HRT Clinical Pathway

This pathway is based on WPATH SOC 8 and Endocrine Society Clinical Practice Guidelines, providing a standardized framework for transfeminine HRT initiation and maintenance.

WEEK 0

Before starting any medication, complete a full baseline panel to rule out contraindications and establish your personal reference values.

Sex hormones (E2, T, SHBG, LH/FSH)
Hepatic & renal function, lipid panel
Coagulation panel & D-dimer
Fasting glucose + CBC

INITIATION · 1-6 MONTHS

Route	Starting Dose	Source
Oral estradiol	2.0 mg / day	Endocrine Society 2017
Transdermal patch	50-100 µg / 24h	Endocrine Society 2017
Topical gel	1.5 mg / day	Endocrine Society 2017
IM estradiol valerate	1-2 mg / week	Rothman 2024

Anti-androgen (if needed): CPA 5-12.5 mg/day or spironolactone 50-100 mg/day

Target E2

50-100 pg/mL

Target T Trend

↓ Declining

Safety warning: Your body needs time to adapt to receptor changes. Never increase dose without blood work. Do not escalate even if you feel “nothing is happening.” Breast bud signals typically appear at 3-6 months.

3 MONTH

DECISION

E2 30-100 pg/mL and T declining → Continue current regimen to 6 months

E2 <30 pg/mL → Consider escalating to Phase 2 dosing

Abnormal LFTs / PRL >30 / severe mood deterioration → Stop and seek medical care

TITRATION · 6-12 MONTHS

Adjust based on 3-month lab results. The goal is to reach the standard physiologic range for transfeminine individuals.

Route	Adjusted Dose
Transdermal patch	100-200 µg / day
Oral estradiol	4 mg / day
Topical gel	3 mg / day
IM estradiol valerate	2-4 mg / week

Target E2

100-200 pg/mL

Target T

<50 ng/dL

Progesterone (optional)

Consider based on breast development (Tanner 3+)

IM E2V 2-4 mg/weekTopical gel 3.0-4.5 mg/day

6 MONTH

STABILITY

E2 100-200 pg/mL and T <50 ng/dL → Enter maintenance phase

T >50 but E2 on target → Adjust anti-androgen (do not increase E2 to suppress T)

E2 <100 pg/mL → Continue escalation within safe limits

STEADY STATE · 12 MONTHS+

Once levels and physical changes stabilize, transition to low-frequency monitoring. Maintain the minimum effective dose to keep E2 100-200 pg/mL, T <50 ng/dL.

Monitoring Frequency

Months

Full hormone panel and VTE risk factors every 6 months. Annual lipids and fasting glucose. Consider bone density screening.

E2 >200 pg/mL does not produce more feminization — it only increases risk (Endocrine Society 2017, Rec 2.2)

END OF INITIAL PHASE

System Active | Monitoring Continued

Sources: Hembree et al. 2017 (Endocrine Society); Coleman et al. 2022 (WPATH SOC 8); UCSF Transgender Care Guidelines; Rothman 2024.

HRT Clinical Pathway

阶段 0: Baseline Assessment

阶段 1: Low-Dose Initiation

阶段 2: Dose Titration

阶段 3: Long-Term Maintenance