Advice: Masculinization without Anti-Androgens

[Picklehorse]

Hello all,

My Endo has taken me off Spiro after my blood tests revealed that it was overdoing it and my testosterone was lower than the range they test for. That was 3 months ago and since then I've had body hair / oily skin return, the return of semen production and erections, and re-masculinization of the face. But all of this with T levels now in normal female range.

I'm not supposed to see the endo until July, but this just doesn't seem right. Should I make an appointment or are these symptoms normal after stopping Spiro and I just have to live with it?

This is stressing me out!

[AnonyMs]

Hello all,

My Endo has taken me off Spiro after my blood tests revealed that it was overdoing it and my testosterone was lower than the range they test for. That was 3 months ago and since then I've had body hair / oily skin return, the return of semen production and erections, and re-masculinization of the face. But all of this with T levels now in normal female range.

I'm not supposed to see the endo until July, but this just doesn't seem right. Should I make an appointment or are these symptoms normal after stopping Spiro and I just have to live with it?

This is stressing me out!

I've had my T lower than female range from spiro and my endo said the test is not accurate at those low levels. I didn't feel any adverse effects from it, and stayed on the same dose.

I'd be tempted to see the endo about using a lower dosage of spiro and adjusting it until its right.

[Ms Grace]

I'd be tempted to see the endo about using a lower dosage of spiro and adjusting it until its right.

I second this.

[KayXo]

It's normal to see increasing androgenization after spiro withdrawal since spiro inhibits androgen action. Stopping it just because T levels were undetectable or "too low" is not right, in my opinion. Instead, the doctor should have asked you how you were feeling, determine your rate of feminization, assess your overall health to find out if any complications arose and if everything looked fine, then I see no reason to change anything. This change seems to have hurt you more than benefited you. My 2 cents...perhaps get a second opinion from another doctor?

They prioritized numbers over everything else, it seems, when your actual response to levels (how you feel, how your body is responding) should be the main determinant. If you felt good and responded well, then why change anything at all?

[Soli]

your actual response to levels (how you feel, how your body is responding) should be the main determinant.

I fully agree... (I'll leave it at that)

[Cindy]

This does sound like a strange response. Yes you do need some T for mental health and libido. The 'normal' way and endo would respond would be to give a shot of T and keep the spiro going while measuring SHBG. I'd want to know what the SHBG was doing.

I suggest a second opinion if you can get it. I would certainly tell your endo of your physical changes ASAP.

Oh and the androgen testing we do is accurate at the level of T being discussed, unless they are a poor pathology testing lab. Then I would be worried about lots of things.

[KayXo]

Yes you do need some T for mental health and libido.

Two things:

- how much T someone needs, the doctor cannot know in advance because every individual is different and responds differently. Someone might be very sensitive to T and need very little while another might need more. Levels alone do not reveal anything useful. Furthermore, if the patient feels good, is developing well, why change anything?? Makes no sense. Just because the doctor arbitrarly establishes that a certain range is IDEAL for everyone? This is not right. The individual's well-being and response is being ignored over numbers.
-  I actually question whether T is even needed at all IF enough E is taken because women who are completely androgen insensitive do quite well without any T at all. They are mentally healthy and as far as I know, their libido seems fine. I, myself, have a T level which is very low, undetectable and yet I remain mentally fine and libido is good.

The 'normal' way and endo would respond would be to give a shot of T and keep the spiro going while measuring SHBG. I'd want to know what the SHBG was doing.

Again, I ask why if the patient has no complaints and feels well? Isn't that the goal rather than aiming for a certain level? Doctor's insistence on numbers may be harming patients in the end, it blinds them from what is really important, sometimes.

[luna nyan]

Again, I ask why if the patient has no complaints and feels well? Isn't that the goal rather than aiming for a certain level? Doctor's insistence on numbers may be harming patients in the end, it blinds them from what is really important, sometimes.

I'd respectfully say that feeling well and actually being well can be completely different beasts altogether.

As a patient you have the right to refuse treatment.

As the treating physician you are held to a duty of care to diagnose correctly.  To do so requires that all appropriate tests and examinations be performed.   That would include anything that a peer in the profession with similar levels of training and expertise would do.

You may argue till the cows come home about what appropriate levels for transgender individuals should be but at the end of the day, at least from diagnostics, certain things need to be done.

[KayXo]

As the treating physician you are held to a duty of care to diagnose correctly.

And as a human being caring for another human being, you are held to a duty of using your common sense and taking the patient's well-being/feedback into consideration which allows to gauge sensitivity to sex hormone levels which the test cannot measure. There is only so much numbers, in this particular context, can tell you.

To do so requires that all appropriate tests and examinations be performed.   That would include anything that a peer in the profession with similar levels of training and expertise would do.

Not all doctors test sex hormone levels in the course of HRT. Some consider them to provide no useful information and instead rely on patient's feedback. Hence, peers vary in their approach and what they consider necessary tests and examinations. I think it is important to question what we do instead of blindly following protocols which sometimes can be improved after objective assessment.

You may argue till the cows come home about what appropriate levels for transgender individuals should be but at the end of the day, at least from diagnostics, certain things need to be done.

I am arguing that the appropriate level varies from one individual to another (and even in the same individual across their lifetime) and that a doctor cannot possibly know what they are. The patient's feedback and body's response allow the doctor to know whether the current treatment is working as expected and producing optimal results. One needs to understand the purpose of doing blood tests and how relevant each and everyone of them is, their limitations and usefulness within the context.

I am not a doctor but just from using my common sense, this seems obvious to me.

[luna nyan]

I am not a doctor but just from using my common sense, this seems obvious to me.

When it comes to the medico-legal minefield, there is no such thing as common sense.  What may seem to be sensible and appropriate in the initial circumstances get pretty much destroyed in the court of law as the systems favour plaintiffs.

As as result, health care isn't just about health anymore, a certain amount of it is defensive practice which means more testing than may be strictly necessary in some circumstances. Society has now made its bed, and now has to lie in it with increased cost, and poorer access as a result.

Edit:  We've now hijacked this thread and turned it into treatment philosophy - apologies to the OP.

Picklehorse - agree with most of what ppl saying - contact your endo, if you're not feeling great then get a second opinion.  Good luck!

[Soli]

Edit:  We've now hijacked this thread and turned it into treatment philosophy

Yeaaa, love philosophy. Jumping in. May I?

What you say luna nyan must vary in degrees according to which jurisdiction one is in, I don't hear of many GP, nor specialist getting sued in Canada. I don't know about UK where I think Picklehorse is. Specialists are not omniscients, they are humans and make mistakes like others and science doesn't know everything about our brain and body, plus we're all different, doctors know this and always adjust the prescription according to what the patient reports (more, less, something else), or should... Thinking seems to have evacuated the mind of many working in the medical field who sometimes I think could be replaced by robots... software... artificial intelligence? oh sorry getting lost here. Basically, we're all guinea pigs, medecine is more of an art than pure science and I think a good doctor thinks more than refers to the books and protocols.

[Soli]

sorry to have participated in this thread hijack  I'll get off this wagon then since it's not moving. Just hope Picklehorse will get access to what she obviously needs.