I had a meeting with a new doctor yesterday. During the visit he said I was a post menopausal woman. I had never heard that and it didn't sit well with me. This was not because of the age thing, but rather because I know for a fact my male past has permanently altered my physical self and I will never physically be like a natal female. And I don't mean just bone structure and things like that. But I am not a post menopausal women because I've never been through menopause. And I am not XX and all the physiology that goes with that.
My previous doctor started treating trans patients some 40-50 years ago. I know some patients who were with him for 30 years, maybe more. He adamantly insisted the idea of treating a transwoman the same as a natal woman was flat out bad medicine. The science didn't support it. For instance, the belief higher doses of estrogen will cause higher incidences of venous thrombosis (VTE). In all his years of treating transwomen, my previous doctor said he has not had one patient suffer from VTE. Yet many doctors today prescribe "low" levels of hormones to their trans patients for fear of VTE.
In the 11 years I have been on HRT my doctor has prescribed hormones that keep my E levels 2-3 times higher than what is typically thought to be safe for natal females. He does that with all his trans patients. And no cases of VTE in what must be hundreds of patients, maybe even into the thousands. What I do know is when I have been religious with self-injections my cholesterol and trigs are perfect. When my E levels drop to what a pre-menopausal women's should be, they rise. And when they drop to post-menopausal levels, the alarms start to go off.
I realize the medical community had to start somewhere and they started with what they knew about natal females and applied it to transwomen. But today there should be sufficient data available that the medical community can comfortably abandon the idea they can look at natal female data and use that to apply to transwomen.
It's apples to oranges and it needs to end.
Is another doctor an option?
Quote from: Julie Marie on May 17, 2016, 03:16:02 PM
I had a meeting with a new doctor yesterday. During the visit he said I was a post menopausal woman.
Menopausal women may develop issues like vaginal dryness, even some atrophy, libido issues, bone isues, etc.
In post op people the neovagina reacts to estrogen levels like a cis vagina.
Those issues are well known. You might tell them to be raised to levels well in the female range.
Many endos strive for levels of 180-200 pg/ml or above.
Studies concerning problems with higher levels usually were done with oral intake and non bioidentical forms of estrogen.
Cis people have higher levels without adverse effects, for example during pregnancy.
If bioidentical estrogen is applied sublingually there is few clotting, applied via gel, injection or implants even less.
Transgender people are not menopausal people.
Imo they need adequate levels for a normal libido and health, like cis people.
If explained its possible they come around.
If they have restraints you might ask them to look it up. Imo its likely they are based on studies on oral intake and non bioidentical estrogen.
And you might consider looking up endos aquainted with transgender subjects in your area.
LGBT centers or plannedparenthood might help with a referral. Some plannedparenthood also provide hrt.
hugs
This was not a rant because the new doctor refused to treat me like my previous doctor did. In fact, he said he would be open to following in the steps of my previous doctor if I so desired.
The reason for the rant was I had no idea doctors experienced with treating trans people still held to what I, and many transwomen I have known for over a decade, consider antiquated hormonal treatment.
Laura, you said many endos strive for levels of 180-200 pg/ml. That, to me, my previous doctor and all of his patients, is way too low. He goal was for levels of 350-450 pg/ml. I was unable to achieve that with orals and had to go back to injections to achieve that. When I did, my cholesterol and trigs dropped and in general I felt better.
I'm not an E addict, like it's be-all, end-all to successful transitioning. It's just that I know for a fact my body responds better at those higher levels. I don't care what my E levels are but I do care what my cholesterol and triglycerides levels are.
But getting back to VTE, I have to point out my previous doctor (now very retired) has decades of data that has shown his patients have had ZERO incidents of VTE.
He has been my only doctor since I began my transition and I've never been treated like or compared to a natal female. My doctor knew that was a faulty medical practice. This from a doctor who was highly recommended by my therapist and highly recommended by women I knew already in transition. In the Chicago area he was probably considered the best. His credentials are pretty impeccable.
Over the years I have spent a lot of time with him in and out of the office. I learned a lot from him. He really knew his stuff and often took WPATH sticklers to task. He was never afraid to take on the establishment if his data showed he should.
When I began HRT I accepted the fact there wasn't a lot of good data out there for us. But it's been over 10 years now and there should be some pretty good data, that is if the medical community in general opened themselves to stop seeing transwomen as natal women. And thus, my rant.
I think you'd like my endo, Dr Jon Hayes, in Sydney.
https://www.susans.org/forums/index.php/topic,207756.msg1843224.html#msg1843224
He has a huge experience and is following on from another doctor who I think must have retired some years ago.
Quote from: Julie Marie on May 17, 2016, 04:54:55 PM
Laura, you said many endos strive for levels of 180-200 pg/ml. That, to me, my previous doctor and all of his patients, is way too low. He goal was for levels of 350-450 pg/ml. I was unable to achieve that with orals and had to go back to injections to achieve that. When I did, my cholesterol and trigs dropped and in general I felt better.
I'm not an E addict, like it's be-all, end-all to successful transitioning. It's just that I know for a fact my body responds better at those higher levels. I don't care what my E levels are but I do care what my cholesterol and triglycerides levels are.
Many people have higher levels and are happy with that.
I have added the "or above" 200 pg/ml.
Especially with injections and implants levels can be higher and people are happy with that.
With implants and injections it may also be possible to go without anti androgens.
hugs
Understand though that everyone is different in how they react to it. Even low levels of estrogen caused immediate results for me mentally and physically.
My levels are currently in the lower range you describe and i feel amazing, and my body continues to change for the positive. I added progesterone but that has been the only real change over the last year. i wonder if i had not started out at low does what the differences would have been.
Quote from: RobynD on May 17, 2016, 06:11:01 PMi wonder if i had not started out at low does what the differences would have been.
The doctor I had for the last 11 years started all his patients out slowly and gradually upped their prescription until they reached the 350-450 level. He really seemed to have his thumb on the right button because everyone I talked to raved about him. The only time someone left him is if they moved. I wish they didn't break the mold when they made him.
My level doesn't go much below 250 pg/ml, and probably gets up around 400 to 500. I really notice it when its "low", and its horrible.
My doctor prescribes as far as I know is what is normally prescribe according to all the information I can come up with and I have no complaints. I've developed quite well. I'm mean if you take down the T and have all E that's what the genes would be doing. Your not going to alter bone structure anyway.
Quote from: AnonyMs on May 18, 2016, 08:53:09 AM
My level doesn't go much below 250 pg/ml, and probably gets up around 400 to 500. I really notice it when its "low", and its horrible.
I'm like robo cop under an emergency shut down when is gets low.
Quote from: stephaniec on May 18, 2016, 08:57:57 AM
I'm like robo cop under an emergency shut down when is gets low.
Me too, last time I had trouble doing anything. Really lost my energy and that was about 250pg/ml. I feel fantastic now I've got a new implant, such a difference. I don't understand how people survive on that level and below.
I live in the Chicago area and it seems like that is what my doctor is doing for me. We had my levels checked on a Thursday as I do my injection every Friday. He wanted to see my levels at their lowest. I was at 238pm/mmol and he said that was too high when it was the day before but said he was going to monitor me.
Natal or transwomen, it doesn't make a difference, in my opinion. I believe a doctor's goal for either should be WELL-BEING, overall health and positive impact on the body as a WHOLE. The fears behind HRT are based on studies which consisted of estrogen that was NOT bio-identical and sometimes combined with a progestogen, also not bio-identical and known to be associated with several health risks and side-effects. Not one study has shown that such and such a level or beyond a certain level, health risks significantly increased. On the contrary. Studies in men with prostate cancer aged 49-91 yrs old, given estradiol non-orally, with levels up to 700 pg/ml confirmed DVT and cardiovascular risk was NOT an issue. Same with pregnant women whose levels go as high as 75,000 pg/ml and whose risks of having a DVT are around or even less than 0.05-0.2%. Other studies have confirmed that levels alone aren't an accurate predictor of health risks whereas the type of estrogen, especially and the route of administration matter more.
I am under the supervision of three doctors, self-inject. My levels are in the range of 1000-4000 pg/ml. Blood test results are good, I'm healthy, feel good. Clotting times remain normal.
Every individual should be treated uniquely as we all differ in our response. The goal...well-being and for transwomen who are beginning, feminization that should be optimized while keeping risks negligible.
Doctors are, I think, just not interested (for the most part) in this matter so don't know much about it and rely on guidance from authorities that also don't take the time to really dig deep into the matter and/or close-minded and think they know it all. Thankfully, some doctors truly care for us and have an interest in us but in my experience, there are not many of them. Perhaps, my assessment is wrong and I'm exaggerating. I hope so.
My 2 cents...
I am going to throw my hat into the ring on this one because some of the talk is apples and oranges. From 1977 to 2006 I was on Premarin mostly on a quarter dose but up to a transition dosage for a few years. I suspect at peak dosage my estradiol might have reached 25 pg/ml and total estrogen around 1400 but the levels were never tested. Yesterday I had my doctors appointment and my estradiol is 51 with a total estrogen of 733 on my first test. I suspect most of the total estrogen was made up of estriol which is almost useless as far as transitioning is concerned. The person monitoring my treatment figures a total estrogen level of 300 is all us older girls need.
OK, I can understand if you had a high dosage of estradiol when you are young, there might be a point in life were you should enter the menopause range of 15 to 60 ph/ml of estradiol BUT I HAVE NEVER LEFT THE MENOPAUSAL RANGE. This may also explain my rather boyish build and some what masculine face. The last 3 months were on about a half transition dosage but she was more that willing to write my next prescription for a quarter transition dosage. I am beginning to wonder why I have spent $600 getting back on HRT when the doctors are doing there best to make it not work!
Where I go they do not monitor E; they monitor T. They ask how I feel and go from there ( they see 1800 trans). The IM dose they prescribe is on a 14 day cycle. I am on the same amount of E as a 25 year old but on a 10 day cycle. I had to promise no smoking, alcohol or drugs and exercise every day in order for him to lower the cycle time. He knows I am straight edge but made me promise anyway. I feel good at this level. My T is less than 3 ng/dl with low dose spiro (1/2 normal dose). I take prometrium and my T is still low. Female range for T is 36-150 ng/dl but woman do not have a prostrate to convert T to DHT.
I do not know the optimum levels but feeling good is a good indicator.
Quote from: Dena on May 18, 2016, 04:59:18 PM
I am going to throw my hat into the ring on this one because some of the talk is apples and oranges. From 1977 to 2006 I was on Premarin mostly on a quarter dose but up to a transition dosage for a few years. I suspect at peak dosage my estradiol might have reached 25 pg/ml and total estrogen around 1400 but the levels were never tested.
Premarin also contain equine estrogens that have an estrogenic effect in your body, test does not account for this. Total estrogen is the sum of estrone and estradiol. Premarin consists of mostly estrone (around 50%) and very little 17 beta estradiol (less than 1%). It contains a little 17-alpha estradiol (around 3-4%) which is less potent than the beta version.
This is the list of the three most abundant estrogens in Premarin:
Estrone (49%)
Equilin (23%)
17alpha-dihydroequilin (13.5%)
QuoteYesterday I had my doctors appointment and my estradiol is 51 with a total estrogen of 733 on my first test. I suspect most of the total estrogen was made up of estriol which is almost useless as far as transitioning is concerned. The person monitoring my treatment figures a total estrogen level of 300 is all us older girls need.
Total estrogen does NOT include estriol, only estrone and estradiol.
http://www.mayomedicallaboratories.com/test-catalog/Clinical+and+Interpretive/84230
"Serial specimens must be drawn over several days to evaluate baseline and
peak total estrogen (E1 + E2) levels."
E1 is estrone, E2 is estradiol, E3 is estriol.
You are most likely taking estradiol ORALLY since your estrone is much higher. Figures vary according to route of administration. By injection, estradiol is about twice as much as estrone which approximates women's normal physiological ratio before menopause. After menopause, estrone is twice as much.
What each person needs varies, in my opinion and can be determined on the basis of how well the person is responding.
QuoteOK, I can understand if you had a high dosage of estradiol when you are young, there might be a point in life were you should enter the menopause range of 15 to 60 ph/ml of estradiol BUT I HAVE NEVER LEFT THE MENOPAUSAL RANGE. This may also explain my rather boyish build and some what masculine face. The last 3 months were on about a half transition dosage but she was more that willing to write my next prescription for a quarter transition dosage. I am beginning to wonder why I have spent $600 getting back on HRT when the doctors are doing there best to make it not work!
You need to see a more informed and competent doctor. She is probably worried about health risks with higher levels not understanding that levels are not an accurate gauge but rather the type of estrogen and route and that all the health risks found were in women taking non bio-identical estrogens.
Quote from: Rachel Lynn on May 18, 2016, 07:14:40 PM
Where I go they do not monitor E; they monitor T. They ask how I feel and go from there ( they see 1800 trans). The IM dose they prescribe is on a 14 day cycle. I am on the same amount of E as a 25 year old but on a 10 day cycle. I had to promise no smoking, alcohol or drugs and exercise every day in order for him to lower the cycle time.
Doctor worries about higher estrogen levels non-orally when that fear is really unfounded. But, all good advice nonetheless. :)
Prostate 1989;14(4):389-95
Estrogen therapy and liver function--metabolic effects of oral and parenteral
administration."Oral estrogen therapy for prostatic cancer is clinically effective
but also accompanied by severe cardiovascular side effects.
Hypertension, venous thromboembolism, and other cardiovascular
disorders are associated with alterations in liver metabolism. The
impact of exogenous estrogens on the liver is dependent on the route
of administration and the type and dose of estrogen. Oral
administration of synthetic estrogens has profound effects on
liver-derived plasma proteins, coagulation factors, lipoproteins, and
triglycerides, whereas
parenteral administration of native estradiol
has very little influence on these aspects of liver function."
Think of pregnant women with extremely high levels and VERY low risk OR men with prostate cancer who are old, who had high levels and nonetheless, did not have increased complications, rather their cardiovascular health suggested improvement.
Br J Obstet Gynaecol. 1990 Oct;97(10):917-21."There is some anxiety about the possible harmful sequelae of supraphysiological estradiol levels but no data are currently available to show any deleterious effects of these levels on coagulation factors, blood pressure, glucose tolerance or the occurrences of endometrial or breast cancer (Hammond et al. 1974; Thom et id. 1978; Studd B Thom 1981; Armstrong 1988)."
QuoteFemale range for T is 36-150 ng/dl but woman do not have a prostrate to convert T to DHT.
Range varies by lab. I have seen as low as 2 ng/dl. Women have other tissues with high concentration of 5 alpha reductase like scalp, liver, etc where T can be converted to DHT. Estrogen appears to reduce concentration of this enzyme.
Quote from: Dena on May 18, 2016, 04:59:18 PM
I am going to throw my hat into the ring on this one because some of the talk is apples and oranges. From 1977 to 2006 I was on Premarin mostly on a quarter dose but up to a transition dosage for a few years. I suspect at peak dosage my estradiol might have reached 25 pg/ml and total estrogen around 1400 but the levels were never tested. Yesterday I had my doctors appointment and my estradiol is 51 with a total estrogen of 733 on my first test. I suspect most of the total estrogen was made up of estriol which is almost useless as far as transitioning is concerned. The person monitoring my treatment figures a total estrogen level of 300 is all us older girls need.
OK, I can understand if you had a high dosage of estradiol when you are young, there might be a point in life were you should enter the menopause range of 15 to 60 ph/ml of estradiol BUT I HAVE NEVER LEFT THE MENOPAUSAL RANGE. This may also explain my rather boyish build and some what masculine face. The last 3 months were on about a half transition dosage but she was more that willing to write my next prescription for a quarter transition dosage. I am beginning to wonder why I have spent $600 getting back on HRT when the doctors are doing there best to make it not work!
- you might consider sublingual intake.
The liver destroys a part of estrogen with oral intake and metabolizes a part to estrone. It also raises clotting factors since there are estrogen sensors in arteries from the oral tract.
With sublingual intake clotting factors are much less.
Its also more efficient.
Here is a picture:
https://www.susans.org/forums/index.php/topic,186946.msg1665088.html#msg1665088
It is advisable to spread the daily dose in a few small doses throughout the day to keep levels more steady.
Otherwise levels may drop hours later and affect mood.
Doctors may be wary to raise levels:
-because of non biodentical estrogen may be dangerous in higher doses. This is not the case with bioidentical estrogen.
-because of raised clotting factors, far less with sublingual intake.
You might talk all of it through with your doctor.
Well it shows again how important information is that can then be brought back to med personnel .
Many people are simply not that versed with transgender subjects.
hugs
I currently take estradiol valerate sublingually, spiro swallowing, and micronized progesterone soft gels sublingually. All biological-identicals. I will NEVER take any synthetics for any reason and if a doctor in whatever country might say otherwise I will find a different doctor. For me this is non-negotiable. I'm doing great and feeling great, especially since I added bio-identical progesterone to my daily regimen once again since January 2016 because my finances got a bit better and now I can afford it again and I pay for all privately. I am not permitted in this group to discuss dosage levels although I consider myself quite knowledgeable about this but I guess I have nothing more to say about this in this group. I'm doing great. Need to have my levels checked again shortly from an independent lab. xx
Quote from: Laura_7 on May 19, 2016, 04:39:41 PM
It also raises clotting factors since there are estrogen sensors in arteries from the oral tract.
Not in arteries but in portal vein from intestines to liver. There are estrogen RECEPTORS.
Quote from: Julie Marie on May 17, 2016, 03:16:02 PM
I had a meeting with a new doctor yesterday.
I realize the medical community had to start somewhere and they started with what they knew about natal females and applied it to transwomen. But today there should be sufficient data available that the medical community can comfortably abandon the idea they can look at natal female data and use that to apply to transwomen.
It's apples to oranges and it needs to end.
I'm really sorry for your experience Julie Marie, but I'm also glad you posted this because it tallies with something I've been mulling for a while.
The default position on here and often elsewhere, which is partly for legal protection, is 'go and see your doctor / endo / clinician.' This is of course sound for safety. Self-medicating is potentially very dangerous and various levels need testing on a regular basis. All of that is right and proper. But it doesn't alter the fact that on trans issues a lot of trained medics are simply rubbish. They weren't trained in it, haven't studied it and don't know what they're doing.
Quote from: Richenda on May 24, 2016, 04:39:05 PM
The default position on here and often elsewhere, which is partly for legal protection, is 'go and see your doctor / endo / clinician.' This is of course sound for safety. Self-medicating is potentially very dangerous and various levels need testing on a regular basis. All of that is right and proper. But it doesn't alter the fact that on trans issues a lot of trained medics are simply rubbish. They weren't trained in it, haven't studied it and don't know what they're doing.
If I assume my endo is correct, and I do, then its quite close to 100% of doctors and endo's don't know what they are doing.
;D ;D
Yeah the whole post-op dosage thing being lower was always kinda screwy. I'm at the same or even more of a dosage than I was pre-op and have been for years. My doc monitors my clotting factors (platelets) every 6mo-1yr though.
Quote from: Julie Marie on May 17, 2016, 04:54:55 PM
... many endos strive for levels of 180-200 pg/ml. That, to me, my previous doctor and all of his patients, is way too low. He goal was for levels of 350-450 pg/ml.
Bleh ... My levels as of May 20, 2016 were 182 pg/ml and I was told that they would be concerned if it were any higher. That's already slightly higher than they'd like, but before they increased my estradiol dosage it was only 119 pg/ml.
Don't get me wrong, I'm very happy with my results, but it's a little frustrating to know that things could possibly be going better. :(
Quote from: Richenda on May 24, 2016, 04:39:05 PM
I'm really sorry for your experience Julie Marie, but I'm also glad you posted this because it tallies with something I've been mulling for a while.
The default position on here and often elsewhere, which is partly for legal protection, is 'go and see your doctor / endo / clinician.' This is of course sound for safety. Self-medicating is potentially very dangerous and various levels need testing on a regular basis. All of that is right and proper. But it doesn't alter the fact that on trans issues a lot of trained medics are simply rubbish. They weren't trained in it, haven't studied it and don't know what they're doing.
There is only one doctor I know who ignored data done on natal females and he would tell you right now that data needs to be ignored because it isn't relevant. Natal is not the same as trans. Period.
My new endo got the blood test results and they called today. The nurse said, "Your levels are normal." First thing I thought was she is used to patients who only need to hear, "You levels are normal." The nurse was about to hang up when I said, "What were the numbers?" I think she was surprised. My previous doc would have a lengthy discussion about the levels and what they meant. He would also tell you where he thinks levels need to be. I wanted numbers, not "you're normal, goodbye."
So she started rattling off the numbers. E was 160. I said, "That's pretty low."
There was a pause on the other end. "Oh, no, that's normal."
"Not for a transwoman, it isn't."
No reply...
So she gave me the rest of the numbers and transferred me to the front desk so I can make an appointment to see the doctor.
I think some people will be going to school very soon. And it won't be me.
My doc shied away from estrogen levels that came back at 700. My blood work was OK but protein levels a bit out if whack and so we reduced (injection) dose 1/2. I'm fine with that as long as T is still suppressed. While the serum albumin was at the low end of normal I don't care to ever flirt with VTE, having poor circulation in my feet already worries me.
Quote from: Julie Marie on May 27, 2016, 06:43:58 PM
There is only one doctor I know who ignored data done on natal females and he would tell you right now that data needs to be ignored because it isn't relevant. Natal is not the same as trans. Period.
Some of the data on natal women is indeed relevant to transwomen while other isn't. One shouldn't be so absolute. We still belong to the same species. ;)
QuoteSo she started rattling off the numbers. E was 160. I said, "That's pretty low."
There was a pause on the other end. "Oh, no, that's normal."
"Not for a transwoman, it isn't."
There is no such thing as normal levels for either trans or ciswomen. Levels in ciswomen can be anywhere between 20-75,000 pg/ml depending on the woman and her reproductive status. Individuals vary. 160 might well be sufficient for some transwomen for optimal feminization and well-being while for others, higher is needed. It depends. There is too much focus on numbers while the rest, what matters most, like well-being and degree of feminization is ignored. Should be case by case, I think.
Quote from: SadieBlake on May 30, 2016, 06:11:42 AM
My doc shied away from estrogen levels that came back at 700. My blood work was OK but protein levels a bit out if whack and so we reduced (injection) dose 1/2. I'm fine with that as long as T is still suppressed. While the serum albumin was at the low end of normal I don't care to ever flirt with VTE, having poor circulation in my feet already worries me.
I think it's important to mention units when stating levels. Also, estrogen levels is not the same as estradiol levels. Estrogen is the sum of estrone (a less potent estrogen) and estradiol.
Levels as high as 2,500 pmol/L (close to 700 pg/ml) in men with prostate cancer , aged 49-91, weren't associated with an increased incidence of thrombosis. Pregnant women with levels as high 75,000 pg/ml suffer blood clots at a rate of less than 0.2%.
And this...
Am J Obstet Gynecol. 1993 Dec;169(6):1549-53.
Fibrinolytic parameters in women undergoing ovulation induction."As serum estradiol levels increased throughout each phase (maximum mean estradiol 739.8 pg/ml)"
"Down-regulation of the fibrinolytic system was observed as estradiol levels increased. However, thrombin formation did not change, thus suggesting that
elevated circulating estradiol alone does not predispose to a thromboembolic event."
Br J Obstet Gynaecol. 1990 Oct;97(10):917-21."There is some anxiety about the possible harmful sequelae of supraphysiological estradiol levels but no data are currently available to show any deleterious effects of these levels on coagulation factors, blood pressure, glucose tolerance or the occurrences of endometrial or breast cancer (Hammond et al. 1974; Thom et id. 1978; Studd B Thom 1981; Armstrong 1988)."
My own levels are between 1,000-4,000 pg/ml. Clotting factors remain normal.