How direct are you with questioning dosage?

[AlyssaJ]

I'm just curious how direct you folks are with your conversations about dosage with your doctor. I'm on what I've learned is a very low dose (uncommonly low) of Estradiol to start my HRT.  I trust in my doctor and her experience with Trans women, but at the same time I feel like I may really just be wasting time on such a low dose.  Obviously, most of us do get impatient with the whole process anyway and want to see things speed up.  But I've also noticed that many here have a pretty good working knowledge of the technical particulars of this.

So my question is, how do you deal with your doctor on this?  Would you directly question why they're starting you at one dose versus another?  Would you push for them to move you to a particular dose?  Would you be more subtle and just ask about their care plan for you?  I tend to be so non-confrontational at times that I wonder if I should push harder or ask more direct questions than I do.  I don't want to insult my doctor or make her feel like I'm playing internet doctor, but at the same time I do need to be comfortable with my care.

Thoughts??

[jentay1367]

You are new and your Endo is being prudent by tritation. This is the best course of action because it allows them to see how you'll react. If you have a ton of HGH in your system, a low dosage could easily give you more than adequate results. Your numbers after 3 months will tell the tale. If all your other numbers are good, they'll raise your amount. The general rule of thumb is 30 pg/ml an somewhere around 200 pg/ml for E. The amount of AA and E it takes to achieve this is different for everyone. Again, you need to slooooooooooooooow doooooown. This is a marathon, not a 100 yard dash. No girl went through puberty over night. Neither will you. Settle in and follow your Endo's advice. If after 3 months all your panels look good and your t is still high and your E is low, then it's time to ask your endo why they wouldn't raise your prescription amounts. Remember, you want the least amount of drugs to achieve the desired numbers. More does not equate to more feminization, period. That's a fact. DVT and liver damage are real possibilites that must be faced. Titration mitigates that outcome. Your health is the imperative here. If you react badly to large amounts of Hormones and AA'S out of the gate, it could destroy your transition plans. There's a girl on this site right now that is on a relatively low dose and she's found herself lactating. That generally only happens on large amounts but she is very young and is having a very good result from low dosage. My advice to you is.................Patience Grasshopper...patience. lol

[Devlyn]

If youve learned your dosage is low, point out the error to your doctor immediately.  If you think you've learned that your dosage is low because other girls tell you they're taking more, proceed with caution.

Hugs, Devlyn

[TonyaW]

Trick is to do it without making it seem that you are questioning their judgement, expertise or what ever.

It is definately ok to ask why they picked the starting dosage that they did.  Should be willing and able to tell you.

You posted a bit ago that you hit one month, do you have a follow up?  My doctor doubled me after a month so basically the first month was to see if I tolerated the meds. 

Sent from my SM-G930V using Tapatalk

[staciM]

Alyssa, I seem to remember you mentioning you had confidence in your Dr's methods because she had many years of working with trans patients.....I would say that her protocol is what she is comfortable with and you should trust her.  At the next appointment, she "should" have your blood work in-hand and will make appropriate changes based on what she sees.  It's frustrating not being able to discuss real dosages on here to compare but I'm on a relatively low dose (also just started) and although I'm eager to get a bump, I trust my Dr's experience.  FWIW, I'm seeing drastic changes in several aspects of my body....muscle burning away quickly, skin dramatically softer, noticeable face changes and breasts starting.  Everyone is different and my thought is that HRT "really" starts after the first 3month blood work can be analyzed for reaction.  If at that point you feel it's still too conservative, have a conversation.

[ainsley]

So, if you've read any of my other posts on this subject then you know I am very straightforward with my doctors.  I will cite studies, standards, and other reference material to support my opinion, which I let them know is important to me---my opinion, that is. 

My doctor flipped out with my E levels last fall, dropped my E dosage (I did not argue with her) and they fell to a level below my expectations for my continued feminizing.  I told her my current levels are half of what I want to maintain.  She listened to me, I explained why, and she acquiesced.  She added more frequent labs checking with my higher than her planned E levels goal to ensure no negative physical effects from it.  That is a partnership and how it should work.

I don't pull punches, I am respectful, and I maintain a voice in MY care with any doctor.  Advocate for yourself if you feel something is not the way it should be for YOUR care.

[KayXo]

You are new and your Endo is being prudent by tritation.

I am not a doctor but my own opinion is that bio-identical estradiol is safe enough that it doesn't need to be *that* low, especially considering she's NOT pubertal. In her case, I believe her doctor may be overcautious and personally, I would ask the doctor some questions about this, ask for justification, etc and check with sources (scientific, journals). Perhaps, even seek a second opinion on the matter.

Anti-androgens are different and starting low makes sense to me although that is not her case either. The starting dose given was not low. Lowering androgens too much while not giving enough E can trigger menopausal symptoms which may be very uncomfortable (and risky long-term) for the person.

Your numbers after 3 months will tell the tale. If all your other numbers are good, they'll raise your amount. The general rule of thumb is 30 pg/ml an somewhere around 200 pg/ml for E.

I believe you mean to say 30 ng/dl for total testosterone. I personally don't think relying on E and T levels is the way to go and is the lazy approach because it's an arbitrary number that was chosen and people react differently to levels so that some may need more, some less to get optimal results. At least, that is how I and my doctors see it, some other doctors also share our perspective. Just think alcohol concentrations in the blood and how people vary in their reactions to more or less similar concentrations. In addition, E & T levels are all over the place and fluctuate so that the number you see is one point in time and far from accurate.

I think finding the right dose for the individual is more appropriate by paying close attention to physical and psychological results. Patient feedback is important. My 2 cents. As indicated above, I'm not a health expert.

No girl went through puberty over night. Neither will you. Settle in and follow your Endo's advice.

True. Changes take time. But, time is also precious and there is no rule against discussing things with your doctor, sharing your opinion on the matter, asking questions, presenting data from journals, etc. My doctors don't mind my feedback and sometimes even value it. Blindly following is also not wise. It's good to be proactive in one's health, I think.

Remeber, you want the least amount of drugs to achieve the desired numbers.

IMHO, the least amount for desired results (mental health and breast growth/feminization).

More does not equate to more feminization, period. That's a fact.

+ 1. But too little may not also be best for the person, mentally and physically.

If you react badly to large amounts out of the gate, it could destroy your transition plans.

Again, my opinion based on several studies I've come across...as far as bio-identical estradiol is concerned, it is relatively safe enough that this is rarely an issue, especially considering how little she is taking. But, this needs to be discussed with her doctor or another health professional who can prescribe her the appropriate medications/hormones.

There's a girl on this site right now that is on a relatively low dose and she's found herself lactating.

Could be something else she is on or that she is stimulating her breasts. One needs to be careful when reporting someone else's case.

If youve learned your dosage is low, point out the error to your doctor immediately.  If you think you've learned that your dosage is low because other girls tell you they're taking more, proceed with caution.

In her case, yes, the E2 dosage is low compared to recommendations published in several journal studies. Basing oneself on others' reports can indeed be misleading and sometimes dangerous. Remain critical, at all times. Even when reading journals...

[Rambler]

Definitely discuss this with your doctor, it might not get you anywhere, but you should make any concerns known regardless of the reason. The only other input I can add is that regardless of the method of starting increasing doses, there is nothing but anecdotal evidence suggesting one way is better than any other, and even then, there is no consensus within the medical or trans communities that anything is better. Arguably, the starting low and ramping up is "safer," but again, there isn't any consensus on how much of a difference it makes or if it's true at all.

[AlyssaJ]

Thanks everyone, just so we're clear, when I say low, I'm talking in relation to recommended starting low-dosage numbers that I've seen in a number of published guidelines and articles.  My Estradiol dose is half of the low end of those low dosage numbers which is the only reason I question it.  I'm not as worried about the doses that other women take, I know better than to compare myself to other people when it comes to medical care.

JenTay, yes as usual I want to run as fast as I can.  However, in this case its just that I want to make sure that I'm not standing still or moving ultra slow unnecessarily.  I do trust my doc, she is great and has plenty of experience so I know she's been down this road before.  Still I would like a comfort level of at least understanding a little more of why she chose this dose to start with when it is so low and what the future looks like as far as progressing the dosage.

I have a 2-month follow-up coming up and I'm just planning ahead for if and how I want to address this.  If I remember correctly, she at least mentioned doubling the Spiro, I would hope that would also mean at least doubling the E as well.

[LizK]

I started with a very conservative dose for 3months to see how I would handle it...after that straight into slow release implant...which was so much better than the pills although I take a supplementary pill anyway.

I understand your frustration and wanting to be on the most effective dose you can. But as the many good answers have said this is a marathon not a sprint. Puberty takes several years and so does developing proper regime that suits your body to induce this correctly.

I have always been very straight up and down with my Dr and simply asked. Telling her what I had "heard" or been "told" and asking her opinion. She is not one to beat around the bush either and will usually tell me what she thinks. Speaking to them with respect is important but you have the right to ask questions without fear that your care will compromised because of it.

[jentay1367]

JenTay, yes as usual I want to run as fast as I can.  However, in this case its just that I want to make sure that I'm not standing still or moving ultra slow unnecessarily.  I do trust my doc, she is great and has plenty of experience so I know she's been down this road before.  Still I would like a comfort level of at least understanding a little more of why she chose this dose to start with when it is so low and what the future looks like as far as progressing the dosage.

I can certainly appreciate your concerns. I would ask her outright the what's, the why's and what her intentions for the future are. She ultimately works for you. You're entitled to be in the loop and now that you know more about what's what, you have a good idea of what to ask. Hell... call her tomorrow. Get some peace of mind.
     Reality though? You're already pretty and at your age, I think the writing is on the wall. If you follow through, you're most probably going to end up a very beautiful woman. Consider yourself blessed. You simply don't have too far to fall to land on the other side of the fence. 

[AlyssaJ]

Reality though? You're already pretty and at your age, I think the writing is on the wall. If you follow through, you're most probably going to end up a very beautiful woman. Consider yourself blessed. You simply don't have too far to fall to land on the other side of the fence. 

Oh m'gosh, now I'm blushing like crazy.  Thank you for the kind words and thank you for tolerating my impatience and continuing to offer helpful advice and thoughts.  I'm sure my impatience can be a lot to take at times, so thanks for sticking with me and resetting my expectations.   

I ended up sending an email to my doctor and just asked her about what she see's as the path forward as far as increasing dosage, etc.  I tried to focus it more on a curiosity about her approach rather than letting it sound like I was second guessing her based on internet sources

[jentay1367]

Good on ya' girl!  I think most of our Doctor's really want us to be proactive. It's your transition. You're the one who gets to live in this world and body you're creating. I don't blame you for being impatient. Once you make the decision to transition, you want it all yesterday. These are heady times my friend. All new and very exciting! and I'm certainly excited for you!  Good luck with your Doctor and perhaps you can share with us what you find. 

[JeanetteLW]

 Hi Alyssa,

    at about a month and a half after I started getting my HRT from the VA. with about 2 1/2 months before my next scheduled labs I tried to get my dose for estradiol increased and progesterone added to my regimen, So I sent a note to my doctor. This is what I said.

  "The first is that I read your entries regarding my telling you that I felt I was trans and told you what I had been self medicating with. I mentioned the Climara xxx patches and I'm sure I mentioned  that I was also taking a xxxmg Progynova at the same time. So I was taking about double the dose I am now. I have not deviated from the dosage you prescribed. But I am curious about an increase. I am seeing some results.

The second is along the same line. I had ordered  Progesterone in the form of Microgest xxxmg soft gels before we met. I was wondering what your thoughts are regarding it. I know it is not considered necessary among the medical community, but there is quite a lot  of anecdotal data that it may help achieve fuller development. Again I have not deviated from your prescriptions and therefore have not taken any of it."

   Well it didn't work though he did say he does understand my wanting to hurry things along as quickly as possible so I can have the body changes I desire. But  that we need to take it slower until we see how the medications are working. So be patient and wait until the labs are in then adjust might be made.

  You can bet we will be having this conversation again.. Like later this month bu messaging as we ar not schedule a face to face meet again fro a couple more months yet.

  So the answer for me is yes I am going to be involved with my HRT meds dosages. It will be a discussed collaborative process.

  Hugs,
   Laurie

[RobynD]

I also have been pretty straight forward with my doc and have been responsible for one of the two dosage increases that we have done. I brought in some supporting material etc and she was quite receptive.

[AlyssaJ]

OK so to close the loop on this, I heard back from my Gyno this morning.  She said she starts at a low dose of Estradiol for two reasons.  First, in her experience, it helps avoid Tuberous Breast growth (which can only be corrected with plastic surgery). Not sure how often that occurs as I know plenty of women who started higher and have great looking breasts.  But ok, she's being cautious.  Second, and her bigger concern is the risk of blood clots. She admitted she and likely other OB/GYN's are probably more conservative about this than an Endo would be given that they work with pregnant women who are at a much higher risk of blood clots.  So in the end, she's more conservative than an Endo, I'm ok with that.  She closed out the email saying that we'll certainly be upping my dose at my 2 month appointment as long as everything is still going well.

So a nice response all in all, maybe she's a bit over-conservative but given the potential risks, I appreciate her watching out for my best interests

[Laurie]

She closed out the email saying that we'll certainly be upping my dose at my 2 month appointment as long as everything is still going well.

Two Months!  I'm jealous.
  I sent a message to my doctor asking a few things. One of them posed an inquiry about increasing my estradiol. In his reply hes indicated at my next regular meeting with him on the 22nd (4 months from last when he prescribed my HRT) he will order more labs and see hows my hormone levels are then decide what to do. In answering another question about adding progesterone he said that will not happen until I am on a "Full" dose of estradiol. So there is hope of an increase in estradiol sometime in the future for me. It's hard to be patient. I've broached the subject to him twice now. I think he knows I am anxious for more. lol

hugs,
Laurie

[AlyssaJ]

Yeah the waiting game is a really difficult aspect of this.  I hope you're at least not on as low a dose as I am.  If I had to wait 4 months to get bumped up from where I started, I'd have gone to see an Endo for a second opinion.  I'm good with taking it slow and cautious to a point, but I do also want to see results in an efficient yet responsible timeline.

[Laurie]

Yeah the waiting game is a really difficult aspect of this.  I hope you're at least not on as low a dose as I am.  If I had to wait 4 months to get bumped up from where I started, I'd have gone to see an Endo for a second opinion.  I'm good with taking it slow and cautious to a point, but I do also want to see results in an efficient yet responsible timeline.

   If you look around you can find tables with what they refer to as "normal" dosage range.  Mine would be the lowest on one of those. It could double twice and still be on the table. If I was a cheerleader  you could appreciate the table with a cheer.

Laurie

[AlyssaJ]

Yep I'm familiar with those tables, and I'm not even on the table yet Now she didn't say how much she's going to increase me but I'm assuming she'll double it which will put me at that very bottom of the range.