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Im curious because my endo wanted to put me on pills but because I had heard so many good things about injections and patches, I asked if I could have one of those instead. So he wrote me a prescription for patches and pills and said I can decide on my own which method I am more comfortable with. Anyone have any important advice as to what is the best method with the least side effects and why? Thanks a bunch girls!

Patches = a pain (meaning annoying as can be), although they do work well.

Pills = sub-lingual (under tongue), to avoid strain on one's liver.

Injections = Unknown.

I had very good results with the patch. I wasn't really happy with them because the patches that I was using were large, and wouldn't really stay flat on the skin. They would wrinkle, but most people are able to wear them without a problem. The patch maintains a steady level of estrogen, which is a good thing. I didn't stay with the pills for very long, although they seemed to be alright. There are also very small patches on the market which I never used.

My choice is injection, although if I didn't have the problem with the patch wrinkling I may have stayed with them. As for sub-lingual pills, it depends upon which doctor you ask. It may not make that big a difference if you put it under your tongue or swallow it because the estrogen goes to the liver anyway. I'm not a doctor, and I don't have an interest in debating this. I really have no opinion on how to take the pills.

If you'd like an opinion, I'd probably try the tiny patches if that's what the doctor wrote the prescription for. Otherwise, the pills are convenient. Any way that you do it, nothing happens over night, so it's a question of dosage and time as much as anything else. You'll have the least side effects with the lowest dosage that produces good results. The same with the spiro, which you didn't mention. As long as it's doing its' job, the lowest effective dosage is best.

Having used all three methods, I would say that all three work.  Pills are fine for younger people though they can stress the liver a bit in the more mature lady  I like the patch the best as it provides a constant level of estrodol.  Placement of the patch is important so that it stays on.  Injections work well but I found my moods spiking a day or two before the next injection.  For a while I used injections with a single patch to reduce the estrodol swing in the system.

With injections there is a risk of infection that you don't have with patches. 

Just my 2 cents

Beni

Highest level variation, and thus potential non liver related estrogen side-effects are
related to injection. That's why people often supplement with pills at the end of their cycle.
With injections you have to make sure you don't hit a vein and keep your needles new.

Patches, very safe, the new small ones much better than larger ones, but its hard to
get a GG physiological level unless you plaster yourself with them (one patch rellieves
menopausal symptoms, but that's far from normal GG level. They are also very expensive
if you want to get a decent level of estrogen into you.

Pills, dirt cheap, convenient, non painful and
quite safe if you use the right pills.
If you use estradiol or estradiol valerate and
NOT ethnilestradiol, a conjugated estrogen or premarin.

BTW, don't know why people keep talking about the liver load of estrogen,
its minor for bio identical estrogens (estradiol), much
smaller than that caused by a tylenol tablet.

Its the clotting promoting byproducts of liver removing estrogen
from the blood that is the issue and its only a big issue really with ethinilestradiol,
conjugated estrogens, premarin or very very high serum levels (pregnancy levels) of
estradiol (which is not easy to do with pill form estradiol (much pills per day)).
This is supported by studies on the DVT effect of ethinilestradiol and conjugated estrogens
versus using bio identicals.

Injections can be inconvenient if you fly a lot given the restriction on items in hand luggage.  You may get the needles through with medical evidence, but do you wish to produce that? 

Personally I prefer something I can take with me in hand luggage without too much difficulty (I use gel packets which are within the size limits and had no problem through security checks in either UK or USA).  In your case, either pills or patches should be easy to take in hand luggage if you fly.

It mean seem like an odd way of deciding what method to go for but honestly after you've been on hormones for a time you will be fearful of anything which may interrupt taking them.

Sunbird

Pills - Sublingual, currently Estradiol.  Safe as long as you have your liver checked.  I also take Zocor for cholesterol, so I have two doctors checking my liver.
Patches - Cant Allergic to the adhesive
Injections - Haven't tried, but my Doctor likes pills.  But no reason given.

Personally I like the pills, but I have not tried the injection.  My doctor said that there are no fast results with injections.

Janet

Quote from: Kimberly on August 31, 2008, 07:26:30 AM
Patches = a pain (meaning annoying as can be), although they do work well.

Pills = sub-lingual (under tongue), to avoid strain on one's liver.

Injections = Unknown.

My endo said that sublingual is still processed by the liver...

Quote from: deviousxen on August 31, 2008, 10:02:50 PM
My endo said that sublingual is still processed by the liver...

It is - but one pass instead of two.  Well ... sort of ... in practice some is obvously swallowed rather than absorbed through the tongue. Sublingual reduces the impact on the liver rather than avoids it - but then even patches require the liver to do some work.

Sublingual increase the effect so you shouldn't take hormones sublingually unless that is what your endo has advised.

Sunbird

Thanks all so much for the helpful responses. I have decided now to try the estradiol patches he prescribed me first and if they are really bothersome, I'll just switch to the estradiol pills.

Also, can anyone give me some very detailed / specific advise as to where to place the patch for it to have the best effect and least wrinkling? Also if I have hair lets say on my buttocks, do I need to shave the hair first for the patch to have effect or does hair anywhere not make a difference in the estrogen being absorbed? Thanks so much girls!

Everything we eat is processed by the liver twice, that's not the question, as I
just said, Tylenol has probably 10 times the impact on the liver than
an estradiol pill.

Drinking 3-4 beers has a major impact, probably 100 times what one pill can do!

The liver is made to process bio-identical estrogens (estradiol in pill, gell, whaterver form)
at physiological levels; that's what happens in women. During
pregnancies, the body is flooded with ultra
massive amounts of estrogen and
its the liver who cleans it up with no problems.
The DVT risk, even with those huge estrogen levels, only
increases slightly for normal weight women.


I think endo's better educate themselves,
because obviously they're propagating unfounded fears.

yes i must admit my endo had said basically what's repeated here but after Keira said about it in another thread the more ive read up on the liver processing i really have to agree with her.

Not that theres never any risk but i feel very confident continueing with my sublingual regime where before i was getting quite concerned.

Thanks for always keeping us informed Keira.

Quote from: Keira on August 31, 2008, 10:33:34 AM

Highest level variation, and thus potential non liver related estrogen side-effects are
related to injection. That's why people often supplement with pills at the end of their cycle.
With injections you have to make sure you don't hit a vein and keep your needles new.

Patches, very safe, the new small ones much better than larger ones, but its hard to
get a GG physiological level unless you plaster yourself with them (one patch rellieves
menopausal symptoms, but that's far from normal GG level. They are also very expensive
if you want to get a decent level of estrogen into you.

Pills, dirt cheap, convenient, non painful and
quite safe if you use the right pills.
If you use estradiol or estradiol valerate and
NOT ethnilestradiol, a conjugated estrogen or premarin.

BTW, don't know why people keep talking about the liver load of estrogen,
its minor for bio identical estrogens (estradiol), much
smaller than that caused by a tylenol tablet.

Its the clotting promoting byproducts of liver removing estrogen
from the blood that is the issue and its only a big issue really with ethinilestradiol,
conjugated estrogens, premarin or very very high serum levels (pregnancy levels) of
estradiol (which is not easy to do with pill form estradiol (much pills per day)).
This is supported by studies on the DVT effect of ethinilestradiol and conjugated estrogens
versus using bio identicals.

I bet you wrote that all from memory, you really know your facts on hormone theraphy.

Why do people keep thinking taking estrodial sublinguly is somehow better???

Sublingual is better because you get a higher dosages (more is lost when going through the digestive
loop), a better mix of estrogen derivatives (more potent since the first pass through the liver
when takiing a pilll
breaks down estradiol into several estrogenic compounds of lesser potency).

Each time estradiol goes through the liver, breaking down its molecules, it
produces clotting agents. So, one pass (injection,sublingual,gels,patches)
is better than two (swallowing pill). But. that's difference is minor
except for very very high estrogen doses.

Premarin, Conjugated estrogens and  Ethinilestradiol, the last one in particular
are hard to break down by the liver, it can take dozens of passes which each produces
clotting factors that cause DVT. Ethinilestradiol should never be used since its
a major cause of DVT.

Quote from: Princess_Jasmine on September 01, 2008, 12:18:31 AM
Thanks all so much for the helpful responses. I have decided now to try the estradiol patches he prescribed me first and if they are really bothersome, I'll just switch to the estradiol pills.

Also, can anyone give me some very detailed / specific advise as to where to place the patch for it to have the best effect and least wrinkling? Also if I have hair lets say on my buttocks, do I need to shave the hair first for the patch to have effect or does hair anywhere not make a difference in the estrogen being absorbed? Thanks so much girls!

I'll wish you luck with the wrinkling. I was never able to find a spot where I didn't have a problem. I would like to think that I'm the only one who had this experience, since I was using a patch that was supposed to be worn for 7 days. Typically, I'd think that it SHOULD stay flat on the skin, like it SHOULD also stay on in the shower! I didn't have an issue with hair, but I'd think that it would be more comfortable removing the patch if the area was hair free. 

Quote from: Keira on September 01, 2008, 08:33:11 AM
Sublingual is better because you get a higher dosages (more is lost when going through the digestive
loop), a better mix of estrogen derivatives (more potent since the first pass through the liver
when takiing a pilll
breaks down estradiol into several estrogenic compounds of lesser potency).

Each time estradiol goes through the liver, breaking down its molecules, it
produces clotting agents. So, one pass (injection,sublingual,gels,patches)
is better than two (swallowing pill). But. that's difference is minor
except for very very high estrogen doses.

Premarin, Conjugated estrogens and  Ethinilestradiol, the last one in particular
are hard to break down by the liver, it can take dozens of passes which each produces
clotting factors that cause DVT. Ethinilestradiol should never be used since its
a major cause of DVT.

DVT?

I probably know what it is, but what is it again?

Quote from: deviousxen on September 01, 2008, 11:36:20 AM
DVT?

I probably know what it is, but what is it again?

Deep Vein Thrombosis. Blood clots. :)

Quote from: Leiandra on September 01, 2008, 11:38:34 AM

Quote from: deviousxen on September 01, 2008, 11:36:20 AM
DVT?

I probably know what it is, but what is it again?

Deep Vein Thrombosis. Blood clots. :)

Gotcha.

So is it from an excess of platelets, cause I recall reading that once?

I believe the liver byproduct increases coagulation, thus promoting blockage.
Its most often in the legs, but it could happen elsewhere too.

Ughhh.


Jello in my veins...

Quote from: deviousxen on September 01, 2008, 04:41:14 PM
Ughhh.


Jello in my veins...

Actually, it's worse. Think more like clumps. It's more like a hard mass of coagulated blood.  Blood clots that can break free and travel to other parts of the body, such as the brain. DVT can be fatal or require emergency surgery.  I once worked with a man who had fallen as a child playing baseball. He suffered a blood clot in his leg which required amputation. While the accident happened many years ago; modern surgery may have been able to save his leg, it illustrates the threat posed to the body by blood clots.

Whatever form is used, pills, patches or injections, as Keira so clearly explains, estradiol valerate is the safest form of the various available drugs. While each manner of administration has its' supporters, in the end, it's all a question of the correct dosage and time.   

Currently I'm on low level estradiol patches as these are considered to be the safest for older people. Since I'm taking warfarin, DVT is not really a problem.

Hi

I am a 28yr transexual and I am going on patches soon and I have been on pills for 3years and nothing really much has happened I took them orally but just swallowed them progenova do u think its better to place under tongue then?  Now patches am thinking of using them in conjunction with taking pills asn I will be monitoring my change carefully on this.

What u think?

Lisa x

I do not think it advisable to mix pills and patches. Patches and gel nmaybe OK

Joanne

I know some take pill's to suppliment at the end of their patch or injectible cycle is that what you meant Lisa? or on a daily basis

Pills are often used at the end of cycle.
The problem with injections is that depending on how you inject
and your estrogen metabolism which depends
on environmental factors (food, activity, etc), estrogen
can run low before the next injection. It doesn't happen all
the time, but when it happens you'll have a strong energy and mood
crash.

Another solution is to inject at closer intervals.
But, then you get more spiking, since  serum estrogen
levels in the days after injections can be very high
which can make you nauseous and other side effects.

Some people have a higher sensitivity to those variations than
others. Some people will have wild mood and energy swing during
their cycle and thus need something more stable like patches, pills,
gels, etc.

Unless taking much patches, you won't get as high a dosage with
patches as taking many sublingual pills. Remember, one patch is
used to get menopausal levels, so, to get GG level you'll need a
lot of patches.

If using patches, using an anti-androgen is I believe
kinda necessary to accentuate the regulatory
feedback loop affect that eventually
shuts down the testes and counters the T from the adrenals
which with higher E dosage would not be a problem in
feminisation, but could be at a lower dosage.

The biggest problem with hormones taken PO that I haven't seen mentioned in the thread is that the body will (and relatively consistently with oral drugs) attempt to regulate any spikes in hormone levels by countering with SHGB.

And you can guess what happens next :(

The countering in non-linear, and usually only happen at high sustained levels,
which are not prescribed by most doctors. That's why there is a diminishing
return on higher levels of estrogen, added to receptors becoming saturated
and that response to estrogen at the receptor depends on genetics of the
tissue having these receptors (muscle, fat, etc).

Some can respond strongly to low levels while others won't respond
to the highest of levels.

If the spikes are short, this is not usually not a big issue.

Yeah at the end of the cycle thats what I ment.
Also My Dr, Dr Curtis has not perscribed any anti enrogens (poor spelling), why could this be? 

Am thinking am still not going to get anywhere by using patches then pills at the end as I would need something to reduce my testosterone  level.

Am seeing my GP 2morrow for the patches am going to ask him also will ask best place to place patches.

I just need enough to round out my arse and thighs and also get me some breast tissue ready for my implants next year :)

Thanks for the info.

Lisa x x x   

Quote from: April221 on September 02, 2008, 07:11:32 AM

Quote from: deviousxen on September 01, 2008, 04:41:14 PM
Ughhh.


Jello in my veins...

Actually, it's worse. Think more like clumps. It's more like a hard mass of coagulated blood.  Blood clots that can break free and travel to other parts of the body, such as the brain. DVT can be fatal or require emergency surgery.  I once worked with a man who had fallen as a child playing baseball. He suffered a blood clot in his leg which required amputation. While the accident happened many years ago; modern surgery may have been able to save his leg, it illustrates the threat posed to the body by blood clots.

Whatever form is used, pills, patches or injections, as Keira so clearly explains, estradiol valerate is the safest form of the various available drugs. While each manner of administration has its' supporters, in the end, it's all a question of the correct dosage and time.   

Its always fascinated me that our bodies kill themselves for random reasons...

I go to Dr Curtis

is it based on your blood work, i would have a chat to him about your wish for AA's

Quote from: lisa01707 on September 03, 2008, 09:37:57 AM
Yeah at the end of the cycle thats what I ment.
Also My Dr, Dr Curtis has not perscribed any anti enrogens (poor spelling), why could this be? 

Am thinking am still not going to get anywhere by using patches then pills at the end as I would need something to reduce my testosterone  level.

Am seeing my GP 2morrow for the patches am going to ask him also will ask best place to place patches.

I just need enough to round out my arse and thighs and also get me some breast tissue ready for my implants next year :)

Thanks for the info.

Lisa x x x   

A couple weeks ago I switched from pills to injections and very quickly observed a dramatic difference. Within a few days my nipples had doubled in thickness and length, while my breasts became discernibly larger. They have also been constantly more tender since then. I had my second shot tonight. I had been warned that I might feel the drop in E during the days before a shot, but I did not notice anything lacking. I am very pleased with the results after only one shot. Waiting to see how much more growth I will be getting now. I wish I had started injections years ago instead of wasting my time on pills. The only downside is the cost: I'm now paying about four times as much per month for E as I did when I took pills. Good thing it's worth it.

I will be strting HRT in few weeks and my endo will give injections cuz she
thinks they are superior method of estrogen delivery to any other. I would like to
hear from you, like Hypatia who are already using injections; your experience.
Do you andimister injections yourself?
My idea was to have someone, a nurse, teach me and/or to be there when i inject
myself for the first couple of times, cuz i want to learn to self inject?
Do you do it or you have someone give you injection? What is safer?
I mean can you lern to self inject that good that there is no need for nurse or anything
else. I found some online tutorilas but they seem to be overly complicated.
Anyway...  would like u guys to share your experience  :)

Hypatia, I don't doubt what your saying,
but are you actually getting the same dose as before?
If in fact you're getting twice the physiological dose, then
your recent result has nothing to do with injection VS pills.

You can ALWAYS get similar results to injection with pills if
you take enough of them. That's a fact.

I often hear people hail injections as more efficient when
in fact when I see their dosage, its much higher than with
pills.

Maybe the doctor is simply giving you a higher dosage because
there is no first pass through the liver and thinks its safer
to go higher.

Quote from: Keira on September 04, 2008, 11:34:23 PMHypatia, I don't doubt what your saying,
but are you actually getting the same dose as before?

Beats me! I e-mailed my endocrinologist to ask:

How do you compare the quantity of estrogen effectively delivered to the tissues by (such and such amount in ml) of biweekly injected Delestrogen vs. (such and such amount in mg) of daily oral Estrace?

He never answered my question. It's imponderable to me. Do you know the answer, Keira?

All I know is the results since I started injecting really rock & roll.

Quote from: Keira on September 04, 2008, 11:34:23 PM

Hypatia, I don't doubt what your saying,
but are you actually getting the same dose as before?
If in fact you're getting twice the physiological dose, then
your recent result has nothing to do with injection VS pills.

You can ALWAYS get similar results to injection with pills if
you take enough of them. That's a fact.

I often hear people hail injections as more efficient when
in fact when I see their dosage, its much higher than with
pills.

I beg to differ
Using Estradiol Valerate as an example because it is available in both oral and IM forms, over a 7 day period, the patient must consume over 4 times (or more) the amount of drug in pill form compared to its IM administered counterpart to have the same approximate pharmakenetic effect. Some of it gets SHGB bound, some is converted into substances not usable where we want them, but the biggest killer of all oral drugs is the GI tract. That is why so many pills are needed.

Quote from: Keira
Maybe the doctor is simply giving you a higher dosage because
there is no first pass through the liver and thinks its safer
to go higher.

If Hypatia where being RX'ed a higher dose then is necessary ONLY because the claim of hepatic safety, then that is nothing more that a waste of drug (at best, at worst overdosing may reduce the sensitivity of the receptor sites) because, as you mentioned earlier, bodily tissues can only uptake a certain amount of free estrogens, (regardless of current SHGB levels) the rest to put it bluntly, gets pissed away.

Quote from: Hypatia on September 04, 2008, 11:53:58 PM

Quote from: Keira on September 04, 2008, 11:34:23 PMHypatia, I don't doubt what your saying,
but are you actually getting the same dose as before?

Beats me! I e-mailed my endocrinologist to ask:

How do you compare the quantity of estrogen effectively delivered to the tissues by (such and such amount in ml) of biweekly injected Delestrogen vs. (such and such amount in mg) of daily oral Estrace?

He never answered my question. It's imponderable to me. Do you know the answer, Keira?

All I know is the results since I started injecting really rock & roll.

That is one of the problems with current lab technology which annoys me to no end.
To the best of my knowledge, there is no way of knowing how much of ANY administered drug is put to use by the body except by analysing the excreted waste and guessing the uptake rate based on the intake dose. (If anybody knows such a way please tell me, so that I can become less stupid)

Just from what I have read, IM seems to absorb better, and while there are spikes, it can be taken care of.  It passes less through the liver, and even those spikes are a natural thing.  GG have hormone spikes all the time, its called a period.  As much of a no fun a period would be, it would make being stealth a lot easier.

Flan Princess,
My "claim" of hepatic safety (which makes no sense to me since bio estrogen
is not toxic to the liver at all)
of direct absorption (gel, injections, patches), is made all the time by doctors... And thus could
be a reason for lower dosage.

I said EQUIVALENT dosage, in pills is possible (that number varies a bit from person to person)
I can't discuss dosages here, but this has been discussed at length zillions of times
on the Yahoo DIY group.

Though, as you state, the random variation in absorption of pills
(swallowed or sublingual) will require a certain overshoot to
be approximately equivalent.

If it takes 4 times more estrogen to get the same level as the
injected one, so what? Pills are made with this loss in mind,
which can be somewhat bypassed by going sub lingual.

Swallowed progesterone capsules
also suffers massive losses, yet
if you take enough, you;ll get good levels.

Doctors think all estrogen is an equivalent DVT risks
and thus under treats in general, and in particular
in pill form.

I've been self injecting Estrogen valerate for several months. There was someone at the clinic who watched over me for 3 lessons before I was given a prescription for my own syringes. No responsible doctor is going to allow anyone to self inject who hasn't been properly trained.

I prefer the injections for several reasons. I liked the patches, but they would not stay flat on my skin, so I needed an alternative. I was taking the pills for about a month, the dosage was considered to be maximum for the pills. With the injections, I inject once every two weeks. It took a bit of time before the body really became accustomed to the timing, and now I can feel the estrogen level dropping off at about the 10 day mark, but not enough to be a problem. Once I inject, it takes a day or so before the estrogen level rises to a noticeable degree. By noticeable I mean that I feel a little bit "better."  I've never experienced the mood swings that some people have reported. Either I feel "solid," or more stable emotionally, or when the estrogen level is low, I feel more like I felt before HRT. I do not experience highs or lows with HRT to the degree where it really affects my mood or behavior.

The dosage that I inject is the maximum. It really is high, my doctor is very much up to date on the current research and is extremely experienced and cautious. He doesn't take unnecessary risks; I trust him. Because of the high dosage, I have no interest in adding pills to the regimen. I'm not interested in adding anything else, my spiro is at the low average end, and everything seems to be moving along. I'm not expecting overnight results, breast growth is in spurts, my only problem is with weight gain. I will not say that injections are superior to pills. To make a statement like that from personal experience is impossible. I only know how different forms of estrogen administration affect me, no one else. I've had good results with patches and injections, insufficient time to evaluate the pills. It's all a question of the correct dosage as well as time, I would think. It's all a matter of personal preference, all methods work.

 Hi Mari,
I switched to injections just over a month ago, I asked him for the switch, I had been taking the pills for 10 months
and just got tired of putting them under my tongue twice every day, he felt that it was a good idea and asked if I was taught
how to do it could I inject myself to save me all the travel time. the first one the nurse did, explaining to me what to do, the second
time they had me do myself while at the clinic, and the last two I did myself at home. for me there is nothing to it, I dont even feel it.
I don't have an opinion on which is better I just got tired of the sublingual route, but the pills were quite effective. I would think that
most doctors would start any program with pills only because if there is an adverse reaction, the pills would be in your system for much less time. My body metabolizes estradiol rather fast so my doc has given me a lesser IM dose more frequently. At my next test which is
quarterly he will see how my levels are. But I am happy that I made the switch. I am sure that I get a spike just after the dose because the first two times I got a small headache but like Hypatia has stated I too do not feel any lows, perhaps it is because of the more frequent injections.


   

Hmm, my doctor forgot to arrange injection training for me, just prescribed liquid E and syringes and left me on my own. My friend is dating a nurse, and set up a meeting between us where she trained me in self-injection technique. Now I'm good to go.

However, the nurse had me do it in my quad, I guess because it's within easy reach for me. Since that muscle has to contract a lot when climbing stairs, it hurt for a couple days afterward. I think I will inject myself there only if no one else is available when I need it. In general, my girlfriend is happy to inject me in the gluteus medius where I did not feel any pain.

 Hypatia,  that is where they taught me to do the injection, in the vastus lateralis muscle, which is limited in the amount in ml
that can be injected there. I also experienced some soreness the first time because the nurse did it pretty quick. When I do it
I push the plunger really slow and do not experience any soreness even going upstairs. But again the amount being injected could
be a factor.   

Quote from: Leiandra on September 01, 2008, 11:38:34 AM

Quote from: deviousxen on September 01, 2008, 11:36:20 AM
DVT?

I probably know what it is, but what is it again?

Deep Vein Thrombosis. Blood clots. :)

Were'nt they a heavy metal band in the seventies?

Quote from: Sarah Dreams on October 05, 2008, 03:04:51 AM

Quote from: Leiandra on September 01, 2008, 11:38:34 AM

Quote from: deviousxen on September 01, 2008, 11:36:20 AM
DVT?

I probably know what it is, but what is it again?

Deep Vein Thrombosis. Blood clots. :)

Were'nt they a heavy metal band in the seventies?

That thing in your signature, where did you get that lol.

But yeah, I think your right.

Hi, Rachel.

The hair thingy is from http://www.blogthings.com. The part about "Your Brain is 87% Female, 13% Male" is part of the results from a quiz on the same site.

Quote from: Sarah Dreams on October 05, 2008, 04:51:43 AM
Hi, Rachel.

The hair thingy is from http://www.blogthings.com. The part about "Your Brain is 87% Female, 13% Male" is part of the results from a quiz on the same site.

k, thank you

That quiz doesn't seem to exist any more.