By Beverly Cosgrove, version 4, 4-4-2023

Malaysia is a difficult place for trans women, and good health care is hard to find. Due to high cost, social oppression of trans people, and shortages of providers, many feel forced to treat themselves there. While self-treatment is hardly optimal it can be the only choice. For those in the Pacific Rim where there is no other option, there is a regimen which may give a relatively acceptable level of safety, effectiveness, and cost under these extremely difficult circumstances.

Injection of estradiol produces excellent feminization while minimizing associated risks of thrombosis compared to taking pills orally. Combining the estrogen with small amounts of injected progesterone is generally believed to add additional safety, as long as the progesterone is not one of the several synthetic progesterone substitutes (progestins) such as medroxyprogesterone. There are reports that these two injectable products are available in the region. So, here is one regimen to consider. If possible, of course, see a doctor for tests and monitoring before starting any hormone regimen.

At present, counterfeit hormone drugs are flooding the market, and are sold by individuals on Facebook and auction sites. Despite their claims, nearly ALL the “Progynon Depot”, “Pelanin” and similar ampules of Estradiol Valerate are counterfeit. They are risky and may have been produced without proper sterilization, monitoring, and based on industrially produced hormone powders, by-products, surplus products, discarded and defective products, which may be generally unsafe for human use. For more information on counterfeits, see this article. But these two products, Estradiol Benzoate ampules and Phenokinon-F, may have a higher chance of being safe and authentic. It is possible to combine the two to form what may be a nearly ideal estrogen/progesterone balanced hormone mix.

In this situation, this is what I would do. With Estradiol Benzoate, twice a week injections are best because of the shorter half life. The ratio of Estradiol to Progesterone is important. In this method, each injection would consist of a half ampule of Estradiol Benzoate (EB) and a quarter ampule of Phenokinon-F. That is 3.75mg of Estradiol Benzoate plus 12.5mg of Progesterone per injection, or 7.5 mg of Estradiol Benzoate and 25mg of Progesterone per week. By filling syringes ahead of time, one can fill 4 syringes from a Phenokinon-F ampule split into quarters, then add half an ampule of EB to each one. That means one would use 4 EB ampules per month and 2 Phenokinon-F ampules per month. Assuming that EB is a little more potent than EV, and the ratios work about the same, this is a reasonable starting place for a regimen that might work.

So, here is step-by-step information. Be sure you have the right syringes and needles. I would take four 1ml syringes and put 22g 1.5 inch needles on them. Then, open two Estradiol Benzoate ampules and one Phenokinon-F ampule. Take one syringe. Remove the needle cap. Draw about 0.1ml of air into the syringe. Then put the draw needle into the Phenokinon ampule and draw up about 0.2ml very slowly, trying to draw no more air. Take the needle out and put it into the EB ampule, and draw up about 0.45ml more. The syringe plunger will be about at the 0.8ml mark. It is important to keep the needle pointing down at all times – the liquid must not touch the rubber of the syringe plunger until it is time to inject. Carefully put the needle cap back on, keeping the needle pointing down. Put the loaded syringe into a cup or other holder, so that the air in the syringe is touching the rubber plunger, not the oil. Now pick up the next syringe and repeat. In this way, fill all 4 syringes. Now, the 4 syringes are ready for the next two weeks of doses, and as long as they are kept “needle down” the hormone mix will not touch the plunger seal.

This method would require two injections per week. The method of IM injections into the outer upper quadrant of the buttocks is recommended. For IM injections, replace the 1.5 inch 22 g needle with a 1.5 inch 25g needle. Subcutaneous injections are NOT recommended, because the progesterone does not form an effective depot in fatty tissue. However, if you must use a subcutaneous technique, put on a 0.5 inch 30g needle, instead, and follow these instructions for a shallow injection into fat around the abdomen or hip.

During the time when the needle is pointing down, and there is an air gap between the plunger and the hormone level, the syringe is acting as a storage vessel. The air gap is essential because the hormone oil can in some cases deteriorate the seal of the plunger. In any event, it’s important not to store hormones this way for longer periods of time. Remember when picking up the filled needle to do the injection, one must shake the syringe so all the air goes to the needle end. Press the plunger to expel the air, then inject.

I wish those of you in South Asia and Pacific Rim had better options. Trained doctors willing to help are essential, and if there are none, I understand that the trans women there are desperate. But taking large quantities of dangerous pills, especially Ethinyl Estradiol, without medical supervision, is likely to result in deaths. The above regimen is certainly not the first choice, but it is safer. Good luck and please be careful.