Susan's Place Transgender Resources

Any MTF Post-Op members care to chime in with their "recommended" serum estradiol level (aka E2 level) that their medical provider likes to aim for?

I generally have kept my E2 level anywhere from 120-200 pg/ml depending on when the sample is drawn prepop. I have a new doc and he is very conservative, wants to maintain my postop levels around 50-80 pg/ml, and I'm wondering what others are using as the standard range

PS: If you live outside the US, please include units like pg/ml or pmol/L as it makes a huge difference.

TIA!

SEX
  pg/ml
  Women (> 18 years old)   
  Follicular Phase  30-120
     Ovulatory Peak  130-370
     Luteal Phase  70-250
     Post-Menopausal  15-60

Well many aim for above 150-200...

The recommended levels of your doc are in the Post-Menopausal range, which might make for slight vaginal atrophy...
the neovagina reacts to hormone levels...

many also do not only regard hormone levels
"treat the patient not the lab"
decisive should also be how it makes you feel...
concerning libido, overall feeling etc.

Some additionally use bioidentical progesterone...
it might help with mood, even out some side effects of estrogen and have some anti andogen effects...

and possibly a very small dose of testosterone... it might help with orgasmic abilities and overall drive...
levels should be in the female range.


*hugs*

This is what I'm concerned about. He's trying to teat me as... and prescribe to me as if... I were a postmenopausal cis-female... which I am not. I've been doing just fine on my current dosages, method of administration, and E2 serum levels... why change now? Because my anatomy has changed? Physiologically, I'm great... so why change? I think he's being conservative based solely on his inexperience and lack of education.

Thanks.

Quote from: JennX on October 12, 2015, 04:38:18 PM
This is what I'm concerned about. He's trying to teat me as... and prescribe to me as if... I were a postmenopausal cis-female... which I am not. I've been doing just fine on my current dosages, method of administration, and E2 serum levels... why change now? Because my anatomy has changed? Physiologically, I'm great... so why change? I think he's being conservative based solely on his inexperience and lack of education.

Thanks.

There is no need to be conservative.
Females have levels of well over 300.
And cis females also are given additional estrogen in menopause... there are additional dosages.

My endo prefers to keep my serum estrogen levels in the normal PRE-menopausal range.

Quote from: Laura_7 on October 12, 2015, 04:45:05 PM
There is no need to be conservative.
Females have levels of well over 300.
And cis females also are given additional estrogen in menopause... there are additional dosages.

Sort of what I was thinking.

Quote from: Northern Jane on October 12, 2015, 04:47:08 PM
My endo prefers to keep my serum estrogen levels in the normal PRE-menopausal range.

That amounts to 150-200 or above ?


hugs

Quote from: Northern Jane on October 12, 2015, 04:47:08 PM
My endo prefers to keep my serum estrogen levels in the normal PRE-menopausal range.

This is more or less, the same thing I've heard from other docs and my SRS surgeon... just because you have something changed anatomically... your physiology should remain the same for the most part. If it isn't broke, don't fix it.

Looks like the search for another doc continues.

Thanks for replying.  :)

Quote from: JennX on October 12, 2015, 04:51:07 PM
Looks like the search for another doc continues.

Have you tried plannedparenthood ?  :)

Quote from: Laura_7 on October 12, 2015, 04:55:32 PM
Have you tried plannedparenthood ?  :)

I might just. I can have my own labs run, so that isn't an issue.

It's just really sad that there are so few educated MDs out there when it comes to trans-health care.

Is anyone else still using sublingual oral administration post-op? Any difference if you've change the route of delivery?

Quote from: JennX on October 12, 2015, 04:59:24 PM
I might just. I can have my own labs run, so that isn't an issue.

It's just really sad that there are so few educated MDs out there when it comes to trans-health care.

Is anyone else still using sublingual oral administration post-op? Any difference if you've change the route of delivery?

Well poeple are individual... so a change of the method of delivery can make a difference...
patches and implants might make for a more steady delivery...
it might be possible to combine patches and pills...
and concerning oral/sublingual, it might be an idea to spread the daily dose in a few small parts instad of two big ones...
this way levels might be more steady, instead of a peak and a low later...

Quote from: Laura_7 on October 12, 2015, 05:08:59 PM
Well poeple are individual... so a change of the method of delivery can make a difference...
patches and implants might make for a more steady delivery...
it might be possible to combine patches and pills...
and concerning oral/sublingual, it might be an idea to spread the daily dose in a few small parts instad of two big ones...
this way levels might be more steady, instead of a peak and a low later...

This is what I'm currently doing. Dividing my oral/sublingual dosage in to 3 times per day. X amount every 8 hours.

I might do the patch + pill method. I have also read about that being prescribed. I just don't see how patches alone will maintain my E2 levels where they are currently. And I really don't want to go thru the fluctuations just to prove my point to some doc that really isn't educated.

I asked my endo about this a while ago and he said he keeps it the same as pre-op, which is around 1000 pmol/L. He also replaces implants when they get down to 800 pmol/L.

He's very experienced and has a huge number of trans patients.

I'd be looking for another doctor if he won't keep it at that kind of level. I feel terrible when it drops.

Handy chart
https://en.wikipedia.org/wiki/File:Estradiol_during_menstrual_cycle.png

My doctor is happy if I'm anything under 1000 pmol/L. Using my pre-op estradiol dose I tested around 1200 post-op so he dialed my dose down. At last test I was a little above 800, which he is happy with.

My levels are in excess of 1,000 pg/ml. Higher levels are not necessarily indicative of higher risk (type of estrogen is), my endocrinologist has been treating several hundred transpatients and has no problem with this. No studies have noted an increased risk with higher levels when bio-identical estradiol is involved and is provided non-orally.

Just to illustrate:

- studies on men with prostate cancer, ranging from 45-91 yrs old, on levels ranging from 400-700 pg/ml, were not found to have increased risks, in fact, one paper noted decreased risk.
- pregnant women have levels that go up to to 75,000 pg/ml as noted in one study at end of pregnancy. Risk of DVT (deep vein thrombosis) during pregnancy is 0.05-0.2 %.

Levels in ciswomen range from 20 pg/ml to up to 650 pg/ml during menstrual cycle, depending on woman, age and lab. These are the "normal" levels when a woman is not pregnant...during pregnancy, levels rise significantly, from 800-75,000 pg/ml. Ciswomen also develop breasts and other characteristics during puberty when growth hormone levels are significantly higher so that lower levels of estradiol may have a potent effect.

All things to consider and often (in my experience) ignored by doctors, unfortunately. I think it's important to be well-informed when discussing with your physician.

Quote from: KayXo on October 17, 2015, 03:12:09 PM
My levels are in excess of 1,000 pg/ml. Higher levels are not necessarily indicative of higher risk (type of estrogen is), my endocrinologist has been treating several hundred transpatients and has no problem with this. No studies have noted an increased risk with higher levels when bio-identical estradiol is involved and is provided non-orally.

I've a vague recollection of discussion this before, so please excuse me if it was with you. Anyway, my endo said something similar but he also refused to give me another implant until it got down to 800pmol/L (around 200 pg/ml). He was saying its not dangerous if you accidentally overdose, but he's not going to do it long term.

Women don't stay on these levels long term, and if you're purposely doing this you will be. There may well be not studies showing its dangerous, but I think this is a case where absence of evidence is not evidence of absence. Given the poor state of research in transgender medicine I'd be very reluctant to trust it. Having said that, if I were not getting results on lower levels I'd be seriously tempted to accept the possibly increased and unknown risk.

1000 pg/ml is off the top of this chart.
https://en.wikipedia.org/wiki/File:Estradiol_during_menstrual_cycle.png

Quote from: AnonyMs on October 17, 2015, 06:46:53 PM
I've a vague recollection of discussion this before, so please excuse me if it was with you. Anyway, my endo said something similar but he also refused to give me another implant until it got down to 800pmol/L (around 200 pg/ml). He was saying its not dangerous if you accidentally overdose, but he's not going to do it long term.

Women don't stay on these levels long term, and if you're purposely doing this you will be. There may well be not studies showing its dangerous, but I think this is a case where absence of evidence is not evidence of absence. Given the poor state of research in transgender medicine I'd be very reluctant to trust it. Having said that, if I were not getting results on lower levels I'd be seriously tempted to accept the possibly increased and unknown risk.

1000 pg/ml is off the top of this chart.
https://en.wikipedia.org/wiki/File:Estradiol_during_menstrual_cycle.png

There are endos who go well above 250-300 pg/ml.
With injections and implants, its possible to drive testo down into the female range, without anti androgen.
Its a well known effect.
It can be complimented by bioidentical progesterone, which has anti androgen effects.
https://www.susans.org/forums/index.php/topic,192953.msg1733564.html#msg1733564
Its also available as pellet implant.

Pregnant women have levels way above for months.
Decisive is also the kind of application. Implants and injections are internal applications.

Quote from: Laura_7 on October 17, 2015, 06:55:58 PM
There are endos who go well above 250-300 pg/ml.

That doesn't means it safe, just that its done. It wouldn't be the first time the medical profession gets it wrong. I'm not saying its wrong, I prefer to reserve judgement. The lack of serious research is not reassuring.

Quote from: Laura_7 on October 17, 2015, 06:55:58 PM
Pregnant women have levels way above for months.

Yes, but it's months not decades.

Given everything I know and have read, 200  pg/ml should be fine.  Higher doses may (and I emphasize may) carry some slight (emphasis on slight) increased risk of blood clots if the person is a nonsmoker.  Smoking increases the risk by quite a bit.

I don't know the effect of that type of level for the 75+age bracket as there is no data that I have found....

Jen

Quote from: JLT1 on October 17, 2015, 11:09:10 PMI don't know the effect of that type of level for the 75+age bracket as there is no data that I have found....

Men with prostate cancer (median age was 75, up to 91) were given patches or injections and levels ranged from 400-700 pg/ml. I believe these studies were for up to a year and no complications arose in respect to thrombosis or cardiovascular incidents. In fact, one paper noted that such levels were protective of such incidences.

It is true that pregnant women experience high levels for 8-9 months, BUT if levels climb up to 75,000 pg/ml, with the absolute risk of DVT being 0.05-0.2% during pregnancy AND given we only reach, AT MOST 4,000 pg/ml, but usually less, I personally (my opinion, I'm not a doctor) consider the risk to be low. Pregnancy has also been shown to be associated, interestingly, with a lesser risk of breast cancer while nuns who never become pregnant, experience a higher risk. 

I've also known, throughout the years, many transwomen, in their forties and fifties on levels exceeding 1,000 pg/ml, some of whom had experienced complications such as DVT on oral non-bio-identical estradiol and who had absolutely no problems on such high levels when on injections.

I don't see how if complications such as DVT don't occur (even in older populations who are more at risk and individuals with predispositions, like Factor V Leiden mutation) in the short-term (1-5 years), complications will suddenly arise later. Researchers often even remark that should complications arise, they usually do within the first year. Risk should be immediately reflected in blood tests within months of starting treatments as clotting factors, proteins would jump up or down, CRP (C reactive protein) would increase, blood pressure should rise etc. Studies have shown this is not the case. If one is worried, one could have tests done every 3-6 months...

Lastly, going back to the sixties, prostate cancer stricken males were put on high dose oral estrogen and breast cancer was unheard of, same was true of Harry Benjamin's patients on high dose injectables.

If one considers all the above, I would say the risk is quite low but like I said, this is only my opinion and some doctors also share this view. To each their own but to me, it just makes a whole lot of sense. I've been on high levels for more than a year.

I'm not advocating high levels, please don't misinterpret me BUT in my case, they were most beneficial and in some others, they might be where lower levels didn't produce the desired results.

As always, discuss with your doctor, share with them and in the end, follow their orders. ;)