Courtney's life begins here, redux

[Courtney G]

Hi, all. This week, I see the hematologist that may decide my HRT fate. I expect him to order a blood test to see whether or not my levels indicate an increased clotting risk on injections versus patches. I intend to present him with printed copies of studies on estradiol valerate injections and the risk of clots versus patches versus ethinyl estradiol (birth control estradiol, not used for our HRT). I'll tell him that I want to live and I want to do the right thing, but that we need to have an objective look at the data, using the most up-to-date information. I hope I can continue on injections.

My wife and I attended a coffee shop gathering hosted by our little county pride org yesterday. I shaved the little bit of stubble on my chin, put a little foundation/primer on and a little mascara (no lipstick). Told my wife on the way that I'd thought of wearing some lipstick but didn't think I should. She asked "why not?" I'm more worried about her reaction than I need to be, sometimes.

I wore girl jeans, some cute purple sneakers and a native American-inspired woven pullover hoodie with a tint of lavender color. The weather was a little cool but I only wore a cropped red cami/shelf bra with spaghetti straps beneath the hoodie so I wouldn't overheat. Well, it turned out to be pretty warm in the coffee shop, so I ended up taking the hoodie off, which revealed this tiny top with my breasts overflowing it. I felt very exposed but also proud of my body. I was chatting with three ovary-having, estrogen-based people (one of the three identifies solely as a woman) and they gushed about how nice my body looked, complimenting my boobs in particular. I squealed with joy inside. I asked them if I'm "fooling" anyone with my strangely-shaped body beneath a loose sweatshirt and one of them said that they could tell I was "curvy" when I walked in. The other said they love their breasts (despite having a masculine side to their identity) and breasts in general and that mine were amazing, and that they found themself admiring mine. I was so flattered. The whole thing felt so good. I had a wonderful time and my wife really enjoyed herself.

I'm very much involved in my electrologist training course. I completed one chapter and passed the quiz at the end. The chapter I'm on now is a big one and covers all parts of human anatomy. I don't see how I can remember even 10% of the stuff I'm learning. I hope that there isn't much of this in the board exam at the end. My goal is to open my practice early next year, start taking clients in the evenings and weekends and get the education and equipment investment paid off before summer begins.

I'll hopefully have completed the second round of facial feminization surgery before I start heading into the electrology school for hands-on time, so I plan on going there in girl mode. I'll be interacting with instructors, other students and clients (patients) and I suspect they will all be women of one type or another.

[Lori Dee ✅]

I think it is wonderful that you are going through with your training. You are not just starting a business. You will also be providing a very much-needed service to the community. That is wonderful.

[Gina P]

Sounds interesting, even with a hoody they could tell you had boobs. Great place to get comfortable with your new presentation.
 Just curious, how much does an electrolosis machine cost?

[Courtney G]

Just curious, how much does an electrolosis machine cost?

In the neighborhood of $10k, I think.

[Courtney G]

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 🔗

I'm prepping for my hematologist visit tomorrow and noticed that the results of this study (as quoted above) say that vaginally-administered HRT and injected HRT both have a significantly higher risk than patches.

[Lori Dee ✅]

I'm prepping for my hematologist visit tomorrow and noticed that the results of this study (as quoted above) say that vaginally-administered HRT and injected HRT both have a significantly higher risk than patches.

Now I am wondering if I posted the study I intended to. (Sorry)

They are looking at different types of cardiovascular events, so they are separating clots from strokes and embolisms.

I just had this discussion with my endocrinologist. The simple way to remember it is that oral medications pass through the liver first. When estradiol is metabolized in the liver, it affects the Coagulation Factor (thus clots, strokes, etc.).

Transdermal patches, sublingual preparations, vaginal preparations, and injectables are absorbed into the bloodstream first. So they do their work before the liver clears them from the bloodstream.

Is the risk still there? Yes. Because eventually, everything will get processed through the liver. But with oral medications, a higher dose is needed so that some sneaks past it and can do its job. With the others, they do their job, then get cleared, so a lower dose can still be effective.

And doctors all believe a lower dose of anything is safer. If it were up to them, the dose would be zero, but even that doesn't remove all risk. For them, everything is about risk management, not about what you want to accomplish.

I looked for another study, but they were not helpful. They are from four years ago, say the same thing, and state that more studies are needed because there isn't enough evidence yet.

[Courtney G]

Yeah, I've used the liver metabolism explanation many times. But there's data to show that the mere presence of estradiol increases risk of a cardiovascular event. What I can't find is a study that conclusively shows that injections are as safe as patches with regard to increased risk.

I can't find explain that most clots occurred when the dose was high but the fact that I had a previous clot puts me in a higher risk category, and no doc is going to want to take a chance with me.

I think my only hope is if labs from today show no increased levels of clotting factors.

[Lori Dee ✅]

But there's data to show that the mere presence of estradiol increases the risk of a cardiovascular event. What I can't find is a study that conclusively shows that injections are as safe as patches with regard to increased risk.

Taken at face value, the mere presence of estradiol causing risk would indicate that women are suffering cardio events as soon as they hit puberty. And we don't see that in the population.

The difference in safety between patches and injections is in the resulting serum levels. Patches tend to maintain a steady, even dose, while injections cause peaks and troughs, a pattern also seen with oral doses. They don't worry about the troughs, where we experience mood swings, hot flushes, and night sweats. They focus on the peaks. Because it will eventually pass through the liver and affect coagulation.

So it isn't a case of injections = patches. It is that both have less risk than oral.
With a history of a clot and age factored in, patches might be a safer option because they provide a steadier dose without the peaks and troughs, and the peaks are the risk they are looking at.

[KristaFairchild]

.I've been wearing women's jeans and tight fitting women's tops with a heavily padded bra.  I've been doing this almost full time for about a year.  And you know what, nobody cares.  Or at least they don't say anything. I'm treated the same at work as I've always been, and I've been there a long time.  When I'm out shopping or just out for a walk, no one says anything.  I don't notice that I'm treated any differently. 

I'm at the point now where if someone does say something or tries to make a scene, I'm just going to smile at them and walk away.  I don't know how I would have reacted a year ago, but now I know most people don't care and I'm not going to let the "less than 1%" bother me.

I am having similar experiences. It took three years for me to slowly build up to a truly feminine presentation. Now I realize I didn't need to wait that long. For the last couple of days I've worn skirts to work and nobody bats an eye. In fact, many people are overly affirming of my appearance. My work includes well over 100 people that I come into contact and I've not had anybody say anything negative and many people have come out as affirming.

I live in a county where about 70% of the people voted for Donald Trump. We had our primary election yesterday and it looks like we are going to pass a measure about elections that is illegal according to state and federal law. You can imagine the approach to trans people.

Yet I'm finding as I walk around and grocery stores and department stores that I am not getting a lot of stairs and I'm not getting any negative comments. I'm sure it will happen and then I will take the approach Pauline suggested. Even in this area, I'm finding a lot of people compliment me on my earrings or nails, as a code way of saying that they see me and it's good. 

Where I work, we have a catchphrase every year and this year it is "Make It Happen!" It is said with excitement not obligation. Earlier in the year, our superintendent had a conversation with a high school student who added something to that phrase that I've never forgotten. "And do it scared". She didn't mean that we should be frightened only that we should take on the things we should make happen and we might be scared when we do it.  In fact, that can be an indicator of what we're doing this important. 

Today the important thing I am doing is being in public, wearing a plaid skirt, a cute little red V-neck, peplum blouse, and heeled sandals. 

[Courtney G]

UPDATE

Holy cow. First of all, I just (this minute) got the estradiol portion of my latest blood test: 685 pg/mL. I've never seen anything near this level. Obviously, my doc is going to have a problem with this. But it's a strong indication of the efficacy of injections versus patches. I had trouble getting past 50 over the 4 years I was on patches, even while using 4 patches, twice a week! I'm pretty excited about this. Now I have to adjust my dosage to get the level down a good bit. I have my follow-up scheduled with my gender NP (nurse practitioner).

OK, so I saw the hematologist. To my surprise, he didn't draw blood for testing. Instead, we discussed my NP's concern (a clot) and he did some research while I waited, commenting on how little info there is about trans people. He downplayed my clot a bit, noting that a clot in the calf is nowhere near as dangerous as other locations and that it was one clot, one time. This was a much milder response that I'd expected. He understood my concerns (I don't want to die and I really like injections). He scratched his chin for a minute, then suggested a low dose blood thinner as an ongoing prophylaxis. I start this weekend and we'll meet in three months to see where I'm at.

I was quite surprised at how interested he was in my story and how willing he was to listen and to figure out a way to deal with this. It seems I chose a good doctor! And I'll be staying on injections for now.

Yes, it could be that I don't need the blood thinner. It could be that injections are as safe as patches, or at least much safer than pills. But this pretty much takes concerns of a clot off of the table. The low dose means I shouldn't have concerns about side effects or about bleeding out if I experience some sort of trauma.

In other news, I'm continuing my electrologist training. The "Systems of The Human Body" module was a whopper. I took the module quiz this morning and passed, fortunately, so I'm on to skin now.

I've been out as myself a lot more lately, just not in my neighborhood. Pretty much any time I leave the house, I either go out as a woman or as I feel myself to be: a genderfluid person, masculine and feminine.

I usually peep out of the door before I go outside on the deck at home because there's a possibility one of the neighbors might see me in a tank top, breast shape showing prominently through my clothes. But I walked outside the other day, completely forgetting to do that. No one saw me. But if I'm honest, I sort of wish someone had. I'm getting more and more tired of hiding.

I went to the gas station in girl mode yesterday and had been feeling pretty good about myself, but I caught my reflection in my car windows while refueling and I looked "hard." I'm sad that I never got to be young, cute and fresh-faced. I look older than I feel. But I still look 15 years younger than I am!

Once my second FFS surgery is complete and most of my facial electrolysis is finished, I plan on looking into any and all dermatological treatments I can get to smooth my skin and even out the pigment. I have some hyperpigmentation (spots) and the texture of the skin on my chin is pretty coarse. I know that micro needling can be helpful and there are topical medications that can address the hyperpigmentation, as well as laser treatments. But if I take a really objective look at myself, I do know that my skin is quite nice, considering my age. I guess I just want more.

[Lori Dee ✅]

Congrats, Courtney!

I had a hematologist do a check for me due to high white blood cell counts over a year. Same thing, he didn't draw blood, but instead looked at my labs over the past five years. He concluded that it was no big deal (i.e., not cancer).

Your level is a wee bit high, but nothing to panic over. The option I was given when I hit 400 on two consecutive labs was to space out the dosing rather than decrease. So instead of weekly, I inject every ten days. I'm not saying that is for you, just an option to keep in mind when discussing it with your providers.

Good job on the exams too! You will be providing a great service to the community, and I hope you find it very rewarding, especially financially.

[Courtney G]

Thanks @Lori Dee for the support and kind words!

I was prescribed once-weekly injections but after doing some research I learned that many do better on a twice-weekly schedule. In that case, one often needs a lower dose of the medication. In my case, I was injecting 6 mg weekly, so I started injecting 3 mg twice weekly, but I think 2 mg might be a better dose. Or I'll go to 5 mg weekly. I'll have to see what my NP says when I have my appointment. I'm just so happy to have a proper level of E in my system.

[Lori Dee ✅]

My dose is .5mL and we talked about dropping to 4. The other benefit of twice weekly at a lower dose is that it smooths out the peaks and troughs we discussed. I had that discussion with my endo too, and I am not opposed to it, but we agreed to let the labs tell us the next step. I'm not too keen about stabbing myself twice a week, but I can get used to it.

[Courtney G]

Same about the stabbing. I have had a really hard time getting my T down/keeping it there, so I'm very leery about a cycle longer than a week.

[Lori Dee ✅]

Same about the stabbing. I have had a really hard time getting my T down/keeping it there, so I'm very leery about a cycle longer than a week.

If insurance will cover it, look into Eligard injections (leuprolide). It stops T production at the source. It is expensive, but the injections are done by a nurse every 30 days to six months. I got mine every 90 days for a year. By then, the estrogen levels were high enough to suppress the T, and I stopped getting the injections. You may not need it if your E levels can do the job without it.

[Courtney G]

Thanks for the info. I'll look into it. But I agree - hopefully, the big boost in E levels has suppressed my T. I should know by Monday when the T value from my test comes in.

What I'd really like is an orchiectomy. It was be affirming, would help with wardrobe options, and would lead to less medication in my body. My wife is a little freaked out by the idea, which is kind of funny considering the fact that they're not serving any purpose right now.

But I do wonder if I'll lose function. Things work surprisingly well right now and the thought of possibly losing that concerns me.

[Stottie Girl]

Thanks for the info. I'll look into it. But I agree - hopefully, the big boost in E levels has suppressed my T. I should know by Monday when the T value from my test comes in.

What I'd really like is an orchiectomy. It was be affirming, would help with wardrobe options, and would lead to less medication in my body. My wife is a little freaked out by the idea, which is kind of funny considering the fact that they're not serving any purpose right now.

But I do wonder if I'll lose function. Things work surprisingly well right now and the thought of possibly losing that concerns me.

I would love to get an orchie too but in the UK I think it will work out around £6,000-£7,000 for the operation and consutancy referral fees. I would rather put that money towards GRS. I've bought a lottery ticket for tonight though so it might all change in the morning ha ha! If I got a windfall I'm booking my GRS immediately!