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For general reference, when I talk about 'healthy dosages,' I'm speaking about anything that achieves greater than 150pgml/550pmol estradiol right before the next dosage. When I talk about monotherapy, I'm speaking of something which achieves between 200pgml~400pgml/734pmol~1468pmol before next dosage, as these are the healthy levels needed for feminization without taking T blockers. You can read about it here.

WHERE I STARTED: Before I even moved here, my husband and I figured out that the name brand medication Natifa is literally just Estradiol Hemihydrate. If you don't know, that is the same type of estradiol as in the famous blue/teal/green pills typically given to transfems in the US - it is more or less just pure Estradiol-b17, and like the famous titty skittles, you can take it sublingually (under the tongue). This allows for healthy estradiol levels, compared to oral which has really bad bioavailability and thus can put a damper on transition. Unfortunately, it's not generic, so I was paying about R$400 a month for a reasonable dosage (2mg, 3 times per day). Even as someone earning in USD this is a massive sum to be paying out, and since the SUS doesn't seem to subsidize it, I can't imagine it being viable for almost anyone long-term. And, because sublingual estradiol is generally Not Good at suppressing testosterone by itself, I also took espironolactona (spiro) alongside it, just as I had done before. That, thankfully, is generic and cheap, but it still caused me fatigue and sleepiness like it always has. It is famously Pretty Mid and makes you piss a ton (in a lame way). Nevertheless without having the time or energy to investigate many other options, I kept on with this for about 11 months until I decided I should probably do something different.

WHAT I CONSIDERED: Digging around with my now way better Portuguese skills, and talking with trans Brazilians, I got told about a couple common regimes. The first is just to take ~4mg oral valerato de estradiol (EV) daily alongside a blocker, which is... I guess functional for some, but oral EV is both weaker than almost any other administration method resulting in low levels, and the monthly costs can still add up (almost R$200 per month!). There is a combined EV + progestin as well, but again, oral EV isn't great, and synthetic progestogens carry health risks. I wanted something more stable that wouldn't necessitate taking 8mg a day.

The second regime was to take injections of Perlutal. Perlutal is enantato de estradiol (EEn) + algestone acetophenide (DHPA), which on paper is pretty solid. You can get it at about R$15 for 2 weeks worth (5mg/week), and EEn is a really stable form of estrogen for injections. Like, arguably the best besides the relatively understudied undecyclate, as seen in the Ester monotherapies comparsion on Estrannise. The problem is DHPA; a synthetic progestin that may cause prolactinomas. I read a study on this a while back but unfortunately I can't seem to track it down, but people refer to the incidence regularly. While lactation is fun and all and I partake in it myself with domperidone, you REALLY don't want to induce it by a benign brain tumor. A crazy spike in prolactin might also be bad for your mental health.

Finally, the last is to do patches. I do not know nearly enough about this to say, but the cost of this also seems way too high if not subsidized, since getting healthy levels with blockers seems to require 200mcg per week. That's still nearly R$200 a month at the lowest far as I can tell.

WHAT I DO NOW: Given the lack of readily available pure estradiol ester injections here (valerate, cypionate, enantate, etc), I did what a lot of trans women do now and got it from Certain Sources. I paid by Bitcoin using Paybis (which supports PIX!!!!!!), tossed the seller my CPF to write on the package so Correios wouldn't upend my soul and steal my girl juices, and got sweet sweet clean EEn 3 weeks later. I won't say from where, but any place that sells discreetly packaged estradiol should be fine, which is most of them these days. The general going rate is about R$600 after all fees, which is about as pricey as the monthly cost of Perlutal in a single sum.

And that's it. I just take 5mg of EEn every week by subcutaneous injection, and have been feeling fantastic. BD and Sol-Care make good supplies for needles and such, personally I use the 27g from BD for injecting and 25g + syringe from Sol-Care for drawing my EEn. I also found an endo who is pretty knowledgable and supportive, which is a godsend since I just need someone who can monitor my levels.

OVERALL: I can say I'm pretty happy with where my transition is going at this point, and how things have been here in Brazil. Estradiol being over the counter was amazing for getting me through a rough period of not being able to see a doctor, and the trans community in my local area has been wonderful to talk to. Even as things are greatly imperfect here with trans people (especially as the CFM is trying to make life more miserable for trans youths), I have still found it far, FAR easier to live than in the best of times when I was in the US.

Vai Brasil!!!