Hopelessly low estradiol level, even on injections

[Steph34]

I have a very fast metabolism, so nothing seems to bring my estradiol level where it needs to be for feminization. It was in the male range on gel or spray, so I switched to oral estradiol. Despite taking a reasonable amount orally, my level never even made it to 80, and it felt even lower with all the interference from estrone. My first doctor said to add patches, but since the expensive, 3.5-day patches only seemed to help for a day or so, that was not a viable option. Since he also thought any level over 100 was too high, I switched to another doctor. She told me the best way to raise my estradiol level was with a weekly injection. After switching to a weekly subcutaneous injection of estradiol valerate (supervised or given by a nurse, so I know it was injected properly), my level actually declined back into the male range! My doctor's 'solution' is to raise the dosage by a tiny fraction or to give me a low dose twice a week, neither of which would produce a reasonable level in me given how fast I lose it. This doctor herself has admitted that the best feminization occurs at a level of 200-400, but she is totally unwilling to bring my level anywhere near there for any meaningful length of time. I find that very perplexing. She does not seem to understand that physical feminization requires a higher level than is necessary to normalize mood.

So, are subcutaneous injections worthless, or do I just need a higher or more frequent dose? My doctor wants to continue them.

My only other thought is to try the pills sublingually, but spending so much time with the poor-tasting pills in my mouth, only to obtain a wildly unstable level, really does not appeal to me. I will see the doctor again on Monday. As the sun is now stronger and the heat will soon follow, my window of opportunity to feminize is closing. I need a higher level now, because I see improvements overnight when my level is good. Is there something I am not thinking of that I should suggest to the doctor?

[Laura_7]

There are implants available from compounding pharmacies, both for bioidentical estrogen and progesterone.

Each is the size of a rice grain and last ca. 4 months.

Some people recommend them especially if other methods fail ( and they recommend them otherwise, either ).
If your endo is willing to administer enough of them to raise levels enough is another question.

Some side effects are lessened because of internal application, like the shots.

As aside, some gender clinics do not go mainly by levels but by how good feminization is and how the person feels.

You might think about adding bioidentical progesteron, topical or in implant form, for example.
Theory is it might help with breast development, has some antiandrogenic effects, balances some effects of estrogen and evens mood.

hugs

[Rachel]

Hi Steph,

I think you are doing the right thing by discussing it with your doctor.

Do you know your free T level? Is it being suppressed adequately?

[Deinewelt]

My only other thought is to try the pills sublingually, but spending so much time with the poor-tasting pills in my mouth, only to obtain a wildly unstable level, really does not appeal to me. I will see the doctor again on Monday. As the sun is now stronger and the heat will soon follow, my window of opportunity to feminize is closing. I need a higher level now, because I see improvements overnight when my level is good. Is there something I am not thinking of that I should suggest to the doctor?

This might be worth a try at least?  I know people talk about sublingual as if the levels are unstalbe, but I've read estradiol has something like a 13 hour half life.  I'm not sure if that means anything as I'm no expert, but I would hope it would mean that sub lingual is a decent way to take it.

[TransSasha]

After switching to a weekly subcutaneous injection of estradiol valerate

subcutaneous injection of sex hormones is pretty odd unless I'm mistaking you for taking implants instead?

[TransSasha]

Also wanted to add that the sublingual experiment everyone seems to reference can be seen here:



Source: http://www.sciencedirect.com/science/article/pii/S0029784496005133 (there is a pay wall though)

PO is SIG code for "by mouth" or orally, and SL obviously sublingual. There is definitely a difference with taking sublingual vs oral as demonstrate by the graph. One thing to note though is this is specifically micronized oestradiol aka estrace or estrofem

[PhoenixGurl2016]

The timing of when u get your testing done could play a part in it. I myself get worried myself because my level was 79 5 hours after taking it and 96 3 hours after taking it. However I feel great and am seeing changes. I would say that the levels it takes to develop depends on your body. There are plenty of cis women with low estradiol. That being said as long as you are in normal range then I would try not to worry about it too much. However seeking options to increase your levels is not a bad thing. I am trying to do the same but right now it is a wait and see approach.


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[Eva]

Sounds like you need to find a new doctor You should be getting your EV shot deep into a large muscle like your butt or thighs with a 1 1/2" long needle... Once a week is the usual frequency but some like to start at once every 2 weeks....

[KayXo]

After switching to a weekly subcutaneous injection of estradiol valerate (supervised or given by a nurse, so I know it was injected properly), my level actually declined back into the male range!

Why subcutaneous instead of intramuscular which is the usual way it's done with injections? I've heard that it doesn't absorb quite the same way, someone suggested to me that it might give faster/higher peaks and lows and a nurse said it just wouldn't absorb as effectively. But, I also heard from transmen that T works as well both ways. So who knows? I take mine intramuscularly as directed by my doctors.   

This doctor herself has admitted that the best feminization occurs at a level of 200-400, but she is totally unwilling to bring my level anywhere near there for any meaningful length of time.I find that very perplexing.

Have you asked her why she doesn't want to maintain those levels? I just wonder because ciswomen can experience levels up to 650 pg/ml during their menstrual cycle, and if we took an average between the lowest and highest levels during a cycle , we would probably come up with an average around 300 notwithstanding the much higher levels they are exposed to during pregnancy (in the thousands). So, if these levels are fine for them, for several decades, why should they be a problem for us? I'm not a doctor, I'm just left quite perplexed as you are and would really be curious to get an answer. Have there been any papers showing that such levels are harmful to transwomen? 

I think these questions should perhaps be raised when discussing next time with your doctor as well as the reason why subcutaneous is favored by her when the vast majority of us take it intramuscularly and EV is indicated to be taken that way. Let us know what she says.

I would say that the levels it takes to develops depends on your body.

+1.

[Kyla]

Also wanted to add that the sublingual experiment everyone seems to reference can be seen here:



Source: http://www.sciencedirect.com/science/article/pii/S0029784496005133 (there is a pay wall though)

PO is SIG code for "by mouth" or orally, and SL obviously sublingual. There is definitely a difference with taking sublingual vs oral as demonstrate by the graph. One thing to note though is this is specifically micronized oestradiol aka estrace or estrofem

What an interesting & useful graph this is - thankyou Sasha, for posting it.

I'm also wanting to find out how soon estradial levels rise after a sub-lingual dose is placed in the mouth. Does anyone know?

This study also has a really interesting graph in it on page 3, as it shows the two distinct (but 'separate') estradial cycles operating on a daily basis in natal-born women: www.eje.org/content/148/2/227.full.pdf

[Kyla]

Looking at the graph Sasha posted more carefully, it looks like it's indicating that when estradial is taken sub-lingually, it takes an hour to show in blood serum, and that at that first hour interval, it is at a peak.

Of course, it could just be that the first measurement in the study was taken at the first hour interval. Presumably the study text as a whole provides this detail.

[KayXo]

I've read studies where high levels of estradiol are detected 30 minutes after sublingual administration and other studies have noted an effect within minutes...sublingual delivers the hormone directly to the blood right away so that levels shoot up quite quickly in a matter of seconds to minutes.

[Steph34]

There are implants available from compounding pharmacies, both for bioidentical estrogen and progesterone.

I really do not want any foreign objects inside my body. Feminization is meant to awaken the 'real me' from the masculine shell, and implants would make me feel fake.

As aside, some gender clinics do not go mainly by levels but by how good feminization is and how the person feels.

I like to be actively involved in my health care decisions, and levels are an important part of that for me. If my average level is less than a cis woman my age would have, I can be pretty certain that I am getting sub-optimal feminization, since if anything, post-pubertal feminization requires *higher* levels due to lower sensitivity and past damage from testosterone. My feminization has been rather poor recently, although my doctor disagrees because she saw me once last April pre-transition and then not again until January, during which time I did feminize somewhat. Going by how I feel can be problematic because, as I said, a full feminizing dose will initially be interpreted by my brain as an intense high because it has been craving the stuff for so long.

You might think about adding bioidentical progesteron, topical or in implant form, for example.
Theory is it might help with breast development, has some antiandrogenic effects, balances some effects of estrogen and evens mood.

My problem is clearly one of low estradiol. I tried progesterone and unfortunately, it did none of that for me. I had rapid weight gain in a male pattern on the shoulders and stomach, my face masculinized, and I became tired and depressed. It seemed to counteract the benefits I was getting from the estrogen.

Do you know your free T level? Is it being suppressed adequately?

My free T has been in the female range for several months now, and actually dipped to a new low this month.

This might be worth a try at least?  I know people talk about sublingual as if the levels are unstalbe, but I've read estradiol has something like a 13 hour half life.  I'm not sure if that means anything as I'm no expert, but I would hope it would mean that sub lingual is a decent way to take it.

That half-life sounds reasonable for oral estradiol. Sub-lingual (dissolved under the tongue) is different from oral (swallowed). Sub-lingual estradiol, as indicated by the graph, results in a sharp peak and rapid drop following each dose. Also, my unusually fast metabolism means that my hormone level tends to decline much faster than the references indicate. I need a doctor who is willing to compensate for that by prescribing a higher or more frequent dose.

Anyway, while I complained about poor taste and time investment, those would be minor nuisances if it were otherwise effective. My larger concern is that some of it may be taken orally by accident since I tend to have a lot of saliva and a difficult time keeping it suppressed under the tongue. Oral estradiol worsens my persistent yeast infection on the scalp, presumably because it passes through the digestive tract, causing a greater increase in Candida growth than other ways of taking my hormone. The end result is hair loss, so I really cannot take my estradiol orally.

subcutaneous injection of sex hormones is pretty odd unless I'm mistaking you for taking implants instead?

No, it really is a subcutaneous injection in the abdominal area. I will not use implants.

PO is SIG code for "by mouth" or orally, and SL obviously sublingual. There is definitely a difference with taking sublingual vs oral as demonstrate by the graph. One thing to note though is this is specifically micronized oestradiol aka estrace or estrofem

I was given a generic version of the above, so I believe that is what I have.

The timing of when u get your testing done could play a part in it. I myself get worried myself because my level was 79 5 hours after taking it and 96 3 hours after taking it. However I feel great and am seeing changes. I would say that the levels it takes to develop depends on your body. There are plenty of cis women with low estradiol. That being said as long as you are in normal range then I would try not to worry about it too much. However seeking options to increase your levels is not a bad thing. I am trying to do the same but right now it is a wait and see approach.

My level has been very low for a woman, and I am seeing poor feminization. You have a point about the timing, but my doctor prefers to test the 'trough' level, and given my fast metabolism, it is practically gone by the time she feels I am ready for another dose. She really does not care about my 'peak' level, which I find rather odd because that is when I do feminize, only to lose my femininity when my level crashes.

Why subcutaneous instead of intramuscular which is the usual way it's done with injections? I've heard that it doesn't absorb quite the same way, someone suggested to me that it might give faster/higher peaks and lows and a nurse said it just wouldn't absorb as effectively. But, I also heard from transmen that T works as well both ways. So who knows? I take mine intramuscularly as directed by my doctors.

She has expressed concern about my level going too high, which I find rather odd and irritating because my level has never even been where she wanted it. Intramuscular injections typically produce a peak much higher than her target levels.

So, if these levels are fine for them, for several decades, why should they be a problem for us? I'm not a doctor, I'm just left quite perplexed as you are and would really be curious to get an answer. Have there been any papers showing that such levels are harmful to transwomen?

I am not aware of any evidence suggesting that such a level is dangerous, yet my doctors seem to be treating this hormone as if it is a toxic drug rather than the healthy hormone that it is. I think they fear being reprimanded for violating Endocrine Society guidelines or whatever, since my current doctor herself has admitted there is no evidence to suggest a level of 400 is unsafe. She also wants to go really slowly to find my perfect dose, as if I would drop dead if my level reached 401, unlikely anyway given my metabolism. I think she is just cautious to a fault, but what really made me cry hysterically in the office was her totally deaf ear to my concerns.

I've read studies where high levels of estradiol are detected 30 minutes after sublingual administration and other studies have noted an effect within minutes...sublingual delivers the hormone directly to the blood right away so that levels shoot up quite quickly in a matter of seconds to minutes.

I do feel a rush of positive energy within minutes after taking it that way. If everyone felt the way I did, people would be doing it to get high.

[Laura_7]

I really do not want any foreign objects inside my body. Feminization is meant to awaken the 'real me' from the masculine shell, and implants would make me feel fake.

Well of course it is up to you.
One of them is the size of a rice grain, implanted with an incision and they simply dissolve over months.
There are people who say this is close to what an ovary does.
But as said it is up to you.

I tried progesterone and unfortunately, it did none of that for me. I had rapid weight gain in a male pattern on the shoulders and stomach, my face masculinized, and I became tired and depressed. It seemed to counteract the benefits I was getting from the estrogen.

Do you happen to know if this was bioidentical progesterone or the more synthetical form progestin ?
They have different effects.
In oral form, one is a capsule, the other pills.

[Steph34]

Well of course it is up to you.
One of them is the size of a rice grain, implanted with an incision and they simply dissolve over months.
There are people who say this is close to what an ovary does.
But as said it is up to you.

I really do not want to feel fake by trying to mimic a cis female body; I am very uneasy with the prospect of anything inside of me.

Do you happen to know if this was bioidentical progesterone or the more synthetical form progestin ?
They have different effects.
In oral form, one is a capsule, the other pills.

I tried both and had similar problems with each. The bioidentical progesterone capsules were harsher than the synthetic MPA pills, but they both had the same undesirable effects, no feminizing effects at all aside from a little breast swelling during the first day or two that quickly subsided without any lasting growth.

[TransSasha]

ok best case scenario, you switch to IM injections. oil suspended hormones are meant to be shot deep muscle. its really odd they have you shooting sub Q. Sub Q is better for water based suspensions like growth hormone, or hcg.

I mean you can shoot oil suspended sub q but typically it takes a far longer time to de ester and released into the blood stream. I personally would see about getting switched to IM. Now I'm not saying you can't shoot sex hormones sub q. In fact theres studies where this was done and levels were still within normal range:

http://www.ncbi.nlm.nih.gov/pubmed/17143361

but IM is definitely the more popular route. no harm in trying and switching back if the outcome isn't favored

[kelly_aus]

Implants are considered the gold standard of hormone delivery by many endo's and gyno's, regardless of specific application - be it HRT or contraception or cancer treatment. They release a consistent dose that can be specifically tailored to the patient. Also, for most formulations of HRT, there is no external capsule that requires removal at the end of the implants usefulness, it is entirely absorbed by the body.

Many 1000's of cis women all over the world use implanted hormones for a variety of reasons. This doesn't really mimic anything, just delivers a customisable and consistent dose.

Do you really want to discount a proven method for what seem like not so good reasons, Steph?

[KayXo]

Steph,

from everything that I came across, it seems levels vary a lot from one ciswoman to another and fluctuate so much during a menstrual cycle, going much higher during pregnancy that trying to mimic levels of a ciswoman is senseless. Some women are more and some women less sensitive to the same level, and remember that even if you measure your levels, chances are that these are not at all indicative as your levels might be twice as high or low on another day. My doctors stress the importance of finding the right dose for ME without compromising my health.

Progesterone might not be essential as some do quite well on estrogen alone. It depends. To each their own.

[Steph34]

ok best case scenario, you switch to IM injections. oil suspended hormones are meant to be shot deep muscle. its really odd they have you shooting sub Q. Sub Q is better for water based suspensions like growth hormone, or hcg.

I will ask the doctor about IM when I see her today. I have not previously discussed it, but I think she would have her concerns. Most people on here who inject that way seem to have very high levels, and neither I nor my doctor think a level of 1000 would be good for me at this time.

Do you really want to discount a proven method for what seem like not so good reasons, Steph?

For me, it would invalidate the whole psychological benefit of transitioning. I stand by my reasoning even if it seems senseless to some. My doctor might not even prescribe it, anyway.

from everything that I came across, it seems levels vary a lot from one ciswoman to another and fluctuate so much during a menstrual cycle, going much higher during pregnancy that trying to mimic levels of a ciswoman is senseless. Some women are more and some women less sensitive to the same level, and remember that even if you measure your levels, chances are that these are not at all indicative as your levels might be twice as high or low on another day. My doctors stress the importance of finding the right dose for ME without compromising my health.

I am not trying to mimic cis female levels or shoot for some ideal level, but to me it just seems to be common sense that having *less* exposure to estradiol each month than most non-pregnant cis women would be insufficient for feminization, given my lower sensitivity to the hormone due to my age and past development in the wrong body.

Thanks anyway to all who responded to my post. I will see the doctor this afternoon and see how it goes.

[KayXo]

I hope you and your doctor find the route and dose (and overall regimen) that best suits you so that mentally and physically you get all the possible benefits without compromising your health.  I personally think you may be focusing too much on levels instead of just how you feel and overall feminization as indicators whether the regimen is working for you or not. Even when you test levels, levels fluctuate from one hour to another, one day to another so what's the point really? They may be quite low one day, relative to what your "target" level is and quite high another. To get a rough estimate of average levels, you would have to take measurements every single day over the course of the cycle of the injection, I think.

Let us know how it goes.