HRT emergency UK-USA

[JS UK]

I'm hoping a kind lady in the USA can help me here.

I'm UK based and have been diagnosed as trans by my therapist/doctor. Today this  diagnosis has been confirmed by a trans specialist psychiatrist within the practice. I believed that this would allow my therapist/doctor to prescribe me hormones. I therefore emailed her asking her if there was anything further she needed from me (my blood tests have recently been done) before we meet next week as I didn't want a delay in my prescription.

She emailed me back saying that unless I commit to RLE right now then she can only prescribe Zoladex and not estrogen. I'm absolutely devastated by this. It really feels like the end of the world. I've been clinging on to the hope that I'll get hormones for the last couple of months and it's literally kept me from falling apart.

I've reread a message from a friend here and it appears to be the case that in the UK hormones will only be prescribed once you start the RLE.

As I can't start the RLE 'till next year for a number of reasons I'm looking to have them prescribed in the USA.

Assuming my doctor confirms her diagnosis in writing, and I see no reason why not, could someone point me in the direction of somewhere in the USA, preferably east coast and reachable easily from London (i.e. a major city) where a doctor can prescribe the estrogen I need to keep me alive? Also, I'm going to have to pay for flights and accommodation etc so an indication of costs would be helpful.

Many thanks,

Julie

[Laura_7]

You have a few options.

The RLE is not mandatory any more to my knowledge. So you might hint that this changed in the rules.
There are threads on this, like some doctors do not insist.
There were changes in the guidelines in 2014 so your doc might read it up.

Another option is this:
https://www.susans.org/forums/index.php/topic,197023.msg1753642.html#msg1753642

And another option would be the us and informed consent.
There are clinics in LA which do implants.
So steady doses and no further hassle with meds. Implants last 4-6 months, with some people even 12 months.
Cost is around 1200 for the first treatment. This kind of treatment does not need anti androgens so no further meds.

There are other informed consent clinics which do pills, patches or injections.
Costs are lower there, maybe a few hundred usd.


hugs

[SophieD]

Julie, I sent you a PM with an option in Washington, DC that might work for you.

[Lisa55]

There is a private GP here in the UK who looks too good to be true, but there are quite a few girls on another forum who speak highly of her and i am seriously considering giving her a call myself.  But reports are about a month from first contact to skittles in hand and a lot cheaper than return flight to USA. May even be quicker or easier as you already have a diagnosis.

https://www.mywebdoctor.co.uk/transgender/

[JS UK]

Thanks for all the replies and PM's ladies.

I'm hopeful that I can persuade my doctor to prescribe me HRT, if not I'll give serious consideration to all of the options as I feel I can't continue like this.

Julie

[Devlyn]

I'm in Boston and wrote to the "Ask the Doctors" section of the Fenway Health services website, they offer informed consent HRT. I asked if a person from the UK could use their informed consent clinic and recieved the following reply:

Good morning Devlyn,



Thank you for your question submission to Ask The Docs. I received the following feedback from our Clinical Team. Prescribing, monitoring, and medication adjustments are ongoing with HRT. A person would not be able to just come and receive a prescription and then go home. The team also believes that the UK uses an alternative to Spiro which could lead to challenges refilling the prescription. Also, we would not be able to take international insurance. Payment for appointments and medications would be full price out of pocket.



For additional guidance, support and navigation I encourage you to contact Cei Lambert. Cei is very resourceful and perhaps has additional ideas that could assist you.



Cei Lambert, Patient Advocate

CLambert@fenwayhealth.org

857-313-6589





Best,

Daniel


Daniel Jones, MSN, RN  | Clinical Nurse Manager of Prevention and Screening
The Fenway Institute | Ansin Building | 1340 Boylston St.- 5th Floor | Boston, MA | 02215
Office: 617.927.6030 | Fax: 617.867.8647 | www.thefenwayinstitute.org

[calicarly]

You're so misinformed!!! OMG!!

If You are going to an NHS GIC Clinic (public healthcare) you have to be on RLE , yes. But Private care is available through informed consent  look up dr Webberley or Dr seal they are here in the UK.

You go to them privately and upon signing informed consent you can have your prescriptions within weeks. this is essentially the same thing you would have done in the US. So you will pay a fee and what not to see them but they will get you on your way.

Good luck

[JS UK]

I'm in Boston and wrote to the "Ask the Doctors" section of the Fenway Health services website, they offer informed consent HRT. I asked if a person from the UK could use their informed consent clinic and recieved the following reply:

Good morning Devlyn,



Thank you for your question submission to Ask The Docs. I received the following feedback from our Clinical Team. Prescribing, monitoring, and medication adjustments are ongoing with HRT. A person would not be able to just come and receive a prescription and then go home. The team also believes that the UK uses an alternative to Spiro which could lead to challenges refilling the prescription. Also, we would not be able to take international insurance. Payment for appointments and medications would be full price out of pocket.



For additional guidance, support and navigation I encourage you to contact Cei Lambert. Cei is very resourceful and perhaps has additional ideas that could assist you.



Cei Lambert, Patient Advocate

CLambert@fenwayhealth.org

857-313-6589





Best,

Daniel


Daniel Jones, MSN, RN  | Clinical Nurse Manager of Prevention and Screening
The Fenway Institute | Ansin Building | 1340 Boylston St.- 5th Floor | Boston, MA | 02215
Office: 617.927.6030 | Fax: 617.867.8647 | www.thefenwayinstitute.org

Thanks for taking the time Devlyn.

It looks like the web doctor in the UK will do what's required. Thanks for that Lisa.

Julie x

[JS UK]

Further to my posts above it looks like Lisa's recommendation of mywebdoctor will be the most cost effective method of acquiring my E. This brings more questions though. I've spoken with my local GP and she is happy to prescribe for me anything that's recommended by my private doctor. This is significant as the Zoladex appears to be very expensive.

I'm thinking trying to persuade my private doctor to prescribe me E in addition to the Z. Failing this, accept the Z from her and get my E from mywebdoctor. If I chose to use mywebdoctor for everything I'll be stuck with Finasteride (which I'm already taking) as a T blocker and from what I can understand it's not that effective.

This leaves me in the position of hoping that my local GP will accept this situation and continue to prescribe my my Z while I get my E from MWD.

It's a bit of a messy situation and I can't make my mind up which way to go. I'm particularly concerned about using F as my only T blocker and would welcome any opinions on this.

Edited to add: Cyproterone Acetate is also prescribed by the online doc. I'd appreciate opinions on whether how effective this would be in conjunction with F and E...

Thanks,

J

[KayXo]

Finasteride is a poor substitute for an anti-androgen as it only reduces DHT through inhibiting conversion of T to DHT. If it's commonly prescribed to males (male pattern baldness), you know it's a VERY weak anti-androgen.

Cyproterone acetate is a much more powerful anti-androgen as it not only reduces T (and hence DHT) to female levels, at even low dosages, but also partially blocks androgens from binding to receptors. Zoladex only reduces T. Both are fine and effective as anti-androgens. Finasteride may be useful as a COMPLEMENT to either anti-androgen but cannot be your ONLY anti-androgen.

Something you may ignore is that E is also anti-androgenic and can reduce T levels to female levels ON ITS OWN. Without the need for any anti-androgen and without compromising safety, IF taken by injections or pellets. In some, a safe enough dose of oral E, taken alone, can also reduce T sufficiently.

Hope this clarifies things.

[Lucie]

[...]

Something you may ignore is that E is also anti-androgenic and can reduce T levels to female levels ON ITS OWN. Without the need for any anti-androgen and without compromising safety, IF taken by injections or pellets. In some, a safe enough dose of oral E, taken alone, can also reduce T sufficiently.

Kay, I really appreciate advices you give about HRT (and also about nutrition ). They are very informative and well argued.
As concerns anti-androgenic action of E, a lot of people don't know it or deny it. Would you have scientific and/or medical references which establish that A-A are not mandatory for full transition of trans women ?

[KayXo]

Would you have scientific and/or medical references which establish that A-A are not mandatory for full transition of trans women ?

Any doctor will know that estrogen exerts a negative feedback on the pituitary gland and hypothalamus, thereby reducing LH and FSH production which signal testes to produce testosterone and maintain sperm production. If your doctor ignores this, run...FAST.

Studies have also suggested, in addition to this, that estrogen has the following anti-androgenic effects:

- reducing conversion of T to DHT
- increasing aromatase responsible for converting T to E
- downregulating (decreasing) androgen receptors.


The reason many doctors do not only use E is because they wrongfully believe that the doses of E needed to shut down T will increase health risks, especially liver damage and thrombosis, perhaps cardiovascular complications. This may have been, indeed true, with non bio-identical forms of estrogen but studies have shown when bio-estradiol is used, in high doses, in transsexual women and men with prostate cancer (49-91 yrs old), none of these complications occurred. Most of the time, estradiol was also taken non-orally. One can also bring up the situation of pregnant women who have extremely high levels and despite this, this neither increases breast cancer risk (on the contrary, inverse associations have been found) and DVT/embolism risks remain VERY low, under 0.02%.

I will PM you references.

[Lucie]

The reason many doctors do not only use E is because they wrongfully believe that the doses of E needed to shut down T will increase health risks, especially liver damage and thrombosis, perhaps cardiovascular complications. This may have been, indeed true, with non bio-identical forms of estrogen but studies have shown when bio-estradiol is used, in high doses, in transsexual women and men with prostate cancer (49-91 yrs old), none of these complications occurred. Most of the time, estradiol was also taken non-orally. One can also bring up the situation of pregnant women who have extremely high levels and despite this, this neither increases breast cancer risk (on the contrary, inverse associations have been found) and DVT/embolism risks remain VERY low, under 0.02%.

Again it comes back to bio-identical vs non bio-identical hormones.
Thanks a lot for the references !

[calicarly]

JS-UK,

You don't have to convince Dr Webberley, I'm sure she will suggest a blocker herself.

Out of all the blockers you mention, Cyproterone is definitely the most powerful. If she gives you a choice. It blocks T and DHT, basically all the free androgens made not only by the gonads but by your adrenal glands too.

Actually I'm only repeating what Kay said aren't I?

So yeah what Kay said^^ lol

All I can add is Zoladex has a very safe side effect profile if you were to take it for a long long time. Years. Where as to Cyproterone is so powerful it can have some side effects but they are rare when taken at low doses. It's side effects increase depending on duration of treatment but only if you're on it for a long long time say 3 years plus.

[JS UK]

Thanks for the further replies ladies.

Dr W has only prescribed Finasteride and Estrogen at this point. She wants to monitor my T levels and will prescribe a stronger blocker 'if required'. As I've been on F for 6 weeks with little effect I'm going to give it another few weeks then ask for something stronger.

Julie

[KayXo]

Finasteride does not reduce testosterone, it only reduces DHT (the strongest androgen, dihydrotestosterone) levels. Estrogen, on the other hand, reduces T.

Clin Pharmacokinet. 1996 Jan;30(1):16-27.

"Therapeutic doses of finasteride produce a rapid and pronounced effect in reducing both plasma and prostate tissue levels of DHT."

"Serum testosterone levels increase in patients receiving finasteride, but are not normally outside the upper limits of the normal range."

[AshleyT]

I took one look at the NHS waitlists and went private with Dr Curtis. Great experience with him so far, and it hasn't broken the bank.

FWIW as above the NHS dropped the RLE requirement a couple of years back, so that shouldn't be an issue.

I was prescribed E only (I started on Fin early 2015 then switched to Dutasteride when I started E in August 2015), and after a slight adjustment to dose at three months everything is going swimmingly. Had my six-month bloods a couple of weeks back - E is right in female range, T is at top end of normal female range, free androgen index right bang in the middle of female range, everything else pretty much in F range...

Not having a dedicated blocker doesn't necessarily mean you're going to be battling T so just see how it runs for 3-6 months and check levels once everything has settled down.

[KayXo]

What matters most? Levels on a sheet of paper or how you feel and feminization (breast growth, softening of skin and traits, curves, body/scalp hair, erections/size of testicles)? You can tell when HRT is working, levels won't tell you more than what you already know.