Susan's Place Transgender Resources

Hi! I'm new to Susan's! Please be nice? :D

I'm two weeks into HRT (MtF), and I can't help but feel that there's something wrong about my hormone regimen. First, a little background: the therapist who wrote my HRT letter is considered the top gender specialist in the area, and the Endrocrinologist she referred me to is well-respected in the medical community, and has over forty years of experience working with male-to-female patients. So -- as I'm sure you can see -- I have no reason to doubt the competence of my doctor. The doctor said he's putting me on a "high-estrogen regimen", and that anti-androgens will be unnecessary and would really only cause extra complications. Is this plausible?

TL;DR, is it possible/okay/effective to go through HRT without anti-androgens?

Quote from: Jack LaRue on December 04, 2011, 06:09:09 PM
Hi! I'm new to Susan's! Please be nice? :D

I'm two weeks into HRT (MtF), and I can't help but feel that there's something wrong about my hormone regimen. First, a little background: the therapist who wrote my HRT letter is considered the top gender specialist in the area, and the Endrocrinologist she referred me to is well-respected in the medical community, and has over forty years of experience working with male-to-female patients. So -- as I'm sure you can see -- I have no reason to doubt the competence of my doctor. The doctor said he's putting me on a "high-estrogen regimen", and that anti-androgens will be unnecessary and would really only cause extra complications. Is this plausible?

TL;DR, is it possible/okay/effective to go through HRT without anti-androgens?

Highly unusual, unless somehow because health reasons you cannot have spiro

It is probably OK if the dose is indeed high enough. If your T levels don't come down to normal female range after several months he may re-evaluate his strategy.

Huggs

Emily

Quote from: Laura91 on December 04, 2011, 07:10:50 PM
what if the person is post-op?

Then just a bit of estro to mantain

I should ask what estrogen form you are using? Premarin at high levels does carry an increased risk of DVT and other blood clotting disorders. Oral 17b estradiol does as well to a slightly lesser degree. One of the reasons for using an AA like spiro is the same results can be achieved with lower doses of E and a corresponding lower risk of clotting problems. It might be difficult to use enough patches to reach the needed levels alone because of the need to change locations between new patches, but there is a very reduced risk of clotting problems. I also hope that you are not a smoker because that can make your risks skyrocket.

Huggs

Emily

I'm taking estradiol; about twice as much as is supposedly recommended with spiro. I don't smoke -- it makes everything smell really gross! -- so hopefully I won't clot up and die.
So, by "the same results can be achieved with lower doses of E" you mean that with high doses of E you can achieve the same results as if you were using spiro?

AA's being widely used in the treatment of us is something that started in the 90's I believe. Some clinics swear they do improve feminization while others such as your doctor don't see the benefit. I personaly have always been on spiro and a quite high dose at that. I am afraid that all we have is anecdotal evidence.

Huggs

Emily

Quote from: Jack LaRue on December 04, 2011, 06:09:09 PM
Hi! I'm new to Susan's! Please be nice? :D

I'm two weeks into HRT (MtF), and I can't help but feel that there's something wrong about my hormone regimen. First, a little background: the therapist who wrote my HRT letter is considered the top gender specialist in the area, and the Endrocrinologist she referred me to is well-respected in the medical community, and has over forty years of experience working with male-to-female patients. So -- as I'm sure you can see -- I have no reason to doubt the competence of my doctor. The doctor said he's putting me on a "high-estrogen regimen", and that anti-androgens will be unnecessary and would really only cause extra complications. Is this plausible?

TL;DR, is it possible/okay/effective to go through HRT without anti-androgens?

Possible... Yes.

Most recommended and/or prescribed method of treatment... No.

A very high supplemented E2 level may cause your body to reduce T production... or it may not. Everyone's physiology is different. Spironolactone and/or anti-androgens block T-prodcution without question and are the most common and prescribed method of HRT for MTF persons when combined with Estradiol.

I'm currently only receiving Estrogen as well (almost four weeks into HRT).  I'm going to contact my Endocrinologist and see if I can begin Spiro soon.  In terms of health, I'm absolutely fine, so I'm going to assume my Endo is merely taking it one step at a time.  It wouldn't hurt to ask them, though. ;)

Thanks for your input everyone! I suppose that if I don't see adequate/any progress by my next checkup, I'll speak with my doctor about antiandrogens again. :D

I´ve had only Estradiol patches and my T is in female levels. It´s been 2 years now.

Im starting strictly on E patches as well with no AA. I am going to see if The E drives the T down. If we see that my T is resistant to that, then we will re-evaluate. My Dr is completely on board with this approach as AA's carry their own baggage.

I spoke with my endo about E with no AA and she said that it was possible, but did not feel there was any reason to follow that method.  Her school of thought (and one of a majority of endo's) is that the risks associated with the AA are significantly less than an E dose high enough to counter natural T production in a woman my age (am almost 50).

I might ask my endo what advantage the E only method offers over E/AA.

I am seeing some people who are naturally responsive to estrogen and a normal transition dosage is sufficient to suppress testosterone. Even in my therapy group with far less effective estrogens, some of the girls remarked about a reduction in function and size of the male bits. Most of us require a blocker but if one wants to avoid the problems associated with a blocker, they could start on estrogen and see if they are one of the lucky ones.

Most doctors believe that a high dose of estrogen is risky as it can lead to hypertension, stroke and blood clots but this was only observed with non bio-identical oral estrogen. Studies have shown in men, for instance, who have prostate cancer, aged 49-91 yrs old, a high dose of bio-identical estrogen taken non-orally, high enough to sufficiently suppress T, was SAFE and even seemed to be protective.

Cancer. 2005 Feb 15;103(4):717-23.

"The authors tested the safety and efficacy of transdermal estradiol (TDE), as well as the effect of therapy on hot flashes, sex hormones, the procoagulant cascade, and bone turnover in patients with AIPC."

"Patients with prostate carcinoma progressing after primary hormonal therapy received TDE" (a high dose)

"The mean (+/-95% CI) serum estradiol level
increased from 17.2 pg.mL (range, 14.8-19.6 pg/mL) to 460.7 pg/mL
(range, 334.6-586.7 pg/mL). The total testosterone level remained stable in the
anorchid range during treatment, but the free testosterone level decreased as a
result of increased sex hormone binding globulin."

"No change in factor VIII activity, F 1.2, or
resistance to activated protein C was observed, whereas a modest
decrease in the protein S level was observed. CONCLUSIONS: In
patients with APIC, TDE was well tolerated and produced a modest
response rate, but was not associated with thromboembolic
complications or clinically important changes in several coagulation
factors."

J Urol. 2005 Aug;174(2):527-33; discussion 532-3.

Transdermal estradiol therapy for prostate cancer reduces
thrombophilic activation and protects against thromboembolism.

"Levels of VIIa and XIIa were unaffected by transdermal estradiol therapy. Although levels of TAT III were increased in some patients at 12 months, the increase was markedly less than that observed historically with equivalent doses of oral estrogens. Levels of the inhibitory and fibrinolytic factors including protein C, protein S, APC-R, TPA and PAI-1 remained stable. Reductions in F1+F2, fibrinogen and D-Dimer levels represented a normalization from increased levels to the physiological range."

"These results suggest that transdermal estradiol reduces
thrombophilic activation in men with advanced prostate cancer, and
protects against the risk of thrombosis."

Am J Clin Oncol. 1988;11 Suppl 2:S101-3.

"Serum concentrations of testosterone (T) and estradiol-17 beta (E2) were analyzed in prostatic cancer patients treated with (...) polyestradiol phosphate (PEP) i.m. every fourth week as single drug therapy during a 6 month period."

"Orchidectomy levels of T were reached within 3 weeks (...) and 3 months (...). (...), mean T levels reached the upper limit of orchidectomy values after 6 months. Accumulation of E2 occurred to mean levels 1,300-2,500 pmol/L at 6 months"

"No cardiovascular side effects occurred during single-drug PEP treatment."

Prostate 1989;14(4):389-95

"Oral estrogen therapy for prostatic cancer is clinically effective
but also accompanied by severe cardiovascular side effects.
Hypertension, venous thromboembolism, and other cardiovascular
disorders are associated with alterations in liver metabolism. The
impact of exogenous estrogens on the liver is dependent on the route
of administration and the type and dose of estrogen. Oral
administration of synthetic estrogens has profound effects on
liver-derived plasma proteins, coagulation factors, lipoproteins, and
triglycerides, whereas parenteral administration of native estradiol
has very little influence on these aspects of liver function."

J Lipid Res. 2006 Feb;47(2):349-55.

"This prospective pilot study of 18 men with androgen-independent prostate cancer receiving ADT measured effects of TDE on lipid and inflammatory CVD risk factors before and after 8 weeks of TDE. During treatment, estradiol levels rose 17-fold; total cholesterol, LDL cholesterol, and apolipoprotein B levels decreased. HDL2 cholesterol increased, with no changes in triglyceride or VLDL cholesterol levels. Dense LDL cholesterol decreased and LDL buoyancy increased in association with a decrease in HL activity. Highly sensitive C-reactive protein levels and other inflammatory markers did not worsen. Compared with ADT, short-term TDE therapy of prostate cancer improves lipid levels without deterioration of CVD-associated inflammatory markers and may, on longer-term follow-up, improve CVD and mortality rates."

TDE = transdermal estradiol
ADT = androgen deprivation therapy

CLIMACTERIC 2005;8(Suppl 1):3–63

"In women with supraphysiological estradiol levels during treatment with implants, no adverse effects on lipid metabolism, but a reduction in LDL cholesterol and fasting insulin were observed."

Also,

Am J Obstet Gynecol. 1993 Dec;169(6):1549-53.

"As serum estradiol levels increased throughout each phase (maximum mean estradiol 739.8 pg/ml)"

"Down-regulation of the fibrinolytic system was observed as estradiol levels increased. However, thrombin formation did not change, thus suggesting that elevated circulating estradiol alone does not predispose to a thromboembolic event."

J Thromb Haemost. 2014;12(3):297-305.

"This prospective study suggests that high endogenous concentrations of estradiol and testosterone in women and men in the general population are not associated with increased risk of VTE, DVT or PE."

Br J Obstet Gynaecol. 1990 Oct;97(10):917-21.

"There is some anxiety about the possible harmful sequelae of supraphysiological estradiol levels but no data are currently available to show any deleterious effects of these levels on coagulation factors, blood pressure, glucose tolerance or the occurrences of endometrial or breast cancer (Hammond et al. 1974; Thom et id. 1978; Studd B Thom 1981; Armstrong 1988)."

Consider that pregnant women have levels as high as 75,000 pg/ml (http://cebp.aacrjournals.org/cgi/content-nw/full/12/5/452/T1) and their risk of blood clots is less than 0.2%.

Curr Opin Obstet Gynecol. 2014 Dec;26(6):469-75.

« Venous thromboembolism is, in the developed world, a major cause of maternal morbidity and mortality during pregnancy or early after delivery, with a reported incidence ranging from 0.49 to 2.0 events per 1000 deliveries."

Ann Intern Med. 2005 Nov 15;143(10):697-706.

"Women with deep venous thrombosis or pulmonary embolism first diagnosed between 1966 and 1995, including women with venous thromboembolism during pregnancy or the postpartum period (defined as delivery of a newborn no more than 3 months before the deep venous thrombosis or pulmonary embolism event date, including delivery of a stillborn infant after the first trimester)."

« The relative risk (standardized incidence ratio) for venous thromboembolism among pregnant or postpartum women was 4.29 (95% CI, 3.49 to 5.22;P < 0.001), and the overall incidence of venous thromboembolism (absolute risk) was 199.7 per 100,000 woman-years. The annual incidence was 5 times higher among postpartum women than pregnant women (511.2 vs. 95.8 per 100,000), and the incidence of deep venous thrombosis was 3 times higher than that of pulmonary embolism (151.8 vs. 47.9 per 100,000). Pulmonary embolism was relatively uncommon during pregnancy versus the postpartum period (10.6 vs. 159.7 per 100,000). "

"Among pregnant women, the highest risk period for venous thromboembolism and pulmonary embolism in particular is during the postpartum period." (When estrogen levels drop and are low)

Hence, most cases of DVT and PE, already quite low, are present post-partum, not during pregnancy.

Compare this with blockers/anti-androgens that aren't native to the body and can pose risks for a few. I personally prefer a high dose of E. Show this documentation to your doctor.

High E appears to pose a problem only if non bio-identical estrogen is taken.

I am on one <Dosages Not Allowed> patch/4 days and no AA. I was of the impression that this is a low dose.

My second blood test at 3mths showed very high E compared to the pre HRT test so we reduced the change frequency. My T has plummeted. Dr was quite surprised about E levels and said AA are often an unnecessary complication and T often just comes down without them. The blood test seems to bear that out it but its the results that speak for themselves.

I am in my fifties but after a few months have already had significant breast growth, I am sure a reduction in body hair, and my jeans are noticeably tighter - I would say an inch more round my hips (I have measured but sometimes I think I must be dreaming). Maybe I have just been eating too much chocolate. 

There have also been some other wonderful changes like first thing in the mornings and I even have follicles coming back to life on my head ! I have been really amazed.

The only down side so far is that I seem to be able to eat for England now but have only added about 4lbs over the 4 or 5 months since starting.

Dawn

Moderator Edit

Quote from: Skinnyd on September 20, 2016, 03:30:06 PM
I am on one <Dosages Not Allowed> patch/4 days and no AA. I was of the impression that this is a low dose.

My second blood test at 3mths showed very high E compared to the pre HRT test so we reduced the change frequency. My T has plummeted. Dr was quite surprised about E levels and said AA are often an unnecessary complication and T often just comes down without them. The blood test seems to bear that out it but its the results that speak for themselves.

I am in my fifties but after a few months have already had significant breast growth, I am sure a reduction in body hair, and my jeans are noticeably tighter - I would say an inch more round my hips (I have measured but sometimes I think I must be dreaming). Maybe I have just been eating too much chocolate. 

There have also been some other wonderful changes like first thing in the mornings and I even have follicles coming back to life on my head ! I have been really amazed.

The only down side so far is that I seem to be able to eat for England now but have only added about 4lbs over the 4 or 5 months since starting.

Dawn

Moderator Edit

Dawn,

Welcome to the site. I think Dena welcomed you before. Glad to hear you are having such strong results. I had to edit your post because it is against our Terms of Service to post dosages. If you could look those links Dena left you(actually I will add them here too). That defines pretty much all the rules here.

I am just over 50 myself and having pretty good results on pretty low dosages but with spiro.

Good luck on your journey.

I also want to share some links with you. They are mostly welcome information and the rules that govern the site. If you have not had a chance to look through them, please take a moment:

Site Terms of Service & Rules to Live By (https://www.susans.org/forums/index.php/topic,2.0.html)	Standard Terms & Definitions (https://www.susans.org/forums/index.php/topic,54369.0.html)	Post Ranks (including when you can upload an avatar) (https://www.susans.org/forums/index.php/topic,114.0.html.)
Reputation rules (https://www.susans.org/forums/index.php/topic,18960.0.html)	News posting & quoting guidelines (https://www.susans.org/forums/index.php/topic,174951.0.html)	Photo, avatars, & signature images policy (https://www.susans.org/forums/index.php/topic,59974.msg383866.html#msg383866)

Once again, welcome to Susan's. Look around, ask questions and join in.

With warmth,

Joanna

Thanks, sorry to break the rules so soon...8I Will definitely check out the links!

Those patches are amazing little things. Just those little molecular compounds whizzing around making cells go through all these changes. I wish I'd paid more attention in biology class at school!