I was very fortunate in my choice of physicians. I needed a new PCP anyway (mine had moved), so my research librarian partner did what she does and found a wonderful physician in an LTBGTQ+ focused practice. I live in a big blue city, so that's a thing. My current PCP is aware of all of the major standards of care for trans patients, and she's willing to work with patients to meet their own reasonable needs and goals.
She uses a six-week testing window when establishing levels or making changes, then longer windows once things have stabilized. She insists on trough readings rather than mid-cycle, and I completely agree with that. She started me on transdermal estradiol, and the patches were great until they stopped working. At that point she gave me options - injections, trying a higher transdermal dosage to counteract lower absorption, or other delivery methods - and let me choose. After a week of waffling, I went with injections.
We also talked a lot about antiandrogens. I had done a lot of research on spironolactone and alternatives, and I wasn't very happy with any of them. The option she suggested was no antiandrogen at all, just going straight for estrogen dominance, only adding an antiandrogen later if that failed. That was absolutely the right call. My T level dropped to basically zero within six months and only bounced back briefly when the patches stopped working.
I'm not an expert in biomedical science, but I do have a math degree and a solid grasp of statistics, and I know how to read a scientific paper when I have to. I've been lucky in that most physicians treat me as a well-informed adult, don't talk down to me, and allow me to make my own informed choices. If they don't, I go elsewhere.
Have you considered writing about estrogen monotherapy?
I see that the UCSF guidelines include both estrogen and a T-blocker. It seems like there's just not a lot of research on estrogen-only therapy.
Similarly to Rachel, my metamour has been on estrogen-only therapy for a few years and swears by it.
I feel like if I can get the effects I want from one drug instead of two, shouldn't that be the first approach?
(This is my second comment on this substack asking about specific topics to be written about: I hope this isn't intrusive: if so please let me know and I can hold off!)
Unfortunately, SGW sticks to research in the field--science that we can reasonably rely on--and monotherapy just hasn't been studied. This doesn't make it significantly different than other modes of hrt we use, but it means that I can't write a solid article on it (or, frankly, any comparison approach of hrt regiments).
Doc, this was EXCELLENT. Thank you for writing this and for making so many important points accessible to the community. We need more of this.
I wish I'd known some of this at the start of my own HRT journey, and my experience was pretty typical. I waited months to get an appointment with an endo who really wasn't that interested in listening to me or my experience. My lab numbers started changing and he didn't tell me, didn't warn me that a problem was growing. By the time I finally discovered the issue for myself, he decided (unilaterally) to take me off T for an undefined period of time. The withdrawal was horrific and ramped up dysphoria for me in ways I could not have anticipated. Spoiler: I found a new doctor who is more interested in having open conversations with me about my care, and I'm steadily getting back on track. Getting there, however, was brutal.
Informing ourselves is so important, but so inaccessible to most folks. There are access barriers, language barriers, educational barriers, financial/economic barriers... And above it all is this terrifying power dynamic when any of us walks into a clinic to see a physician. I don't know how to solve those problems, but articles like this one are a great start to making that conversation available. Thank you.
We're taught that doctors hold this much power over us, but the reality is that nobody in that room is more powerful than we are, because we have the power to say no to them. Patients rights are so crucial, and yet so few of us know what ours are.
I lucked out in two factors. The first isn't exactly luck; I developed a rare and painful nerve condition after an accident and through my research into my own condition, I quickly learned through doctor interactions that I knew more about the condition than most of the specialists I had to see to get treatment, including surgeons. I also learned how to fight insurance companies and go through appeals and out of network exception requests. So I got a really good lesson on advocating for my own medical care, motivated by severe pain.
The second was that I lucked out in my PCP. I'm in a relatively remote area that I would described as mixed, politically, which has definitely affected the care and treatment I've received. When I realized I was trans (in my mid 40s), I knew I needed a new PCP. My PCP admits she isn't an expert in trans health care, but she is willing to listen and research. And in the time that she's been my PCP, she's also come to trust me with my own care as well. She has trust that when I ask for a specific dose, she knows I'm not going to take more or abuse it, particularly with injectables. We've always discussed my dosages and delivery routes, and they've been that, discussions until the two of us agree on the path forward. And I've also made sure that when I come to her with an idea of how I want my care to be, I also want her opinion, and I've let her talk me out of things I wasn't sure of, mainly because I trust her medical expertise and judgement, and I'd rather build that medical relationship with her than just blindly trust something I read on the internet somewhere. The internet is great, but ultimately, you need a medical professional who's going to stand by you and provide you care. Having that person on your side and collaborating is really important.
200mg spiro out the gate is straight up negligent. He prescribed a 'fuck you' dose because you questioned it. 150mg is supposed to be the "it's been two years and you're still >200ngdl" dose. He clearly either wanted you to suffer or is truly absolutely incompetent and was just agreeing with whatever to shut you up.
Planned Parenthood is currently trying to ratchet down E levels and tries to demand I test mid-cycle instead of trough every time. They were great when I wanted to start on patches and then switched to IM monotherapy but now it seems they've got some new director guy who wants to rip it down.
The obsession with AAs is the worst thing in HRT approaches even after WPATH v8 came out. The myth that 'estrogen alone can't suppress everyone' needs to be killed already, because it's based on conservative garbage levels.
They want us to have menopause levels at best. They want us to suffer.
I was very fortunate in my choice of physicians. I needed a new PCP anyway (mine had moved), so my research librarian partner did what she does and found a wonderful physician in an LTBGTQ+ focused practice. I live in a big blue city, so that's a thing. My current PCP is aware of all of the major standards of care for trans patients, and she's willing to work with patients to meet their own reasonable needs and goals.
She uses a six-week testing window when establishing levels or making changes, then longer windows once things have stabilized. She insists on trough readings rather than mid-cycle, and I completely agree with that. She started me on transdermal estradiol, and the patches were great until they stopped working. At that point she gave me options - injections, trying a higher transdermal dosage to counteract lower absorption, or other delivery methods - and let me choose. After a week of waffling, I went with injections.
We also talked a lot about antiandrogens. I had done a lot of research on spironolactone and alternatives, and I wasn't very happy with any of them. The option she suggested was no antiandrogen at all, just going straight for estrogen dominance, only adding an antiandrogen later if that failed. That was absolutely the right call. My T level dropped to basically zero within six months and only bounced back briefly when the patches stopped working.
I'm not an expert in biomedical science, but I do have a math degree and a solid grasp of statistics, and I know how to read a scientific paper when I have to. I've been lucky in that most physicians treat me as a well-informed adult, don't talk down to me, and allow me to make my own informed choices. If they don't, I go elsewhere.
That's wonderful!
Have you considered writing about estrogen monotherapy?
I see that the UCSF guidelines include both estrogen and a T-blocker. It seems like there's just not a lot of research on estrogen-only therapy.
Similarly to Rachel, my metamour has been on estrogen-only therapy for a few years and swears by it.
I feel like if I can get the effects I want from one drug instead of two, shouldn't that be the first approach?
(This is my second comment on this substack asking about specific topics to be written about: I hope this isn't intrusive: if so please let me know and I can hold off!)
I always, always welcome user requests!
Unfortunately, SGW sticks to research in the field--science that we can reasonably rely on--and monotherapy just hasn't been studied. This doesn't make it significantly different than other modes of hrt we use, but it means that I can't write a solid article on it (or, frankly, any comparison approach of hrt regiments).
Doc, this was EXCELLENT. Thank you for writing this and for making so many important points accessible to the community. We need more of this.
I wish I'd known some of this at the start of my own HRT journey, and my experience was pretty typical. I waited months to get an appointment with an endo who really wasn't that interested in listening to me or my experience. My lab numbers started changing and he didn't tell me, didn't warn me that a problem was growing. By the time I finally discovered the issue for myself, he decided (unilaterally) to take me off T for an undefined period of time. The withdrawal was horrific and ramped up dysphoria for me in ways I could not have anticipated. Spoiler: I found a new doctor who is more interested in having open conversations with me about my care, and I'm steadily getting back on track. Getting there, however, was brutal.
Informing ourselves is so important, but so inaccessible to most folks. There are access barriers, language barriers, educational barriers, financial/economic barriers... And above it all is this terrifying power dynamic when any of us walks into a clinic to see a physician. I don't know how to solve those problems, but articles like this one are a great start to making that conversation available. Thank you.
Oh my god, that's a harrowing story!
We're taught that doctors hold this much power over us, but the reality is that nobody in that room is more powerful than we are, because we have the power to say no to them. Patients rights are so crucial, and yet so few of us know what ours are.
I lucked out in two factors. The first isn't exactly luck; I developed a rare and painful nerve condition after an accident and through my research into my own condition, I quickly learned through doctor interactions that I knew more about the condition than most of the specialists I had to see to get treatment, including surgeons. I also learned how to fight insurance companies and go through appeals and out of network exception requests. So I got a really good lesson on advocating for my own medical care, motivated by severe pain.
The second was that I lucked out in my PCP. I'm in a relatively remote area that I would described as mixed, politically, which has definitely affected the care and treatment I've received. When I realized I was trans (in my mid 40s), I knew I needed a new PCP. My PCP admits she isn't an expert in trans health care, but she is willing to listen and research. And in the time that she's been my PCP, she's also come to trust me with my own care as well. She has trust that when I ask for a specific dose, she knows I'm not going to take more or abuse it, particularly with injectables. We've always discussed my dosages and delivery routes, and they've been that, discussions until the two of us agree on the path forward. And I've also made sure that when I come to her with an idea of how I want my care to be, I also want her opinion, and I've let her talk me out of things I wasn't sure of, mainly because I trust her medical expertise and judgement, and I'd rather build that medical relationship with her than just blindly trust something I read on the internet somewhere. The internet is great, but ultimately, you need a medical professional who's going to stand by you and provide you care. Having that person on your side and collaborating is really important.
Are the Standards of Care an American thing or do they apply in Europe too?
Very much worldwide. Which organization issues them might change, but then again, might not. For instance, WPATH is global.
200mg spiro out the gate is straight up negligent. He prescribed a 'fuck you' dose because you questioned it. 150mg is supposed to be the "it's been two years and you're still >200ngdl" dose. He clearly either wanted you to suffer or is truly absolutely incompetent and was just agreeing with whatever to shut you up.
Planned Parenthood is currently trying to ratchet down E levels and tries to demand I test mid-cycle instead of trough every time. They were great when I wanted to start on patches and then switched to IM monotherapy but now it seems they've got some new director guy who wants to rip it down.
The obsession with AAs is the worst thing in HRT approaches even after WPATH v8 came out. The myth that 'estrogen alone can't suppress everyone' needs to be killed already, because it's based on conservative garbage levels.
They want us to have menopause levels at best. They want us to suffer.