HRT Regimen Advice

[Sleepykitty123]

Hello everyone, i could use some advice from some of the more experienced  members of the delightful susan community. So for the last 2 monthes i was prescribe the normal amount of spironolactone and estradiol being the 21 year old 145 weight person i am, which for sometime was working amazingly for me with me experiencing all the delightful effects of transitioning, soft skin, lack of body hair and so on. only problem was 2 weeks later im in the hospital experiencing extreme nausea, fatigue, and seshions of feeling as if im going to passout while standing. After getting out of the hospital i inform my doctor of what ive been experiencing and he switches me over to the normal amounts of finasteride and a above normal amount of estradiol. Its only been 2 1/2 weeks but i feel as if im loseing the progress i gained while on spiro, with me experiencing insane amounts of sweat, rosetta of my face, regaining my sour body odor, arm pit hair, greesier face and so on...I feel as if im at a loss of what to do at this moment since i cant take spiro, cant get cypro due to being in the U.S, and the two other choices of bicalutamide and flutamide would make me go broke on how much they are even with my good insurance...Any advice is appreciated because im on verge of just switching back to spiro, deal with the crippling effects and just pass away happily.

[Deborah]

If you're taking spiro you need to be drinking a lot of water and eating a lot of salt. Spiro is a diuretic and without a lot of extra water and salt you will get dehydrated with the symptoms you describe.  How much is a lot depends on your activity and climate but for me here in the summer it's a minimum of a gallon of water and 6000+ mg of salt daily.   Any less than that and the dizziness and weakness starts creeping back in.

[Devlyn]

I agree with Deborah. It took a lot of conscious effort to increase my salt and water intake to the amount needed to feel right, without lightheadedness and being dizzy.

Hugs, Devlyn

[Sleepykitty123]

First off thank you for being the first to answer my post!  but as poorly described by me, i was taken off of spiro and put onto finasteride and had my estradiol raised to a above average regimen

[Bari Jo]

Just for others reading too, but adding a low dose daily aspirin is supposed to help with side effects of estrogen.  I love salt, so Spiro allows me to indulge:)

[Deborah]

First off thank you for being the first to answer my post!  but as poorly described by me, i was taken off of spiro and put onto finasteride and had my estradiol raised to a above average regimen

An option is that you could talk to your Dr., tell him your current meds are a problem, and revert to spiro with a high salt and water intake.  Unless you were having some kind of allergic reaction that will take care of the original problem.


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[Sarah.VanDistel]

[...] a low dose daily aspirin is supposed to help with side effects of estrogen.

Hi Bari Jo!

Interesting. Is there any scientific evidence backing this up or is it just a theoretical benefit? I'm asking because, in cis-women, I'm not aware of any benefit of adding aspirin to estrogen, at least not in primary prevention of acute coronary events (acute myocardial infarction, etc.) And, alas, theoretical benefits don't necessarily translate to actual clinical benefits. But I may be misinformed...

Hug, Sarah

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[Bari Jo]

Hi Sarah, yes it's from the side effects of the delivery methods for estrogen.  Endos will change your delivery method as your age determines which is more at risk.  To help alleviate clotting or deep vein thrombosis, they recommend the low does aspirin as a blood thinner.  CIS women don't have to worry about this, but we do, as we don't actually create our own like they do.  It might very well be a theoretical benefit, but it's so easy and inexpensive I'm doing it anyway.

As always talk with your doctor.  I'm not one, I just read too much cause, well, obsessed!

[Dena]

Low dose aspirin targets certain conditions but you need to be careful with it. One of our members was put on low dose aspirin and then had a minor injury which resulted in serious bleeding. It took us a little time to uncover the low dose aspirin and tie it to the bleeding. If your doctor places you on it, be careful until you know how your body will react to it.

[Sarah.VanDistel]

Hi Sarah, yes it's from the side effects of the delivery methods for estrogen.  Endos will change your delivery method as your age determines which is more at risk.  To help alleviate clotting or deep vein thrombosis, they recommend the low does aspirin as a blood thinner.  CIS women don't have to worry about this, but we do, as we don't actually create our own like they do.  It might very well be a theoretical benefit, but it's so easy and inexpensive I'm doing it anyway.

As always talk with your doctor.  I'm not one, I just read too much cause, well, obsessed!

Ok... Well, it's not the difficulty of the treatment nor its price which concerns me, but the risks. [emoji53]

For any treatment, there's a risk vs. benefit relationship that one must consider. In a patient with, for example, established coronary disease or a coronary stent, no doubt that the risk of an acute coronary syndrome is higher than the risk of an aspirin-induced bleeding.

However, in otherwise healthy people, even taking estrogen, there's no indication to take aspirin or any other platelet anti-aggregant. Why?

For one, they are ineffective against the sort of thrombotic events that may affect people taking high dose E (people on high dose E have a higher risk of deep VENOUS thrombosis and there's no solid evidence that aspirin significantly reduces the chances of VENOUS thrombosis; aspirin is effective at preventing ARTERIAL thrombosis, such as the one which causes most heart infarctions). In order to prevent VENOUS thrombosis, ONLY when medically indicated (e.g. people with a history of previous pulmonary embolism), we use an entirely different kind of medication (anticoagulants).

For two, in a recent and very large meta-analysis, "there was an approximately 40% increased risk of all gastrointestinal bleeding with low-dose aspirin in the observational studies reviewed, a finding very similar to that reported in randomized trials" (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4973997/).

So be careful... And if you insist on taking low-dose aspirin (hopefully under the supervision of your doctor), consider suggesting to your physician the prescription of a gastric acid supressor (such as omeprazol) to reduce the risk of gastrointestinal bleeding.

Peace and hugs,

Sarah [emoji66]

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[Bari Jo]

Thanks Sarah, at my next appointment I'll bring this up.

[KayXo]

Just for others reading too, but adding a low dose daily aspirin is supposed to help with side effects of estrogen.

This has more to do with clotting propensity (unrelated to symptoms described by poster). Estradiol, being bio-identical, has shown to affect coagulation to a very slight degree as compared to other forms. Aspirin's effect on the risk of DVT has also shown to be subject to controversy and has never shown, in users of oral contraceptives or HRT to reduce the risk, AFAIK.

in cis-women, I'm not aware of any benefit of adding aspirin to estrogen, at least not in primary prevention of acute coronary events (acute myocardial infarction, etc.)

Overall, the evidence seems to suggest that bio-identical estradiol (even sometimes, non bio-identical forms) reduces the risk of coronary events, hence why it's lower in ciswomen than men before menopause. Many studies confirm this. 

Hi Sarah, yes it's from the side effects of the delivery methods for estrogen.  Endos will change your delivery method as your age determines which is more at risk.

You should know this is based on oral intake of non bio-identical forms of estrogen, as in Premarin or ethinyl estradiol. In other words, protocol based on much earlier studies in transwomen not taking into account that we now use safer forms of estrogen.

To help alleviate clotting or deep vein thrombosis, they recommend the low does aspirin as a blood thinner.

Evidence-based? I doubt it.

CIS women don't have to worry about this, but we do, as we don't actually create our own like they do.

If we take estradiol parenterally, we are in the same situation as ciswomen because we get the same form of estrogen and secreted directly into our blood.

it's so easy and inexpensive I'm doing it anyway.

Aspirin is not without side-effects (i.e. hemorrhaging, ulcers).

people on high dose E have a higher risk of deep VENOUS thrombosis

The absolute risk remains low, even in older populations with more than one risk factor if estradiol is bio-identical and especially if taken non-orally. Pregnant women have very high levels of E, up to 75,000 pg/ml. Risk of DVT is 0.1%.

ONLY when medically indicated (e.g. people with a history of previous pulmonary embolism), we use an entirely different kind of medication (anticoagulants).

Interestingly, it has been shown that transdermal estrogen is safe even in individuals (including transgendered) who have a mutation or previous incident making them more likely to have clots.

Taking aspirin, in my unprofessional opinion but based on studies so far, appears to be more harmful than beneficial in someone taking bio-identical estradiol because the latter protects against heart disease and has very little effect on coagulation and aspirin's protective effect as regards to DVT is questionable and its side-effects can be serious.

[Pisces228]

I have had several pharmacists at work tell me that aspirin helps with clots in arteries, not veins, therefore is a waste for preveting DVT.  DVT risk is also pretty low unless you smoke or are on premarin from what I have read. 

[Sarah.VanDistel]

The absolute risk remains low, even in older populations with more than one risk factor if estradiol is bio-identical and especially if taken non-orally. Pregnant women have very high levels of E, up to 75,000 pg/ml. Risk of DVT is 0.1%.

Yes, it remains low. My point was that high dose E is associated with an (albeit small) increase in VENOUS thrombosis and not ARTERIAL thrombosis. I didn't say anything about the magnitude of that effect. [emoji848]

Pregnant women may have levels of E "up to" 75,000 pg/mL, but they seldom do; typical maximum levels at around mid-pregnancy are more in the 8000's pg/mL. I suspect that if we observed a sufficiently large cohort of pregnant women with typical E levels of ~75.000pg/mL, the incidence of venous thrombotic events would increase. It must also be remembered that women are exposed to such high levels of E for ~9 months, versus years or decades for a transwoman, and risk increases with duration of exposure. But there are other confounding factors which make a direct comparison difficult; pregnant women have more risk factors than the mere high E levels: more venous stasis in the lower limbs, sometimes less mobility...

Interestingly, it has been shown that transdermal estrogen is safe even in individuals (including transgendered) who have a mutation or previous incident making them more likely to have clots.

Yeah... I don't have any identified risk factor for DVT or PE. However, my endo recently suggested on the phone that considering my highly oscillating E levels (I'm on IM estradiol valerate) we should consider switching to TD on our next appointment. I've already tried TD E in the past and found it really unpractical (patches were peeling off on the second day... arghhh) and somewhat more expensive. Well... I'm willing to try it again. [emoji20]

Hey, KayXo... You seem so much into studies, etc. Are you aware of any evidence that oscillating E levels are less effective than constant E levels at feminizing MtF transsexuals? Or has it simply to do with the AUC of concentration vs. time?

And by the way... it's always a pleasure to read your lines! [emoji4]

Hugs, Sarah


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