Hi Ladies!

I was on your typical dose of Estrogen.  They up'd it from that to 4 points above the amount I was taking.  So I went from 30  to 126 for my "E" count! So that's good! My Doc wanted to know if I wanted to go a little more.

My libido has gotten better.  I'm sleeping better too. And I don't feel as tired as I did before.

Has anyone had a similar situation? Did you go up on your "E"? Would you go up on your "E"? Should I just play it safe.

Here's my issue.  I'm borderline Hypertension.  I'm going on a Low salt diet as well. I'm taking it in pills.  The patches gave me a rash. 

Thanks for your help and wisdom.

What I found strange is that your doctor was asking you if you would like to get your E levels a bit higher... Does he know what he is talking about. It shouldn't be you making that decision. He is supposed to be the expert.... That's why we should not self medicate....


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Quote from: JessicaSondelli on December 01, 2016, 04:09:20 PM
What I found strange is that your doctor was asking you if you would like to get your E levels a bit higher... Does he know what he is talking about. It shouldn't be you making that decision. He is supposed to be the expert.... That's why we should not self medicate....


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Thanks for your concern

I think he was just trying to ask me if I felt ok at that level. I was feeling down and slow because 30 is pretty low.  Now I'm at 126 (50 to 200 is norm). I feel much better. No depression etc etc.  But thank you for chiming in.  This is what the forum is for--to look out for one another.  HUGS

Quote from: JessicaSondelli on December 01, 2016, 04:09:20 PMWhat I found strange is that your doctor was asking you if you would like to get your E levels a bit higher... Does he know what he is talking about. It shouldn't be you making that decision. He is supposed to be the expert.... That's why we should not self medicate....

I disagree -- we should absolutely have a say in how our bodies are treated, and be as educated as possible to advocate for ourselves as best we can.

Much of HRT has to do with how we feel, as well as how happy we are with the physiological changes we get.  And frankly, there's a lot of latitude here.  The doctor can look at our results and say exactly what they said -- in their opinion, she can take more if she wants.  Maybe she needs more energy, more breast growth, more libido... or maybe she's very happy where she's at and doesn't want to change her regimen.  And the doctor would presumably advise when she shouldn't take more, or take less, depending on the rest of her blood work.  Regardless, it's her body, and her needs that should be attended to, not the number associated with her serum level of estrogen.  (Much more important are the other components of the profile, from her liver to her hemoglobin.)

What's at issue here isn't the actual levels of estrogen in her system.  It's how she responds to it, her and her body. The levels themselves are kind of arbitrary -- some people are more sensitive or receptive to it than others.  Some people's bodies start getting out of whack, others stay smooth as silk. 

KarmaGirl, as to hypertension, estrogen can help to keep blood vessels dilated. Most women with hypertension develop it after menopause, and the research linking long-term HRT to hypertension is primarily based on Premarin, if I recall correctly.  (I'm sure KayXo will come in to straighten this all out.)  So it actually does make sense that your doctor would ask if you want to go higher on E, given that it could possibly help with hypertension, assuming you're taking a bio-identical form of estradiol.

Quote from: KarmaGirl on December 01, 2016, 07:58:27 PM
Thanks for your concern

I think he was just trying to ask me if I felt ok at that level. I was feeling down and slow because 30 is pretty low.  Now I'm at 126 (50 to 200 is norm). I feel much better. No depression etc etc.  But thank you for chiming in.  This is what the forum is for--to look out for one another.  HUGS

You're very welcome

I didn't realize he was asking you this question when you were at 30, I thought he asked you after he upped you dosage. I totally agree that 30 is way too low, it could even cause some serious issue together with low T. My concern was that you went to a doctor who isn't really specialized in trans issues - there's a lot of them, unfortunately - and he didn't know exactly what he was doing. I also suspected - based on your information about the dosage increase - you were already on the maximum recommended dosage and asking you if you want more, just sounded strange, if not dangerous to me...

I totally agree with what Sophia is saying. We should be involved in all this but we should not be expected to be the expert - although sometimes I think we know more than many doctors who are allowed to prescribe hormones. Doctors should ask us how we're feeling, verify how feminization is progressing and then make decisions based on those facts plus blood-levels to keep our bodies save. Higher E levels don't necessarily mean better feminization, everybody is different.

Hugs
-Jessica

I like my E levels above 1000 pmol/L, and feel terrible if they are 250. I've tried both.

pg/ml is about quarter of those. No way I'd be happy on 126 pg/ml.

Quote from: KarmaGirl on December 01, 2016, 03:44:52 PM
Here's my issue.  I'm borderline Hypertension.  I'm going on a Low salt diet as well. I'm taking it in pills.

If you are taking bio-identical estradiol (estradiol, estradiol valerate), this shouldn't be a concern, according to studies. Spironolactone is an anti-androgen that can reduce blood pressure, bio-identical progesterone can also help with this.

Ann Clin Res. 1983;15 Suppl 38:1-121.
Blood pressure and hemodynamics in postmenopausal women during estradiol-17 beta substitution.

"Estradiol-17 beta substitution decreased the systolic and diastolic blood pressure in normotensive, hypertensive and borderline hypertensive postmenopausal women. The blood pressure of the hypertensive subjects decreased on average more than the blood pressure of the normotensive subjects."

"Irrespective of the pretreatment blood pressure levels, heart rate decreased during estradiol-17 beta substitution"

"Estradiol-17 beta substitution caused an increase in the blood volume in all groups of postmenopausal women"

"Cardiac output increased in the normotensive test subjects but decreased in the hypertensive and borderline hypertensive subjects"

Horm Mol Biol Clin Investig. 2014 May;18(2):89-103.

"The cardiovascular protection observed in females has been attributed to the beneficial effects of estrogen on endothelial function."

"estrogen alone or combined with progesterone has been associated with decreased blood pressure"

Climacteric. 2013 Apr;16(2):265-73.

"Estradiol decreased systolic blood pressure, plasma aldosterone levels, and the expression of renal sodium transporters."

Hypertension. 1999 May;33(5):1190-4.

"Fifteen healthy postmenopausal women were studied in each of 3 conditions: on placebo, after 8 weeks of transdermal estradiol (...) twice per week, and again 2 weeks after addition of intravaginal progesterone"

"Levels of estrogen and progesterone similar to those in premenopausal women were achieved. On estradiol, nocturnal systolic BP (110+/-3 mm Hg), diastolic BP (63+/-2 mm Hg), and mean BP (77+/-2 mm Hg) fell significantly (P<0.02) compared with placebo systolic BP (116+/-2 mm Hg), diastolic BP (68+/-2 mm Hg), and mean BP (82+/-2 mm Hg). Daytime BP followed the same trend but was significantly lower only for mean BP. There was no activation of the RAAS. The addition of progesterone resulted in no further fall in BP but a significant activation of the RAAS. Thus, contrary to what is often assumed, administration of estradiol with or without progesterone not only did not raise BP but rather substantially lowered BP. This BP-lowering effect may be responsible for the lower incidence of hypertension in premenopausal than in postmenopausal women."

BMJ. 2012 Oct 9; 345

"In this randomised trial including 1006 women we found a significantly decreased risk of the composite endpoint of death, heart failure, or myocardial infarction when hormone replacement therapy was started early in postmenopause. The beneficial effect occurred in the 10 years randomisation phase and was maintained for an additional six years of non-randomised follow-up. The trend for all components of the endpoint was in the same direction (figs 3 to 6) and this finding was not associated with an increased risk of cancer, stroke, deep vein thrombosis, or pulmonary embolism. Thus this study implies that hormone therapy started in recently menopausal women and continued for a prolonged duration does not increase or provoke adverse cardiovascular events such as mortality, stroke, heart failure, or myocardial infarction."

Obstet Gynecol. 2015 Mar;125(3):605-10.

"In transgender women, estrogen therapy, with or without antiandrogen therapy, was associated with lower BP."

"Transgender women were treated with estrogens. Fourteen (88%) were given sublingual micronized 17-beta estradiol (....) twice daily. One subject was given (...) estradiol via transdermal patch, and one subject received estradiol valerate (...) intramuscular every 2 weeks. All but one transgender woman (who wished to retain erectile function) were administered spironolactone"

"All transgender women had estradiol levels at least in the physiologic female – range at 6 months, with 3/16 (19%) having supraphysiologic levels > 1000pg/dl (including the one transgender woman using intramuscular estradiol valerate)."

Should read pg/ml (typo).

"Transgender women (persons assigned male at birth, but who identify as females and who use estrogens with or without an anti-androgen to develop female secondary sex characteristics) had normal median baseline and 6 month body mass index (24.8 kg/m2 (IQR=4.3) and 23 kg/m2 (IQR=4.5) respectively). Both systolic and diastolic median blood pressures in this group dropped significantly from baseline to 6 months (130.5 mmHg (IQR 11.5) to 120.5 mmHg (IQR 15.5) p=.006; 78 mmHg (IQR 21) to 67 mmHg (IQR 12), p=.001 respectively)."

Menopause. 2014 Jan 6.

"Rylance et al39: Results of this small, double-blind, placebo-controlled, cross-over study showed that the use of orally administered natural progesterone caused a significant reduction in BP in individuals with mild to moderate HTN who were not using any other antihypertensive medications »

Br Med J (Clin Res Ed). 1985 Jan 5;290(6461):13-4.

"In a placebo controlled, double blind crossover study natural progesterone was given by mouth, in increasing doses, to six men and four postmenopausal women with mild to moderate hypertension who were not receiving any other antihypertensive drugs. When compared with values recorded before treatment and during administration of placebo progesterone caused a significant reduction in blood pressure, suggesting that progesterone has an antihypertensive action rather than a hypertensive one as has been previously thought. This possible protective effect of progesterone should be investigated further."

Climacteric. 2013 Aug;16 Suppl 1:44-53.

"in the PEPI trial43, an increase in blood pressure occurred after 1 year in all CEE + MPA regimens but not in those receiving CEE + micronized progesterone. The addition of micronized progesterone to CEE has been reported to abolish the increased daytime blood pressure of normotensive women and potentiate the CEE-related decreased daytime systolic blood pressure in hypertensive women26."

MPA and CEE are non bio-identical forms of progestins and estrogens, they can have an adverse effect.

Endocrine Reviews, April 2013, 34(2):171–208

"Interestingly, no changes were observed in blood pressure with progesterone administration to normotensive postmenopausal women, although a slight reduction in blood pressure was observed in hypertensive women (198)."

My levels of estradiol are between 1,000-4,000 pg/ml, women's levels during pregnancy are as high as 75,000 pg/ml (1,000-75,000), levels in the range of 400-700 pg/ml in men with prostate cancer (49-91 yrs old) given estradiol non-orally with no cardiovascular complications and improved lipid profiles. I take oral progesterone as well. My blood pressure is fine, I'm under the supervision of three doctors.

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)."

"Supraphysiological oestradiol levels are an uncommon consequence of oestradiol implants (...). These high serum oestradiol levels were not associated with any deleterious effects and may be necessary for the control of symptoms in specific women"

"The mean serum oestradiol level of the 1388 women attending the clinic in 1988 was 767 pmol/l (range 78-2925 pmol/l), 66% had serum oestradiol levels <1000 pmol/l and 3% (38 women) had levels >1750 pmol/l (Fig 1)."

"The 15 women with PMS had a mean serum oestradiol of 2209 pmol/l (range 1760-2820 pmol/l). Their mean age at the start of treatment was 40 years (range 34-54) and the mean duration of therapy was 5.5 years (range 1-12)."

"The 23 menopausal women had a mean serum oestradiol of 2015 pmol/l (range 1785-2925 pmol/l). Their mean age was 46 years (range 29-58) and the mean duration of therapy was 4.5 years (range 1-10)."

pmol/L to pg/ml: divide by 3.671

Lowering carbohydrates has also shown to have a positive impact on blood pressure as the lower insulin is, the less there is sodium (and water retention).

Am J Physiol Heart Circ Physiol. 2013 Jun 15;304(12):H1733-42. (in hypertensive rats)

"In conclusion, a low-carbohydrate/high-fat diet reduced blood pressure and improved arterial function in SHR without producing signs of insulin resistance or altering insulin-mediated signaling in the heart, skeletal muscle, or vasculature."

Nutr Res. 2013 Nov;33(11):905-12.

"In conclusion, these findings demonstrate that individuals undergoing statin therapy experience additional improvements in metabolic and vascular health from a 6 weeks CRD as evidenced by increased insulin sensitivity and resistance vessel endothelial function, and decreased blood pressure, triglycerides, and adhesion molecules."

CRD = carbohydrate restricted diet

Arch Intern Med. 2010;170(2):136-145.

"Two potent weight loss therapies, a low-carbohydrate, ketogenic diet (LCKD) and orlistat therapy combined with a low-fat diet (O + LFD), are available to the public but, to our knowledge, have never been compared."

"In a sample of medical outpatients, an LCKD led to similar improvements as O + LFD for weight, serum lipid, and glycemic parameters and was more effective for lowering blood pressure. »

I believe having a doctor who encourages feedback and involvement from the patient is great. Best of luck.

Quote from: AnonyMs on December 01, 2016, 09:02:35 PM
I like my E levels above 1000 pmol/L, and feel terrible if they are 250. I've tried both.

pg/ml is about quarter of those. No way I'd be happy on 126 pg/ml.

So I am post op.  So we had to adjust to that.  I am ONLY taking E right now. I tried Progesterone at first but that made me depressed.  Last year I was at 50 then 30 so they had to bump me up. I've been on HRT since 2010.  When I went to the LGBT Center for help, THAT doctor actually told me that if I felt good, for me not to worry too much about my levels.

  As you can see on my profile pic, HRT worked wonders for me ( I recently had FFS. And after my orchiectomy things went a little wild and I was moody and depressed.

My family doctor who is familiar with HRT and has more than a few TRANS patients  chimed in, and we have been carefully upping it every 3 months.  He wants me to break up my three pills with two in the morning and one at night. So I'm only up by 1 from what they were giving me before my op.  (I'm sorry if I sound vague but I'm trying to stay within the RULES of this Forum). 

We are debatting on injections.  I am borderline Hypertensive...I wasn't before HRT.  So, I'm also wondering if it has to do with THAT (both from a positive or negative perspective)---Meaning; will I be better with a bit more to place me in the 1000 mark, or is it that what is causing me to have some issues with blood pressure and so on).  My doctor and I are carefully trying to see what works best.

My doctor is afraid of upping me too fast for fear of DVT's. He had a patient that came from another doctor, and she was on injections. She actually died of DVT.  So the con to injections is that you just can't stop it as quickly as pills, but pills can cause problems too.  We have to find that sweet spot for me I guess. I can't wear patches they give me rashes.

PLEASE feel free to give me your suggestions if you have had a similar issue(s).  I'm trying to investigate as much information as I can. 
I had forwarded some info to him this week, but he said a lot of what I sent him was proven wrong...especially if its stuff from the 80's and 90's.  He's reaching out to several doctors he knows around the globe to fine tune my regiment. He's also a friend of mine so, I know he's doing his best. 
The LGBT center is great, but I wasn't getting the one-on -one attention that I needed. I was getting more of a cookie cutter situation, and we know that isn't the way to go with this kinda stuff.

I do feel much better. I don't have heat flashes like I did and my libido ( I know it's all about the Testosterone but it's also about balancing that with Estrogen) is up. 

For now, I'll just keep going with the amount he gave me, and then testing again in another 3 months to see if I"m doing better ALL AROUND.

I really appreciate all of you that have posted on this.  Thanks for taking the time.
HUGS

I am on injections of estradiol valerate and my clotting times were measured several times. Despite high estradiol levels, between 1,000-4,000 pg/ml, clotting remains unaffected. I earlier provided studies where women were on injectable estradiol with levels in the 2,000-3,000 pg/ml range. Some women were between the ages of 45-55 and despite this, there were "virtually no side-effects".

Also,

Archives of Sexual Behavior, Vol. 27, No. 5, 1998

"The incidence of thromboembolic events during cross-gender hormone treatment in our patients was zero."

"None of our patients developed deep vein thrombosis or embolism during cross-gender hormone therapy performed in our clinic."

Despite 17 women being on VERY high dose injectable estradiol valerate.

Also,

Exp Clin Endocrinol Diabetes. 2011 Feb;119(2):95-100

"84 male-to-female transsexuals (MtFs) were treated with (...) oestradiol-17β valerate every 10 days. The study population was treated with subcutaneous injections of (...) goserelin acetate every 4 weeks to suppress endogenous sex hormone secretion completely."

"We observed one case of deep vein thrombosis in a 49 years old MtF who had uneventful medical history prior hormone therapy. No further side effects or other complications were observed during the study."

Estradiol levels ranged from 340.5 pmol/L to 1,362.4 pmol/L " at the nadir immediately prior the oestradiol-17 β valerate injection whenever possible."

At the nadir = when levels are the lowest

Mean age of 36.3 years (SD 11.3).

So, overall, out of 101 people treated with injectable estradiol valerate, only 1 person had a DVT.

Finally,

Adolesc Pediatr Gynecol (1995) 8:20-23

"This consisted of a combined intramuscular injection of (...) estradiol valerate (...) and (...) hydroxyprogesterone caproate (Proluton Depot , Schering Company, Germany) given weekly for 6 months."

Ages 16-30.
Estradiol levels (range, between 3 and 6 months):
920 – 6789 pg/ml

"High-dose intramuscular injections of estrogen and progestogen were well tolerated. We have experience with more than 200 patients treated for mammahypoplasia using this regime with minimal side effects. 18 All six patients completed the treatment and some were eager to continue therapy."

All this suggests injectable E, in general, poses little risk.

QuoteHe had a patient that came from another doctor, and she was on injections. She actually died of DVT.

Was this person a smoker, HIV infected, predisposed to DVT due to genetic and environmental causes, obese, diabetic? Had they just undergone an operation? Were they taking something else in addition to injectable E? Was E estradiol valerate or another ester combined with a progestin? DVTs can also occur due to many other reasons.

Quote from: KarmaGirl on December 02, 2016, 02:10:51 PM
pills can cause problems too.

When bio-identical estradiol is taken, the risks seem much lower.

JAMA. 2009 August 19; 302(7): 774–780.

One arm of the study, consisting of 32 people aged 59.5 yrs old (39.4-77.7) took a very high dose of oral bio-identical E and "the mean [standard deviation] trough levels of estradiol at one month were (...) 2403 [2268] pg/ml"

Despite this and the fact they had advanced breast cancer, there was only one incidence of DVT after 6 months.

Exp Clin Endocrinol Diabetes. 2005 Dec;113(10):586-92.

"Sixty male-to-female transsexuals were treated with monthly injections of gonadotropin-releasing hormone agonist (GnRHa) and oral oestradiol-17beta valerate for 2 years to achieve feminisation until SRS."

"Two side effects were documented. One, venous thrombosis, occurred in a patient with a homozygous MTHFR mutation. One patient was found to be suffering from symptomatic preexisting gallstones. No other complications were documented. Liver enzymes, lipids, and prolactin levels were unchanged."

1 out of 60.

Estradiol levels ranged from 325-1183 pmol/L, at 12-24 months.
Average age was 38.37 yrs old (SD 11.36).

J Sex Med. 2016 Nov;13(11):1773-1777.

"CSHT in the United States typically includes estradiol with the antiandrogen spironolactone"

"A retrospective chart review of transgender women who had been prescribed oral estradiol at a District of Columbia community health center was performed."

"The primary outcomes of interest were deep vein thrombosis or pulmonary emboli."

"From January 1, 2008 through March 31, 2016, 676 transgender women received oral estradiol-based CSHT for a total of 1,286 years of hormone treatment and a mean of 1.9 years of CSHT per patient. Only one individual, or 0.15% of the population, sustained a VTE, for an incidence of 7.8 events per 10,000 person-years."

"93.8% of the transgender women receiving oral estradiol also were prescribed the antiandrogen spironolactone and 16.6% received the antiandrogen finasteride. Conjugated equine estrogens or oral progestins were prescribed to 6.2% and 4.0% of the total study population, respectively. In addition, three patients were prescribed intramuscular medroxyprogesterone acetate in combination with oral estradiol."

"The population examined in this study is young and has a lower prevalence of obesity, hypertension, diabetes mellitus, and renal disease compared with the general American population"

Average age was 33.2 yrs old.

"our population has a high prevalence of HIV and tobacco use and a large number of African-American individuals, which would be expected to increase the risk of thrombophilia." BMI was also relatively high in this population.

"the incidence of VTE observed in the present study is slightly lower than the 8 to 27 events per 10,000 person-years observed in the general population and lower than the 30 events per 10,000 person-years observed in postmenopausal women on unopposed estrogen therapy."

"There was a low incidence of VTE in this population of transgender women receiving oral estradiol."

Despite limitations of this study, the incidence was still very low, especially considering a few were taking non bio-identical estrogen or medroxyprogesterone known to increase risks and considering four demographic factors known to increase risks were also present to a significant degree. The one incident occurred in someone severely obese. Body mass index was 37. 

I have been on Spiro for 25 years for hypertension and a multitude of other heart problems. I do remember my blood pressure dropping and has now settled in the 100 - 120 over 65- 70. Due to a heart valve problem I am also on warfarin which helps prevent DVT. My E level is 176; so we are not too different. My Doc consulted the Department Head for advice and here I am 3 1/2 months on estradiol.

Quote from: DawnOday on December 02, 2016, 03:32:07 PM
I have been on Spiro for 25 years for hypertension and a multitude of other heart problems. I do remember my blood pressure dropping and has now settled in the 100 - 120 over 65- 70. Due to a heart valve problem I am also on warfarin which helps prevent DVT. My E level is 176; so we are not too different. My Doc consulted the Department Head for advice and here I am 3 1/2 months on estradiol.

Wow, thank you for sharing with me! I'm taking aspirin low dosage now. My Doc just emailed me. He seems pretty confident about where I'm at right now. He's really careful with me since he knows me too.  But yeah, I like to look into things and not just follow ANY Doctor. 

I really appreciate you taking the time.  I hope everything goes well for you and your health.

Hugs
KG

Hi KarmaGirl,

I'm very interested in your thread which I've just spotted. You and I share some similarities e.g. the orchie and FFS and I posted this up yesterday: https://www.susans.org/forums/index.php?topic=217198.new;topicseen#new

I find the whole E level issue quite arbitrary but I also know that, for me, the dose they whacked me on which saw my E2 level rising fast (577 pmol/L when tested on 16/11) was making me feel ill.

If there's no T in the system I can't really see the point of massive estrogen dosing? Softly softly catchee monkey.