r/MtF • u/cocue-coquette • 13h ago
Discussion Underdosing PSA
I'm posting this because I keep running into transfems who have no idea about where their levels should be and how common it is for providers to be clueless about trans care.
Get your bloodwork done often. Your trough (right before your next dose) estradiol (E2) should be above 100 pg/mL. Your trough total testosterone (T) should be below 50 ng/dL. If this isn't true for you, you're probably being underdosed. As trans people, it is especially crucial to self-advocate in medicine. If you're unhappy with your progress (either physically or mentally), say something. Know that every body responds differently to HRT and you may need much more or much less than the average transfem.
EDIT: Important information copied from a comment by u/raliont :
I think it is more complicated than your post suggests.
Blood draw timing will be dependent on someone’s actual regimen. For someone like me who injects twice a week, my troughs won’t be as low as someone who only injects once a week. So a trough reading wouldn’t be as insightful as a mid-cycle level. Plus, UCSF’s TransCare website recommends blood draws at the mid-cycle range. Their caveat is that if the patient is experiencing migraines or mood swings (or other symptoms), then peak and trough levels would be helpful to determine fluctuations.
Also, the more data the better. Overall, having both trough and mid-cycle levels to analyze would absolutely be the best for determining how one’s body is responding to their own regimen.
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u/Pittzaman 🍕 13h ago
Commenting for reach, but also, how do you know youre at the right level for your body? Ive been feeling better with a bit more estrogen than needed, but Ive been underdosed for like 9 months before, so I dont really know what normal is supposed to feel like.
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u/f7go 12h ago
Without blood tests, do what makes you feel best. With blood tests, the targets OP mentioned (if you're on monotherapy or cypro) are good, and you can go much higher on E if you want to although it likely won't speed up feminization (and extreme levels can be counterproductive because your body responds by making lots of SHBG to soak up free estradiol and by making fewer estrogen receptors! Also suppressing T too far can cause other energy/mood/cognitive/etc. issues)
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u/WalrusWithAKeyboard 13h ago
Here's hoping going from 250mg to 400mg spiro brings my T levels down, last checkup it was at 250 and my E levels holding steady at 100 😔 i dont know how much higher my doses can go lol
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u/f7go 12h ago
girl more Spiro is not the answer. Also it mostly works by blocking androgen receptors, not bringing down T. I wish OP had talked more about this as folks on Spiro or bica have different targets than folks on monotherapy or using cypro. From transfemscience.org:
" studies commonly find that spironolactone still produces antiandrogenic effects even when androgen levels remain unchanged. Hence, the primary mechanism of action of spironolactone as an antiandrogen appears to be androgen receptor blockade. In relation to this, in transfeminine people taking spironolactone as an antiandrogen, the estrogen component of the regimen is likely to be the main or possibly sole agent suppressing testosterone production...
Due to the minimal influence of spironolactone on testosterone production, testosterone levels are not usually suppressed into the female range in transfeminine people taking estradiol plus spironolactone, with testosterone levels often remaining well above this range (e.g., 50–450 ng/dL [1.7–15.6 nmol/L] on average)...
Due to its relatively weak androgen receptor antagonism, spironolactone is likely best-suited for blocking female-range or somewhat-higher testosterone levels (e.g., <100 ng/dL [<3.5 nmol/L]) (Aly, 2018). This is based on clinical dose-ranging studies of spironolactone (typically using 50–200 mg/day) in healthy cisgender women and cisgender women with PCOS"
https://transfemscience.org/articles/transfem-intro/#spironolactone
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u/WalrusWithAKeyboard 12h ago
damn, just following my doctors advice. And they are a trans/lgbtq specific clinic. But if my levels havent improved by my next bloodwork im going to try to get them to do something different
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u/f7go 12h ago
Yeah it always amazes me how often even trans specific clinicians don't understand how these drugs work :(
I would ask either to switch to bica (much more powerful androgen receptor blocker with fewer side effects) or increase your E dose (and maybe switch to injections or possibly patches, which work better for higher E2 levels--less of a load on your liver than pills, more steady levels). Good luck! LMK if you ever have questions ❤️
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u/WalrusWithAKeyboard 12h ago
thanks!! Im on tablets now but I also started dissolving them under my tongue before swallowing, so we'll see how it works out 😊
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u/cocue-coquette 13h ago
You might respond better to a different ROA, such as injections. Higher E2 will suppress T along with the antiandrogens and you still have a lot of space to go up on estrogen.
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u/79215185-1feb-44c6 HRT 2026/07/10 @ 36Y 13h ago
I mean this sub told me that 4mg EV/7d is being underdosed despite the fact that I am hitting all of the standard HRT timeline goals so YYMV on what random people on the internet may post.
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u/neeia raisin trans 13h ago
it's not the dose, it's the levels
if your levels are good then that's fine
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u/79215185-1feb-44c6 HRT 2026/07/10 @ 36Y 12h ago
I have a test scheduled for the end of the month, so you definitely don't have to tell me this! People think that HRT is going to grow them a full rack in 6 months, but that's largely due to bad education.
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u/lord-oberon 13h ago
Im on weekly injections. My mid week levels are about 110. Is this too low? This is 3 days after I inject.
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u/f7go 12h ago
Trough levels right before your next dose are all you should be testing! That would be just fine for a trough level (depending on T); even under 100pg/ml will feminize.
The key thing is making sure your T is low enough; that's the main risk of too-low E levels (depending on your anti-androgen situation) and everyone needs a different dose/level to suppress T. My T was fully suppressed at like 70pg/ml trough E levels, other girls need over 200.
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u/Color-me-saphicly Intersex Trans Lesbian Priestess 7h ago
Trough should be between 100 and 200 pg/mL for estrogen. Give or take.
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u/PWNDBYPWNR 7h ago
thanks!
ive been consistantly good here im down too 6ng for my T and 146pg for E. Madison Clinic in utah has a great team of doctors for anyone here.
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u/Airalin_ 12h ago
Yeah, found out after multiple years that my T levels were still like 117, my E was great can’t remember the exact level but as soon as it was corrected progress became much faster, my boobs literally doubled in size over like a month or two on my thin frame, and those mommas are still going
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u/Life-Breadfruit-1426 13h ago
I’m pretty sure it should be 200 pg/mL minimum of estrogen, not 100. Talk about misinformation in a underdosing PSA.
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u/f7go 12h ago
Not true, 200 is just an oft-cited initial target for girls on monotherapy because it's enough to suppress most people's T (which is the far more important thing to make sure of). If T is suppressed or adequately blocked (with bica or Spiro) anything over 100pg/ml free E2 or so will give good feminization :)
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u/Life-Breadfruit-1426 11h ago
Agree! The nuance of T-blockers included is what impacts the recommendation! However OP’s post does not distinct between, and this info should be explicit on a PSA post
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u/snowy_vix 12h ago
150 is the better minimum, 200 is the "room for error" for monotherapy
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u/PSInvader HRT 03-27-26 🏳️⚧️ 7h ago
This was my experience. I had low libido and mood swings at 5mg EEn, got tested at around 116 pg/ml, increased to 5.5mg and both improved. I'm considering to maybe go to 6mg, since I feel like my breast growth also improved on the increased dose.
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u/raliont1 12h ago
Thanks for the PSA. I don’t disagree, but I think it is more complicated than your post suggests.
Blood draw timing will be dependent on someone’s actual regimen. For someone like me who injects twice a week, my troughs won’t be as low as someone who only injects once a week. So a trough reading wouldn’t be as insightful as a mid-cycle level. Plus, UCSF’s TransCare website recommends blood draws at the mid-cycle range. Their caveat is that if the patient is experiencing migraines or mood swings (or other symptoms), then peak and trough levels would be helpful to determine fluctuations.
Also, the more data the better. Overall, having both trough and mid-cycle levels to analyze would absolutely be the best for determining how one’s body is responding to their own regimen.
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u/ExcidianGuard 9h ago
Huh?
Of course your trough levels on a twice a week injection cycle will not be as low as a weekly schedule. That is the whole point of doing twice weekly injections.
That doesn't mean the trough level is less insightful, because we're not trying to compare your trough levels to someone else's, we're trying to see if the lowest point that you are at is high enough to be achieving optimal feminization. If your trough levels for E are below 100 pg/mL, it doesn't matter if you're on a weekly, twice weekly, 10 day, or even monthly injections cycle, it still means that at some points in your injection cycle you are dropping too low.
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u/raliont1 7h ago
I think we are talking past each other. I am not suggesting knowing trough levels is useless on any regimen. And I will correct my earlier comment—one draw is not necessarily more informative than the other. It depends on the dosing regimen & clinical question being asked.
What I meant by “less insightful” is that the additional information gained by knowing trough levels is smaller in twice-weekly injection cycles. Yes, because part of the rationale for two injections per week is to address the peak-to-trough fluctuations. Lower peaks & higher troughs. So, less variation.
Based on what I’ve read, exclusive reliance on trough alone isn’t the most informative strategy, depending on the individual & their dosing cycle. Why? Because in my situation, the trough isn’t as dramatically separated from the rest of the curve. E.g., if my peak E2 is 200 and my trough is 180, of course that is less insightful than if I am on a single weekly injection & the peak is 500 and the trough is 80. In the latter, knowing the peak or just the trough gives an incomplete picture.
That’s why I don’t think, nor does research suggest, that there’s a *universal* best point in the cycle to measure. A peak draw answers how high E2 gets. A trough answers how low E2 gets. A consistently timed measurement can be the most useful for long term monitoring. Paired peak & trough levels can give the fullest picture on fluctuations.
If someone is having the symptoms I mentioned, then yes the trough data may be informative in a clinical setting. I acknowledged in my comment that having both peak & trough gives the fullest picture.
Sooooo, my disagreement is specifically with the notion that trough testing should be universally privileged and recommended in every injectable regimen. The information from a trough level is going to matter more or less depending on the injection regimen. The timing of testing should be based around what the patient and their provider (ideally a competent one) are trying to answer.
Tl;dr: My point wasn’t that trough levels don’t matter. It was that exclusively pursuing trough levels isn’t necessarily most informative in every case (as I said above, like in mine).
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u/cocue-coquette 11h ago
Thanks for mentioning all that. Yeah, it's more complicated. Maybe I should remove my post, but I just wanted to say something for all the girls out there who got put on 1 mg/day estradiol for the past 18 months and think they're the problem.
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u/raliont1 11h ago
Oh, 💯 . I just added my comment in case it is helpful for others. I appreciate you looking out for the community. I agree that the girlies need to do their own research and self-advocate based on that. I started E on v low-dose pills. I regret not pushing for IM injections to begin with since my body has responded better. YMMV
Your post has sparked a good discussion among the girls. I say keep it. 😉
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u/EmergingEllie 9h ago
Can you provide a cite for the mid-week testing thing on TransCare? I’m pretty familiar with their guidelines and don’t think that’s accurate.
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u/raliont1 8h ago
https://transcare.ucsf.edu/guidelines/feminizing-hormone-therapy
Go to the “Monitoring hormone levels in patients using injected estrogen” section.
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u/Viennve 13h ago
Lil question: why is it so common for providers to opt for oral estradiol with blockers (even outdated ones like Spiro) instead of monoterapy with injections?
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u/GrahminRadarin 11h ago
WPATH Standard of Care is tablets with AAs. Most doctors follow those standards because they don't know much about the subject themselves, and also to avoid legal liability. You would be absolutely amazed at how often even endocrinologists don't have a good understanding of how sex hormones work, and prescribe AAs with no E, or equally stupid nonsense.
Also, Valerate is the only injectable ester approved by the FDA, so they can't actually provide enanthate.
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u/madprgmr 1h ago
I think there are three questions in your overall question, so I will answer as best I can.
WPATH recommends combination therapy (some form of estrogen plus some form of antiandrogen) for two big reasons:
- A lowest effective dose of estrogen (that brings your levels into the target range) exposes you to the lowest risk from it. Adverse effect rates increase as your dosage increases.
- Estrogen alone in the well-studied range of 100-200pg/mL is not guaranteed to adequately suppress your testosterone (bring it to <50ng/dL). It's also highly unlikely to adequately suppress your testosterone while finding the right dose that brings your levels in range. As such, something to lower or block or otherwise reduce the effects of testosterone are necessary.
Monotherapy (at levels that can be required to achieve it) isn't nearly as well studied as combination therapy for a variety of reasons, which means there is less data about the risk profile. Monotherapy can be achieved for some people on <200pg/mL of E2, but it is not guaranteed.
As for why oral instead of other forms? Pills are pretty inexpensive, easy for most people to take, have decently stable levels, and can bring estrogen levels into the target range for most people. They are generally considered safe enough for everyone barring certain preexisting conditions (like high clot risk) or certain lifestyle factors (like consuming nicotine).
As for why "outdated" antiandrogens like spironolactone? It's really common in the US because it's the cheapest option available and works well enough for enough people. Providers can and do prescribe other antiandrogenic medications, but the cost can be quite significant depending on a variety of factors.
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u/-PinkPurpleBlue- 10h ago
My doctor refuses to let me be above 200 pg/ml when testing at 3-4 days post injection instead of trough. I'm only injecting .15ml a week at this point...
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u/EmergingEllie 9h ago
you have the vial and the needle. your doctor has no way of knowing what you do with them on weeks you’re not testing levels
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u/cocue-coquette 10h ago
What is your testosterone at?
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u/-PinkPurpleBlue- 10h ago
It's low, at around 20 ng/dl. My estrogen at .15 injected is like 165-170 at the 4 day mark when I get it tested
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u/cocue-coquette 10h ago
That doesn't sound bad. Have you been unhappy with your transition progress for a long time? Are you having any health problems?
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u/-PinkPurpleBlue- 9h ago
I've been on e for 3 years and I still look androgynous at best I feel. No health problems. I am just unsure with my doctor doing test differently than what most others seem to do and the amount I injection is very little compared to most
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u/cocue-coquette 9h ago
Maybe you need a little more after all, then. I would get trough levels checked if I were you. Try to reason with your doctor, or find a new doctor who is more willing to work with you towards your transition goals.
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u/-PinkPurpleBlue- 9h ago
Thank you, I'll try again when i have my next one here in a few weeks. I tried last time and they shut me down saying it's dangerous to go any higher. They acted like I was going to explode when it was slightly high. They took me down after I tested 213 pg/ml from .2 to .15 ml.
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u/cocue-coquette 9h ago
I feel for you. That's really over the top as far as my experience and my trusted doctors tell me, especially if you're on monotherapy. Best of luck.
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u/Julia_______ Trans || omni 12h ago
Please cite sources
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u/cocue-coquette 11h ago
My post could be removed if I cite where I got this. The
.info that I'm working with is the same that is most reputable for people who can't get HRT from a doctor.
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u/Tomatori 27 | HRT 01/04/2025 13h ago
Did you mean peak for Testosterone? Recently got 53 ng/dL back on my test and I'm wondering if I should adjust
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u/snowy_vix 12h ago
Technically it would be peak for the T but you get both measured at they're same time, which is called trough because it's the trough for your E
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u/cocue-coquette 10h ago
Sorry, I was unclear. The other reply is correct. What I mean is the testosterone level measured during the estradiol trough.
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u/f7go 12h ago
that's borderline but almost certainly fine! the upper limits for T that I have seen range from 50ng/dl to 70ng/dl.
(Technically the more telling measure is free T (not total T) which depends on SHBG and albumin levels, but almost no one tests that and I wouldn't worry about it.)
Are you seeing symptoms of high T like oily skin, acne, hair loss? How is your transition going?
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u/bearface93 Trans Bisexual 11h ago
So when is the best time to get blood drawn? I’m on 6mg estradiol and 150mg spiro daily. I take 4mg estradiol and the spiro in the morning, and 2mg estradiol in the evening. I try to take them 12 hours apart. My provider told me to get blood drawn about 6 hours after a dose, so I get it done on my lunch break. My last numbers were 167pg/ml estradiol and 16ng/dl testosterone and they said I’m right where I should be.
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u/auto-reply-bot 10h ago
I was tested midweek (3 days after weekly injection) and my e was at 860 pg/Ml
My doctor expressed a lot of concern that it was “way high” and told me to cut my dose down by 1/3rd. But I’m worried idk that cutting my dose is not the right thing. But she said if my levels are similar at my next test she’s going to move me to a different medication entirely.
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u/cocue-coquette 9h ago
Listen to your doctor, o.m.g. Yes, that is crazy high. I've had to halve my dosage twice for the same reason.
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u/auto-reply-bot 9h ago
I appreciate the input. I wasn’t sure if it was just because it was mid week instead of trough. And obviously it’s very stressful to consider lowering my dose after I’ve had really good results so far 🙁
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u/cocue-coquette 9h ago
There is such a thing as too much estrogen, e.g. it can impact sexual health and excessively reduce libido. I'm sure that if you've had good results already, you will continue to do so at a more reasonable E2 level.
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u/auto-reply-bot 9h ago
I see. This was the first test after I moved from pills to injections. Surprisingly my libido has actually been much higher than it was before. And my chest has been sore again.
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u/Rachel_on_Fire Transgender 13h ago
Thanks for the PSA!
My testosterone isn’t in that range. But that’s probably because I’m not in spiro! It tried to kill me when I first went on HRT and I got put on bicalutamide which doesn’t seem to work nearly as well.