Its been about year since i've started HRT and I'm feeling frustrated. I haven't really changed at all even after a year. I have some breasts (the only thing changing) and my hair has been growing. That's about it. I don't even look half female and still being referred as male.
So I use the VA for my care and I was looking through my blood tests. I take estradiol pills and spiro. I was also off of estradiol for a week and half during the test.
Estradiol - 44 pg/ml
T - 3.47 ng/ml
what do you guys/girls think? I was thinking of second opinion.
I have been on a low dosage of pills almost all the way through my transitioning. I didn't really start to see much change until I put weight on. I was skinny as a rake handle to start with at 67kg and 6ft tall. It doesn't hurt to get a second opinion from another doctor though. Maybe you are more resistant to oestrogen or something.
Maybe you should ask your doctor why your levels are so low and if you don't get a satisfactory answer and a plan to raise them you should see another.
E levels are low, T is high. Not good and not surprising you don't see much change but you said you stopped E during test for a week and a half, why?
Quote from: KayXo on January 21, 2016, 09:45:43 AM
E levels are low, T is high. Not good and not surprising you don't see much change but you said you stopped E during test for a week and a half, why?
I had ran out because I moved to different states. I had a primary care appointment but they wouldn't give me any emergency supply until then.
They increased my dosage for to last time. Now they increased to . I had taken 2 before off and on just to see what would happen.
And my last blood test before the one in my orgianl post was:
E - 33 pg/ml
Mod Edit - No dosages please. TOS 8
I would ask your doctor about it and let them know how you feel about the results your getting. If your up to it and the doctor is willing, then it might be time to consider seeing if they will up the dose. Hugs
Mariah
E is low. Should be around 200. What form of E are you taking (pills, patches or cream)?
Also, dosages are not to be posted. You need to delete them.
Hugs
Jen
Quote from: JLT1 on January 21, 2016, 08:10:45 PM
E is low. Should be around 200. What form of E are you taking (pills, patches or cream)?
Also, dosages are not to be posted. You need to delete them.
Hugs
Jen
I'm using pills. At first I was using patches, but it made me have rashes. But I think worked better. I tried to get them to do injections a few days ago but the VA doctors wouldn't do it.
Your last 2 tests have both shown your E to be very low. Have the test results prior to these also been that low? If so, what did your doctor say about this? 12 months is more than enough time to reach your desired levels. Are you meant to be on low dose or a transitional dose of HRT?
Quote from: Saki on January 20, 2016, 09:31:37 PM
Its been about year since i've started HRT and I'm feeling frustrated. ... I was thinking of second opinion.
Quote from: Saki on January 21, 2016, 06:53:38 PM
I had ran out because I moved to different states.
You should discuss things further with your doctor and/or, as you suggested, you might want to find a trans-specific care provider to get a second opinion or guiding input.
I can't offer advice but it seems like something is off because 12 months is a long time to be at low levels unless you specifically wanted those low levels. Some people do want low or slight levels because they're not seeking max changes, just softer skin and slight changes.
My care provider has been both attentive yet conservative with dosages, leading up to finding something that works for me. I'm still in the process, but I had started on one patch, then two patches, finally three but E stayed down. Spiro worked great on T, but E was in a holding pattern. (Patches just aren't effective with everyone. I've seen this elsewhere. ->-bleeped-<- has posts on this, for example. I can't speak about pills.) Anyway, we switched to deep subcutaneous injections and levels went way up. I have a follow-up to possibly reduce the dosage depending on test results. But that all happened in healthy conservative stages, yet relatively fairly quickly (within 6 months) given consistent attentive care, follow-ups, and so forth. Unplanned or undesired breaks in dosages certainly wouldn't have helped me.
Again, I agree with your instincts that you should probably discuss things with your doctor and/or consult with a trans-specific healthcare provider to get a second opinion or input on how to navigate with your main care provider.
An possibly helpful side point... I'm not sure if this applies everywhere, but use of Estradiol for trans patients is often (in all cases I've seen) technically considered an off label use. For that reason, I'd personally work to either go to a doctor very experienced with trans patients, or at least consult with one to discuss any confusion which may exist about the process/dosages.
Quote from: Saki on January 20, 2016, 09:31:37 PM
... I don't even look half female and still being referred as male. ...
You probably know this but starting HRT may or may not effect how passable one is. Given my own very limited experience at this point, I know not to expect changes, but to appreciate what changes there are, and realize it does not always lead to a hugely more female appearance by itself. (I've lost lots of weight, gotten facial electrolysis, started eating healthier and many other things, including some surgery.) I've also come to appreciate the unseen positive effects of HRT which seems oddly understated in much literature. My focus with HRT is currently about discovering, and about "being" more so than "looking." That said, I'm seeing some nice physical changes, but I'm not holding my breath for FFS-like changes. ;D I'm guessing you know but I wasn't sure given how you stated things. With HRT, I do believe it's safe to say that one's mileage does vary in terms of at least phys changes.
Best of luck getting things worked out!
Quote from: JLT1 on January 21, 2016, 08:10:45 PM
E is low. Should be around 200.
Around 200 is not enough for some, including me. Sensitivity to levels varies for several reasons. Doctors have set around 200 as the ideal level without basing themselves on any scientific evidence. I question this practice. I'm not a doctor but still I question this based on my own reading of the literature and anecdotal evidence.
Quote from: Kao3 on January 22, 2016, 08:02:40 AM
Anyway, we switched to deep subcutaneous injections
Why subcutaneous and not intramuscular which is the common route for estradiol? How long is your needle? Where do you inject?
QuoteThat said, I'm seeing some nice physical changes, but I'm not holding my breath for FFS-like changes.
You might be surprised after a few years. I have!
Quote from: KayXo on January 22, 2016, 11:32:08 AM
Around 200 is not enough for some, including me. Sensitivity to levels varies for several reasons. Doctors have set around 200 as the ideal level without basing themselves on any scientific evidence. I question this practice. I'm not a doctor but still I question this based on my own reading of the literature and anecdotal evidence.
I pulled the value of 200 from the "Endocrine Treatment of Transsexual Persons: And Endocrine Society Clinical Practice Guide".
In the guide, 200 is a good place to start. The team that authored the guidance placed a very high value on avoiding harm. I'd agree with that, it's a good place to start. Unfortunately, they stop there....
Once changes start happening and if the person likes the change, 400 would be the next step - in MY opinion. From there, it's about the patient and the bodies ability/requirements to establish and maintain normal physiological function. However, some people will need higher levels and some will not tolerate those high levels without adverse effects. The guide does call for routine monitoring of a number of relevant parameters. It doesn't seem that many doctors do the correct monitoring....... But monitoring is critical.
As far as patches, they can perform much better if the skin is washed with rubbing alcohol and allowed to air dry prior to placing the patch. Second is that three day rotation rather than a 3 day/4 day rotation does a much better job eliminating adverse effects to the skin. Lastly, removing the patch in the shower followed by liberal washing with soap and then with rubbing alcohol almost eliminates adverse skin reactions in most patients.
In one trial, off the books, the washing routine more than doubled estrogen levels in the blood and reduced skin inflammation to almost nothing....
Jennifer
Quote from: KayXo on January 22, 2016, 11:32:08 AM
Why subcutaneous and not intramuscular which is the common route for estradiol? How long is your needle? Where do you inject?
You might be surprised after a few years. I have!
I cannot remember the precise reasons other then there are some reasons why it's preferred. I'll ask for a reminder next follow-up.
I use two needles, an 18 gauge ~1.5" needle (not including to hub), which is relatively thick, to prep the syringe with Estradiol, and a 23 gauge ~1" more thinner needle for the actual injection.
My injection site alternates left/right thigh, once per week.
The experience is so much better than my particular "patch hell!" :) I'm fairly surprised by the ease and convenience of injections... it seems to take not more than about 15 minutes once per week or less as I get better at doing it. No intra-week patch changes or adhesive removal, and no patch to lose either.
I'm not saying patches are bad, just that they didn't work for me given what I wanted out of my particular HRT trial period. I need the levels to go up, and I really didn't want to deal with stuff multiple times during the week.
Quote from: KayXo on January 22, 2016, 11:32:08 AM
You might be surprised after a few years. I have!
That is great news! :) Is there a way to describe the major changes you've seen? If it's too personal beyond the general mention, no worries.
Quote from: JLT1 on January 22, 2016, 04:19:51 PM
In the guide, 200 is a good place to start. The team that authored the guidance placed a very high value on avoiding harm. I'd agree with that, it's a good place to start.
A good place to start is the lowest effective dose for an individual that triggers well-being and feminization (including breast growth), regardless of E levels. With time, that dose may have to be upped and so on and levels beyond 200 may or may not be necessary. Stopping at around 200 robs many women of their full feminization potential and sometimes well-being. On top of that, this level was arbitrarily established, no scientific support. Yet, no one questions this because of their titles and authority in the field. I personally think it's unfortunate.
I think guidelines are too conservative, there is over cautiousness and not much scientific support behind their statements. If the proper research had been conducted, guidelines could be improved significantly. Do they not care about us? Are we not their priority? I wonder...
My 2 cents. Sadly, I'm not a doctor so don't have much influence. But, I try by educating myself as much as possible on the matter and sharing with as many ppl as I can. :)
Quote from: Kao3 on January 22, 2016, 04:45:45 PM
a 23 gauge ~1" more thinner needle for the actual injection.
My injection site alternates left/right thigh, once per week.
1 inch in thigh could end up in muscle anyways.
QuoteIs there a way to describe the major changes you've seen?
If I showed you my photos pre-HRT and now, you would be amazed. Face is fuller, more female looking, less angular and squared. Forehead smoother and less harsh. Bigger eyes, fuller lips.
More curvaceous body including butt, thighs and better waist to hip ratio. Breast development, larger and darker areolas, thicker nipples. Much less body hair growth, that took some time to manifest. Scalp hair grows fast and is quite long. No one could ever tell I was ever a guy, from all angles. I also look younger.
Patience, an adequate HRT and good genetics help. I wasn't overly masculine to begin with but definitely looked male pre-HRT.
Quote from: JLT1 on January 22, 2016, 04:19:51 PM
As far as patches, they can perform much better if the skin is washed with rubbing alcohol and allowed to air dry prior to placing the patch. Second is that three day rotation rather than a 3 day/4 day rotation does a much better job eliminating adverse effects to the skin. Lastly, removing the patch in the shower followed by liberal washing with soap and then with rubbing alcohol almost eliminates adverse skin reactions in most patients.
In one trial, off the books, the washing routine more than doubled estrogen levels in the blood and reduced skin inflammation to almost nothing....
I used to be on the patches but it gave me a rash. They told me to wear it for a week so i showered with it on. I think they worked alot better.
I also have acid reflux so pills might be affected from that.
Quote from: Kao3 on January 22, 2016, 08:02:40 AM
An possibly helpful side point... I'm not sure if this applies everywhere, but use of Estradiol for trans patients is often (in all cases I've seen) technically considered an off label use. For that reason, I'd personally work to either go to a doctor very experienced with trans patients, or at least consult with one to discuss any confusion which may exist about the process/dosages.
Yes its menopausal women. I'd like to get a second opinion but I dont know who specializes in Trans patients in my area. I live in AL which is not pro-LGBT . But my area is starting to get better. I'll see if the local trans support group has any suggestions. Thanks for the input!
Quote from: KayXo on January 22, 2016, 05:05:27 PM
If I showed you my photos pre-HRT and now, you would be amazed. Face is fuller, more female looking, less angular and squared. Forehead smoother and less harsh. Bigger eyes, fuller lips.
More curvaceous body including butt, thighs and better waist to hip ratio. Breast development, larger and darker areolas, thicker nipples. Much less body hair growth, that took some time to manifest. Scalp hair grows fast and is quite long. No one could ever tell I was ever a guy, from all angles. I also look younger.
Patience, an adequate HRT and good genetics help. I wasn't overly masculine to begin with but definitely looked male pre-HRT.
That's quite encouraging... congratulations but also thank you for the foresight. Really amazing changes!
I was out shopping not long after having switched from several months of patches to injections, where the combination of it all had started to have some noticeable complexion-related effects as well as some positive facial muscle/fat thinning (or something like that)... anyway, ran into folks I knew who complimented me... something had changed for the positive, seemed more refreshed/brighter, better complexion. It was the HRT effects because a day or so before I'd started to notice subtle changes in the mirror but had thought it too soon, must have been reading into things. :) My face seemed slightly different in some almost inexplicable way. I was shocked because it'd only been like 4 months or so. What you describe sounds like there's much more to come. Thanks for sharing those details!
Some great replies.
This may help too.
http://www.hemingways.org/GIDinfo/hrt_ref.htm (http://www.hemingways.org/GIDinfo/hrt_ref.htm)
Quote from: Jessika on January 22, 2016, 06:25:25 PM
This may help too.
http://www.hemingways.org/GIDinfo/hrt_ref.htm (http://www.hemingways.org/GIDinfo/hrt_ref.htm)
Some information provided on that site might be erroneous so don't take everything you read as gospel. That goes for any information you read or hear about, including mine or anyone's on this forum. Question things, do your research, you will begin to see more clearly. Use your common sense too, don't get emotional about it. Remain objective.
Quote from: Kao3 on January 22, 2016, 05:51:31 PM
ran into folks I knew who complimented me... something had changed for the positive, seemed more refreshed/brighter, better complexion. It was the HRT effects
It's the "glow" that is often noticed in pregnant women. I got the same comments when I switched to higher levels and injections. :)
Oral estradiol passes through the intestinal tract and is first processed by the liver; most of it is lost. If you've been taking oral pills (not sublingual or transbuccal) for a year much of the estradiol will have been broken down into less effective metabolites (e.g. estrone) by the liver. There is a blood test which tests estrone levels vs. estrogen. Oral estradiol can also increase the risk of blood clots in some people. One pathology test for this is the thrombophilia screen but there are other indicators too.
I would expect a well informed endocrinologist to be testing at least every 3 months for LFT (liver function test), clotting (thrombophilia), androgens (free and bound testosterone), estrogens (as well as estrone). Other tests which are recommended are lipids, hsCRP, LH, FSH and prolactin. These are pretty basic pathology indicators for your health while on HRT and well understood. I may have missed a few too... If an endo isn't testing for all of these I would have to wonder why?
Second, some endocrinologists take a conservative approach because of their concerns with complications, especially clotting. However these risks are mainly associated with the older estrogens (ethinyl estrogen and conjugated estrogens). The newer estrogen synthetics (estradiol hemihydrate and estradiol valerate) are bio-identical and a lot safer. The latest study oh MtF HRT declared it to be safe (I can't post citations yet, but you should find it by googling "largest study to date: transgender hormone treatment safe"). By contrast one of the original studies on Premarin, a conjugated estrogen, was aborted part way through due to complications and deaths!
My last comment is that estrogen 17-beta itself is an androgen antagonist. There is arising evidence to suggest that for many people E will suppress T to female levels, but this is still relatively new thinking.
I think the moral of HRT is you need to be well informed, because the endocrinologists may vary wildly on approaches, conservatism, and how up-to-date their knowledge is.
Now you're on estradiol IM/subcutaneous you should see E levels improve a great deal. I agree with the 200-300 range for E, and your T should be in the low to mid female range.
Sami
Quote from: SamKelley on January 22, 2016, 06:57:56 PM
Oral estradiol passes through the intestinal tract and is first processed by the liver; most of it is lost. If you've been taking oral pills (not sublingual or transbuccal) for a year much of the estradiol will have been broken down into less effective metabolites (e.g. estrone) by the liver. There is a blood test which tests estrone levels vs. estrogen. Oral estradiol can also increase the risk of blood clots in some people. One pathology test for this is the thrombophilia screen but there are other indicators too.
I would expect a well informed endocrinologist to be testing at least every 3 months for LFT (liver function test), clotting (thrombophilia), androgens (free and bound testosterone), estrogens (as well as estrone). Other tests which are recommended are lipids, hsCRP, LH, FSH and prolactin. These are pretty basic pathology indicators for your health while on HRT and well understood. I may have missed a few too... If an endo isn't testing for all of these I would have to wonder why?
Second, some endocrinologists take a conservative approach because of their concerns with complications, especially clotting. However these risks are mainly associated with the older estrogens (ethinyl estrogen and conjugated estrogens). The newer estrogen synthetics (estradiol hemihydrate and estradiol valerate) are bio-identical and a lot safer. The latest study oh MtF HRT declared it to be safe (I can't post citations yet, but you should find it by googling "largest study to date: transgender hormone treatment safe"). By contrast one of the original studies on Premarin, a conjugated estrogen, was aborted part way through due to complications and deaths!
My last comment is that estrogen 17-beta itself is an androgen antagonist. There is arising evidence to suggest that for many people E will suppress T to female levels, but this is still relatively new thinking.
I think the moral of HRT is you need to be well informed, because the endocrinologists may vary wildly on approaches, conservatism, and how up-to-date their knowledge is.
Now you're on estradiol IM/subcutaneous you should see E levels improve a great deal. I agree with the 200-300 range for E, and your T should be in the low to mid female range.
Sami
Thanks for the advice!
Quote from: SamKelley on January 22, 2016, 06:57:56 PM
Oral estradiol passes through the intestinal tract and is first processed by the liver;
...
Oral estradiol can also increase the risk of blood clots in some people.
...
I think the moral of HRT is you need to be well informed, because the endocrinologists may vary wildly on approaches, conservatism, and how up-to-date their knowledge is.
I agree with the 200-300 range for E, and your T should be in the low to mid female range.
Really great points. My primary concern prior to starting HRT was the potential for negative side effects, especially clotting and it being too hard on the system (liver processing).
One thing I like about patches (which I personally no longer use but still appreciate) is I'd heard they were connected with lower probabilities of clotting. A great thing about both patches/injections, they bypass the liver. Despite the convenience of pills, I'm glad to not be taking that path. Actually, one injection, which I expect to get down to 5 or 10 minutes per week, is that it's once a week, not daily... so I guess pills may not be as convenient as they seem.
Thanks for your great overall info.
Quote from: SamKelley on January 22, 2016, 06:57:56 PM
Oral estradiol can also increase the risk of blood clots in some people.
I have only read one study that reports blood clots or DVT/pulmonary embolism from taking oral bio-identical estradiol and that was on VERY high or smaller doses given to women who had advanced breast cancer. I have never heard from any transsexual woman blood clot issues from taking estradiol orally. I'm not saying it can't increase risks but so far, the reports are practically absent which makes me think it's pretty safe. Please don't mix estradiol with other forms such as Premarin and ethinyl estradiol which HAVE shown to produce blood clots on many occasions.
QuoteI would expect a well informed endocrinologist to be testing at least every 3 months for LFT (liver function test), clotting (thrombophilia), androgens (free and bound testosterone), estrogens (as well as estrone). Other tests which are recommended are lipids, hsCRP, LH, FSH and prolactin. These are pretty basic pathology indicators for your health while on HRT and well understood. I may have missed a few too... If an endo isn't testing for all of these I would have to wonder why?
I personally disagree and not all endos/doctors test all these parameters. It depends on your HRT regimen, your personal health history, etc. It is important to understand how hormones affect body and the differences. Some values don't reveal much and are unnecessary. It's a case by case thing and all these things shouldn't always be measured, especially clotting, estrogens/androgens (you can tell physically and psychologically), LH/FSH, etc. Blood tests are expensive for some and the doctor should discern what is essential from what is not.
QuoteMy last comment is that estrogen 17-beta itself is an androgen antagonist. There is arising evidence to suggest that for many people E will suppress T to female levels, but this is still relatively new thinking.
Estrogen sends a negative feedback to the hypothalamus/pituitary gland, hence reducing their signals (LH/FSH) to produce testosterone and sperm. Enough E in the body, the body stops producing T/E. Enough T in the body, the body stops producing E/T. This is just how the body works and we have known this for quite some time, decades or even more. This is the thinking behind birth control pills which have existed since the mid-1900's and estradiol treatment in transsexuals during the first decades we started treating them.
Also, within cells, E has various effects on androgen sensitivity, metabolism, etc. This has been verified by studies.
Quote from: Kao3 on January 23, 2016, 05:40:38 AM
My primary concern prior to starting HRT was the potential for negative side effects, especially clotting and it being too hard on the system (liver processing).
These concerns stem from issues with older forms of estrogens that were not bio-identical. Estradiol itself has very rarely and never (to my knowledge) been shown to affect clotting and liver health, respectively. Search through articles and studies and I challenge you to find just one study where oral estradiol in humans caused liver problems. Clotting seems quite rare as well. So these concerns, in my opinion, are over exaggerated in the case of bio-identical estradiol. I've personally been prescribed by my doctor quite high dosages of oral estradiol throughout the years with not one single clotting or liver issue.
Quote from: KayXo on January 23, 2016, 07:52:53 AM
I have only read one study that reports blood clots or DVT/pulmonary embolism from taking oral bio-identical estradiol and that was on VERY high or smaller doses given to women who had advanced breast cancer. I have never heard from any transsexual woman blood clot issues from taking estradiol orally.
In the most recent study I cited
Largest Study to Date: Transgender Hormone Treatment Safe, they state "The primary serious side effect, venous thromboembolism, occurred in 1% of persons undergoing male-to-female (MTF) transgender transition and was due to estrogen treatment." However they don't seem to distinguish the comorbidity by transdermal / oral / parenteral which is unfortunate.
Quote from: KayXo on January 23, 2016, 07:52:53 AMPlease don't mix estradiol with other forms such as Premarin and ethinyl estradiol which HAVE shown to produce blood clots on many occasions.
I didn't - I specifically separated the different forms in my post.
Quote from: KayXo on January 23, 2016, 07:52:53 AM
I personally disagree and not all endos/doctors test all these parameters.
No, not all endocrinologists will test everything, and not all tests are of equal importance. However the tests I referred to are taken from the Endocrine Treatment of Transsexual Persons paper written by the Endocrine Society.
Quote from: KayXo on January 23, 2016, 07:52:53 AM
Estrogen sends a negative feedback to the hypothalamus/pituitary gland, hence reducing their signals (LH/FSH) to produce testosterone and sperm. Enough E in the body, the body stops producing T/E. Enough T in the body, the body stops producing E/T. This is just how the body works and we have known this for quite some time, decades or even more. This is the thinking behind birth control pills which have existed since the mid-1900's and estradiol treatment in transsexuals during the first decades we started treating them.
Yes however the currently recommended regimen for MTF hormone treatments is anti-androgen(s) plus estrogen. So the treatment you're referring to isn't actually used afaik. With ethinyl and conjugated estrogens it was too dangerous to get high enough estrogen levels to suppress T in most people - why anti-androgens were used.
I'm not sure if I'm not communicating properly or I've said something to annoy you :)
xox
Sami
Quote from: SamKelley on January 23, 2016, 09:52:47 AM
In the most recent study I cited Largest Study to Date: Transgender Hormone Treatment Safe, they state "The primary serious side effect, venous thromboembolism, occurred in 1% of persons undergoing male-to-female (MTF) transgender transition and was due to estrogen treatment." However they don't seem to distinguish the comorbidity by transdermal / oral / parenteral which is unfortunate.
Estrogen can also include not bio-identical such as Premarin and ethinyl estradiol. Cyproterone acetate is also known to increase this risk and if taken with estrogen, DVT cannot be attributed to one or the other as there is more than one factor involved. I'm reading the study as we speak. Will dig more deeply into it to try and find out if DVT was noted with oral bio-identical estradiol only. You have to be careful not to jump to conclusions too fast and read between the lines.
Quotethe tests I referred to are taken from the Endocrine Treatment of Transsexual Persons paper written by the Endocrine Society.
That doesn't mean they are necessarily right. I think it's important to always question and rely on science hen formulating recommendations. I find some of their assertions and guidelines don't always follow scientific findings.
QuoteYes however the currently recommended regimen for MTF hormone treatments is anti-androgen(s) plus estrogen. So the treatment you're referring to isn't actually used afaik. With ethinyl and conjugated estrogens it was too dangerous to get high enough estrogen levels to suppress T in most people - why anti-androgens were used.
But we aren't using ethinyl or conjugated estrogens any longer. Times have changed. :)
Please understand that I'm not aiming my comments directly at you but rather at these guidelines that need to be updated, elaborated on, based on more extensive science that is available as I've browsed through it so that transgendered patients can receive a better treatment.
About this study, one interesting statement is this:
"Gooren et al. (2008), reported no increase in VTE among 2236 male-to-female (MTF) transgender individuals on HT from 1975 to 2006 compared with controls, with the exception of those who used ethinyl estradiol, for which there was a 6–8% incidence [4]."
This would confirm my earlier statement.
Also...
"Additionally, while Wierckx et al. (2013) observed 5% of 214 MTF individuals to have a VTE within the first three years of estrogen therapy, 10 out of 11 of these women had at least one VTE risk factor such as smoking, immobilization due to gender confirmation surgery, or a hypercoaguable disorder [5]."
HRT consisted of
- cyproterone acetate (n=2)
- oral EV + CPA (n=2)
- oral EV only (n=1)
- transdermal estradiol (n=3)
- ethinyl estradiol (n=1)
- conjugated equine estrogens (n=1)
- unknown (n=1)
So, 4 out of the 11 only took bio-identical estradiol and nothing else. But, out of those 11,
- 7 smoked
- 3 were immobilized due to surgery
- 1 had a clotting disorder
In reviewing all cases of DVT/pulmonary embolism and cardiovascular complications in this study, the first thing one notices is that smoking is quite prevalent, 14 of 19 being smokers or former smokers (n=1). 11 out of 19 ppl were 50 yrs of age or older. 6 out of 8 ppl with cardiovascular problems were 50 yrs of age or older.
The smoking frequency or presence/absence is not noted in the control groups so we have no way of knowing whether transsexual women smoked more, as much, or less than the control groups. This is unfortunate as this would have elucidated the role of HRT in the etiology of DVT/CVD more clearly.
One must not also ignore the fact that some transsexual women supplement by taking more estrogen illegally (self-medicating) after realizing that the doses prescribed are too low and aren't producing satisfactory results. The type of estrogen and dose may be adversely affecting their health. This not factored in so who knows? And are they reporting accurately and honestly what they are taking?
Cancer was also not more prevalent among transsexual women. Ten transpersons (9 women, 1 man) died. 6 because of suicide which seems quite prevalent among our population, sadly. 2 from CVD, 1 from cancer and 1 unknown.
They state in the discussion section
"The incidence of venous thrombosis and/or pulmonary embolism in this study (5.1%) was lower than that reported by Van Kesteren et al. (7), who showed that 6.4% of their sample experienced this during hormone treatment. The use of high-dose oral ethinyl estradiol (*μg OD) may explain the higher incidence in the latter study, as the type and route of administration of this estrogen are known to affect the coagulation system negatively (5, 17, 18). However, Ott et al. (19) did not observe any venous thrombosis and/or pulmonary embolism incidents during their follow-up study of 162 trans women (mean age 36 years) who received transdermal 17β-estradiol therapy for an average of 4.4 years. This may be a safer type of estrogen and route of administration, although 37% of the trans women who experienced venous thromboses in our sample received transdermal 17β-estradiol therapy. The older age of the participants and the longer follow-up period in the present study may also contribute to the higher incidence of these events."
How about maybe those women on transdermal having a venous thrombosis experienced this because of their smoking (or immobilization due to surgery or genetic predisposition) or because they didn't reliably report what they really took as a result of supplementing outside or were assumed to follow protocol when they really didn't because they found the doses too conservative and not enough to produce results. These are all important factors to consider.
"the majority of trans women who experienced myocardial infarction or CVD were aged over 50 years, had one or more cardiovascular risk factors (mainly smoking), and had undergone cross-sex hormone therapy for a short duration."
"We discovered that both trans men and women had a higher prevalence of type 2 diabetes than the control men and women, with almost all diagnoses being made before starting hormone therapy in trans women."
In an earlier study by Wierckx
http://www.ncbi.nlm.nih.gov/pubmed/22906135 (no control group)
of those transsexual women who had a thromboembolic event and cardiovascular problems (n=6), it is interesting to note that of those women
- 5 were smokers or former smokers with years of smoking ranging from 18-45.
- all but one (or two, the second not specifying which type of estrogen) were on estrogens that were NOT bio-identical AND cyproterone acetate (n=2)
It is also stated
"a quarter of the transsexual women had osteoporosis at the lumbar spine and radius."
which strongly suggests the estrogen doses prescribed were too low, increasing the likelihood that transsexual women supplement outside their protocol due to unsatisfactory results. Doctors don't realize they are harming their patients by underprescribing because for one, they are increasing health risks due to insufficient sex hormones in the body AND because they are giving women more incentive to source estrogen from outside sources which might increase risks. Underprescribing also increases likelihood that feminization will be less than optimal and that FFS will be resorted to, with all the risks associated with this type of surgery.
Furthermore, it is stated in the original study that
"Venous thrombosis events (VTE) were reported in MTF individuals as early as 1976, when a 29-year old transgender woman with no history or risk factors for VTE presented with pulmonary embolism after beginning estrogen therapy of diethylstilbestrol (DES) [7]. A 1978 paper also observed an occlusion of the middle cerebral artery during estrogen therapy in a transgender woman, where the patient was reported using mestranol, a 3-methyl ether of ethinyl estradiol [8]."
In both cases, the estrogen taken is not bio-identical.
"Wilson et al. (2009) also observed increases in inflammatory markers (cytokine IL-6, IL-1 and IL-8, clotting factors FV11 and FVIX and superoxide dismutase) consistent with this hypothesis for MTF individuals taking oral estrogen, but not for those taking transdermal estrogen [14]."
In this study, those taking oral estrogen were taking Premarin (moderate dose). NOT bio-identical estradiol.
On a positive note
"While some guidelines for transgender medical care express concerns for elevated cancer risk with certain hormone regimes, current data suggest that the risk of cancer may not rise."
"Although studies are small, overall cancer incidence in transgender men and transgender women to-date has not been found to be different than their respective male and female controls [5]. There are no reports of change in breast cancer specific risk among transgender individuals on estrogen compared to secular trends of male breast cancer incidence. Rates are lower relative to secular trends of female breast cancer rates."
"A comprehensive study among the medical records of 2306 orchidectomized MTF individuals reported an overall rare but possible incidence of prostate cancer of 0.04%"
"Additionally, there are ten case reports of breast cancer development among MTF individuals on estrogen since 1968"
This is VERY low.
"The three largest studies to date on mortality and transgender hormone therapy suggest no direct increased risk in mortality." Although suicide seems to be more prevalent among this population.
"Roberts et al. (2013) (n = 55) reported elevated median triglyceride levels of 120 mg/dL among MTF adults compared to both male (80 mg/dL median) and female (60 mg/dL median) control groups, with the range of participant values spanning from 34.2 to 242.6 mg/dL [46]. Cholesterol (LDL) levels among MTF individuals resembled female controls."
We don't have any information about their HRT.
"Roberts et al. (2013) reported that for MTF adults on estrogen therapy the values of hemoglobin and hematocrit were similar to female controls [48]."
"In Roberts et al, 2013 among MTF individuals, alkaline phosphatase, potassium and creatinine values resembled male controls [48]."
"Roberts et al. (2013) reported no difference in blood urea nitrogen values"
"Yahyaoui et al. (2008) found that fractional excreted of uric acids (FEUC) levels increased among 22 MTF individuals"
Of those 22, 18 took conjugated equine estrogens.
"Most studies on glycemic control in transgender individuals on HT report increased insulin resistance and fasting glucose."
Whether these are caused by cyproterone acetate, non bio-identical estradiol, smoking or bad eating habits in transsexual women, who knows? In all these studies, most women had been on estrogen that wasn't bio-identical.
"Studies with the greatest statistical power show increased rates of osteopenia in transgender women on HT, however these may be limited by including participants who used anti-androgens for one year before starting estrogen therapy."
What did I say about only taking anti-androgens? And underprescribing?
"There are reports of enlarged pituitary glands among MTF individuals on HT [60], as well as six case reports of prolactinoma [61], [62], [63] and [64]. Prolactin levels have also been reported to be elevated among MTF individuals during long-term HT [60]."
All these cases included estrogen that wasn't bio-identical and/or cyproterone acetate which both stimulate prolactin to a significant degree and abnormally. One case involved extremely HIGH doses of injectable estrogen, unheard of, combined with EE and CPA.
"There are two case reports of systemic lupus erythematosus occurring in MTF individuals with no prior history of autoimmunity deficits; one case presented with SLE 1 year after starting estrogen injections, and another after 20 years on HT [68] and [69]."
In the case of estrogen injections,
"He had been taking "hormone shots" to induce feminization for at least 1 year prior to admission. He was evasive about the injections, and declined to give information on how he acquired them, and the brand and formulation used. He had developed obvious feminine features, including a higher pitched voice and gynecomastia."
Vague information and researcher bias and ignorance as they call the woman a "he" and reported higher pitch due to HRT which cannot happen. LOL.
In the second case, where HT was taken for 20 yrs, the hormone was Premarin (moderate dose).
"Hypercoaguable risk factors, including the use of a thrombogenic estrogen, ethinyl estradiol, have been associated with many of the cases of reported VTE, and as such the risk of these adverse events may continue to decline as the usage of this drug diminishes [3]."
"The Standards of Care (SOC) released by the World Professional Association for Transgender Health (WPATH) report that the greatest risk factor of MTF HT to be VTE and increased triglycerides, which is supported by this literature review [70]."
VTE should be an non-issue if all TS women were given bio-identical estradiol (oral and non-oral), without exception. I think we would then find no difference between this population and the general population IF the factor of smoking is controlled for (same in both populations).
Triglycerides, I suspect, could be caused by cyproterone acetate as well as non bio-identical estrogen. If CPA was discontinued as a treatment and substituted instead with either a GnRh analogue or just estrogen, I think this would greatly improve things.
To conclude, this study does not really fully address health risks with bio-identical estradiol only, without CPA, without estrogens such as ethinyl estradiol and conjugated equine estrogens.
There are only four cases where VTE was associated with the use of bio-identical estradiol but other factors such as smoking, age, clotting predisposition and immobility were present and as such, we cannot conclude with certainty that bio-estradiol CAUSED VTE/DVT. There is also the issue of supplementation that cannot be verified.
Interestingly, there are two studies from Germany (1998 and 2005) where all except 2 out of 103 took bio-identical estradiol (orally and non-orally), where doses on average were not conservative, sometimes combined with cyproterone acetate or GrNh analogue. There was only one case of DVT due to a genetic predisposition (mutation) and one case where clotting factors were abnormal but we don't know what type of estrogen was used and if CPA was taken.
I intend to reread several times this study and other related studies to really get a clear picture of it all. :)
...and lastly, I realized that...
smoking not only increases DVT to a greater extent when estrogen is taken orally, more so if the estrogen is NOT bio-identical BUT also interferes with its metabolization, decreasing concentrations of estrogen in the body which may be the reason why in some, not enough is circulating in the body, causing bone problems, other health issues related to not enough sex hormones in the body including mood disorders (i.e. suicide, probably affected more by other social factors) and causing some to supplement/self-medicate.
I suspect a few, at least, were smoking and taking oral estrogen at the same time.
But, OVERALL, in the big scheme of things, liver function was never adversely affected AND there was only one case where the use of oral bio-identical estradiol taken alone was associated with DVT. Since DVT was also associated with transdermal estrogen (3 cases), known not to affect coagulation, one can likely attribute this incidence not to estrogen but to some outside factor such as smoking, immobility, supplementation or genetic predisposition which is probably the case for oral bio-identical estradiol as well.
Individuals in this forum often express concern about the risk of liver damage and clotting when starting HRT (which almost always includes bio-identical estradiol these days) but this concern is not supported by the evidence. One should be more concerned about other factors like smoking, excess alcohol consumption and excess carbohydrate intake which affect much more significantly coagulation, liver and triglycerides. One should also be somewhat concerned about progestins such as medroxyprogesterone acetate, cyproterone acetate AND other medications they may be taking. Enough said. You make up your own mind. ;)
KayXo I don't think we necessarily disagree with each other, however this is a complex topic and happy to continue this friendly argument in private :) xox
Quote from: KayXo on January 23, 2016, 03:58:36 PM
But we aren't using ethinyl or conjugated estrogens any longer. Times have changed. :)
According to whom? I don't think this statement is true. I've spoken to several people who are using conjugated estrogens. Also both conjugated estrogens and ethinyl estradiol are still manufactured and for sale, implying there is market demand.
It is extremely rare these days to see transwomen use conjugated equine estrogens or ethinyl estradiol. Doctors, for the most part, have finally understood the risks involved. But, ciswomen are still prescribed birth control pills containing EE and menopausal women, to a greater degree, conjugated equine estrogens and Provera although doctors are also slowing changing their ways in that respect due to recent studies and more informed patients requesting bio-identical homones. It may also be the case that in less developed countries, where people are poorer and riskier estrogens are cheaper that they are more in demand and used more frequently coupled with the fact that there is less knowledge about their risks.
We can continue this friendly discussion in private, I agree. :)
I don't think anybody has really pointed this out but your T-levels are actually very low, so there is that. E is on the low side though. I can only speak on the (cis) female reference ranges provided by the lab I use, but here are the averages I calculated:
Averaged Estrogen Reference Range Across Menstrual Phases
High: 291 pg/mL
Mid: 169.5 pg/mL
Low: 47.3 pg/mL
Also worth noting, the extreme low in the reference ranges was 12.5 pg/ml in the follicular phase, and the extreme high was 498 pg/ml in the ovulation phase.
To quickly come back to that earlier study (Wierckx et al. (2013)) where DVT/PE (deep vein thrombosis/pulmonary embolism) was observed in 11 cases and cardiovascular complications in 8 cases, where most were on bio-identical estradiol,
it is noteworthy to mention that the group of transsexual women differed in some important respects from the control group which makes this study much less reliable and could account for the increased prevalence of thrombosis and cardiovascular events
- Before the start of HRT, there were already more transsexual women who had had DVT/PE (9/1,000) vs. the control groups (0/1,000). Hence, TS women were already more at risk compared to other groups.
- Before the start of HRT, there were already more transsexual women who had Type 2 Diabetes (37.3/1,000) vs. the control groups (between 6.2 and 14.9/1,000). Diabetes is a risk factor for cardiovascular complications and DVT/PE.
- As mentioned before, smoking prevalence was high in those who had complications and smoking habits were not compared between the group of transsexual women and control groups, which is a factor that is lacking in this study.
- TS women were less employed than control groups, less often in relationships and poorer which could account for higher stress levels on top of their situation as transwomen, which as we all know, stresss increases the likelihood of cardiac events.
So, to summarize, in this study, the TS population is more diabetic, more DVT/PE prone, perhaps bigger smokers (we don't know), more stressed and less fortunate psychosocially than our control population to begin with, even before the start of HRT. Can we really attribute later complications to HRT when those groups differ in so many other respects? The answer is a clear no.
This is why it is so important to read studies fully, look at details so that when the time comes when authorities tell us certain things, we can more intelligently and critically assess what they are saying. We don't just blindly accept their assertions.
I plan to write to the researcher and explain to them the flaws I found with this study. :)
Quote from: Ashey on January 24, 2016, 04:55:58 AM
I don't think anybody has really pointed this out but your T-levels are actually very low, so there is that. E is on the low side though. I can only speak on the (cis) female reference ranges provided by the lab I use, but here are the averages I calculated:
Averaged Estrogen Reference Range Across Menstrual Phases
High: 291 pg/mL
Mid: 169.5 pg/mL
Low: 47.3 pg/mL
Also worth noting, the extreme low in the reference ranges was 12.5 pg/ml in the follicular phase, and the extreme high was 498 pg/ml in the ovulation phase.
So I should be higher? I'm taking E pills and spiro. I have already increased the dosage and it only affected me a little.
Quote from: Saki on January 24, 2016, 11:33:53 AM
So I should be higher? I'm taking E pills and spiro. I have already increased the dosage and it only affected me a little.
Well, your T-levels are fine, but your E should definitely be higher. So I would talk to your doctor about that.
Quote from: Ashey on January 24, 2016, 03:07:35 PM
Well, your T-levels are fine, but your E should definitely be higher. So I would talk to your doctor about that.
I kinda did but they wanted to up the dosage again. I told them I wanted injections but nope. This is how the VA treats transgender veterans. Hey at least its free for me.