I'm just curious how direct you folks are with your conversations about dosage with your doctor. I'm on what I've learned is a very low dose (uncommonly low) of Estradiol to start my HRT. I trust in my doctor and her experience with Trans women, but at the same time I feel like I may really just be wasting time on such a low dose. Obviously, most of us do get impatient with the whole process anyway and want to see things speed up. But I've also noticed that many here have a pretty good working knowledge of the technical particulars of this.
So my question is, how do you deal with your doctor on this? Would you directly question why they're starting you at one dose versus another? Would you push for them to move you to a particular dose? Would you be more subtle and just ask about their care plan for you? I tend to be so non-confrontational at times that I wonder if I should push harder or ask more direct questions than I do. I don't want to insult my doctor or make her feel like I'm playing internet doctor, but at the same time I do need to be comfortable with my care.
Thoughts?????
You are new and your Endo is being prudent by tritation. This is the best course of action because it allows them to see how you'll react. If you have a ton of HGH in your system, a low dosage could easily give you more than adequate results. Your numbers after 3 months will tell the tale. If all your other numbers are good, they'll raise your amount. The general rule of thumb is 30 pg/ml an somewhere around 200 pg/ml for E. The amount of AA and E it takes to achieve this is different for everyone. Again, you need to slooooooooooooooow doooooown. This is a marathon, not a 100 yard dash. No girl went through puberty over night. Neither will you. Settle in and follow your Endo's advice. If after 3 months all your panels look good and your t is still high and your E is low, then it's time to ask your endo why they wouldn't raise your prescription amounts. Remember, you want the least amount of drugs to achieve the desired numbers. More does not equate to more feminization, period. That's a fact. DVT and liver damage are real possibilites that must be faced. Titration mitigates that outcome. Your health is the imperative here. If you react badly to large amounts of Hormones and AA'S out of the gate, it could destroy your transition plans. There's a girl on this site right now that is on a relatively low dose and she's found herself lactating. That generally only happens on large amounts but she is very young and is having a very good result from low dosage. My advice to you is.................Patience Grasshopper...patience. lol
If youve learned your dosage is low, point out the error to your doctor immediately. If you think you've learned that your dosage is low because other girls tell you they're taking more, proceed with caution.
Hugs, Devlyn
Trick is to do it without making it seem that you are questioning their judgement, expertise or what ever.
It is definately ok to ask why they picked the starting dosage that they did. Should be willing and able to tell you.
You posted a bit ago that you hit one month, do you have a follow up? My doctor doubled me after a month so basically the first month was to see if I tolerated the meds.
Sent from my SM-G930V using Tapatalk
Alyssa, I seem to remember you mentioning you had confidence in your Dr's methods because she had many years of working with trans patients.....I would say that her protocol is what she is comfortable with and you should trust her. At the next appointment, she "should" have your blood work in-hand and will make appropriate changes based on what she sees. It's frustrating not being able to discuss real dosages on here to compare but I'm on a relatively low dose (also just started) and although I'm eager to get a bump, I trust my Dr's experience. FWIW, I'm seeing drastic changes in several aspects of my body....muscle burning away quickly, skin dramatically softer, noticeable face changes and breasts starting. Everyone is different and my thought is that HRT "really" starts after the first 3month blood work can be analyzed for reaction. If at that point you feel it's still too conservative, have a conversation.
So, if you've read any of my other posts on this subject then you know I am very straightforward with my doctors. I will cite studies, standards, and other reference material to support my opinion, which I let them know is important to me---my opinion, that is.
My doctor flipped out with my E levels last fall, dropped my E dosage (I did not argue with her) and they fell to a level below my expectations for my continued feminizing. I told her my current levels are half of what I want to maintain. She listened to me, I explained why, and she acquiesced. She added more frequent labs checking with my higher than her planned E levels goal to ensure no negative physical effects from it. That is a partnership and how it should work.
I don't pull punches, I am respectful, and I maintain a voice in MY care with any doctor. Advocate for yourself if you feel something is not the way it should be for YOUR care.
Quote from: jentay1367 on May 02, 2017, 03:03:10 PM
You are new and your Endo is being prudent by tritation.
I am not a doctor but my own opinion is that bio-identical estradiol is safe enough that it doesn't need to be *that* low, especially considering she's NOT pubertal. In her case, I believe her doctor may be overcautious and personally, I would ask the doctor some questions about this, ask for justification, etc and check with sources (scientific, journals). Perhaps, even seek a second opinion on the matter.
Anti-androgens are different and starting low makes sense to me although that is not her case either. The starting dose given was not low. Lowering androgens too much while not giving enough E can trigger menopausal symptoms which may be very uncomfortable (and risky long-term) for the person.
QuoteYour numbers after 3 months will tell the tale. If all your other numbers are good, they'll raise your amount. The general rule of thumb is 30 pg/ml an somewhere around 200 pg/ml for E.
I believe you mean to say 30 ng/dl for total testosterone. I personally don't think relying on E and T levels is the way to go and is the lazy approach because it's an arbitrary number that was chosen and people react differently to levels so that some may need more, some less to get optimal results. At least, that is how I and my doctors see it, some other doctors also share our perspective. Just think alcohol concentrations in the blood and how people vary in their reactions to more or less similar concentrations. In addition, E & T levels are all over the place and fluctuate so that the number you see is one point in time and far from accurate.
I think finding the right dose for the individual is more appropriate by paying close attention to physical and psychological results. Patient feedback is important. My 2 cents. As indicated above, I'm not a health expert.
QuoteNo girl went through puberty over night. Neither will you. Settle in and follow your Endo's advice.
True. Changes take time. But, time is also precious and there is no rule against discussing things with your doctor, sharing your opinion on the matter, asking questions, presenting data from journals, etc. My doctors don't mind my feedback and sometimes even value it. Blindly following is also not wise. It's good to be proactive in one's health, I think.
QuoteRemeber, you want the least amount of drugs to achieve the desired numbers.
IMHO, the least amount for desired results (mental health and breast growth/feminization).
QuoteMore does not equate to more feminization, period. That's a fact.
+ 1. But too little may not also be best for the person, mentally and physically.
QuoteIf you react badly to large amounts out of the gate, it could destroy your transition plans.
Again, my opinion based on several studies I've come across...as far as bio-identical estradiol is concerned, it is relatively safe enough that this is rarely an issue, especially considering how little she is taking. But, this needs to be discussed with her doctor or another health professional who can prescribe her the appropriate medications/hormones.
QuoteThere's a girl on this site right now that is on a relatively low dose and she's found herself lactating.
Could be something else she is on or that she is stimulating her breasts. One needs to be careful when reporting someone else's case.
Quote from: Devlyn Marie on May 02, 2017, 03:07:45 PM
If youve learned your dosage is low, point out the error to your doctor immediately. If you think you've learned that your dosage is low because other girls tell you they're taking more, proceed with caution.
In her case, yes, the E2 dosage is low compared to recommendations published in several journal studies. Basing oneself on others' reports can indeed be misleading and sometimes dangerous. Remain critical, at all times. Even when reading journals... ;)
Definitely discuss this with your doctor, it might not get you anywhere, but you should make any concerns known regardless of the reason. The only other input I can add is that regardless of the method of starting increasing doses, there is nothing but anecdotal evidence suggesting one way is better than any other, and even then, there is no consensus within the medical or trans communities that anything is better. Arguably, the starting low and ramping up is "safer," but again, there isn't any consensus on how much of a difference it makes or if it's true at all.
Thanks everyone, just so we're clear, when I say low, I'm talking in relation to recommended starting low-dosage numbers that I've seen in a number of published guidelines and articles. My Estradiol dose is half of the low end of those low dosage numbers which is the only reason I question it. I'm not as worried about the doses that other women take, I know better than to compare myself to other people when it comes to medical care.
JenTay, yes as usual I want to run as fast as I can. However, in this case its just that I want to make sure that I'm not standing still or moving ultra slow unnecessarily. I do trust my doc, she is great and has plenty of experience so I know she's been down this road before. Still I would like a comfort level of at least understanding a little more of why she chose this dose to start with when it is so low and what the future looks like as far as progressing the dosage.
I have a 2-month follow-up coming up and I'm just planning ahead for if and how I want to address this. If I remember correctly, she at least mentioned doubling the Spiro, I would hope that would also mean at least doubling the E as well.
I started with a very conservative dose for 3months to see how I would handle it...after that straight into slow release implant...which was so much better than the pills although I take a supplementary pill anyway.
I understand your frustration and wanting to be on the most effective dose you can. But as the many good answers have said this is a marathon not a sprint. Puberty takes several years and so does developing proper regime that suits your body to induce this correctly.
I have always been very straight up and down with my Dr and simply asked. Telling her what I had "heard" or been "told" and asking her opinion. She is not one to beat around the bush either and will usually tell me what she thinks. Speaking to them with respect is important but you have the right to ask questions without fear that your care will compromised because of it.
Quote from: AlyssaJ on May 02, 2017, 04:44:06 PM
JenTay, yes as usual I want to run as fast as I can. However, in this case its just that I want to make sure that I'm not standing still or moving ultra slow unnecessarily. I do trust my doc, she is great and has plenty of experience so I know she's been down this road before. Still I would like a comfort level of at least understanding a little more of why she chose this dose to start with when it is so low and what the future looks like as far as progressing the dosage.
I can certainly appreciate your concerns. I would ask her outright the what's, the why's and what her intentions for the future are. She ultimately works for you. You're entitled to be in the loop and now that you know more about what's what, you have a good idea of what to ask. Hell... call her tomorrow. Get some peace of mind.
Reality though? You're already pretty and at your age, I think the writing is on the wall. If you follow through, you're most probably going to end up a very beautiful woman. Consider yourself blessed. You simply don't have too far to fall to land on the other side of the fence. ;D
Quote from: jentay1367 on May 02, 2017, 05:57:38 PM
Reality though? You're already pretty and at your age, I think the writing is on the wall. If you follow through, you're most probably going to end up a very beautiful woman. Consider yourself blessed. You simply don't have too far to fall to land on the other side of the fence. ;D
Oh m'gosh, now I'm blushing like crazy. Thank you for the kind words and thank you for tolerating my impatience and continuing to offer helpful advice and thoughts. I'm sure my impatience can be a lot to take at times, so thanks for sticking with me and resetting my expectations.
I ended up sending an email to my doctor and just asked her about what she see's as the path forward as far as increasing dosage, etc. I tried to focus it more on a curiosity about her approach rather than letting it sound like I was second guessing her based on internet sources :)
Good on ya' girl! I think most of our Doctor's really want us to be proactive. It's your transition. You're the one who gets to live in this world and body you're creating. I don't blame you for being impatient. Once you make the decision to transition, you want it all yesterday. These are heady times my friend. All new and very exciting! and I'm certainly excited for you! Good luck with your Doctor and perhaps you can share with us what you find.
Hi Alyssa,
at about a month and a half after I started getting my HRT from the VA. with about 2 1/2 months before my next scheduled labs I tried to get my dose for estradiol increased and progesterone added to my regimen, So I sent a note to my doctor. This is what I said.
"The first is that I read your entries regarding my telling you that I felt I was trans and told you what I had been self medicating with. I mentioned the Climara xxx patches and I'm sure I mentioned that I was also taking a xxxmg Progynova at the same time. So I was taking about double the dose I am now. I have not deviated from the dosage you prescribed. But I am curious about an increase. I am seeing some results.
The second is along the same line. I had ordered Progesterone in the form of Microgest xxxmg soft gels before we met. I was wondering what your thoughts are regarding it. I know it is not considered necessary among the medical community, but there is quite a lot of anecdotal data that it may help achieve fuller development. Again I have not deviated from your prescriptions and therefore have not taken any of it."
Well it didn't work though he did say he does understand my wanting to hurry things along as quickly as possible so I can have the body changes I desire. But that we need to take it slower until we see how the medications are working. So be patient and wait until the labs are in then adjust might be made.
You can bet we will be having this conversation again.. Like later this month bu messaging as we ar not schedule a face to face meet again fro a couple more months yet.
So the answer for me is yes I am going to be involved with my HRT meds dosages. It will be a discussed collaborative process.
Hugs,
Laurie
I also have been pretty straight forward with my doc and have been responsible for one of the two dosage increases that we have done. I brought in some supporting material etc and she was quite receptive.
OK so to close the loop on this, I heard back from my Gyno this morning. She said she starts at a low dose of Estradiol for two reasons. First, in her experience, it helps avoid Tuberous Breast growth (which can only be corrected with plastic surgery). Not sure how often that occurs as I know plenty of women who started higher and have great looking breasts. But ok, she's being cautious. Second, and her bigger concern is the risk of blood clots. She admitted she and likely other OB/GYN's are probably more conservative about this than an Endo would be given that they work with pregnant women who are at a much higher risk of blood clots. So in the end, she's more conservative than an Endo, I'm ok with that. She closed out the email saying that we'll certainly be upping my dose at my 2 month appointment as long as everything is still going well.
So a nice response all in all, maybe she's a bit over-conservative but given the potential risks, I appreciate her watching out for my best interests :)
Quote from: AlyssaJ on May 04, 2017, 12:50:05 PM
She closed out the email saying that we'll certainly be upping my dose at my 2 month appointment as long as everything is still going well.
Two Months! I'm jealous.
I sent a message to my doctor asking a few things. One of them posed an inquiry about increasing my estradiol. In his reply hes indicated at my next regular meeting with him on the 22nd (4 months from last when he prescribed my HRT) he will order more labs and see hows my hormone levels are then decide what to do. In answering another question about adding progesterone he said that will not happen until I am on a "Full" dose of estradiol. So there is hope of an increase in estradiol sometime in the future for me. It's hard to be patient. I've broached the subject to him twice now. I think he knows I am anxious for more. lol :laugh: :laugh:
hugs,
Laurie
Yeah the waiting game is a really difficult aspect of this. I hope you're at least not on as low a dose as I am. If I had to wait 4 months to get bumped up from where I started, I'd have gone to see an Endo for a second opinion. I'm good with taking it slow and cautious to a point, but I do also want to see results in an efficient yet responsible timeline.
Quote from: AlyssaJ on May 04, 2017, 01:21:56 PM
Yeah the waiting game is a really difficult aspect of this. I hope you're at least not on as low a dose as I am. If I had to wait 4 months to get bumped up from where I started, I'd have gone to see an Endo for a second opinion. I'm good with taking it slow and cautious to a point, but I do also want to see results in an efficient yet responsible timeline.
If you look around you can find tables with what they refer to as "normal" dosage range. Mine would be the lowest on one of those. It could double twice and still be on the table. If I was a cheerleader you could appreciate the table with a cheer.
Laurie
Yep I'm familiar with those tables, and I'm not even on the table yet :) Now she didn't say how much she's going to increase me but I'm assuming she'll double it which will put me at that very bottom of the range.
Quote from: AlyssaJ on May 04, 2017, 12:50:05 PMShe said she starts at a low dose of Estradiol for two reasons. First, in her experience, it helps avoid Tuberous Breast growth (which can only be corrected with plastic surgery).
Any science, studies to back up that claim?
QuoteSecond, and her bigger concern is the risk of blood clots.
Not a good reason, in my opinion. Bio-identical estradiol is a relatively safe estrogen (I hope she can distinguish between this and other forms of estrogen like Premarin and birth control pills) and there are several studies supporting the use of higher doses of ESTRADIOL (in transgendered women) and even VERY high doses (used for advanced breast/prostate cancer) with little risk ("that do give rise to major concerns"), sometimes in much older women (and men), up to 92 yrs old. Studies estimate (I can provide the studies by PM for anyone interested, you can show doctor) the potency of birth control pills to be the equivalent of anywhere between 10 mg and 50 mg oral estradiol. And older birth control pills containing more, just a decade ago or so, to be the equivalent of 15 mg and 75 mg oral estradiol. The risks of blood clots associated with older birth control pills in absolute numbers was 0.03%, now probably lower with birth control pills containing the equivalent of 10-50 mg oral estradiol. Birth control pills are prescribed to millions of premenopausal women, sometimes without even checking for predisposition to clots. Why be so cautious with oral estradiol when it comes to transgendered women when the same is not true for premenopausal women? Something is not right...
The problem is some doctors are unaware of the above information and have fears regarding estrogen or oral estrogen because of large studies using other forms of estrogen combined with non bio-identical progestogens in post-menopausal women without understanding the intricacies of the studies, the differences between estrogens.
The dose she prescribed to you is far far smaller than all the above and you are still young. Her explanations do not justify her actions, I think. I'm not the expert though. I base my opinion on information I've come across in studies in journals and statistics provided by reputable sources.
QuoteShe admitted she and likely other OB/GYN's are probably more conservative about this than an Endo would be given that they work with pregnant women who are at a much higher risk of blood clots.
Still not a good reason, in my opinion. Pregnant women have levels as high as 75,000 pg/ml, typical levels around 1,000-40,000 during the course of pregnancy. The ABSOLUTE risk of deep vein thrombosis is 0.1%, the ABSOLUTE risk of pulmonary embolism is 0.01%. Your levels are probably under 100 pg/ml, more than 10 to 75 times lower. Calculate your risks...draw your own conclusions.
QuoteSo in the end, she's more conservative than an Endo, I'm ok with that.
I wouldn't be satisfied with her answer given what I know. If you want, I can send you those studies privately and you share these with her. Your call. But, it is our job and responsibility, I think, to also educate our doctors about a subject matter that is far from extensively studied and taught in medical schools and for which several misconceptions continue to circulate. We need to start somewhere and WE can make a difference.
Quote from: Laurie on May 04, 2017, 01:00:28 PMOne of them posed an inquiry about increasing my estradiol. In his reply hes indicated at my next regular meeting with him on the 22nd (4 months from last when he prescribed my HRT) he will order more labs and see hows my hormone levels are then decide what to do.
Levels of estradiol in men with prostate cancer around 300-600 pg/ml, aged 49-91. No increase in risks but decreased risk of DVT and cardiovascular risk improved. Levels seen in women during menstrual cycle, from less than 100 to up to 650 pg/ml. During pregnancy, read reply above. My own levels, from around 1,000 to 4,000 pg/ml, I'm neither very young, nor old. Clotting factors remain normal, everything is fine according to my three doctors. Studies with high levels in post-menopausal women (older than 45) with levels anywhere from 100 to 3,000 pg/ml showed no complications.
Why do doctors keep on relying on levels to determine risks? It has no bearing on breast cancer risk as pregnant women actually seem to have a decreased risk of breast cancer incidence in the long-term (breast cancer risk also does not increase in transgendered women) while prolactinoma is very rare in transwomen despite decades of aggressive doses of estrogen and the few times they were present, bio-identical estradiol was not taken exclusively.
QuoteIn answering another question about adding progesterone he said that will not happen until I am on a "Full" dose of estradiol.
Why not? What are his reasons?
I apologize for bringing this up, again and again but I can't just say nothing knowing what I know. I've personally taken the time (because I can, I realize not everyone has the luxury) to research this matter because I didn't want doctors making the wrong decisions, I wanted to understand what I was putting in my body, the benefits and risks, I wanted to play an active role in my treatment and not blindly follow with potential harm being done to me. I'm not a doctor, nor a health professional. But thanks to the knowledge I gather, the doctors that treat me can't just do as they please, we have a discussion and sometimes, their opinions are changed. I also have the luxury of choosing my doctors. :)
^KayXo, I would be interested in any studies you have on the benefits of Progesterone that I can send my Dr. I brought this up very briefly on my first visit with my Endo and he dismissed it as something that didn't really show any benefit, but some negatives....I don't push because I wasn't armed with any good data.
Kay I knew you were going to weigh in on this one for sure :) No idea if she has sources for the Tuberous Breast growth, both times she's mentioned it she has referenced her experience as the primary source, so IDK. As far as the clotting risks, I've seen studies referenced on both sides of this argument, I honestly have not done any research to really understand the details but at the end of the day if I can get bumped up to a more appropriate dosage, that's all I really care about. In the end if things get to a point where I'm not happy with my dosing and I can't get a change from her, I always have the option to switch my care to an Endo in the same hospital group (so they'd have access to all my info already). So right now I'm playing a wait and see here. I do still trust her judgement and I definitely like her "bedside" manner. IDK yet about approaching her with the info you have, I'll see how the discussion goes with her during my follow-up and maybe I'll bring it up. I want to make sure that if she doesn't have all the info that I help present it to her like you suggested, but at the same time I do have a certain hesitancy to play internet doctor and second-guess the work of a professional who's dealt with a large number of transgender patients.
Quote from: AlyssaJ on May 04, 2017, 02:36:00 PM
Yep I'm familiar with those tables, and I'm not even on the table yet :) Now she didn't say how much she's going to increase me but I'm assuming she'll double it which will put me at that very bottom of the range.
Alyssa,
Well being on the table would be a good thing. After 5 months I've had pleasing results so far as you can see in my avatar. I may even be a bit bigger since then. Today in my new t-shirt top and bra I think I look it. And it's a concern for me too. I'm worried a bit that my doctor may take one look and decide not to make an increase because he is happy with the progress I'm getting at the dosage I am currently at. MORE! MORE! I want MORE!
Of course as usual YMMV
I hope you get your increase and it does well for you.
Hugs,
Laurie
Quote from: AlyssaJ on May 04, 2017, 03:28:47 PMAs far as the clotting risks, I've seen studies referenced on both sides of this argument
I would be interested in seeing those studies on the other side of the argument. I remain open, as always. You can privately message me. :)
QuoteI do have a certain hesitancy to play internet doctor and second-guess the work of a professional who's dealt with a large number of transgender patients.
It is your right as a patient to question and second guess any doctor. You are the one taking these hormones and medications. It's your body, don't ever forget that. You are not playing internet doctor, you are gathering scientific information on the matter and sharing it with your doctor. Then, it's her call. A good doctor, in my opinion, will listen to what you have to say.
Quote from: staciM on May 04, 2017, 03:25:32 PM
^KayXo, I would be interested in any studies you have on the benefits of Progesterone that I can send my Dr.
Done. Keep us posted. :)
^ thank you, I'll see him next month and see what he says.
Quote from: staciM on May 04, 2017, 03:25:32 PM
^KayXo, I would be interested in any studies you have on the benefits of Progesterone that I can send my Dr. I brought this up very briefly on my first visit with my Endo and he dismissed it as something that didn't really show any benefit, but some negatives....I don't push because I wasn't armed with any good data.
Curiously so did mine...she said it really was a waste of time, but from what I see around here many of the girls seem to be on it and it seems to contribute to their well being...
Ask your doctor why it's a waste of time, based on what? What is your doctor referring to? Provera? Other progestogens? Questions, questions... you are allowed to ask questions. :)
Quote from: KayXo on May 04, 2017, 08:17:39 PM
Ask your doctor why it's a waste of time, based on what? What is your doctor referring to? Provera? Other progestogens? Questions, questions... you are allowed to ask questions. :)
I am researching stuff to take to my next appointment that contradicts her point of view and will be interested to see how she reacts
Sometimes, just asking will reveal a lot. ;) Best of luck. :)