They ramp up over time if they're following WPATH. They have to see how your body responds to that dose, so you'll probably do this for a couple months or so, get blood work and talk to them and they'll probably increase your dose until you stabilize your estradiol levels and decrease T levels to whatever you and them think is good and then only do check ups every once in a while.

There are risks to E which is why they're cautious and ramp up but the risks are a little overstated imo (for example your risk of thromboembolisms does go up... to cis women's levels lol and similarly with breast cancer after something like 5 years, yes it goes up but just to parity with cis women).

Also feeling like you're crashing after spiro for the first few times is probably more normal, it's a diuretic so its forcing your liquids out - you should probably adjust in a couple days and your BP will stabilize and you'll probably just feel normal to good! I did like it as they increased my E fwiw, but I still felt pretty good on 2 mg of E compared to pre HRT lol

yeah my doc usually would do sublingual 4mg, 1 in morning 1 in evening