Courtney's life begins here, redux

[Courtney G]

One more thing: the insurance company refused my last 4 electrology claims. They decided that they needed a federal form W-9 and copy of the business license from my electrologist! I'd already jumped through all of their hoops, so they sat down and came up with a couple more. And they already have my electrologist's tax ID number, address and so on and they can easily Google her and verify that she's legit. Plus, I submit the credit card receipt for each invoice as well as the invoice itself so they can see that I actually paid for each visit. I suppose they'll want to see my credit card statements yet.

No worries, I've already submitted the requested info. I'll submit a DNA sample if I need to. I won't let them win. I have to believe that I'm being discriminated against due to the type of treatment I'm getting (gender-affirming care).

[Courtney G]

I think you look amazing.  I can only hope I look half as good.😗

I'm sure you will, hon. HRT is magic, as is positive thinking.

[Charlotte Kitty ✅]

Honey, I DO need someone to massage my ego, lol. I have low self esteem. Clinically speaking, I have some form of body dysmorphia, which means even when people tell me I look good (or pass as a woman, etc) I have trouble believing them. My eyes see and my brain tells me that I'm not enough. FFS has helped a little bit and the body development this medical transition has caused has helped a lot, but it's a slow process. Sometimes, I think I look cute but I don't know if I'll even believe I could pass or even get by.

Thanks so much for the kind words of encouragement and flattery!

Totally get all this too if I'm honest, although I take it totally to heart because of my mental health. Like you since FFS I've been happier with my facial femininity bar a few dips occasionally. I wont go as far as ever having thought I look even remotely cute to myself. Body is a different thing. That I'm currently completely unhappy with and can only wait and hope it gets better.

Like you say believing what people say is difficult and often hard to accept. For me that is because I know many people will lie to make someone feel better. Also someone's silence / word choice is actually a much better determination of someone's true appraisal of how one appears. I carefully consider each word and often notice that wording can be passive in its usage. For example citing that and outfit looks good whilst avoiding reference to the person being nice in the outfit. I guess I'm very sensitive to reading between the lines and maybe to much so!

Charlotte X

[Lori Dee ✅]

I agree that you look amazing!

I think that many of the issues we have stem from the procedures being labeled as Gender Affirming Care. Since all of my medical care comes from the VA, I have informed them that, according to their own records, I transitioned in 2022. Therefore, I am not receiving Gender Affirming Care. The care I receive is no different from what any other cis-woman veteran would receive. HRT is Hormone Replacement Therapy, which is common for women my age, especially those who lack ovaries or have diminished ovarian output due to age or disease. My electrolysis is still considered "cosmetic" because I have yet to convince them that my correct diagnosis is "hirsutism" and I am being treated by a non-VA provider.

As my friend, the accountant, told me, "It's not what you say, but how you say it."

[Courtney G]

Totally get all this too if I'm honest, although I take it totally to heart because of my mental health. Like you since FFS I've been happier with my facial femininity bar a few dips occasionally. I wont go as far as ever having thought I look even remotely cute to myself. Body is a different thing. That I'm currently completely unhappy with and can only wait and hope it gets better.

Like you say believing what people say is difficult and often hard to accept. For me that is because I know many people will lie to make someone feel better. Also someone's silence / word choice is actually a much better determination of someone's true appraisal of how one appears. I carefully consider each word and often notice that wording can be passive in its usage. For example citing that and outfit looks good whilst avoiding reference to the person being nice in the outfit. I guess I'm very sensitive to reading between the lines and maybe to much so!

Charlotte X

Sadly, I do think that the affirmations people provide us with are often borne of kindness, which means they are willing to exaggerate a little or say something nice whilst not necessarily believing it themselves. Trans people in online spaces will tell a very masculine-looking trans woman that she's "gorgeous" but it's sort of a rote comment in many instances. This is made worse when they pour extra compliments on a person who isn't meeting most people's standards for what they think gorgeous is.

The more evolved among us are saying it from a place of absolute honesty, since any trans woman living her truth is, in fact "gorgeous." It's not about "oh, you have features that are just like Michelle Pfeiffer," rather it's "I see the beauty that is you and I won't hold you to any unnecessary standards of what any person should look like."

I'm working on evolving my way of thinking on a daily basis and I'm starting to see people's true beauty without trying to compare them to some useless template. This is something we should all aspire to. If everyone could do that, then you and I wouldn't spend so much energy trying to measure ourselves against our perception of beauty and/or femininity.

Charlotte, I see the beauty in you. I look at your face and see a cute roundness, devilish eyes, a pretty nose and really lovely lips. But I see a woman, not because of those features, but because that's what I know you to be. I see you for who you truly are.

[Petunia]

Courtney, it is kinda hard to really judge how you look from one photo and to be fair that is only one part of passing. If your posture and movement is like mine you won't pass as a woman.

But it doesn't look like that to me.  Your face looks like a nice middle age lady. Your body looks like someone who has taken care of themselves and you look quite fit. Your obviously pleased with your breasts and if you wear a low cut top like the other photo you posted I know where most peoples eyes will go, you will be looked at.

But I don't see anything that says guy.

[Petunia]

Charlotte, like I've said before I can only see a woman in you.

You have a liking for super feminine clothes in really girly colours. How you dress is your choice and I'm glad you found a look.

Like I've said before I'd like to see how you look with a bolder colour choice. Even if you just hold up a cushion or two next to your face.

Your beautiful pale skin seems to dissappear next to lightly coloured clothes.

That's just my one opinion and you have to wear what you feel comfortable in.

Maybe play around with AI and change clothing colours?

[Charlotte Kitty ✅]

Charlotte, I see the beauty in you. I look at your face and see a cute roundness, devilish eyes, a pretty nose and really lovely lips. But I see a woman, not because of those features, but because that's what I know you to be. I see you for who you truly are.

I say the same back to you too. You're definitely someone I'd love to look as good as. You're feminine, cute and hot all at once. Quite the combo thats for sure. I guess we all find our own ways to be beautiful and feminine.

Charlotte 😻

[Courtney G]

I'm a little frustrated and can use some help. I have a new doc (through Plume) who has taken me off of shots and put me back on patches, claiming that the risk of a blood clot is too high. Here's the history/data:

About a year before HRT, I had a deep vein thrombosis in my leg, most likely caused by taking low-dose pueraria mirifica (a phytoestrogen) for several months. I had to take several months of medication, as well as a few follow-up blood tests.

Fast forward to about a year later, when I started pharma HRT, in the form of patches. The choice was due to my age (mid 50s) and the clot risk associated with other available delivery methods (injections, oral). I used the patches for 4 years but barely achieved acceptable levels. I had trouble suppressing my testosterone as well.

In January of this year, my nurse practitioner at Plume offered injections, stating that there isn't a significantly increased risk of clots. I enjoyed higher E, more suppressed T and a better overall experience.

I've started poring through online info and there seems to be some recent data that shows that estradiol valerate presents a significantly lower risk to pulmonary trouble due to being bioidentical. I may be mistaken, but it seems (and I've heard this) that the medical community is basing their decisions on VERY outdated studies using ethinyl estradiol.

Last week, my new practitioner told me that the only way she'll put me back on injections is if I get clearance from a hematologist. I have an early June appointment with one. The question is, will they be willing to look at the current data or will they just dismiss the option? There's a ton of gatekeeping around this, as you all know.

With all of this in mind, my goal is to arrived prepared, with as many credible, peer-reviewed studies as possible in the hope that the hematologist is willing to consider the data. I don't want to [unalive] myself but I would prefer injections if they truly are safe, so I'd appreciate any data you might have to help bolster my case. Thanks.

[Lori Dee ✅]

The doctor at Plume is ignoring the science.

Patches allow the estradiol to be absorbed through the skin and stored in the fatty tissue below. Injections bypass the skin and deliver it directly into the fatty tissue (assuming subcutaneous injections). There is no difference in clot risk. The risk comes from oral, not sublingual, because the digestive system first processes it in the liver. That is what affects clotting.

The real risk with injections, per my Endo, is a higher peak dose. You bypass the first-pass effect in the liver; however, once the hormone enters the bloodstream, it is processed by the liver. So, a higher blood dose can increase the risk. My Endo has suggested going back to patches (not happening), or decreasing the dose, and maybe changing injections from once a week to twice a week to avoid the high peaks.

My gynecologist in SD had a similar concern, so she changed my injections to once every ten days without decreasing the dose. I explained this to my current Endo and told him I do not want to change anything without evidence. I have no history of blood clots (me or my family), and I refuse to go back to patches.

He agreed to wait until September and review my labs between now and then. I know he is going to be looking for what he considers "high" peaks, but that also ignores basic biology. I am a fast metabolizer, per my Primary doctor, so my body eliminates some drugs very quickly before they can have the desired effects. The healthcare system seems to want my levels below 200, and when they see a peak of 400, they freak out. They ignore the fact that many cis-women have levels that peak over 400-600. During pregnancy, they can go over 1,000, and you don't see very many pregnant women having blood clots and strokes unless they have a history.

In the past, when I have argued this, they have admitted that I am correct and have changed to complaining about my progesterone dose. I tell them it is the same situation, and if they are that concerned, then take me off oral progesterone and let me have progesterone injections. They can't. (The VA does not have it in its formulary for available prescriptions.) So they back off until the next check-up.

It is like they feel they need to constantly tweak stuff. I tell them it ain't broke, so stop fixing it. I will let you know if I have any symptoms. For now, leave it alone.

I'll see if I can find the research I used to support my position.

Good luck.

[Lori Dee ✅]

Women who were prescribed transdermal HRT were 22% less likely to have an ischemic stroke, 25% less likely to have a thromboembolism, 26% less likely to have a myocardial infarction (MI), and 27% less likely to have a pulmonary embolism (PE) compared to those who received their HRT vaginally. Women prescribed oral HRT were 26% more likely to have an arterial clot but 7% less likely to have a stroke compared to those who received their HRT vaginally. We did not observe a difference in the likelihood of clotting disorders between injectable HRT and HRT administered vaginally.
Epic Research Study - April 23, 2025
Dual-Team Study
Team A: Kersten Bartelt, RN|Nitesh Mathur, PhD|Joe Deckert, PhD
Team B: Dave Little, MD|Emily Higgs
https://www.epicresearch.org/articles/blood-clot-risk-influenced-by-hormone-therapy-administration-route-in-women-50-and-older 🔗

Another article from 2023 that cites numerous other studies is at:
Estrogens and Their Influences on Coagulation and Risk of Blood Clots
By Aly | First published October 20, 2020 | Last modified March 28, 2023
Transfeminine Science

Injections of short-acting estradiol esters like estradiol valerate and estradiol cypionate are notable in that they are often used by transfeminine people and are generally used at doses that achieve high estradiol levels. As with high-dose transdermal estradiol patches, little to no quality data on the risk of blood clots exists for these preparations at present. Pyra and colleagues found that the risk of blood clots with injectable estradiol valerate in transfeminine people was increased by around 2-fold, but the confidence intervals were very wide and statistical significance was not reached (Pyra et al., 2020). The doses used in the whole population for the study were not provided, but in the actual VTE cases, the doses of injectable estradiol valerate were described and ranged from 4 to 20 mg once per week and 10 to 40 mg once every 2 weeks (Pyra et al., 2020).

[Courtney G]

@Lori Dee Thank you so much for your studied and informative response. I appreciate the links, as well. This tracks with what I've been reading.

It has been suggested that 2x injections per week is better for many to maintain levels and control peaks, so that's sounding attractive to me.

What's crazy here is that Plume is known for siding with trans people, so you'd expect that the practitioners would have waded through the outdated or incorrect information. This practitioner might be new to the practice and not generally inclined towards trans care, so she might be reading from the "script" that she's been exposed to. While I don't wish to argue with her, I'd love to try to turn her eyes to more trans-relevant, newer information than she might be looking at.

I feel the same about the hematologist and I haven't even met him yet. Whether he's even willing to look at this data is a crapshoot, but I'm going to prepare myself. For starters, I'll mention three big things:
1. Many are still referring to studies using synthetic estrogen
2. Most studies are based on very high levels of estradiol
3. The trans community is largely underserved and disregarded when it comes to research and data

[Lori Dee ✅]

I feel the same about the hematologist and I haven't even met him yet. Whether he's even willing to look at this data is a crapshoot, but I'm going to prepare myself. For starters, I'll mention three big things:
1. Many are still referring to studies using synthetic estrogen
2. Most studies are based on very high levels of estradiol
3. The trans community is largely underserved and disregarded when it comes to research and data

4. There is very little difference, if any, in clot risk between patches and injections.

[Courtney G]

4. There is very little difference, if any, in clot risk between patches and injections.

I'll modify that and say "As I understand it, there is very little difference, if any, in clot risk between patches and injections." so as not to raise his ire. I know that doctors hate it when patients think they know something. The doctor/patient relationship is much like the man/woman one as I understand it.