Feeling frustrated after a year HRT, low hormones?

[Saki]

Its been about year since i've started HRT and I'm feeling frustrated. I haven't really changed at all even after a year. I have some breasts (the only thing changing) and my hair has been growing. That's about it. I don't even look half female and still being referred as male.

So I use the VA for my care and I was looking through my blood tests. I take estradiol pills and spiro. I was also off of estradiol for a week and half during the test.

Estradiol - 44 pg/ml
T - 3.47 ng/ml

what do you guys/girls think? I was thinking of second opinion.

[DanielleA]

I have been on a low dosage of pills almost all the way through my transitioning. I didn't really start to see much change until I put weight on. I was skinny as a rake handle to start with at 67kg and 6ft tall. It doesn't hurt to get a second opinion from another doctor though. Maybe you are more resistant to oestrogen or something.

[iKate]

Maybe you should ask your doctor why your levels are so low and if you don't get a satisfactory answer and a plan to raise them you should see another.

[KayXo]

E levels are low, T is high. Not good and not surprising you don't see much change but you said you stopped E during test for a week and a half, why?

[Saki]

E levels are low, T is high. Not good and not surprising you don't see much change but you said you stopped E during test for a week and a half, why?

I had ran out because I moved to different states. I had a primary care appointment but they wouldn't give me any emergency supply until then.

They increased my dosage for  to  last time. Now they increased to . I had taken 2 before off and on just to see what would happen.

And my last blood test before the one in my orgianl post was:

E - 33 pg/ml


Mod Edit - No dosages please. TOS 8

[Mariah]

I would ask your doctor about it and let them know how you feel about the results your getting. If your up to it and the doctor is willing, then it might be time to consider seeing if they will up the dose. Hugs
Mariah

[JLT1]

E is low.  Should be around 200.  What form of E are you taking (pills, patches or cream)?

Also, dosages are not to be posted.  You need to delete them. 

Hugs

Jen

[Saki]

E is low.  Should be around 200.  What form of E are you taking (pills, patches or cream)?

Also, dosages are not to be posted.  You need to delete them. 

Hugs

Jen

I'm using pills. At first I was using patches, but it made me have rashes. But I think worked better. I tried to get them to do injections a few days ago but the VA doctors wouldn't do it.

[Violets]

Your last 2 tests have both shown your E to be very low. Have the test results prior to these also been that low? If so, what did your doctor say about this? 12 months is more than enough time to reach your desired levels. Are you meant to be on low dose or a transitional dose of HRT?

[Ashley3]

Its been about year since i've started HRT and I'm feeling frustrated. ... I was thinking of second opinion.

I had ran out because I moved to different states.

You should discuss things further with your doctor and/or, as you suggested, you might want to find a trans-specific care provider to get a second opinion or guiding input.

I can't offer advice but it seems like something is off because 12 months is a long time to be at low levels unless you specifically wanted those low levels. Some people do want low or slight levels because they're not seeking max changes, just softer skin and slight changes.

My care provider has been both attentive yet conservative with dosages, leading up to finding something that works for me. I'm still in the process, but I had started on one patch, then two patches, finally three but E stayed down. Spiro worked great on T, but E was in a holding pattern. (Patches just aren't effective with everyone. I've seen this elsewhere. ->-bleeped-<- has posts on this, for example. I can't speak about pills.) Anyway, we switched to deep subcutaneous injections and levels went way up. I have a follow-up to possibly reduce the dosage depending on test results. But that all happened in healthy conservative stages, yet relatively fairly quickly (within 6 months) given consistent attentive care, follow-ups, and so forth. Unplanned or undesired breaks in dosages certainly wouldn't have helped me.

Again, I agree with your instincts that you should probably discuss things with your doctor and/or consult with a trans-specific healthcare provider to get a second opinion or input on how to navigate with your main care provider.

An possibly helpful side point... I'm not sure if this applies everywhere, but use of Estradiol for trans patients is often (in all cases I've seen) technically considered an off label use. For that reason, I'd personally work to either go to a doctor very experienced with trans patients, or at least consult with one to discuss any confusion which may exist about the process/dosages.

... I don't even look half female and still being referred as male. ...

You probably know this but starting HRT may or may not effect how passable one is. Given my own very limited experience at this point, I know not to expect changes, but to appreciate what changes there are, and realize it does not always lead to a hugely more female appearance by itself. (I've lost lots of weight, gotten facial electrolysis, started eating healthier and many other things, including some surgery.) I've also come to appreciate the unseen positive effects of HRT which seems oddly understated in much literature. My focus with HRT is currently about discovering, and about "being" more so than "looking." That said, I'm seeing some nice physical changes, but I'm not holding my breath for FFS-like changes.   I'm guessing you know but I wasn't sure given how you stated things. With HRT, I do believe it's safe to say that one's mileage does vary in terms of at least phys changes.

Best of luck getting things worked out!

[KayXo]

E is low.  Should be around 200.

Around 200 is not enough for some, including me. Sensitivity to levels varies for several reasons. Doctors have set around 200 as the ideal level without basing themselves on any scientific evidence. I question this practice. I'm not a doctor but still I question this based on my own reading of the literature and anecdotal evidence.

Anyway, we switched to deep subcutaneous injections

Why subcutaneous and not intramuscular which is the common route for estradiol? How long is your needle? Where do you inject?

That said, I'm seeing some nice physical changes, but I'm not holding my breath for FFS-like changes.

You might be surprised after a few years. I have!

[JLT1]

Around 200 is not enough for some, including me. Sensitivity to levels varies for several reasons. Doctors have set around 200 as the ideal level without basing themselves on any scientific evidence. I question this practice. I'm not a doctor but still I question this based on my own reading of the literature and anecdotal evidence.

I pulled the value of 200 from the "Endocrine Treatment of Transsexual Persons: And Endocrine Society Clinical Practice Guide".

In the guide, 200 is a good place to start.  The team that authored the guidance placed a very high value on avoiding harm.  I'd agree with that, it's a good place to start.  Unfortunately, they stop there....

Once changes start happening and if the person likes the change, 400 would be the next step - in MY opinion. From there, it's about the patient and the bodies ability/requirements to establish and maintain normal physiological function.  However, some people will need higher levels and some will not tolerate those high levels without adverse effects.  The guide does call for routine monitoring of a number of relevant parameters.  It doesn't seem that many doctors do the correct monitoring.......  But monitoring is critical.   

As far as patches, they can perform much better if the skin is washed with rubbing alcohol and allowed to air dry prior to placing the patch.  Second is that three day rotation rather than a 3 day/4 day rotation does a much better job eliminating adverse effects to the skin.  Lastly, removing the patch in the shower followed by liberal washing with soap and then with rubbing alcohol almost eliminates adverse skin reactions in most patients.

In one trial, off the books, the washing routine more than doubled estrogen levels in the blood and reduced skin inflammation to almost nothing....

Jennifer

[Ashley3]

Why subcutaneous and not intramuscular which is the common route for estradiol? How long is your needle? Where do you inject?

You might be surprised after a few years. I have!

I cannot remember the precise reasons other then there are some reasons why it's preferred. I'll ask for a reminder next follow-up.

I use two needles, an 18 gauge ~1.5" needle (not including to hub), which is relatively thick, to prep the syringe with Estradiol, and a 23 gauge ~1" more thinner needle for the actual injection.

My injection site alternates left/right thigh, once per week.

The experience is so much better than my particular "patch hell!" I'm fairly surprised by the ease and convenience of injections... it seems to take not more than about 15 minutes once per week or less as I get better at doing it. No intra-week patch changes or adhesive removal, and no patch to lose either.

I'm not saying patches are bad, just that they didn't work for me given what I wanted out of my particular HRT trial period. I need the levels to go up, and I really didn't want to deal with stuff multiple times during the week.

You might be surprised after a few years. I have!

That is great news! Is there a way to describe the major changes you've seen? If it's too personal beyond the general mention, no worries.

[KayXo]

In the guide, 200 is a good place to start.  The team that authored the guidance placed a very high value on avoiding harm.  I'd agree with that, it's a good place to start.

A good place to start is the lowest effective dose for an individual that triggers well-being and feminization (including breast growth), regardless of E levels. With time, that dose may have to be upped and so on and levels beyond 200 may or may not be necessary. Stopping at around 200 robs many women of their full feminization potential and sometimes well-being. On top of that, this level was arbitrarily established, no scientific support. Yet, no one questions this because of their titles and authority in the field. I personally think it's unfortunate.

I think guidelines are too conservative, there is over cautiousness and not much scientific support behind their statements. If the proper research had been conducted, guidelines could be improved significantly. Do they not care about us? Are we not their priority? I wonder...

My 2 cents. Sadly, I'm not a doctor so don't have much influence. But, I try by educating myself as much as possible on the matter and sharing with as many ppl as I can.

a 23 gauge ~1" more thinner needle for the actual injection.

My injection site alternates left/right thigh, once per week.

1 inch in thigh could end up in muscle anyways.

Is there a way to describe the major changes you've seen?

If I showed you my photos pre-HRT and now, you would be amazed. Face is fuller, more female looking, less angular and squared. Forehead smoother and less harsh. Bigger eyes, fuller lips.

More curvaceous body including butt, thighs and better waist to hip ratio. Breast development, larger and darker areolas, thicker nipples. Much less body hair growth, that took some time to manifest. Scalp hair grows fast and is quite long. No one could ever tell I was ever a guy, from all angles. I also look younger. 

Patience, an adequate HRT and good genetics help. I wasn't overly masculine to begin with but definitely looked male pre-HRT.

[Saki]

As far as patches, they can perform much better if the skin is washed with rubbing alcohol and allowed to air dry prior to placing the patch.  Second is that three day rotation rather than a 3 day/4 day rotation does a much better job eliminating adverse effects to the skin.  Lastly, removing the patch in the shower followed by liberal washing with soap and then with rubbing alcohol almost eliminates adverse skin reactions in most patients.

In one trial, off the books, the washing routine more than doubled estrogen levels in the blood and reduced skin inflammation to almost nothing....

I used to be on the patches but it gave me a rash. They told me to wear it for a week so i showered with it on. I think they worked alot better.

I also have acid reflux so pills might be affected from that.

[Saki]

An possibly helpful side point... I'm not sure if this applies everywhere, but use of Estradiol for trans patients is often (in all cases I've seen) technically considered an off label use. For that reason, I'd personally work to either go to a doctor very experienced with trans patients, or at least consult with one to discuss any confusion which may exist about the process/dosages.

Yes its menopausal women. I'd like to get a second opinion but I dont know who specializes in Trans patients in my area. I live in AL which is not pro-LGBT . But my area is starting to get better. I'll see if the local trans support group has any suggestions. Thanks for the input!

[Ashley3]

If I showed you my photos pre-HRT and now, you would be amazed. Face is fuller, more female looking, less angular and squared. Forehead smoother and less harsh. Bigger eyes, fuller lips.

More curvaceous body including butt, thighs and better waist to hip ratio. Breast development, larger and darker areolas, thicker nipples. Much less body hair growth, that took some time to manifest. Scalp hair grows fast and is quite long. No one could ever tell I was ever a guy, from all angles. I also look younger. 

Patience, an adequate HRT and good genetics help. I wasn't overly masculine to begin with but definitely looked male pre-HRT.

That's quite encouraging... congratulations but also thank you for the foresight. Really amazing changes!

I was out shopping not long after having switched from several months of patches to injections, where the combination of it all had started to have some noticeable complexion-related effects as well as some positive facial muscle/fat thinning (or something like that)... anyway, ran into folks I knew who complimented me... something had changed for the positive, seemed more refreshed/brighter, better complexion. It was the HRT effects because a day or so before I'd started to notice subtle changes in the mirror but had thought it too soon, must have been reading into things. My face seemed slightly different in some almost inexplicable way. I was shocked because it'd only been like 4 months or so. What you describe sounds like there's much more to come. Thanks for sharing those details!

[Jessika]

Some great replies.

This may help too.
http://www.hemingways.org/GIDinfo/hrt_ref.htm

[KayXo]

This may help too.
http://www.hemingways.org/GIDinfo/hrt_ref.htm

Some information provided on that site might be erroneous so don't take everything you read as gospel. That goes for any information you read or hear about, including mine or anyone's on this forum. Question things, do your research, you will begin to see more clearly. Use your common sense too, don't get emotional about it. Remain objective.

ran into folks I knew who complimented me... something had changed for the positive, seemed more refreshed/brighter, better complexion. It was the HRT effects

It's the "glow" that is often noticed in pregnant women. I got the same comments when I switched to higher levels and injections.

[SamKelley]

Oral estradiol passes through the intestinal tract and is first processed by the liver; most of it is lost. If you've been taking oral pills (not sublingual or transbuccal) for a year much of the estradiol will have been broken down into less effective metabolites (e.g. estrone) by the liver. There is a blood test which tests estrone levels vs. estrogen. Oral estradiol can also increase the risk of blood clots in some people. One pathology test for this is the thrombophilia screen but there are other indicators too.

I would expect a well informed endocrinologist to be testing at least every 3 months for LFT (liver function test), clotting (thrombophilia), androgens (free and bound testosterone), estrogens (as well as estrone). Other tests which are recommended are lipids, hsCRP, LH, FSH and prolactin. These are pretty basic pathology indicators for your health while on HRT and well understood. I may have missed a few too... If an endo isn't testing for all of these I would have to wonder why?

Second, some endocrinologists take a conservative approach because of their concerns with complications, especially clotting. However these risks are mainly associated with the older estrogens (ethinyl estrogen and conjugated estrogens). The newer estrogen synthetics (estradiol hemihydrate and estradiol valerate) are bio-identical and a lot safer. The latest study oh MtF HRT declared it to be safe (I can't post citations yet, but you should find it by googling "largest study to date: transgender hormone treatment safe"). By contrast one of the original studies on Premarin, a conjugated estrogen, was aborted part way through due to complications and deaths!

My last comment is that estrogen 17-beta itself is an androgen antagonist. There is arising evidence to suggest that for many people E will suppress T to female levels, but this is still relatively new thinking.

I think the moral of HRT is you need to be well informed, because the endocrinologists may vary wildly on approaches, conservatism, and how up-to-date their knowledge is.

Now you're on estradiol IM/subcutaneous you should see E levels improve a great deal. I agree with the 200-300 range for E, and your T should be in the low to mid female range.

Sami