Non-binary Transfem HRT
What are interventions you can take if you are non-binary?
Day 23/30 of posting daily. This area is particularly complex and under-studied, so there may be some misunderstandings on my part
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.