Pellet Implants vs. Oral Estradiol (blue pills)

[JennJenn]

My pellets are called BioTE. I'm paying $350 and that includes the office visit and procedure. My NP likes to do new pellets every 3 months,  so that's $1400/ year. This is in Texas,  BTW.

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Just curious, what level of estradiol in the blood does your doctor target. (My endo is happy if my estradiol is in the 125 to 200 range, for me personally.) And since on the pellets, do you notice a  lot lower levels of estrone compared to estradiol tablets?  Ever have your estrone checked?

[StacyRenee]

 I've only been on the pellets. She hasn't told me what my levels were. She checked it at 1 month and said that my levels were ideal. She never gave me the exact numbers.

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[OU812]

I definitely consider any kind of trans-/sub-dermal absorption a superior form of HRT over oral methods, even if just for avoiding the liver first-pass, which on rare occasions can cause tumors.

I'm going to start advocating for people to get as much information from their doctors as possible. Specific levels are worth having, and I sometimes have to pressure mine for that. 20+ years of doctors and the only time I was ever even given my blood type was in Thailand where they took it and told me for some reason.

[yuna]

I got my implant about 5 weeks ago. The recent lab shows my estradiol is at 52 pg/ml. When I was on sublingual estradiol my E level was 48. Sigh, I guess I just have really fast metabolism or something. Hopefully my doctor can increase the implant dosage next time in October. Does low estradiol level mean slow feminization?


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[Toni]

Hello girls.  I just started BioTE in Texas like StacyRenee.  We're shooting for numbers of about 50 to start with and will ramp up considerably at 6 weeks if blood work looks good.  I've read a couple of things about HRT that, in spite of my enthusiasm, make me want to be patient.  One is that starting a bit slower may actually be better for breast growth in the long term because it allows breast buds and underlying connective tissues and ducts to form without being rushed, a better foundation if you will.  The other thing that seems to be as important as the estradiol level is how low can you get the testosterone.  If you can't get T down, then even high doses of E will be hampered.  I went with the pellet because I had read that others who tried it seem to have been pleased with the results and the convenience of not having to travel with pills or keep remembering to take something when I'm having fun on vacation.  I will say that my butt was a bit more sore than I expected, felt like I got kicked in the butt and bruised, but became pretty normal after a week.  It was difficult to veg for three days after the insertion (mandatory) as I exercise daily. 

[KayXo]

I definitely consider any kind of trans-/sub-dermal absorption a superior form of HRT over oral methods, even if just for avoiding the liver first-pass, which on rare occasions can cause tumors.

Latter part of your sentence not proven to be causal relationship and only perhaps in the case of non bio-identical forms of estrogen. It's important to mention this.

Specific levels are worth having

Levels of estradiol and testosterone aren't useful to measure, IMHO. I explained the reasons why several times before and went into detail.

I got my implant about 5 weeks ago. The recent lab shows my estradiol is at 52 pg/ml. When I was on sublingual estradiol my E level was 48. Sigh, I guess I just have really fast metabolism or something.

Levels fluctuate, especially on sublingual, one reason measuring them is not very useful. Had you measured the levels on sublingual at 1-2 hours, they would have been strikingly different while on implants, less likely but perhaps higher and even so, how do you know what level is IDEAL for you? You don't.

Does low estradiol level mean slow feminization?

Not necessarily and as I explained, your levels could have been higher at a different time so really average level could be higher. Everyone has a different response and sensitivity. Some might do quite well on lower levels, some needing higher. Doctors are unable to assess beforehand what levels will be best for a given individual. They estimate (guesswork) based on average levels in ciswomen but ciswomen developed at much lower levels and most of us would probably not do well at those levels; this indicates that for various reasons, we cannot use ciswomen as a reference in this context.

how low can you get the testosterone.  If you can't get T down, then even high doses of E will be hampered.

High doses of E will naturally significantly reduce testes' production of testosterone through pituitary gland negative feedback. The higher the levels get, the weaker the signal from the pituitary gland to the testicles to secrete testosterone. You can't have both high E and high T unless you also take T exogenously.

Measuring T has its own problems as total T is inaccurate since part of it is inactive due to being bound to SHBG. Some anti-androgens block T so that the level measured only tells part of the story. One study in transsexual women found feminization was similar despite higher or lower levels of T. Each individual responds differently and is unique so the right T is not the same for all. Etc.

[Nora Kayte]

Levels of estradiol and testosterone aren't useful to measure, IMHO. I explained the reasons why several times before and went into detail.

High doses of E will naturally significantly reduce testes' production of testosterone through pituitary gland negative feedback. The higher the levels get, the weaker the signal from the pituitary gland to the testicles to secrete testosterone. You can't have both high E and high T unless you also take T exogenously.

Measuring T has its own problems as total T is inaccurate since part of it is inactive due to being bound to SHBG. Some anti-androgens block T so that the level measured only tells part of the story. One study in transsexual women found feminization was similar despite higher or lower levels of T. Each individual responds differently and is unique so the right T is not the same for all. Etc.

Wow Kay that's some good info. It pretty much how my doctor explained a lot of it to me.

My doctor was just telling me that I don't need spiro anymore as after a while the Progesterone and Estradiol will keep my t levels down. So if I am reading the last part of your post right. That confirms it?

Oh and I never care what my levels are. Because basically what you and my doctor say. They fluctuate and I have no way of knowing what's good for me level wise. So my doctor reads results asks how I feel at different times and adjusts from there.
She has been pretty right on so far. I get new pellets about every 4 months and I am on Progesterone so it does not work with me. Still every 4 months. Never known anybody that got better results from anything other than pellets.
I always thought in order of how well it worked was pellets, injections, patches creams and under the tongue. Then pills. But what do I know. That's why I don't think to much. Lol


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[OU812]

Latter part of your sentence not proven to be causal relationship and only perhaps in the case of non bio-identical forms of estrogen. It's important to mention this.

Yes, it is important, because otherwise somebody might make the terrible mistake of choosing a delivery method that's actually superior to the oral dosages that must filter through the liver before circulating throughout the body. In a pragmatic perspective, you have to assume a large portion of the oral estrogen available, especially for those who are taking it as their only option, is not bioidentical, or they would likely have better delivery methods available to begin with. If no other option exists, it's probably tolerable in the short-term, but even in a bioidentical form, the combination of liver first-pass with a spike makes it inferior to virtually every other form of HRT. And your insistence that "it doesn't cause tumors" just completely misses the forest for the trees.

Levels of estradiol and testosterone aren't useful to measure, IMHO. I explained the reasons why several times before and went into detail.

Levels fluctuate, especially on sublingual, one reason measuring them is not very useful. Had you measured the levels on sublingual at 1-2 hours, they would have been strikingly different while on implants, less likely but perhaps higher and even so, how do you know what level is IDEAL for you? You don't.

Compounded with the above, it astounds me that you're truly suggesting it's irrelevant to know your levels. If you're testing levels responsibly you're going to anticipate where the spikes or ebbs will occur in the same way you fast before a wide variety of blood tests, and you're not going to just trust a physician (who perhaps knew less about transition-related HRT than you when you came to them with a need) to just tell you what's okay and what's not. What if they're secretly throwing shade your way? What if you change doctors? Several times?

Appropriate level is based on how well it's working and whether you're having too much in the way of side-effects. It's laughable, yes, that anyone in the world would just "know" some abstract number that is ideal, but you absolutely should have data available on yourself that points one way or the other over time. Your extent of feminization changes. Metabolisms change. Delivery methods change. Two points of data on a scatterplot won't help you - but a large data set compiled over the long-term will let you know if you enter outlier territory on the high or low end. This is what you want.

[KayXo]

you have to assume a large portion of the oral estrogen available, especially for those who are taking it as their only option, is not bioidentical

Today, most transwomen worldwide get prescribed bio-identical estradiol, whether orally or not, so the oral form is, most of the times, bio-identical as that is what's recommended unanimously for us due to risks associated with other forms of estrogen.

even in a bioidentical form, the combination of liver first-pass with a spike makes it inferior to virtually every other form of HRT.

Studies suggest bio-identical estradiol, even taken orally, and especially at the doses prescribed to transwomen, is quite safe and even as or more effective than if it were taken non-orally, in some people.

Appropriate level is based on how well it's working and whether you're having too much in the way of side-effects.

IMO, appropriate DOSE. Levels will be all over the map and aren't reliable.

a large data set compiled over the long-term will let you know if you enter outlier territory on the high or low end. This is what you want.

You are unlikely to be outside of the female range as it is VERY wide, from as a little as 20 pg/ml to up to 75,000 pg/ml. On 1,000-4000 pg/ml, for several years, under the supervision of 3 doctors. Never had any health problems, blood test results came back fine.

[LizK]

I am currently experiencing one of the downsides to implanted pellets

I have one about 5 months old and had a blood test awhile ago that showed I had very high levels of Oestrogen and nil levels of Testosterone. I was tested 2 weeks ago and the levels have fallen off 600 to 432. That drop occurred over an  8 week period, however I was also up until 2 weeks ago taking an oral dosage as well.

The last time my pellet stopped working I had a couple of weeks that were just horrible. I did not know if it was just me or there was a problem with my levels. I got really dysphoric and stressed out for that period of time. I didn't even think about it being my E levels until the nurse told me the day I got the pellet replaced, that if I didn't feel right, to call and they would send out a blood form. I had already been through one phase of this pellet breakup, where you get as spike in the oestrogen levels before they begin to decline and I didn't really want to have to go through it again.

Overall though, I am incredibly happy with the results I have had and will definitely be continuing with them. I have a new Dr who is more proactive with keeping an eye on levels so I may have an even better experience.

[Pisces228]

I am taking oral estradiol now for 10 years.  Actually switched to sublingual as of late and it's working much better for me.  Getting some good development now after like 10 years of post menopausal levels -- breasts are really taking off.

Anyways, I was considering bio-identical estradiol implants because I heard there is a good ratio of estrone to estradiol and it has lower risk of complications.

What's your take on it ?   I could afford $1000 a year or so on it if having lower estrone levels is really beneficial.

If you use it, which brand do you use?

Just curious, but if you are having good development, why worry about the estrone/ estradiol ratio?  Are you pleased with the changes?

[OU812]

Today, most transwomen worldwide get prescribed bio-identical estradiol, whether orally or not, so the oral form is, most of the times, bio-identical as that is what's recommended unanimously for us due to risks associated with other forms of estrogen.

Specious argument. This was one of the key points from my last post, that standards and recommendations often don't pan out in a practical sense. The "bio-identical" form I was getting turned out to actually not be such (only upon investigation with the pharmacy) and it was prescribed by a physician specializing in care of trans people.

This is what bothers me about insistently defending oral methods - it's all theory. If I had not come down with an unrelated illness, that only by exploratory diagnostics revealed the asymptomatic tumor I referenced, I very likely could have seen my tumor continue to grow over the years until one day it ruptured and put me at (at least) a 10-20% risk of hemorrhaging to death. Not cool. I don't see why this anecdote constitutes a good reason to put a carte blanche approval on oral methods and assume everyone using it has access to the highest quality ingredients, when they may well be simply taking whatever they have access to. There are more reliably-safe ways to take hormones.

Studies suggest bio-identical estradiol, even taken orally, and especially at the doses prescribed to transwomen, is quite safe and even as or more effective than if it were taken non-orally, in some people.

Even if it were, which we do not know, I'm not convinced it would even be worth the gamble. Delayed absorption is much better aligned with typical female physiology, even given the fluctuations of the menstrual cycle, than the constant spikes and ebbs characteristic of male-pattern daily hormone levels. Besides, one more pill to take... ugh...

IMO, appropriate DOSE. Levels will be all over the map and aren't reliable.

Dose is what creates levels. The same dose and administration method can create different levels at different times in your life, which is why your levels are what actually matter. Levels are only "all over the place" if you're not thorough with keeping records on yourself and you're basing it on a handful of blood workups.

You are unlikely to be outside of the female range as it is VERY wide, from as a little as 20 pg/ml to up to 75,000 pg/ml. On 1,000-4000 pg/ml, for several years, under the supervision of 3 doctors. Never had any health problems, blood test results came back fine.

I said nothing about outlier territory being based on the female range; in fact, I didn't say anything about the female range at all, which obviously is incredibly wide depending on age, pregnancy status, etc. I said you'll have a sense of what levels are normal or abnormal for you, and that this is based on how well your feminization is setting in or being maintained, along with any side effects you may or may not experience at higher levels (again, higher being relative to your own biology and subjective experience.)

Also, and I mean this as no critique because you claim to be doing alright on your current dosage, but levels of 1,000-4,000 pg/mL sound exceptionally high when compared with reference ranges ranges that are typical of pre-menopausal, non-pregnant women (generally less than 500 pg/mL even at the peak of cycle) and standard practice for transitioning, which in practicality favors keeping levels at the lower end of the spectrum particularly after GRS.

http://emedicine.medscape.com/article/2089003-overview?pa=Hr8nVvDPfSiufkOezSTYzKZO%2B0VV59DLatJyEZLdU3lPzaOUVbwOwCfopLOQzkgRU6AjIeeL3uJ4ryUHXc%2Bz%2FF%2FDMAtBBAsM6eN9kpLn%2Fas%3D

[JennJenn]

I got my implant about 5 weeks ago. The recent lab shows my estradiol is at 52 pg/ml. When I was on sublingual estradiol my E level was 48. Sigh, I guess I just have really fast metabolism or something. Hopefully my doctor can increase the implant dosage next time in October. Does low estradiol level mean slow feminization?


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Does a faster metabolism generally mean you get less estradiol levels in blood the faster it is?  If so, that'd explain why with a pretty high dose I barely get over 100 pg/mL.  I have a very fast metabolism since I am obese and active.  I burn about 4800 calories per day.

[yuna]

Does a faster metabolism generally mean you get less estradiol levels in blood the faster it is?  If so, that'd explain why with a pretty high dose I barely get over 100 pg/mL.  I have a very fast metabolism since I am obese and active.  I burn about 4800 calories per day.

I am relatively skinny( 5'7'' 116lbs) and have always had trouble gaining weight and muscles. My body fat is at 5%. I heard it from somewhere that body fat helps the body absorb estradiol or something. I don't remember where I read it and I could be totally wrong though. Girl you are at 100 pg/mL, which is twice as much as me! I am so jealous ; )

[kelly_aus]

Dose is what creates levels. The same dose and administration method can create different levels at different times in your life, which is why your levels are what actually matter. Levels are only "all over the place" if you're not thorough with keeping records on yourself and you're basing it on a handful of blood workups.

Is it worthwhile to check levels occasionally? Probably, but it shouldn't be the controlling factor in dose. I find that results are the key.

Dose does not create levels on it's own. Dose + metabolism = level. And given that I can dose 2 people the same, via the same delivery method, at the time and get quite different results, you have to wonder. Also, some people react better/differently at different levels. I ran for 6 years on levels that were "accepted best practice" and had little in the way of results. My solution? In consultation with a specialist, I upped my dose until I started seeing results. Yes, I've had my levels checked simply to answer my specialists curiosity..

I do have regular blood done and check a variety of other things, but rarely bother with E or T levels - they don't really provide me with usable data.

[Jessica Lynne]

Hi Kelly, I'm always interested in your opinions since you always bring something intersting and educational to any converstation. I have recently done just what you said and had my endo literally double my IM injections after q5 months of very so so results. Just recently, I'm noticing some substantial breast growth. That seems positve, particularly since I feel fine. I'm 59 years old and as such have tempered my  hope for mezningful results but am still hopeful. Might you have any opinion as to what I might anticipate or look for regarding real results? I feel I'm toclose to the forest to see the trees and wonder how I might objectively make the ascertain that results are actually occuring. Since you've been doing this substantially longer and you yourself are closer to my age than say 20 I was wondering if you might offer any anecdotal info I can use or may be helpful.  Thanks and all my best! Jess

[JennJenn]

That seems very frequent. My first ones lasted only 6 months or so, but the longer you are on them the longer they last. My endo also told me that if you take progesterone, which I do, it increases the interval further. I'm at 15 months interval now.

This is interesting.  I wonder how.

[JennJenn]

Well anecdotally speaking, I've seen more people get better results from injected pellets than any other protocol. All anecdotal mind you. But I've seen some astounding and outstanding results from the medium. I'd do it if it wasn't so ridiculously expensive over here.

Do you think this might be due to the fact of that mass amount of estrones produced via oral estrogen, competing with the estradiol for the estrogen receptors?

I read somewhere it's like 10:1 estrone to estradiol via oral.  Is this true? I can't recall the exact ratios.  But isn't a normal female ratio like 1:1 2:1 or 3:1 not 10:1?

[JennJenn]

Hello girls.  I just started BioTE in Texas like StacyRenee.  We're shooting for numbers of about 50 to start with and will ramp up considerably at 6 weeks if blood work looks good.  I've read a couple of things about HRT that, in spite of my enthusiasm, make me want to be patient.  One is that starting a bit slower may actually be better for breast growth in the long term because it allows breast buds and underlying connective tissues and ducts to form without being rushed, a better foundation if you will.  The other thing that seems to be as important as the estradiol level is how low can you get the testosterone.  If you can't get T down, then even high doses of E will be hampered.  I went with the pellet because I had read that others who tried it seem to have been pleased with the results and the convenience of not having to travel with pills or keep remembering to take something when I'm having fun on vacation.  I will say that my butt was a bit more sore than I expected, felt like I got kicked in the butt and bruised, but became pretty normal after a week.  It was difficult to veg for three days after the insertion (mandatory) as I exercise daily.

How low on the testosterone?  Do you mean in normal female range with respect to free testosterone?  My Free Testosterone, Direct tested at 0.4 and 3.6 recently.   Normal range is 0.8-4.2 pg/mL

The first blood test result at 0.4 pg/mL was with a higher dose of Spiro.  Having some problems with the diuretic aspect of the drug and tried ditching the evening dose, so my dose was cut by 1/3rd.  The result of the fasting AM free testosteorne was 3.6.   

Wondering if the progesterone I just started taking will make up for less spiro.  Wondering as long as I stay in the 0.8 to 4.2 range , I'll be okay.  So much to learn

[JennJenn]

You are unlikely to be outside of the female range as it is VERY wide, from as a little as 20 pg/ml to up to 75,000 pg/ml. On 1,000-4000 pg/ml, for several years, under the supervision of 3 doctors. Never had any health problems, blood test results came back fine.

Wow! Your E2 levels are that high?  Maybe that's why progesterone didn't work well for you because of the sensitizing of the receptors then BAM overload with estrogen dominance.