Feminizing HRT

This guide is harm-reduction information. It is not medical advice, and it is not a substitute for care from a qualified clinician. We provide it because most readers do not have access to an informed clinician — the goal is that anyone who is going to do this anyway does it as safely as possible. If you have access to a doctor who will work with you, see them first.

Feminizing HRT in Iraq uses two medications together: an estrogen and an antiandrogen. This page covers what is realistically available, how to dose it safely, and — most importantly — the long-term risks of cyproterone acetate that most pharmacy inserts do not mention.

Estrogen options in Iraq

Estrofem (Novo Nordisk) — 2mg estradiol hemihydrate

Estrofem is the most commonly available oral estrogen in Iraqi pharmacies. It comes in foil strips, and a strip typically holds 28 pills.

Typical dosing:

• Starting dose: 2 mg/day
• Maintenance dose for full feminization: 4–6 mg/day
• Many people split the dose (for example, 2 mg in the morning, 2 mg at night) to keep blood levels more stable.

Sublingual administration. Placing the pill under your tongue and letting it dissolve over about 15 minutes gives higher peak estradiol levels than swallowing it. Do not chew the pill or rinse your mouth for at least 15 minutes. Many trans women in resource-limited settings use sublingual administration to stretch supply, since you can sometimes get the same effect from a lower dose.

Therapeutic estradiol levels. For full feminization, target serum estradiol of roughly 200–300 pg/mL. Below that range, feminization is slow and incomplete; well above that range, the cardiovascular and clotting risks rise without any added benefit.

Estradiol patches and injections

Patches and injections are extremely difficult to source in Iraq. We are not aware of any consistent supply chain inside the country. Do not plan around them. If you have access through a contact abroad, that is a different story — but Estrofem is what is actually available domestically.

Antiandrogen options in Iraq

This is where care matters most. The choice and the dose of antiandrogen has more long-term safety implications than the estrogen itself.

Cyproterone Acetate (CPA) — Androcur or Androfarm

CPA is the workhorse antiandrogen in Iraq. It is strong, cheap, and effective. It is available as:

• Androcur (Bayer) — branded, more expensive, more reliably stocked.
• Androfarm — generic, cheaper, harder to find but available in larger cities.

Both come in 50 mg tablets.

Pricing observed (2025–2026):

• ~15,000 IQD per strip
• ~30,000 IQD per packet (approximately 180-day supply at proper trans-feminine doses)

Critical: dose far lower than the package insert says.

The pharmacy insert and the older medical literature describe CPA at doses of 50–100 mg/day for prostate cancer. Trans-feminine HRT does not need anywhere close to that dose. Modern guidance is 6.25–12.5 mg/day, which is a quarter to a half of one 50 mg pill, often taken every one or two days.

To split a 50 mg pill into 12.5 mg portions, you can use a pill cutter (available in any pharmacy) to halve and then quarter the tablet.

The CPA meningioma warning — read this carefully.

Long-term high-dose CPA causes meningiomas, slow-growing brain tumors. The risk goes up sharply above a cumulative lifetime dose of about 10 grams. To put that in concrete terms:

• At 12.5 mg/day, you reach 10 g cumulative in about 2 years.
• At 50 mg/day, you reach 10 g cumulative in about 200 days.
• At 100 mg/day, you reach 10 g cumulative in about 100 days.

This is not a theoretical risk. Meningiomas have ended people’s transitions and sometimes their lives. Use the lowest effective CPA dose. Stop CPA once your testosterone is reliably suppressed by estrogen alone or once you have had an orchiectomy. No other antiandrogen carries this specific risk.

If you are taking CPA long-term and you develop new headaches, vision changes, or other neurological symptoms, get a brain MRI. This is non-negotiable.

Bicalutamide (bica) — Casodex and generics

Bicalutamide is sold as Casodex (AstraZeneca) and as generics. It comes in 50 mg tablets. It is more expensive than CPA and is available in larger Iraqi cities.

• Dose: 25–50 mg/day.
• Mechanism: Bica blocks the androgen receptor rather than suppressing testosterone production. Your testosterone level may stay normal or even rise slightly on bica, but the testosterone cannot bind to its target tissues.
• Liver monitoring: Bicalutamide is hepatotoxic. Get liver function tests at baseline, three months, then yearly. If your ALT or AST climb significantly, stop and consult a doctor.

Spironolactone (spiro)

Spironolactone is the standard antiandrogen used in the West, but it is less commonly stocked in Iraqi pharmacies. If you can find it:

• Dose: 100–200 mg/day for trans-feminine HRT. Not 25 mg (too low to do much), not 400 mg (harsh on potassium balance).
• Spiro is a potassium-sparing diuretic, so it makes you urinate frequently and raises blood potassium.
• Avoid potassium supplements and foods that significantly elevate potassium: avocados in large quantity, bananas in large quantity, salt substitutes that contain potassium chloride.
• Get a basic metabolic panel periodically to check potassium.

Finasteride and Dutasteride

These drugs block the conversion of testosterone to dihydrotestosterone (DHT). They are not primary antiandrogens. They do not suppress testosterone, they only block DHT specifically.

• Useful as an add-on for androgenic hair loss if your scalp hair is thinning.
• Useless as the sole antiandrogen for transition. Do not let anyone tell you that finasteride alone is a transition drug — it is not.

A typical Iraqi feminizing regimen

A common, safe starting regimen for trans women in Iraq using locally-sourced medications:

• Estrofem 2 mg, sublingual, twice daily (4 mg/day total)
• Androcur or Androfarm 12.5 mg, once daily (a quarter of a 50 mg tablet)

After three months, get blood work. Adjust based on:

• Estradiol below 200 pg/mL → consider increasing to 6 mg/day or improving sublingual technique.
• Testosterone above 50 ng/dL → continue current CPA dose; if still high after another three months, slightly increase CPA. Do not exceed 25 mg/day.
• Once testosterone is consistently below 50 ng/dL on repeat tests → consider reducing or stopping CPA. Estradiol alone, if levels are adequate, can hold testosterone suppressed in many people.

Realistic timeline of changes

This is the standard timeline. Bodies vary. These are the average windows for changes to begin and to mature.

Existing facial hair, height, voice (in this direction), and bone structure do not change with HRT.

What to do if HRT feels wrong

Some people find that feminizing HRT does not feel right for them after starting. This is more common than the internet suggests. If your mood worsens significantly, if you feel detached or dysphoric in new ways, or if something just feels wrong — stop and talk to someone in the community before continuing. It is okay to pause. It is okay to change directions. HRT is not a one-way door, and the first few months are when many people learn what their body actually wants.

If you continue and it feels right — welcome. The harder months get easier.