To start – On the journey of my medical transition, I have been to 3 doctors. For many, interacting with a doctor who has so much control over your dosage and prescriptions can be intimidating. I share my information and lived experience in hopes of helping other trans people take control of their transition.
My history with doctors – Too often, doctors who offer HRT are not knowledgeable in transgender medicine. For me, the first doctor I went to mismanaged my dosage so severely that my testosterone was four times higher than what it started (82 ng/dL to 305.4 ng/dL). I am sure that if I had more knowledge of hormones, things would have gone differently.
There is great value in understanding HRT for any transgender person. Something as simple as learning hormone levels can be incredibly important in understanding your blood work.
Target Hormone ranges: MTF
Estradiol (E2) – 100 – 300pg/mL, however being in the ranges of 400, 500 or 600 pg/mL is not uncommon especially for those on injections.
Estrone (E1) – For cis women, estrone seldom goes higher than 200 pg/mL. However, trans women who take oral estradiol can have increased amounts of estrone. Some may have as much as 10, 15, or 20 times as much estrone as estradiol on oral. Making sure to test estrone along estradiol can give valuable insight into your body. Not only that, but taking your pills buccally or sublingually will increase estradiol over estrone.
Free estradiol % – 1 – 2% is optimal. If your provider is unwilling to test free estradiol as a percent, you can calculate your free estradiol percentage by dividing your serum-free estradiol by your total.
Testosterone – <50 ng/dL. However, some may feel better having their testosterone lower at 10, 20, or 30 ng/dL.
DHT – <10 – People who are post orchiectomy or post vaginoplasty may experience increased masculation after surgery. The reason being your body sees that you are no longer producing testosterone from your testicles, which upregulate your adrenal glands. Adding a low dose of a blocker like bicalutamide will solve this problem.
Progesterone – 4 – 24 ng/mL is optimal. For some, they may have trouble getting high enough levels of progesterone on oral alone. Rectal administration of progesterone can help to increase your absorption, as well as injections or gels.
Sex Hormone Binding Globin (SHBG) – 15 – 115 nmol/L – SHBG binds to sex hormones in the body, removing them from circulation. Higher SHBG will lead to lower free estradiol, which may give you less feminization.
Luteinizing hormone (LH) and follicle-stimulating hormone (FSH) – LH and FSH in the case of trans women, is the signal to your testicles to produce androgens. Having your LH and FSH at an undetectable amount will ensure the only hormones your body is receiving is through your HRT and adrenal glands.
Prolactin – <20 ng/mL. High levels of prolactin can lead to a prolactinoma, which is noncancerous tumors. Making sure to test for prolactin on medications such as cyproterone acetate is critical. Cyproterone acetate has side effects of elevated prolactin levels.
Target Hormone ranges: FTM
Testosterone – 300 – 100 ng/dL, the average for men being 679 ng/dL. However, being in the ranges of 700, 800 900, or even 1,000 ng/dL testosterone is common.
Estradiol – <40 ng/dL is optimal. High levels of testosterone will decrease your estradiol, which is one of the reasons trans men do not commonly take estradiol blockers.
Free testosterone – .5 – 5% with 2% being the average.
Sex Hormone Binding Globin (SHBG) – 15 – 115 nmol/L – SHBG binds to sex hormones in the body, removing them from circulation. Higher SHBG will lead to lower free testosterone, which may give you decreased masculation.
DHT – 15 – 80 ng/dL. For trans men, DHT plays an important role in both bottom growth and voice dropping.
Luteinizing hormone (LH) and follicle-stimulating hormone (FSH) – LH and FSH for trans men signal their ovaries to produce androgens. Having your LH and FSH at an undetectable amount will ensure the only hormones your body is receiving is through your HRT and adrenal glands.
Working with your doctor – Countless times, transgender folk go to the doctor hoping to raise their dosage or make an addition to their HRT regimen only to be shut down. In my experience, coming to the doctor with a gameplan and studies indicating why you want to make this decision, such as adding progesterone to your regimen, can help convince them that this is right for you. Not only that, confidence can play an essential role in assuring your doctor.
In my experience, doctors who I have worked with treat HRT as a mutual agreement. If I want to increase my dosage, I tell them why I want to do so and what I hope to achieve. However, some doctors do not have enough experience with some medications to feel comfortable prescribing.
For example, in the United States, the standard anti-androgen is Spironolactone. If you go to a doctor and say you want to take bicalutamide instead, they may not feel comfortable prescribing medications without sufficient information. You may have to find another doctor who is willing to prescribe you that type of medication.
In short, Going to the doctor who has so much control over your dosage can be intimidating. By understanding your blood work, you can alleviate some of the anxieties that the doctor can bring. Not only that but if your doctor does not understand trans medicine, you can stand up for yourself and be in control of your levels. I hope my information can be helpful to you. I wish you good luck on your journey 🙂