The Story of Lori, Chapter 2

[Lori Dee ✅]

Thanks, ladies.

Today's appointment was almost a 180-degree difference. They were on-time and engaged. The first doctor introduced himself, confirmed my name, and my pronouns. He scored points for that.

We discussed some medical history, and I could see he was often referring to my chart. Then he got to the "we need to change your dose due to risks" part. He explained that they follow WPATH Guidelines (which shocked me since Trump bashed them), and that the guidelines aim to minimize risk. I corrected him and stated that the purpose of the guidelines, as stated are:

"The overall goal of the guidelines from WPATH, called 'Standards of Care, is to provide clinical guidance for health professionals to assist transgender and gender diverse people with safe and effective pathways to achieve lasting personal comfort with their gendered selves, and to maximize their overall health, psychological well-being, and self-fulfillment." (I didn't quote this; I paraphrased, but he got the message.)

I told him that I understand they are overworked and understaffed and do not have time to research or read the studies. I am retired. I have time, and I do research and read the studies. He said he would go get Dr. Iwamoto, their head Endocrinologist.

He was a very nice man, and it didn't take long for him to realize I wasn't a dumb patient. We sparred for a few quick moments, just to establish that we had common ground and could speak the same language, I think. So he tried to tell me that he wanted to reduce my dose of estradiol to reduce the risk of blood clots. I disagreed. I am not on oral estradiol, and injectables have the same risk as patches, and patches have not worked for me.

He wanted to reduce my progesterone dose for the same reason. I agreed that, as an oral medication, it passes through the liver but does not increase the risk of clots. The danger lies in the metabolites' side effects, which cause dizziness and drowsiness. I told him that I have been on this dose for two years and I am not bothered by the side effects any longer.

He then tried to tell me that the pharmacy may push back because the maximum recommended dose is 200mg per day, and I take 300mg per day. I told him the VA pharmacy has been filling that prescription for two years without any "push-back".

Finally, we reached an agreement. He said he will document our conversation in which he explained the risks (i.e., Informed Consent), and that no changes will be made to my prescription. At the end of May, we will do labs to check my hormone levels, and we will talk again. If the labs show my levels are elevated, then we will discuss decreasing my dose. I agreed. However, what he calls "elevated" is my normal. I told him that if he drops my levels and I start to experience symptoms (hot flushes, night sweats), I will call him in the middle of the night to complain. He smiled and said most people don't feel any symptoms. I said if that were true, he would not ever prescribe hormones for women in menopause.

He smiled at that and left the video call.

Overall, I think it was a good appointment. I achieved my goal of not changing anything until they understand who they are dealing with, and made it clear who they are dealing with. If they continue to listen and have intelligent discussions with me, I will be more willing to accept their recommendations. They now know that I will call them out if they try to BS me.

They are sending out new prescriptions with no changes, and I will talk to them in six months.

Life is good.

[ChrissyRyan]

Thanks, ladies.

Today's appointment was almost a 180-degree difference. They were on-time and engaged. The first doctor introduced himself, confirmed my name, and my pronouns. He scored points for that.

We discussed some medical history, and I could see he was often referring to my chart. Then he got to the "we need to change your dose due to risks" part. He explained that they follow WPATH Guidelines (which shocked me since Trump bashed them), and that the guidelines aim to minimize risk. I corrected him and stated that the purpose of the guidelines, as stated are:

"The overall goal of the guidelines from WPATH, called 'Standards of Care, is to provide clinical guidance for health professionals to assist transgender and gender diverse people with safe and effective pathways to achieve lasting personal comfort with their gendered selves, and to maximize their overall health, psychological well-being, and self-fulfillment." (I didn't quote this; I paraphrased, but he got the message.)

I told him that I understand they are overworked and understaffed and do not have time to research or read the studies. I am retired. I have time, and I do research and read the studies. He said he would go get Dr. Iwamoto, their head Endocrinologist.

He was a very nice man, and it didn't take long for him to realize I wasn't a dumb patient. We sparred for a few quick moments, just to establish that we had common ground and could speak the same language, I think. So he tried to tell me that he wanted to reduce my dose of estradiol to reduce the risk of blood clots. I disagreed. I am not on oral estradiol, and injectables have the same risk as patches, and patches have not worked for me.

He wanted to reduce my progesterone dose for the same reason. I agreed that, as an oral medication, it passes through the liver but does not increase the risk of clots. The danger lies in the metabolites' side effects, which cause dizziness and drowsiness. I told him that I have been on this dose for two years and I am not bothered by the side effects any longer.

He then tried to tell me that the pharmacy may push back because the maximum recommended dose is 200mg per day, and I take 300mg per day. I told him the VA pharmacy has been filling that prescription for two years without any "push-back".

Finally, we reached an agreement. He said he will document our conversation in which he explained the risks (i.e., Informed Consent), and that no changes will be made to my prescription. At the end of May, we will do labs to check my hormone levels, and we will talk again. If the labs show my levels are elevated, then we will discuss decreasing my dose. I agreed. However, what he calls "elevated" is my normal. I told him that if he drops my levels and I start to experience symptoms (hot flushes, night sweats), I will call him in the middle of the night to complain. He smiled and said most people don't feel any symptoms. I said if that were true, he would not ever prescribe hormones for women in menopause.

He smiled at that and left the video call.

Overall, I think it was a good appointment. I achieved my goal of not changing anything until they understand who they are dealing with, and made it clear who they are dealing with. If they continue to listen and have intelligent discussions with me, I will be more willing to accept their recommendations. They now know that I will call them out if they try to BS me.

They are sending out new prescriptions with no changes, and I will talk to them in six months.

Life is good.

Sounds like an open discussion.  But you said that you will take labs in May and talk then, so you will not need to wait to talk six months.

[Lori Dee ✅]

Sounds like an open discussion.  But you said that you will take labs in May and talk then, so you will not need to wait to talk six months.

You are sharp, Chrissy! It does look that way. The labs happen in May for my Primary doctor. They are tacking on hormone tests, too. They will watch them and, if necessary, order more labs before the next six-month appointment. They want enough data to show my levels are consistently high, range from low to high, or whatever they fluctuate. You can't see that with one set of labs.

My last labs with them showed my levels were high a few days before my injection, then my labs (for my Primary) showed normal a few days after the injection. They want to ignore the normal lab results and focus on the elevated levels to justify dropping my dose.

So we will see how my levels are tracking over time. If they are high, I agreed to lower my dose. If not, they have no evidence to back their decision, and they know I will call them out on it.

[ChrissyRyan]

Lori,

I hope it all works out.  I wonder if there is a "guideline age" to drop the estradiol dose.
Maybe it has more to do with other risk factors. 

So far my dosage has remained the same.  I do split my tablets and take one half early in the day sublingually and the other half later in the day sublingually to spread out the dosage.  But it is not more than prescribed.  My MD is just fine with this.

Chrissy

[Lori Dee ✅]

Lori,

I hope it all works out.  I wonder if there is a "guideline age" to drop the estradiol dose.
Maybe it has more to do with other risk factors. 

So far my dosage has remained the same.  I do split my tablets and take one half early in the day sublingually and the other half later in the day sublingually to spread out the dosage.  But it is not more than prescribed.  My MD is just fine with this.

Chrissy

Splitting your dose helps keep your blood levels more even, so they aren't swinging high and low throughout the day. That's a good thing.

There is no guideline for strictly reducing the dose to adhere to an age-appropriate level. The reason is that women my age are post-menopause, which is age-related, and due to reduced natural hormones. The treatment is to add HRT to increase levels to avoid that.

HOWEVER, age also affects every other system in our bodies. So we start to have issues with heart health, osteoporosis, arthritis, breathing issues, etc. The reason for lowering the dose is not to force menopause because of age, but to reduce risks like cardiovascular problems (clots and strokes).

Estrodiol actually protects the body against osteoporosis, and some studies suggest progesterone may protect against estrogen's risk of clots and stroke, but more studies are needed on this.

The doctor told me he knows transgender women who have suffered blood clots at early ages, one as early as 20, and Ron DeSantis' daughter at age 40. I never accept such stories as "proof" because I don't know their medical history or family history of such problems. They may have been in the high-risk category all their lives.

I can only vouch for my own history and family history to determine my own risk. Doctors tend to look at populations instead of patients. They can't identify a tree because the forest is in the way.

[Charlotte Kitty ✅]

So glad your session went ok, even if you did have to fight your corner. I always thought it was upto the individual whether they lower their dose of E with age to mimic the natural drop or continue with pre menopause levels. I expect most people would like to keep just above the level needed to keep menopause symptoms away.

Charlotte 😻

[Lori Dee ✅]

So glad your session went ok, even if you did have to fight your corner. I always thought it was upto the individual whether they lower their dose of E with age to mimic the natural drop or continue with pre menopause levels. I expect most people would like to keep just above the level needed to keep menopause symptoms away.

Charlotte 😻

Doctors like to see everything as risk management. Even if you do not have anything that would increase your risk, they fall back on what the general population experiences. The first doctor tried telling me about the Women's Health Initiative findings. He was shocked when I told him it doesn't apply to ME.

The study was designed to determine whether adding a synthetic progestin to Conjugated Equine Estrogen (Premarin) would improve cardiovascular health in postmenopausal women.

Out of 51,000 women who participated in the study, not one of them was transgender.

The study added a synthetic progestin. I take a bioidentical progesterone, not a synthetic one.

The study used Premarin (Pregnant Mare Urine), an estrogen derived from horses. My estradiol is bioidentical to human estrogen.

A follow-up study revealed that horse hormones in humans cause health risks (duh), like blood clots and strokes.

The follow-up studies also found that synthetic progestins at those doses cause cancers. However, they have been safe to use at very low doses in birth control pills.

So, yes, it should be up to the individual to decide whether to lower their dose.

I do not believe any physician would disagree with that. The way they see it, zero dose = zero risk, and everything above that escalates. After spending four years with PMS symptoms, I just don't understand why anyone would want to do that, except to reduce a real risk.

Many people have medical issues that pose a risk, and in that case, it makes sense.