If you are trans, you need medical care to achieve the outcomes you need. Depending on your situation, you should consider carefully whether you want to go through official channels vs gray-market sources, or you can try informed consent pathways, or you can also do some combination.

Official Medical Channels

This is the de-facto default. Most people throughout their lives interact with an established medical system in their country, and thus it can make sense to continue to do this for trans healthcare too. But there are some considerations.

Additionally, this depends a lot on what country you are from.

Pros

The main advantage of official medical channels, is that you can be very certain that you are very certain what you are getting. Medications will be exactly as labelled, healthcare workers will be risk-averse in providing care, and so you are unlikely to receive medicine that has significant unknown side-effects.

Theoretically, it also means that you don’t personally need to have good knowledge on how effective different medications are.

For many procedures (e.g: surgical procedures like FFS/FMS, VFS, etc. or more modern medicines like estrogen pellets and long-lasting GnRH agonists) going through official medical channels is the only choice.

In some countries this can be provided for free (some European countries). In others, it can be expensive but covered by insurance (USA). In some other still, the only reasonable option can be to pay without having access to insurance.

It is also generally easier to get other treatment in your country, such as surgery and in some countries, name change recognition, if you have been going through official channels.

Cons

A key disadvantage, is that medical workers are very often risk-averse. They avoid potential side effects or less-known medicine, at the detriment of side effects that are not as visible to them (effects on mental health, etc.)

Many workers can be subtly or blatantly transphobic, and either refuse to prescribe, or to placebo-dose (to provide such low-level doses of medication that any reported effects are likely due to placebo, though it could be sufficient for a very small portion of the population).

For example, in medicine there is often some preference to know what the “minimum possible dose of estrogen to get desired effects.” While there are non-zero risks, the current guidance is directionally misguided (see footnotes1), but it can be difficult to convince medical workers otherwise.

While there are a few health workers who can be excellent and know the latest research and best regimens. Many, however, continue to follow the weakest form of HRT permissible in WPATH SOC 8 guidance2 as coded by downstream UCSF guidance. Standard clinical procedure is to start with oral estradiol typically 2–6 mg/day, and spironolactone 100–300 mg/day, and typically starting at the lowest dose for both, and titrate up. This is too risk-averse for most people, and for most is a waste of time.

There is also aversion to giving longer-lasting medicines. Even when giving injectable HRT (the best form), the only pharmaceutically available form in the US for example, is to prescribe Estradiol Valerate. Other forms such as Estradiol Cypionate or Estradiol Enanthate, can be more practical, even if not strictly leading to different results.

This is more of a borderline con, but more experimentally useful medicines such as pioglitazone3 typically are avoided overall until there are larger academic publications on it’s efficacy, while being adopted earlier in less-regulated settings form weaker forms of evidence.

Lastly, many countries have particularly terrible medical systems and bad laws very often. Some countries do not have injectable HRT as an option. Some don’t have any surgeons for most trans-related procedures. Some ban basic anti-androgens such as Cyproterone Acetate4. Some countries have a 12-year waiting list as the only option. And these are examples in countries where things are “particularly good”. Some do not prescribe progesterone for later-stage feminization. Many require you to jump through hoops and questionnaires and committees. Many countries or states may be better or worse than this on any individual question.

It can be worth trying to move somewhere the medical options are better suited to you, but this is not always an option.

Other thoughts

If you have a functioning medical system, financial access to the system, and are lucky with doctors, and don’t have privacy concerns with your government, then going through the normal medical system can be a great option.

If not all of these are true, then it can still be worthwhile to engage with the system (to gain access to things such as surgeries via insurance or for legal sex change, etc. - depends on jurisdiction), but it can be beneficial to seek some assistance outside the medical system in your country, either by changing country or by using grey-market channels.

Informed-consent Pathways

In some countries, it is possible to get access to some medications without strictly needing to go through the whole medical system. This is called informed consent.

Depending on your jurisdiction and location, this can be a reasonable middle-ground for people who have sufficient knowledge about what medications they need, while not needing to necessarily jump through as many hoops.

This alleviates some (but not quite all) of the cons above, and is worth pursuing if it’s an option in your area.

Unofficial Medical Channels

There are also unofficial channels for obtaining medication. These have their own pros and cons too. All else being equal with standards of care, this is a worse option. But all else is not equal, and so it can be worth engaging with grey-market channels.

Pros

Grey-market channels tend to be much more specialized for dealing the problems you are dealing with. Often some of the best forms of medications (Estradiol Enanthate injections, Progesterone, and more experimentally useful Pioglitazone5) are only accessible via grey-market channels in most countries, or from highly specialized medical professionals.

They tend to be able to offer no-judgement medicine if you know what medicine you need. They will not attempt to placebo-dose you or gaslight you, or tell you your estrogen levels are too high for being slightly above the normal female range.

They tend to be quite inexpensive for the most standard medicines. They are often (but not always) reselling identically produced medicines from different countries.

While it is harder to verify, many actors in this space are incredibly good willed. If you are in really dire financial circumstances, some unofficial channels can sometimes provide you with subsidized or free medical care too.

Cons

With things being often more underground, it can be much more difficult to verify authenticity or safety of any products sold. Yes, the number of reported negative incidents is very low, and yes, are various organizations that try to test and verify. But even with this, standards are not to the same level as exist in pharmaceutical settings where you have multi-billion-dollar market caps and very high levels of legal liability. Batch variance can be much higher. Sanitation and sterility can be much worse.

Secondly, there is a much higher chance of user-error. Most know that if one is taking feminizing HRT or masculinizing HRT, that some drugs need you to monitor your blood levels for different things (e.g: bicalutamide has very rare liver complications that need to be monitored, and could lead to fatalities otherwise, CPA has risk for elevated prolactin, Spironolactone has risk for elevated potassium). Most people who have the information and knowledge to pursue grey-market medicines, also do have the knowledge to monitor blood levels for liver function and other things. But it is also much easier to neglect. The traditional medical system this is forced upon you, which makes catching edge cases more likely.

Third, if one only relies on grey-market channels, then it can be more difficult to get access to things such a surgery through one’s medical system. Thus it can be worthwhile to still interact with an official medical system even if one doesn’t use it for official medications, but given this, it might be sometimes easier to just use the medical establishment medications anyway.

Fourth, while there are reasons to believe that anecdotal evidence and small scale observational evidence can be superior, some of the more experimental medicine tends to have significantly less academic literature or certainty on the effectiveness of less standard medication. There is more tolerance for taking medicine that may have less upside and more risk of downside, though this can be avoided if one sticks to grey market medicine that is pharmaceutical-grade and more standard.

Lastly, there are also sometimes practical and legal risks. Estrogen is a very legally safe substance, even if requiring a prescription in many places, while testosterone tends to have much more legal risk. Reported incidents for these tends to only target people who are selling and distributing large amounts of these, and not for personal use, but the legal risk is non-zero.

Conclusions

I think most people understand the potential risks of grey-market medicines. Being denied medical care through official medical channels also has it’s own risks. My impression is that people who have no knowledge of grey-market channels tend to significantly overestimate the risks of the former, while people who use grey-market channels tend to slightly underestimate these same risks.

In a few places, official channels can be the best option. In others, informed consent can be a reasonable option. For yet other places, grey-market channels can be the only option for reasonable care. I wish it were the case that grey-markets were not needed, but in the current world, it seems important that they continue to exist.

I have made progress writing on various topics relating to looksmaxxing and some other related trans things. I will list some of the articles that have been written, as well as some that are yet to be written. I will add links to completed articles, but also list some which are yet to be done. I also link to some of the resources I like.

I will finally then look at some information on what to do next.

Wiki of Dark Arts (to be updated)

• Full steps on what to do

• Aspects of Passing

  • what matters

  • main traits

  • noticing features

  • passing vs attractive

• Voice

  • what matters with voice

  • how to voice train

  • types of voice surgery

  • Yeson VFSRAC Experience (pre-tests, surgery, next week, first speaking)

• HRT

  • Feminizing HRT

  • Non-binary Transfem HRT

  • Masculinizing HRT

  • Growth Hormone axis

  • Genetic aspects to hormones

• Hair removal:

  • short-term (eg: shaving, waxing)

  • medium-term (eg: laser)

  • long-term (electrolysis)

• Head Hair

  • Preventing hair loss

  • Restoring Head Hair

  • Styling and care

• Weight Cycling

  • Appetite Supression

  • Selective Fat Removal

  • Gaining Weight

  • Gaining Weight in the Right Places

• Skin

  • Basics of skincare

  • More advanced skin improvement (laser, resurfacing, facelift)

  • Specific issues (laxity, acne scars, etc)

  • Verteporfin for scarless healing

  • Altering skin melonin levels

• Other

  • Things to consider if you're not sure about transitioning.

  • Banking Sperm, specific examples

  • Storing Eggs, specific examples

  • Chemically Affecting Libido

Topics I didn’t get to write at all about yet

• Body Altering

  • Waist-to-hip ratio (TO WRITE)

    • Waist / Rib training

    • Rib surgeries

    • Hip surgery

  • Shoulders (TO WRITE)

    • Delt muscle atrophe

    • Surgical Shortening

• Face

  • Facial Fat Distribution

  • Facial Feminisation Surgery (FFS)

  • Teeth

  • Makeup

• Breast Growth / Breast removal

• Other

  • Clothing

  • Social aspects to passing

Considerations

I wish I had more time to research and write about all of the topics. There is a huge amount of information on all of these topics. there are issues in just knowing all the info, then recording things, then also distilling it in a form that is more useful.

I also just appreciate all the people who make information about various topics easier to access. Some inspirations have been:

• u/darthemofan on reddit, who has been banned

• @endocrinemoder from papers.lgbt

• transfemscience, especially Aly

• mesityl on substack

• @catkaldir and @soft_fox_lad

• various people on reddit

  • r/transgender_surgeries

  • r/estrogel

  • r/transvoice

  • r/DrWillPowers

  • sometimes r/4tran4 and 4chan, not really reccomended

  • r/diyhrt

• Various discord servers

  • Scinguistics

  • Fox Kaldir’s server

• Various in-person conversations with people

Some topics have been more easy or difficult to write about than others. Comparing surgeons has been quite difficult for me due to the sheer quantity of them that I find it overwhelming.

What is missing in the ecosystem

This community is full of people who are extremelly knowledgable about their various topics of interest, and spend much time on online discussing these ideas with others. But a lot of this knowledge is so scattered.

There is excellent early guidance on understanding HRT. This makes sense, as this is probably the single most important thing. But beyond this standard path, there are other marginal things that can be done, and finding this information is difficult.

I think it is really impressive what Aly managed to do with transfemscience. I also appreciate other people who have spent time understanding the research in hormones outside of traditional academia.

I think it would be good if:

• People spent time writing in detail about topics they spend time researching.

• There could be better directories and guides beyond binary HRT

• It could be made easier to answer when people have the same questions

• Media more accessible than long + dense online text.

• There could be better ways of funding to make the ecosystems better.

• Studies could be run on medicines with weak and scattered anecdotal evidence

• It was easier to safely access hrt and other medicine in various contries.

I have recently learned some information about associated medical conditions and genetic factors correlated with gender dysphoria, and it seems like this is not understood by enough people. Things like breast development stages and stalling also seem poorly understood. There could be better ways to ensure safety and efficacy of medicines.

I am cautiously optimistic that many things could be done to improve these landscapes, but I guess I feel it is hard to coordinate on these.

If you have a wound that is large, then typically, while healing, then typically this forms scar tissue rather than normal skin tissue.

However, there might eventually be ways of healing that doesn’t cause the scar to form. But this is still a highly experimental technique.

Why does scarring occur?

When you get a wound, you want to close it up as soon as possible to reduce chance of infection. The body naturally does this by having platelets form a scab, and then heal the wound underneath the scab more gradually.

However, in healing, the body optimizes for speed, and thus uses fibrous tissue to scaffold a fix that can be done sooner.

There is a time period over which you can determine whether the wound will cause scar tissue or normal healing. This is typically determined in the first 24-48 hours.

This process can be altered. If one physically closes the wound, with stitches, then one typically gets less scarring. But are there other ways we can try work on this.

Verteporfin

One pathway that seems to affect this, is the YES-Activating-Protein (YAP) route. Verteporfin is an experimental drug that has been repurposed to try affect YAP.

This was mostly found as a contender from being an existing drug with a new possible use, and such, it is difficult to fund large scale trials for researching this.

Thus, current science relies on small-scale animal studies with a few people doing self-tests too.

Case studies

Most of these are taken from the telegram server on verteporfin.net. The site also has some old case examples.

I try to list a couple, but they are limited and varied. Initial experiments were via injection, but there is some reason to think that a topical gel might work even better. I guess both are understudies.

Animal Studies

Most of the inferred research is form looking at a pig study, where they made a scar, then sewed it up, and used a different dose of a single verteporfin injection.

Mouse incision showed almost scar tissue with saline solution, vs close to perfect healing after 30 days with a single verteporfin injection.

Pig skin also was tried, “Tested 1, 2, 4, 8 mg/mL. "Wounds (1 and 2 mg/mL) had minimal apparent scarring by 8 weeks, whereas some scarring was observed at higher doses (4 or 8 mg/mL)...”

But there are few studies even on animals

Case study: Dr Bloxham

They studied using this to try induce hair regrowth instead of scarring.

“highest dose seems to work the best”

Some noticeable results, where there were a few different doses tried to induce head hair to grow back instead of hairless scar tissue on the head.

The best result was the highest dose, which was ~0.8mg/cm², which showed some better than the smaller doses.

Since then people have continued to do 0.8mg/cm^2 though it seems like possibly higher could be better too.

Case Study: Lucy & Sage

These people tried two times.

• first a basic solution when there was some scar, didn’t work that well since it didn’t dissolve

• second, they made a real solution, but maybe didn’t use enough (hard to tell)

First attempt

The Verteporfin was purchased from MedChemExpress (https://www.medchemexpress.com/Verteporfin.html, 50 mg for $552) in preparation of an upcoming reconstructive surgery in May next year for which I wanted to evaluate its usefulness in scarless wound healing. We were preparing to compound some Verteporfin following the Hydrogel preparation described by Jiang-Tao Yang, Dingwei Wu, Jianping Li et al this weekend, but after I cut myself in a woodshop accident this Thursday I kinda improvised and did a preliminary trial of using the unprocessed Verteporfin powder in a suspension of Hank’s Balanced Salt Solution (HBS) by weighting out 10mg of Verteporfin into a presteralized 5ml amber glass vial. I then added 5ml of the freshly opened HBS which I had laying around for another project as a improvised PBS replacement and after crimping the vial i placed it on a vortexer for 60s until the Verteporfin was fully suspended (but not dissolved, as seen in the video). What followed is documented in the recording; I did all of this within an hour of injuring myself and before replacing the dressing I withdraw 1ml from the 5ml suspension using a 25G needle and injected 5x 0.2ml doses (ie a total of 2mg undissolved Verteporfin suspension) into the fresh wound as seen in the video.

Follow up:

I had a very bad reaction with non dissolvable vp

I don’t think it was a good idea that u used the non dissolvable VP into your wound

Cover your wound from the sun for more than 2 weeks

Because your body will take time to absorb the VP particles

Enrico, [20 Sep 2024 at 00:25:12]:

Any reason for injecting more?

Should be noted that there’s an upper limit to VP, after which results have been noted to get worse in animal studies

Also the fluid looked super clear, not sure if that’s alright

Lucy Vertoperfin, [20 Sep 2024 at 00:26:15]:

i just feel like when i did the initial wound care i didn’t really inject it into the tissue and as someone pointed out, a lot of it just ran down my arm so this time i wanted to make sure it actually ended up in the skin tissue

i think we are still far below that

well since its still not soluable it kinda just undissolved, suspended VP particles in solution that are hard to see in the video

but i am confident that 2mg of it ended up in my skin tissue

Enrico, [20 Sep 2024 at 00:28:19]:

I think bloxham said it’s supposed to become a thick green liquid

Lucy Vertoperfin, [20 Sep 2024 at 00:31:42]:

if you reconstitute the liposomeized version of it (ie Visudyne) or you dissolve the unprocessed VP in a solvent other than water (ie ether, ethanol or DMSO), yes

as i explained in #general there is a lot of confusion in this group around verteporfin as in verteporfin the raw benzoporphyrin derivative you can buy as a chemical reagent (not water soluable) and the FDA approved drug Visudyne

i have verteporfin powder, but as you pointed out it’s not water-soluble so it is useless for injection. all the papers that are cited by stanford etc say verteporfin but in the methods section they usually mention that they actually use Visudyne, which makes sense. i dont have the means to make the lipid myself from verteporfin but im wondering if i could still use it if i use DMSO for delivery

Second attempt

Sage, Ivy and I refined the protocol for preparing the verteporfin liposom from the verteporfin powder we obtained from medchemexpress. We plan to publish a paper on this some time soon, but im happy to share the protocol. if you end up replicating this research before we get a chance to publish, it would be appreciated if you credit our efforts appropriately

verteporfin simple liposome protocol:

verteporfin and soy lecithin are combined in a 1:8 molar ratio in a brown glass vial. They are dissolved using a minimal amount of methanol and chloroform in a 1:2 v:v ratio. The solution is gently agitated to get as much of the solids into solution. The non-polar solvents are removed by gently heating the glass vial at no higher than 55c. When all solvents have disappeared the vial is placed in a vacuum chamber to remove any remaining solvent (or heated further for another hour or more to ensure remaining solvent is driven off). The mixture is rehydrated using the desired final volume of saline, warmed above 30c. The vial is then placed in an ultrasonic bath at 40c for 20 minutes. After sonication the film should have dissolved into the saline and is ready for sterile filtration. Ensure that sterile filtration is performed with a liquit tempature at or above 30c.

ie to compound 4mg of VP in a 1mg / ml solution, you can follow these steps:

• weight out 34mg of lecithin and 4 mg verteporfin on a microgram scale in a brown glass vial

• dissolve lecithin and VP by adding 2ml of CHCl₃ + 1ml MeOH

• plug the vial with a silicon stopper and agitate the vial on a vortex mixer for 2-3 minutes to help with dissolving the lecithin + VP in the organic solvent

• remove stopper, place open vial on a hotplate set to 55C for about 20min to evaporate most of the organic solvent. i attached a TC probe to make sure the temperature inside the vial does not exceed 50C

• after all solvent is evaporated, there should be a thin dark film in the bottom of the vial. remove any remaining solvent by placing the vial in a vacuum chamber down to ~1mbar, i used a vacuum desiccator

• [video 1]

• start warming up the some saline (i used presteralized 0.9% 5ml sodium chloride solution) to 40C in an incubator or water bath before for sonification

• preheat sonicator (i used a vevor brand ultrasonic cleaner) water bath to 40C

• add 4ml of the pre warmed saline to the vial and plug with a silicon stopper and crimp the vial using a hand vial crimper

• [video 2]

• shake the sealed vial with the redissolved VP + lecithin thin film and place it in the sonicator for 20min at 40C

• [video 3]

• prepare a second empty brown glass vial and sterilize in an autoclave or buy a presteralized, pre crimped vial. this is the vial we will fill with the filtered VP suspension.

• use a 5ml or 10ml syringe with any (ie 18G) needle to withdraw the unfiltered VP solution while it is still warm. it is important to perform the filtration step quickly so the liquid temperature is at or above 30C during the filtration. use a 0.22um PTFE syringe sterile filter to filter and inject the VP solution into the empty sterile vial using a fresh needle following common practice for pharmaceutical compounding of sterile preparations like this (ie ideally working under a laminar flow hood, read “Compounding Sterile Preparations”, Fourth Edition, by E. Clyde Buchanan et all for advice).

• the filtered and sterile VP is now ready for application following the protocols discussed in other channels in this group. if you follow this specific protocol, you end up with 4ml of saline with 1mg / ml VP.

we used the VP prepared this way for Sage about 48h after surgery. more to come and we will update with results of her recovery

results were not that good though:

I unfortunately don’t have good before/after pics. My very subjective review is: 0.4mg/cm^2 is not a large enough dose to make a significant effect. I am now about 8 months into recovery and I don’t see a huge difference between the treated and untreated parts of my wound.

Case Study: Dr. Taleb Barghouthi

Some notes from telegam on different trials being attempted

Dr. Bargouthi’s VP FUE trials

Yes, bargouthi recently tried 0.4, 0.6, 0.8 and 1 mg (in seemingly a single cm2)

https://www.hairrestorationnetwork.com/topic/64737-verteporfin-hair-regeneration-human-trial-dr-barghouthi-official-thread/page/112/#comment-781643

Dr. Ted Miln is confirmed to do a VP trial in 2025. Likely a hairtransplant. https://www.hairrestorationnetwork.com/topic/64737-verteporfin-hair-regeneration-human-trial-dr-barghouthi-official-thread/page/114/#comment-782509

bargouthi had comparable results in both 0.8 and 1

Conclusion

Through some self-tests, we can see that some people have attempted various methods for using Verteporfin to get scar-free healing. However, the success is very mixed. There are some vert small scale clinical trials happening eventually, but things in this space are slow.

I guess it seems like it could potentially be used in conjunction with surgeries to prevent scar formation after (eg: post-FFS or something), but it’s unclear if the evidence is good enough for this yet.

I will try to edit and add more info on this when it comes up.

After 2 months of silence post Yeson VFSRAC, you can go back to speaking normally, but need to do voice training for a while. I will describe the recovery instructions, and my current progress.

Current Recovery

While the no-speaking period is 2 months, the full recovery takes longer.

While one might hope that you get a speedy easy recovery after being able to speak again, it can be a bit disappointing at first.

It’s kind of hard to know whether you are just in the “slow recovery” case, or in the “I coughed too hard and broke the sutures” case, and you can’t really inspect it. So it is easy to worry. The sutures are probably more sturdy than you think though.

My Recovery

My initial starting pitch when doing the rainbow passage, was:

• pre-surgery: ~119Hz (102-145Hz)

The day I started speaking again, I measured it prior to voice training, and found that it had been unchanged:

• 0 days speaking: ~121Hz (103-140Hz)

I was pretty worried and slightly disappointed, my vocal range mostly felt unchanged. The exercises maybe make it seem like the higher pitches are easier than before.

• 1 week speaking: 147Hz (113-207Hz)

It’s hard to measure, but I think my vocal weight has also changed somewhat.

There are some ways in which it feels like it “didn’t do much”, though other than my voice feeling kind of weak overall (as if I was in a loud night club or something recently stressing my voice), it feels probably easier to do higher pitches than lower pitches now than it did before but it’s hard to remember when you haven’t spoken in 2 months and it’s all slightly more difficult from feeling weak.

I also, while writing this, realized I maybe that I had misinterpreted some of the exercises, so that might be a factor, I will try do them better this week.

[I will probably update this with progress for the next few weeks]

Recovery Voice Training Exercises.

There are a few exercises we are told to do. These are mostly pretty standard.

It’s annoying because you need to do these sets like 4-5 times per day.

Warm Up

These are done first at a normal frequency (200Hz), 2 times, then followed by

• Lip Trills (breath and let lips frill)

• /m/ sound

• /mi/ sound

• /m/ + /a,i,o,e,u/

Then repeat these but going smoothy up and down in pitch

Main Power exercises

You want to individually “hmm”, for as long as you can. Try to make sure to be using “head voice” which you can verify by holding your finger on your nose, and seeing that it vibrates when you make noise.

Make sure this is at 200Hz note as a starting point.

Sustain (ie: do it for as long as you can)

Then repeat 4 more times, increasing pitch by one note each time. Ie:

• ( /m/ ) x (200Hz, …. 4 notes)

Repeat, but this time do a “mi” sound before:

• ( /mi/ ) x (200Hz, …. 4 notes)

Do the hmm sound sound, followed by one vowel sound, repeated for each vowel sound. Repeat for all the different notes.

• ( /m/ + /a,i,o,e,u/ ) x (200Hz, …. 4 notes)

Repeat, the last but last one, but each time do a 3-point scale (C D E D C). repeat increasing pitch each time.

Scaled 3 notes (Going up and down 3 steps)

• ( /mi/ + /a,i,o,e,u/ ) [200z, +1 note, +2 notes.] * [5 starting notes]

Repeat, but with 5 point scale

Resonance Technique

Try to make sure that you are using head voice again, and start at 200Hz.

• [ /ing/ + /a/ ] * [5 different starting pitches], sustained

• [ /ing/ + /a/ ] * [5 different starting pitches], scaled

Then repeat with different phrase:

• [ /mm/ + /ya/ + /ing/] * [5 different starting pitches]. sustained

• [ /mm/ + /ya/ + /ing/] * [5 different starting pitches]. scaled

Physical Exercises

Abdominal Breathing: breathe but try to keep ribs small and stomach changing in size.

Laryngeal Massage: First, hold your laringeal cartillage/voice box, then massage it and move it side to side. Second, use thumb and index finger about the laringeal cartillage and and rub/encircle. Third, in a v shape use thumb and index finger to rub downwards from there multiple times. Forth, individually, hold one of the two diagonal things to the side of your neck slightly and hold it and rub it up and down.

Bubble Exercises: Have a large straw with flat bottom into a cup of water. Start with a hum phonating into water. Then do glides. Then do scales.

It’s also better to record yourself doing these. Once you have an idea of what the 200Hz pitch is, as then I could do it while on a walk if nobody was around. Not sure if that is good.

It’s worth noting that most things here have a lot of variance between people. I give my general impression, but this is more speculative than many other posts I have done. I err towards painting a concrete image that is mostly true, rather than a muddy picture that is more technically accurate.

Types of Libido

It’s worth understanding that libido can be felt differently depending on the person, but roughly there are two main axes for what libido can feel like.

Both feel like an urge/desire to have sex, but can feel qualitatively different

One axis, is a more “spontaneous” libido. This can feel like:

• Libido is never quite off, more like low enough to be not noticeable behind the background of everything else. If this were a gas stove, one can dial it down the the lowest setting, but one need only turn up the dial, not reignite it again.

• Heightened sensitivity is felt localized in the genitalia.

• The means are nice but the end is what you most strive for.

• Once achieving a final orgasm, the drop in libido is quite sharp and sudden.

• Refractory period before next orgasm is typically moderately long.

The second, is a more “Responsive” libido style. This can feel like:

• Libido is often completely off, and takes more effort to ignite, though can sometimes ignite more spontaneously. And more sensitive to relatively sudden turn-offs.

• Heightened sensitivity is felt all over the body

• The means are perhaps a larger part of the experience than the end be default.

• Refractory period is typically quite short

• Achieving orgasm leads a drop in libido over a slower period of time

People differ significantly, and can have a combination of factors between the two. A lot of this can be altered by various medical aids.

Sex Hormones

There are a few main hormones that can alter profile of sexual experience for people:

Testosterone

This has the strongest effect on libido. Transfeminine people often experience a huge drop in libido after lowering testosterone levels, and transmasculine people often experience a huge surge upon raising testosterone levels.

There are many other effects from testosterone though. It’s worth noting that some women do supplement testosterone to be in upper female range to have some higher libido without masculinizing effects

It is possible to lower

Estrogen

This has a relatively weaker effect on libido. Some transfeminine people report regaining a more feminine-style libido after having their hormone levels in the feminine range for a long time. Others do not.

Progesterone

Though anecdotes, people do report higher libido on Progesterone if their libido was low on Estrogen. True for some, not for all.

Synthetic Progestins

There exist synthetic variants of progesterone, called progestins, which typically lower libido. These can lower libido. Part of this is by lowering testosterone, but they can also separately block libido even if testosterone is replaced.

There are many forms, Medroxyprogesterone acetate, cyproterone acetate, levonorgestrel, drospirenone, etonogestrel, levonorgestrel IUD. These can be looked at seprately.

Blood Flow Enhancers

PDE5 inhibitors

Sildenafil, aka Viagra, is perhaps the most well known drug used for sexual purposes. It generally is just a blood-flow enhancer, and can lead to making it easier to getting errections. It does not generally affect libido directly (mental state), rather only affecting physiology (physical state).

Tadalafil, aka Cialis, is basically a longer-lasting version of Sildenafil. The elimination half-life of Tadalafil is 17.5 hours, compared to 4 hours for Sildenafil.

It is contraindicated with some few medical conditions and other medications. Though it generally has few side effects, and there is moderate evidence it might be correlated with reduced all-cause mortality for older people.

Direct Libido Enhancers

Flibanserin was the first drug approved for improving libido. It had many side effects and was not very effective.

Bremelanotide/PT-141 is another libido enhancing drug, used to treat low sexual desire in women. It is typically administered by injection. The elimination half-life is reported to be 2-4 hours, though may be different depending on route of administration.

It depends on the person, but effects can be useful or can be modest. It has more potential side-effects than the previous drugs. Hyper-pigmentation is one rare side effect(~1 in 100, higher if abused), for interesting reasons.

Melanotan II, is a peptide that is used for increasing melanin production in skin. This was found to raise libido in people, and so was used as inspiration when discovering PT-141. If you want to use either, you should use PT-141

kisspeptin is currently under study, and might be approved as a replacement for PT-141.

Dopamine can also affect libido significantly. Drigs that affect dopamine (eg: bupropion) though this is usually a secondary concern for most of these drugs.

Direct Libido Dampeners

The main libido drop comes from dropping testosterone/blocking androgen signalling. See feminizing HRT.

Synthetic progestins help, as mentioned before

There are various other levers too, often incidental. Affecting dopamine, or prolactin-raising drugs can reduce libido.

Refractory Period

There is little research on how to affect this directly.1 My vague current understanding:

There are separable neural circuits for orgasm and ejaculation

Things like ejaculation and refractory period seem to be affected by testosterone-driven maturation.

It might be possible to affect the circuits separately to alter refractory period.

Cabergoline

This drug that has some interesting effects. It affects prolactin and dopamine D2, and also maybe helped reduce refractory period:

Administration of cabergoline decreased prolactin levels and significantly enhanced all parameters of sexual drive (P<0.05), function (P<0.01) and positive perception of the refractory period (P<0.01).

It has a half-life of ~65 hours, and at long-term high doses can lead to heart valve failue, so it’s mostly only used treat prolactinomas and Parkinson’s disease.

Closing Thoughts

There are many drugs that chemically affect libido. Some drugs can affect how easy physical sex is.

These will not, necessarily make you enjoy sex if you didn’t enjoy it before, or vice versa. These can be different axes.

If you enjoy sex, you may benefit from raising libido, if you don’t enjoy sex, you may benefit from lowering libido.

Many of these things that affect libido, however, will be incidental compared to other parts of your life.

It is common that when people have some inkling that they would prefer to look different to how they are, they don’t know how to act.

The no-bullshit answer is, you should just try to get on HRT as soon as possible. I have some brief guides on types of HRT:

• Feminizing HRT

• Non-binary Transfem HRT

• Masculinizing HRT

But if you are choosing how obtain, or whether this is something you really want to do, you may end up on the fence for a while. I will discuss some things to consider.

Why should you get on HRT sooner?

If you are in your teens or early 20s, this is the period of your life when you are experiencing the most changes per year while being on a type of hormone.

Early changes finish pretty quickly, male hormones cause a growth in ribcage and facial features, and a deepening of voice, but mostly stop after teenage years. Over time, they will still cause you to have more face/body hair and masculinize your skin when young

Female hormones do cause breast growth and pelvic widening, but beyond this the changes are not as pronounced as you get older.

Your bones tend to fuse at some ages between 20 and 25, and so if you want to be able to get some gain to bone structure, it is better to get started sooner.

But even if you are above 25, hormones just tend to cause gradual changes over a long time.

Getting started on HRT causes body fat and skin texture changes for most, and this is gradual and takes a long time, and there is genetic variance on how well this works such that you may need to make adjustments to the standard regimens.

For more permanent changes (such as voice masculinization on male hormones, or breast growth on female hormones), my personal vibe is there is a degree to which final results can depend on age too, but this has not been well studied.

What should I do before I have fully decided?

If you are transfeminine:

If you ever want to have kids, Gamete storage is good to do as soon as possible. It’s often slow and annoying, and takes a long time. Getting gamete storage before starting HRT is more likely to give good outcomes than needing to stop later. See guide

It is also beneficial to get started on hair removal ASAP. This takes a long time, and does not interfere with basically any other forms of life. Getting some laser sessions booked soon is just generally good.

It is hugely beneficial to get started on DHT blockers at the least. These generally have few side-effects you would be worried about as a transfem, and help prevent future facial hair growth and head hair thinning.

If you are transmasculine:

If you ever want to have kids, doing egg freezing is also something to consider ASAP. It is a more annoying process than sperm banking, requiring around 2 weeks of injections and usually also removing you IUD if you have one. You should do this sooner anyway, as egg quality degrades with age rapidly, often becoming quite poor in mid 30s. The optimal age is around 19years and it only degrades from then.

Other factors are not as urgent for transmasculine people.

Dipping Your Toes

Often when people are not sure, people want to know what they might look like if they were to transition, or what it would be like, whether they would pass or not.

Unfortunately, it’s difficult to give generalizable advice here.

There are social costs to transitioning and not passing, but the degree of these costs depends a lot on field of work and location. If you are a software engineer on west-coast USA, then being visibly trans is considered pretty normal. If you are in the middle-east, then the costs are significantly higher, though also people tend to be significantly worse at clocking people.

You can try various methods to try see whether you would ever pass or not, you can try consider your height and measuring parts of your body, and these can give some indication, but are much more lossy than is optimal. You can attempt to use a “face gender swap” visualiser, but often even these are kind of limited. You can look on reddit r/transtimelines though there is a lot of variation and it’s difficult to see people similar to you, and people often have more or less luck, and various surgeries help too, and effects such as lighting and angle and expression and makeup make a huge difference.

I write some about different factors here:

It is very difficult to judge how people might perceive you with some changes. You have seen yourself everyday for your whole life, and assigned your birth label to your appearance, so it’s difficult to judge otherwise.

You can try some low-cost methods to see what it’s like, but these are very lossy and generally feel jarring when contrasted to the features on you that are not yet femminine.

You may be tempted to try: wearing different clothing, using makeup and contouring, doing various physical exercises, using a face swap AI. These are OK, but quite lossy.

You can also try a dose of hormones for a while. This can give an idea of what it feels (a week is rarely enough for any long-term changes, but can give some idea of the mental effects, such as on libido)

Overall, most people who do choose to transition end up not wanting to permanently detransition, even if they don’t fully pass. (many need to take a break for various reasons, but I don’t count this). The fraction is low single-digit percents.

My vague recollection is something like (EDIT: I need to look into this more):

For transfeminine, the tiny fraction of people who do de-transition, this tends to be from not being able to pass, (such as being 6’5 + having a rugby build, and living in an area that is particularly unaccepting).

For transmasculine people, the tiny fraction who do detransition, the main two factors is from finding male social life quite socially isolating, or from finding that they were transitioning not so much for a desire to look masculine, but to run away from some of the stressful parts of womanhood.

But most people who do de-transition, still end up somewhere non-binary rather than a binary version of their original gender.

What to do?

You should do the partial steps now.

For most, the thoughts and yearning never go away. Conditioned on this, it is better to get started as soon as possible no matter what age you might be.

You may also consider spending more time actually considering what it would be like. It is easy to dismiss initially that “it would not be worth it to transition” before trying to understand what the costs and the benefits would actually be.

But ultimately, every decision is case by case and is too difficult to

Masculinizing HRT, in some ways, is much simpler than feminizing HRT, if you want all of the effects.

Testosterone tends to be a more dominant hormone, and so if levels of testosterone and estrogen are both high, the effects of testosterone tend to be more pronounced than those of estrogen, and high levels also tend to control and lower estrogen levels and surpress cycles

Testosterone causes many changes, with a larger proportion being more permanent than changed transfeminine people experience.

If you want only a subset of these, then it becomes more difficult, though depending on what subset you want most, it can vary.

Testosterone

The main masculinizing hormone you would want to take is testosterone.

You probably should look in more detail on another site with better information. For example:

• https://trans.diy/masculinizing

Some of the common permanent changes include: voice deepening, facial/body hair once mature, clitoral/bottom growth, scalp hair loss if follicles are lost.

More reversible changes include: muscle mass, fat distribution, libido increase, skin oiliness/acne, cessation of menses, vaginal atrophy.

Testosterone is also converted in the blood into DHT via 5-alpha-reductase, and into estradiol via aromatase.

Here are some common forms of Testosterone:

Injectable Testosterone

The main method for administering testosterone is via injecting it into subcutaneous fat (subQ) or into muscle (IM).

Testosterone Cypionate

This is the best/most common form. The half-life is about 7-8 days, making weekly injections quite viable

Testosterone Enanthate

This is another common form. The half-life is somewhat shorter (4-5 days) so it tends to be better to take weekly.

Testosterone Undecanoate

This is much less common, and has a much longer half-life. It’s better to take this once you have tried the other methods somewhat, and have an idea of what levels work for you.

Testosterone Gel

It is possible to get reasonable testosterone levels by applying gel to yourself daily. This can work well, though absorption is not as reliably consistent as injections.

Testosterone Pills

Normal testosterone gets broken down by the liver, and thus is not viable. There are old non-bio-identical forms of tesotsterone (eg: methyltestosterone), but like with many synthetic hormones, this has many risks and should be avoided.

Testosterone undecanoate is more modern, and can be taken in pill form. It is less common due to being new, but it can work if you don’t want to use injections or gels.

DHT

dihydrotestosterone is responsible for some effects of masulinisation. In particular: skin, hair, genital tissues.

It generally causes growth of facial and body hair, scalp hair loss, bottom growth, and skin texture changes (especially acne).

Avoiding DHT

As mentioned in “Retaining Head Hair”, it is possible to take 5-alpha-reductase inhibitors that prevent DHT form being created.

This mostly means taking finasteride or dutasteride.

DHT Gel

On the other hand, some people might particularly want bottom growth to occur. DHT is the main mechanism for this, and applying DHT gel to the clitorophallus may lead to some more growth, direct evidence is weak though. Liberal application would also lead to systemic absorption and increase in DHT.

Nandrolone

One potential androgen that is interesting but experimental is Nandrolone. The best source for this is by transfemscience.

Essentially, this works almost identically to testosterone in the blood, but instead of being converted into DHT, is deactivated. This, it might have less impact on skin, hair follicles, while still having most of the effects that testosterone has in muscle growth, fat, voice, bottom growth, and libido.

However, the research for this is still relatively limited and it has not been widely studies.

Gaining Muscle

Many transmasculine people are particularly interested in gaining muscle. Having high testosterone levels does help with this significantly.

There is an array of other things that also help. There are many peptides and steroids that can increase muscle growth, but often at the cost of also increasing health risks and cancer risks.

I will probably do a separate post on this at some point.

Other considerations

• As mentioned, DHT can also cause hair loss, so you may want to consider methods for retaining head hair.

• Acne is common early on, especially with peaks from injections. Dermatology treatment can help: retinoids, isotretinoin, benzoyl peroxide, etc.

• Fertility may decrease, but is not reliably eliminated. Consider egg/embryo freezing before starting or before long-term use

It is also possible to gain partial permanent effects, by taking lower doses and then stopping. (Eg: getting a slightly lower voice but only partially masculinized)

I would like to overall know more about all of these things, and you may be often better off looking at more specialized resources on this. If you know of any, please consider linking them below.

In this post, I describe some of the more simple skincare methods most people can keep in mind. I will leave more complex methods for different post

TLDR

The most important tips:

• Wear SPF, cover up your skin, and wear hats and sunglasses to limit sun exposure which can cause premature aging.

• Use Retinol to make skin look younger

• Limit your alcohol, avoid tobacco, avoid hard drugs and keep an active lifestyle.

• Use Hyaluronic acid, niacinamide, vit C in some cases.

• Exfoliate for temporarily smoother skin

Photoaging

Basically the largest factor to improve long-term skin quality, is to attempt to reduce aging caused by sun exposure.

Sunscreen

The single most important thing is also the most boring. You should be applying sunscreen to your face everyday. For the most part, it doesn’t matter which sun cream you get as long at the SPF is high enough, though there are marginal differences I will discuss.

Sunscreen protects against UVA (320–400 nm) and UVB (290–320 nm) radiation.

There is a lot of evidence on how effective sun-cream is at preventing photo aging, and wearing it everyday is better than wearing it often.1 You should wear sunscreen even if you only stay indoors but next to a window, as UVA is only partially blocked through glass, and can still have effects on aging of skin.

You should likely prefer chemical sunscreen filters (rather than mineral ones). US FDA has banned most of the best sun blocking ingredients, so it is better to get ones not non-US ones. East Asian and Australian SPF products are generally the highest regarded. Much of this is in large part that they work on making the texture of sun cream when applied more tolerable.

If you want to really optimize, most sunscreens are quite weak in the 380-400nm range, but there are two options that help here:

• The first is Iron Oxides/Titanium Oxide, which have the downside of having a tint and thus being visible on the skin. These are rarely used in products for this reason.2

• The other option is Mexoryl 400, which is particularly effective in the 360−400 nm range, but is still under patent by L’Oréal.

Thus, the “best” suncreams are mostly from L’Oreal, such as La Roche Posay UVMune 400 products. See review by Lab Muffin. But these are somewhat on the pricer end, and I find the texture not as good as some other suncreams.

I have personally found Korean and Japanese have the best texture, and personally like SkinAqua products the most out of various things I have tried (especially SkinAqua UV Super Moisture milk, as it is unscented and has a pleasant texture). But I am no expert on this, you may be better trusting a real reviewer such as Lab Muffin.

If you want a flowchart to choose a sunscreen, here is a nice one: Sunscreen Flowchart

Physical Sun Blocks

You can also physically block the sun with shadow. This means wearing hats and clothes to prevent the sun from hitting you.

This is helpful, but should be done in addition to sunscreens, rather than instead of using sunscreens.

Retinoids

Eg: Retinol, Retialdehyde, Tretinoin, Adapeline, isotretinoin

Causes skin to churn more often, and makes it more fresh. These are all essentially forms of Vitamin A. These can have many positive effects on the skin. But these also can tend to feel harsh on the skin, and are contraindicated with many things (eg: pregnancy, hair removal, eye issues, etc).

There are older and newer retinoids, some are studied for different aspects. Most help a lot with acne and effects of photo-aging, and can even help slightly reverse some of the photo-aging at the end of a day. They can also help, to a lesser extent, with hyperpigmentation, pore visibility, and slightly with scarring appearance and laxity.

It is possible to take a form of retinoid orally, such as isotretinoin,and it can be quite effective. though this has more chance of side effects or mental effects than topical solutions.

There are many topical solutions. It is usually worth starting with lower concentrations less frequently (eg: 1-2x per week), then working up to higher concentrations and/or more frequency over time (eg: daily)

• Retinol is a simple weak form of retinol, that can be used as a starter dose.

• Tretinoin is the strongest, most studied form of retinoid, that has the best results, but also has the highest risk of sensitivity issues. It is very easy to apply too much and leave your skin texture feel burned.

• Adapalene is the newest form, and has much better tolerability. It is mostly studied in 0.1% form as an anti-acne medicine, but there is some limited research showing that 0.3% adapalene might be as effective as 0.05% tretinoin for photoaging effects.

I would recommend adapalene overall, starting with 0.1% and moving up to 0.3%, and if you prefer that tretinoin has a much larger evidence base than adapalene, then you can upgrade to tretinoin afterwards.

Other things

Here are some other things that can help.

Lifestyle

Some general things, such as:

• avoiding smoking and some hard drugs (eg: Heavy cigarette smokers (greater than 50 pack-years) were 4.7 times more likely to be wrinkled than nonsmokers)

• limiting alcohol consumption (evidence here exists but is weaker)

• exercising regularly (“significantly improved skin elasticity and upper dermal structure, and RT also improved dermal thickness”)

Niacinamide

Slightly improves fine lines, tone, radiance, and barrier function, and does not irritate skin. It pairs well with retinoids, as it can reduce irritation while maintaining efficacy.

Sensitive / damaged / dry skin

Ceramides can help somewhat if your skin barrier is damaged or your skin feels sensitive (such as after too much retinoids)

Hyaluronic acid can also help to moisturise your skin.

Vitamin C and derivatives

There is some limited evidence this might slightly reduce photo-aging, but the effect is far smaller and more marginal compared to suncreams. It can also slightly exfoliate.

Callogen supplements

Multiple RCT meta-analyses show modest benefits for skin hydration/elasticity after ~8–12 weeks. Source seems less important than dose and hydrolysis.3

Exfoliants

There are some exfoliating solutions (acids, scrubs, etc) that temporarily brighten & smooth the skin, but at the cost of damaging the skin’s moisture barrier and being generally harsh. You can try these, but I generally err towards thinking gentler skincare is better.

Red light therapy

Some early results says it helps with modest anti-aging and laxity benefits, but requires consistent daily use for 8-10+ weeks. Home devices have lower irradiance than professional panels. Low risk but there is a lot of inconsistency on best techniques.

Closing

These are some of the main basic things with skincare. I will discuss more complex specialized methods another day

Yesterday I talked about feminizing HRT, assuming you mostly want to achieve a binary female look. However, some people would prefer a more feminine aesthetic without being strictly female. Typically this means having more feminine facial features, softer skin, less hair, while also having no breast development, and also potentially having more upper body muscle. I will discuss these in this section.

Estrogen Receptors

Your body has two kinds of estrogen receptor: estrogen receptor alpha (ERalpha) and estrogen receptor beta (ERbeta), and these are all over the body in various combinations. The roles are somewhat different. ERalpha is the one promarily responsible for growth of new tissue It should.

In skin, the prominent receptor seems to be ERbeta

In increasing fat distribution and breast growth, the prominent receptor seems to be ERalpha.

Therefore, it seems possible in theory to achieve feminization across most of your body without inducing breast development one of two ways:

• If you can somehow activate only the beta receptors and avoid activating the alpha receptors. (Unclear how)

• If you could block the estrogen receptors specifically in the breasts, that could also prevent growth.

Both are tricky to achieve in practice, but there are some attempts I will discuss.

Temporary Growth

An alternative solution, is to simply to follow the standard feminisation procedure, temporarily allow breast development to happen, and once mature, to do a mastectomy to remove the breast bud tissue. This removes most of the mass from the chest. High estrogen levels will allow some fat to be deposited, but the effect should be much more minor. You would need to put up with some level of breast growth on the order of a year or two though, so it’s better to avoid this if that would be distressing.

HRT Options

The main thing that is difficult, is blocking the effects of testosterone enough to remove masculinisation, but not raising estrogen enough to cause breast development, and also not having low levels of both such that you feel symptoms of menopause (hot flashes, etc).

This is also an area where the medical establishments have not done much research, as most people have a relatively binary understanding of gender and sex. Thus most of the “recommendations” here are to be taken lightly. Sometimes they work, but they often won’t work. I will describe some of the key ingredients you can use, and later describe how some people end up using them.

Bicalutamide

Bicalutamide is an androgen-receptor blocker, as mentioned in the previous post. This blocks some (but not all) uses of testosterone in the body. This typically causes one to have an increase in serum testosterone levels.

Although this does not directly provide estrogen, it is worth knowing that some fraction of testosterone gets converted into estrogen through the aromatase enzyme. Having higher testosterone (up to 2x) thus causes a larger amount to get converted to estrogen, raising estrogen levels (up to 2x). Depending on your baseline levels, this could be sufficient to get some feminisation, though the exact amount depends on the person

Bicalutamide blocks Androgen receptors (including testosterone and DHT receptors), so things downstream of this are typically affected. This includes skin texture, hair growth, and to a lesser extent muscle building and libido. This does cause Testosterone and GnRH/LH/FSH to rise also.

There are some potential concerns with liver toxicity, so make sure to get liver function blood tests before and after starting, and within the first few months of using

17alpha-estradiol

This is another form of estradiol other than the standard one (17beta-estradiol) which is much weaker and affects fewer aspects. You may think this has something to do with the alpha/beta receptors, but the naming here is mostly unrelated. Higher 17alpha-estradiol may have some health benefits, but that is out of scope for this post.

Selective Estrogen Receptor Modulators (SERMs)

One of the key ingredients you might hear about as an estrogen blocker, are SERMs. These are molecules that selectively block some estrogen receptors but not others. These are typically prescribed for breast cancer risk mitigation purposes.

The two main contenders are raloxifene (most common, less effective) and tamoxifen (more effective, maybe more chance of side effects ), but there are others.

In a semi-related study they found that:

69% of prostate cancer patients in the high-dose bicalutamide (150 mg/day) group had gynecomastia, but this was reduced to only 9% in the group receiving both bicalutamide and [tamoxifen] (10-20 mg/day).

SERMs act by physically binding to estrogen receptor sites and deforming them slightly for the duration they are bonded without causing the effect, such that estrogen can no longer bind to the sites. This means estrogen cannot activate these sites.

SERMs are mostly such that they prevent estrogen from binding in some sites, and enhances binding in other sites. This generally means preventing estrogen binding in the breasts, and increasing estrogen effects in the bones, and other effects tend to depend on which exact medicine. My understanding of how it works exactly is kind of vague.

How effective they are depends on how much estrogen is in your blood stream. Thus, if you take a very large dose of estrogen (such as needed for estrogen mono-therapy), you would also need a very large dose of SERMs, which is typically not advisable. It is easier to instead, have barely high enough estrogen levels to achieve feminising effects.

There are some concerns with it affecting the liver and affecting blood clotting.

Mastectomy (breast removal)

This is a surgical procedure that involves cutting open the chest, and removing breast tissue. This prevents functional breast tissue from growing back, but doesn’t prevent fat from growing there completely. This is one of the most common aesthetic surgical procedures. But probably deserves it’s own post.

Some regimens

Bicalutamide mono-therapy.

This achieves feminising effects while keeping testosterone levels high. Most under this regimen end up gaining some breast development.

Bicalutamide + SERM

This achieves most feminising effects while keeping testosterone levels high, and decreases the risk of breast development

Bicalutamide + SERM + low-dose AA + Low-dose Estrogen

Some find that bicalutamide causes their testosterone to get too high to the point it’s an issue. It is therefore possible to take a low-dose anti-androgen.

—

Other things worth considering

You should probably also consider other things:

• Hair removal (see previous posts),

• preventing hair loss w DHT blockers (see previous post)

• Skincare / FFS (future posts)

• Exercise to gain desirable muscle (future post)

Closing

The issue with each of these, is that there is a good chance that it might still caused breast development, and there is also a lot of things being taken, such that there is a higher likelihood that you might have some liver concerns, so you should take regular blood tests.

In general, full feminization is easier to aim for and is far more studies.

TLDR: taking a weekly injection of estradiol enanthate is the best option, taking bi-weekly valerate is a close second, but there are other options too.

This is a brief dump to try explain the main HRT methods. There are are better guides for this, such as this one, but for completion, I include some discussion here as well. Thing here are a mix of paper-backed evidence, as well as common-knowledge best things, and also some more anecdotal things too.

This mostly considers that you have standard reactions to HRT, but it is also quite common for this not to be the case for people with gender disphoria. I will discuss potential things to consider if you have weird genetics in a different post.

Best resources:

Here are a few of the best links for learning more (some others below too1)

• https://transfemscience.org/articles/transfem-intro/

• https://trans.diy/feminizing

• https://old.reddit.com/r/TransDIY/wiki/index#wiki_transfeminine

Goals of Feminizing HRT

The main goal is to alter blood hormone profiles to match female hormone patterns. This means raising estrogen, and to decrease testosterone function. To some extent, the hardest part is making sure testosterone is low enough, as it’s effects are more potent than those of estrogen. Modifying progesterone levels can also help in later stages of feminization, though it’s effects are more debated.

The key axes you can use to modify things:

• Estrogens

• Anti-Antrogen

• Progesterone

• Non-hormonal

If you manage to get testosterone down under control, you want to make sure that your estrogen levels are high enough. Otherwise, you may get menopausal symptoms.

Anti-Androgen

This is the most important part to get right. There are a few ways to lower testosterone which I will mention, you may want to do your own research on side-effects and risks.

High estrogen levels

The simplest “anti-androgen”, is by having sufficiently high estrogen levels, that your body stops producing testosterone or estrogen on it’s own. This is only achievable with some methods of estrogen admission, which I will discuss later. This is my personally preferred method.

GnRH-Agonists

GnRH Agonists (and Antagonists2) are the most modern class of drugs for controling hormone levels.

This is a whole class of drugs, and ranges from pills, injectables and implants. The most easily obtainable being Relugolix pills, but depending on where you live you, medical systems can prescribe injectibles (such as triptorelin 3.75 mg/month or goserelin 3.6 mg/month) or by multi-month implants too.

These are the most effective and have the fewest side-effects compared to other methods, but are also more expensive, so are often not used as a first-line.

Bicalutamide

Bicalutamide is a non-traditional anti-androgen. It acts by blocking testosterone receptors rather than by lowering testosterone production, and thus often can lead to a rise in testosterone but a lowering in effects.

It is generally quite safe, there is some very rare liver risks (~1 in 1000) so you should take a couple of blood tests the first year or two that you use it to check for this, otherwise you should be fine. The elimination half-life is also relatively long (~1 week) so dose timing is not as important, typically it’s taken daily.

It is the best method if you can’t do the other methods, and has potential use as a non-binary HRT as I will discuss in a different post.

Cyproterone Acetate

This is another anti-androgen, that primarily acts similar to a progestin that blocks testosterone production and leads to lower testosterone levels. It has more potential side effects than previous options. It does slightly prevent testosterone receptors but is wak, . Normal dosing for feminizing is around 12.5mg/day or per 2 days.

It has some potential mental side effects, prolactinomas, liver toxicity, and mental effects. For this reason was not allowed by the FDA in the US through official channels, but it is one of the most common anti-androgens in the rest of the world.

Spironolactone

This is the weakest / worst anti-androgen that is prescribed, in doses of 100-200mg/day. It has relatively limited and inconsistent effects on testosterone levels in clinical studies. It is also a diuretic and makes people need to pee more.

It is seen as benefical to supplement B12 if you take spiro.

Other Anti-androgens

There are also a few others that are also work as anti-androgens, but don’t lower testosterone levels much / at all. You can see more in Retaining Head Hair post (which also includes discussion on Minoxidil)

Finasteride

Finasteride is typically only given as a DHT blocker In larger doses, of 5mg, it has some slight testosterone blocking effects too. Not typically enough to lower testosterone to female ranges.

Dutasteride

Dutatsteride is another DHT blocker. It also does not typically affect testosterone enough to lower it to female ranges.

Estrogen Admission Methods

There are a few types of estrogen, for most people we are interested in the most potent form, 17beta-estradiol, but there are other forms too (estrone, estrione, 17-alpha-estradiol). I will mostly only discuss the main kind of estradiol today.

It’s also worth knowing that estradiol can come in esters. This means that there is a little tail attached to it, which helps it be dissolved more easily in oil. This ester tail gets removed after entering the bloodstream, and thus the esters end up being bio-identical.

There were, in the past, synthetic estrogens which had bad side-effects such as blood clots, such as Ethinylestradiol, which can have longer elimination half-lives, but which also lead to increased risk of blood clots and some rare adverse effects. These are typically not recommended, though some continue to prescribe it.

Medical systems are difficult to work with in this space, and can have arcane requirements, so it can be worth working with medical systems or pharmaceutical vendors from places other than your home country. You can often find communities in your local area who can give better guidance on best medical options.

Different methods need different

Injectable Estradiol

The highest-consistency form of estrogen is to directly inject an ester of estrogen either into fat under your skin (subcutaneous or subQ) or into your muscle (intra-muscular or IM). This then stays around for a while, and the ester of estrogen leaks out into your bloodstream over the course of days.

This is most recommended, as it leads to most predictable results, and most reliably can be used for suppressing levels without an anti-androgen.

Based on estrannai.se, the half-life of esters are approximately:

• estradiol valerate: ~4 days

• estradiol cypionate: ~8 days

• estradiol enanthate: ~7 days

• estradiol undecylate: 20 to 30 days ish?

The best, most stable and reliable ester is Estradiol Enanthate. This can easily be injected once a week with relatively low spikes, and gives the most consistent levels from injection.

Estradiol cypionate is a close second, it’s slightly more “spikey” but has a similar half-life to enanthate.

Estradiol Valerate is one of the most common, as it is widely prescribed by medical institutions. It is significantly more “spikey” and has a shorter half-life, so is better to take on a 5-day or twice-weekly schedule instead of weekly.

Estradiol Undecylate has the longest half-life, around 20-30 days. This means it can be particularly useful as an option to take in advance of longer trips. However, it’s half-life is much harder to predict because there is less data, and there seems to be much more variance with what levels people achieve, and how it depends on carrier oil, etc.

There is non-zero concern that having slightly fluctuating levels of estradiol can be beneficial, but there is not much research into this.

Overall, Enanthate is probably the best option, or Estradiol valerate is good if it’s more accessible.

You can see guides online for injection technique.

Long-term Estrogen

It is possible to get Polyestradiol Phosphate intramuscularly, and Estradiol pellet implants implants, which can last for 3-6 months or so. These are quite uncommon, but can sometimes get directly from medical professionals in some countries.

Again, I have seen some little evidence that slightly fluctuating levels of estradiol can be beneficial, but there is not much research into this, so most likely you should not be too concerned.

Estradiol Transdermal (Gel / Patches)

Applying Estrogen transdermally (through the skin) is the next best way to achieve high estrogen levels. It is, however, much less consistent with dosing than with injections. It is sometimes possible to achieve mono-therapy this way, though an anti-androgen is recommended.

You can either get patches, or put on gels. Either option is fine.

If using a gel, site of application alters absorption significantly. Highest absorption but also highest variance is application to scrotum. Application to the chest is not advised due to potential breast-cancer risks.

Estradiol (Oral / Sublingual)

It is also common and possible to take estradiol orally or sublingually.

Sublingual (under the tongue) is generally much better as absorption can be significantly higher, 2-4x more.

With orally taken estradiol, it is typically not possible to reach mono-therapy levels, as it gets processed by the liver before entering the bloodstream. Thus taking an anti-androgen is advised.

Estradiol Stickies

If you have a limited supply of estrogen, then it is possible to create stickies that only need 0.4mg of estradiol per day. See this interesting description to learn more

• https://stickies.neocities.org/stickies

Progesterone

The last main hormone that varies in women is Progesterone. You can read this paper on it.

There is evidence to suggest this is helpful for advancing breast growth from earlier stages to later stages (causing the breast bud ducts to mature). This it is typically better to start this much later in transition.

The two main methods of administration are:

• orally (taking around 200mg), though most of this gets converted to allopregnanolone, and only a small fraction remains as progesterone. Allopregnanolone typically makes people sleepy, so people sometimes take it before bed.

• boofing, administering rectally daily makes it easier to absorb higher levels without being converted to allopregnanolone.

It is possible to get injections of progesterone, but the half-life is much shorter, and it’s not as important as estradiol. This, most people don’t find that it’s worth ~daily injections and it is not particularly commonly prescribed.

There are some gel recipes for progesterone too, but these have not been tested that much either.

The main issue, is that it is not possible to easily add an ester to progesterone, and only synthetic progestins are common. However, these are associated with bad side effects and are not particularly safe to take long-term.

Other compounds

Pioglitazone

Another drug, as mentioned in “gaining fat in the right places” is pioglitazone. This has been shown to somewhat improve feminine fat distribution and promote the creation of fat cells. It is somewhat recommended to only take this after you have already been on HRT for a while.

Domperidone

This is another drug that can be used to induce lactation, and can lead to larger breasts while taking the drug. It is probably better to not take this too early on in transition. It may have some risks too, so you should look into those.

This is typically only used to treat nausea, and the lactation is more of a side-effect, so it’s not commonly prescribed.

Final Thoughts and Other Considerations

There is a lot of research into these various compounds for femenizing HRT.

One default that doctors like to err towards, is to have the minimal possible amount of estrogen that leads to feminizing effect, and often start with prescribing placebo-level doses. However, the risk of high-estrogen levels is not particularly with non-orally administered bio-identical estrogen (other than some possible increase in breast-cancer risks over very long periods of time), so you may want to consider starting at a higher dose and working down, as time on a sufficient level of HRT is what leads to results.

You also might want to consider that many people with gender dysphoria often have some abnormalities in their processing of hormones, in their testosterone and estrogen receptors. You may want to try different things if this is the case, rather than blindly increasing estrogen levels. I will write about this more a different day.

It may be worth looking at my weight-cycling series for some more info on that too.

I will probably spend another day discussing non-binary HRT and masculinizing HRT as the requirements for these are different.

If you are assigned male at birth, then for various reasons, you may want to do gamete storage. Having kids is one aspect on which people have a relatively reasonable chance of changing their minds about as they get older, so it can be worth preserving optionality by storing gametes sooner.

If storing male gametes (sperm), it is typically not as pressing and urgent to bank them ASAP as with female gametes (eggs), but there are plausibly minor benefits to banking sooner in the base case (risk aversion), and if you are reading this, then there are various medicines and treatments that can interfere with sperm production (gametogenesis), including both feminizing HRT (anti-androgens) and some masculinizing HRT (eg: exogenous testosterone or anabolic steroids). This is often reversible, which I will discuss later.

I will discuss briefly how gametogenesis works, what factors to consider before doing storage, and briefly what the process looks like

Sperm Creation / Spermatogenesis and Heat Exposure

The sperm creation cycle takes about 74 days from start to completion, and occurs within the scrotum. This process is very heat-sensitive, and so the scrotum is typically kept at a lower temperature, about 2-4°C below body. Too much heat in some parts of the process leads to apoptosis (when cells die voluntarily).

Eg, from a paper:

A short exposure of the testes to heat by immersing the scrotum in a hot water bath at 43 °C for 15–20 min also results in germ cell apoptosis

The amount of apoptosis depends on how hot it is, and also how long the exposure is. If you are storing, you want to avoid heat as much as possible. This includes avoiding saunas and hot-tubs, but also generally avoiding being outside in very hot weather. There are small but measurable reductions in birth rates in national statistical following particularly hot days / heat waves.

If you have any medications that are contraindicated with sperm storage / conception, then you should avoid them, the washout period depends on what drug, sometimes it’s a short time, but other times it can be for the whole 75 day period.

Quality Metrics

There are a few metrics people use as a proxy of sperm quality, and the WHO guidelines on what is acceptable (though clinics may have different thresholds)

• volume (>1.4 mL)

• conc. of sperm (>16M)

• progressive/total motility (% that move) (>30% and >42%)

• morphology (most vibes-based and doesn’t matter as much, but >4% is “good”)

You can also measure other metrics, but they cost more money. If you want to consider an additional one, you could look at:

• DNA fragmentation (how much of the DNA is damaged)

the exact measurements that are good that differ between clinics, but there is typically a minimum threshold they need for each of these to consider banking.

Measurements can also differ substantially between samples.

Things that affect metrics

The main thing, as mentioned before, is to avoid heat.

A main supplement you may want to consider, is a moderate dose of Zinc. This has been shown to often increase volume so you get more stored per session.

Being generally healthy and active and avoiding alcohol helps.

Some others from wikipedia:

Dietary deficiencies (such as vitamins B, E and A), anabolic steroids, metals (cadmium and lead), x-ray exposure, dioxin, alcohol, and infectious diseases will also adversely affect the rate of spermatogenesis.

If you are not currently on any medical regimen, then it’s not that expensive to test the main metrics, though it is somewhat annoying. I will discuss the process in a later section

Can you restart spermatogenesis again post-HRT?

Most HRT regimens causes spermatogenesis to be greatly reduced or stopped. People used to believe this might be permanent, but there is a small study with 9 transgender women, who stopped HRT who all could later produce sperm again.

The majority were producing sperm within about 7 months or sooner, but some took more than a year

And though the evidence is in favor, it is also is not guaranteed that it will work. You can consider yourself whether you would find it more mentally painful to delay transition by some time, or to see yourself re-masculinize at some later point in time

If you started HRT at a very young age before the testes were fully developed, it’s unclear whether it’s possible to induce spermatogenesis later post puberty. It’s highly uncertain, but plausible that it might take years, or it might not be possible at all. There is not research in this direction

Storage Process

Generally, the process for gamete storage looks like this:

• Find a place that offers sperm storage, most typically this will be an IVF clinic that happens to also offer sperm storage. In this case, you probably want to see how good their IVF success rates are, but it is also usually possible to ship gametes between clinics. (Cross-country this can be more difficult though, check restrictions)

• Make an appointment with them

• You will need to do some tests before you do storage. This means typically producing a sperm sample, as well as a blood/urine test to see if there are any STIs (depending on the clinic, they may reject you, or they may just need to handle the sample differently)

• Producing a sample involves abstaining1 for about 2-7 days, but depends on the clinic. A period of 2-3 days is considered around optimal, you don’t want it to be too short or too long.

• Depending on your quality and volume, you probably want to produce at least 2-3 samples to be stored.

• It is possible to directly store embryos if you already have a partner and they are willing to store embryos at the same time

Then after this, they will be split up into multiple “straws” per sample, placed in a cryoprotective fluid, and stored under liquid nitrogen temperatures (-196°C) for as long as you are willing to pay them, and for as long as the laws in your jurisdiction allow.

In many places, it is also alternatively possible to extract gametes surgically if you are unable to produce samples otherwise, or if parameters

Depending on where you live, it may be easier to leave your country and store them in a neighboring country where situation can sometimes be more favorable.

Post-Freezing

After freezing the sperm, it’s worth noting that that there will be some degradation in quality from the process of freezing them, this is partially why there are minimum standards to freezing.

Depending on how much you stored, different procedures can be more or less viable.

The lowest-cost procedure is to do IUI (intra-utary insemenation) which involves directly inserting sperm into a womb after inducing an ovulation cycle. This requires the most amount of sample

If you have less to work with, IVF or ICSI done with extracted eggs is more sample-efficient.

It’s also worth considering the legalities with gamete storage. Some countries only allow storage for a very limited time. Some don’t make it easy to transfer samples abroad. Some have different rules on what happens after death. Some places have special restrictions if you want the option of surrogacy. You should probably look into these questions for your country.

Closing

I may try to provide some anecdotal examples of what this process looks like at a later point.

• short term hair removal

• medium-term hair reduction

While laser can do a lot to help reduce hair growth, it’s rare for it to completely fix the issue. It also has limitations based on

The only currently known way to permanently remove hair is via electrolysis. I will describe the main advice briefly, then yap a bit more about other things.

This requires your hairs to be growing in order for them to be easily accessible, which means no plucking/waxing for 4-8weeks prior, and no shaving for ~48 hours prior.

Electrolysis TL;DR

Electrolysis is the only method FDA allows to be labelled as “permanent hair removal” rather than merely reduction.

It involves, one-by-one, applying a needle-like probe into a hair follicle, and killing the hair follicles with heat and/or electricity, then plucking the hair out.

As you can imagine, this killing hair follicles one-by-one is slow and painful.

Usually one goes to a clinic, and pays in intervals of, eg, 15 minutes. I have found a typical pace to be an average 1 hair follicle per 10 second, or like 3-400 in an hour-long session. So with 1000s of hair follicles on the face it can take a long time, and you need to come back as the different hairs grow in their different cycles.

For many, you probably want to apply numbing cream before going, probably AMETOP cream and take an ibuprofen before going.

Electrolysis in depth

Types of Electrolysis

There are tree main types of electrolysis:

• thermolysis - this involves heating the root of the follicle, and damaging the hair follicles locally

• galvanic - this involves using electrical current to cause a chemical reaction that locally damages the follicles. rarely done alone anymore

• blend - you can also do a combination of the two, which also allows the heat to speed up the the chemical reaction.

The most common method by far is thermolysis, it is the fastest and cheapest of the methods.

The other option is to do a blend of galvanic and thermolysis, which is less common but still sometimes available in north america.

An old study from 1996 found that galvanic blend works better then thermolysis, mostly meaning that a smaller portion of incisions lead to regrowth.

If you want to minimize how many electrolysis insertions you can get, a galvanic blend is the best method, but in practice it depends on availability, and thermolysis will usually get you the same results but with more sessions.

Pain Numbing

It depends a lot on clinician and machinery and the person, but many find electrolysis quite painful, and there are ways you can reduce the pain. The simplest way is to take ibuprofen/acetaminophen. But the reduction in pain is not that pronounced for this kind of procedure, so more topical solutions are helpful.

Before using these, you should check you don’t have pre-existing conditions that might mean they are not recommended. Most people are fine when applying to a small area such as lower face, but if applying numbing cream to much larger areas or to your whole body, there is additional risk of complications.

A common thing that helps, is to apply a numbing cream before the procedure. The two most common ones are:

• ELMA cream (2.5% lidocaine + 2.5% prilocaine) applied 60 minutes before

• AMETOP (tetracaine 4%) applied 30-45 minutes before

The difference is not huge, but AMETOP is is slightly better (lasts longer/reduces pain more), so it is the preferable of the two options.

To apply, you put it on clean skin, then cover with a film to prevent it from evaporating (you can use included applicator strips or standard kitchen cling film) some time before the procedure. Then go to the clinic and remove immediately before the procedure.

In some places, it is possible to get a stronger numbing cream, though availability can vary, and often a prescription is needed. For example:

• Pliaglis (7% lidocaine + 7% tetracaine)

Occasionally, it is also possible to get a stronger numbing directly by the clinician, by getting direct lidocaine injections near the site of electrolysis. Though for this you will need to search for a clinic that provides this.

Scarring

One possible issue from electrolysis is that you may get some scarring. In theory, electrolysis should not cause scarring, but technique is not perfect, and so this depends somewhat on clinician. Thermolysis has higher risk of this than galvanic and blend. And it is probably slightly better to try to distribute the electrolysis over the whole area you are getting processed to reduce inflammation.

Other Electrolysis Options

It is possible to do electrolysis DIY, but the method for this is pretty sketchy, and less safe than clinical. You can see this guide by Lena as one possible method. I don’t recommend this.1

Additionally, clinical electrolysis machines are not that expensive, that it is possible to get a community project to fund a location and train someone to do electrolysis.

Closing

Overall, electrolysis is pretty effective. It is incredibly annoying to do, but means that generally all the hair is gone permanently. You still need to potentially worry about hormonal driven future hair growth, which can also be controlled by managing DHT as mentioned in a previous post.

Yesterday I wrote about short-term hair removal techniques.

Today I move on to medium-term hair reduction techniques. I mostly talk about laser here, but briefly talk about home IPL and Eflornithine.

As discussed yesterday, you may want to also make sure your DHT levels are low too, to prevent new follicle formation and somewhat reduce intensity of growth. This can be done with an 5-alpha reductase inhibitor such as finasteride or dutasteride (as mentioned in preventing hair-loss article), but spironolactone and cyproterone acetate or a GnRH-agonist can help too.

Note that for the most part, many of these only work if the hair is currently growing in the hair follicles, so doing laser after waxing is a no-go. You want to wait like 4 weeks until the hairs grow back. You also want to avoid too much UV exposure and retinoids on the areas too.

And none of these are truly permanent, they only reduce hair growth. I will talk about permanent hair-removal tomorrow (ie: electrolysis)

Laser Hair Removal

One of the most common and well-known hair reduction techniques is via laser hair removal.

How long does it take?

Typical starter pack is to do ~8 sessions spaced apart by 4 weeks (though for many it takes much longer, 12-20 sessions, or spaced apart more, 6-8 weeks) followed by lower frequency “top up sessions” afterwards.

Only actively growing follicles are affected by laser, and you have many hairs each in different phases of growth. Thus it typically takes many sessions to get all the hairs while they are in the growing phase.

If you want to get the most hair removed in the fewest number of sessions, then you typically want to wait around 4 weeks between sessions on face, and longer on other parts of the body.

If you have more money than time, you are also able to do it more often than this, but there are diminishing returns.

Some Considerations on Hair and Skin Color

It is possible to do procedures that remove hair more. The main contender for this is laser. Before going into detail about it though, it’s worth knowing vaguely how it’s supposed to work.

The main idea is to shining very high intensity light in short bursts, which should hopefully get absorbed mostly by your hair, but not interact much with your skin. Ideally for this, you would want to have a combination of:

• very dark hair

• very light skin

deviation from this does not necessarily mean that it wouldn’t work, but the further away from this ideal you are, the less well it would work.

Hair color types

If you have black or dark brown hair, laser is usually viable.

If you have a middling ligher brown hair, or red hair, then it’s more iffy, but it can still sometimes work and be helpful.

If you have grey or blonde hair, then hair removal is unlikely to work at all, and there is higher chance of potential risks.

It’s worth noting that people’s body hair and facial hair can often differ in color, so you should be judging based on the color of the hair you want to remove, but typically these are quite correlated.

Skin color types

There are rough categories for skin types, labelled on the fitzpatrick scale.

I will roughly categorise these as:

• Fitz I-III light skin

• Fitz IV medium skin

• Fitz V-VI dark skin

The lighter the skin you have, the easier a time it will be to get laser hair removal, though there do exist different laser types that can help.

Laser Hair Removal Types

The balance with light sources is that you want it to be as absorbed as possible by the hair melanin, but as non-interacting as possible with skin melanin. There are a few different methods but it’s kind of variable.

There are a three main laser types used these days:

• Alexandrite 755 (most absorbed by melanin, but for lighter skin only)

• Diode 810 (intermediate)

• Nd:YAG 1064 nm (least aborbed by skin but also less absorbed by thin/light hair)

it is also common to get non-laser high intensity pulsated lights (IPL 500-1200 nm).

Clinical IPL is supposedly not quite as good as 755nm for light-skinned people, but is inexpensive and can sometimes give similar results to 810nm and 1064nm. For darker skinned people, Nd:YAG is the safest option and IPL is much worse.

If you are light-skinned and dark-haired, you can mostly just go to any laser clinic and it will be fine. If you are not, you may want to put more optimization into looking for the best solution.

Risks

if you have medium skin, or particularly darker skin, then there is a higher risk of Paradoxical Hypertrichosis, meaning that you may get increased hair growth instead of a reduction. This is relatively rare and treatable, but it’s annoying.

Home IPL

Same mechanism as Laser Hair Removal, but using intense pulsated light (IPL) instead of any of the laser options.

It depends a lot on device, and on your skin/hair type. If you have black hair + pale white skin, then it can be quite helpful, but there is a lot of variation in how much devices work, and they are not that well regulated.

Most home machines are much weaker than clinical machines, and deliver much less energy per pulse

rough guess by claude: home 3-10 J/cm² vs clinical 15-30+ J/cm²

It is also to get paradoxical effect (getting more hair growth) if you are unlucky.

Don't use on tattoos, moles, or near your eyes, and be careful to wear goggles.

Eflornithine HCl (Vaniqa)

If applied twice daily, it can be used to help slow hair growth somewhat (supposedly by about ~35%), though growth returns to baseline after ~8 weeks of stopping. Mostly just product that can marginally help.

Closing

Remember that none of these techniques are perfect or going to completely kill your existing hairs. The only true method for this is electrolysis, which has its own tradeoffs, and which I will talk about tomorrow.

There are a few main methods of hair removal. I will discuss the main things below about shorter-term options (ones that you need to do consistently, that don’t address longer-term growth), and in the next post I will discuss longer-term options.

Preventing Hair Follicles from Forming

You probably want to make sure that the hair follicles have stopped forming. These are mostly downstream of DHT levels. If your estrogen and testosterone levels are in the female range, growth of new hair follicles should be minimal. Otherwise, you may want to consider anti-androgens, or especially DHT blockers, for which the discussion is mostly the same as in the retaining head hair page. This should make hair growth slightly less overall also.

Short-Term Hair Removal

There are ways to remove your hair in the short term. These can be fine, but you will need to keep doing them.

Surface-only Methods

Shaving

This one is mostly obvious. You run a blade over your skin to cut the hair that is sticking out off. It does not cause your hair to be thicker, but it can appear so due to the larger cross-section at the cutting site.

My understanding is that Multi-blade razors can cut slightly below the surface of the skin, which makes the time until it’s visible again slightly longer, though for some people, especially with curly-haired people, this can cause razor bumps/PFB.

Hair Removal Creams

Thioglycolate creams somewhat dissolve the keratin disulfide bonds, at or just below the skin surface. Also obvious, lasts longer but non-permanent

This can lighten and thin out the hair somewhat, also temporary.

Some people (~10%) get dermatitis, so it’s worth patch testing if you haven’t tried it before. Don’t apply to broke skin or more often than every 72h. Creams used on face should be weaker than ones used on the body, don’t get burned.

Deeper Methods

These involve pulling the whole hair out, regrowth takes 2-8 weeks.

These should NOT be done in the prior 6-8 weeks before you do longer-term hair removal such as Laser or Electrolysis.

Waxing & Sugaring

Most commonly known, pretty obvious. You apply a wax strip or sugaring substance to your hairy skin, and pull to take out the full hair down to the root.

There is some risk of getting some folliculitis (spots from your follicles getting slightly infected).

You should, avoid applying retinoids to areas you intend to get waxed for ~5 days, as it can increase risk of epidermal tears.

Threading

This is mostly a higher-precisision way of pulling out hairs, where you use a twisted cotton loop against across the skin, and hairs get caught and pulled out.

Most commonly you will see this for brows, but it can also be done for upper lip and jawline.

Tweezing, Plucking, Epilation

This is essentially the same method. Epilation just plucks more hairs at once.

Repeated plucking can rarely cause focal scarring or distorted growth.

I will discuss more about longer-term methods in the post tomorrow.

Now given that you have had your hairline stable for 6-12 months, there are other things you can try. (Some of these you can also try sooner, but there is a higher chance that you won’t get the results you want.

Note that I did not personally need to get any of these, so there is the caveat that this research was mostly recreational. There are likely more mistakes than in other sections.

Supplemental Therapies to hair regrowth

To supplement your finasteride/minoxidil regiment, you can try:

Microneedling Minoxidil

While you can be using topical minoxidil to prevent balding in the first place, you can additionally supplement the topical by microneedling minoxidil to sites where you want it to regrow hair. It has some effect, but it’s not particularly guaranteed to have large effects. It seems to have a lot of variation between people

Low-level Laser Therapy (LLLT)

Another method which uses lasers with red light to stimulate growth. I don't know as much about this method, but it can have some marginal gains to hair growth over time. If your case is borderline, it can help make it a bit better. It needs 3 times weekly adherence of 20 minute sessions, and help by maybe like +20 hairs/cm2, which is good but annoying and still relatively marginal

Platelet-rich Plasma (PRP)

I haven’t really heard of this much. There are some small trials showing it might have marginal help too, but it’s not going to save you on it’s own, and it’s kind of expensive. I will probably need to update with more info when I learn more.

Things still under research

There is some potential for the future on things that might also help regrowth:

• PP405 is in clinical trials, entering phase 3

• HMI-115 is also in clinical trials, entering phase 2.

But it’s too early yet to know. If you know anything about these you can comment about them.

Hair Transplant Surgery

The solution that works most strongly is hair transplant surgery. This is costly and time consuming, but it has been shown to work. You want to be sure that your existing hair-loss has stabilized and stopped before starting this though. There are a couple of main different methods for this.

The hope with hair transplant is that if you get donor hair (from other parts of your body), that it does not have the same DHT sensitivity as your own hair that might have caused you to lose hair in the first place. The two main techniques are below:

Follicular Unit Transplantation (FUT)

FUT is a slightly faster and cheaper procedure. A strip of scalp is removed from the donor area, and that strip is then dissected into individual follicular units for implantation. This means that there will often be some minor scarring that is visible, though usually hidden under hair. This does mean to some extent that shorter haircuts become less viable.

FUT is limited to only taking donor hair from other parts of the scalp, such as the back of your head.

There is some limited research on preventing scar formation from wounds, but the research here is relatively lacking and early days. I will write about it in a future post.

Follicular Unit Excision (FUE)

FUE is the most common hair transplant procedure these days, but costs slightly more. It slower and more time consuming procedure, where they graft hairs one by one. This means that fewer hairs can be grafted overall, but also that there is no particular visible scars.

FUE has the benefit that it can take donor hair from other parts of your body than just your scalp (such as Beard, Chest and Back), though these are slightly dis-preferred for having different growth cycles and textures

It is also possible to get a combination of both methods, such as FUT followed by FUE in the surroundings so there is less visible scarring.

Conclusions

Overall, there are some methods for regaining hair on your head, but there is not simple silver-bullet solution.

You need to first stop hair loss by using a hair loss prevention technique, and you can try to restore some growth with some more early stage experimental techniques, but restoring a full head of hair typically does require surgery, and even then the results are limited depending on how much hair loss you have already had.

Most people do not want balding on their head.

If you are a man, you have high testosterone levels may also lead to downstream balding too.

If you are a woman, and transitioned only when you were older, you may have experienced some balding.

I will try to explain what causes balding, and some interventions you can do to try to prevent it.

What causes Male Pattern Baldness (MPB)?

There are a few kinds of balding, but the most common kind is called androgenetic alopecia (AGA), which is seen as Male Pattern Baldness (MPB). It is highly heritable.

Testosterone in the blood is converted by the 5-alpha-reductase (5-AR) enzymes into DHT. (there are 3 types of 5-alpha-reductase). This then causes balding in some, depending on genetics.

The typical pathways differ:

• The most common genetic factor, is that your follicles become more sensitive to dihydrotestosterone (DHT).

• For some, the DHT just causes more growth inhibitors locally.

• For some, some DHT production is locally higher at the scalps.

DHT Is also responsible for stimulating facial and body hair growth, but in adulthood is not that responsible for that many other things.

This, one key pathway to preventing Male Pattern Baldness is to prevent DHT.

Other factors?

Some other factors that can also increase the chance or severity of balding:

• Smoking might increase risk. One study showed it increased the chance of MPB by about 2x compared to non-smokers, but I have not read broadly here.

• Sleep, stress, insulin resistance, and dermatitis can maybe affect things, though the effect seems likely not that big from most of these. I haven’t read much here.

• Diet can matter, if you are deficient in some nutrients that can sometimes cause balding too.

But these are not usually the main factors

Norwood Scale

It’s worth briefly touching upon the Hamilton-Norwood Scale. It shows the progression typical for Male Pattern Baldness (MPB). You can see the diagram above. It is common to describe your hair as having a certain level of MPB, such as “Norwood IV”.

The Standard Recommendations

The most typical recommendations to try to prevent balding, is to use a DHT blocker such as finasteride/dutasteride, and/or to use minoxidil. I will discuss these somewhat below.

Finasteride

The most common prescription, is to take 1mg of finasteride orally daily. It has a half-life of about 6 hours.

This primarily acts on inhibiting 5-alpha-reductase type 2.

This then means that scalp DHT levels drop by about about 64% on average, enough such that for most men, hair loss is halted.

One hope for some amount of regrowth, but it’s mostly the case that only hair lost in the past few years will grow back.

Risks?

There are non-zero risks for men, but they are quite small. Erectile dysfunction increases from ~0.7% in the placebo to 1.3% in the active group, and gynecomastia risk increases from ~0.1% to 0.4%. I overall count this as not significant and pretty minor.

Topical Finasteride

Alternatively, one can apply finasteride topically. A 0.25% solution of finasteride spray applied once daily is non-inferior to 1mg of oral finasteride, but has a less significant drop in serum DHT (~34% vs ~56%).

Dutasteride

An alternative to finasteride to have stronger effects, is to take dutasteride. This blocks all three 5-alpha-reductase receptors (though type 3 to a lesser extent), and also has a longer half-life (~4 weeks instead of 6 hours).

While people can take 5mg finasteride, the difference in DHT is not big compared to 1m doses, but it does have more side effects.

Instead, 0.5mg dutasteride reduces DHT by about ~92%.

There is, however, more chance of adverse sexual effects with dutasteride too.

Minoxidil

The last common treatment discussed is minoxidil, typically taken as a 5% topical solution applied to the areas where you want hair to grow.

Effectiveness of minoxidil is somewhat variable and depends on genetics. You need to have SULT1A1 enzyme activity for it to work.

The way it works is more complicated than I have time to describe rn, but I will maybe come back to it at some point.

Oral minoxidil

It is also possible to take minoxidil, and 1mg of oral has been shown to be similar in effectiveness to 5% topical on some axes, but it’s much less studied, so I’m not sure

Risks

Minoxidil can be fatal for pets

It can also cause hair growth in undesirable locations if you let it drip

Other Considerations

If you have low testosterone, this should already cause you not to produce DHT. It is possible to to have other kinds of balding, but I will discuss those some other time maybe.

Other Topical Solutions

These are some alternatives have more limited evidence:

• Ketoconazole 2% shampoo might work

• Topical 17-alpha-estradiol might work, used moreso for female pattern baldness though.

Here are some other compounds that are still undergoing clinical trials, but these topical solutions have had some promising results:

• Clascoterone 5% topical (Breezula)

• GT20029 (Kintor)

• Pyrilutamide / KX-826 (Kintor)

Actual recommendations?

It may be worth doing a genetic test to see whether you are at risk of male pattern baldness. If you are not, then there is no need to do any of these steps. This can be expensive, but is getting cheaper every year. Alternatively, you can just look at your family history to get an idea, or notice if you have any changes to your hairline.

If you do want to take these steps, it may be worth doing a Prostate-Specific Antigen (PSA) Test, in order to have some baseline, especially if you have a prostate and are at high risk of prostate cancer, and are not sure if you want to do full feminization. But if you do decide to transition, then you don’t really need to worry about it.

Otherwise, the standard recommendation, is to go:

• start with 1mg finasteride taken orally daily.

If you prefer a topical solution or want to double up, you can go:

• 5% topical minoxidil daily

You will need to take at least 6 months to see if it’s working. If not, you may want to upgrade to to dutasteride.

There are other things, but I will need to add them at some later point.

You want to gain weight in the “right places”. Generally as a man, this means gaining muscle (which will be discussed separately), and as a woman this means gaining both fat and muscle. I will discuss here for women on how to try to gain desirable fat deposits (hips, thighs, buttocks, breasts) rather than in undesirable places (abdomen, back, chin, arms).

Yet again, as said in the weight cycling and down-cycling post, the most important factor is making sure your hormones are correct. Some of this will naturally cause your fat to redistribute in desirable way. This has the strongest effect of anything here.

A lot of content from here is directly inspired by this Mesityl post. See content in related posts too:

• weight cycling introduction

  • maintaining downcycle + selective fat removal

  • maintaining upcycle + selective fat gain (you are here)

Interventions

(beyond making sure your hormone levels are correct)

Surgical/Fat Grafting

It’s not specific to gaining weight, and there is a lot of content on this, so it mostly warrants its own post. You need to have enough fat on your body as a whole to to be able to graft it to desireable areas though.

The main option for gaining fat in areas is to do surgical fat transfer. This includes hip/butocks procedures like BBL, and in the breast like FTBA. These typically lose around half of the transferred fat in the final results (depending on method, technique, and after-care), but is still typically quite effective.

There do also exist procedures for implanting more guaranteed forms such as silicone instead, though some dislike that it can have an unnatural effect, and may need to be replaced after a long time. There have been various methodological advances all of these surgical procedures, and some older methods can be quite risky and dangerous.

Active Interventions

Exercise

This page is more focused on desired fat gain rather than muscle gain. But you should also be considering muscle gain and some exercise anyway.

This should be obvious. If you aren’t doing it, do this first. It is, for the most part, basically free. (Yes you! Stop ignoring this! I know you don’t want to hear it!)

If trying to get a wider hips, lower body exercises such as trapbar deadlifts or hip thrusts would help increase hip circumference, and would improve both your waist-to-hip ratio and shoulder-to-hip ratio. Even 2x per week having like 3 sets of both of these is good. It’s really much less effort than you are probably putting into reading.

Exercise can reduce waist circumference independent of body-weight change—i.e., you can gain/maintain weight from lean mass while the waist still shrinks (android fat/visceral fat falls).

Sleep and Stress

Cortisol can cause some increases in abdominal fat. You should get enough sleep because this decreases cortisol and stress somewhat. Prioritise getting 7-9h sleep per night.

Alcohol Avoidance

Alcohol has modest androgen increases in women, raises cortisol, and also of abdominal fat. You don’t want that.

Weight gain supplements

Thiazolidinediones (TZDs)

One can take TZDs, most commonly Pioglitazone or “pio”, though there exists others such as Rosiglitazone (which is less good).

Pioglitazone

“Pio” is an anti-diabetic medication that activates PPAR-gamma systemically, reducing insulin resistance, gluconeogenesis and overall blood sugar.

It can improve WHR, and a main mechanism of this is by causing more fat cell creation (adipogenesis), but in a manner that seems to specifically target feminine fat distribution

Here is a more detail paper on pioglitazone. This article has some more detail too:

It has been shown to lower visceral fat70 and WHR even in patients who’s overall BMI remained the same71. It seems to protect subcutaneous fat in a way similar to estrogen72. There has even been one documented case of pioglitazone use to achieve female fat distribution in a transgender patient in the medical literature73.

Anecdotal reports of people taking pio seem quite good too.

The main risk, with bone-fractures after long-term use. This is because activating PPAR-gamma reduces oseteoblast bone cell creation to cause the increased adipocyte fat cell creation. Evidence is thin, but suggests it’s an issue for women but not men.

There is also risk of increased water retention (so is contraindicated in late-stage heart disease, though is beneficial in reducing heart disease overall), and some smaller possible potential bladder issue (in the form of slight bladder cancer risk increase1)

Using it long-term continuously generally not recommended. Trying it for a few months while upcycling, or having a few phases month-on month-off are some strategies that people do use.

Topical Pioglitazone

Typically people take it orally, but there are some reports of taking it topically: * Topical Pio + AH38. Unclear how much it helps or not, probably a lot is from systemic absorption.

Topical Solutions

Most of these are highly speculative, and rely on anecdotes and small industry funded studies.

Acetyl-Hexapeptide-38 (Adifyline®)

Adifyline®, topically applied increases PGC-1alpha expression, stimulating adipogenesis and lipid accumulation as a consequence

The local effect of the drug could be leveraged to selectively increase fat in certain areas and thus improve WHR/fat distribution.

In general, reports are pretty hit-or-miss, unclear if due to application method differences or genetic differences or both. There is like, one study on it:

• Adifyline Peptide Brochure

Stories from people:

• Reddit post on Adifyline with information on dosing, as well as Follow up comments from the author, seems to think it works.

• Other reddit post, no method reported, didn’t seem to work for them.

• Other reddit post, strong positive results, reports increasing from A/B-cup to C-cup. “I made the mistake of putting it on my butt and I feel like an hourglass and I don’t like it perhaps because I wasn’t ready for such a transition”

Acetyl-Hexapeptide-39 (Silusyne®)

Topically AH-39 supposedly decreases PGC-1α expression, diminishing adipogenesis and lipid accumulation as a consequence.

It could potentially be used topically to selectively reduce fat accumulation in certain areas and thus improve WHR/fat distribution.

However, there is, in general, very little literature on this.

The Mesityl - MTF Weight Cycling post has some discussion on this, and implies that it would work for the down cycle, though it could also make sense for the up cycle to inhibit growth in certain areas.

Volufiline

Volufiline is a patented cosmetic preparation containing Sarsapogenin which has been reported to stimulate adipocytic differentiation and adipogenesis by activation of PPAR-gamma. Similarly to the hexapeptide-38, it can be applied topically and perhaps even used synergistically.

• Volufiline Brochure / Patent filing

Some recommend buying sarsapogenin directly:

• Reddit post on buying sarasapogenin

I am less convinced about this than some other things here.

Growth Hormones and Various Peptides

There exist various other peptides and growth hormone related products, these are generally used for gaining weight in general, or trying to gain muscle. These are out of scope for the topic of this post.

Overall

There are some things you can try doing to improve distribution of fat, and muscle. Some of this is limited by your bone structure, but that is discussion left for another post, and often people perhaps overestimate what is doable through shaping of soft tissue too.

In general, a lot of these are under-studied, so if you are interested in funding research in this, or trying to take any of these things and record your results, then that would be helpful in understanding how effective any of this is.

If you are weight cycling, or otherwise trying to gain weight so as you generate new fat deposits in desirable places in your body, there are a few things you can consider.

While people often think that losing weight is hard, and thus gaining weight must be easy, this is not true. At least, not if you want to purposefully gain weight on a short time scale.

Personally, I found it very difficult, as I would constantly feel bloated and sluggish from eating too much food, and many others experience this too.

That being said, there are some marginal things to consider that may be helpful

The single thing that technically matters, as with the down-cycling post, is that you need to make sure that your caloric intake is higher than your caloric output.

As mentioned in the Mesityl post, this does not mean that you should avoid doing any exercise or physical activity, as these are also important and beneficial. It also does not mean eating countless unhealthy foods, as these also can negatively affect you. Alcohol should also be avoided as it increases abdominal fat.

Are there things you could focus on?

Diet

In terms of diet, eating denser foods generally helps. Eating nuts or protein bars is pretty effective, but you still need to continue eating even once you feel full. Adding more oil to your meals or eating oil directly sometimes helps. Eating more liquid calories in general sometimes helps.

Supplements

There are various supplements and medications that may or may not help. Leucine and Argenine may help activate mTOR, and stimulate lipid synthesis and cell growth. But the effects of most things are relatively marginal.

Medications

There are some medications that have weight gain as a side effect. These generally are not recommended to take for the sole purpose of this though.

Feminising HRT, as a side effect already causes some to gain weight. Embracing this is useful. Pioglitazone has been noted to have some effect in weight gain, which I will discuss tomorrow in more detail for its fat re-distributive effects too. Domperidone can help too.

Some others are SSRIs/SNRIs, Antihistamines, non-bioadentical progesterone, Beta-blockers, Corticosteroids. But these are typically not worth taking for weigh gain effects alone

Peptides

There has been some research in trying to find peptides, but the research so far has not been particularly promising for candidates.

Anamorelin is the only one that has been approved in Japan showing lean-body-mass and appetite benefit for cancer cachexia patients, but there is not much research outside this area. It was not approved by FDA because there was no improvement on strength metrics, though that doesn’t necessarily mean it makes no difference for us.

Capromorelin has been shown to work as an appetite stimulant in animals and is used in vetinary circumstances sometimes, but research in humans was discontinued.

Other petptides like Relamorelin, and Native ghrelin also are not really worth considering.

Overall, the main advice for consistently gaining weight is to just put will power into eating more. Often through eating denser foods.

I will discuss in the next post on attempts for making the fat goes in the right places.

In this post, I try to describe some of the research in compounds used for selectively reducing fat more from some places than others. Part of this is in relation to weight cycling, but some of it is more specific.

If you are losing weight, you also want to try to make sure you are losing it from the right places.

This can be broken down in two ways: altering the hormones that push some fat cells to empty faster than others, and actually removing adipocyte cells rather than emptying them.

The single biggest factor is having your hormones correct. If your body has a hormone profile of the wrong gender, you will not get good effects, and other things will be marginal. You should be on HRT1. There is detailed information on this. Many of the things listed here are marginal, and would be achieved anyway were you to have the correct hormone profile for a longer period of time.

There are a lot of things NOT worth trying based on current evidence, so I add all of those in a footnote

Removing Adipocyte Cells

By default, losing weight does not kill adipocyte cells. They instead just lose some of the fat that they contain and get smaller. This makes it harder to control where weight will be regained in the future.

There are a few methods actually removing adipocyte cells, but they are all somewhat costly and invasive.

Liposuction fat removal and fat transfer

You can directly remove fact cells from the body surgically, and doesn’t require weight loss otherwise. This is the main baseline.

For health effects, this does not have the same effect as losing weight, since it only covers external fat, and not visceral fat on organs. There are also is issues with skin tightness/laxity, and complications rates are still non-zero for surgical procedures.

Generally people prefer to get fat-transfers rather than pure fat removal, as some tend to regain weight in other parts of the body later, but the removed fat stays removed.

Subtype: Laser-assisted liposuction

You can possibly help skin-tightening somewhat with lasers, but there is no medical consensus yet. There is some an increase in surgical complication. I have yet to look into this more.

Cryolipolysis Fat Freezing

One can cause fat cells under the skin to die by lowering them to a temperature that causes them to die and be cleared up. Shows losses on the order of ~3.56 cm circumference; ~5.22 mm fat thickness in this review.

There is however some risk of a paradoxical reaction too, where one

Fat killing injections

There are some injectable compounds that can cause a similar effect to fat freezing. These are still usually kind of specific and experimental. Some treatments have been called out by FDA as dangerous. There are a few that I will note as perhaps use-case specific but these mostly will not be helping with local fat loss.

Deoxycholic acid

KYBELLA is “FDA-approved use for persistent SMF” (submental fat) and “appears to be a safe and efficacious alternative to surgical reduction of unwanted adipose tissue in non-submental areas”. I have yet to do much of a deep dive on this, but it seems not worth considering yet.

CBL-514

It is not yet available. “has shown promising efficacy and safety for subcutaneous fat reduction” in phase 2 clinical trials.

Retatrutide

This is a triple agonist peptide acting at GIP, GLP-1, and glucagon receptors. It is mainly used to help lose weight in general (see previous post for this), and helps somewhat to stimulate fat loss more when losing weight as a whole (by losing less muscle). It can help lose more weight in general, but it’s not a solution for sculpting specific areas.

There are other procedures, but I did not find them particularly worth considering, I add them to the Appendix2

Burning the right fat

There are some more marginal things that help stimulate lipolysis, but these are less pronounced.

Topical Aminophylline

Aminophylline is most commonly use is in the treatment of airway obstruction from asthma. But it has been shown to inhibit dual phosphodiesterase (PDE) which causes cAMP to break down more slowly and thus to surge, and thus increase lipolysis locally.

• Link to Meta-analysis of a few studies

In particular, one study on 25 men/women, when on a 1200kcal diet, achieved a reduction in waist circumference of 11 ± 1.0 cm when using 0.5% aminophylline cream, compared to a reduction of 5.0 ± 0.6 cm in the control group.

The only double-blind study done showed null results when it was not paired with weight loss. Some say this invalidates the effectiveness of aminophylline, but I guess I disagree. Based on my understanding of the mechanism this just means that you need to be already losing weight for there to be any effect.

I think it seem worth trying, paired with weight loss, but the data is limited. See the wiki for more info.

But more than anything, I think aminophylline just needs to be studied more. If anyone wants to fund this or to contribute data, that would be extremely helpful.

Topical Caffeine

Caffeine appears to affect the same PDE pathway as aminophylline.

There are a lot more studies on topical caffeine for various things, often mixing it with various other compounds like retinol, carnitine, glycyrrhetinic acid.

Some amount does get systemically absorbed, so do note that it will cause a raise in blood caffeine levels too.

However the evidence base is also pretty mixed, so I’m not sure.

I think overall, it is worth trying to get a topical creme that contains aminophylline and caffeine and other things.

Considerations

This currently only covers things that are useful for the down cycle.

In the next couple of posts, I will consider things that are useful for the up-cycle instead.

Overall, the main thing you should be worrying about is your hormone levels. You can then do some surgical things like cryolipolysis and liposuction, which are costly, and I think that aminophylline is promising, but it needs more study.

There is just a lot of content in this direction, so I could not look at everything. Many attempts to try different things, but most of them seem not that promising.

If you are interested in weight-cycling or losing weight in general, there are a few things to consider.

In general, your body has two aspects to controlling weight, which are deceptively simple: kcalories in, and kcalories out.

kcalories output is determined by your metabolism, which consists of your BMR + Active kcalories. The most important aspect is the, BMR, which depends mostly on your age, height, and body weight, but given this, there is still some variation of about 10%. Another factor that can affect your BMR is whether you’ve recently lost weight. Active kcalories also contribute, but for most people doing most amounts of exercise, is a relatively small adjustment to daily kcalorie output, and typically increases appetite to compensate.

kcalories in is determined by what you eat, and can be controlled through diet. The degree to which it is easy or hard to control your diet is highly variable and depends on appetite. For some, it is pretty easy to lose weight. For others, it can be very difficult. People generally have some baseline level of “appetite”, and going over or under this intake can have people respond more or less viscerally.

Anybody could lose weight if they restrict kcalories, but the amount of psychic damage caused to people to eat at a level below or above appetite for different people varies a lot, and thus different people need different levels of willpower.

There are, however, things that can be done to affect this. The main axes are diet, supplements, and medicines.

Side note: Important prior considerations.

If one is on a kcaloric deficit, one eats fewer or sometimes no nutrients, and thus one may need to supplement nutrients, and make sure one drinks enough water. Make sure you do this.

Diets.

There are countless diets people use for losing weight. There is no single strategy that is effective for everyone, and in general, dieting is not as effective as medical interventions. I can list some ideas anyway. I am not a medical professional though.

One method, as suggested in this post, is to do water fasting. This involves not eating any food, and only drinking water, for multiple days straight. Thus without any food intake, one only has a kcaloric output and no input. This works for some, and people sometimes find that their hunger goes away after around one or two days. But it is important to supplement vitamins and minerals in this case.

Some other ideas, which I won’t list in too much detail:

• VLCD / Total Diet Replacement (altering your diet completely can be helpful)

• Meal Replacements (which make measurement of intake very easy)

• High-Protein (small effect due to it being more satiating, may help retain muscle mass)

• Low-Carb (due to entering ketosis)

• Intermittent Fasting (people like it, but the effect size is weak)

• Mediterranean (also weak effect)

One could consider doing some intermediate of water fasting, but still eating protein powder, to try to preserve more lean body mass also.

Supplements:

There are many supplements, many of which have very little effect. I list a couple that might be useful, but I probably miss most things.

Psyllium / Soluble Fiber, also suggested in this post. One mechanism of appetite is from having your stomach feel full. Eating more fiber shortly before meals with water can improve satiation. Make sure to drink sufficient water as it expands significantly and can lead to dehydration.

Caffeine can also slightly increase metabolism by a couple percentage points. The effect is not huge but has been shown to work

Medications

The single most effective method for losing weight, is to use a modern GLP-1 Agonist medication. Some of the most common such peptide medications are:

• Retatrutide - currently in clinical trials, but so far shown to be highly effective.

• Tirzepatide - loss of 15.0% to 20.9% of body weight at 72 week, more effective than semaglutide.

• Semaglutide - 14.9% to -15.2% in flagship obesity trials

There are also many other medications such as Cagrilintide and Mazdutide, and it is an active area of research to make peptides that help lose weight faster, and with less lean muscle loss.

It can be difficult or expensive to obtain, but prices are going down, and there are potentially grey-market methods for obtaining these medications too, but these are less safe than buying pharmaceutical grade products.

This is a brief dump on some of the methods of weight loss that I know of and which seem to be most effective. There was more discussion in this post by Mesityl, and I recommend reading it.

In my next post, I will talk about potential factors that help make sure you lose fat in the correct places in your body as well.