I am having doctor troubles, what do you all think?

[SamanthaW]

I have been on HRT for 6 months now, at month 4 1/2, my dr took me off estradiol pills, and put me on a low dosage Patch, the result was at month 5 1/2 my estrogen levels is nearly nothing and my testosterone went thru the roof.  So he now put me back on a regular dosage of Estradiol Pills but took me off of Spiro, her reason was I was already on Finistride and that should take care of the Testostrone, forget my testrotrone went thru the roof.  The reason for the patch change was she was concerned bout blood clots, I have o history of problems.  My doctor is a Gynocologist that is also working with The transgender community.  I am thinking of leaving her to go to a Endocrinologist who knows hormones and works with Trans, she is just a little more expensive.  Any comments? Thanks  Samantha

[Rachel]

That is a tough one. You may want a consult with the new doc and see what she says and then make an informed decision.

[Emjay]

With my own HRT situation suddenly being in a tailspin I'm reluctant to say anything more than it does sound odd and there isn't anything wrong with getting a second opinion.

I'm definitely going to with my own situation.....

Best of luck to you Samantha, I hope you get it figured out. 

[jentay1367]

Some Endo's are going to be ultra conservative and more so if you are over 50 years of age and fall under the obesity guidelines regarding your weight. Do you meet any of that criteria? If not, than you may want to find someone that's willing to be a bit more pro-active with your treatment. You don't say why she took you off the oral regimen? Were you showing signs of liver stress? Did she share that info with you? You obviously know your T has not dropped so I will assume she has at least done some testing. If in fact you're not obese nor over 50 and have no co-morbid issues that failed to make mention, my personal opinion is that your Endo may be overly cautious, thus cheating you of your ability to live as your authentic self. We're in this alone (your friends here on this board can only comment and advise)....you'll need to ascertain your circumstances and make a pro-active decision that helps YOU. If that means changing Doctor's, then that's what you'll need to do. If that's so, interview them and let them know your goals. See if they're in line with what you expect....then, hold them to it! If they don't intend to follow your path or you feel their agenda is not in line with yours, thank them for their time and keep looking! As I've pointed out before many times, these people aren't gods and they work for YOU...not the other way around. Good luck Sis!  Lisa

[AnonyMs]

I've read many times that pills are not for older people due to the risk of blood clots. I'm not entirely sure if its true, and my endo says I could safely take pills. I don't like patches or gel as they don't work at all well for me. You could also try injections or implants (if you can get them).

I'd be very careful with respect to blood clots as it could effect you chances of getting SRS (and that will fix your T problems).

[Maybebaby56]

I have been on HRT for 6 months now, at month 4 1/2, my dr took me off estradiol pills, and put me on a low dosage Patch, the result was at month 5 1/2 my estrogen levels is nearly nothing and my testosterone went thru the roof.  So he now put me back on a regular dosage of Estradiol Pills but took me off of Spiro, her reason was I was already on Finistride and that should take care of the Testostrone, forget my testrotrone went thru the roof.  The reason for the patch change was she was concerned bout blood clots, I have o history of problems.  My doctor is a Gynocologist that is also working with The transgender community.  I am thinking of leaving her to go to a Endocrinologist who knows hormones and works with Trans, she is just a little more expensive.  Any comments? Thanks  Samantha

You definitely should see a trans-friendly endocrinologist.  A anti-androgen such as spironolactone is essential to most all MtF drug regimens. Finasteride is specifically a 5-alpha-reductase inhibitor and blocks the conversion of testosterone to dihydrotestosterone (DHT), and can actually raise serum T levels. It does nothing to inhibit testosterone production. Spironolactone lowers circulating T levels by increasing its metabolic clearance and by preventing a compensatory increase in testicular androgen production, most likely through direct inhibition of testosterone biosynthesis.  Spiro also raises estradiol levels by increasing peripheral conversion of T into E.

Pathophysiology of Spironolactone-Induced Gynecomastia
Annals of Internal Medicine 87:398-403 (1977)

It's an old paper, but highly cited. 

I've read many times that pills are not for older people due to the risk of blood clots. I'm not entirely sure if its true

It is true. The thromboembolitic effect is due to first-pass metabolism of estradiol if taken orally. If you are over 40, or smoke tobacco, do not take estradiol pills orally.  Let them dissolve sublingually.

Venous Thrombosis and Changes of Hemostatic Variables during Cross-Sex Hormone Treatment in Transsexual People
Journal of Endocrinology and Metabolism 88(12):5723-5729 (2003)

~Terri

[Deborah]

I'm 56 and my endo has me on max dose pills.  I've been on that dose for 20 months and have absolutely no issues.  I am otherwise healthy, not overweight, and quit smoking when I started this.

According to my Dr, the risks are overstated.

[AnonyMs]

It is true. The thromboembolitic effect is due to first-pass metabolism of estradiol if taken orally. If you are over 40, or smoke tobacco, do not take estradiol pills orally.  Let them dissolve sublingually.

Venous Thrombosis and Changes of Hemostatic Variables during Cross-Sex Hormone Treatment in Transsexual People
Journal of Endocrinology and Metabolism 88(12):5723-5729 (2003)

I've not made the effort to read that paper properly, but I'm not confident its very credible. The sample sizes are tiny and one of the estrogen's they use is Ethinyl Estradiol. Also its out of the Netherlands, and I've seen some really poor trans related papers from there.

[Maybebaby56]

I've not made the effort to read that paper properly, but I'm not confident its very credible. The sample sizes are tiny and one of the estrogen's they use is Ethinyl Estradiol. Also its out of the Netherlands, and I've seen some really poor trans related papers from there.

That was one of the points of the paper.  Cyproterone acetate (CPA)-only, transdermal estradiol (E2) + CPA, oral E2 +CPA, and oral ethanol estradiol (EE) were compared.  Only oral EE resulted in a large increase in activated protein C (APC) resistance.

There was an increased risk of blood clots associated with oral estradiol (E2), but not transdermal E2, and more pronounced risk associated with oral ethinyl estradiol (EE), or oral E2 plus progestins (such as in birth control pills, or HRT using oral EE or E2 plus cyproterone acetate, CPA) or CPA alone.

I have posted this elsewhere, but again, these results are consistent with other studies on cis-women:

"Our data show that oral, unlike transdermal, estrogen induces APC  resistance and activates blood coagulation. These results emphasize the importance of the route of estrogen administration".

Differential Effects of Oral and Transdermal Estrogen/Progesterone Regimens on Sensitivity to Activated Protein C Among Postmenopausal Women
Arteriosclerosis, Thrombosis, and Vascular Biology 23:1671-1676 (2003)

The sample size was 30 MtF and the correlations were highly significant (P <0.005). I don't know what you find questionable about it, but you're certainly entitled to your opinion.

~Terri

[Deborah]

The study is probably valid.  But my endo who treats lots of trans said she had never seen anyone actually have a problem with oral E.

[Maybebaby56]

The study is probably valid.  But my endo who treats lots of trans said she had never seen anyone actually have a problem with oral E.

That's quite believable. The baseline risk of venous thrombosis for a woman in her 40s is about 54/100,000 and 62-122/100,000 for women in their 50s. HRT using estradiol alone is associated with a 20-50% relative increase in risk.
(American College of Obstetricians and Gynecologists: Committee Opinion No. 556 April 2013)

Even if your doctor treated 1000 trans patients, she still might not encounter one case of thromboembolic complications from HRT.

~Terri

[SamanthaW]

Thanks for all the response, in a brief, I am 65 yrs old, a am 30 pounds overweight, not a lot, I am in good health, I do exercise daily, have not missed a day of work in 4 years.  So I am in good health.  My current doctor is a Gynocoligist with University of Kansas Womens health center whom has been working in the Transgender field for a few years now, but she is not an endo.  I have asked her why she put me on the low dose patch and she said was concerned about deep vein thrombosis (blood clots). After a month I took a blood test and my estro levels were non-existant and my testost levels were at 150, previous test my estro levels were 500 way too high and testost level was at less than 20.  I talked to my therapist and she has a Endo for me to see if I want?  I do like the current doctor and am concerned that the Endo will be way to conservative.  Samanthaa

[Harley Quinn]

You might have to play the game with her for a while.  Sounds like she's looking out for you.  High levels or estrogen and clotting is definately an issue, as well as excessive strain on your liver.  If she's concerned about DVT, then I would suggest IM shots or implants.  They put less strain on your liver and reduces your risk for DVT/Clots.  IM shots are expensive and you will get some highs and lows at the beginning and end of your cycles.  However, from what I have learned, you may not require Spiro while on shots because the required doses are high enough that they will floor your T levels anyway.  And Implants are very cool as you don't have do worry about pills, and needles... get pellets implanted every 4 to 6 months and forget about the daily routines...  With a constant level of estrogen, your highs and lows are a mute point