I had my first visit with a "real" gender doctor yesterday. She was pleased with my progress but she also said that I was taking too much estrogen and wanted me to decrease the dosage by half. My dosage is considered within normal boundaries but she said the general way of thinking on HRT for transsexuals is now changing in that it is more important to stop the testosterone production then it is to increase the estrogen level.
I have no problem in doing this as I am concerned about the health risks estrogen brings. However, I am not willing to stop or slow the effects estrogen brings if she is wrong.
Thoughts?
-Dora
I have some reservations about that statement, it is infact the other way around for my own case but then she is the doctor not me.
If your levels are a constant female range and feminisation is occuring then yes she is correct to a point. There is no point flooding your system if levels are optimal.
Spiro or any AA as the key though is simply not true in my findings, it is the AA that can be dropped and estrogen that controls your T levels after it has been suppressed long enough. Just stop your AA, check those blood tests and see for yourself depending on delivery method ofcourse as it requires a depo type of hrt.
Long term use of AA is a risk, it is what we do to reclaim our lives.
I think this is a dangerously simplified statement. It may be true for you, but blanket statements like this bother me. The key is both. T needs to be dealt with and E needs to be increased. Else a body does not feminize. Not every genetic male has the same level of T either. I know of one who has to take T shots because of some other medical problems, nothing to do with TG issues at all. Any good endocrinologist will take your levels and adjust your regimen accordingly. Else it is all guesswork.
(https://www.susans.org/proxy.php?request=http%3A%2F%2Fganjataz.com%2F01smileys%2Fimages%2Fsmileys%2FloopyBlonde-blinking.gif&hash=4545ddf8251cf9c32ae6074d56e48bc34a755857)Kristi
I may be way of, but my understanding was that AA was used to shut down T production, until E took over. Once E has taken over you should need a lot less AA.
Regardless, AA will only stop T, it will not feminize enough to pass. It will leave you stuck in between and going crazy without any other hormone replacement.
My doctor has me on estrogen , Spironolactone, and Proscar. He goes by my progress and not tests. I don't think he would do this if it wasn't helpful.
Janet
Quote from: Kristi on April 02, 2009, 11:58:26 AM
I think this is a dangerously simplified statement. It may be true for you, but blanket statements like this bother me.
I don't know if it is true for me, or for anyone else for that matter, hence my posting here what she said. She doesn't want to stop the estrogen, just lower the dosage to a minimum amount (which is below what is generally prescribed for MTFs).
I have a feeling she is coming from a "safety" point of view because she then stated that over the years she has had two patients die, and she now believes they were both estrogen related.
I'm confused because she was highly recommended to me via a local gender center and several sisters there. I still have 7 months on my old prescription so I may just stay on the same dose. Of course that probably rules her out for any future visits.
Dora
My doctor does this for all his patients and has already reduced my E to the minimum amount. There isn't really any way to argue with him either, I don't have any medical knowledge and if I didn't do as instructed I'd probably get kicked out of the gender clinic. It doesn't make any sense to me, because hrt seems to have had very little effect so far, but he's been completely dismissive of taking any path other than the one prescribed to all his patients.
Quote from: Laura91 on April 02, 2009, 12:51:22 PM
While I am not a doctor I think that saying that estrogen is somehow not important seems odd.
That was my fault. I was trying to sum up everything she said in 1 sentence. I believe she is saying that Estrogen is not as important as it was thought to be and lowering the testosterone levels and adding a minimal amount of estrogen will get the same results.
Dora
Take either one of them away from me and I'd probably gouge out the doctors eyeballs with a rusty spork!
I would love to get an orchi soon though because I am concerned about the long term complications from prolonged use of Spiro and I don't know when or if I will ever be able to get full GCS.
I remember reading somewhere that there were 2 ideas on this. One was to not worry as much about e levels but get the t down real low and the other was pretty much the opposite getting the e up and not worrying as much about the t level. Who knows, it probably should just be a case by case based on what is working for an individual.
I think if you trust your gender doctor you should listen to them. If this does not work for you, then you can always up the dose.
The sad fact is that very little bio-medical research has been done on the results and optimal regimen for either FTMs or MTFs. For the most part your doctor, pretty much no matter who they are, is reading labs to indicate to them that you are falling into a normal range for non-transitional human beings.
They generally prescribed based on keeping your blood E level in the low-to-mid range levels of what a menstruating female would show on a blood test at ovulation if you're MTF and I'm not at all sure what sort of range they would look at for the guys.
Post SRS/GCS they will drop you, usually, to a post-menopausal level. In other words, you are being treated according to the lab protocols that would be in effect for someone who has two ovaries and adrenal glands producing estrogen around the clock.
When she says she believes that estrogen may have played a role in the deaths she's telling you the absolute truth, I suspect. That she believes that. It's a guess, hunch, fear of hers, not something that is necessarily factual.
Most doctors are going to go for lower ranges because they do not know and seldom do loads of research to find what sorts of regimen tend to be most effective for most women and men. And that's just the abject truth.
This is why it is soooo important to do your own research to at least be able to provide the doctor, yes, even experienced endos, with info that you can find through net searches. You can never do enough research on the drugs you'll be taking.
Just stop and consider this. How many girls do you know who, without high levels of testosterone, begin puberty at age 12 and are post-menopausal by age 14? Now how many MFTs can you find who have had exactly that experience. Yet, that is SOP for most doctors who work with us.
Does it not sound ludicrous on the face of it?
If you are showing no signs of liver, prolactin or any other anomalies that would indicate you are getting "too much estrogen" then I would say you need to argue with your doctor and be able to provide her with some sort of evidence that might alleviate her own fears.
What she's told you that you have related here just is not making sense to me at all. No, I am not a medical professional but I can follow an argument reasonably well. And something smells rotten in Denmark. But not with just your doc, with the field in general. I wonder how many of them have ever thought about a 2 year puberty-to-post-menopause life and how that might affect a body.
Way too many post-ops complain of tiredness, lack of sex drive, etc.... Does it dawn on the docs that they give higher estrogen doses to post-menopausal natal females to combat some of those very symptoms? Now why would someone who operated for years with a high-testosterone level in her body need just two years of estrogen therapy at lower doses?
Puh-leez.
Nichole
Quote from: Laura91 on April 02, 2009, 12:51:22 PM
While I am not a doctor I think that saying that estrogen is somehow not important seems odd. If spiro alone is so important then what happens to the body on a regimen of spiro by itself? Wouldn't the body suffer from the loss of T with no E to take its place?
I might actually be able to help here, when i was 14 i was on a high dose of spiro to help treat my liver condition, whilst on it i experienced lowered sex drive, genital shrinkage *blush*, and it also made my slight gender dysphoria manefest itself more strongly, after stopping taking spiro my sex drive returned (altho not as strong) genitals unshrank, but the dysphoria remained as strong as ever.
Ive never talked to a professional about these issues but i believe being put on spiro during key stages of my development helped created the genderconfused mess you see before you today.
I think I would change doctors.
I have, that was on the advice of the doctors of kings college hospital in london which is "Regional and national secondary and tertiary centre for Liver disease and transplantation"
That said they did save my life so i cant complain too much
Quote from: MMarieN on April 03, 2009, 08:07:27 AM
I think I would change doctors.
A bit puzzled with that suggestion. Is there some overflow of doctors who work with transsexuals that I am unaware of? Most endos who do work with us also work with fertility clinics and such. They cannot make a living strictly with transsexuals.
The transsexuality is usually a rather small slice of their work. They expend their energy and clinical study on other things, mostly dealing with non-transitional women. If one doesn't do the research herself it very often doesn't get done.
Changing doctors is most likely to find the exact same worries and SOP.
Nichole
I too have heard the rhetoric about dropping the E to post-menopausal levels after 2-3 years.
My surgeon recommended that to me and I will have that discussion with my endocrinologist as well. My surgeon has dropped her level as well a couple of years ago, though she did not share with me how her energy/libido had been affected.
The rule of thumb with born women is to reduce the essential time they remain on estrogen to the minimum amount to reduce the possibility cancer and other HRT related problems. Though in the case of WBW many of them may remain on HRT for ten years or more. And, yes, for that population, it has been statistically proven that the longer they remain on HRT the more likely they are to develop a cancer related illness.
Transsexual HRT, or Contra Hormone Treatment (CHT) as it is sometimes called, has not, to my knowledge, had any statistical study made of its long term effects. Most physicians I would wager, simply use the born gender rules of thumb and follow with blood tests. My endocrinologist admitted that he has no statistical information regarding transsexuals and said that trying to keep my hormone levels to those of a similar gender background is the best that he could recommend.
When Christine Jorgensen made her transition, she only had a orchiectomy and penectomy. She did not have vaginopasty/clitoralplasty, nor did she have any anti-androgens. The physician who treated her dosed her with an overwhelming amount of estrodial. Testosterone is a very powerful steroid and it takes quite a bit of estrogen to overcome it. But it is not the *amount*, but the T/E ratio that really has a contra gender effect. Once you reduce the T levels with A-A's you can use a much lower amount of E to achieve the same effect.
There has been great progress in the medical support for people like us, but not because medical science has pursued the study of transsexuals. Rather the general progress of medical science has allowed other medicines to be used effectively to treat our condition.
Face it. We're still the red-headed step children to the medical community. And we will continue to be that way for the foreseeable future.
\soapbox
-Sandy
Quote from: Sandy on April 03, 2009, 09:37:44 AM
Though in the case of WBW many of them may remain on HRT for ten years or more. And, yes, for that population, it has been statistically proven that the longer they remain on HRT the more likely they are to develop a cancer related illness.
I don't doubt that that is true. Is it also true that WBW who decline HRT also "statistically prove" to be more likely to develop cancer-related illnesses through time as well? If that statistical probablity is there, then it seems to me that solely saying HRT is cancer-producing over time maybe isn't as sure a truth as anything else.
Fact is that medical research into women of all kinds tends to lag well behind research for men of all kinds. Yes, there has been some real progress in reserach related to WBWs and the gap has closed drastically over what it was 30-35 years ago.
And I may be wrong since my memory isn't encyclopedic :laugh: and I am not going to expend the effort to check and be absolutely certain, but I seem to recall that the concerns about estrogen and cancer have declined if the estrogen isn't paired with progesterone simultaneously.
The rest, especially the parts about the development, as a sidelight, (I mean do you really think that is a huge concern for the guys? :) ) of anti-androgens is absolutely true. An excellent post, Sandy.
And you might ask Christine if you're going to be asking why she lowered her dosages to post-menopausal levels? Because she knows something or because she didn't, but is concerned.
Nichole
I have halved my estradiol dosage at the recommendation of my doctor because I have had an orchi. It has been two months and I have been much more depressed during this time. She indicated that if it did have this effect, that I could go back to the original dosage.
Note though we all talk ( including the media and doctors) about estrogen as if it is one hormone and one drug. It is not. Most of the medical evidence that condemned "estrogen" is actually a synthetic hormone made from an estrogen like hormone found in pregnant horse urine. To say that estradiol which is the most potent human estrogen is dangerous when the tests were done on the synthetic variety is an apples and oranges comparison. It could be a byproduct of the chemical reaction process or another contaminant from the horse urine that is causing cancer and deaths. There are hundreds of thousands of chemicals in urine and it is impossible to isolate with 100% purity any single one.
That is why I take sublingual Estradiol. The human estrogen. I think I will go back to my prior dose.
Maggie
Hi, Maggie, another good post. You make some good points and I'd have to agree, were I the medical professional, with your decision.
I've just seen, heard, read too many women who have found in many different ways that a 2-5 year span between pubertal onset and post-menopause is not effective for them. I'll add you to that list asw ell.
:icon_hug:
Nichole
Quote from: Nichole on April 03, 2009, 08:34:13 AM
Changing doctors is most likely to find the exact same worries and SOP.
That is true in my case, Nicole. I live in one of the larger cities and there are only 3 doctors here who are offering services directly to MTFs. This in itself is a good reason to not carelessly dismiss a doctor on -- especially on a controversial issue such as this is.
I could always hunt down someone who would be willing to administer HRT to me but I really don't want to train him or her on how to administer HRT to MTFs (like I had to do in Smalltown, Nebraska.) A major reason for moving to the big city was to get the gender support I couldn not find previously.
-------------------------------------------------
In the interest of full disclosure, although she did not mention my age as a factor in her decision, I am 57 years old which could be a huge reason in wanting me to be on a lower dose. Also, I have been on estrogen for 2 years coming this July.
I haven't made any decisions yet on my dosage yet as I am gathering as many facts and theories as I can before doing so. I am thinking that because of my age, and that I have been on e for 2 years, I do think I should at least halve my dosage.
Thanks everyone for the great feedback!
Dora
Quote from: Cami on April 02, 2009, 03:51:34 PM
I would love to get an orchi soon though because I am concerned about the long term complications from prolonged use of Spiro and I don't know when or if I will ever be able to get full GCS.
That's an interesting statement to make, Cami. I asked her if it was true if I need to have the SRS or an Orchi within 5 years for safety reasons and she replied, no. She said if there are no other problems (liver function etc.) Spiro has been shown to be safe for long term use.
Dora
Get the T levels down to female norm and adding E at that point should cause the same results regardless of how much or how it is taken. (given that you take enough that it doesn't just get flushed through the system). Granted if you were to take enough estrogen to have, lets say 1/4 that of a normal female, versus taking enough to have 1/2 that of a normal female, the 1/4 is going to take longer to change anything. The reverse of that also seems to be true however, in that getting the E levels to high can cause quicker changes, but the end results tend to not be the same for whatever reason. Also keep in mind that E can be broken down into T if the body has to much of it.
Quote from: Dora on April 03, 2009, 12:56:41 PM
That's an interesting statement to make, Cami. I asked her if it was true if I need to have the SRS or an Orchi within 5 years for safety reasons and she replied, no. She said if there are no other problems (liver function etc.) Spiro has been shown to be safe for long term use.
Dora
That is true enough. If A-A's are continuously used for about 18 months, the effect is permanent chemical castration. The testes will become so atrophied that they would only become minimally functional if the A-A's are discontinued. Testosterone production would fall to such a low level that only the amount produced by the adrenal gland would have any measurable effect.
Additionally, in the absence of testosterone, the prostate will shrink, which actually is the purpose of spironolactone in the first place.
-Sandy
Quote from: Birdie on April 02, 2009, 03:44:41 PM
My doctor does this for all his patients and has already reduced my E to the minimum amount. There isn't really any way to argue with him either, I don't have any medical knowledge and if I didn't do as instructed I'd probably get kicked out of the gender clinic. It doesn't make any sense to me, because hrt seems to have had very little effect so far, but he's been completely dismissive of taking any path other than the one prescribed to all his patients.
This is called "standards of care." The doctor protects himself from malpractice by doing what most other doctors do, and the same thing with all patients.
You have to have medical knowledge, and if not accquire it; so you can take charge of your own treatment in order to customize it to what works for you. Then dealing with the doctor becomes a process of negotiation and compromise.
There is also a thing called "harm-reduction". Recently the AMA adopted a harm-reduction protocol for transsexuals using black market hormones. Essentially, it says that a General Practitioner can order and interpret tests for transsexuals who don't want to use Endocrinologists, or who use black market hormones, or purchase without a prescription through the Internet.
So endocrinologists do not have transsexuals
by the balls anymore.
When I went to an endo she chopped my E in half and left the anti-T alone. She was worried about my health and told me I could go to another doctor if I kept self-medicating. I did not feel as good under her doses so that she prescribed me anti-anxiety drugs. She is more concerned about keeping the T low. She told me not to expect much more from the HRT. She continued me on sublingual Oestradiol at the lowered dose. My body adjusted after a few months.
It is unethical for a doctor to refuse to treat you (or threaten to do so) because you choose self-medication.
To quote a relevent webpage:
Self-medication is a risky process that is neither encouraged, nor condoned. The information offered here is not intended to enable an individual to self-medicate, but rather, as a guide to help understand what to expect from properly monitored treatment, and as a guide to help understand the risks that are present.
While we do not encourage or condone self medication, we do believe strongly in the principles of least-harm and of harm reduction. We recognize that some people may have no other option, or be pressed into believing they have no other option. We hope that the information we present here will help even those individuals to protect themselves as best possible.
Please note, that if you are already self-medicating, you have an "out" - it is unethical for a medical provider to refuse to help you obtain properly supervised care when the alternative is for you to continue unsupervised treatments. This is enshrined in the medical principle of "first do no harm" and in the medical doctrine of "least-harm". It is also a guideline within the widely-followed HBIGDA standards of care.
[urlhttp://www.tssupport.org/Medication]http://www.tssupport.org/Medication
Link made inoperable. Please allow staff and suthorized posters only to make links. See Rule #1in the TOS (https://www.susans.org/forums/index.php/topic,2.0.html) --- Nichole
Gina Douglas wrote, "It is unethical for a doctor to refuse to treat you (or threaten to do so) because you choose self-medication.
To quote a relevent webpage:...some people may have no other option, or be pressed into believing they have no other option... "
Well a doctor can say they do not want to treat you because you represent a liability to them. They can accept you if you self medicate but can refuse to continue to help you if you do whatever you please.
Actually in my mind I felt I had no other options.
I visited my endo today and she showed me my T was at 26 which she said was fine. I asked her about my E levels and she said she did not measure them. She said I had gained nothing from my high doses and I risked hurting myself. Many friends told me that but it was not easy to go to the doctors for help. I will keep the doses low and consider other options. I listened to her for the past month and did what she asked and she helped me today.
T level of 26 ?????
...... if that's pmol then it seems WAY too high....normal male level!
My GIC at Charing Cross London has told me unequivocally that the target range for T is "under 3".
.... natal females have around 1.4 ...... those who are prone to be a bit hairy have levels of around 1.8
Quote from: Steffi on April 25, 2009, 11:35:56 PM
T level of 26 ?????
...... if that's pmol then it seems WAY too high....normal male level!
My GIC at Charing Cross London has told me unequivocally that the target range for T is "under 3".
.... natal females have around 1.4 ...... those who are prone to be a bit hairy have levels of around 1.8
The doctors are very cautious. I got copies of all the test. She told me under 40 was good. The results from the sheet are:
23 L ng/dl with average adult male at 241 to 827.
I was never a hairy male but my features are very male. My body hair is currently less than many females. I have about 75% of the beard removed. I calculated yesterday that I lost 38 pounds of muscle from 4 years of HRT. Actually I wanted the endo to up the anti-T and E but to no avail.
...................
Update: Kiera gave me a bunch of statistics on her site and I worked out the conversion numbers.
Stephi 23 ng/dl is equivalent to .79 nmol/L. If I convert your 1.4 nmol/L for natal females then I get 40 nmol/L.
Thanks for info, corrections etc :)
( Wow.... I'm surprised that T in Premenopausal Females can be up to 2.43 nmol/L )
Quote from: Kristi on April 02, 2009, 11:58:26 AM
I think this is a dangerously simplified statement. It may be true for you, but blanket statements like this bother me.
Excellent.
I agree partially with the OPs physician. However that doctor wasn't speaking at a lecture. He wasn't at a board meeting. He wasn't speaking to colleagues. He was speaking to her as an individual, unique patient. Therefore what he said was for her ears, and not intended to be cited as a medical reference for everyone.