause — Combined HRT (Patches + Progesterone)

Standard combined menopausal HRT: oestradiol patches for symptom relief with cyclical or continuous progesterone for endometrial protection. The NICE 2024 menopause guideline recommends transdermal oestradiol as first-line for lower VTE risk vs oral.

Progesterone 100–200mg at bedtime. Continuous or sequential.

NHS Pathway — Patches + GnRH Analogue

NHS Gender Dysphoria Clinic standard pathway: oestradiol patches with goserelin (Zoladex) GnRH analogue for testosterone suppression. Safest VTE risk profile. Goserelin implant every 1 or 3 months administered by GP or GIC nurse.

Progesterone oral after 3 months once E2 stable.