Liver problems would probably rule out taking a certain anti-androgen (bicalutamide) since it is bad for the liver, but otherwise the only liver concern for HRT is with oral estrogen, and tbh oral estrogen is the worst route of administration anyway (doesn't create stable blood estrogen levels, and can be much slower at feminizing, much worse at suppressing testosterone, etc.).

In that case I would just recommend monotherapy estrogen injections. What that means is you inject enough estrogen frequently enough that your brain gets the memo that it doesn't need to produce more sex hormones and shuts down testosterone production.

I lived for over a year on monotherapy injections until I could get an orchiectomy (which is a relatively affordable and simple out-patient surgery that removes the testes).

In my opinion (esp. if just temporary until you get surgery), this is the path with the least health risk and fewest side effects.

The common alternative to monotherapy is to prescribe lower oral estrogen doses and an accompanying anti-androgen.

In the US that's usually a combo of oral estrogen (usually starting at 2 mg / day) and spironolactone for the anti-androgen. In Europe they usually use a synthetic progestin for the anti-androgen (there are pros and cons to progestins instead of spiro, but overall it's probably better).

Spiro can cause lots of unpleasant side effects, but it's more of a tax on the kidneys. Still, I think monotherapy is better than unnecessarily risking side effects and having slower feminization to boot. The concerns doctors have about too much estrogen are not well evidenced in the case of injecting bioidentical hormones - the studies that spook doctors were all of Premarin (synthetic horse estrogens) which were taken orally and were found to cause increased risk of various diseases, but no studies have found this to be true of bioidentical hormones, let alone when those bioidentical hormones are injected instead of taken orally (which causes the liver to filter >80+% of the estrogen).

In terms of heart disease, testosterone increases heart risks and estrogen lowers it - starting estrogen injections would probably decrease your heart disease risk. The idea that taking HRT increases heart disease risk is actually a debunked myth.

There was actually a recent study (from Oct. 2025) that found that within 12 months, HRT causes the heart to change in ways researchers didn't even expect:

The troponin threshold to predict cardiovascular events is lower for women due to the greater cardiac mass typically seen in men.

Since estradiol and testosterone were not thought to directly impact cardiac mass, researchers expected that troponin would remain similar to individuals’ assigned gender at birth.

However, they found the opposite to be true.

The clinical research team found that troponin levels shifted towards the affirmed gender after 12 months of hormone therapy.

Troponin decreased in transgender women to a level not statistically different from cisgender women, but which was 78% lower than in cisgender men.

In general, cross-sex HRT brings your biology and thus risks in alignment with those of your gender (e.g. estrogen causes trans women to have higher chance of stroke and lower risk of heart attack, but not any different than the risks cis women have).

Here is a decent intro / guide showing the effects of taking estrogen:

https://www.rainbowhealthontario.ca/TransHealthGuide/gp-femht.html

You may notice that almost all of the changes are reversible, the only non-reversible change from taking estrogen is breast growth, and that's mostly after a certain point (i.e., you could take estrogen usually for around 3 months without any permanent breast growth, then at that point you just have to decide whether you want to continue or not).

If you want to learn more about HRT for trans women, I highly suggest reading this article for the nitty-gritty details:

https://transfemscience.org/articles/transfem-intro/

Also, if you're scared of needles and not sure you could do injections (like I am, I nearly faint when my blood is drawn), don't worry - you can use really thin and small needles to inject subcutaneously (into the fat) rather than the scary big and long needles used for intramuscular (IM) injections. Most of the time I do injections now I don't feel any pain at all, and it's very do-able (just a hurdle, something to learn and overcome - but totally achievable).

Let me know if you have any questions anytime, feel free to DM me too!