Yet another lab results post ;-)

[TechGirl]

I started my HRT in December 2016 on pills and switched estrogen to estradiol valerate to go along with my spiro.

The frustrating part:  my Endo (military) never requested a full lab panel for initial nor this one.  Only results I have are these:

• Initial prolactin dtd 18 Nov 2016:  8.9 ng/mL
• Two month estradiol check (taken inbetween injections):  739.0 pg/mL

The good part:  I feel good, nipples are sensitive (can't jog w/o sports bra  ), eyelashes have grown much longer, and my face has softened noticeably (as others tell me).  And, I am assuming that the single lab drawn for estradiol looks good.

I've asked my Endo to switch me to cypionate vice valerate (want smoother peaks/valleys) and also to add bio-identical micronized progesterone.  I'm hoping he doesn't think my estradiol level is too high.  We'll see what he does.

Thanks all, wouldn't be here w/o your support!




--note: edited to change year from 2017 to 2016; flux capacitor broken 🙂

[Susan]

Most trans women do not have much if any prolactin levels.

Sent from my Vivo V5 using Tapatalk

[KayXo]

On injections, my levels range anywhere from 1,000 to 4,000 pg/ml. Pregnant women have levels as high as 75,000. I am on estradiol valerate and levels do indeed drop quite rapidly. I also take bio-identical progesterone.

Your prolactin levels may well increase significantly because higher estradiol stimulates prolactin synthesis. Mine are anywhere from 80-130 ng/ml. This is perfectly normal as estradiol increases, it happens in ciswomen too. 🙂

[ainsley]

I don't think the numbers you put forth are correct, KayXo.  Unless you are striving for a pregnancy level all of the time.

From the Mayo Clinic:
ADULTS
Males: 10-40 pg/mL
Females           
Premenopausal: 15-350 pg/mL**
Postmenopausal: <10 pg/mL
**E2 levels vary widely through the menstrual cycle.
Conversion factor
E2: pg/mL x 3.676=pmol/L (molecular weight=272)

These are the reference values from my Doctor (University of Missouri):
Estradiol Level, Serum
1037.00 pg/mL
Date: Aug 24, 2016 06:00 p.m. CDT
Reference Intervals
Normal female follicular  12.50 - 166.00 pg/mL
Normal pre-ovulatory peak  85.80 - 498.00 pg/mL
Normal female luteal  43.80 - 211.00 pg/mL
Postmenopausal Female  <5.00 - 54.70 pg/mL
First Timester Pregnancy 215.00 - >4300.00 pg/mL
   
Normal Males  7.63 - 42.6 pg/mL

My level hit 1037.00 pg/mL and my Doctor is cutting mine back.  She was genuinely surprised at it and had the lab restest because she thought it was a mistake.  It was staying around 600 pg/mL until after GRS, then it spiked since I was no longer opposing any T.

My prolactin level dropped from 91.5 ng/mL to 60.4 ng/mL to 30.6 ng/mL and my Doctor was fine with that.  I was too because when my level was at 60-90 I was lactating. (for 2 straight years!)  It helped with growth quite a bit, but I got pretty tired of socking through garments.

I am on depo estradiol (cypionate) and prometrium.  I was on patches, as well as those two, but those were cessated after the high E levels last fall.  New levels this Fri with just depo estradiol and prometrium.

[TechGirl]

I might have used my flux capacitor

thx, fixing 🙂

[KayXo]

I don't think the numbers you put forth are correct, KayXo.  Unless you are striving for a pregnancy level all of the time.

From one source, levels during first trimester pregnancy are 1,000-5,000, levels during second term are 5,000-15,000 and during the last term 10,000-40,000 pg/ml. One study found levels up to 75,000 pg/ml just before giving birth (at term). Other studies gave average levels of around 20,000-25,000 near term. I did mention these numbers were for pregnant women. Despite such high levels, pregnant women's risk of DVT, as was observed in more than one study, was around 0.1% while that of pulmonary embolism was 0.01%, quite low.

Other studies have shown levels above 1,000 (2,000-3,500) in ciswomen (including older women, 45-55 yrs old) to be quite safe and to be associated with minimal side-effects. They were taking estradiol valerate IM.

Transwomen given very high doses of estradiol valerate IM in one study were not found to develop any clotting complications at all, the age of the women was anywhere from 20-60 yrs of age although the vast majority were 20-40. The duration of the study was 2 years.

In men with prostate cancer, levels between 300-600 pg/ml were not associated with any complications and were actually found to reduce the risk of thromboembolism and have positive effects on cardiovascular risk. These men ranged in age from 49 to 91 yrs old.

Lastly, in older women (50-80 yrs old) taking a VERY high dose of oral estradiol for advanced breast cancer, despite levels between 2,000-3,000 pg/ml, the occurrence of DVT after 6 months was 1 in 30. This would suggest, although many more studies are needed, that even oral bio-identical estradiol is RELATIVELY safe, in contrast to non bio-identical hormones.

My level hit 1037.00 pg/mL and my Doctor is cutting mine back.

My levels came back higher. My three doctors did not find it necessary to cut back as all my other numbers were fine (i.e. comprehensive testing). They don't consider these levels to pose health risks. To each their own. Just goes to show you that even among experts, there isn't necessarily a consensus.

My prolactin level dropped from 91.5 ng/mL to 60.4 ng/mL to 30.6 ng/mL and my Doctor was fine with that.  I was too because when my level was at 60-90 I was lactating. (for 2 straight years!)  It helped with growth quite a bit, but I got pretty tired of socking through garments.

Like I said, it's perfectly normal for prolactin levels to increase as estrogen increases, this is what happens during pregnancy with women and doctors don't bat an eye. I personally believe the same attitude should be adopted with us if we take bio-identical estrogen. Pregnancy has not been shown to induce prolactinomas, despite very high prolactin levels, up to 600 ng/ml.

I probably don't lactate because I also take a high dose of progesterone which inhibits milk production. Stimulation of nipples promotes milk production and secretion.

I am on depo estradiol (cypionate) and prometrium.  I was on patches, as well as those two, but those were cessated after the high E levels last fall.  New levels this Fri with just depo estradiol and prometrium.

So you do take progesterone too. Perhaps, the dose is not as high as mine. I also take mine with fatty food which has shown to substantially increase levels compared to taking it on an empty stomach, up to 8x the maximum levels and double the concentration over 24 hours. I also take it twice daily.

[ainsley]

From one source, levels during first trimester pregnancy are 1,000-5,000, levels during second term are 5,000-15,000 and during the last term 10,000-40,000 pg/ml. One study found levels up to 75,000 pg/ml just before giving birth (at term). Other studies gave average levels of around 20,000-25,000 near term. I did mention these numbers were for pregnant women. Despite such high levels, pregnant women's risk of DVT, as was observed in more than one study, was around 0.1% while that of pulmonary embolism was 0.01%, quite low.

Other studies have shown levels above 1,000 (2,000-3,500) in ciswomen (including older women, 45-55 yrs old) to be quite safe and to be associated with minimal side-effects.

Transwomen given very high doses of estradiol valerate IM in one study were not found to develop any clotting complications at all, the age of the women was anywhere from 20-60 yrs of age although the vast majority were 20-40. The duration of the study was 2 years.

In men with prostate cancer, levels between 300-600 pg/ml were not associated with any complications and were actually found to reduce the risk of thromboembolism and have positive effects on cardiovascular risk. These men ranged in age from 49 to 91 yrs old.

Lastly, in older women (50-80 yrs old) taking a VERY high dose of oral estradiol for advanced breast cancer, despite levels between 2,000-3,000 pg/ml, the occurrence of DVT after 6 months was 1 in 30. This would suggest, although many more studies are needed, that even oral bio-identical estradiol is RELATIVELY safe, in contrast to non bio-identical hormones.

My levels came back higher. My three doctors did not find it necessary to cut back as all my other numbers were fine (i.e. comprehensive testing). They don't consider these levels to pose health risks. To each their own. Just goes to show you that even among experts, there isn't necessarily a consensus.

Like I said, it's perfectly normal for prolactin levels to increase as estrogen increases, this is what happens during pregnancy with women and doctors don't bat an eye. I personally believe the same attitude should be adopted with us if we take bio-identical estrogen. Pregnancy has not been shown to induce prolactinomas, despite very high prolactin levels, up to 600 ng/ml.

I probably don't lactate because I also take a high dose of progesterone which inhibits milk production. Stimulation of nipples promotes milk production and secretion.

So you do take progesterone too. Perhaps, the dose is not as high as mine. I also take mine with fatty food which has shown to substantially increase levels compared to taking it on an empty stomach, up to 8x the maximum levels and double the concentration over 24 hours. I also take it twice daily.

Are you saying that attaining and maintaining a pregnancy level is acceptable or that doing so is ideal?  I've not had a problem with my levels, but I think my Dr. is concerned about sustaining these levels for the rest of my life.  I guess the question is how high and for how long should the level be?  I take a baby aspirin and run 5k at least 4 times a week. 

I am not concerned with clots.  Is there a period after GRS and HRT that someone over 40 should maintain a lower level of estradiol?  The changes to our bodies from the effects of the estradiol are what we want, but do they take 5 years, 10 years, or 20 years in some people?  My point was that it was my understanding that estradiol makes significant changes in the first several years, but then it is continued in a maintenance mode level after those changes, which would not be at 1000+ pg/mL, right?  I am not medical professional, either.  But I tend to advocate heavily for myself in my doctor's office.

I did plan to speak with her about raising my prometrium dose.  I have peeling and brittle nails and am under the understanding that high estrogen can cause that, and increasing progesterone can counter that.  Any input on that?

[rikki88]

I've been on progesterone for a month and my nails are a lot less brittle. They use to snap left and right. I have also noticed what feels like better development.  I've also noticed that my breasts are rounding more. At least that's what it looks like lol.

[KayXo]

Are you saying that attaining and maintaining a pregnancy level is acceptable or that doing so is ideal?

Perhaps ideal in some, not necessary in others. This is up to the doctor to decide. If the person requires higher levels to feel good and have decent results (i.e. breast growth, face feminization, fat redistribution), then studies suggest these higher levels are quite safe. My own experience and lab results as well as those of a few other girls I've come across confirm this.

It's also important to note that on injections, especially when it comes to estradiol valerate, levels fluctuate widely so that one might be exposed to higher levels one day and substantially lower levels several days later. My levels dropped from 2,500 pg/ml to 1,300 pg/ml in only 2 days!

Interestingly enough, in my case, breast growth is better on oral estradiol despite substantially lower levels of estradiol in my blood (although estrone levels are probably way high). This goes to show you that higher may not always necessarily translate to better.

I've not had a problem with my levels, but I think my Dr. is concerned about sustaining these levels for the rest of my life.  I guess the question is how high and for how long should the level be?  I take a baby aspirin and run 5k at least 4 times a week.

Why is she concerned? Do studies suggest high levels for a long time have negative repercussions? Many ciswomen experience pregnancy several times, with levels of estradiol several times (up to 75 times) higher than those we get on injections. It used to be (and still is, in some countries) that ciswomen had several children during a lifetime, sometimes up to 10-12 children and if that were unsafe, so many women wouldn't have lived to bear so many children. Remember that this occurred at a time when care and hygiene were also less ideal than today. Studies have even shown an inverse association between number of children and risk of breast cancer. Studies also suggest that estrogen in ciswomen has a cardioprotective effect and the data as it relates to bio-identical hormones (estrogen and progesterone) seems to also move in that direction. Women have far less cardiac problems than men before menopause, when estrogen levels remain somewhat high. After menopause, this trend is slowly abolished.

Indeed, we don't know the long-term effects of high levels in transwomen but based on all the information we have at the moment and which I shared with you, it would seem that the risks are low rather than high. The problem is doctors will often refer themselves to studies where non bio-identical estrogens were used in high doses and think the same risks observed with those hormones apply to bio-identical hormones when the scientific literature has clearly shown this not to be the case. Or doctors will rely on recommendations and assume that because these recommandations were established by "experts", exceeding those levels recommended is risky when there is no evidence-based data to justify this. On the contrary, as I have shown you. I just think if more research had been done and more interest had been shown for our population that perhaps, the scientific community could have come to the same conclusion I have and shared my opinion. But, because our population is so small and so little time/effort has been invested, that knowledge is evolving very slowly, too slowly, in my opinion. I'm seriously considering going back to medical school for this reason alone.

Is there a period after GRS and HRT that someone over 40 should maintain a lower level of estradiol? The changes to our bodies from the effects of the estradiol are what we want, but do they take 5 years, 10 years, or 20 years in some people?  My point was that it was my understanding that estradiol makes significant changes in the first several years, but then it is continued in a maintenance mode level after those changes, which would not be at 1000+ pg/mL, right?  I am not medical professional, either.  But I tend to advocate heavily for myself in my doctor's office.

I guess if after several years (10-15 years) where all options have been tried and maximum development has been reached, one could lower levels as long as what was gained and well-being aren't compromised. Why not? Lowest effective dose, I'm all for that! Makes good sense.

I did plan to speak with her about raising my prometrium dose.  I have peeling and brittle nails and am under the understanding that high estrogen can cause that, and increasing progesterone can counter that.  Any input on that?

My understanding of the matter is that estrogen reduces sebum production (either directly and/or indirectly through lowering testosterone by stimulating SHBG and reducing gonads production pre-op) and that testosterone has the opposite effect so it should be no surprise that as T goes down and E goes up, we find ourselves having drier skin and increasingly brittle nails (oil produced by skin strengthens nails). As far as progesterone goes, to be fair, the results of several studies are mixed BUT myself and other transwomen have noticed an improvement when progesterone was added. Skin and hair became less dry, even very soft and shiny while nails became stronger. The only way to find out for oneself is to try. One can also add a small amount of testosterone post-op to help with this and other issues like energy levels, mood, libido, skin elasticity and thickness. Every individual is different so the regimen, I believe, must be tailored to them and determined by a doctor who sees us as individuals, not numbers and who is open-minded, interested in the matter and willing to listen and learn.

My 2 cents as a non professional. 🙂 As always, follow your doctor's lead.

[ainsley]

Why is she concerned? Do studies suggest high levels for a long time have negative repercussions? Many ciswomen experience pregnancy several times, with levels of estradiol several times (up to 75 times) higher than those we get on injections. It used to be (and still is, in some countries) that ciswomen had several children during a lifetime, sometimes up to 10-12 children and if that were unsafe, so many women wouldn't have lived to bear so many children. Remember that this occurred at a time when care and hygiene were also less ideal than today. Studies have even shown an inverse association between number of children and risk of breast cancer. Studies also suggest that estrogen in ciswomen has a cardioprotective effect and the data as it relates to bio-identical hormones (estrogen and progesterone) seems to also move in that direction. Women have far less cardiac problems than men before menopause, when estrogen levels remain somewhat high. After menopause, this trend is slowly abolished.

Indeed, we don't know the long-term effects of high levels in transwomen but based on all the information we have at the moment and which I shared with you, it would seem that the risks are low rather than high. The problem is doctors will often refer themselves to studies where non bio-identical estrogens were used in high doses and think the same risks observed with those hormones apply to bio-identical hormones when the scientific literature has clearly shown this not to be the case. Or doctors will rely on recommendations and assume that because these recommandations were established by "experts", exceeding those levels recommended is risky when there is no evidence-based data to justify this. On the contrary, as I have shown you. I just think if more research had been done and more interest had been shown for our population that perhaps, the scientific community could have come to the same conclusion I have and shared my opinion. But, because our population is so small and so little time/effort has been invested, that knowledge is evolving very slowly, too slowly, in my opinion. I'm seriously considering going back to medical school for this reason alone.

I ask the same question (why is she so concerned?) and plan to ask her tomorrow.  I feel surely that she is following recommendations of established 'experts'.  I want to point out to her that I have had good feminization in many areas while at high levels, have never felt that I had any issue from it, am not concerned whatsoever with cardiac related side effects from high levels, and generally feel better about myself when the level is higher.  She does listen to me and takes my input as part of her consideration, so I feel like my voice will be heard.  I mean, frankly, I like my estradiol that high, feel like the physical effects (sans the brittle nails) are desirable, and want to continue with them at that level.

As far as progesterone goes, to be fair, the results of several studies are mixed BUT myself and other transwomen have noticed an improvement when progesterone was added. Skin and hair became less dry, even very soft and shiny while nails became stronger. The only way to find out for oneself is to try.

I plan to lobby for more prometrium, also. 

Thanks for the feedback!