First follow up blood test

[Rambler]

Hey ladies, just a quick update! I had my first follow up and blood test last week (seven weeks post start of treatment) and the results just came through last night. Total T was down to 53 pg/dl from 798 pg/do and my E was only up to 4 pg/dl from 3.6 at my baseline tests. I can't believe the drop in the T but I'm disappointed in the Estradiol levels. I'll be discussing with my doctor on Monday and hopefully upping E dosage, I'm not sure that anything will need to be done about lowering T anymore as it seems to be at or getting to where it should be. I'm wondering if the E was only low because I take sub-lingually morning & night and I was a good 10 hours past my dose at the time of testing. Everything else came back normal & healthy!

[Dayta]

Heya!  I had a similar experience with very low E levels in tests taken ~11 hrs past my last dose.  She had me repeat it within 3-4 hours of my dose and saw much more favorable results. It may be worth repeating the test with better timing before adjusting the dose.  Glad to hear everything else checks out A-ok! 

Erin

p.s. I also take sublingually, which I must do based on some other medical conditions precluding other methods, but I like it a lot, and have been quite satisfied with my results to date. 

[Rambler]

Erin, thanks for the input. It's good to know that's likely the case and that there's probably nothing wrong. I may talk with my doc about doing testing closer to the dosage next time, but it won't be for 3 months, so we'll see what he recommends when I speak with Monday. I'm hoping to raise my dosage anyways so I can start splitting 3X per day instead of morning & evening. I think it will help my mood more since my levels are all over the place with 12 hours between doses instead of the typical 8 I've seen described by most sublingual users.

[KayXo]

I believe the units for T are ng/dl and for E, pg/ml. Correct? Estradiol levels seem VERY low, as normal range in males is 10-60 while in women it is 20-650 pg/ml during a menstrual cycle.

[Rambler]

I believe the units for T are ng/dl and for E, pg/ml. Correct? Estradiol levels seem VERY low, as normal range in males is 10-60 while in women it is 20-650 pg/ml during a menstrual cycle.

For some reason the lab that my clinic uses converts the estradiol levels from pg/ml to ng/dL. They probably think it's easier to read when both T and E are written in the same terms. That would put my E at 40 pg/mL once I convert it back. I was confused at first too.

[rmaddy]

When you measure does make a bit of a difference--all the more so as the half-life of your form of estrogen decreases.  I self-inject weekly.  This tends to keep things relatively even for me, with a peak level 2 days post injection of 230 and a pre-injection level of 90.  This seems to be relatively stable over time, so we don't do levels much anymore.

[Rambler]

When you measure does make a bit of a difference--all the more so as the half-life of your form of estrogen decreases.  I self-inject weekly.  This tends to keep things relatively even for me, with a peak level 2 days post injection of 230 and a pre-injection level of 90.  This seems to be relatively stable over time, so we don't do levels much anymore.

Wow! I imagine your mood isn't on quite the daily rollercoaster as well. Based on my research, sub-lingual administration spikes e levels to 1000+ within an hour and by hour 8 levels are typically down to under 100. After 2 months (today!) I'm already tired of keeping a pill in my mouth for 20+ minutes 2x per day. I'd like to switch to injections but they cost a bit more and I have crap insurance until my company's new plan kicks in on 9/1. I'm going to be looking into changing over then and I might even switch my hrt doc from the HBHC in Chicago to an actual Endo in the area.

[KathyLauren]

Wow! I imagine your mood isn't on quite the daily rollercoaster as well. Based on my research, sub-lingual administration spikes e levels to 1000+ within an hour and by hour 8 levels are typically down to under 100. After 2 months (today!) I'm already tired of keeping a pill in my mouth for 20+ minutes 2x per day. I'd like to switch to injections but they cost a bit more and I have crap insurance until my company's new plan kicks in on 9/1. I'm going to be looking into changing over then and I might even switch my hrt doc from the HBHC in Chicago to an actual Endo in the area.

Rambler, have you asked your doctor about patches?  My doc prescribed a patch for me because of my age: the patch is the easiest on the liver.  It also smoothes out the peaks and dips, and it is not expensive: about $35/month.  I have another checkup tomorrow, so I'll get an update then, but last checkup, they were all good: 0.21 for T and 600 for E.  (Not sure if the units they use here are comparable to yours.  I'll ask her about units tomorrow.)

[Rambler]

Rambler, have you asked your doctor about patches?  My doc prescribed a patch for me because of my age: the patch is the easiest on the liver.  It also smoothes out the peaks and dips, and it is not expensive: about $35/month.  I have another checkup tomorrow, so I'll get an update then, but last checkup, they were all good: 0.21 for T and 600 for E.  (Not sure if the units they use here are comparable to yours.  I'll ask her about units tomorrow.)

We haven't discussed patches specifically, but my Dr. suggested sublingual tablets to start and and adjusting from there based on how I'm responding and how well the method works for me. I'm going to talk over patches and injections at my next visit in 3 months. It's likely that I'll just go for injections, but I'll definitely keep my options open.

[KayXo]

All non-oral routes, not just patches, are easy on the liver as estradiol bypasses it and has much less effects on hepatic parameters such as coagulation factors, proteins, renin substrate and triglycerides. The higher the dose though, the greater the effect. Overall though, bio-identical estradiol remains quite safe, even at higher doses, according to several studies.

On injections, my levels fluctuate significantly, at 2,500 pg/ml on day 3, down to 1,300 pg/ml on day 5. APTT, a test that can apparently predict the risk of DVT, has come back normal, time and time again, despite those high levels.

[rmaddy]

Wow! I imagine your mood isn't on quite the daily rollercoaster as well. Based on my research, sub-lingual administration spikes e levels to 1000+ within an hour and by hour 8 levels are typically down to under 100. After 2 months (today!) I'm already tired of keeping a pill in my mouth for 20+ minutes 2x per day. I'd like to switch to injections but they cost a bit more and I have crap insurance until my company's new plan kicks in on 9/1. I'm going to be looking into changing over then and I might even switch my hrt doc from the HBHC in Chicago to an actual Endo in the area.

I don't really notice much in the way of mood spikes from day to day.  Good thing or I'd have Tuesday afternoon menopause every week.  The thing is, the effects of estrogen on my mood overall have been quite subtle, and took me months before I was convinced of them.  I don't know what to make of all the reports of wild mood swings based on the dosing interval.  We all own our experiences, I suppose, but I tend to suspect that the more extreme a reported shift in thinking/personality, the more likely it is to be placebo effect.

Here's an example.  When I travel and won't be home for my Wednesday shot, I take a double dose (some women do shots every other week anyway--I usually do half the dose weekly) the week before.  I typically notice no impact whatsoever from levels that probably reach roughly twice that of my average week.  Zero.  I think that we just need to be somewhere in the range and let the stuff interact with our neurons over months, years and decades.

[Dani]

The higher the dose though, the greater the effect.

I have to dispute this statement. 

The dose just needs to be high enough to get the desired result. Any additional drug will not produce additional results. There are many other factors that affect the results we desire. I have been arguing this point for over 40 years. I am a licenced Pharmacist.

The original post was about low blood levels of Estradiol. When the sample was taken about 10 hours after the last sublingual dose, any reference to peak blood levels is nonsense, since the time lag is so great that most of the Estradiol is already metabolized and out of the blood system. You need to take a blood sample within 1 hour after the time of the last dose to get a peak blood level.

If you want a more steady blood level, then go with patches or injectable. For low cost and easy administration, I prefer sublingual. All of these routes of administration are equally effective.

[LShipley]

I have to dispute this statement. 

The dose just needs to be high enough to get the desired result. Any additional drug will not produce additional results. There are many other factors that affect the results we desire. I have been arguing this point for over 40 years. I am a licenced Pharmacist.

Good information! I just try to be consistent with timing. For the OPs first follow up the important thing is that the T is going down and E is going up however small. Personally my e levels were low until my t levels were suppressed. My E went from 35 to upper 300s after the first test where the T went down

OP just schedule in the morning closer to your last dosage 

[Barb99]

Here's an example.  When I travel and won't be home for my Wednesday shot, I take a double dose

I travel all the time with syringes, needles and Estradiol. As long as you have the prescription with you you won't have any problems. I two years I've never even had anyone ask to see it or even open my carry on bag.

[rmaddy]

I travel all the time with syringes, needles and Estradiol. As long as you have the prescription with you you won't have any problems. I two years I've never even had anyone ask to see it or even open my carry on bag.

It's a choice I make based on personal convenience.  My prescription is for an injection every two weeks anyway.  My endocrinologist knows that I prefer to take half the dose once a week instead and is fine with that.  The shots don't bother me, and the weekly rhythm seems to result in me forgetting less often.  As someone who is recovering from a conservative religious background, I think the weekly injection has become a new communion of sorts:   

"Take, inject, remember and believe..."

Anyway, if I'm headed out of town, I just do the two week dose and have one less thing to pack and/or worry about.  I am glad you haven't had problems taking it with you, but I choose not to, at least if it only would involve one cycle.  The reason I thought it relevant to the question is that I have not personally found that one's levels at any given moment of time makes a bit of difference as long as you are in range.  Your mileage may vary, but I personally suspect it won't.

[KayXo]

I have to dispute this statement. 

I meant to say that the greater the dose, the greater the effect on HEPATIC PARAMETERS, not on feminization, necessarily.

The dose just needs to be high enough to get the desired result. Any additional drug will not produce additional results.

Sometimes, it will, sometimes, it won't. It DEPENDS on many factors that the patient and doctor need to consider and talk about.

The original post was about low blood levels of Estradiol. When the sample was taken about 10 hours after the last sublingual dose, any reference to peak blood levels is nonsense, since the time lag is so great that most of the Estradiol is already metabolized and out of the blood system. You need to take a blood sample within 1 hour after the time of the last dose to get a peak blood level.

Yes. Levels fluctuate a lot on sublingual and measuring levels won't give you an accurate reading of what's really going on in 24 hours. Besides, levels in and of themselves, in this context, don't appear to be useful for gauging effectiveness (feminization, well-being) as sensitivity to levels varies in many orders, from one individual to another.

If you want a more steady blood level, then go with patches or injectable.

As mentioned before, on injectables, my levels went from 2,500 to 1,300 pg/ml in just two days. Not steady. Even on patches, as confirmed by studies, levels can fluctuate to some extent.

For low cost and easy administration, I prefer sublingual.

I found sublingual quite inconvenient and annoying. Orally was easier and gave the same results, at least in my case.

[Rambler]

Just a quick update everyone, I went back to the clinic yesterday after discussing with my Dr. I'll be doing weekly injections of estradiol valerate subcutaneously going forward. I'm not sure why he recommended that instead of IM, there was even another gal getting the tutorial with me who was doing IM.

[rmaddy]

Just a quick update everyone, I went back to the clinic yesterday after discussing with my Dr. I'll be doing weekly injections of estradiol valerate subcutaneously going forward. I'm not sure why he recommended that instead of IM, there was even another gal getting the tutorial with me who was doing IM.

Let us know how it goes.  Apparently the absorption is quite similar between subcutaneous and intramuscular, but when I tried subcutaneous, I noticed a lot of medication leaking out.  Probably a matter of technique, but I ended up going back to intramuscular.

[Dani]

Just a quick update everyone, I went back to the clinic yesterday after discussing with my Dr. I'll be doing weekly injections of estradiol valerate subcutaneously going forward. I'm not sure why he recommended that instead of IM, there was even another gal getting the tutorial with me who was doing IM.

Estradiol Valerate is always given as deep intramuscular injection. The only reason for subcutaneous injection is that it is easier to teach than intramuscular. Learning to give yourself an intramuscular injection is not hard to do, it just takes a little time, a good teacher and a willing student.

In my profession of Pharmacy, I have, for many years, reviewed physician orders and the most common mistake is route of administration. The error is commonly questioned by nurses who actually have to give the drug to the patient. Too many physicians do not appreciate the subtle differences in the various injectable techniques.

I would question the subcutaneous order and ask why the physician ordered it that way instead of deep intramuscular. Be nice and don't hurt your physicians ego.   

[Rambler]

Estradiol Valerate is always given as deep intramuscular injection. The only reason for subcutaneous injection is that it is easier to teach than intramuscular. Learning to give yourself an intramuscular injection is not hard to do, it just takes a little time, a good teacher and a willing student.

In my profession of Pharmacy, I have, for many years, reviewed physician orders and the most common mistake is route of administration. The error is commonly questioned by nurses who actually have to give the drug to the patient. Too many physicians do not appreciate the subtle differences in the various injectable techniques.

I would question the subcutaneous order and ask why the physician ordered it that way instead of deep intramuscular. Be nice and don't hurt your physicians ego.   

I did question the subq route and asked the differences between that and IM over email. He just said the subq route is effective for 90% of people who try it. Apparently it's a newer practice. The pharmacist who works at an LGBT onsite pharmacy and medical assistant who trained me (knowing it was for mtf hrt and alongside someone who was learning IM) didn't question it so it may just be a standard agency practice.

I'm also wondering if the reason they gave me subq is because they know I'm not good with needles but they want me to try out injections/get used to them, but if that's the case nothing was ever said. Some other subq users on ->-bleeped-<- said the difference was trivial compared to IM but less painful and the only issue I might find is faster absorbtion that might require splitting doses twice per week. I'll continue on this method for a while and see how I feel and if need be I'll ask for a switch up.

Another thing I discovered is that jabbing myself with a needle triggers a vasalvagal response for me, so when I inject, I need to be prepared to lie down for a minute with a glass of water handy.